Nottingham attacks NHS trust faces manslaughter probe

The NHS trust that treated Nottingham attacks killer Valdo Calocane is being investigated for corporate manslaughter.

Calocane, who had been diagnosed with paranoid schizophrenia in 2020 before he fatally attacked Barnaby Webber, Grace O'Malley-Kumar and Ian Coates in June 2023, was previously sectioned by Nottinghamshire Healthcare NHS Foundation Trust.

A statutory public inquiry, which finished hearing evidence in May, was told he had been discharged in 2022 because he failed to turn up for appointments and the team had "lost" him.

The families of Calocane's victims said the NHS trust had "catastrophically failed at every level" and welcomed the investigation.

Northumbria Police confirmed it was carrying out the investigation "on behalf of Nottinghamshire Police".

A spokesperson for the Northumbria force said: "We are in contact with the victims' families and survivors and are committed to supporting them throughout this process.

"It would not be appropriate for us to comment any further."

Nottinghamshire Police has been criticised over its history of interactions with Calocane and its handling of the response and investigation into the attacks.

A spokesperson for Nottinghamshire Healthcare NHS Foundation Trust said: "Northumbria Police, acting on behalf of Nottinghamshire Police, have begun an investigation into matters relating to the care and treatment of Valdo Calocane.

"We know how important the independent inquiry and police investigation are for the affected families, the survivors and our local communities.

"We will, of course, be co-operating fully with Northumbria Police, as we have with the statutory inquiry into these matters which is being chaired by Her Honour Deborah Taylor, and which will hear final submissions from all the parties involved later this year."

Nottinghamshire Healthcare NHS Foundation Trust was responsible for Calocane's care for two years before he was discharged in September 2022.

He was sectioned under the Mental Health Act four times during that two-year period and warned by a doctor he would end up killing somebody.

Following the attacks, he pleaded guilty to three counts of manslaughter, on the grounds of diminished responsibility, and to three counts of attempted murder.

Calocane is currently serving an indefinite hospital order in a high-security facility.

The Nottingham Inquiry, which heard evidence from doctors, nurses and other NHS staff, was told there had been numerous errors in Calocane's care and management.

Dr Sanjoy Kumar, Grace O'Malley-Kumar's father, said he was "delighted" the "very high threshold" for a corporate manslaughter investigation had been met and believed it was "crucial" to avoid future deaths.

He told the BBC: "I think what the inquiry showed us is that the failings weren't just at the senior management, they went all through this organisation, all the way from the people who work with the parents, all the way to the top."

"I think this mental health trust failed catastrophically, and from every angle.

"I think it [the investigation] will put every mental health trust across the country on notice so that these catastrophic failings don't happen again."

In a statement, Emma Webber, the mother of Barnaby Webber - who had been walking from a night out with Grace when they were attacked - said the investigation signified the "beginning of the reckoning" and accountability the families had been calling for.

"This has to be the line in the sand - when those who fail, neglect and cover up, from the leaders at the top down, are fully held to account and made to recognise their failures," she said.

"This includes chief executives, chairmen of the board, non-executive and executive board members, as well as the negligent clinicians, practitioners and hospital managers who over a sustained period failed to manage and recognise the threat posed by Valdo Calocane.

"We now ask that, for the first time, all of those involved who will be required to participate do so with full candour and transparency."

Lee Coates, one of Ian Coates's three sons, said: "We found out a little while ago that [Northumbria Police] were going to be looking into this. We're really happy that they are looking into it. It kind of solidifies everything that we we've been fighting towards," he said.

Lee added the while the investigation related to corporate manslaughter, he was told individual accountability "could be looked at as well", if deemed appropriate.

If the trust was to be found guilty of corporate manslaughter, it could face an unlimited fine.

Under sentencing guidelines in England and Wales, a large organisation - with a turnover of more than £50m - could be fined up to £20m, depending on the severity of the offence as well as aggravating and mitigating factors.

One of the key themes in the evidence about the triple killer's care under the Nottinghamshire trust was that his risk to others was not properly assessed or managed.

Calocane had a history of non-compliance with his medication and was known to become violent when he was unwell, the inquiry heard.

The trust had already been under the close scrutiny of the health and social care watchdog, the Care Quality Commission (CQC), before Calocane was under its care.

In October 2021, an email to staff said the trust had reached a point where services were "not safe", with concerns raised about staffing levels.

By then, Calocane had been sectioned three times.

Gary Carter, a former mental health nurse who was one of Calocane's care co-ordinators, told the inquiry the killer had "out-manoeuvred medical and nursing services within the trust".

In his evidence, he said: "The inpatient services had failed. And basically, people ran out of ideas.

"People had just run out of ideas as to how to manage this man, when it was blatantly obvious what needed to happen to him."

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