A “series of errors and misjudgments” in Valdo Calocane’s mental health care led to him being discharged, despite repeatedly not taking medication and showing signs of aggression, months before he killed three people in Nottingham, a report says.
A review by the Care Quality Commission (CQC) of the treatment that Calocane received from Nottinghamshire healthcare NHS foundation trust over two years between May 2020 and September 2022 found that “the risk he presented to the public was not managed well”.
The report concludes: “In Calocane’s case there was no single point of failure but a series of errors, omissions and misjudgments.”
It says there are “systemic issues with community mental health care which, without immediate action, will continue to pose an inherent risk to patient and public safety”.
Calocane killed Grace O’Malley-Kumar and Barnaby Webber, both 19 and university students, and Ian Coates, 65, a school caretaker, in a knife rampage through Nottingham in the early hours of 13 June last year. He then stole Coates’ van and drove into three pedestrians who were seriously injured.
In January, Calocane was given an indefinite hospital order after pleading guilty to three counts of manslaughter on the grounds of diminished responsibility due to a diagnosis of paranoid schizophrenia, which experts concluded had caused him to carry out the killings.
In a joint statement, the Coates, O’Malley-Kumar and Webber families said the CQC report made for “devastating reading”.
“Clinicians involved at every stage of Calocane’s care must bear a heavy burden of responsibility for their failure and poor decision making,” they said, adding that departments and individual professionals had “blood on their hands”.
“Alarmingly, there seems to be little or no accountability amongst the senior management team within the mental health trust. We question how and why these people are still in position.”
They said the report called into question “the accuracy of the evidence provided to court about Calocane’s condition and treatment”.
A public inquiry into Calocane’s case will take place, as confirmed during a meeting with the health secretary and the attorney general last week, the families said.
Calocane was first referred to mental health services when he was arrested in May 2020 for breaking down the door of a neighbour’s flat. He was assessed and sent home, but arrested again an hour later after breaking into another flat, where a woman was injured jumping out of a first-floor window to escape.
Over the course of the next two years, Calocane was hospitalised on four occasions, each time displaying “threatening and assaultive behaviour as a result of psychosis”, the CQC report says.
It says Calocane frequently “provided misleading information” and showed “little understanding or acceptance of his condition”, and evidence showed he was not taking his medication at home.
The report says Calocane’s family repeatedly contacted the trust to share concerns about his deteriorating mental state, but this was not always acted upon. In December 2021, Calocane told mental health staff to stop contacting his family.
The CQC criticises the trust for not assessing whether Calocane was in a position to make his own decisions about his treatment, and for not opting to medicate him via depot injection, a slow-releasing form of medication, since he was not taking it himself.
In an interview with BBC Panorama, Calocane’s mother, Celeste, and brother, Elias, said the mental health system was “broken” and that the “tragedy that could have been prevented”.
Elias said: “I don’t think he was ever really treated. He was sort of managed so he had interventions. But with regards to a proper treatment plan, I’m not sure that we ever saw that.”
Hospital records show that in July 2020 a psychiatrist noted: “There seems to be no insight or remorse and the danger is that this will happen again and perhaps Valdo will end up killing someone.”
Calocane was discharged from mental health services to his GP in September 2022 due to a lack of engagement, nine months before the killings, and on the same day an arrest warrant was issued over his assault of a police officer while being sectioned.
The CQC report says it was “beyond any real doubt” that Calocane would “relapse into distressing symptoms and potentially aggressive or intrusive behaviour” without antipsychotic medicine and monitoring. He was not seen by medical professionals again until after the killings.
Chris Dzikiti, the CQC’s interim chief inspector of healthcare, said: “While it is not possible to say that the devastating events of 13 June 2023 would not have taken place had Valdo Calocane received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed.”
The report’s recommendations include that NHS England issues new guidance on care for people with complex psychosis and paranoid schizophrenia within 12 months.
Marjorie Wallace, the chief executive of the mental health charity Sane, said: “This is the most damning indictment of the fact that psychiatric services are not in crisis but in complete breakdown. The rights of patients override those of the families, carers and public. How can it be that a highly disturbed patient with his history of sections and incidents of violence could choose not to engage with services and disappear into the community?”
The Nottinghamshire healthcare trust’s chief executive, Ifti Majid, said: “We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out. 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.”