How could this happen? That’s a question many have asked since it became known that Valdo Calocane, a highly vulnerable man with a serious mental illness, and history of violence, was left free and untreated before going on to kill three people in Nottingham.
Louis Appleby, who leads the National Suicide Prevention Strategy for England and directs the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, put a different – essential – question on X (formerly Twitter).
“Arguably, there’s no more important task for clinicians than preventing homicides caused by someone’s mental illness”
He asked: “Much discussion about benefits of outreach teams in mental health. And promises to ‘learn the lessons’ from the Nottingham tragedy – a phrase that infuriates families. But the real question is why we unlearned past lessons and what this tells us about future safety.”
That is because there was nothing new in this shocking case. And the painful lessons had had to be learned 30 years ago.
Mr Calocane was diagnosed with paranoid schizophrenia in June 2020. Three years later he fatally stabbed students Barnaby Webber and Grace O’Malley-Kumar and school caretaker Ian Coates, then seriously injured three others after driving Mr Coates’ van at them.
Detained under the Mental Health Act four times in two years, Mr Calocane was not attending appointments and remained non compliant with medication when discharged from mental health services back to his GP in September 2022.
This seems extraordinary, to the degree that one might think it’s an isolated case. But it’s not.
Arguably, there’s no more important task for clinicians than preventing homicides caused by someone’s mental illness. So, this tragedy raises profound questions about the state of mental health care today.
It must always be remembered that people with a mental illness are far more likely to be victims of violence rather than perpetrators, and the number of homicides perpetrated by people with a mental illness has always been relatively low.
However, numbers of homicide related to mental illness have more recently been contested and are even more difficult since NHS funding of research was cancelled in 2019.
The National Confidential Inquiry into Suicide and Homicide (NCISH) reported an average of 60 homicides per year perpetrated by people with a serious mental illness from 2009 to 2019.
However, Julian Hendy, who founded hundredfamilies.org after his own father was killed by a man with a psychotic illness, claims mental health services frequently – and sometimes deliberately – minimise the problem of violence in mental health patients, particularly homicides, and estimate patient homicides at an average of 120 per year.
This discrepancy is, in part, because the NCISH only includes cases where the perpetrator was in contact with secondary mental health services in the 12 months before the offence, and excludes cases where perpetrators later took their own life as well and, therefore, wasn’t charged or convicted.
Also, the NCISH counts the number of convicted perpetrators rather than victims. The number of victims is higher, as there are always cases of multiple homicide – as in Nottingham.
The Care Quality Commission’s (CQC) interim report into Mr Calocane’s care and treatment, which was published earlier this year, highlighted “errors, omissions and misjudgements”.
They also sampled 10 different patients’ records and noted examples of risk assessments “minimising or omitting key details”, as had been the case with Mr Calocane.
Significant concerns were highlighted in the following areas of care:
- Assessing and managing risk in the community
- Care planning, and the involvement of families
- Discharge planning.
- Medicines management
- Managing people who find it difficult to engage with services
- Clinical decision making around detaining patients under the Mental Health Act
Following publication of the report, there was no shortage of criticism of the trust as well as suggestions for how to prevent further tragedies, including the re-establishment of assertive outreach teams, better use of community treatment orders, a focus on severe mental illness, and a better balance of patient autonomy and stigma against safety and risk.
All eminently sensible, practical and often evidence based. But why weren’t they in place in Nottingham? And if they were everywhere else, why was it not identified as a clear outlier and steps taken to bring it into line with the rest of the country?
“Following publication of the report, there was no shortage of criticism of the trust as well as suggestions for how to prevent further tragedies”
Because it wasn’t an outlier, but acting in common with most mental health services.
The CQC’s first report into Nottinghamshire Healthcare NHS Foundation Trust noted: “Like many other mental health services across the country, mental health services at NHFT were in high demand, with long waiting lists for community mental health teams, difficulties in accessing crisis care and lack of access inpatient beds.
“A lack of oversight for people on waiting lists and too many patients without a care coordinator was putting them, and the public, at risk of harm.”
These are systemic, deep rooted problems. The picture across all mental health services is disturbing, with the independent inquiry into the deaths of more than 2,000 mental health patients under the care of Essex Partnership University NHS Trust or its predecessors the most extreme.
To understand how we got here, however, we must look back at why services such as assertive outreach teams were established.
The 1980s saw the rise of patient advocacy and campaigning groups, particularly hostile to the large psychiatric hospitals still dominating the provision of services for those with mental health problems.
Between 1968 and 1981, there were 24 major inquiries into allegations of abuse and/or ill treatment, including a series of deaths by suicide at Warlingham Park. Many revealed systemic abuse and cruelty.
This fed into a wider, growing consumer rights movement, focus on individual freedoms and the Thatcher government’s aim to cut health service spending.
Alongside advances in drug treatments and the reforms of the 1959 Mental Health Act, this all fuelled a rapid – broadly welcomed – shift to community based care.
The 87,396 available beds in NHS hospitals in 1980 had shrunk by more than 50% by 1993-94, with only 27,000 available in 2012. The promised funding for community mental health services, however, failed to materialise.
