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The NHS has published the full independent investigation into the care and treatment of Nottingham triple killer Valdo Calocane in the months leading up to the events of 13 June, 2023.
Calocane, who had been diagnosed with paranoid schizophrenia, was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O’Malley-Kumar, and 65-year-old caretaker Ian Coates, and attempting to kill three other people, in a spate of attacks in Nottingham.
The publication follows an outcry by all three families following reports that the full version was going to be kept confidential due to “data protection legislation relating to patient information”. A spokesman for the families of the victims said they believed it was in the public interest for the full details to be published.
The NHS said it had taken the decision to publish the report in full “in line with the wishes of the families and given the level of detail already in the public domain”.
After his initial arrest on 24 May, 2020 at the age of 28 for criminal damage to a neighbour’s flat, Calocane entered into a criminal justice system which had been failing mentally ill people for over a decade.
A Criminal Justice Joint Inspection (CJJI) body report in 2021 concluded that thousands of people with a mental illness are entering the criminal justice system each year with their needs being missed at every stage. It also described a “broken system” for the sharing of information between agencies, with incomplete/inaccurate records. The pandemic had worsened an already bad situation.
The report outlined “unacceptable delays” in psychiatric reports for courts and in transferring extremely unwell prisoners into secure mental health hospital beds for treatment. Inspectors labelled the findings “disappointing” and said too little progress had been made since the last review in 2009.
Following his initial arrest, Calocane was assessed by a nurse from the Mental Health Liaison and Diversion Service in Bridewell Police Custody suite. Officers noted he was experiencing a first episode of psychosis brought on by sleep deprivation and social stressors, namely course work and an upcoming exam.
Calocane acknowledged that he was unwell and that he needed help, but he was not detained under the Mental Health Act. Instead, he was referred to the City Crisis Team and prescribed two medications, a sleeping pill and an antipsychotic medication that helps to manage symptoms of mental health conditions such as schizophrenia. The latter was not given before he was released from the custody suite.
Calocane was rearrested for a similar offence shortly after he returned home on the same day. He was detained in hospital the following day under section 2 of the Mental Health Act, following assessment at the police station.
Missed opportunities
The report detailed two years of violent and disturbing behaviour by Calocane – including frightening a neighbour so much she jumped out of a first floor window, leading to a serious back injury, punching a police officer in the face and holding his flatmates “hostage”.
After a six-week stay in hospital, Calocane was discharged into the community the day after a risk assessment was completed on 21 October, 2021. His risk was assessed to be low in all areas. He was marked as a medium risk for historical non-compliance with medication, and historically high risk for self-neglect, violent, aggressive, intimidating behaviour and for absconding or escape.
Under “other risk factors” it is recorded that Calocane “may be able to mask symptoms to get discharged” and that “circumstances of current admission has been serious and violent”.
The independent review highlighted how, in one assessment carried out by mental health workers, the risk to staff was “managed” by making arrangements for workers not to visit Calocane’s home alone, but a plan for the “hazards” if he came off his medication and disengaged with mental health services was not developed.
The report also highlighted how Calocane’s family was concerned his second hospital admission was only two weeks long – despite being detained under the Mental Health Act allowing for an initial treatment period of up to six months. Such a short stay was a “missed opportunity to fully understand VC [Calocane]’s diagnosis, risk and to get to grips with a treatment plan”.
Calocane was not forced to have long-lasting antipsychotic medication because he did not like needles, the 302-page report has revealed.
Repeated requests were made for Calocane to be put on antipsychotic depot medication – a type of treatment which releases slowly over time, meaning patients need to administer medications less frequently – with the report highlighting evidence that he did not consistently take his medication when he was out of hospital.
The report said: “The inpatient teams involved in VC’s care were trying to treat VC in the least restrictive way and took on board VC’s reasons for not wanting to take depot medication which included him not liking needles.”
From left to right, Valdo Calocane’s victims Ian Coates, Barnaby Webber and Grace O’Malley-Kumar (Photo: Nottinghamshire Police/PA Wire)Calocane was detained in hospital, including a private unit, on four occasions between May 2020 and January 2022, by which time NHS staff knew he failed to agree to take his medication after being released back into the community. He also had multiple contacts with community teams before he was discharged to his GP because of a lack of interaction with mental health services.
While he was detained in hospital, requests were made for Calocane to be put on a community treatment order (CTO), which can include a condition to comply with depot medication, with the option of recall to hospital if he was non-compliant. No CTO was made.
The report added: “A theme running through VC’s clinical records is that he did not consider himself to have a mental health condition. His insight into his condition did not appear to increase and therefore his understanding of the importance of medication in his case never appeared to be understood by VC.”
It said this “may have meant that he lacked full capacity” to make decisions about his care and treatments.
Care plan ‘cut and paste’ job
The report raised concerns over Calocane’s care plans, including one from July 2020 which was created before he was discharged from hospital for the second time.
“Most of the document is cut and pasted from the previous care plan completed at the first admission… no further risk assessments were completed during his inpatient stay or upon discharge,” according to the report.
The fact that care plans and risk assessments were duplicated with few additions or modifications “suggests that completing such documentation was perceived necessary for record keeping rather than a meaningful, active opportunity to review hazards, risks and effectiveness of controls across different care settings”, the report concluded.
Each hospital admission was seen in isolation with a “lack of cumulative perspective” over how Calocane appeared to engage in hospital but not when he was at home.
Risk assessments were only made based on the current team responsible for Calocane based on a specific context of care, rather than gaining perspectives from other medics and clinicians that would have given a broader assessment.
