Asha Patel
BBC News, Nottingham
Nottinghamshire Police
Valdo Calocane, who was diagnosed with paranoid schizophrenia, was given a hospital order in January 2024 after admitting manslaughter on the basis of diminished responsibility
Triple killer Valdo Calocane was not forced to take his anti-psychotic medication in part because he did not like needles, a major review of his NHS care has revealed.
The detail was published among a catalogue of failings identified by an independent report, which revealed “the system got it wrong” with Calocane, who stabbed to death Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham in June 2023.
It laid out how Calocane, who has paranoid schizophrenia, had no contact with mental health services or his GP for about nine months prior to the killings – after he was discharged when he repeatedly failed to engage with them.
Mr Webber’s mother Emma described the report as a “horror show”.
In response, the government repeated its commitment to a public inquiry into the attacks, with work ongoing to establish its scope.
The NHS said it had taken the decision to publish the report in full, in line with the wishes of the families, and “given the level of detail already in the public domain”.
The independent review, by Theemis Consulting, looked into the treatment given to Calocane by Nottinghamshire Healthcare NHS Foundation Trust prior to the killings, as well as the interactions the NHS had with other agencies involved in his care.
The key findings of the report include:
Calocane’s risk “was not fully understood, managed, documented or communicated”There were missed opportunities to take more assertive action towards Calocane’s careThe voice of Calocane’s family “was not effectively considered to support the dynamic evaluation of risk” during his treatmentOther 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 2023Calocane had no contact with mental health services or his GP for about nine months prior to the killingsSupplied
Ian Coates, Barnaby Webber and Grace O’Malley-Kumar died on 13 June 2023
The case, which resulted in Calocane being sentenced to a hospital order in January 2024, sparked a number of reviews including the mental health homicide review, commissioned by NHS England.
Another, by the Independent Office for Police Conduct (IOPC), is looking into both Leicestershire and Nottinghamshire Police.
A review into the Crown Prosecution Service (CPS) found while prosecutors had been right to accept Calocane’s pleas of manslaughter on the basis of diminished responsibility, they could have handled the case better.
And in May, a judge ruled Calocane’s sentence was not unduly lenient.
Speaking after the release of the new report on Wednesday, Mrs Webber said: “It’s been additional trauma, horror, disbelief and fury – but all of that was anticipated and expected by all three families.”
She added: “It leaves us feeling horrified, heartbroken, but even more determined now to make sure that it’s addressed – that the government and the agencies react and listen properly.”
Mrs Webber also revealed she had been contacted by the family of one of the Southport stabbing victims.
“It’s very rare that you can say to someone ‘I know how dreadful that is’ and know that that person really does know,” she said.
Footage shows timeline of attacks and killer’s arrest
In an interview on BBC Radio 4’s Today programme, Ian Coates’s son James said the main focus was to keep working to make sure mistakes were not repeated.
“I know my father would be proud of me to keep fighting,” he said.
Health Secretary Wes Streeting said the governmen
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