Valdo Calocane's case has unveiled significant lapses in mental health care, as revealed by a recent independent investigation. Calocane, who experienced his first psychotic episode in May 2020, committed heinous acts in June 2023, leading to the killing of three individuals and injuring others. The review scrutinized the mental health care he received prior to these tragic events, highlighting numerous failings in communication, risk assessment, and medication management.
Calocane had a troubling history marked by his first psychotic episode in May 2020. During this episode, he broke into neighboring flats, instilling fear to such an extent that a woman jumped from a first-floor window, resulting in a back injury. He was sectioned four times before the attacks but consistently refused depot medication due to his aversion to needles. Despite the clear risks associated with his condition, a risk assessment in February 2022 advised staff against visiting him alone at home. However, he was discharged from mental health services in September 2022 after missing several appointments and providing incorrect contact details.
The report found that while the assessment evaluated risk to staff, it failed to address the potential consequences of Calocane not taking his medication, including possible violence. His refusal to take medication remained a critical oversight. The review documented that Calocane's family frequently expressed concerns about his treatment, but their warnings were not adequately considered in risk evaluations.
The tragic outcome was the killing of university students Grace O’Malley-Kumar and Barnaby Webber, along with school caretaker Ian Coates on June 13, 2023. Following these events, Calocane was sentenced to an indefinite hospital order after pleading guilty to manslaughter on the grounds of diminished responsibility due to his paranoid schizophrenia and three counts of attempted murder.
“This should act as a watershed moment revealing the truth and honouring the needs of the families of victims of homicides by people with mental illness or disorder.”
— Marjorie Wallace, Chief Executive of the mental health charity Sane
The report, released by NHS England under pressure from the victims’ families, spotlighted basic communication failures and risk assessment inadequacies in Calocane's care. The trust responsible for his care was placed in NHS England's highest oversight and support programme due to these failings. This programme has driven significant changes, including an overhaul of risk assessment processes.
“Today’s findings expose the same flaws and fault lines that have resulted in tragedies, yet little seems to have changed: basic failings of communication, inadequacies in assessing risk, and in over half the cases we analysed, not heeding the warnings of families or those close to the patient.”
— Marjorie Wallace, Chief Executive of Sane
“It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.”
— Dr Jessica Sokolov, Regional Medical Director at NHS England (Midlands)
Dr. Jessica Sokolov offered a heartfelt apology to the victims' families on behalf of the NHS and associated organizations.
“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.”
— Dr Jessica Sokolov
Claire Murdoch noted that placing the trust under heightened oversight reflects recognition of these failings and a commitment to reform.
“It is clear there were failings in the care provided to Valdo Calocane, which is why the trust responsible was placed in our highest oversight and support programme which has seen them overhaul their risk assessment processes.”
— Claire Murdoch, NHS England’s National Mental Health Director
The report highlighted that inpatient teams were attempting to treat Calocane in a non-restrictive manner by respecting his refusal of medication due to his dislike of needles. Nonetheless, the risk assessment noted his history of violence and aggression when detained.
“The inpatient teams involved in Calocane’s care were trying to treat Calocane in the least restrictive way and took on board his reasons for not wanting to take depot medication, which included him not liking needles.”
— The report
“The risk assessment notes state that Calocane had a ‘history of violence and aggression when detained … violence and aggression towards housemates … poor insight [and] does not agree that he has been unwell over the last 12 months’.”
— The report