The families of the three victims of the 2023 Nottingham attacks say a Statutory Public Inquiry must now examine and address not only ‘an appalling picture of failings’ in mental health services – but also new questions which have been raised over the evidence which led to killer Valdo Calocane being spared a prison sentence.
They say the findings of a new report on the NHS treatment of Calocane, who brutally killed their loved ones, requires the promised Judge-led Inquiry to be held as soon as possible – with statutory powers including to compel people to appear, give evidence and produce documents.
The report, carried out by Theemis Consulting, underlines repeated failures by multiple Government agencies which led to the tragic deaths of Grace O’Malley-Kumar, Barnaby Webber and Ian Coates.
It also raises new questions about psychiatric evidence presented to the Criminal Court which resulted in their killer receiving a Hospital Order.
Calocane stabbed and killed Barnaby Webber and Grace O’Malley-Kumar, both 19-years-old, as they were walking back to their student accommodation at 4 am on June 13, 2023.
He then went on to stab and kill Ian Coates, a 65-year-old caretaker; stealing Mr Coates’ van before driving it into three other people, causing serious injury.
He was charged with three counts of murder and three counts of attempted murder.
Psychiatrists said he had ‘treatment-resistant paranoid schizophrenia’, which led to him committing the offences, impairing his ability to exercise self-control. He pleaded not guilty to three counts of murder, but guilty to manslaughter on the basis of diminished responsibility. He also pleaded guilty to three counts of attempted murder.
He was made the subject of a Hospital Order in January 2024, rather than having to serve a life sentence in prison as part of a Hybrid Order.
The families say this new report paints an appalling picture of failings across many Government agencies and raises questions about the sentence he received.
Investigation covered three-year period under mental health services
The investigation, carried out by Theemis Consulting, which specialises in systematic investigations and reviews, was commissioned by NHS England. Theemis were asked to compile a full chronology of Calocane’s contact with mental health services and care providers and determine if his care needs were fully understood and best managed.
The investigation covered the period from his first contact with the mental health service in May 2020 to June 13, 2023, when he carried out the attacks.
Over the three years Calocane was supervised by mental health services and spent four periods detained in hospital. On the first occasion he was admitted he was given medication and was soon considered fit to release. On each subsequent occasion that he was admitted to hospital he had not been taking his medication.
Calocane appeared to recover very quickly from each psychotic episode when he was treated as an inpatient when he was receiving medication. He refused Depot medication, a slow releasing, long-acting medication, often used to manage symptoms of psychosis.
He told his inpatient care team that he didn’t want it because he didn’t like needles – something they accepted. His community psychiatric worker made repeated requests for him to be given Depot medication because he was non-compliant with oral medication in the community, but her advice was not followed.
He was involved in numerous incidents of violence of escalating seriousness when in the community; including assaulting police officers who had visited his flat at a time when he had not been taking his medication.
When he assaulted officers, it took significant efforts to get Calocane under control, requiring the use of a Taser, amongst other things.
He was last placed in community care in February 2022. Notes reveal that he was transferred from his longstanding care coordinator due to concerns about the risk he posed. It was felt necessary that he should be cared for by two members of staff.
Despite detaining him for being of high risk of violence and aggression, he was documented in treatment notes as being a patient of medium risk of harm.
He was last seen by mental health staff on July 4, 2022. Over the following two months he did not collect medication, or answer calls. He gave the wrong address to a new care coordinator, and even lied about being abroad when, in fact, he was in Nottingham.
He was discharged from community care on September 23, 2022, because of his lack of co-operation with mental health services. That was done without him having a face to face assessment and despite the risk of violence from him that required mental health workers to take precautions when seeing him. He had no contact with mental health services again between the date of his discharge, on 22 September 2022, and the carrying out of his attacks in June 2023.
By cruel coincidence, Calocane was discharged from NHS care on the very day that a warrant was issued for his arrest for failing to attend court to answer charges relating to his very serious assault of police officers.
Shockingly, that warrant was never executed by the police and he remained at large until he killed Grace, Barnaby and Ian, despite police being called out to another assault by him in Leicestershire in the interim.
Not surprisingly, the Theemis Investigation concluded that ‘discharge in the absence of a face-to-face meeting with a patient creates the potential for greater risk from the person using mental health services to others.’
The report also found that ‘limitations in sharing information’ ‘impacted on the ability of those caring for Calocane to fully understand his needs’, and said that at times, healthcare professionals were making decisions without a full understanding of information held by all organisations involved with him.
It added that staff involved in his care and treatment ‘appeared to view each admission in isolation’.
It concluded:
We found that the offer of care and treatment available for Valdo Calocane was not always sufficient to meet his needs. This included the service having difficulty in providing Valdo Calocane with support when he did not wish or was unable to maintain contact with services.
