'Clear failings' found in NHS care of triple killer

A major investigation report into the Nottingham triple killing has revealed multiple failures in the treatment of Valdo Calocane, who suffered from paranoid schizophrenia, by the UK's National Health Service (NHS), indicating that "the system failed." These failures highlight the critical need for improvements in mental healthcare services.

On June 13, 2023, Valdo Calocane fatally stabbed 19-year-old students Barnaby Webber and Grace O'Malley-Kumar, as well as 65-year-old school caretaker Ian Coates. In January 2024, Calocane was sentenced to hospital detention. The case has triggered a series of investigations, including a mental health homicide review commissioned by NHS England. The findings from these investigations are expected to bring significant changes to mental health protocols.

Victims' families have stated that the report's findings, released on Wednesday, indicate the need for a judge-led public inquiry, which Prime Minister Keir Starmer has previously pledged to hold "as soon as possible." The government has responded that it remains committed to investigating the attacks and is currently determining the scope of the inquiry. The NHS has stated that it has decided to fully publish the report, in line with the wishes of the families and taking into account the "detailed information already in the public domain."

The independent review by Themis Consulting investigated the treatment of Calocane by Nottinghamshire Healthcare NHS Foundation Trust prior to the murders, as well as the interactions between the NHS and other agencies involved in his care. Key findings of the report include: the risks posed by Calocane were "not adequately understood, managed, recorded or communicated"; opportunities were missed to take more decisive action in Calocane's care; the views of Calocane's family were "not effectively considered to support dynamic risk assessment" during his treatment; and between 2019 and 2023, 15 incidents of "serious violence" were also perpetrated by other patients under the care of the same trust, some of whom had been discharged. Furthermore, Calocane had no contact with mental health services or his GP for approximately nine months prior to the murders.

Dr. Jessica Sokolov, Regional Medical Director for NHS England (Midlands), stated: "It is clear that the system, including the NHS, failed, and the consequences of this have been devastating. This is unacceptable, and on behalf of the NHS and the organisations involved in providing care to Valdo Calocane, I offer an unreserved apology to the families of the victims." Claire Murdoch, National Mental Health Director for NHS England, added: "Nationally, we have asked every mental health trust to review these findings and to develop action plans to set out how they treat and engage with people living with severe mental illness, including how they work with other agencies such as the police. We have instructed trusts that people should not be discharged if they do not attend appointments."

Marjorie Wallace, Chief Executive of the mental health charity Sane, stated that the publication of the review "should be a watershed moment, revealing the truth and respecting the needs of families bereaved by homicides committed by people with mental illnesses or disorders." Calocane's family said in a statement: "We again express our deep sorrow at the horrific tragedy and the enormous pain caused to so many by the acts of Valdo. To all the victims, their families and friends, we are truly sorry." They added that the mental healthcare system is in crisis and requires immediate government intervention.

Ifti Majid, Chief Executive of Nottinghamshire Healthcare NHS Foundation Trust, added: "We offer an unreserved apology for the missed opportunities in the care of Valdo Calocane and fully accept Themis' report, including its findings and recommendations. We are developing a whole-trust plan which has already seen key improvements in areas such as risk assessment and discharge processes." The health inquiries into the case could have far-reaching implications. The report calls for a national debate on how to manage individuals like Calocane and provides policymakers with ample food for thought to propose further answers.