Medics and police have ‘blood on their hands’ over psychotic killer Valdo Calocane, his victims’ families said.
Grieving relatives hit out as a damning report today lays bare a ‘series of errors, omissions and misjudgments’ in his treatment before he killed three people in Nottingham last year.
It reveals how clinicians ‘minimised or omitted’ key details that would have exposed the serious risk Calocane, who was diagnosed with paranoid schizophrenia three years earlier, posed to the public.
It means he was left free to stab students Barnaby Webber and Grace O’Malley-Kumar, both 19, as they returned from a night out on June 13 last year before killing caretaker Ian Coates, 65.
The victims’ families also blasted Nottinghamshire and Leicestershire police forces over the contact they had with Calocane before the triple killing.
Grieving relatives hit out as a damning report today lays bare a ‘series of errors, omissions and misjudgments’ in his treatment before Valdo Calocane killed three people in Nottingham last year
Calocane killed 19-year-old student Grace O’Malley-Kumar as she returned from a night out on June 13 2023
Calocane killed 19-year-old student Barnaby Webber as he returned from a night out on June 13 2023
Calocane also killed 65-year-old caretaker Ian Coates. Clinicians ‘minimised or omitted’ key details that would have exposed the serious risk Calocane posed to the public
CCTV from the morning of June 13 2023 shows Calocane walking along a street in Nottingham after he he stabbed Barnaby and GraceÂ
The report by the Care Quality Commission (CQC) comes the day after a damning BBC Panorama documentary revealed a doctor warned three years before the attack that Calocane’s mental illness was so severe he could ‘end up killing someone’.
The care regulator’s review into the Nottinghamshire Healthcare NHS Foundation Trust (NHFT) found risk assessments played down the fact Calocane was refusing to take his medication, was having ongoing symptoms of psychosis and had become increasingly violent towards others.
The CQC also questioned how well the Trust engaged with Calocane’s family, who had raised concerns about his mental state, and how well his discharge was planned.
The victims’ families said today’s report ‘demonstrates gross, systematic failures’ and warned clinicians ‘must bear a heavy burden of responsibility for their failures and poor decision-making’. A statement from the families of Barnaby, Grace and Ian added: ‘Sadly, this is the first of what we expect to be a series of damning reports concerning failures by public bodies in the lead-up to the killings of our loved ones and beyond.
‘We were failed by multiple organisations pre and post June 13, 2023. Along with the Leicestershire and Nottinghamshire police forces, these departments and individual professionals have 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.’
From left to right: (left-right) Dr Sinead O’Malley and Dr Sanjoy Kumar, parents of Grace O’Malley-Kumar, James Coates, son of Ian Coates, and Emma and David Webber, parents of Barnaby Webber. The victims’ families blasted Nottinghamshire and Leicestershire police forces over the contact they had with Calocane before the triple killing
Court sketch of Calocane. The report by the Care Quality Commission (CQC) comes the day after a damning BBC Panorama documentary revealed a doctor warned three years before the attack that Calocane’s mental illness was so severe he could ‘end up killing someone’
The special review of mental health services at the NHFT was ordered by then health secretary Victoria Atkins in January after Calocane was sentenced to an indefinite hospital order.
The CQC said his records make it ‘clear’ he was ‘acutely unwell’ throughout the two years he was under the care of the Trust after being diagnosed with paranoid schizophrenia in 2020. Between May 2020 and February 2022, eight risk assessments were completed for Calocane by the Trust. While some risks were highlighted, the CQC said other assessments ‘minimised or omitted key details’.
Despite his failure to engage with the Trust’s services and the fact he was known to police, he was still discharged into the care of his GP in September 2022.
Chris Dzikiti, interim chief inspector of healthcare at the regulator, said: ‘This review identifies points where poor decision-making, omissions and errors of judgments 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 June 13, 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.’
Among its recommendations, the CQC said the NHFT should review treatment plans for people with schizophrenia regularly and ensure clinical supervision of decisions to detain people under the Mental Health Act.
It also called for NHS England to publish guidance setting out national standards of care for people with complex psychosis and paranoid schizophrenia in the next 12 months.
The handling of the Calocane case prompted a national outcry and led to numerous inquiries into the public bodies involved, including Nottinghamshire Police and Leicestershire Police.
The families said they have had confirmation that a public inquiry will take place after meeting Health Secretary Wes Streeting and Attorney General Richard Hermer. Although the final form of the inquiry ‘is yet to be determined’, they are calling for ‘a statutory, judge-led one’.
Prime Minister Sir Keir Starmer is understood to back the idea, although the Government has not publicly confirmed one will take place.
Mr Streeting said: ‘This report makes for distressing reading, especially for those living with the consequences of their loss in the knowledge that their untimely deaths were avoidable. Action is already underway to address the serious failures identified by the CQC. I want to assure myself and the country that the failures identified in Nottinghamshire are not being repeated elsewhere.’
Marjorie Wallace, founder of mental health charity Sane, said the report was ‘the most damning indictment of the fact that psychiatric services are not in crisis but in complete breakdown’.
The families said they have had confirmation that a public inquiry will take place after meeting Health Secretary Wes Streeting
Brian Dow, of the charity Rethink Mental Illness, said the recommendations published today ‘must be implemented without delay’.
He added: ‘There were multiple opportunities for mental health services to intervene, and it’s shocking to learn of the errors and misjudgements in [Calocane’s] care.’
An NHFT spokesman said: ‘We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out.’
Claire Murdoch, national director for mental health at NHS England, expressed her sympathies to the victims’ families. She added that the health service has already started work to ‘enact all of the CQC’s recommendations’.
