Systemic failings in mental health care allowed a man with paranoid schizophrenia to kill three people, an inquiry has heard, as the mother and brother of Valdo Calocane say the system itself is a “gaping hole” that leaves families feeling hopeless and patients untreated until it is too late.
On 13 June 2023, Calocane, then 32, carried out a series of attacks in Nottingham that devastated the city and shocked the nation. He fatally stabbed Barnaby Webber, a 19-year-old history student, and Grace O’Malley-Kumar, a 19-year-old aspiring medic, before killing 65-year-old caretaker Ian Coates. He then stole Mr Coates’ van and drove it into three other people – Wayne Birkett, Sharon Miller and Marcin Gawronski – leaving them seriously injured. Counterterror police were deployed, though it was never declared a terror incident.
Calocane later pleaded guilty to three counts of manslaughter on the grounds of diminished responsibility and three counts of attempted murder. In January 2024, Mr Justice Turner sentenced him to an indefinite hospital order at Ashworth High Secure mental health hospital in Liverpool, noting the triple killer had been “governed by paranoid delusions” and that psychiatrists unanimously agreed his schizophrenia was the cause of the crimes.
The attacks came after years of escalating mental health crises. Calocane, who moved to Nottingham from Haverfordwest, Pembrokeshire, to study mechanical engineering, first developed anxiety and paranoia in 2020. Doctors initially attributed it to stress, sleep deprivation and Covid isolation. But in May 2020 he was arrested for breaking into a neighbour’s flat, wrongly believing his mother was being attacked. The woman was so frightened she jumped from a second-floor window, breaking her spine. Shortly after, Calocane was diagnosed with psychosis and later with paranoid schizophrenia.
Between 2020 and 2022, he was admitted four times to mental health hospitals, including Highbury Hospital and units run by the Priory Group and Cygnet Healthcare. However, following each admission he was discharged back to a community team. During that time he stopped taking his medication and attending appointments. In September 2022, he was discharged into the care of his GP without a risk assessment or follow-up from mental health services and despite concerns about his risk of violent behaviour. The inquiry later heard he was discharged because the community team “could not find him”.
A catalogue of care failures
Multiple reports have examined the role of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) in Calocane’s care. A special review by the Care Quality Commission (CQC) found a series of “errors, omissions and misjudgments”. The CQC said the risk Calocane posed to the public was “not managed well”, and that people under the trust’s care “struggled to access the care they needed when they needed it, putting themselves and potentially members of the public at risk of harm.”
Key criticisms of NHFT include inadequate risk assessments that minimised or omitted crucial details and failed to state the serious nature of the risk Calocane posed. A psychiatrist had noted in July 2020 that Calocane showed “no insight or remorse” and that there was a danger of him “killing someone” again. Yet risk assessments did not reflect that. There was also poor discharge planning: Calocane was discharged back to his GP without consulting his family, GP or police, and without adequate consideration of relapse and violence risks. This occurred despite an arrest warrant being issued for assaulting a police officer on the same day he was sectioned. The CQC suggested he could have been detained under Section 3 of the Mental Health Act during his fourth admission, allowing for depot medication and a community treatment order.
Engagement with Calocane’s family was severely lacking. His mother, Celeste Calocane, said she repeatedly warned clinicians that her son was “not doing well”, but was told he was fine because he was not in “imminent crisis” and was “stable”. An NHS report found services did not properly assess the risk he presented to himself and others and did not effectively consult with the family, who were kept in the dark about his condition.
NHFT’s leadership and governance have also been criticised. The trust has undergone frequent changes in executive leadership, leading to a loss of experience, and senior leaders lacked clear oversight of risks. In May 2026, the trust referred three nurses to the Nursing and Midwifery Council and a doctor self-referred to the General Medical Council over failings in Calocane’s care.
The CQC’s special review found failings in community mental health services and Rampton Hospital, making 17 recommendations in Part 1 and 8 in Part 2. Another independent report into NHS failings found the care and treatment available to Calocane before the attacks “was not always sufficient to meet his needs”, prompting health officials to admit it was “clear the system got it wrong”.
A system built to react, not prevent
Calocane’s brother, Elias, a Cambridge University graduate, described the mental health system as “firefighting” – built to react to patients in crisis, stabilise them and discharge them, rather than to prevent things getting worse. “It doesn’t really prevent fires. It reacts when the fire is there,” he said. “You just get this build-up of crisis, until eventually something unimaginable happens.”
