‘The system got it wrong’: Nottingham attacks killer was able to miss vital medication too easily, report says

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Valdo Calocane, 32, fatally stabbed three people on the morning of June 13.

An investigation has found Nottingham attacks killer Valdo Calocane was able to skip vital mental health medication too easily and decisions weren’t shared properly across those responsible for this care.

The long-awaited report, published today, reviews the NHS care and treatment provided to Valdo Calocane by Nottinghamshire Healthcare NHS Foundation Trust and other services before he fatally stabbed three people on June 13 2023.

It identifies a catalogue of failings, and makes a series of recommendations for Nottinghamshire Healthcare NHS Foundation Trust and NHS England.

The NHS’s medical director for the area said “it’s clear the system got it wrong” in Calocane’s care and apologised to the families of the victims.

NHS England released the full document after pressure from the victims’ families followed earlier reports only a redacted version was expected to be made public.

Calocane killed students Barnaby Webber and Grace O’Malley-Kumar, both 19, with a knife as they walked home from a night out, before going on to fatally stab 65-year-old school caretaker Ian Coates.

Calocane then stole Mr Coates’ van and used it to inflict serious injuries on three other people.

The 302-page report makes 27 key findings about his care and the system which organised it. There are two areas of recommendations for national change and ten for Nottinghamshire Healthcare Trust.

It concludes: “Whilst decisions made were thought to be appropriate by those involved at the point at which they were made, what appears to be missing is shared decision making across all teams involved in VC’s (Valdo Calocane’s) care.”

The report also adds Calocane’s risk was “not fully understood, managed, documented or communicated” and his missing of medication was sometimes “explained away by his
misunderstanding of the number of tablets to take at a time and by forgetting to collect his medication”.

This meant his acceptance and use of medication to treat his conditions was too hard to determine.

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

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.

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

Dr Jessica Sokolov, Regional Medical Director at NHS England, said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.

“This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”

Claire Murdoch, NHS England’s National Mental Health Director, said: “Our thoughts continue to be with the families and loved ones of Barnaby Webber, Grace O’Malley-Kumar and Ian Coates, who have suffered the most unbearable loss.

“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.

“Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police. And we’ve instructed trusts not to discharge people if they do not attend appointments.”

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