Review Finds NHS Failures Led to Release of Schizophrenic Killer Valdo Calocane
The review discovered that hospital risk assessments failed to address important details, such as his violent tendencies, ongoing symptoms of psychosis, and his refusal to take medication.
A report revealed a series of failures in the treatment of paranoid schizophrenic Valdo Calocane, resulting in his discharge without further contact with mental health professionals, despite awareness of the significant risk he posed to others.
The Care Quality Commission’s (CQC) review released on Tuesday regarding the treatment of Calocane also highlighted that Nottinghamshire Healthcare NHS Foundation Trust (NHFT) had downplayed or left out crucial details about the threat he posed during the two years they were involved with him before he committed the tragic killings.
According to the review, Calocane’s medical records indicated he was severely unwell and displayed symptoms of psychosis early on in NHFT’s interactions with him.
Despite this, and his consistent refusal to take medication even in the community, he was discharged after disengaging from mental health services.
The CQC’s Interim Chief Inspector of Healthcare Chris Dzikiti remarked that the report exposed failures in health professionals’ handling of Calocane, pointing out instances of poor decision-making, omissions, and errors in judgment that contributed to the lack of necessary support and follow-up for a patient with severe mental health issues.
“While it can’t be definitively stated that the devastating events of 13 June 2023 would have been prevented with proper support for Valdo Calocane, it is evident that the public risk he posed was not effectively managed, and opportunities to mitigate that risk were missed,” Dzikiti added.
The review of mental health services at NHFT was initiated following Calocane’s sentencing to an indefinite hospital order in January for the murders.
Risk Assessments Ignored the Severity of Danger
Calocane had been in contact with mental health services and law enforcement since May 2020 when he was first detained in a mental health facility under the Mental Health Act (1983).
By June, he had been discharged and transferred to the early intervention in psychosis (EIP) team before being diagnosed with schizophrenia in July.
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The CQC report details several incidents in Calocane’s records where he was in and out of interactions with police, multiple instances of sectioning, and discharges back into the community and with the EIP team.
Reviewers observed that records indicated Calocane’s condition had worsened, and there was an alleged assault on a fellow student at one point.
By Sept. 23, 2022, Calocane had been discharged back to his GP due to non-engagement with mental health services.
The CQC report highlights that after this date, there are no further records. Nine months later, Calocane attacked six people in Nottingham, resulting in the deaths of three.
NHFT had conducted eight risk assessments on Calocane between May 2020 and February 2022, with reviewers noting that while some key risks were identified, others were downplayed or omitted, including his refusal to take medication, persistent symptoms of psychosis, his violent behavior when not managing his psychosis, and the escalation of that violence towards others in later stages of care.
“Our review indicates that in [Calocane’s] case, there were no isolated failures, but a series of mistakes, omissions, and misjudgments in all these areas,” the review concluded, with the CQC suggesting various measures, including the publication of national guidance by the NHS on treating individuals with complex psychosis and paranoid schizophrenia.
‘Blood on Their Hands’
In response to the findings, an NHFT spokesperson acknowledged, “We recognize and accept the findings of this report and have made significant enhancements to processes and standards since the review was completed.”
Health and Social Care Secretary Wes Streeting assured the public that “the shortcomings identified in Nottinghamshire are not being replicated elsewhere.”
“I anticipate the findings and recommendations in this report to be examined and implemented nationwide to prevent other families from enduring the unimaginable pain being felt by Barnaby, Grace, and Ian’s families,” Streeting added.
The families of the victims stated that the report uncovered “serious, systematic failings in the mental health trust in their interactions with Calocane from beginning to end” and emphasized that they and their loved ones had been let down by multiple agencies from the initial stages until June 13, 2023.
The families of the victims added that multiple agencies, police departments, and individual professionals involved in Calocane’s case “have blood on their hands.”
“Alarmingly, there appears to be little to no accountability within the senior management team of the mental health trust. We question how and why these individuals are still in their positions,” they remarked.
PA Media contributed to this report.
