Health and Social Care Secretary has today called for the recommendations made by an
independent review to improve mental health services to be
implemented across the country following the tragic death of
three people in Nottingham.
Valdo Calocane was known to police and mental health services
prior to the attack in June 2023 where he killed Ian Coates,
Barnaby Webber and Grace O'Malley-Kumar and seriously injured
three others with a van. He had previously been treated by
Nottinghamshire Healthcare NHS Foundation Trust for mental health
issues.
Earlier this year, the government commissioned the Care Quality
Commission (CQC) to carry out a rapid review into the local NHS
trust and mental health services provided, in order to get
answers for the victims' families and ensure any failings are
urgently addressed. The report published today is the final
strand of that review, which has found that failings in
Calocane's care may have contributed to the tragic events after
he was discharged from the Trust's mental health services.
The NHS has already accepted all of the CQC's recommendations
from strands two and three of the CQC's review and initiated a
series of measures, including ensuring every provider of mental
health services across the country reviews the care that people
with serious mental illness receive.
Health and Social Care Secretary said:
My thoughts are with the families and friends of Barnaby, Grace
and Ian. This report makes for distressing reading, especially
for those living with the consequences of their loss in the
knowledge that their untimely deaths were avoidable.
Action is already underway to address the serious failures
identified by the Care Quality Commission and I expect regular
progress reports from the Nottinghamshire Healthcare NHS
Foundation Trust.
I want to assure myself and the country that the failures
identified in Nottinghamshire are not being repeated elsewhere. I
expect the findings and recommendations in this report to be
considered and applied throughout the country so that other
families do not experience the unimaginable pain that Barnaby,
Grace and Ian's family are living with.
Other measures the NHS has already undertaken include:
- ensuring every provider of mental health services has clear
policies and practice in place to treat patients with serious
mental illness
- issuing guidance to trusts reiterating instructions not to
discharge patients with serious mental health issues if they do
not attend appointments
- commissioning an independent investigation into the incident,
which will be published by the end of 2024
- increasing funding to community mental health services by
£2.3 billion per year to transform services
- continuing to improve data on community mental health
services including developing metrics around access to
psychological therapies for severe mental health problems and
outcomes for people accessing community mental health services
- establishing an expert advisory group to oversee the
development of core standards for safe care in community mental
health services
Whilst there is no single point of failure identified in the
report, strand one of the CQC's review, published today,
identified serious shortcomings in Valdo Calocane's care
including being discharged too early and failings in follow ups
when he evaded contact with the community mental health team.
Strands two and three of the Section 48 review, which were
published in March 2024, assessed the progress made at Rampton
Hospital as well as patient safety and the quality of care
provided by Nottinghamshire Healthcare NHS Foundation Trust.
The Health and Social Care Secretary recently met with NHS
England to discuss how they and the Nottinghamshire Healthcare
NHS Foundation Trust are taking all the recommendations from all
three strands of the CQC review forward and how they will work
together to make swift, sustained improvements to mental health
services.
Specific actions the local Trust has taken include:
- putting a new crisis telephone system in place, attending to
the issues with responsiveness
- reviewing the approach to managing beds - there are early
positive signs of a reduction in patients being placed in
incorrect care settings as a result
- the patients waiting to access community support have been
reviewed and the waiting list has reduced from 1500 to 1092