Calocane’s community care team told investigators that he knew the way to be discharged from hospital was simply to “abide by the rules, making it very difficult for him to be kept on a [mental health] section”.
The report added: “This suggests clinicians making decisions on discharge and level of oversight required may not have taken a longer-term view and considered the full picture of the risk VC may pose to himself and others.”
The responsible consultant during Calocane’s fourth admission said he did not have access to Calocane’s notes from the private hospital where he was detained in October 2021. They also said there was “conflicting information throughout” Calocane’s medical file regarding his schizophrenia diagnosis.
High caseload
When Calocane was discharged to GP services in September 2022, his care co-ordinator had an average caseload of 20 service users – five above the limit advised by leading psychiatrists. This “may have impacted their ability to carry out all expected tasks”, the report found.
As Calocane’s care co-ordinator was the only male within the team he often took on cases where the service user had a history of violence or sexually inappropriate behaviour. “His caseload was therefore often not only high but also complex,” the report said.
The care co-ordinator told investigators: “If I’d have had just [Calocane], as an example, an unrealistic situation, I could have been more assertive, shall we say, in my monitoring.”
Other patients cared for by Nottinghamshire Healthcare NHS Foundation Trust, the mental health trust involved with Calocane’s treatment, also committed “extremely serious” acts of violence including stabbings, between 2019 and 2023, investigators found.
“Between 2019 and 2023 there were 15 incidents of patients either under the current care of the trust or who had been discharged from the trust, perpetrating serious violence towards members of the community,” the report said.
While some of the victims were known to perpetrators, in some incidents the victims “appeared to be strangers”.
“The level of violence in the incidents was extremely serious and in three cases resulted in fatalities,” the report said. “The majority of these incidents involved stabbings.
“Most notably, in February 2023 there was an incident where a patient in receipt of mental health services from Nottingham Healthcare NHS Trust was arrested for stabbing five people over the course of a weekend.”
The review team looked to see if these incidents had been discussed by the trust board but found “limited evidence regarding discussions of these particular serious incidents or subsequent investigations”.
‘The system got it wrong’
Investigators said NHS England should examine the “dissonance between what people think should be happening, for example, care described in national policies and guidance, compared to what is actually being delivered in some services”. Recommendations have also been set out for the trust, including enhancing family engagement, care planning and information sharing.
Dr Jessica Sokolov, regional medical director at NHS England (the Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating. This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”
Claire Murdoch, NHS England’s national mental health director, said: “It is clear there were failings in the care provided to Valdo Calocane which is why the trust responsible was placed in our highest oversight and support programme, which has seen them overhaul their risk assessment processes.
“Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police. And we’ve instructed trusts not to discharge people if they do not attend appointments.
“We are determined to do everything possible to transform how the NHS treats people with a serious mental illness who often require long-term support.”
Calocane was sentenced to an indefinite hospital order in January 2024 after pleading guilty to three counts of manslaughter on the basis of diminished responsibility, and three counts of attempted murder.
However, his victims’ families said the report shows Calocane may have been “spared prison on the basis of incomplete evidence”.
They said the independent review showed the killer was “responsible for his actions and was allowed to make these decisions by his treating teams”, and added that “when he came to court, we were told a very different story”.
In a statement released after the report’s publication, the families of the three murder victims said: “This is now a matter which must now be dealt with as a matter of urgency. This latest report suggests the court may not have been given the full picture, potentially leading to an injustice of the highest order.
“He may have been spared prison on the basis of incomplete evidence. We have now seen report after report highlighting the failings of police forces and the health services.
“These repeated failings led to this man being in the community and able to take our loved ones from us, and now we see evidence that he may have been sentenced in court on the wrong basis.”
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The families called for a statutory public inquiry into the care of people sectioned with mental illness across the country.
Their statement continued: “The picture presented to the court with regards to his mental capacity was very different to the one in the notes of those treating him.
“This was a man who actively avoided his medication and treatment, knowing when he didn’t take his medication that he would become paranoid and violent. He was responsible for his actions and was allowed to make these decisions by his treating teams, but yet when he came to court, we were told a very different story.
“The court, the general public and us as families were all potentially misled, and this needs full scrutiny now, as we face the prospect of seeing him walk back into society again if he responds well to treatment in hospital, which again this report demonstrates he has always done in the past.
“If we don’t act to make real change now, change which can prevent these horrific events in our society, then we will remain in the same situation we have for decades, reacting to tragic, avoidable loss of life, and making false promises that it won’t happen again. There are similar incidents week after week and it has to stop.
“That is why the full statutory inquiry must now happen as soon as possible, not only examining what happened to our loved ones, but also the wider failings in the care, treatment and sectioning of those with mental illnesses, as we cannot keep allowing innocent people and communities to be left at risk.”
Ifti Majid, chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “We apologise unreservedly for the opportunities we missed in the care of Valdo Calocane and accept the Themis report in its entirety including its findings and recommendations.
“We are making clear progress with a trust-wide plan, which is already delivering key improvements in areas such as risk assessment and discharge processes. We are also improving the way we listen and engage with patients, families, our colleagues, and local partners – to make sure concerns are acted on as quickly as possible.
“I know that this will never undo the catastrophic damage caused by these events – when three lives were tragically lost, and others changed irreparably.
“But we will do everything possible to prevent similar incidents happening again and remain totally committed to improving services for the communities we serve.”
the nhs and police failings that led to valdo calocane rsquo s nottingham
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