Failures of health bodies ‘raised but not acted on’ before Nottingham attacks

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Grace O'Malley-Kumar, Barnaby Webber, both 19, and Ian Coates, 65, died in the June 2023 attacks.

By Joe Locker, Local Democracy Reporter

Failures by various health organisations had been “raised for years” and not acted on before the Nottingham attacks, a city councillor overseeing scrutiny of health services has said.

Students Barnaby Webber and Grace O’Malley-Kumar, both 19, and Ian Coates, 65, were fatally stabbed by Valdo Calocane, who has paranoid schizophrenia, on June 13, 2023.

An independent review into his NHS treatment and care, published on Wednesday (February 5), revealed the “system got it wrong” and identified a raft of errors, including bad communication, missed opportunities and families not being listened to.

Theemis Consulting’s review looked into Calocane’s treatment under Nottinghamshire Healthcare NHS Foundation Trust before the killings, as well as oversight by other involved agencies.

These include the Care Quality Commission (CQC), which regulates and inspects health and social care services, as well as the Nottingham and Nottinghamshire Integrated Care Board (ICB), which commissions services.

Nottingham City Council’s health scrutiny committee chair, Cllr Georgia Power (Lab), told the Local Democracy Reporting Service she – and others – had been raising problems with the various bodies “for years” before the tragedy.

“Clearly there are failings in the trust’s ability to listen to patients and families, but that is all recognised,” she said.

“But it is not just the trust that has failed. We wrote to [the CQC] first years ago, and most recently about a case in August. They have never responded.

“Are the services that are being commissioned meeting the needs of people? I don’t think they are. But also are the services being commissioned actually being delivered? We have raised with the ICB multiple times where we think there is evidence that is not the case and they have not been addressed.

“There needs to be the same sort of scrutiny there has been, rightly, on the trust, on all the other agencies that have failed. I don’t think we have seen that. The Government needs to lead on that.

“There needs to be some assurance from Government this will never be able to happen again.

“This cannot just be done by the trust. If the systems like the CQC, monitoring by the ICB, if they all worked, this would not have happened because the failures would have been recognised.

“It had been raised with all of the agencies which should have stepped in, and they haven’t. If they aren’t going to do it, what mechanism is the Government going to put in to ensure there is a route to have concerns heard?”

Nottingham’s Labour MPs Nadia Whittome, Lilian Greenwood and Alex Norris, have also issued a joint statement stating they will continue to “hold the NHS locally to account”.

The 302-page report, released on Wednesday, made 27 key findings about Calocane’s care and the system that organised it.

There are two areas of recommendations for national change and ten for Nottinghamshire Healthcare Foundation Trust (NHFT).

NHS England made the decision to publish the report in full, after the victims’ families called for it to be made public.

The families of Barnaby Webber, Grace O’Malley Kumar and Ian Coates held a London press conference on Wednesday following the release of the report into the killings.

Amanda Sullivan, Chief Executive of NHS Nottingham and Nottinghamshire Integrated Care Board (ICB) says the recommendations from the report are “fully accepted”, and says it has developed an action plan in response.

The ICB also holds regular ‘Safe Now’ meetings with the trust and uses shared reporting and metrics to assess progress against the more immediate safety challenges.

“We are committed to safe and high-quality services for our communities and we will continue to provide support and challenge to Nottinghamshire Healthcare NHS Foundation Trust to ensure sustained improvements in the delivery of safe services,” she added.

The CQC said it had undertaken 11 inspections of mental health services at the trust since February 2020, and that it had not been rated above ‘Requires Improvement’ for the past five years.

Inspections in 2019 and 2022 found breaches that led to monitoring, oversight and engagement, and the CQC’s own report into the Calocane’s care, published in August last year, revealed “a series of errors, omissions and misjudgements” by mental health services.

NHS England says it has placed the trust into the highest level of national oversight and an experienced improvement director is in post to manage the trust’s progress, with support from NHS England.

Cllr Georgia Power

Meanwhile, the Department for Health and Social and Social Care (DHSC) says it has committed to establishing an inquiry into the Nottingham attacks, and work is ongoing to establish the exact scope of it.

Health Secretary Wes Streeting (Lab) added: “We have worked closely with NHS England to ensure the publication of this report in full.

“The findings will help to support an inquiry into this attack and we’ll set out the next steps as this develops.

“It’s clear there were failings in how the care provided to Valdo Calocane was managed at every level, which is why I’ve personally called for all the recommendations made in the CQC report to be implemented across the country.

“I want to see the recommendations from this new report implemented as soon as possible and I will be keeping track of progress and performance to make sure that they are.”

Calocane was given a diagnosis of paranoid schizophrenia in July 2020 and, between May 2020 and February 2022, he had six mental health assessments, which led to four hospital detentions.

A warrant had then been issued for his arrest in September 2022, ten months before the attacks, for an assault on an emergency worker.

Following the June 2023 attacks, Calocane was sentenced to an indefinite secure hospital order in January 2024.

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