Nottinghamshire Healthcare NHS Foundation Trust says that it has implemented all of the changes recommended by NHS England and the Care Quality Commission since the Nottingham Attacks. But what are they?
On June 13, 2023, paranoid schizophrenic Valdo Calocane, who had been in and out of mental health care services run by Nottinghamshire Healthcare Trust in the three years prior, killed three people, and seriously injured three more, in a spate of horrific attacks.
In the years since, a number of investigations have taken place into the care of Calocane, with each recommending what the trust needed to change in order to help ensure that something so tragic would not happen again.
As well as the trust’s internal investigation, the Care Quality Commission, which regulates healthcare facilities across England, published its own review – under Section 48 of the Health & Social Care Act 1948 – in August 2024.
NHS England also conducted a review, using an external independent consulting agency called Theemis, which was published in February 2025.
At a meeting of the Nottinghamshire Healthcare board of directors in March 2026, the trust said it had completed all 66 actions across 10 recommendations set out by NHS England and all 8 CQC recommendations directly related to Valdo Calocane’s care.
Here are the most important ones.
Family information sharing
In the years since the attacks, the public have learnt how Valdo Calocane’s family did not know he had been diagnosed with schizophrenia until after the attacks had happened, and that in late 2021, Calocane was allowed to decide that he no longer wanted information about his treatment shared with his family.
NHS England’s report said: “We found that whilst there were attempts to actively engage Calocane’s family in aspects of his care, there were important milestones when decisions were not discussed with them.”
It added that there were ‘opportunities’ to co-produce aspects of care planning with Calocane and his family, particularly around safety and scenario planning – but that there was limited evidence that this had happened.
The report said: “Arrangements need to be put in place to ensure co-production of care documentation. In Calocane’s case, there was a sense that a shared understanding between clinicians and Calocane about his diagnosis and factors to keep him well was never fully reached.
Victims Ian Coates, Barnaby Webber and Grace O’Malley-Kumar, who died in the attacks of June 13, 2023(Image: Nottinghamshire Police/PA)
“We did not find evidence that safety planning or scenario planning took place to help support VC and his family.”
The CQC’s report found similar, referring to incidents such as when Calocane’s family contacted the trust after he was first discharged from hospital in July 2020, to say they were concerned his mental state was deteriorating again.
Evidence showed that these concerns were documented, but there was no record of any attempts by teams to contact Calocane afterwards.
The report says: “This raises questions about how well the team engaged with Calocane’s family, as well as questions over the quality of record keeping.”
The CQC recommended that Nottinghamshire Healthcare must ensure that, in line with national guidance and best practice, staff are aware of the importance of involving and engaging patients’ families and carers.
The CQC report adds: “(The trust must ensure) that they do so in all aspects of care and treatment, including at the point of discharge, with patient consent.
“Where patients do not give consent, [it should be ensured that] this [is] reviewed on a regular basis in line with best practice and on all the available information available to the multidisciplinary team.”
Nottinghamshire Healthcare said it has employed a “director of participation, co-production, patient and carer experience”, developed a participation strategy, created videos for staff about the importance of involving carers, increased the number of care support workers and tripled the number of volunteers working in the trust.
In addition, it said there was now a policy for the “co-production of care and safety plans”, and that the care plan template on the trust’s RiO system – where medical notes and logs are kept – had been reviewed to ensure it met the standards for co-produced care plans and was written in a language accessible for patients and their families.
Training is now also delivered on the co-production of care and safety planning, including by former patients and families who have been involved with the trust’s services.
Peer support
The Nottingham Inquiry has been told how Valdo Calocane was adamant that he was not mentally ill. He told family he ‘knew’ the voices in his head were part of a conspiracy by authorities such as the police and security services to watch him.
NHS England said in its report that, throughout his entire time in the mental healthcare system, Calocane was never introduced to anyone else with a paranoid schizophrenia diagnosis like his, a similar level of care or a similar cultural background.
The recommendations say: “We found that Calocane may have benefited from being offered peer support within the Early Intervention in Psychosis (EIP) service.
“We did not find evidence that he was given the opportunity to meet with people who had a shared experience of diagnosis, care or cultural background. We consider there were limited opportunities to try to engage him in being curious about his diagnosis and how to keep him well.
“The Trust should ensure that there is a robust peer support offer for those under community mental health services with access to culturally appropriate groups with lived experience.”
Nottinghamshire Healthcare says that its ‘participation strategy’ will expand the ‘breadth and diversity’ of peer support workers so that people are able to access culturally appropriate groups.
The strategy will also ensure robust and supportive systems are in place for the recruitment, enhanced supervision, support plans and training of those peer support workers.
Discharge process
Valdo Calocane was discharged from Nottinghamshire Healthcare back to his GP in September 2022 because they couldn’t get in touch with him.
The CQC review says that there was no evidence that his family or GP was even told.
For the next nine months, no medical professionals knew where he was or what he was doing – they’d all but forgotten about him.
