The Nottingham stabbings could – and should – have been avoided

Editorial: Where did things go wrong? For the Nottinghamshire trust, the litany of weaknesses identified by the CQC is damning

The conclusion is that Colcane should have been detained under the provisions of the Mental Health Act 1983 (PA/Nottinghamshire Police)

The Nottingham stabbings were shocking enough when news of the triple killings and three other attempted murders broke in June last year.

Such brutal, random killings are mercifully rare and it soon became apparent that the perpetrator, Valdo Calocane, was suffering from severe mental illness at the time, and indeed had been for a material period – two years.

In due course, Calocane was tried, had his plea of diminished responsibility accepted, and was found guilty of manslaughter. That was the end of any threat Calocane posed to the public; however, it was also when the scale of the scandal began to emerge.

As the final section of the Care Quality Commission (CQC) report into the affair indicates, the Nottinghamshire Healthcare NHS Foundation Trust committed serious failings in its dealings with Calocane.

Not only that but, as The Independent exclusively reports, Calocane was only one of many blunders made by the trust over the years. The contents of these investigations should be deeply shaming and concerning to the authorities concerned.

They are also bound to worry a public concerned with what seems to be an upsurge in extremely violent offences with a link to people suffering mental health issues. It should be stressed from the outset that one in four of the population suffers from some sort of mental health problem at some time in their lives. By no means are all prone to violence.

Other factors, as with the wider population, also come into play, notably family and early relationship instability, alcohol and substance misuse, and shortcomings in medical care and supervision.

Where did things go wrong? For the Nottinghamshire trust, the litany of weaknesses identified by the CQC is damning. In short, the conclusion is that Calocane could and should have been “sectioned” (detained under the provisions of the Mental Health Act 1983). Had he been, then his paranoid schizophrenia and lapses in taking his medication would have been better controlled and he would certainly have posed less of a risk to the public.

Lives would have been saved. Instead, despite his medical history – and after one incident and period of detention – the risk assessments were botched, warnings by his family dismissed and he was discharged to the care of his GP. That GP was in no position to exercise full responsibility when Calocane was disinclined to keep in contact with them. As the CQC shows, the Nottinghamshire trust “did not adequately consider or mitigate the risks of relapse”.

A BBC investigation additionally reveals that one doctor warned three years before the Nottingham attacks that Calocane’s mental illness was so severe he could “end up killing someone”. This has only come into the public domain because Calocane’s mother and brother obtained a 300-page summary of his medical records. That was only after he’d been sentenced for his crimes.

Errors of judgement can, and do, happen from time to time in all manner of organisations; but where mental health professionals are concerned, truly devastating consequences can ensue – both for the patient and the public.

It may be pleaded that no health provider is flawless, which is true enough. Yet the problem with the Nottinghamshire trust is that the CQC, the investigations by The Doctor magazine, the BBC and The Independent have found that concerns about the trust’s services – not confined to Calocane – have been raised repeatedly for several years.

Insufficient action was taken by the trust, or organisations with oversight, local experts say. Lessons were not being learnt. It seems that a “panicked and anxious leadership” presided over “a culture where staff do not feel able to speak up”.

Without wishing to overuse the expression, it seems Nottinghamshire Healthcare NHS Foundation was suffering from institutional negligence.

We have seen parallel scandals unfold elsewhere on the health scene, notably in maternity care, and, in a different context, the long-running infected blood scandal. The unique factor with mental health care is that over the past decade or so, governments have sought to raise the profile and esteem of the neglected sector and place it on a par with physical health, in terms of resources and managerial attention.

It is not, as a general rule, something the authorities were entirely ignorant about; rather, a part of the health system that was given disproportionate and concerned attention. Common sense suggests that Nottinghamshire is not the only area in the UK where such problems are growing.