Why did the mental health care for Nottingham attacks killer Valdo Calocane go so wrong?
Marjorie Wallace from mental health charity SANE explains why 'the same litany of faults is repeated again and again'
The boss of a mental health charity has blamed ideological failings and under resourcing for the series of events which led to Valdo Calocane going on to kill three people and injure three others in Nottingham in 2023.
A Care Quality Commission (CQC) report has found numerous failings in the way mental health services dealt with Calocane, who killed 19-year-old students Barnaby Webber and Grace O’Malley-Kumar before killing 65-year-old Ian Coates in the early hours of 13 June.
'The same litany of faults is repeated again and again'
Marjorie Wallace is the founder and CEO of SANE, a mental health charity.
She has been involved in more than a hundred inquiries and reports into homicide cases like this and 'can see only too well how errors like this happen.'
"The same litany of faults is repeated again and again, it's not just simply a lack of resources, it's also an ideological belief that anyone, however disturbed they may be can be looked after in the community, particularly with the community teams being so overstretched."
'Where are the rights of the families? Where are the rights of the public?'
She says it 'defies common sense' that this was a man who had been sectioned four times, yet was discharged far too quickly and then went on to refuse to take his medication. It was left as his choice, and his right, not to take his medication and to disengage from mental health services.
"Where are the rights of the families? Where are the rights of the public if in fact it's left to the most disturbed patients to choose not to engage in the services?"
'A failure to listen to families'
She argues that there is a misinterpretation of rights afforded to seriously ill people, when there is a fundamental lack of resources.
These include losing half of psychiatric beds since 2000, and a lack of doctors, community nurses and counsellors. Community teams are so overstretched, she says, that they cannot follow up on cases like Calocane.
"But there is another common sense failure - the failure to listen the families.
"His parents were seeking help early on and later they were warning about the deterioration in his mental health but none of that was taken into account in the risk assessment.
"This is where we feel it can change. We need to make it mandatory that when families ring up warning of a deteriorating health state, it must be communicated to the health teams."
'We need to take each case individually'
"The attitude and culture need to change, we need to treat patients individually, there cannot be a quota for the number of people detained or not detained.
"We need to make it possible for people to access care and treatment when they need it, not when the crisis point has come. We need to listen to patients, families and carers.
"Our analysis of a hundred of these types of incidents is one of the key triggers for the tragedy was failure to listen to the carers, families, and patients themselves...
"...The failure to provide safe care and treatment is putting the public at risk"
'This is quite rare'
Wallace confirms that there are very few cases as severe as Valdo Calocane with around a hundred homicides committed by someone with a mental illness or disorder each year.
"The public should not be be alarmed, the chance of being a victim is not very high at all.
"But it doesn't mean that it isn't terrible for the families where there are the victims and it doesn't mean that there aren't a lot of near misses where people could easily put themselves and others at risk, because they haven't had the care and treatment they need."
The report found:
The evidence “indicated beyond any real doubt” that Calocane would relapse “into distressing symptoms and potentially aggressive behaviour”
Risk assessments “minimised or omitted” key details of the serious risk he posed to others
The decision to send him back to GP care “did not adequately consider or mitigate the risks of relapse”
Calocane was refusing to take his medication.
Calocane had ongoing and persistent symptoms of psychosis
Calocane was violent to others when psychosis was not managed well
It also questioned how well the trust engaged with Calocane’s family, who raised concerns about his mental state.
Nottinghamshire Healthcare Chief Executive, Ifti Majid said:
“We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out. Our teams have much more contact with people waiting to be seen in the community to agree crisis plans and ensure they have an up-to-date risk assessment even when they are struggling to engage with our services or primary care.
“Colleagues are also working to improve alignment between our teams, primary care and talking therapies, helping to reduce waiting times as well as communicate more effectively when patients move between services or disengage from treatment.
“We have a clear plan to address the issues highlighted and are doing everything in our power to understand where we missed opportunities and learn from them.”
Wes Streeting MP, the Health Secretary, says the number of failures highlighted in the CQC report is shocking.
Victoria Atkins MP, Shadow Health and Social Care Secretary, said:
“At this difficult time, my thoughts and deepest sympathies are with the families of Barnaby, Grace, and Ian. They have suffered horrific losses which they feel every minute of every day. When I met them, I promised them that we would seek answers for them through this report.
“I want to thank the CQC for their diligent work in conducting this review into this horrific incident.
“It is important that we reflect on the findings and recommendations, including accepting and addressing where failures have been identified, in order to ensure that other families do not have to experience this same suffering.
“Following this report, the new government must now honour its promise to the families and set up a public inquiry into these tragic events. I will work with this new government wherever possible to implement that and the measures set out in this report.”
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