Public Inquiry into Nottingham Hospital

In a harrowing incident last June, Valdo Calocane fatally stabbed students Barnaby Webber and Grace O’Malley-Kumar, both 19, along with 65-year-old Ian Coates. Calocane later pleaded guilty to manslaughter due to diminished responsibility. A recent review by the Care Quality Commission (CQC) into his treatment by Nottinghamshire Healthcare NHS Foundation Trust (NHFT) revealed significant shortcomings in the mental health care he received, particularly regarding risk assessments that downplayed his refusal to take medication and ongoing psychotic symptoms. The CQC's findings highlighted a troubling lack of accountability among senior management at NHFT, stating that clinicians involved in Calocane's care must bear a heavy burden for their failures. The report emphasized that multiple organizations failed to adequately address the risks posed by Calocane prior to the tragic events of June 13, 2023. An earlier CQC report indicated that the trust was discharging patients in worse mental health conditions than when they were admitted, raising serious concerns about patient safety. Between May 2020 and February 2022, NHFT conducted eight risk assessments for Calocane, which noted his refusal to take medication and escalating violent behavior. The CQC concluded that while it cannot definitively state that the stabbings would have been prevented with better care, it is clear that the risks he posed were not effectively managed. In response to these findings, the CQC recommended that NHFT regularly review treatment plans for individuals with schizophrenia and improve clinical supervision for detaining patients under the Mental Health Act. NHS England's national director for mental health, Claire Murdoch CBE, acknowledged the unacceptable failings in Calocane's care, underscoring the urgent need for systemic improvements.