When Dr. Sanjoy Kumar, father of Grace O'Malley-Kumar, stood at a press conference on February 5, 2025, he didn’t just mourn – he demanded answers.
The grieving father’s statement came on the heels of an independent report commissioned by NHS England that laid bare a cascade of systemic breakdowns surrounding the care of Valdo Calocane, the man convicted of the June 2023 Nottingham rampage that claimed the lives of three people, including his own daughter.
What sparked the investigation?
The report, produced by Theemis Consulting, was triggered after families of the victims repeatedly raised concerns that mental‑health services had missed obvious warning signs. It examined every point of contact Calocane had with health, police and local authorities from 2020 through the months leading up to the attacks.
Key finding: Calocane, diagnosed with paranoid schizophrenia, was not "treatment‑resistant" as previously claimed. He simply refused antipsychotic injections because he feared needles, and the system never enforced a compulsory treatment plan.
How the system let a dangerous man slip through
The document details a litany of failures:
- Leicestershire Police failed to identify Calocane as a high‑risk individual and never secured an early arrest.
- Nottinghamshire Police obtained a warrant in August 2023 but did not execute it for nine months, allowing Calocane to remain at large.
- The Nottinghamshire Healthcare NHS Foundation Trust admitted Calocane four times under the Mental Health Act, yet each discharge was made without confirming medication adherence.
- Local council workers missed the opportunity to flag his violent tendencies to the health trust.
Even more unsettling, the report uncovered that between 2019 and 2023, other patients under the same trust were linked to "extremely serious" violent incidents, including stabbings.
Voices from the families
"Grace was the love of our lives," Dr. Kumar said, his voice steady but raw. "We have been failed at every intersection that Valdo Calocane touched. From police to health services, everyone dropped the ball."
Emma Webber, mother of Barnaby Webber, echoed the frustration, calling the findings a "horror show" and insisting that the killer "got away with murder" because professionals "just didn't do their jobs properly."
Solicitor Neil Hudgell, representing both families, warned that while resentencing might not be on the horizon, public confidence in mental‑health care has taken a severe hit.
Political and institutional response
Health Secretary Wes Streeting met with the families in June 2025, agreeing to release the names of every clinician involved in Calocane’s care – a move Dr. Kumar says is "the first step toward accountability."
Following the meeting, NHS England placed the Trust into its highest oversight and support programme. All mental‑health trusts across England have been instructed to audit their discharge practices and ensure no patient who refuses medication is released without a solid safety net.
The government also pledged a £900 million, five‑year investment in community mental‑health services, promising 24/7 crisis centres to open in the spring of 2025.
What comes next?
A public inquiry promised in July 2024 finally kicked off in late 2025, with a mandate to overhaul the interface between police, social services and mental‑health providers. Dr. Kumar urged the inquiry to focus on three pillars: transparent record‑keeping, mandatory treatment compliance checks, and clear lines of responsibility for clinicians.
In the meantime, families are mobilising a national campaign, "#HoldTheDoctorsAccountable," demanding that individual practitioners who neglected duty of care face disciplinary action.
Key facts at a glance
- Victims of the June 2023 Nottingham attacks: Grace O'Malley‑Kumar (19), Barnaby Webber (65), Ian Coates (65).
- Perpetrator: Valdo Calocane, diagnosed with paranoid schizophrenia.
- Independent report released: February 5, 2025, by Theemis Consulting.
- Government response: £900 million investment, 24/7 mental‑health hubs, highest NHS oversight for Nottinghamshire Trust.
- Legal status: Indefinite hospital order (January 2024) after manslaughter plea of diminished responsibility.
Frequently Asked Questions
Why is the report saying Calocane wasn't treatment‑resistant?
Clinical reviews by the Care Quality Commission and the mental‑health trust concluded that Calocane's lack of medication was due to his personal refusal, not a medical inability to respond. He declined injections because of needle phobia, and no compulsory treatment order was enforced.
What failures did the police specifically commit?
Leicestershire Police never flagged Calocane as a serious threat, while Nottinghamshire Police secured a warrant in August 2023 but delayed execution for nine months, effectively allowing him to remain in the community during the critical period before the attacks.
How is the NHS changing its discharge procedures?
All trusts must now retain patients who miss appointments or refuse medication until a robust care‑plan is in place. The new protocol includes mandatory risk‑assessment meetings with police liaison officers before any discharge.
What role will Health Secretary Wes Streeting play?
Streeting pledged to publish the names of every clinician involved in Calocane's care, oversee the public inquiry’s progress, and ensure the £900 million funding is allocated to community crisis services nationwide.
When can the public expect the inquiry's final report?
The inquiry, launched in late 2025, aims to deliver an interim report by mid‑2026 and a comprehensive final report by early 2027, outlining concrete reforms for mental‑health and policing coordination.