Today (5 February 2025) NHS England (Midlands) has published the full independent investigation conducted by Theemis into the care and treatment of Valdo Calocane in the months leading up to the events of 13 June 2023.
The NHS has taken the decision to publish the report in full in line with the wishes of the families and given the level of detail already in the public domain.
The aim of this investigation was to thoroughly review the NHS care and treatment provided to Valdo Calocane by Nottinghamshire Healthcare NHS Foundation Trust prior to the tragic events of 13 June 2023, and the interactions the NHS had with other agencies involved in his care.
Valdo Calocane was convicted of the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber in January 2024.
As part of Theemis Consultancy Ltd’s terms of reference which was agreed by NHS England and representatives from the families involved, the review focuses on providing recommendations for the NHS on how they treat people with a serious mental illness and how they interact with other agencies.
The review identified clear failings in the care and treatment provided to Valdo Calocane and produced a series of recommendations for Nottinghamshire Healthcare NHS Foundation Trust and NHS England.
It followed the Care Quality Commission’s special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust.
NHS England regional teams are responsible for commissioning independent investigations into homicides that are committed by patients being treated for mental illness.
Reports are published and shared in line with legal guidance and with engagement from families. Given the significant medical information contained in these reports, and in light of NHS England’s legal obligations to comply with data protection legislation and ensure patients’ medical records are kept confidential, it is currently reviewing its approach to publication.
NHS England will work with the Department of Health and Social Care and partners to set out next steps for how future independent mental health homicide reports should be published to ensure that it complies with its legal obligations, and also acts transparently and in way that supports those affected.
Dr Jessica Sokolov, Regional Medical Director at NHS England (Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.
“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.”
Claire Murdoch, NHS England’s National Mental Health Director, said: “Our thoughts continue to be with the families and loved ones of Barnaby Webber, Grace O’Malley-Kumar and Ian Coates, who have suffered the most unbearable loss.
“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.
“Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police. And we’ve instructed trusts not to discharge people if they do not attend appointments.
“We are determined to do everything possible to transform how the NHS treats people with a serious mental illness who often require long term support, backed by £900 million investment over the last 5 years into improving community services.
“The next stage of transformation of services for those with the most serious illnesses is the trialling of mental health centres open 24/7 from this spring and providing people and their families with support if they are in crisis without needing to book an appointment – as well as provide housing or employment advice to support them to stay well.”
