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Following a tragic incident in Nottingham where two university students and a school caretaker were fatally stabbed by a man with paranoid schizophrenia, the Care Quality Commission (CQC) conducted a review of the mental health services involved in the case. The review revealed several errors and misjudgments in the handling of the perpetrator, Valdo Calocane, leading up to the devastating event.

One of the key findings of the review was the failure of mental health services to adequately respond to warnings from Calocane’s family about his deteriorating mental health. Despite multiple instances of violent behavior and non-compliance with medication, the risk assessments conducted were deemed inconsistent, under-resourced, and overly optimistic. Additionally, there was a missed opportunity to provide more robust treatment through inpatient injections rather than oral medication.

Perhaps the most concerning aspect of the review was the decision to discharge Calocane from mental health services due to his non-engagement, despite clear evidence that he was at risk of relapsing into aggressive behavior. This lapse in judgment ultimately led to the tragic loss of lives in June 2023.

Moving forward, it is imperative that lessons are learned from this tragedy to prevent similar incidents in the future. The proposed changes to the Mental Health Act and the establishment of national standards for dealing with complex cases of psychosis are crucial steps in the right direction. It is essential to strike a balance between respecting the autonomy of mental health patients and ensuring public safety, especially in cases as severe as this one.

The failures identified in the handling of Valdo Calocane’s case serve as a stark reminder of the importance of robust and responsive mental health care services. By implementing the recommendations of the CQC’s review and prioritizing the safety and well-being of both patients and the community, we can work towards preventing such tragedies from occurring again.