From conversations with others as part of this review, we believe that the experience of Valdo Calocane was not unique in how some people with severe and enduring mental illness are supported by mental health services.
Valdo Calocane’s Prosecution
The new report provides a basis for substantial concern about the evidence given by psychiatrists which led to Calocane being the subject of a Hospital Order for his crimes.
Psychiatrists gave evidence that his failure to take medication was due to his mental disease rather than a rational choice.
However, the new report reveals that:
- He was repeatedly given autonomy by treating teams to make decisions over his own medication; despite the fact he repeatedly failed to take his medication in the community resulting in him relapsing and being re-admitted to hospital.
- On numerous occasions he refused Depot treatment; long-acting medication which is injected to help treat symptoms and improve compliance with treatment.
- He told those treating him that he felt medication slows the mind and that he was concerned it was impacting his ability to study for exams.
- He accepted that not taking medication made him more paranoid and could lead to relapse. He accepted that he could be violent when he relapsed.
- Community-based staff believed he was aware that he needed to abide by the rules when in hospital, as he knew it was the only way to get back out into the community.
- When he was discharged from hospital section, the clinical team noted that he understood the importance of medication.
The NHSE report provides ample evidence that, on the face of it, Calocane was not treatment resistant. In fact, he was well, stable and presented little or no risk to others when receiving treatment as an inpatient:
- He was deemed to have insight and capacity each time he was discharged from treatment whilst detained under section.
- Yet, he chose not to take his medication in the community and chose to disengage with services.
- He was treatment resistive and his illness was not treatment resistant.
If all of that had been presented to the criminal court, he may have been sentenced to a hybrid order whereby he would have received treatment in secure hospital, but then be moved to prison to serve the remainder of his sentence once recovered. He could then only be released from prison when he was no longer a risk to the public.
The families maintain there must be both organisational and individual accountability for the failures made across the NHS, two Police forces and the criminal justice process from May 2020 up to now.
They also wish to have the medical experts in the criminal case give evidence to the Inquiry, and feel this report fails to hold to account NHS consultants who ‘provided an unacceptably poor level of care to protect society.’
Failure to Learn Lessons
This report is not the first report commissioned to investigate mental health related homicide.
Figures from hundredfamilies.org demonstrate that there have been at least 2328 mental health related homicides in the UK since 1993. There have been 963 reviews of such tragedies including more than 600 independent investigation reports commissioned by the NHS.
Despite the repeated investigations of these tragedies, there has clearly been a failure to achieve meaningful change in the systems responsible for patients impacted by mental health issues. Questions need to be answered about why successive Governments have failed to learn lessons.
The NHS has been given six months to consider Theemis’s recommendations. There is currently nothing to compel the NHS to implement them nor is there any mechanism to hold the NHS to account should they fail to do so.
It is the first duty of the Government to keep its citizens safe – it is now clear that the previous Government failed Grace, Barnaby and Ian in that duty.
There are grave questions to be answered about how multiple organisations failed to respond to the risk he posed; allowing him to roam the streets and kill three innocent people.
What happened cannot be allowed to happen to any other families.
Family Statements
The families say:
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.
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.
Statutory Public Inquiry ‘with teeth and full power’ now needed
Neil Hudgell, of Hudgell Solicitors, who represents the families, says the latest findings demonstrate the need for the Statutory Public Inquiry to examine ‘widespread failing in mental health services which pose a risk to all in society’.
“The details within this report published today make horrific reading for the families of those killed by Calocane, but also for wider society too,” he said.
There are so many failings across multiple agencies, from the management of his mental health to the risk this man posed to the public and how the police went about containing that risk.
Then, when it came to court and sentencing, the man presented to the court was a very different man to the one painted in his care plans and assessments.
He was considered a risk to care coordinators, yet he was given autonomy to make decisions over his own medication, which he repeatedly chose not to take, and was allowed to remain in the community with no contact with mental health services.
The question to be asked is how often, across the country, is this happening today, where people suffering with mental illness are released back into the community, not engaging with the support they need, and are posing a real risk of harm to themselves and others. Widespread failing in mental health services pose a risk to all in society.
The Statutory Public Inquiry must have real teeth and compel people to give evidence. We want to see the full details of the psychiatrist reports which influenced the sentencing in court in this case, but also we want wider scrutiny of mental health services.
Failings led to each of these families losing their loved ones. They are not just fighting for justice for them, but for accountability, improved mental health care, and improved safety for all in society. This needs to be made a Government priority today. Change will only occur with individual accountability alongside continued acceptance of systemic failure.
Nottingham Attacks Statutory Public Inquiry