While the deficiencies in 1980s hospital care were obvious and highlighted, their virtues were underrated and often dismissed, including being a place of safety for the most vulnerable. By the early 1990s, new scandals were rocking the world of psychiatry.
The highest profile of these concerned Christopher Clunis, a 29-year-old man with a long history of mental illness, non compliance with treatment and not attending appointments, previously detained under the Mental Health Act and with a history of violence.
In December 1992, he stabbed Jonathan Zito to death in a London tube station due to his mental illness.
The Ritchie Inquiry (1994), which reviewed Mr Clunis’ care, described a “catalogue of failure and missed opportunity”, concluding the “more disturbed Christopher Clunis became, the less effective was the care he received”.
Alongside other serious events – including Ben Silcock, another man diagnosed with schizophrenia, jumping into the lion’s den at London Zoo – this lodged in the public consciousness, with far reaching, positive consequences, partly due to the tireless campaigning of Jayne Zito, Jonathan’s widow.
After its 1997 election victory, Labour introduced national service frameworks (NSF) in the NHS, providing funding for specific targets.
The NSF for mental health recognised that “of the 15,000 people in England with severe and enduring mental illness, between 14 and 200 per 100,000 were difficult to engage.
“They are a diverse group, more likely to live in inner city areas, to be homeless, and to be over-represented in suicide, violence and homicide”.
The NSF legislated for assertive outreach as a “form of intensive case management” to ensure “mental health services stay in contact with people with severe and enduring mental illness, especially individuals who are assessed as at risk of harm themselves or of posing a risk to others”.
“It was ironic that an unintended consequence of the greater specialisation of community mental health teams was greater fragmentation”
To make this initiative work, innovative change was required to both clinical practice and the systems and structures that supported it.
For example, nurses at Lambeth’s award winning community team at Lewin Road, devised the first zoning system to rate the risk of each patient, with specific standards for addressing the risk eg ‘red zone’ patients having to be seen each day, with a cohesive plan for what would be done and ways to track their progress or lack of it.
Caseloads were limited to enable staff to carry out this intensive work, clinical supervision and reflective practice was put in place alongside extended multi professional clinical reviews. Shifts were planned and daily objectives evaluated. Robust clinical leadership was seen as essential.
Dual diagnosis teams were established for people with psychotic disorders who were also misusing substances, ensuring another at risk group didn’t continue to fall through gaps in services with tragic consequences.
It was ironic, therefore, that an unintended consequence of the greater specialisation of community mental health teams, such as early intervention services for people with psychosis, home treatment teams, crisis services etc, was greater fragmentation.
This structural weakness was blown apart when, in 2010, a Conservative government was elected and ‘austerity’ was their response to the banking crash of 2008-09, paving the way for the long-held Tory objective of shrinking the state, with huge reductions in public spending.
Mental health services suffered the double whammy not only of having their own funding cut but also being expected to respond to the psychological and emotional impact on the wider population of cuts in local authority spending, wage stagnation and job insecurity.
Research for Community Care revealed that, between 2010 and 2015, mental health funding was reduced by 8.25%, with community teams overall losing 5% of their budgets while referrals increased by 20%.
A further 2,100 inpatient beds were cut. At the same time, local authority spending on working age adults with mental health needs fell by 13.2% in real terms (McNicoll 2015). Assertive outreach teams lost an astonishing 56% of their budgets.
Having inherited from Labour a mental health nursing workforce of 40,810 in 2010, the Conservative’s austerity programme saw it drop to 36,054 by 2016, only returning to 2010 levels in 2023, though with significant vacancies among that number.
Community teams merged, had bigger caseloads, lost experienced staff, and posts requiring two to three years post-reg experience were opened to newly qualified staff.
Clinicians appointed into management posts had far less experience than their predecessors of a decade ago, with their successors further disadvantaged by having to learn from those relatively inexperienced managers.
Investment in often ambitious training programmes that had marked the 2000s, including in risk assessment, were cut back. Even when their funding was retained, freeing up staff to attend was increasingly difficult.
In this economic climate, admission criteria for community teams, initially about maintaining fidelity to the teams’ core function but which could be problematic, were increasingly used as a rationale for excluding people.
The reductions in inpatient beds saw ‘gatekeeping’, or decisions about who could be admitted to hospital, become a euphemism for locking the gates and letting in as few people as possible.
“The Friday morning ritual of ward nurses being instructed to go through their patient lists to discharge the least unwell is well established”
Over the years, nurses in inpatient units struggling with demand had gone along with deeply troubling practices, eg unwell patients being moved in the middle of the night from one ward to another to ‘make space’ for someone requiring admission.
That morphed into moving patients to different hospitals or forcing people to sleep in chairs in day rooms.
Now, the Friday morning ritual of ward nurses being instructed to go through their patient lists to discharge the least unwell people is well established.
It’s always tempting to point the finger of blame at individual clinicians. In the case of Mr Calocane, the full review into his treatment and care will undoubtedly raise many uncomfortable issues about practice.
