The service which cared for Nottingham killer Valdo Carrocane before his attacks has been accused of having “blood on its hands” after it emerged the NHS trust “trivialised or omitted” key details of the serious danger he posed to others.
Mr Carrocane, who suffers from paranoid schizophrenia, stabbed 19-year-old students Barnaby Webber and Grace O’Malley Kumar before killing 65-year-old carer Ian Coates in June 2023.
He was detained in a maximum security hospital in January – “highly likely to remain so for the rest of his life” – after prosecutors accepted a plea of ​​manslaughter due to diminished mental capacity.
The final part of a three-part review by the Care Quality Commission (CQC) looked at how Nottinghamshire Healthcare NHS Foundation Trust (NHFT) handled 32-year-old Carocaine’s care before the murder.
A risk assessment of the trust between May 2020 and September 2022 found that it downplayed the fact that Carocaine refused to take her medication and had persistent and enduring psychotic symptoms.
The regulator said that while some risks were highlighted, other assessments “downplayed or omitted important details”.
She added that the decision had been made to return the attacker to his GP in 2022 despite clear evidence that Carocane would “relapse into distressing symptoms and potentially aggressive behaviour”.
It also emerged that Mr Carocane had been hospitalised under the Mental Health Act four times before the attack.
The CQC said there appeared to be “a number of errors, omissions and misjudgments” in Carocane’s treatment.
Chris Zikity, the healthcare regulator’s interim chief inspector, said: “The review identifies poor decisions, omissions and errors of judgement which led to situations where patients with very serious mental health problems did not receive the support and care they deserve.”
He said it was not possible to say that the events of June last year would not have happened if Mr Carocane had received the support he needed, but “the risk that it posed to the public is clear. It was not managed properly and opportunities to mitigate that risk were missed.”
“The damage this has done to those affected, their families and loved ones is irreparable,” Mr Zikiti added.
The CQC has also questioned how well the trust was working with Kalokane’s family, who had raised concerns about his mental state on several occasions.
The victim’s family said the inquest findings were “shocking”.
“This report shows serious and systemic failings in the mental health trust’s response to Kalokane, from start to finish,” they said in a joint statement.
“We have been let down by several organisations both before and after June 2023.” These departments and individual professionals, such as Leicestershire and Nottinghamshire police, are bleeding.
“Shockingly, there appears to be almost no accountability amongst the leadership teams in psychiatric hospitals. We wonder how and why these people are still in public office.”
The family confirmed there would be a public inquiry into what led to the attack following meetings with Health Minister Wes Streeting and Attorney General Richard Harmer.
The special review of the NHFT’s mental health services was ordered by the then Health Minister Victoria Atkins in January after Carrocane was convicted.
In its findings published on Tuesday, the CQC said it was “clear that Carrocane was acutely unwell” from the time he was in the trust’s care.
He showed symptoms of psychosis, seemed to have little understanding or acceptance of his condition and had early problems taking his medication, the CQC reported.
The CQC also found that if Caloocan had been treated under section 3 of the Mental Health Act after his fourth hospital admission, medical staff might have considered giving him long-acting medication or placing him in acute care, even against his will, under a Community Treatment Order – which allows for treatment in the community rather than in hospital.
Instead, Caro-Cane was applied to section 2 of the act, which is normally used against people not known to mental health services.
Mr Streeting said the report was “disturbing reading, particularly for those who are living with the effects of her loss and know that her untimely death could have been avoided”.
“I want to reassure myself and the country that the failings identified in Nottinghamshire will not be repeated elsewhere”, he added.
A spokesman for the NHFT said: “Since this review we have made significant improvements to our procedures and standards. “
The handling of the Caro-Cane case sparked protests and led to numerous investigations by relevant public agencies, including Nottinghamshire Police and Leicestershire Police.