A report found that multiple failures in the treatment of paranoid schizophrenic Valdo Calocane led to his discharge without any further contact with mental health professionals, despite knowledge of the serious risk he posed to others.
The review said that Calocane’s medical records showed he was “acutely unwell” and showing symptoms of psychosis from early on in NHFT’s engagement with him.
Despite this, and the “obvious pattern” of Calocane not taking medication when he was released in the community, he was discharged after he had disengaged from mental health services.The CQC’s Interim Chief Inspector of Healthcare Chris Dzikiti said the report revealed points in health professionals’ dealing with Calocane, 32, where “poor decision-making, omissions and errors of judgement contributed to a situation where a patient with very serious mental health issues did not receive the support and follow up that he needed.”
“While it is not possible to say that the devastating events of 13 June 2023 would not have happened if Valdo Calocane had received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed,” Dzikiti added.
Risk Assessments Downplayed Danger
Calocane was known to mental health services and police starting in May 2020 when he was detained for the first time in a mental health facility under the Mental Health Act (1983).By June, he had been discharged and his care moved to the early intervention in psychosis (EIP) team before being diagnosed with schizophrenia in July.
The CQC report goes on to describe a series of incidents in his records where Calocane bounced between interactions with police, further instances of sectioning, and discharges back into the community and with the EIP team.
Reviewers found records stating Calocane’s condition had deteriorated and at one point he had allegedly assaulted a fellow student.
By Sept. 23, 2022, Calocane had been discharged back to his GP due to non-engagement with mental health services.
The CQC report notes that after this date, there are no further records. Nine months later, Calocane stabbed six people in Nottingham, leaving three of them dead.
NHFT had conducted eight risk assessments on Calocane between May 2020 and February 2022, and the reviewers found that while some key risks were identified, others were “minimised or omitted,” including his refusal to take medicine, his ongoing and persistent symptoms of psychosis, his levels of violence when his psychosis was not being managed, and the escalation of that violence towards others in the later stages of his care.
‘Blood on Their Hands’
In response to the findings, an NHFT spokesperson said, “We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out.”Health and Social Care Secretary Wes Streeting said that he wanted to assure the country that “the failures identified in Nottinghamshire are not being repeated elsewhere.”
“I expect the findings and recommendations in this report to be considered and applied throughout the country so that other families do not experience the unimaginable pain that Barnaby, Grace and Ian’s family are living with,” Streeting added.
The victims’ families said in a statement that the reported demonstrated “gross, systematic failures in the mental health trust in their dealings with Calocane, from beginning to end” and that they and their loved ones had been failed by multiple agencies from the beginning until June 13, 2023.
The victims’ families added that multiple agencies, police departments, and individual professionals involved with Calocane’s case “have blood on their hands.”
“Alarmingly, there seems to be little or no accountability amongst the senior management team within the mental health trust. We question how and why these people are still in position,” they added.