But it’s clear there is a political and structural context to the tragic events that unfolded, which are mirrored across the country.
What is happening at an organisational level? Within a team? And how does that impact individual clinicians?
For example, how do trust board members needing to meet savings targets rationalise the risks in merge three community mental health teams into two with all the implications eg increased caseloads, less time for clinicians with patients, longer waiting times to be seen and assessed?
What philosophy do senior managers adopt when they cut back on education in risk assessment? At times it seems to be, ‘Well, nothing’s gone wrong yet…’
What’s the decision making process in a team that has to balance seeing at risk patients on current caseloads with the demands of assessing new referrals? What’s said about what’s missed when a new assessment of a complex patient is completed in thirty minutes?
How is decision making affected for clinicians in a discussion about risk with a patient? Should I ask that question? Should I probe into that thinking? What will I do if I get a worrying answer?
How is the risk assessment documented when the clinician thinks admission is required but there is no bed available or a ‘bed manager’ has vetoed that decision without seeing the patient?
How does it affect a community practitioner who thinks a patient needs to be seen every day but knows that cannot happen?
This has been an incremental process over 14 years. But one that wears people down.
Will the nurse who flatly refuses to transfer patients to a different ward against that patient’s will until instructed to do so, or the clinician who argues patients need admission but is overruled, continue to do the same every time they have that opinion? Of course, they don’t.
What was once unacceptable to clinicians or a team gradually becomes the norm.
The effects go yet deeper. Avoiding detailed assessments, not studying the theory and practice related to risk, not doing the hard yards to engage with reluctant patients or provide the psychoeducation that can promote better understanding for individuals about their mental health problems, abandoning the structures that not only support best practice but help develop it, all create skills’ deficits and a lack of opportunity to develop knowledge and establish high standards the whole team adhere to.
Instead, community teams often report huge levels of stress. Often there’s an underlying anxiety about being the last person to see an ‘at risk’ patient in case there’s a serious incident.
“Most, if not all, of these tragedies will highlight the problems faced by both inpatient and community services”
This has changed the culture in many mental health services. Lower standards are accepted.
Clinicians rationalise the situations they find themselves in, using arguments of patient choice, the right to refuse treatment – completely valid in themselves but ignoring the counter argument for patients having the right to receive treatment, even if they don’t want it, if it means addressing a life-changing deterioration in their mental health or is a matter of theirs or others’ safety.
What we can be pretty sure of is this: in the next 12 months somewhere between 60 and 120 people will be killed by a person with a mental illness. And our current mental health service provision is ill equipped to prevent this from happening.
Most of those homicides will not generate national media coverage, their numbers won’t be aggregated, the cases analysed collectively and themes extrapolated.
Most, if not all, of these tragedies will highlight the problems faced by both inpatient and community services but it’s highly unlikely lessons will be learned across services.
The crisis in our prisons has – finally – dominated headlines but that facing mental health services is no less serious. There are few short term fixes. A coherent, national strategy is required.
The CQC’s recommendations are predictable and can be summarised as ‘ensuring’ (a word that occurs in almost all recommendations) all elements are addressed where deficiencies were found in the treatment and care of Mr Calocane or the wider patient group reviewed.
What’s missing, however, is how this will be done. Referring people who find it difficult to engage with services to non existent teams for ‘assertive and intensive support’ is magical thinking. Robust policies and processes for discharge are meaningless without staff equipped to enact them.
It doesn’t address funding, resources, the huge education and training programme required – not just in knowledge and clinical skills but leadership and management.
It doesn’t look at how effective systems and structures can be established or how to generate the cultural and ideological change needed to promote reflection, supervision, multi-professional team working, or the sticks and carrots that enable trusts to provide sufficient beds, community teams with manageable caseloads and services that are not fragmented and exclusive but cohesive and inclusive.
There are changes teams can make eg using zoning, improving supervision and reflective practice, clinical reviews etc, and trusts can change the climate within their services but this is going to take national leadership from the government, and money.
Admittedly, it was a healthier economic climate in the 1990s, but we brought about positive change in the wake of tragedy.
There is nothing stopping us from doing it now other than a lack of ambition and imagination.
Chris Hart, author of A Pocket Guide to Risk Assessment and Management in Mental Health (Second Edition) and independent nurse consultant and director of The Reducing Deaths in Custody Programme
References
Appleby L et al (2022) The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: UK patient and general population data, 2009-2019, and real time surveillance data. 2022. University of Manchester.
Care Quality Commission (2024) Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust: Part 2.
Department of Health (1999) A National Service Framework for Mental Health. London: HMSO.
Hart C (2023) A Pocket Guide to Risk Assessment and Management in Mental Health (Second Edition). London: Routledge.
McNicoll A (2015) Mental health trust funding down 8% from 2010 despite coalition’s drive for parity of esteem: Community Care (20.03.2015).
Ritchie JH, Dick D and Lingham R (1994) The Report of the Inquiry into the Care and Treatment of Christopher Clunis. London: HMSO.