Review of killer’s treatment finds ‘a series of errors’

A review has found “a series of errors, omissions and errors of judgement” in the handling of a killer who stabbed three people to death in the Nottingham attacks.

Barnaby Webber and Grace O’Malley-Kumar, both 19, and Ian Coates, 65, were killed by Valdo Calocane, who was psychotic and suffered from paranoid delusions, on June 13, 2023.

The review, published by the Care Quality Commission (CQC) on Tuesday, said that without action, the issues identified would “continue to pose an inherent risk to… public safety”.

The government met with victims’ families last week and called for the CQC’s recommendations to be implemented in mental health services across England.

The families confirmed the meeting with the Department of Health and the Attorney General’s Office, who told the BBC that the Prime Minister’s commitment to a judge-led inquiry into the deaths still stood.

However, the families insisted the inquest should be statutory, with the power to compel witnesses to give evidence.

Last year, Mr Calocane went on a rampage through the streets of Nottingham, killing students Mr Webber and Mrs O’Malley-Kumar with a knife as they returned from a night out, before stabbing Mr Coates to death near the school where he worked as a caretaker.

He then stole Mr Coates’ van and ran over pedestrians Wayne Birkett, Marcin Gawronski and Sharon Miller, causing serious injuries.

He was sentenced to a hospital commitment order in January and told he would be in a maximum security unit “most likely” for the rest of his life.

Tuesday’s report looked at Nottinghamshire Healthcare NHS Foundation Trust’s treatment of Calocane from May 2020 to September 2022.

The victims’ families – who have repeatedly called for a public inquiry into the case – said they were “misled by multiple organisations before and after” the killings.

In a joint statement, they added: “This report demonstrates serious and systemic failings at the mental health fund in its dealings with Calocane – from start to finish.

“Sadly, this is the first in a series of damning reports on the failures of government agencies that led to the murder of our loved ones, and more.

“Progress is being made slowly and we will continue our fight to ensure there is full organizational and individual accountability.”

Dr Sanjoy Kumar, Mrs O’Malley-Kumar’s father, told the BBC the families would like the scope of the inquest to be “as broad as possible”.

“We would like it to be a statutory public inquiry led by a judge and one that has real teeth to make a difference and change things in our country,” he added.

“We need to focus on Nottingham first and learn from what went wrong, because these systems are parallel across the country.”

In compiling its report, the CQC reviewed Calocane’s records along with 10 other cases “to allow comparison”.

The CQC said it had “interacted” with Calocane’s and the victims’ families, but the watchdog had not interviewed or spoken to any staff involved in the offender’s treatment at the centre.

The report found that the 32-year-old, a former University of Nottingham student, first came into contact with the fund in May 2020, during the first Covid-19 lockdown.

Documents showed he was “seriously ill”, diagnosed with paranoid schizophrenia and hospitalized four times in less than two years.

But the report said “major” risks were ignored or overlooked, including refusal of medication, ongoing and persistent symptoms of psychosis, levels of violence towards others when his psychosis was not well controlled and Calocane’s escalation of violence towards others in the latter stages of his care under the trust.

There was also “poor planning and engagement” with the killer and his family, who raised concerns about his mental state with the trust and BBC Panorama in their first interview.

“It is clear that after four hospitalizations in two years and repeated dismissals and refusals to take medication, (Calocane) required a much more robust care package,” the report said.

“More assertive engagement and restrictive measures were crucial to controlling his illness and the risk he posed to others when he was unwell.”

The CQC issued five recommendations to the trust, including ensuring staff were aware of the importance of involving and engaging patients’ families and implementing “robust discharge policies and processes”.

Responding to the CQC review, Health Secretary Wes Streeting said: “I want to reassure myself and the country that the failings identified in Nottinghamshire are not being repeated elsewhere.

“I hope the findings and recommendations of this report are considered and implemented across the country so that other families do not have to go through the unimaginable pain that the family of Barnaby, Grace and Ian are experiencing.”

