Mental Health Nurse Admits to Errors in Killer’s Records

Mental health nurse admits errors in killer – During a recent public inquiry, a mental health nurse confessed to inaccuracies in the case records of a man who later became responsible for a series of violent attacks in Nottingham. Valdo Calocane, diagnosed with paranoid schizophrenia, was linked to the fatal stabbing of three individuals in the city on 13 June 2023. The incidents included the deaths of Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates, with three others injured in the process. Calocane had been under the care of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) since May 2020 but was discharged in September 2022 due to limited engagement with his treatment plan.

Nurse’s Admission of Incomplete Documentation

At the Nottingham Inquiry on Monday, Busayo Ajewole, a mental health nurse, acknowledged that her notes sometimes contained incomplete data, were copied and pasted without review, and contained critical inaccuracies. She admitted that the records she maintained for Calocane, referred to throughout the inquiry as VC, were not fully reflective of his behavioral history. Ajewole emphasized that her documentation failed to capture key incidents, such as his prior episodes of aggression, which could have raised concerns about his risk to others.

“That’s not only lacking in detail, but that’s also wrong isn’t it?”

Julian Blake, counsel to the inquiry, questioned the reliability of the records during the hearing. Ajewole responded, “Yes, I understand that was an error from me. It should have reflected that he had a history of violence and aggression on the risk assessment.” Her comments highlighted a growing awareness of the discrepancies in the files, which were later scrutinized by the inquiry.

Timeline of Calocane’s Mental Health Journey

Calocane first presented to NHFT with symptoms of psychosis in May 2020, following an incident in which he broke into a neighbor’s flat. The event occurred at Brook Court in Radford, Nottingham, where he resided. Between May 2020 and February 2022, he underwent six Mental Health Act assessments, resulting in four psychiatric hospitalizations. However, the inquiry revealed that the risk assessment forms from this period contained multiple errors, including incorrect entries about his past behavior.

Calocane’s initial admission to Highbury Hospital in Nottingham began on 25 May 2020. The inquiry was told that this admission followed an incident where he entered a woman’s flat, prompting her to flee and later fall from a window, fracturing her spine. During his first stay, the records indicated he had no prior history of mental health issues or violent behavior. Ajewole, who worked at Highbury Hospital, admitted that her documentation at the time did not reflect the full scope of his actions.

Later, in July 2020, Calocane was transferred back to the same ward after attempting to force entry into another neighbor’s flat. Ajewole claimed she would have been informed about this incident during a handover but noted that her records failed to capture it. Instead, she documented details from an earlier event involving one of Calocane’s neighbors in May. “I can’t recall why that was not recorded in this assessment, it should have been,” she stated, underscoring the gaps in the information.

September Detention and Assault Incident

On 3 September 2022, Calocane was detained under the Mental Health Act after assaulting a Nottinghamshire Police officer, PC Barnaby Pritchard, during a warrant execution. The inquiry detailed how he headbutted and repeatedly punched the officer, requiring the use of a Taser and multiple officers to subdue him. Patient summary records from this period noted that Calocane arrived at the facility with multiple police officers and was described as “angry and agitated.” Despite this, Ajewole’s risk assessment form omitted any mention of the assault, instead referencing a previous incident.

Ajawole explained that she was aware of the September detention but did not include the details in the risk assessment form. She admitted that the form contained the phrase “Valdo is usually a very polite and gentle, personable young man,” which she could not trace back to a specific source. This contradiction raised questions about the thoroughness of the documentation and its potential impact on Calocane’s treatment plan.

“Can you see how that’s a significant problem?”

Blake, the inquiry’s counsel, pressed Ajewole on the implications of these errors. She confirmed that the information collated in the risk assessment was accurate but incomplete. “Upon review, the information contained under [risk] summary and formulation is accurate but not complete,” she said. Blake countered, stating, “It’s quite fundamentally wrong the information that I’ve just showed you.” Ajewole agreed, acknowledging the critical nature of the oversight.

System-Wide Concerns and Reforms

When asked if the issue of inaccurate form-filling was widespread within the trust, Ajewole suggested it was an “individual” problem, though she admitted uncertainty about whether other nurses repeated similar errors. She revealed that she had since modified her usual practice, now prioritizing the verification of documents and creating new risk assessment forms rather than updating existing ones. This change aimed to prevent future inconsistencies in patient records.

Dr. Omar Manzar, a psychiatrist who participated in four of Calocane’s assessments, also testified at the inquiry. He described the situation as “astonishing,” noting that the records presented during the proceedings painted a misleading picture of the patient’s behavior. Manzar emphasized that the lack of detailed information could have contributed to underestimating Calocane’s potential for harm. The inquiry is now examining the broader implications of these errors, including how they influenced decisions about his care and release.

The timeline of events has led to a critical evaluation of the mental health care system in Nottingham. Ajewole’s admission has sparked discussions about the importance of accurate documentation in risk assessments, particularly for individuals with a history of psychiatric conditions. While the trust has taken steps to improve its processes, the inquiry continues to investigate whether systemic issues may have played a role in the tragic outcome. As the proceedings unfold, the focus remains on understanding how gaps in the records affected the decisions made about Calocane’s treatment and how such mistakes can be prevented in the future.

Valdo Calocane’s case has highlighted the challenges of managing patients with complex mental health needs. The inquiry is not only assessing the specific errors in his records but also evaluating the broader practices of NHFT. With each new detail uncovered, the narrative of the incident becomes more intricate, revealing the potential consequences of incomplete or misleading information in healthcare systems. Ajewole’s testimony has added a layer of accountability, prompting questions about the reliability of patient assessments and the need for stricter oversight in mental health documentation.

As the inquiry progresses, it is expected to delve deeper into the chain of events leading to the attacks. The team will analyze whether the errors in Calocane’s records were isolated incidents or part of a larger pattern. This examination could have far-reaching effects, influencing policies and procedures within the mental health sector. The case serves as a reminder of the critical role that accurate records play in ensuring the safety of both patients and the public, especially in cases involving individuals with a history of psychosis and aggression.