CQC publishes final part of special review of mental health services in Nottinghamshire health trust following murders of Grace O’Malley Kumar, Barnaby Webber & Ian Coates

Following the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, former health secretary – and current shadow health secretay – Victoria Atkins MP commissioned the CQC to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT).

Calocane was under the care of NHFT between May 2020 and September 2022.

The review states: “During this period, it is clear that he was acutely unwell.

"He presented with symptoms of psychosis and appeared to have little understanding or acceptance of his condition.

"Issues with him taking his medication were also recorded from early on.

"This review finds that there appear to have been a series of errors, omissions, and misjudgements in his care.”

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 13 June 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.

“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.”

The review found inconsistent approaches to risk assessment and risk assessments 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.

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

The evidence over the course of Calocane’s illness and contact with services and police indicated beyond any real doubt that Calocane would relapse into ‘distressing symptoms and potentially aggressive behaviour’.

Discharging Calocane back to his GP – due to his lack of engagement with mental health services – did not adequately consider or mitigate the risks of relapse.

The review also found that if the decision had been made to treat Calocane under section 3 of the Mental Health Act (MHA) 1983 on his fourth admission to hospital further options would have been available for his care and treatment in the community.

Given Calocane’s known medical history at this point – a diagnosis of paranoid schizophrenia, prior indications that he was not taking his medication, and evidence that he could present a risk to others when relapsing – it could have been possible to detain him under section 3 of the Mental Health Act.

This 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 states: “While we did not find any widespread patterns within our 10 benchmarking cases, many of the issues we have identified are consistent with the problems we found in our wider review of the quality of care and safety of services at NHFT.

“The scope of this review was limited to the period of time that Calocane was under the care of NHFT.

"However, these findings should provide additional evidence for NHS England’s more detailed scrutiny of VC’s interaction with mental health services through their forthcoming independent homicide review.”

Recommendations for Nottinghamshire Healthcare NHS Foundation Trust (NHFT) include requirements for the trust to review treatment plans for people with schizophrenia regularly to ensure treatment is in line with national guidelines.

Ensure clinical supervision of decisions to detain people under section 2 and 3 of the Mental Health Act and regularly carry out audits of these people’s records and repot these to the NHFT board.

Ensure that, in line with national guidance and best practice, staff are aware of the importance of involving and engaging patients’ families and carers in all aspects of care and treatment.

Ensure robust discharge policy and processes that consider the circumstances surrounding discharge and whether discharge is appropriate.

Recommendations for NHS England include providing, within the next 12 months, evidence-based guidance setting out the national standards for high quality, safe care for people with complex psychosis and paranoid schizophrenia.

Ensuring that within three months of the publication of the national standards for high quality, safe care for people with complex psychosis and paranoid schizophrenia, every provider and commissioner develops and delivers an action plan to achieve these.

Ensuring, through provider boards, the delivery of the actions within 12 months of the standards being published.

The review also recommends that NHS England, together with the Royal College of Psychiatrists reviews and strengthens the guidance to clinicians relating to medicines management in a community setting.