Nottingham Inquiry report

Law and practice Other
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As you may have seen in the news the full version of the NHS Nottingham Inquiry report has been published:

What is unusual and striking is how the report investigates how senior Trust quality and monitoring systems - including at Board level - were not working.

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Thank you Julian
Still wading through it. Hope you are well

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Absolutely. Correct. Not surprising. Hugh Trust. Perhaps to big for any Trust Board ‘cocooned’ as they are in their ‘castle’ to be in touch with how grassroots management actually operated - or not! I thank the family of the victims of this tragedy for their efforts to ensure that Trust Boards be proactive in their understanding of the realities and pressures. Ñotably that faced by first line managers in first line management. Often come through the ranks with little preparation or training!

Hey, hey. Be careful out there!

(Hill Street Blues. . If you can rember that line from a past TV drama!

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2 posts were split to a new topic: Failure of NHS England to publish full reports following patient homicides

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I’ve been following the VC situation. Timelines are part of the retrospect-o-scope because most mental health teams *I’ve worked with, never construct them and study them in real-time. [*I work in all the wrong places - long story.]

The following timeline of events was reconstructed from the inquiry report and media sources (there are bound to be errors).

[This user's timeline.]
Date Event Description
Sept 1991 Birth VC born in Guinea-Bissau, West Africa.
1998 Portugal (aet 7) VC and his family moved to Portugal.
2017 Moved to UK Age 16: VC and his parents and siblings moved to the UK.
2017 Education in UK VC began studying for a mechanical engineering master’s degree at Nottingham University (inaccurate in the report)
2019 Mental disorder symptoms Calocane begins experiencing symptoms of mental illness.
24 May 2020 First arrest VC’s first arrest/first mental health presentation. He was sent home from the police station the ‘same day following a mental health assessment. The plan was for VC to be followed-up by the Crisis team.
24 May 2020 Second arrest Arrested again on the same day, after another neighbour jumped out of a first-floor window to escape him. This resulted in his first detention in hospital under Section 2 of the Mental Health Act (MHA) 1983 the following day.
June 2020 Hospital treatment Calocane admitted to inpatient hospital treatment for his mental illness.
June 2020 Psychosis onset Calocane starts hearing voices and develops persecutory delusions. Diagnosed with first episode of psychosis – schizophrenia
17 June 2020 Discharged VC was discharged back to the community under the Crisis team.
30 June 2020 EIP VC’s care was moved to the Early Intervention in Psychosis (EIP) team for voluntary engagement.
14 July 2020 Detained under MHA Police incident. This resulted in VC’s second detention under the MHA. VC was subsequently detained in hospital under Section 3 of the MHA.
31 July 2020 Discharged VC was discharged from hospital to the care of the Crisis team. On 13 August 2020, VC’s care was then transferred back to the EIP team.
29 May 2021 Deteriorating VC’s family recognised that his mental health was deteriorating and contacted mental health services. VC was assessed but not considered to require a hospital admission.
19 Aug 2021 Deteriorating VC’s condition noted by EIP staff to be deteriorating and an increasing lack of engagement from VC was noted.
Sept 2021 Police assault Calocane assaults a police officer trying to assess his mental health.
03 Sept 2021 S135 VC was taken to a place of safety on a Section 135 of the MHA.
11 – 19 Sept 2021 Detained under MHA He was subsequently detained on a Section 2 of the MHA and remained in seclusion in a 136 Suite while a suitable inpatient bed became available.
24 Sep 2021 Section 3 He was sent to an out-of-area private hospital provider under Section 2 which was converted to a Section 3 on 24 September 2021.
01 Oct 2021 Moved VC was moved to a different private hospital back within the area he was from under Section 3 of the MHA as part of step-down care.
22 Oct 2021 Discharged VC was discharged back into the community under the voluntary care of the EIP team.
19 Jan 2022 Assault VC was detained at a place of safety following an alleged assault on fellow university student. VC was assessed for detention under the MHA but not detained as the assessing doctor considered that VC could be managed by the Crisis team and was not detainable.
Aug 2022 Disappearance Calocane disappears from his address and disengages from mental health team.
May 2023 Warehouse attack Calocane physically attacks two colleagues and loses his job.
13 Jun 2023 Stabbings (Nottingham) Calocane fatally stabs two people and attempts to attack others.
13 Jun 2023 Van attack Calocane deliberately hits a pedestrian with his van and tries to run over others.
13 Jun 2023 Apprehension Police apprehend Calocane after he drops a knife after being tasered.
20 June 2023 Detained VC was detained under Section 2 of the MHA 1983
23 Jun 2023 Diminished responsibility Dr McSweeney reports psychosis significantly impaired Calocane’s control.
1 Aug 2023 Police admission Nottinghamshire Police admitted they “should have done more” to stop Calocane.
01 Nov 2023 Ashworth transfer Calocane transferred from prison to Ashworth High Security Hospital.
19 Nov 2023 Psychosis conclusion Dr Shafiulha concludes Calocane’s actions likely due to psychosis.
20 Nov 2023 Partial responsibility Professor Blackwood reports Calocane retained some responsibility but psychosis impacted him.
12 Dec 2023 Diminished responsibility Dr Latham agrees with the conclusion of diminished responsibility due to psychosis.
12 Jan 2024 Illness confirmation Dr Mirvis confirms Calocane’s offences highly attributable to his illness.
28 Jan 2024 Guilty plea Calocane pleads guilty to three counts of manslaughter and three of attempted murder.
28 Jan 2024 Hospital order Court sentences Calocane to a hospital order with a restriction order due to public safety risk.
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What’s your source for his being detained under Section 2 MHA on 20 June 23? Not sure this is correct.

I understood he went straight from Police custody to HMP Manchester until November 23 (ie not detained under S 2) when he was transferred to Ashworth. Dr McSweeney was the defence psychiatrist and I’m not sure he saw him as early as 23 June. Again do you have a reliable source?

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I think based on what I’ve read very briefly - looking at it - you have a person whose actions were mistaken for acts of mental illness than those of someone who really should’ve been charged and incarcerated by the police. That’s the fundamental problem here.

Not saying the MH services failed him either due to their own clear flaws using their own archaic methods of rehabilitation with over-use and sole reliance of harmful medications; their constant inconsistent actions, and use of law that needs to be overhauled completely.

But as soon as he caused criminal damage to that neighbour’s flat in May 2020 - that was when he needed to be charged with a crime by the police - it needed to be recognised for what it was rather than a symptom of a SMI, and then be handed over to them (MH) in it’s entirety over his care.

His case was not the responsibility of MH services - it was the responsibility of law enforcement.

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It was probably from an erroneous report from some media source that I can no longer find (the timeline was being generated many months ago then new data added recently from the Inquiry report).

I am grateful for any other errors to be highlighted. Many thanks.

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I suspect the table above is at least partly generated by artificial intelligence. I had a go this morning. ChatGPT didn’t answer, but Grok produced an impressive table from the prompt: “Set out a chronological table of events in the Valdo Calocane case with headings Date, Event and Description.”

The final two dates in the timeline are also wrong (see R v Calocane [2024] EWCA Crim 490). I’ve not checked any others.