Triple killer Valdo Calocane was not forced to take his anti-psychotic medication because he did not like needles, a major review of his NHS care has revealed.

The NHS England report identified numerous failings that show “the system got it wrong” with Calocane, who stabbed to death Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham in June 2023.

It laid out how Calocane, who has paranoid schizophrenia, had no contact with mental health services or his GP for about nine months prior to the killings – and was discharged after failing to engage with them.

The victims’ families said a judge-led public inquiry, which the prime minister has previously committed to, should be held “as soon as possible”.

In response, the government repeated its commitment to an inquiry into the attacks, with work ongoing to establish its scope.

The NHS said it had taken the decision to publish the report in full, in line with the wishes of the families, and “given the level of detail already in the public domain”.

The independent review, by Theemis Consulting, looked into the treatment given to Calocane by Nottinghamshire Healthcare NHS Foundation Trust prior to the killings, as well as the interactions the NHS had with other agencies involved in his care.

The key findings of the report include:

• Calocane’s risk “was not fully understood, managed, documented or communicated”
• There were missed opportunities to take more assertive action towards Calocane’s care
• The voice of Calocane’s family “was not effectively considered to support the dynamic evaluation of risk” during his treatment
• Other patients under the care of the same trust, some of whom had been discharged, had also perpetrated acts of “serious violence” across 15 incidents between 2019 and 2023
• Calocane had no contact with mental health services or his GP for about nine months prior to the killings

The case, which resulted in Calocane being sentenced to a hospital order in January 2024, sparked a number of reviews including the mental health homicide review, commissioned by NHS England.

Another, by the Independent Office for Police Conduct (IOPC), is looking into both Leicestershire and Nottinghamshire Police.

A review into the Crown Prosecution Service (CPS) found while prosecutors had been right to accept Calocane’s pleas of manslaughter on the basis of diminished responsibility, they could have handled the case better.

And in May, a judge ruled Calocane’s sentence was not unduly lenient.

In a statement, the victims’ families said a statutory public inquiry should happen “as soon as possible”, examining this case as well as “wider failings in the care, treatment and sectioning of those with mental illnesses”.

“It is the first duty of the government to keep its citizens safe – it is now clear that the previous government failed Grace, Barnaby and Ian in that duty,” the statement added.

“There are grave questions to be answered about how multiple organisations failed to respond to the risk he posed; allowing him to roam the streets and kill three innocent people.”

Health Secretary Wes Streeting said the government had worked with NHS England to ensure the report was published in full.

“Sunlight is the best disinfectant,” he said. “The findings will help to support an inquiry into this attack and we’ll set out the next steps as this develops.”

He added he had called for all the recommendations made in a previous Care Quality Commission (CQC) report into the case to be implemented across the country.

The new report also sets out the contact Calocane had with mental health services before he killed Mr Webber, Ms O’Malley-Kumar and Mr Coates, and then stole Mr Coates’s van before driving it into three pedestrians – Wayne Birkett, Marcin Gawronski and Sharon Miller – all of whom were seriously injured.

The report states the former University of Nottingham student first came into contact with mental health services on 24 May 2020, when he was 28, when he was arrested for criminal damage to a neighbour’s flat.

It was documented that Calocane’s behaviour was an episode of psychosis brought on by the stress of course work and a forthcoming exam, coupled with a lack of sleep.

Shortly after returning to his home, Calocane again tried to gain access to a neighbour’s flat. His neighbour was so frightened that she jumped from a first-floor window, sustaining back injuries which required surgery.

Calocane was then detained for the first time under section 2 of the Mental Health Act, which meant he could be kept in hospital against his will for up to 28 days – known as a “section”.

Subsequent contacts with services saw him labelled as having paranoid schizophrenia.

After about a month in hospital, Calocane was sent home with reviews expected from the community crisis team and the early intervention in psychosis (EIP) service.

He was initially called by the crisis team. The contact was a phone call rather than a face-to-face appointment “because of Covid-19 restrictions at the time”.