In its report, the CQC said NHS England would carry out a “more detailed analysis” of Calocane’s wider interaction with mental health services in its “independent homicide review”.

The government said steps the NHS had already taken included issuing guidance to trusts – reiterating instructions not to discharge patients with serious mental health problems if they failed to attend appointments – and ensuring each service provider had “clear policies and practices for treating patients”.

Chris Dzikiti, acting chief health inspector at the CQC, added: “The issues we have identified at Nottinghamshire Healthcare NHS Foundation Trust are not unique.

“We found systemic problems with mental health care in the community, including a shortage of mental health professionals, a lack of integration between mental health services and other health care services… and support services, including the police.

“Without action, this will continue to pose an inherent risk to patient and public safety.”

Timeline of Valdo Calocale’s contact with the trust

The CQC released a timeline of Calocale’s contact with the local NHS Trust. It said:

• May 24, 2020 – Calocane is arrested for the first time. He is sent home after a mental health evaluation, but is arrested again an hour later

• May 25, 2020 – Officers cut Calocane for the first time at Highbury Hospital in Nottingham

• July 14, 2020 – Calocane is involved in a police incident and is hospitalized for the second time

• September 3, 2021 – Calocane is sectioned for the third time and taken to an independent hospital

• January 18, 2022 – Calocane is arrested after attacking another student

• January 28, 2022 – He is hospitalized for the fourth time

• September 23, 2022 – Calocane is dismissed to a general practitioner due to lack of involvement

Mr Dzikiti added that “poor decision-making, omissions and errors of judgement” contributed to a situation where a patient with “very serious mental health issues did not receive the support and follow-up he needed”.

“While it is not possible to say that the devastating events of 13 June 2023 would not have occurred had Valdo Calocane been given this support, what is clear is that the risk he posed to the public was not well managed and that opportunities to mitigate that risk were missed,” he said.

“There are actions that can and should be taken to better support people with serious mental health problems and provide better protection for the public in the future.”

Panorama – The Nottingham attacks: a search for answers

In June 2023, Barnaby Webber, Grace O’Malley-Kumar and Ian Coates were stabbed to death by Valdo Calocane. Reporter Navtej Johal investigates his history of mental health issues and the care he received.

Watch on BBC iPlayer from 20:00 BST on Monday.

Ifti Majid, chief executive of the NHS Trust, offered her “sincere apologies” to the families of the victims.

“We acknowledge and accept the findings of this report and have significantly improved processes and standards since the review was conducted,” he said.

“Our teams have much more contact with people waiting to be seen in the community to agree crisis plans and ensure they have an up-to-date risk assessment, even when they are struggling to engage with our services or primary care.

“We have a clear plan to address the issues highlighted and are doing everything we can to understand where we missed opportunities and learn from them.”

The report is the latest in a series of reviews, including those by the Independent Office for Police Conduct (IOPC), into Leicestershire and Nottinghamshire police.

A review by the Crown Prosecution Service (CPS) concluded that while prosecutors were right to accept Calocane’s manslaughter pleas on the basis of diminished responsibility, they could have handled the case better.

And in May, a judge ruled that Calocale’s sentence was not unduly lenient, following a recommendation from the attorney general.

Analysis

By Navtej Johal, BBC Panorama

There are several points made in this review that support the Calocane family’s view that opportunities to provide him with the care he needed prior to the tragic events in Nottingham in 2023 were missed.

In the first interview, Elias and Celeste, Calocale’s brother and mother, told me they believed the mental health system was “broken” and “not fit for purpose.”

One of the many examples of the problems in his treatment highlighted by the CQC is the decision to discharge his doctor for failing to engage with mental health services nine months before the murders.

The review said the decision “did not adequately consider or mitigate the risks of relapse”.

Celeste Calocane said she felt that at that point, the community mental health team “washed their hands and said, ‘OK, that’s it.’”

They hope the recommendation to strengthen policy and processes that “consider the circumstances surrounding discharge and whether discharge is appropriate” will be among many that will be put into practice.

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