Valdo Calocane, who killed three people in a violent rampage in Nottingham in June 2023, was not forced to take injectable antipsychotic medication because he did not like needles, an independent review into his mental health care has found.
NHS England released the full version of the investigation after pressure from the victims' families. The review examined the care Calocane received before he killed university students Grace O'Malley-Kumar and Barnaby Webber, and school caretaker Ian Coates. He was sentenced to an indefinite hospital order after pleading guilty to manslaughter on grounds of diminished responsibility due to paranoid schizophrenia.
The report found that Calocane refused depot medication — slow-release antipsychotic drugs administered via injection — on each of the four occasions he was sectioned before the attacks. The report stated: 'The inpatient teams involved in Calocane's care were trying to treat Calocane in the least restrictive way and took on board his reasons for not wanting to take depot medication, which included him not liking needles.'
A risk assessment in February 2022 had urged staff not to visit Calocane at home alone, citing his history of violence and aggression. However, the report found that the assessment did not consider how to manage the risk of him not taking medication and the potential violence that could follow. It also noted that concerns raised by Calocane's family were not heeded.
Calocane's first psychotic episode was recorded in May 2020, when he broke into neighbouring flats and frightened a woman so badly that she jumped from a first-floor window, requiring surgery. He was discharged from mental health services in September 2022 after missing appointments and providing an incorrect address, with no further contact before the killings.
NHS England apologised for the failings. Dr Jessica Sokolov said: 'It's clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.' National mental health director Claire Murdoch said trusts have been asked to review their risk assessment processes and not to discharge patients who miss appointments.