His family expressed concerns because they felt he could “play down his symptoms” over the phone.

In July 2020, Calocane was admitted to hospital for a second time after forcibly entering a neighbour’s flat.

He was sectioned again, this time under section 3 of the Mental Health Act, which allows for a longer hospital stay of up to six months.

According to medical records shared by Calocane’s family with BBC Panorama, while Calocane was ill in hospital, a psychiatrist observed that “there seems to be no insight or remorse and the danger is that this will happen again and perhaps Valdo will end up killing someone”.

Two weeks after this entry was made, Calocane was discharged from Highbury Hospital.

According to the report, his family “felt this was a real missed opportunity to fully understand [Calocane’s] diagnosis, risk and to get to grips with a treatment plan that [Calocane] was concordant with”.

Three months before his third hospital admission in August 2021, Calocane’s family again reported concerns over his mental health.

At the end of August, his care co-ordinator visited him at home with a colleague, noting that he was no longer taking his medication and had no intention of continuing treatment.

A month later, the report said he had “significantly assaulted” police officers who attended in support for a Mental Health Act assessment.

On a number of occasions, his care co-ordinator had suggested the use of depot medication – which releases slowly over time meaning patients need to administer medications less frequently.

But, the report said, the inpatient teams were trying to treat him “in the least restrictive way”, and took on board his reasons for not wanting to take injectable depot medication, “which included him not liking needles”.

After multiple missed appointments, in January 2022, officials contemplated discharging Calocane from the EIP service due to a lack of engagement.

But the following day, the EIP learned Calocane had trapped two housemates in their flat, which resulted in the police being called.

He was assessed under the Mental Health Act, but not detained.

Calocane was admitted to hospital at the end of January 2022 for almost a month – his fourth hospital admission.

After being discharged, it was noted that none of Calocane’s care providers should visit him at home alone because of his “history of violence and aggression”.

Calocane then missed a few appointments to collect his medication over the coming months, and a new care co-ordinator tried to contact him multiple times.

After these failed attempts, a decision was taken in September 2022 to discharge Calocane from the EIP service to his GP.

The report said “opportunities to assertively try to reach out to [Calocane] when he disengaged from services were limited” because of pressures in the team.

“Due to multiple factors, including workload, the discharge system did not function as intended,” the report said.

It added there was no contact between Calocane and mental health services, or his GP, for roughly nine months from this time until the killings.

Dr Jessica Sokolov, regional medical director at NHS England (Midlands), said it was “clear the system got it wrong” and apologised to the victims “on behalf of the NHS and the organisations involved” in Calocane’s care.

Claire Murdoch, NHS England’s national mental health director, said the organisation had asked every mental health trust to review the report findings.

Marjorie Wallace, chief executive of mental health charity Sane, said the publication of the review “should act as a watershed moment revealing the truth and honouring the needs of the families of victims of homicides by people with mental illness or disorder”.

In a statement, Calocane’s family said: “We wish to express once again how deeply sorry we are for this horrific tragedy, and the immeasurable pain Valdo’s actions have caused to so many involved. To all of the victims, their families and friends, we truly are sorry.

“The report confirms what we and many others have known for a while: the mental healthcare system is in crisis and in need of immediate intervention, which we believe must come from the government. It is not enough to say that the NHS failed; we must be honest in recognising that the NHS has been set up for failure, and cannot be left to fix itself on its own.

“There are good people in mental healthcare, including in this case as well, and front-line staff need our help more than our condemnation. We maintain that the only way to prevent future tragedies like this is to properly resource mental healthcare throughout the UK, so that workers have the right tools to do their jobs properly.”

The chief executive of the Nottinghamshire Healthcare NHS Foundation Trust, Ifti Majid, added: “We apologise unreservedly for the opportunities we missed in the care of Valdo Calocane and accept the Theemis report in its entirety including its findings and recommendations.

“We are making clear progress with a trust-wide plan, which is already delivering key improvements in areas such as risk assessment and discharge processes.”