Report reveals failures in Valdo Calocane’s mental health care. Officials avoided long lasting injections due to his fear of needles. System also had other issues.
The report found fifteen other violent incidents. Patients under the trust’s care committed them. One patient stabbed five people in one weekend. This happened before Calocane’s attacks.
NHS England first refused to release the full report. They said it would breach Calocane’s privacy. They later changed their minds after pressure.
Calocane had paranoid schizophrenia. In June 2023, he killed three people. Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates died. He also tried to kill three others.
The report detailed two years of his violent behavior. He held flatmates hostage. He punched a police officer. He scared a neighbor, who jumped from a window.
NHS England said the system failed Calocane. Prosecutors accepted his pleas of not guilty to murder. Medical evidence showed his schizophrenia. He was convicted of manslaughter and attempted murder.
The report said risks were not well managed. Experts said this problem was not isolated. They suggested things were not unique to his case.
Requests existed to place him on a treatment order. He would take long-lasting antipsychotic injections. They dismissed these because Calocane disliked needles. Each hospital admission was seen separately. They lacked a wider view.
Calocane did not think he had a mental illness. His understanding of his health did not improve.
The trust had fifteen incidents between 2019 and 2023. Patients committed serious violence while under the trust’s care. It also happened after being discharged.
Most incidents involved stabbings. Three cases involved deaths. One patient stabbed five people in February 2023. This person received mental health services.
NHS England planned to release a report summary. They would keep the full report private initially. They cited data protection laws.
Victims’ families wanted the full report released. They felt it was in the public interest. NHS England then released the full report. They also said they’d review how they release reports.
NHS England apologized to the victims’ families. They said the system failed. The NHS national director spoke about improving care. Trusts should review the findings, she said. Trusts should not discharge those who miss appointments. They are trialing mental health centers and these will operate 24/7.