A series of failings in the care of Valdo Calocane before he killed three people in Nottingham in 2023, have been identified by an independent report.

The report reveals that “the system got it wrong” with Calocane, who stabbed to death Barnaby Webber, Grace O'Malley-Kumar and Ian Coates in June 2023.

He then stole Mr Coates's van before driving it into three pedestrians, Wayne Biretta, Marcin Wronski and Sharon Miller, all of whom were seriously injured.

The report details how Calocane, who has paranoid schizophrenia, had no contact with mental health services nor his GP for about nine months prior to the killings after he was discharged when he repeatedly failed to engage with them.

The independent review, by Theemis Consulting, looked into the treatment given to Calocane by Nottinghamshire Healthcare NHS Foundation Trust before the killings, as well as the interactions the NHS had with other agencies involved in his care.

The key findings of the report include:

• Calocane's risk "was not fully understood, managed, documented or communicated."
• There were missed opportunities to take more assertive action towards Calocane's care.
• The views of Calocane's family "were not effectively considered to support the dynamic evaluation of risk" during his treatment.
• Other patients under the care of the same trust, some of whom had been discharged, had also perpetrated acts of "serious violence" across 15 incidents between 2019 and 2023.
• Calocane had no contact with mental health services or his GP for about nine months prior to the killings.
• Other patients under the care of the same trust, some of whom had been discharged, had also perpetrated acts of "serious violence" across 15 incidents between 2019 and 2023.
• Calocane had no contact with mental health services or his GP for about nine months before the killings.

A detail in the report said that Calocane was not forced to take his anti-psychotic medication partly because he did not like needles.

The NHS said it had taken the decision to publish the report in full “in line with the wishes of the families and given the level of detail already in the public domain.”

The report says the former University of Nottingham student first came into contact with mental health services on 24 May 2020, when he was 28, when he was arrested for criminal damage to a neighbour's flat.

It was documented that Calocane's behaviour was an episode of psychosis brought on by the stress of course work and a forthcoming exam, coupled with a lack of sleep.

Shortly after returning to his home, Calocane again tried to gain access to a neighbour's flat. His neighbour was so frightened that she jumped from a first-floor window, sustaining back injuries which required surgery.

Calocane was then sectioned for the first time under Section 2 of the Mental Health Act, which meant he could be kept in hospital against his will for up to 28 days.

Subsequent contacts with services saw him labelled as having paranoid schizophrenia.

After about a month in hospital, Calocane was sent home with reviews expected from the Community Crisis Team and the Early Intervention in Psychosis (EIP) service.

He was initially contacted by the crisis team by phone rather than a face-to-face appointment "because of Covid-19 restrictions at the time."

His family expressed concerns because they felt he could "play down his symptoms" during a phone call.

In July 2020, Calocane was admitted to hospital for a second time after forcibly entering a neighbour's flat.

He was sectioned again, this time under Section 3 of the Mental Health Act, which allows a hospital stay of up to six months.

According to medical records shared by Calocane’s family with BBC Panorama, while Calocane was ill in hospital, a psychiatrist observed that "there seems to be no insight or remorse and the danger is that this will happen again and perhaps Valdo will end up killing someone."

Two weeks after this entry was made, Calocane was discharged from Highbury Hospital.

According to the report, his family "felt this was a real missed opportunity to fully understand [Calocane's] diagnosis, risk and to get to grips with a treatment plan that [Calocane] was concordant with."

Three months before his third hospital admission in August 2021, Calocane's family again reported concerns about his mental health.

At the end of August, his care co-ordinator visited him at home with a colleague, noting that he was no longer taking his medication and had no intention of continuing treatment.

A month later, the report said he had "significantly assaulted" police officers who attended in support of a Mental Health Act assessment.

On a number of occasions, his care co-ordinator had suggested the use of depot medication which releases slowly over time meaning patients need to administer medications less frequently.

But, the report said, the inpatient teams were trying to treat him "in the least restrictive way", and took on board his reasons for not wanting to take injectable depot medication, "which included him not liking needles."

After multiple missed appointments, in January 2022, officials contemplated discharging Calocane from the EIP service due to a lack of engagement.

But the following day, the EIP learned Calocane had trapped two housemates in their flat, which resulted in the police being called.

He was assessed under the Mental Health Act, but not detained.

Calocane's mother Celeste and brother Elias say there were a series of missed opportunities during three years to prevent the tragedy.

Calocane was admitted to hospital at the end of January 2022 for almost a month, his fourth hospital admission.

After being discharged, it was noted that none of Calocane's care providers should visit him at home alone because of his "history of violence and aggression." 

Calocane then missed a few appointments to collect his medication during the following months, and a new care co-ordinator tried to contact him multiple times.

After these failed attempts, a decision was taken in September 2022 to discharge Calocane from the EIP service to his GP.

The report said "opportunities to assertively try to reach out to [Calocane] when he disengaged from services were limited" because of pressures in the team. It added:  "Due to multiple factors, including workload, the discharge system did not function as intended."

It added there was no contact between Calocane and mental health services, or his GP, for roughly nine months from this time until the killings.

Regional medical director at NHS England (Midlands), Dr Jessica Sokolowski, said it was "clear the system got it wrong" and apologised to the victims "on behalf of the NHS and the organisations involved" in Calocane's care.

NHS England's national mental health director, Claire Murdoch, said the organisation had asked every mental health trust to review the report findings.

Chief executive of mental health charity Sane, Marjorie Wallace, said the publication of the review "should act as a watershed moment revealing the truth and honouring the needs of the families of victims of homicides by people with mental illness or disorder."

Mr Webber's mother Emma described the report as a "horror show."

She added:"It's been additional trauma, horror, disbelief and fury but all of that was anticipated and expected by all three families. It leaves us feeling horrified, heartbroken, but even more determined now to make sure that it's addressed, that the government and the agencies react and listen properly."

In response, the government repeated its commitment to a public inquiry into the attacks, with work ongoing to establish its scope.