Nottingham attacks: Review of killer’s care finds ‘a series of errors’

Dr Sanjoy Kumar, Ms O’Malley-Kumar’s father, told the BBC that the families would like the scope of the inquiry to be “as wide as possible”.

“We would like it to be a statutory public inquiry led by a judge, and one that has real teeth to make a difference and change things in our country,” he added.

“We have to concentrate on Nottingham first and learn from what went wrong because these systems are parallel across the country.”

In compiling its report, the CQC reviewed Calocane’s records alongside 10 other cases “to enable benchmarking”.

The CQC said it had “engaged” with the families of Calocane and the victims, but the watchdog did not interview or speak to any staff members involved in the offender’s care at the trust.

The report found the 32-year-old – a former University of Nottingham student – had first come into contact with the trust in May 2020 during the first Covid-19 lockdown.

Documents showed he was “acutely unwell”, and was diagnosed with paranoid schizophrenia and sectioned four times in less than two years.

But the report said “key” risks had either been missed or omitted, including the refusal of medicine, ongoing and persistent symptoms of psychosis, levels of violence against others when his psychosis was not managed well, and Calocane’s escalation of violence towards others in the later stages of his care under the trust.

It also found “poor planning and engagement” with the killer and his family, who raised concerns about his mental state with the trust and to BBC Panorama in their first interview.

“It is clear that after four admissions in two years, and repeated disengagement and refusal to take medicine, [Calocane] required a much more robust package of care,” the report said.

“More assertive engagement and restrictive measures were crucial to managing his illness and the risk he posed to others when unwell.”

The CQC issued five recommendations to the trust, including ensuring that staff were aware of the importance of involving and engaging patients’ families, and implementing “robust discharge policy and processes”.