Between 2013 and 2023, there were more than 392 homicides by mental health patients in England, according to a freedom of information request by the campaign group Hundred Families. That averages about 65 per year, though some figures suggest the true number may be higher due to discrepancies in data collection. A 2022 Oxford University study indicated the overall risk of violence among people with schizophrenia is low, and guidance from the charity Mind states they are more likely to be victims of crime or self-harm. Nevertheless, the Calocane case highlights how a specific failure to manage risk can have catastrophic consequences.
Elias said the clinicians treating his brother were “firefighting” in a system built to react, leaving the family feeling “hopeless”. Every time, he said, “you’re flipping the coin – is it gonna be a monumental tragedy or is it gonna be something that’s relatively less bad but still bad?” The family believes the “systemic failings” stem from inadequate funding for mental health services. Some 1.8 million patients in England are waiting to access community mental health care, while the number of mental health hospital beds fell from 23,515 in 2010 to 17,789 in 2024. The proportion of overall NHS funding allocated to mental health for 2026-27 will decrease to 8.4% from 8.68% in 2025-26, the third consecutive annual drop.
The Calocane family also highlighted the absence of an assertive outreach team – a specialist psychosis team designed to work proactively with patients who engage poorly with services and repeatedly relapse. Such teams were launched after the 1994 Ritchie inquiry into the case of Christopher Clunis, who fatally stabbed Jonathan Zito in 1992. But only around 30% of the country is understood to have such a team, and one was not in place in Calocane’s area at the time of his attacks. Had he been under one, his family believes earlier intervention and a closer working relationship could have prevented his deterioration. “One thing that is said commonly with illnesses such as schizophrenia, if you treat it early, the earlier the better,” Elias said.
Celeste Calocane said her son had been a quiet, studious pupil who regularly attended church. “I’ve raised three wonderful kids – brilliant, moral and kind – with respect. Just the only difference, one of them went on to develop paranoid schizophrenia,” she said. She and Elias remember the person before the illness, but acknowledge that for the bereaved families, Valdo will be defined by what he did.
Families’ divided views on accountability
The families of the victims have responded to the issues raised. David and Emma Webber, Barnaby’s parents, said in a statement: “While we recognise the Calocane family have themselves spoken about failures in mental health care, we do not share all of the views or evidence presented on their behalf during the inquiry. As Barney’s parents, the central issue for us remains the extensive and entirely avoidable systemic failures across multiple agencies that allowed these killings to happen.” They said they remained “disappointed that certain questions around engagement, decision-making, and accountability have not been fully addressed.”
Grace’s father, Dr Sanjoy Kumar, acknowledged systemic failures but said he did not believe the issue was underfunding. “Almost all the psychiatrists failed to do their duty adequately. This was not because of underfunding – this was because mental health workers who came into contact with him didn’t do their jobs,” he told The Independent. He said Calocane should have been sectioned, staff should have checked he was taking his medication, and he should not have been discharged. Dr Kumar also criticised the Calocane family’s level of engagement, pointing out that Celeste Calocane visited her son fewer than a handful of times in the three years before the attacks, and that Elias failed to forward messages from Calocane sent the night before the attack to police or crisis teams. During the inquiry, both Elias and Celeste said they thought the main risk for Calocane was suicide, not harming others, but Dr Kumar suggested there was no evidence of potential self-harm. “It’s all very good to blame a mental health system but not when that system also relies on the family being an integral part of the cure – this would be hypocritical,” he said.
Celeste Calocane defended herself, saying one of the three years was during the Covid pandemic and that in the months that followed, Calocane wanted to see his family less and less. Barristers for the victims’ families had raised claims during the inquiry that the Calocanes did not properly communicate with doctors over the risk of violence, which they said was reflected in text messages.
A public inquiry and a family’s plea
A statutory public inquiry, chaired by Her Honour Deborah Taylor, was announced in February 2025 and formally established in May 2025. Its terms of reference include examining the management of Calocane’s risk to others, the emergency services’ response on the day of the attacks, a timeline of his interactions with public services between 2019 and June 2023, the effectiveness of multi-agency working, and the Crown Prosecution Service’s handling of the case. Evidence hearings began on 23 February 2026 and are expected to run until the end of May 2026. The final report is due in Spring 2027.
Celeste Calocane said she is hopeful the inquiry will bring change, but warned that lessons should have been learned after the Ritchie inquiry more than three decades ago. “I’ve had enough of thinking lessons are gonna be learned. When will we learn a lesson? Do we need another three decades to learn? We haven’t got time for that,” she said. She believes that without a change in government priorities on mental health funding, there is not “a shadow of a doubt” that more devastating deaths will occur.
“The government needs to sit down and check their priorities because mental health can go on to affect other lives if something goes wrong,” she said. “What happened to Valdo – it didn’t just change my life. It changed seven other families, including us.”