Killer Discharged as NHS Staff ‘Could Not Find Him’

Public Inquiry Highlights Discharge Decision

Killer discharged as NHS staff could – A public inquiry has revealed that Valdo Calocane, a man diagnosed with paranoid schizophrenia, was released from mental health care months prior to his fatal actions. The inquiry, focusing on the events leading to the deaths of Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates, noted that Calocane’s discharge in September 2022 occurred despite clear warnings about his potential to harm others. During his two-year treatment with Nottinghamshire Healthcare NHS Foundation Trust, he underwent four sections and was explicitly informed of the risks he posed.

Staff Struggled to Locate Patient

Emma Robinson, a team leader in the Early Intervention in Psychosis (EIP) service, testified that the decision to discharge Calocane was driven by his unavailability. “We couldn’t work with him, we couldn’t find him at this point,” she stated. The inquiry was told that Calocane had missed appointments and failed to respond to outreach efforts, leaving staff unable to provide consistent care. His last communication with the EIP team was a phone call on 16 July, where he falsely claimed to be abroad.

“When you discharged, did you think about the risk to the public from this man, who EIP would not visit alone, would not visit at home unless absolutely necessary?” asked Tim Moloney KC, representing the bereaved families. Robinson replied: “We did consider that, but we felt that within the time of decision we had no holding powers, we couldn’t work with him, we couldn’t find him to treat him or engage him.”

Discharge to GP Raises Concerns

Moloney pressed further, questioning whether the lack of contact was the primary reason for Calocane’s release. Robinson confirmed this, emphasizing that the EIP team’s inability to locate him made it difficult to continue his care. “He was a very difficult person to engage with,” she explained. “I think he needed a more robust service than early intervention could offer. In hindsight, a team with greater follow-up capabilities might have been better suited.”

The inquiry also examined the trust’s training protocols. When asked about mandatory education for EIP team members, Robinson stated that all staff, regardless of their role, received training covering basic life support, risk management, record keeping, and infection control. However, she admitted there was no specific training focused on early prevention strategies. “We do mental health act training, mental capacity assessments, and care programme approach training,” she said. “But nothing was tailored to the unique challenges of early intervention.”

“Is that primarily why you discharged him?” Moloney inquired. Robinson responded: “Yes, because we couldn’t find him to treat him or engage him. The trust left him to the general public to deal with,” Moloney added, suggesting that the decision to discharge Calocane to his GP created a risk for the community. Robinson disagreed, stating: “I wouldn’t say the general public to deal with. It’s not uncommon for us to discharge non-engaging patients, unfortunately, at that time. I think things are very different now.”

Training Gaps and Disengagement Risks

During the inquiry, Craig Carr, counsel for the chair, questioned whether the EIP team had training on managing disengaged patients, ensuring medication adherence, or knowing when to refer cases to the community forensic team. Robinson admitted that such training was not part of the EIP program’s standard curriculum. “To my knowledge, there was no specific training on these topics,” she said.

Robinson’s rationale for discharging Calocane was further elaborated in a statement. She wrote: “It’s dire for me to think this now, but I used to wonder—was it worse to keep someone open on our caseloads without engagement, or to discharge them? What does it look like if something happens and we’ve got this person open to us, having not seen them for months?” This reflection underscored the tension between maintaining care and the practical limitations of the EIP service.

“I suppose, from previous experience, I’m worried about how that’s looked,” Robinson said. “We’ve got somebody that’s open to us, and perhaps we haven’t been able to treat them for nine months or find them. Sometimes the decision is better to discharge them back to the GP.” Carr interpreted this as suggesting that releasing patients who are hard to track is a safer option. “It feels safer to have someone discharged back to the GP’s queue,” Robinson added, “than to keep them open on a secondary service when we can’t engage them or do anything for them.”

Outcomes of the Discharge and Trust’s Justification

Months after his discharge, Calocane carried out the killings in Nottingham on 13 June 2023. The inquiry chair, Deborah Taylor KC, highlighted that Calocane’s GP received minimal information following his release. “Effectively, very little was shared with the GP about his condition or risk factors,” Taylor noted. This lack of communication raised questions about the continuity of care and the GP’s ability to monitor Calocane’s progress.

Robinson defended the decision, stressing the EIP team’s role as a frontline service for early intervention. “We focus on patients who are more responsive to treatment,” she explained. “Those who are difficult to engage often require a different level of support, which wasn’t available at the time.” However, the inquiry is now scrutinizing whether this approach was sufficient to prevent the tragedy.

Implications for Mental Health Services

The case has sparked debate about the adequacy of mental health care systems. Robinson’s testimony illustrates the challenges of managing patients who actively avoid contact. “When someone isn’t reachable, it’s hard to assess their risk or intervene effectively,” she acknowledged. The inquiry is also exploring whether the EIP team’s structure allowed for timely referrals to specialized services, such as the community forensic team, which could handle more complex cases.

As the inquiry progresses, it aims to determine if the trust’s decision-making process was flawed or if the circumstances were exceptional. The case serves as a reminder of the critical role that consistent patient engagement plays in preventing harmful outcomes. “The human element is essential,” Robinson said. “If we can’t locate someone or build trust, we’re leaving them vulnerable—both to themselves and to others.”

The testimony has also prompted discussions about training and resource allocation. While the EIP team is designed for early intervention, its ability to handle long-term care or high-risk cases may be limited. “If we had more tools to track patients or provide follow-up, we might have acted differently,” Robinson reflected. The inquiry will now assess whether these gaps in training and support contributed to the tragic result.

Broader Questions for the NHS

Calocane’s case has brought renewed attention to the NHS’s approach to mental health care. The inquiry is examining not just the immediate decision to discharge him, but the broader system that allowed such a scenario to unfold. “It’s a complex balance between proactive intervention and the constraints of the service,” Taylor noted. “We need to ensure that patients like Calocane are not overlooked when they slip through the cracks.”

As the inquiry continues, it is expected to provide recommendations for improving mental health services, particularly in cases involving patients who are difficult to engage. The focus remains on understanding how the trust’s actions and limitations led to the discharge decision, and what measures could have been taken to prevent the killings. The outcome may influence future policies, emphasizing the importance of robust follow-up mechanisms and staff training in managing disengaged individuals.