Nottingham rampage killer Valdo Calocane was not forced to have long-lasting antipsychotic medication because he did not like needles. Students Barnaby Webber and Grace O’Malley-Kumar, both 19, and caretaker Ian Coates, 65, were stabbed to death in June 2023. Paranoid schizophrenic Calocane is serving an indefinite hospital order after admitting manslaughter with diminished responsibility. A series of errors by mental health teams and police left him free to roam the streets and eventually kill his three victims. The former University of Nottingham was repeatedly sectioned but then discharged over a three-year period.

An independent report commissioned by NHS England into Calocane’s care reveals a shocking litany of errors. Experts made repeated requests for him to be put on anti-psychotic depot medication - which releases slowly over time. But he was not forced to take the medication because he was scared of needles, the report revealed. It said: “The inpatient teams involved in VC’s care were trying to treat VC in the least restrictive way. They took on board VC’s reasons for not wanting to take depot medication which included him not liking needles.”.

NHS England had planned to only release a summary of the 300-page report, citing patient confidentiality and data protection. But bosses backtracked after outrage from the victims’ families, who will respond to the findings today. The report details two years of violent and disturbing behaviour by Calocane, who grew up in Haverfordwest. It included frightening a neighbour so much she jumped out of a window, punching a police officer and holding his flatmates hostage. It details four hospital admissions between 2020 and 2022 and multiple contacts with community teams.

Calocane was eventually discharged to his GP because of a lack of interaction with mental health services. Investigators found that “the offer of care and treatment available for VC was not always sufficient to meet his needs”. The report revealed how other patients cared for by Nottingham Healthcare NHS Trust also committed “serious” acts of violence. These included three other killings and an incident in which a patient stabbed five people in a single weekend. Health officials admitted that it is “clear the system got it wrong” and apologised to the families.

Dr Jessica Sokolov, regional medical director at NHS England (Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating. This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”.

Across the NHS in England mental health services have been ordered not to discharge people if they do not attend appointments. Health Secretary Wes Streeting said last year that the killings “could and should have been prevented”. A Care Quality Commission report revealed Calocane was repeatedly sectioned but then discharged by mental health teams. One doctor warned three years before the knife attacks that the university student “could end up killing someone”.