NHS has ‘blood on its hands’ over failings in treatment of Nottingham killer

NHS doctors have “blood on their hands” for their failings in treating the Nottingham killer, victims’ families have said.

Valdo Calocane was admitted under the Mental Health Act four times before NHS services lost track of him and released him, according to a new report by the health watchdog.

The Care Quality Commission (CQC) identified five missed opportunities to deal with Calocane’s violent psychosis in the three years before he stabbed to death students Barnaby Webber and Grace O’Malley-Kumar, both 19, and caretaker Ian Coates, 65.

The Health Secretary said the “distressing” report revealed the deaths were “avoidable” and urged mental health services across England to implement its recommendations to prevent future tragedies.

The families of those killed during the Calocale attack in Nottingham in June 2023 said they were “misled by multiple organisations” and said there would be a public inquiry.

“This report demonstrates gross and systematic failures by the mental health trust in its dealings with Calocane, from beginning to end,” they said.

“Along with Leicestershire and Nottinghamshire Police forces, these departments and individual professionals have blood on their hands.

“Alarmingly, there appears to be little or no accountability among the senior management team within the mental health trust. We question how and why these people are still in position.”

The families said they hoped this was the first in a “series of damning reports” as they called for senior managers to be held to account.

“The doctors involved in all stages of Calocane’s treatment must bear a heavy burden of responsibility for their failures,” they added.

The report found a series of “errors, omissions and errors of judgement” in Calocane’s care by Nottinghamshire Healthcare Foundation Trust (NHFT).

Calocane was “seriously ill” and was diagnosed with paranoid schizophrenia in 2020, with a psychiatrist noting three years before the attacks that “there seems to be no insight or remorse and the danger is that it will happen again and perhaps Valdo will end up killing someone”.

He was hospitalized four times in less than two years before health services discharged him for lack of engagement and when they no longer had his correct address.

His family also said they want answers and called for a public inquiry.

His mother Celeste told the BBC: “There are a lot of Waldos out there at the moment and if we don’t have the capacity to care for them I don’t know what will happen. The system is not fit for purpose.”

The report concluded there was a “clear indication” to detain him under section 3 of the Mental Health Act, which would give doctors powers to keep him in hospital for up to six months and administer antipsychotic injections against his will.

It would also have allowed doctors to give him a community treatment order, which would have allowed them to detain him again if he failed to take his medication or attend appointments — things he routinely did.

In August 2021, police searched his apartment after he failed to attend a mental health evaluation and found six months’ worth of drugs.

Doctors also repeatedly failed to follow medical advice for psychotic patients, ensure he was taking medication and consult police, his family or his doctor when discharging him, amid a series of failings highlighted in the report.

During his third hospital admission in September 2021, Calocane was forced to wait a week for a bed before being sent to a private hospital in the Northeast.

He was then transferred back to another private hospital in Nottingham, from where he was discharged on a Friday in October, without his family’s knowledge.

The crisis and problem-solving team that helped care for him in the community was unable to accept him at that time due to a “surge in GP referrals over the weekend”.

He was arrested again in January 2022 after allegedly assaulting his flatmate, but a doctor decided he could be cared for in the community. Nine days later, he was admitted to hospital for the fourth and final time.

NHS services increasingly lost contact with him. They tried to call him at home but had the wrong address. When they called, he said he was out of the country.

He was discharged for “non-involvement” despite evidence “beyond any real doubt” that he would develop “distressing symptoms and potentially aggressive and intrusive behaviour” as he had previously demonstrated.

The service had no guidelines for patients who did not engage despite suffering from psychosis and schizophrenia, the CQC said.

Wes Streeting, the Health Secretary, said: “This report makes for distressing reading, especially for those living with the consequences of their loss, knowing that their premature deaths were preventable.

“Action is already underway to address the serious failings identified by the CQC and I expect regular progress reports from Nottinghamshire Healthcare NHS Foundation Trust.”

Chris Dzikiti, the CQC’s acting chief inspector of healthcare, said the review found a number of errors that “contributed to a situation where a patient with very serious mental health issues did not receive the support and care they needed”.

