Care Quality Commission Section 48 Review of Nottinghamshire Healthcare NHS Foundation Trust

On 30 January 2024, my predecessor as Secretary of State asked the Care Quality Commission to conduct a special review of mental health services in Nottinghamshire in response to the horrendous killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber.

I am grateful to the CQC for the detailed work it has undertaken on this report. My thoughts are with the families and friends of Barnaby, Grace and Ian. This report makes for distressing reading, especially for those living with this unimaginable loss in the knowledge that this tragedy could have been prevented.

The review was composed of three strands. The reports for strands 2 and 3, relating to the safety and quality of services provided by Nottinghamshire healthcare NHS foundation trust and the services provided at Rampton hospital, were published on 26 March 2024.

On 13 August, the CQC published the remaining report for strand 1 of the review into the care and treatment provided to Valdo Calocane by NHFT in the period leading up to the horrific events of June 2023. As part of this review, the CQC was also asked to determine whether its review of Valdo Calocane’s care and that of 10 other benchmarking cases indicated wider patient safety concerns or systemic issues with the provision of mental health services in Nottinghamshire.

This report identified serious failings in the care and treatment provided to Valdo Calocane by NHFT that may have contributed to these tragic killings after he was discharged from the trust’s mental health services. These failings are consistent with the CQC’s findings from strands 2 and 3 of the review, published in March, which identified issues with the safety of services and quality of care at NHFT as a whole.

While there was no single point of failure for Valdo Calocane’s care identified in the report, the strand 1 review identified serious shortcomings relating to four areas: risk assessment and record keeping, care planning and engagement, medicines management, and discharge planning.

I have met with NHS England, which has provided me with assurance that it and NHFT are taking action to address the serious failures identified in the report. I have made it clear to NHS England that I expect regular updates on progress against all the recommendations across the three strands of the review.

In advance of the publication of this report, NHFT has taken action to implement the CQC’s recommendations, specifically relating to managing patients who may be at risk of harming themselves or others. These actions include:

Changing “did not attend” policies to make sure patients are not discharged for not attending appointments.

Implementing systems to make sure staff more robustly consider risks to patients and the public.