Triple killer Valdo Calocane was not forced to take his anti-psychotic medication because he did not like needles, a major review of his NHS care has revealed.
The NHS England report identified numerous failings that show "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 - and was discharged after failing to engage with them.
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 care.
- The voice of Calocane's family "was not effectively considered to support the dynamic evaluation of risk" during his treatment.
- 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.
- Calocane had no contact with mental health services or his GP for about nine months prior to the killings.
Source: BBC News, 5 February 2025
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