Families of the Nottingham attacks victims have warned “further disasters” are “inevitable” after a damning report into the health trust that cared for the schizophrenic killer responsible.
Valdo Calocane was under the care of the Nottinghamshire Healthcare NHS Foundation Trust in the years leading up to the June 2023 attack – which claimed the lives of Barnaby Webber, Grace O’Malley-Kumar, both 19, and Ian Coates, 65.
Now a fresh report from The Care Quality Commission (CQC) has revealed the trust’s mental health services “were not always humane, dignified or gave high-quality care” when treating patients.
Calocane admitted manslaughter by diminished responsibility and attempted murder and was sentenced to an indefinite hospital order in January 2024.
Experts said his schizophrenia meant he was not fully responsible for his actions, and since his trial a long list of missed opportunities to prevent him committing his crimes has emerged.
He was under Nottinghamshire Healthcare NHS Foundation Trust’s care between May 2020 and September 2022.
Between May 2024 and August 2025, the CQC carried out 39 inspections at the trust, before a trust-wide review of its leadership was carried out last September.
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The resulting report said the trust was found to have breached regulations about how it was managed and, following the inspections, it had been asked to provide an action plan.
The CQC said: “Due to the level and nature of risks identified, we have taken enforcement action and asked the trust to make significant improvements and to work collaboratively with key stakeholders in the wider healthcare system to support significant improvement.”
Seven of its 18 services were rated as requiring improvement, including five mental health services.
The families demanded that the trust be put under special measures until issues are addressed.
In a statement, the families of Mr Webber, Ms O’Malley-Kumar and Mr Coates said: “This report confirms what families have feared for far too long: this trust is not safe and should be placed into special measures immediately.
“Families have lost all confidence that this trust will learn on its own. If it is allowed to continue unchanged, there is a real fear that further harm and further disasters are inevitable.
“This is no longer about improvement plans or assurances. It is about urgent intervention, accountability at the highest level, and protecting lives.”
Greg Almond, partner at Rothera Bray Solicitors, who represents attack survivors Wayne Birkett and Sharon Miller, said there were “significant and glaring problems” in Nottinghamshire’s mental health care.
He said in a statement: “The report acknowledges the significant amount of scrutiny the trust was under following the attack. Despite this, the CQC conclude that there remain significant and glaring problems in the mental health provision in Nottinghamshire.
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“For the survivors, who deserve to have faith in the mental health provisions in Nottinghamshire, this is a deeply worrying assessment, and they can’t help but be left with the feeling that nothing has been done to prevent a reoccurrence.”
Ifti Majid, chief executive of Nottinghamshire Healthcare, said: “We accept the CQC’s findings and recognise where improvement is needed.
“We have already made significant improvements since the CQC’s last inspection, but fully appreciate there is still more to do. We will be addressing all areas identified in the report.”
The events leading up to the killing of Mr Webber, Ms O’Malley-Kumar and Mr Coates will be looked at in a public inquiry starting in February.
Calocane also attempted to kill three other people in the attack.
