I have met dozens of Valdo Calocanes. What he did just over a year ago in Nottingham was grotesque, but he was not an exceptional patient. His presentation, elusiveness and early pattern of contact with services are very familiar to someone like myself.
On a summer’s night in 2023, Calocane randomly killed three strangers in Nottingham while experiencing intense delusional beliefs arising from his untreated psychotic illness. He had had intermittent contact with his local NHS healthcare trust over two years, some of it while detained in hospital under the Mental Health Act. However, he was discharged from its community service back to his GP nine months before the killings, on the grounds that he had dropped out of contact with his mental health team. Criticism of Calocane’s management by trust staff, led by the Care Quality Commission’s recent report, has been scathing and almost universal.
I am certain that these deaths would not have happened if there had been a far more interventionist and rigorous approach to Calocane’s care. Objectively, the responses to his devastating illness were grossly inadequate.
However, the process of diagnosing and then working with someone with severe mental health issues is extremely fraught, and community mental health services, especially in the inner city, contend with challenges like those presented by Calocane every day.
During the initial phases of care, clinical uncertainty and missed opportunities for prompt and effective treatment are, in a way, unavoidable. Early on, it is very common for there to be clinical disagreement about whether a patient’s symptoms are due to an emerging illness, the use of drugs, or an underlying antisocial personality. And it often takes years before the optimal pharmacological treatment for a sufferer is arrived at. This is not incompetence. It is the reality of working with serious psychotic illness such as paranoid schizophrenia.
Follow-up with this group of patients is often haphazard. Generally, this is because sufferers actively resist becoming “a patient”, with all that entails, and are determined to avoid contact with services out of a desperation to preserve the identity that is familiar to them and makes them feel safe. Suicide, rather than harm to others, is often a response to the catastrophic loss of authenticity felt at this stage.
Other organisational and cultural factors quickly come into play. Relatives, who almost always understand the extent and risks of their loved one’s illness best, gradually drift to the margins of their care. As a carer of someone with serious mental health challenges myself, I know first-hand that it takes confidence to insist on being listened to and fully included in decisions about discharge and aftercare.
But there is a sad truth which I have witnessed so many times in my different roles. I believe many mental health services in England are anti-family, and that this is institutionalised. Staff don’t set out to behave in this way, and trust policies may well profess otherwise, but commonly there is a resistance to bringing relatives actively and supportively into the circle of decision-making.
Confidentiality is often cited as a reason for not working closely with relatives, and it seems that Calocane told staff to stop contacting his family. To have ignored this may have alienated him further, but a patient’s consent is not needed for simply having contact with relatives and listening to their wishes and concerns. In any event, the need for consent to disclose information to others can be overridden where there is a risk of death or serious harm. Where risk is concerned, the patient is not your only client.
Two further powerful cultural factors stand out from what we know about Calocane’s case. Discharging him back to his GP because he was uncooperative was indeed an egregious and pivotal error – an inability to work with healthcare professionals often being a symptom of psychotic illness rather than a reason for discharge. But such practice derives from a ubiquitous yet hidden organisational imperative, which is to keep people off the trust’s caseload and especially out of hospital wherever possible – even where it is objectively clear that admission to hospital is precisely what a patient needs.
All behaviour and all structures point in this direction. Indeed, as a manager for eight years of an NHS trust community assessment service, receiving referrals from GPs and numerous other agencies, I am ashamed to say that my first instinct became to find reasons for not accepting, or delaying, a referral. Where earlier in my career there was a general eagerness to provide a responsive service, later on the whole motor of the organisation I worked in was tuned towards fending off potential patients and bouncing them back to primary care wherever possible.
Another key factor is that mental health trust services are geared to deal with immediate or short-term risk, not with risk over time, which is much harder to manage. The media latched on to a prediction by a doctor that Calocane would go on to kill someone, but this was a fear we’ve all had in our community mental health teams about a large cohort of patients. Indeed, some years ago I wrote in a report for a mental health tribunal that I believed a patient would kill someone, even indicating the circumstances and the weapon – and this is exactly what happened the following year.
Longer-term risk is far easier to manage in a forensic mental health service, which will exclusively look after patients who have committed serious offences. Caseloads here are stable and low, and Mental Health Act restriction orders (where every decision about a patient’s must be ratified by the Home Office) help staff to be firm and consistent over a number of years. The tragedy, and maybe the absurdity, of this state of affairs is that patients such as Calocane only get the rigorous treatment and management they have always needed once they have committed their offence.
I worry about further inquiries and commissions. Like every investigation back as far as that into the killing of Jonathan Zito by Christopher Clunis in 1992, they will find no new failings. They will come up with a blizzard of recommendations and structural changes which will demoralise staff, sap clinical energy and ensure that the most able staff spend their time managing change when they should be managing illness and treatment.
We need very simple structures, rather than the fragmented, cellular system that trusts have at the moment, which fails to provide the real continuity and consistency of community care that patients such as Calocane need from the outset. But above all, we need this care to be provided by staff who have the tenacity, experience, qualities and interpersonal skills needed to engage with patients and their families fully. The focus must not be on what went wrong in one particular case, but on the attitudinal and deep organisational factors that allow things to go wrong so often and in the same way.
Jeremy Walker spent 25 years working in and managing NHS community mental health teams and nine years as an inspector in the Mental Health Act Commission (now part of the CQC). He also chaired panels reviewing the detention of patients under the Mental Health Act for 14 years
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