A major NHS England report has uncovered a series of failings in the mental health care of Valdo Calocane, the man responsible for the 2023 Nottingham attacks that left three people dead.
The report reveals that Calocane was not forced to take his anti-psychotic medication, in part because he disliked needles, and was discharged despite serious risks.
The victims, Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates, were stabbed to death in June 2023 in an attack that shocked the UK. The investigation found that Calocane, who has paranoid schizophrenia, had no contact with mental health services or his GP for nine months before the killings.
‘The System Got It Wrong,’ Says NHS England
The independent review, conducted by Theemis Consulting, identified multiple missed opportunities to manage Calocane’s care effectively. The report’s key findings include:
• Calocane’s risk was not fully understood, managed, or communicated
• Mental health services failed to take assertive action despite warning signs
• His family’s concerns were not effectively considered
• Other patients from the same NHS trust had also committed serious acts of violence
The report highlights that Calocane had been sectioned multiple times under the Mental Health Act, but his discharge process failed to ensure he continued treatment. Authorities repeatedly ignored his history of violence and missed clear warnings from medical professionals.
Victims’ Families Demand Urgent Action
Following the report’s publication, Barnaby Webber’s mother, Emma Webber, described the findings as a ‘horror show.’ She expressed disbelief and fury but vowed to continue fighting for reform.
“This has been additional trauma, horror, and heartbreak,” she said. “But we are now even more determined to ensure that the government and agencies take real action.”
James Coates, the son of victim Ian Coates, echoed this sentiment, stating: “Our focus is to ensure that mistakes like this are never repeated.”
Government Inquiry and NHS Response
The UK government has reiterated its commitment to an inquiry into the failings surrounding the case. Health Secretary Wes Streeting emphasized the importance of transparency, stating:
“Sunlight is the best disinfectant. This report will support an inquiry into the attack, and we will take the necessary next steps.”
The NHS has pledged to implement nationwide improvements, with every mental health trust instructed to review their practices in response to the findings.
Meanwhile, mental health charity Sane’s CEO, Marjorie Wallace, called the report a ‘watershed moment’, emphasizing the urgent need for reform in how high-risk mental health patients are managed.
History of Missed Warnings and Systemic Failures
The report details years of warnings ignored by mental health services, dating back to 2020 when Calocane was first detained under the Mental Health Act. His violent history included attacking police officers, trapping housemates in their flat, and terrifying neighbors—yet authorities failed to take sufficient action.
Even after a psychiatrist warned that Calocane had ‘no insight or remorse’ and could kill someone, he was discharged from hospital without a solid treatment plan.
His family repeatedly raised concerns, but workload pressures and systemic failures meant he was discharged without proper care in September 2022—just nine months before the deadly attacks.
Call for Urgent Reform in Mental Health Services
In response to the findings, the Nottinghamshire Healthcare NHS Foundation Trust issued a formal apology, admitting to missed opportunities in handling Calocane’s care.
Mental health experts and victim advocacy in groups are now calling for urgent changes in how high-risk psychiatric patients are monitored and treated.
As the government inquiry progresses, the families of the victims continue to demand accountability and lasting reform to prevent future tragedies.
