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 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”.
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.
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 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
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.
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.
Calocane was not forced to have long-lasting antipsychotic medication because he did not like needles, the 302-page report has revealed.
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)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.
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
“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.
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.
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 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
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.
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.
While some of the victims were known to perpetrators, in some incidents the victims “appeared to be strangers”.
“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 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.
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.
“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.”
However, his victims’ families said the report shows Calocane may have been “spared prison on the basis of incomplete evidence”.
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.
“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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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.
“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.
“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.”
“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.
“But we will do everything possible to prevent similar incidents happening again and remain totally committed to improving services for the communities we serve.”
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