Summary

Following the conviction of Valdo Calocane in January 2024, for the killings of Ian Coates, Grace O'Malley-Kumar and Barnaby Webber, the CQC were commissioned to carry out a special review of mental health services at Nottinghamshire Healthcare NHSFT (NHFT) by the Secretary of State for Health & Social Care (s.48 of the Health & Social Care Act 2008).

Part 2 of the review was published on 13th August and focuses on the care of Valdo Calocane, identifying a number of issues and concerns suggesting that there "were a series of errors, omissions and misjudgements" in his care.

The report also highlights that "the issues we have identified at NHFT are not unique" and highlight "systemic issues with community mental health care which, without immediate action, will continue to pose an inherent risk to patient and public safety".

What was the review about?

Following the publication of Part 1 of the review in March, (focusing on safety and quality of care provided by NHFT and Rampton,) Part 2 of the review sets out the results of the rapid review of the care of Valdo Calocane ('VC' and 10 benchmarking cases) to determine whether this indicates wider patient safety concerns or systemic issues.

A more detailed review will, of course, be carried out by NHS England's Independent Mental Health Homicide Review, in due course.

What were the key findings of the review?

The review identified systemic issues with community mental health care, including staff shortages and a lack of integration with other healthcare, social care and support agencies, including the police.

In relation to VC's care the review concluded that:-

• Had VC been detained on a s.3 on his last (fourth) admission, further options would have been available to him, in particular the possible use of a Community Treatment Order (CTO);
• There was a series of 'errors, omissions and misjudgements', including:-
  • the decision to discharge him back to his GP's care;
  • inconsistent approaches to risk assessment;
  • poor care planning & engagement with VC & family;
  • failures to manage capacity to consent & capacity assessments.
• In relation to VC's history of non-compliance with medication and refusal to have medication via a depot injection, the review flagged concerns over the Trust's "balancing of VC's wishes with other information they may have held and what might be in his best interests. This could be seen as a missed opportunity, as his detention under the MHA presented the possibility of changing his medication to be able to treat his symptoms more robustly."
• Discharge plans failed to take a more holistic view, and did not focus on what was required for a successful recovery in the community. Later discharges did not take into account previous failures to maintain recovery in the community, leading to relapses & VC becoming violent.
• The decision to discharge VC from community mental health services back to his GP due to non-engagement "did not adequately consider or mitigate the risk of relapse and violence due to his persistent poor insight and resistance to treatment, which were symptoms of his illness.''

Practical Impact

Whilst the review made recommendations for NHFT at a Trust level, since systemic issues with community care requiring immediate national action were identified, the review also made recommendations at a national level.

This included recommendations that NHS England ensures that:-

• "Providers’ boards fully understand their role in the oversight of the needs of patients who have a serious mental illness and who find it difficult to engage with services. This includes developing local services in partnership with others to provide intensive support in order to prevent this cohort of patients from falling through the gaps."
• "Every provider and commissioner in England undertakes a review of the model of care in place for patients with complex psychosis who typical services struggle to engage and who present with high risk."

What Next?

All providers and commissioners will need to ensure that they have the necessary understanding of their roles and that the required review of relevant models of care is carried out.

Providers will need to ensure that 'lessons are learnt' from the review, in particular, in relation to discharge planning, risk assessment, patient & family engagement, capacity assessments and the use of the MHA, including CTOs.

The Health & Social Care Secretary has responded to the review report (13^th August) confirming that the NHS has accepted the CQC's recommendations and that he expects them to be considered and applied.

Whilst this response does not refer to MHA reform, it has been suggested that any reform may now be 'slowed down' as a result of the review findings. It remains to be seen, however, what the impact of the review will be, both in terms of timescales and content of any reforms.

How we can help

We can provide assistance, advice and training on the issues flagged by the review and in particular, a bespoke session for provider boards on the implications of the review for them in respect of their responsibility for community mental health services.

Our national team of mental health specialists has extensive experience in advising health and social care providers and commissioners in relation to all aspects of the MHA and its interface with the MCA and broader regulatory framework.

We also have extensive experience of the practical challenges of delivering community treatment to individuals who are difficult to engage and the associated risks and adverse outcomes which we regularly see in the context of inquests and other regulatory investigations.