A “series of errors and misjudgments” in Valdo Calocane’s mental health care led to him being discharged – even though he repeatedly failed to take his medication and showed signs of aggression – months before he killed three people in Nottingham, according to a review by the Care Quality Commission (CQC).
The Guardian has spoken to experts about how mental health care in England could be improved in order to better prevent future tragedies.
Properly enforce the current powers of the Mental Health Act
Prof Sir Simon Wessely, chair of the independent review of the Mental Health Act, said that although reform of current legislation was necessary, in the case of the failings that led to Calocane killing three people, it was clear that the powers already afforded by the act were not implemented properly.
“The need to reform the Mental Health Act is not one of those issues, because it is very clear that the necessary powers that might have prevented the killings already exist,” Wessely said. “The question that needs to be addressed is not what needs to change, but why the existing powers to compel Calocane to be treated against his will were not used. We, of course, cannot know what might have happened differently if they had been, but I think most people would agree that the likelihood of the tragedy would have been substantially lower.
“The tragedy in Nottingham does not per se require an overhaul of the MHA – instead we have to look to the inquiry to ask why the existing powers that might have prevented the horror were not engaged.”
Despite this, Wessely maintained that reform to the Mental Health Act was vital. “The reasons that stimulated the review have not gone away and are as important, if not more important, than before,” he said.
More understanding of conditions such as psychosis
Prof Anthony David, director of the UCL Institute of Mental Health, explained that serious disorders such as psychosis commonly impaired a person’s insight.
He argued that more understanding into conditions such as psychosis was needed by mental health professionals, who should not shy away from assessing the capability of patients to recognise and accept that they have a mental illness.
“Some mental health professionals avoid attributing lack of insight to patients because they believe it to be mere labelling or discriminatory, but insight strongly predicts need for treatment, a decision-making capacity, and has a neurological as well as social basis. This needs more understanding,” David said.
Culture change with regard to how mental health is treated
Dr Vishal Bhavsar, a psychiatrist working in forensic and parental mental health in south-east London, said there needed to be a culture change in NHS mental health services around violence, and around how professionals worked with families. “This isn’t just about training – we need training which is backed up by organisational leadership, and proper support and supervision for all staff.”
Andy Bell, the chief executive of the Centre for Mental Health, also called for a culture change. “It’s clear that many people’s experiences of mental health support is that there is a culture of late intervention, waiting for someone to reach crisis point before they are offered support, and not listening to people and families when they ask for help,” he said.
Increase in mental health resources
Minesh Patel, the associate director of policy and campaigns at Mind, said the mental health system in England was at “breaking point”.
“There is a pressing need to deliver not just the quality care, but also safety, that people with mental health problems and the public need,” Patel said. “A clear commitment to prioritising and tackling the crisis in mental health services, which has been mounting for years, is key. The human cost of deprioritising mental health is obvious, not just in the devastating Nottingham case, but through abuse and neglect scandals like [the cases at] Edenfield, Huntercombe and Cheadle Royal hospital.”
A lack of resources was also recognised by Bell, who said: “We can’t not look at the fact that mental health services for decades have been relatively underfunded compared with other areas of healthcare. That’s important because it is one of the reasons why we see people being made to wait a long time, and people being turned away and told they’re not unwell enough, and people being discharged when they clearly still have an ongoing need.
“If we had sufficient funding, those things would be at least less likely to happen. So we have to look at why it is [that] we continue to disadvantage mental health services as compared with other areas of healthcare.”
Reform of the Mental Health Act
Brian Dow, the deputy chief executive of Rethink Mental Illness, argued reform of the Mental Health Act was long overdue. “Too often, we hear how people living with severe mental illness spend their lives stuck in the revolving door of hospital admissions and community care,” he said. “Reform provides the opportunity to give people more choice in their treatment and better trust in the system, factors which play a huge role in supporting people’s recovery.”
Dr Lade Smith, the president of the Royal College of Psychiatrists, said that given the tragic circumstances surrounding the Nottingham attacks, “there has been more focus on the reform of the Mental Health Act in England and Wales. Patient and public safety is one of the major functions of the act and this should continue to be the case.”
Smith added: “The government should concentrate their efforts on ensuring people with a mental illness receive timely, evidence-based treatment.”
More focus on prevention in mental health care
Mark Rowland, the chief executive of the Mental Health Foundation, said prevention had to be the focus of reform. “Anyone who has had dealings with England’s mental health services can tell you that despite incredible progress, the system is still in a precarious state,” he said. “Our current approach invests almost nothing in prevention and cases like those with Valdo Calocane are the tragic consequences.”