The man who killed three people on the streets of Nottingham was allowed to avoid taking long-lasting antipsychotic medication because he did not like needles.
An independent review also reveals that Valdo Calocane punched a police officer in the face and held his flatmates “hostage”.
He frightened one neighbour so much, she jumped out of a first floor window and seriously damaged her back.
Mental health staff did not visit his home alone.
Calocane, who had been diagnosed with paranoid schizophrenia, was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O’Malley-Kumar, and 65-year-old caretaker Ian Coates, before attempting to kill three other people in June 2023.
NHS England initially planned to release only a summary of the report because of data protection laws, but reversed its decision “in line with the wishes of the families”.
Those relatives say the revelation that Calocane was refusing his meds shows he may have been “spared prison on the basis of incomplete evidence”.
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Prosecutors accepted a plea of manslaughter after experts agreed his schizophrenia meant he wasn’t fully responsible for his actions.
But in a statement, the families said: “This was a man who actively avoided his medication and treatment, knowing that when he didn’t take his medication he would become paranoid and violent.
“He was responsible for his actions and was allowed to make these decisions by his treating teams, but yet when he came to court, we were told a very different story.”
The review found a “theme” running through Calocane’s clinical records is that he “did not consider himself to have a mental health condition”.
That meant the importance of medication “never appeared to be understood” by him.
The report detailed four hospital admissions between 2020 and 2022 and multiple contacts with community teams before he was 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 (Valdo Calocane) was not always sufficient to meet his needs” and this was “not unique” to his case.
Health officials have admitted it is “clear the system got it wrong”.
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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.”
Claire Murdoch, NHS England’s national mental health director, added: “Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police.
“And we’ve instructed trusts not to discharge people if they do not attend appointments.”
The report, which found Calocane’s risk “was not fully understood, managed, documented or communicated” should be a “watershed moment”, a mental health charity boss has said.
Marjorie Wallace, chief executive of mental health charity Sane, said there had been “one hundred such inquiries in the last 30 years”.
She added: “Today’s findings expose the same flaws and fault lines that have resulted in tragedies, yet little seems to have changed.”
