With the publication today of the NHS England commissioned report on the NHS treatment of Valdo Calocane there is renewed urgency for the Public Inquiry promised in July 2024 to begin in earnest.
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.
We welcome the offer to meet with the Government next week to discuss the format and scope of that Inquiry, as well as the identity of the Chair.
The Inquiry needs to be on a statutory basis, with teeth to compel witnesses and documents.
The NHS England report illustrates again why individual organisations and their direct governing bodies cannot be left to investigate their own shortcomings.
In the last 30 years there have been at least 600 independent reports commissioned by the NHS into mental health related deaths. Each of those reports commonly cites system failings and claims that “lessons will be learned”.
Today’s report today demonstrates that those lessons have not been learned.
As reported in the media, the NHS England report that was due to be published contained only summary findings. It was of vital importance that the full report was seen by the public.
That was because the Executive Summary revealed only some of the findings of this investigation.
For weeks, the families have petitioned hard for NHS England to publish the full report. Until yesterday this was steadfastly refused, as the “law of the land”, as they claimed, prevented them from doing so.
It is hugely regrettable that only a front-page story in the Times and intervention from Wes Streeting personally (for which the families are grateful) has ensured that the full report sees the light of day.
This has heaped trauma upon trauma for them.
Without the full report, you wouldn’t know today:
- how frightened health professionals were to visit Valdo Calocane,
- how they withdrew on occasion,
- how they planned their exits, yet at the same time were willing to discharge him from care in the face of very obvious risks of danger.
You wouldn’t know the extent to which Valdo Calocane had insight into his own condition. He got better in hospital, he got worse when he was released. He knew what taking his medication did to him.
It slowed him down, it impaired his studies. He didn’t like needles. He also knew what not taking his medicine did to him. He knew how it made him paranoid, knew how it made him violent.
All of this was known to health professionals, who observed the stockpiling of medication at his home.
Those same health professionals who could have insisted on the administration of long-lasting injectable anti-psychotic medication (also known as depot) prior to release but didn’t do so.
Undoubtedly he was unwell, but he had insight and knowledge. He was not treatment resistant, he resisted treatment.
He was discharged 9 months before these attacks, when he did not show up for an outpatient appointment. He was left to the general public to cope with; the NHS washed its hands of him.
After four periods as an impatient no one joined the dots up. He was discharged effectively as a “ticking time bomb”.
The way the families have been treated by NHS England in the run up to publication of their report is sadly reflective of the families’ struggles since the tragic events of June 2023.
That said, even full publication of the report does not provide proper answers as to what went wrong and why, nor does it ensure any proper accountability. That is because the report focuses on the systemic nature of failings and nothing more.
The families expected much more from NHS England, recognising that true accountability and learning cannot be achieved without recognition of gross individual failings.
Serious concerns
So far these traumatised families have had to endure nine investigations. The first was a rapid review into the actions of the Crown Prosecution Service. It gave them a clean bill of health.
Today’s report gives rise to serious concern for the families that the full facts relating to Valdo Calocane’s non-compliance with medication may not have been put before the Court before his case was dealt with.
Those concerns were first expressed by the families during court proceedings. They were offered a meeting with the CPS only on the morning of the plea hearing, where they expressed concern about the quality of the expert psychiatric evidence.
Publication of this report shows that they have again been proved right with those concerns and that Calocane may not have been treatment resistant, as suggested by the expert evidence.
A report by Nottinghamshire NHS Trust itself conceded multiple failings in the context of 15 other serious assaults carried out by mentally unwell people prematurely discharged from their care during the period from 2019 to 2023.
The families were wrongly excluded from contributing to that report until August 2024, contrary to NHS guidelines. Again, they were simply left on the sidelines.
The families welcome Ifti Majid, the CEO of the Trust, confirming a further investigation into whether anyone should be facing disciplinary action as a result of the latest report.
There are four separate investigations ongoing into the actions of the Nottinghamshire and Leicestershire Police, and two further investigations relating to the unauthorised accessing of information by members of staff at HM Court and Tribunal Service and HM Prison and Probation Service.
It is clear there are major failings across every organisation involved, both before and after the attacks, from those responsible for delivering justice to those tasked with ensuring support and care were provided to the victims, their families and the general public at large.
The families believe that the full extent of these failings will never be understood without a Statutory Inquiry and that proper change will not occur, when failings are blamed on systemic error without full and proper accountability.
These families deserve change in the name of their much adored loved ones.
Nottingham Attacks Statutory Public Inquiry