He said: “Wider national action is also needed to address systemic issues in community mental health – including the shortage of mental health staff and the lack of integration between mental health services and other health, social care and support services – so that people receive the right care, treatment and support when and where they need it.”

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Calocale’s Five Missed Opportunities for Dealing with Psychosis

By Michael Searles

Mental health services missed five opportunities to tackle the Nottingham killer’s violent psychosis in a three-year period, the regulator has found.

A report into the NHS’s care of Valdo Calocane found a series of “errors, omissions and errors of judgement” before he killed Barnaby Webber and Grace O’Malley-Kumar, both 19, and caretaker Ian Coates, 65, in June last year.

Calocane was “seriously ill” and had been diagnosed with psychosis and paranoid schizophrenia in July 2020. He had been admitted under the Mental Health Act on four separate occasions.

The victims’ families said the departments and staff at Nottinghamshire Healthcare Foundation Trust (NHFT) responsible for their care had “blood on their hands”.

The Care Quality Commission (CQC) has identified at least five missed opportunities by mental health services to address Calocane’s violent psychosis.

NHS staff allowed Calocane to reject antipsychotic drugs

It was well documented throughout Calocane’s treatment that he regularly failed to take his prescribed medication for his paranoid schizophrenia. He also rejected therapy and was in denial about his condition. He was taking medications and did not believe he was ill.

On three of the four occasions he was detained in hospital, doctors considered giving him a long-acting antipsychotic injection, but chose not to because he preferred oral medication.

These injections release the medication slowly, so it stays in the body for weeks, and are recommended for patients who do not comply with treatment, such as Calocane.

The CQC said there was a missed opportunity to change his medication and that being hospitalised “presented the possibility of changing his medication to be able to treat his symptoms more robustly”.

The report said doctors “did not adequately balance” Calocane’s wishes with the knowledge that he was not taking his medication, which had been made clear by community carers and police, who found six months’ supplies in his home.

No psychological evaluation or intervention

The first missed opportunity to interrupt episodes of violent psychosis occurred on the first day he was arrested and evaluated.

Calocane was arrested after breaking into a neighbor’s apartment believing his mother was being raped there, but was released after a mental health evaluation with a prescription.

He was arrested an hour later after breaking into another neighbor’s apartment, where a woman was so terrified she jumped from the window of the first-floor apartment, seriously injuring herself.

He was first admitted, but although it was known that he was psychotic, the hospital did not perform a psychological evaluation or provide any intervention, which is recommended by medical guidelines.

Staff did not educate him about relapses, his condition or his medication, despite him struggling to cope, the CQC said.

Failure to plan for release into the community and deal with relapses

After his third admission to hospital under the Mental Health Act and subsequent discharge, the hospital missed the opportunity to discuss with other care teams why he continued to relapse and require repeated admission.

The CQC said a meeting between doctors, psychologists and community carers would have allowed them to come up with a better plan for treatment and establish why their treatment plan was not working.

This could have involved considering the use of a long-term antipsychotic medication to manage his symptoms, or a community treatment order (CTO) which would have given them the power to force him to take his medication and attend appointments, for which the report concluded “there was a clear indication”.

Couldn’t stop him and force him into treatment

In January 2022, Calocane was committed for the fourth time, but only under section 2, not section 3, of the Mental Health Act.

Detention under Section 2 allowed staff to hold Calocane for up to 28 days. However, they could not force him to take his medication.

The watchdog said this was a missed opportunity because under section 3 they could have forced him to take long-acting antipsychotic injections against his will and kept him in hospital for up to six months.

It would also allow him to be granted a CTO, whereby he would live in a designated location and if he failed to take his medication or attend appointments, he could easily be detained again.

I lost control of him and released him

The final missed opportunity to try to address his condition came when the hospital decided to hand his care back to his GP. After losing contact with him and not having an up-to-date address, the community team dismissed him for “non-engagement”.

They did this despite evidence “beyond any real doubt” that he would relapse into aggressive and intrusive behavior and without consulting his doctor or the police.

The CQC said staff failed to inform his GP about the known “risk of him not taking his medication and the possibility of him having a psychotic relapse as a result”.

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