CQC review finds ‘series of errors, omissions, and misjudgements’ in mental health care of Nottingham killer Valdo Calocane by Nottinghamshire Healthcare NHS Foundation Trust

A CQC review into an NHS trust’s mental health services has found errors in the care given to Nottingham killer Valdo Calocane prior to the attacks.

Valdo Calocane pleaded guilty to manslaughter and was convicted in January 2024 of the killings of Ian Coates, Grace O’Malley-Kumar, and Barnaby Webber during an attack in Nottingham on June 13, 2023, and was sentenced to an indefinite period in a high-security medical facility.

Calocane, who was diagnosed as paranoid schizophrenic, was under the care of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) between May 2020 and September 2022, and the CQC report has stated that the risk he presented to the public was “not managed well” and that “opportunities to mitigate that risk were missed”.

Victoria Atkins MP, former Secretary of State for Health and Social Care, commissioned the CQC to carry out a rapid review of NHFT under Section 48 of the Health and Social Care Act 2008.

The final part of the review, published on Monday (August 13), is a rapid review of the available evidence related to the care of Calocane during the period he was under the care of NHFT, alongside a small number of other cases for benchmarking purposes, to determine whether this evidence indicates wider patient safety concerns or systemic issues with the provision of mental health services in Nottinghamshire.

During the period Calocane was under the trust’s care, the review found it clear that he was acutely unwell and presented with symptoms of psychosis, appearing to have little understanding or acceptance of his condition, and that issues with him taking his medication were recorded early on.

The review found that there appear to have been a series of errors, omissions, and misjudgements in his care, including risk assessments which minimised or omitted key details and did not make explicit the serious nature of the risk Calocane posed to himself and others based on previous behaviour.

It also showed that Calocane’s family contacted NHFT to raise concerns on a number of occasions, but the information they provided was not consistently acted on.

The review also highlighted the decision to discharge Calocane back to his GP in September 2022 due to his lack of engagement with mental health services, as the evidence over the course of Calocane’s illness and contact with services and police indicated “beyond any real doubt” that he would relapse into distressing symptoms and potentially aggressive behaviour.

Given Calocane’s known medical history and evidence that he could present a risk to others when relapsing, the review determined it could have been possible to detain him under Section Three of the Mental Health Act (MHA) 1983, which gives healthcare professionals the ability to administer depot (longer-lasting medication administered via injection) medicine against the individual’s will, or to consider placing the individual on a community treatment order.

The review also found that if the decision had been made to treat Calocane under Section Three of the Act on his fourth admission to hospital, further options would have been available for his care and treatment in the community.

Section Two is usually used for people who are not known to mental health services, or have not been assessed in hospital before, but can also be used in cases where the individual is known to services but has not been assessed for a considerable time.

Chris Dzikiti, CQC’s interim chief inspector of healthcare, said: “This review identifies points where poor decision-making, omissions and errors of judgements 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.”

The CQC’s review was to consider whether the evidence gathered from Calocane’s care records indicated wider patient safety concerns or systemic issues in Nottinghamshire.

While it did not find any widespread patterns within the ten benchmarking cases, many of the issues it identified are consistent with the problems it found in the wider review of the quality of care and safety of services at NHFT — an earlier part of the special review, alongside an assessment of progress made at Rampton Hospital, which was published in March 2024.

The scope of the review was limited to the period of time that Calocane was under the care of NHFT. The CQC stated the findings should provide additional evidence for NHS England’s more detailed scrutiny of Calocane’s interaction with mental health services through their forthcoming independent homicide review.

The final part of the review made a number of recommendations, which are to be followed in conjunction with the earlier recommendations.

Recommendations for Nottinghamshire Healthcare NHS Foundation Trust include requirements for the trust to review treatment plans for people with schizophrenia regularly to ensure treatment is in line with national guidelines, and ensure clinical supervision of decisions to detain people under section two and three of the Mental Health Act.

Chris Dzikiti added: “For the individuals involved, their families and loved ones, the damage cannot be undone. However, there is action that can, and must, be taken to better support people with serious mental health issues and provide better protection for the public in the future.

“We have made clear recommendations to improve oversight and treatment of people with serious mental health issues at both a provider and a national level. Wider national action is also needed to tackle systemic issues in community mental health — including a shortage of mental health staff and lack of integration between mental health services and other healthcare, social care and support services — so that people get the right care, treatment and support when and where they need it.”