Valdo Calocane was wrongly discharged back to his GP nine months before the Nottingham Attacks – a fatal decision(Image: PA)
On June 13, 2023, he arrived back in Nottingham from London and killed three people.
The CQC told the trust it must implement a number of policies to change the way it deals with patients who disengage.
The report says: “At trust level, Nottinghamshire Healthcare must have a robust policy and processes for discharge that consider the circumstances surrounding discharge and whether it is appropriate.
“For community mental health services for working age adults, the trust must ensure all practicable efforts are made to engage patients who have disengaged from the early intervention in psychosis (EIP) service, which includes referring people who find it difficult to engage with services to a team that provides assertive and intensive support.
“The trust must ensure there is a standard operating procedure in place for early intervention in psychosis and community teams to follow when a patient does not attend for appointments and that follow-up actions are defined for care co-ordinators.”
The Trust explained that it had implemented a new policy whereby no patient is now discharged simply because they have disengaged from services.
Documents say: “A new patient engagement plan and assertive outreach pathway has been created for patients known to be more complex and at risk of disengagement.”
When a team wants to discharge a patient because they can’t get in touch with them, it will be flagged on a new dashboard and trigger a mandatory review by senior bosses.
They will then determine whether discharge is appropriate and whether all engagement steps have been taken.
Liaising with other departments in the trust, third parties and other agencies
NHS England found that cross-department communication within Nottinghamshire Healthcare was poor, as it was with third-party providers who took patients on behalf of the trust.
The report said: “We found that there were limitations in the sharing of clinical information across settings which impacted on the ability of those who were caring for Calocane to fully understand his needs.
“The current system capability does not allow for the timely sharing of important clinical information between the Trust and independent providers who are placing the Trust’s patients in their services.
“Additionally, the sharing of information with Primary Care to inform important conversation, for example in relation to potential patient discharges, needs to be improved.”
The review found that guidance from the Early Intervention in Psychosis (EIP) team, which dealt with Calocane when he was not in hospital, was dismissed by other teams.
The report said: “We observed that inpatient services did not appear to always pay sufficient regard to some potentially important clinical insights and longer-term views provided by the EIP team.
“The EIP team had longitudinal insights into Calocane’s symptoms and their impact upon his behaviour and his ability to engage with a therapeutic regime. This was most notable regarding the EIP’s request for the use of depot medication, which was considered and dismissed by the inpatient team.
“Neither was the use of a Community Treatment Order (CTO) under the mental health legislation considered necessary by the inpatient team.”
Depot medication is long-term, injectable medicine that releases slowly and is an alternative to other options such as oral medication.
Valdo Calocane refused depot medication, supposedly because he “didn’t like needles”.
A Community Treatment Order is only available under a Section 3 Mental Health Act detention and means someone is supervised more closely when out of hospital.
It would have allowed “an enhanced understanding for the individual and the clinical team” involved in Calocane’s care, and would have meant he could have been legally recalled to hospital if he didn’t take his medication or missed too many appointments.
A Section 3 could have also mandated the use of depot medication.
But in Calocane’s final admission to hospital in 2022, only a section 2 detention was used.
Between his first admission to hospital in May 2020 and the attacks, it wasn’t just Nottinghamshire Healthcare that had dealings with Valdo Calocane.
Particularly, Nottinghamshire Police were involved, when they were called on numerous occasions due to his behaviour, including assaults on flatmates and police officers themselves who had been sent to help section him.
The University of Nottingham, where he studied, was also involved, as was Leicestershire Police in an assault incident at a place Calocane was working at, weeks before the killings in June 2023.
The NHS report said that more needed to be done by Nottinghamshire Healthcare to share and receive information with and from other organisations.
It said: “We found that, at times in VC’s care and treatment, healthcare professionals were making decisions without a full understanding of information held by all organisations involved with VC.
“There is the opportunity for system partners to come together to review the arrangements in place for proactively sharing information in a timely manner. “
The Trust said that it has ensured that its internal systems are ‘interoperable’ and allows “sharing of related patient data across all care groups and settings”.
In addition, private providers of hospital beds that the trust uses are now contracted to implement the same ‘continuity of care’ principles as the trust itself, and have access to the Trust’s RiO system, where medical notes and logs are kept.
The Trust has also “reviewed and strengthened” the electronic information sharing processes with external care providers – such as discharge summaries.
And, as well as review of policies and processes to ensure there is a “focus on engagement with external providers”, the trust has worked with the police, the local integrated care board (ICB) and safeguarding partners to “review the existing communication policies”.
Medicine
Because of his delusion that he was not mentally ill and that doctors and staff involved in his care was part of a system of collusion against him, Valdo Calocane often lapsed in taking his prescribed medicine, or refused it altogether.
The CQC recommended that, for community mental health services for working age adults, Nottinghamshire Healthcare must “ensure regular medicines monitoring takes place within the community and address any issues quickly where problems are identified”.
Nottinghamshire Healthcare said it now does this, and that an oversight of medication was now incorporated into clinical supervision and that regular auditing was now in place with weekly oversight of good practice.