The families of Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates, who were tragically killed by Valdo Calocane in June 2023, have expressed their profound dismay following the release of a Care Quality Commission (CQC) report detailing significant failings in Calocane’s mental health care.
The CQC report, published on Tuesday, identified a series of “errors, omissions, and misjudgements” by mental health services that contributed to the fatal attacks. Calocane, who was diagnosed with paranoid schizophrenia three years prior, had been known to the Nottinghamshire Healthcare NHS Foundation Trust but his care was marred by missed risk factors and inadequate responses to his persistent psychosis and violent behavior.
In a joint statement, the victims’ families condemned the involved organizations, asserting that they “must bear a heavy burden of responsibility” for the catastrophic failings. They described the oversight as “gross, systemic failures” and demanded a statutory public inquiry with the authority to compel witnesses.
Emma Webber, mother of Barnaby, described the situation as “dreadful” and criticized the systemic issues within the NHS. She stated, “If any one of those missed opportunities had been addressed, Barnaby and Grace might still be here today.” She emphasized that the issue was not isolated to one trust but indicative of broader systemic problems within mental health services.
The CQC’s review revealed that key risk factors, including Calocane’s refusal to take medication and his escalating violence, were not adequately managed. The report highlighted poor planning and engagement by the NHS trust, which failed to address the severity of Calocane’s condition and his escalating risks.
Health Secretary Wes Streeting, who met with the victims’ families last week, acknowledged the severe nature of the findings and expressed a commitment to implementing the report’s recommendations nationwide. He emphasized the need for accountability and reform within the NHS to prevent future tragedies.
The Department of Health and the Attorney General’s Office have confirmed that a judge-led inquiry into the deaths is still planned. However, the families insist on a statutory inquiry with full powers to compel evidence and testimony.
The report also noted that Calocane’s care was marked by repeated disengagement, missed opportunities for intervention, and inadequate supervision. It called for immediate improvements, including better engagement with patients and their families, and more robust discharge policies.
Dr. Sanjoy Kumar, father of Grace O’Malley-Kumar, called for a wide-reaching statutory inquiry to address the systemic issues revealed by the report. He stressed the importance of learning from the Nottingham case to address similar issues across the country.
Mental health charity SANE described the CQC report as “one of the most damning” ever read, highlighting a crisis in psychiatric services exacerbated by a shortage of resources and insufficient support mechanisms.
In response to the report, Ifti Majid, interim chief executive of the NHS trust, issued an apology and outlined plans for reform, including improved crisis management and risk assessment protocols.
The CQC’s findings underscore the urgent need for systemic change within mental health services to safeguard public safety and prevent future tragedies.
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