CQC publishes final part of special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust

Following the conviction of Valdo Calocane (VC) in January 2024 for the killings of Ian Coates, Grace O'Malley-Kumar and Barnaby Webber, Rt Hon Victoria Atkins MP, former Secretary of State for Health and Social Care commissioned CQC to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008.

This review has been delivered in three parts. The first two parts, an assessment of patient safety and quality of care provided by the trust and assessment of progress made at Rampton Hospital since the most recent CQC inspection, were published in March 2024.

The final part, published today is a rapid review of the available evidence related to the care of VC during the period he was under the care of NHFT, alongside a small number of other cases for benchmarking purposes, to determine whether this evidence indicates wider patient safety concerns or systemic issues with the provision of mental health services in Nottinghamshire.

VC was under the care of NHFT between May 2020 and September 2022. During this period, it is clear that he was acutely unwell. He presented with symptoms of psychosis and appeared to have little understanding or acceptance of his condition. Issues with him taking his medication were also recorded from early on. This review finds that there appear to have been a series of errors, omissions, and misjudgements in his care. Key among these were:

• Inconsistent approaches to risk assessment. Risk assessments minimised or omitted key details and did not make explicit the serious nature of the risk VC posed to himself and others based on previous behaviour.
• Poor care planning and engagement. VC's family contacted NHFT to raise concerns on a number of occasions but the information they provided was not consistently acted on.
• The decision to discharge VC back to his GP in September 2022. The evidence over the course of VC's illness and contact with services and police indicated beyond any real doubt that VC would relapse into distressing symptoms and potentially aggressive behaviour. Discharging VC back to his GP - due to his lack of engagement with mental health services - did not adequately consider or mitigate the risks of relapse.

The review also found that if the decision had been made to treat VC under section 3 of the Mental Health Act (MHA) 1983 on his fourth admission to hospital further options would have been available for his care and treatment in the community.

Section 2 is usually used for people who are not known to mental health services, or have not been assessed in hospital before, but can also be used in cases where the individual is known to services but has not been assessed for a considerable time.

Given VC's known medical history at this point - a diagnosis of paranoid schizophrenia, prior indications that he was not taking his medication, and evidence that he could present a risk to others when relapsing - it could have been possible to detain him under section 3 of the Mental Health Act. This gives healthcare professionals the ability to administer depot (longer-lasting medication administered via injection) medicine against the individual's will or to consider placing the individual on a community treatment order.

A core part of this review was to consider whether the evidence we gathered from VC's care records indicated wider patient safety concerns or systemic issues in Nottingham. While we did not find any widespread patterns within our 10 benchmarking cases, many of the issues we have identified are consistent with the problems we found in our wider review of the quality of care and safety of services at NHFT.

The scope of this review was limited to the period of time that VC was under the care of NHFT. However, these findings should provide additional evidence for NHS England's more detailed scrutiny of VC's interaction with mental health services through their forthcoming independent homicide review.

Chris Dzikiti, CQC's Interim Chief Inspector of Healthcare, said:

This review identifies points where poor decision-making, omissions and errors of judgements contributed to a situation where a patient with very serious mental health issues did not receive the support and follow up he needed.

While it is not possible to say that the devastating events of 13 June 2023 would not have taken place had Valdo Calocane received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed.

For the individuals involved, their families and loved ones, the damage cannot be undone. However, there is action that can, and must, be taken to better support people with serious mental health issues and provide better protection for the public in the future.

We have made clear recommendations to improve oversight and treatment of people with serious mental health issues at both a provider and a national level. Wider national action is also needed to tackle systemic issues in community mental health - including a shortage of mental health staff and lack of integration between mental health services and other healthcare, social care and support services - so that people get the right care, treatment and support when and where they need it.

This final part of the review makes a number of recommendations, which should be viewed in conjunction with the recommendations from parts one and two.

Recommendations for Nottinghamshire Healthcare NHS Foundation Trust (NHFT) include requirements for the trust to:

• Review treatment plans for people with schizophrenia regularly to ensure treatment is in line with national guidelines.
• Ensure clinical supervision of decisions to detain people under section 2 and 3 of the Mental Health Act and regularly carry out audits of these people's records and report these to the NHFT board.
• Ensure that, in line with national guidance and best practice, staff are aware of the importance of involving and engaging patients' families and carers in all aspects of care and treatment.
• Ensure robust discharge policy and processes that consider the circumstances surrounding discharge and whether discharge is appropriate.

Recommendations for NHS England include:

• Providing, within the next 12 months, evidence-based guidance setting out the national standards for high quality, safe care for people with complex psychosis and paranoid schizophrenia.
• Ensuring that within 3 months of the publication of the national standards for high quality, safe care for people with complex psychosis and paranoid schizophrenia, every provider and commissioner develops and delivers an action plan to achieve these.
• Ensuring, through provider boards, the delivery of the actions within 12 months of the standards being published.

The review also recommends that NHS England, together with the Royal College of Psychiatrists:

• reviews and strengthens the guidance to clinicians relating to medicines management in a community setting, for example depot vs oral medication.
• reviews how legislation is used in the community to deliver medication for those patients who have a serious mental illness and where it is known they are non-compliant with medication regimes.

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