A report which has highlighted failings in the care Nottingham triple killer Valdo Calocane received should be “a watershed moment”, a mental health charity boss has warned.
Calocane was sentenced to an indefinite hospital order after killing students Barnaby Webber and Grace O’Malley-Kumar, both 19, and 65-year-old caretaker Ian Coates before attempting to kill three other people in a spate of attacks in Nottingham in June 2023.
He had been diagnosed with paranoid schizophrenia and the independent review into his care detailed two years of violent and disturbing behaviour prior to the attacks.
A number of criticisms of NHS services were highlighted in the report, including that Calocane’s risk “was not fully understood, managed, documented or communicated”.
Marjorie Wallace, chief executive of mental health charity Sane, said the publication of the review on Wednesday “should act as a watershed moment revealing the truth and honouring the needs of the families of victims of homicides by people with mental illness or disorder”.
“We have been involved in and supported the families of both victims and perpetrators in over one hundred such inquiries in the last 30 years,” Ms Wallace said.
“Today’s findings expose the same flaws and fault lines that have resulted in tragedies, yet little seems to have changed: basic failings of communication, inadequacies in assessing risk, and in over half the cases we analysed, not heeding the warnings of families or those close to the patient. As in this case, it is too often cited that it was the individual’s choice to ‘disengage with services’ as a reason for the lack of effective follow-up and care.
“Why does it seem that however often these failures are repeated, so little seems to have been done to prevent unnecessary loss of life, the grief which rips through families, and headlines which further stigmatise mentally ill people, the majority of whom are never violent?”
NHS England commissioned Theemis Consulting to carry out the independent investigation into the treatment and care Calocane received from NHS services.
It detailed four hospital admissions between 2020 and 2022 and multiple contacts with community teams before he was discharged to his GP because of a lack of interaction with mental health services.
Investigators found that “the offer of care and treatment available for VC (Valdo Calocane) was not always sufficient to meet his needs” and this was “not unique” to his case.
Health officials have admitted it is “clear the system got it wrong”.
Brian Dow, deputy chief executive of the charity Rethink Mental Illness, said it is “essential” that the report’s key recommendations are implemented nationwide, including ensuring that people are not discharged for failing to attend appointments.
“Our thoughts today remain with the families of Grace, Barnaby and Ian, whose tragic loss reminds us of collective effort needed to prevent history repeating itself,” Mr Dow said.
“This report underlines the imperative of ensuring mental health services have the resources they need to provide safe and timely care.
“As the NHS grapples with long waiting lists and faces difficult decisions on priorities as a result of high demand, the Government must provide support to ensure the implementation of these recommendations is both prioritised and funded, including the necessary investment to deliver Mental Health Act reform. Trusts must be held accountable to ensure patient safety is prioritised so people get the essential treatment they need, to help prevent future avoidable loss of life.”
