The Care Quality Commission (CQC) has identified points of “poor decision-making, omissions and errors of judgement” in its review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust (NHFT) and the care Valdo Calocane received there, before he killed Ian Coates, Barnaby Webber and Grace O’Malley-Kumar in June 2023.
Today’s publication is the final strand of the review ordered by former health secretary Victoria Atkins at the start of this year. The CQC has concluded that, between May 2020 and September 2022 when Calocane was being treated for paranoid schizophrenia, a series of mistakes were made, including:
- the decision to discharge Calocane back to his GP in September 2022;
- inconsistent approaches to risk assessment; and
- poor care planning and engagement with Calocane and his family.
Findings
The CQC says that risk assessments were minimised or omitted key details and did not outline how serious a threat Calocane was to himself and others. The report also finds that Calocane’s family contacted NHFT to raise concerns numerous times but their concerns were not always acted on.
Also, the decision to discharge Calocane back to his GP because of his lack of engagement with mental health services did not appropriately consider or mitigate the risks of relapse – especially given the evidence that, in the CQC’s words, Calocane’s contact with services and the police suggested “beyond any real doubt” that he would relapse into distressing symptoms and potentially aggressive behaviour.
The review also found that if, during his fourth admission to hospital, the decision had been taken to treat Calocane under section 3 of the Mental Health Act 1983, there would have been more options for care and treatment in the community.
Recommendations
The report outlines a series of recommendations for a number of parties. They include that NHFT must regularly review treatment plans for schizophrenia patients to ensure they are in line with NICE guidelines. Also in line with national guidelines and best practice, staff must be cognizant of the importance of family engagement in all aspects of care and treatment.
NHFT should also ensure it has robust discharge policies and procedures in place that are mindful of the circumstances surrounding discharge and whether it is appropriate or not. The trust should also ensure that there is clinical supervision of all decisions to detain people under section 2 and 3 of the Mental Health Act, with regular audits of these people’s records which is then reported to the NHFT board.
For NHS England (NHSE), the CQC says that a named individual must be appointed to deliver these recommendations. Other recommendations include ensuring all provider boards fully understand their role in the oversight of patients who suffer from serious mental health issues and find it difficult to engage with the NHS.
Every provider and commissioner in England should also review its own treatment models for patients with complex psychosis who also find service engagement challenging.
Meanwhile, NHSE should also publish national standards for high-quality care for those with complex psychosis and paranoid schizophrenia – within three months of this publication, NHSE also needs to ensure every relevant body in England has developed an action plan to achieve these standards. The standards themselves should be achieved within 12 months.
In conjunction with the Royal College of Psychiatrists, NHSE should review and strengthen guidance pertaining to medicines management in community settings, as well as review how legislation is used in the community to deliver medication for patients with serious mental illness.
Reaction
“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,” said the CQC’s interim chief inspector of healthcare, Chris Dzikiti.
“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.”
Dzikiti adds that, as well as the aforementioned actions, wider national action is needed to tackle systemic issues in community mental health – this includes a shortage of staff and a lack of integration between mental health services and other services.
Responding to the report, health secretary Wes Streeting said: “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 Ian’s family are living with.”
He added: “Action is already underway to address the serious failures identified by the CQC and I expect regular progress reports from the NHFT.”
The NHS has already accepted all of the recommendations from the first two strands of the report, which were published back in March. The CQC itself is under review and is “not fit for purpose” according to Streeting after interim findings from Dr Penny Dash’s report were brought to light.
Image credit: Nottinghamshire Police
