Today sees publication of the review in to the mental healthcare delivered to Valdo Calocane, the man who responsible for three killings and three attempted killings in Nottingham in July 2023. We saw the headlines and summary from the BBC News article as this report was supplied in full to UK media on Tuesday after a concerning moment where it was reported NHS England would block full publication issuing only an executive summary of around a dozen pages.
The families of Grace O’Malley-Kumar, Ian Coates and Barnaby Webber had pressed through their lawyers for full publication and it is reported the health secretary had urged full publication stating, “sunshine is the best disinfectant”.
The BBC’s article is a decent summary of events so I won’t repeat it all here, except to give the key findings of the review and make some comments –
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Calocane’s risk “was not fully understood, managed, documented or communicated”;
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There were missed opportunities to take more assertive action towards Calocane’s care;
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The voice of Calocane’s family “was not effectively considered to support the dynamic evaluation of risk” during his treatment;
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Other patients under the care of the same trust, some of whom had been discharged, had also perpetrated acts of “serious violence” across 15 incidents between 2019 and 2023;
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Calocane had no contact with mental health services or his GP for about nine months prior to the killings.
DAMNING
It is just utterly, utterly damning – especially the headline about other patients in the same trust which, strictly speaking isn’t relevant to Calocane’s own care, but is obviously massively relevant to the overall conclusion about what brought about such poor care – massive, systemic AND individuals failings
I don’t see how the Chief Executive of the Trust can continue not least because I find myself remembering that I know his name. I know longer work on this topic formally, I don’t live in Nottingham and never had massive dealings with that trust and yet, because Mr Ifti Majid has been in the news so often, apologising for failures under his leadership.
And my only point here is the one made so powerfully by Emma Webber, Barnaby’s mother at the press conference just now. Why is there a 300-page report which makes little to no mention of individual professional decisions which amount to the overall systemic failures?
ACCOUNTABILITY
It was a doctor acting as responsible clinician under the Mental Health Act who discharged Mr Calocane from care, apparently without obvious consideration of things like a Community Treatment Order, which was a legislative instrument specifically brought in to break the kind of treatment cycles of similar patients who get in to crisis, relapse, do something, get sectioned, admitted, recover and are discharged to start it all over again. So are we happy with the professional standards of the doctors who made those decisions?
Whilst Calocane was not in hospital, what responsibility do nurses carry for things like following up missed appointments, etc.? Now we do know a doctor did flag the risk Mr Calocane could go on to kill someone … we also know nurses did flag concerns, but where we see contact failures like this in policing, investigations tend to be the opposite of what we find in this NHS England report. In policing, my frustration often is conduct investigations go after officers for failings or perceived failings without really touching on more organisational issues.
So the complexity of this stuff remains overwhelming and today’s healthcare report is just one part of the reviews we need to care about. We are still to learn what view will be taking about police actions and inactions which are under review by the College of Policing and these reviews are speaking to each other, as it were. That’s why I’m pleased the families have been granted a wider public inquiry in lieu of an inquest, where a judge can consider the various issues across the organisations and consider the short-comings in this report. Dr Sanjoy Kumar, Grace’s father has said “I’m disgusted – it doesn’t answer my questions”.
Mine either.
NB: this is the latest in post about the terrible events in Nottingham, June 2023. You can find all the others collated on a specific Nottingham resources page along with other materials, inc reports and legal documents.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025.
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 