Health trust chief apologises 'unreservedly' to families of Nottingham attacks killer
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A long-awaited review by Theemis Consulting into the NHS care and treatment provided to Calocane by Nottinghamshire Healthcare NHS Foundation Trust and other services has highlighted ‘a catalogue of failings’.
The investigation found Calocane was able to skip vital mental health medication too easily and decisions weren’t shared properly across those responsible for this care.
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Hide AdNow, the NHS’s medical director for the area said it was ‘clear the system got it wrong’.


Calocane stabbed and killed former Bulwell Academy caretaker Ian Coates, aged 65, and 19-year-old Nottingham University students Barnaby Webber and Grace O’Malley-Kumar on June 13, 2023.
Calocane then stole Mr Coates’ van and used it to inflict serious injuries on three other people.
He was given an indefinite hospital order for manslaughter after the court accepted psychiatric reports heard in court which concluded that Calocane was suffering from ‘extreme’ mental illness and described him as a ‘paranoid schizophrenic’ without which he would not have carried out the attacks.
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Hide AdThe sentence was heavily criticised by the victims famlies who said Calocane had been effectively allowed to ‘get away with murder’ after Court of Appeal judges ruled it was not unduly lenient.


In subsquent months, it was revealed that senior doctors had warned about Calocane three years before the Nottingham attacks.
It has now emerged that he had not been forced to take his medication because he’d said he ‘did not like needles’.
In a statement, Ifti Majid, chief executive of Nottinghamshire Healthcare NHS Foundation Trust said: “The events of 13 June were tragic, and once again our deepest condolences go out to the families of Valdo Calocane’s victims who died – Ian, Grace and Barnaby – and to the victims who were injured Wayne, Sharon and Marcion.
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Hide Ad“We apologise unreservedly for the opportunities we missed in the care of Valdo Calocane and accept the Theemis report in its entirety including its findings and recommendations.
“We are making clear progress with a trust-wide plan, which is already delivering key improvements in areas such as risk assessment and discharge processes.
"We are also improving the way we listen and engage with patients, families, our colleagues, and local partners – to make sure concerns are acted on as quickly as possible.
“I know that this will never undo the catastrophic damage caused by these events, when three lives were tragically lost and others changed irreparably.
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Hide Ad"But we will do everything possible to prevent similar incidents happening again and remain totally committed to improving services for the communities we serve.”
The report makes 27 key findings about his care and the system which organised it.
There are two areas of recommendations for national change and 10 for Nottinghamshire Healthcare NHS Foundation Trust.
It concludes: “Whilst decisions made were thought to be appropriate by those involved at the point at which they were made, what appears to be missing is shared decision making across all teams involved in Calocane’s care.”
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Hide AdThe report also adds Calocane’s risk was ‘not fully understood, managed, documented or communicated’ and his missing of medication was sometimes ‘explained away by his misunderstanding of the number of tablets to take at a time and by forgetting to collect his medication’.
This meant his acceptance and use of medication to treat his conditions was too hard to determine.
Between 2020 and 2022, Calocane was arrested and sectioned four times under the Mental Health Act.
During the second of these, a psychiatrist warned about him potentially killing someone.
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Hide AdHe was diagnosed as a paranoid schizophrenic but his family were not told.
During his second sectioning he lied to doctors that he was no longer hearing voices so he could released from hospital as he believed the voices he heared were real people.
After being sectioned a third time, he was deemed well enough to be discharged back into the care of his community health team after only three weeks.
And when he was sectioned for a fourth time in January 2022 he family were not informed as Calocane told his mental health team he did not want them to know.
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Hide AdWhile in hospital, he reportedly repeated missed appointments and did not take tablets and in September 2022 he was discharged back to his GP for the final time.
It later emerged that also that month, a warrant for his arrest for not attending court had been issued – but it was never acted upon and Nottinghamshire Police subsequently admitted they should have done more at the time to detain him.
The case 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.
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Hide AdMeanwhile, 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.
Speaking to the BBC, Dr Jessica Sokolov, regional medical director at NHS England (Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.
“This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”
Claire Murdoch, NHS England's national mental health director, said the organisation had asked every mental health trust to review the report findings.
Also speaking to the BBC, Ian Coates's son, James said the main focus was to ‘keep working to make sure mistakes were not repeated’.
He said: "I know my father would be proud of me to keep fighting.”
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