The Guardian view on a Nottingham tragedy: mental health services must learn the lessons | Editorial

Following the fatal stabbing by Valdo Calocane of two Nottingham university students and a school caretaker last June, police initially liaised with counter-terrorism officers as they searched for a motive. It soon emerged that, in the normal sense of the word, there wasn’t one. Calocane had been diagnosed with paranoid schizophrenia three years previously, and had a history of violence when unwell. Grace O’Malley-Kumar, Barnaby Webber and Ian Coates had the tragic misfortune to encounter him on such an occasion.

Nothing can bring back those lives now. But as the review of Calocane’s care and treatment by Nottinghamshire Healthcare NHS foundation trust makes agonisingly clear, there were steps that could and should have been taken to mitigate the risk of such horror occurring. Analysing why they were not made, and revising national guidelines accordingly, will be fundamental to reducing risks to public safety from similar cases in the future.

The Care Quality Commission’s (CQC) review identified a series of “errors, omissions and misjudgments” by mental health services, as they handled Calocane’s case from May 2020 to September 2022. During that period – in which he was sectioned four times – the CQC found that warnings from family members about deterioration in his mental health were not adequately heeded, and recurrent violent episodes did not prompt a rethink in treatment or approach.

Risk assessments, according to the review, were patchy, inconsistent, underresourced and inclined to be overoptimistic, given Calocane’s persistent incomprehension of the realities of his condition. Despite a growing failure to turn up for appointments, and evidence that he was failing to take his medication when out of hospital, Calocane’s preference for oral medicine continued to be respected, when inpatient injections would have allowed his symptoms to be controlled more robustly.

Disastrously, Calocane was then effectively allowed to remove himself from support structures in 2022, when the trust discharged him from mental health services on the grounds of his non-engagement. Damningly, the review notes: “Evidence over the course of [Calocane’s] illness and contact with services and police indicated beyond any real doubt that he would relapse into distressing symptoms and potentially aggressive … behaviour.” His next contact with medical professionals would be after the killings in June 2023.

These are alarming findings. Balancing the dignity and autonomy of mental health patients with the requirement to assertively act in their best interests, and those of the wider community, is a complex and challenging task. It is made all the more difficult when proper staffing resources are lacking, as the CQC reported in March in an earlier stage of its inquiry. In the case of Calocane, the wrong balance was struck, with catastrophic results.

Immediate lessons must be learned. It may be that proposed changes to the Mental Health Act, previewed in the king’s speech, will now be assessed in light of the CQC’s findings. Separately, as recommended by the review’s authors, more stringent national standards for dealing with cases of complex psychosis and paranoid schizophrenia must be put in place, recognising what went wrong in Nottingham. Everything possible must be done to ensure that the failures that allowed Calocane to become a menace to public safety are not repeated elsewhere.