Care Quality Commission
- Health and Social Care Secretary responds to CQC report outlining failings in Valdo Calocanes care
- NHS England has already started actioning CQC recommendations, with every provider of mental health services reviewing serious mental health care
- Valdo Calocane killed 3 people and injured 3 others in Nottingham in June 2023
Health and Social Care Secretary Wes Streeting has today (13 August 2024) 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 3 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 OMalley-Kumar and seriously injured 3 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 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 Calocanes care may have contributed to the tragic events after he was discharged from the trusts mental health services.
The NHS has already accepted all of CQCs recommendations from strands 2 and 3 of CQCs 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 Wes Streeting 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 CQC 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 Ians 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
While there is no single point of failure identified in the report, part 2 of CQCs review, published today, identified serious shortcomings in Valdo Calocanes care including being discharged too early and failings in follow ups when he evaded contact with the community mental health team.
The findings of the first part 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 3 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