- He was sentenced to a hospital order in January and told he would be in a high-security facility "very probably" for the rest of his life.
- Tuesday's report looked into Calocane's care by Nottinghamshire Healthcare NHS Foundation Trust from May 2020 to September 2022.
The families of the victims of the Nottingham attacks say those responsible for failings in Valdo Calocane’s care have "blood on their hands".
Barnaby Webber and Grace O'Malley-Kumar, both 19, and 65-year-old Ian Coates were killed by Calocane, who was psychotic and suffering from paranoid delusions, on 13 June 2023.
A review published by the Care Quality Commission (CQC) on Tuesday found "a series of errors, omissions and misjudgements" by mental health services.
In a statement, the victims’ families said the organisations involved "must bear a heavy burden of responsibility".
The CQC review said "key" risk factors in Calocane's case had either been missed or omitted, including his refusal to take medicine, his persistent symptoms of psychosis and level of violence towards other people.
Without action, it said, the issues identified would "continue to pose an inherent risk to… public safety".
Health Secretary Wes Streeting met the victims' families last week. He said he expected the recommendations from the report to be applied across the country.
The Department of Health and the Attorney General's Office both told the BBC that the prime minister's commitment to a judge-led inquiry into the deaths still stood.
However, the families have insisted the inquiry must be statutory, with the power to compel witnesses to provide evidence.
Speaking to BBC Radio 5 Live, Mr Webber's mother Emma said the failings were "dreadful" and highlighted problems across the NHS.
She said: "If any one of those missed opportunities had been addressed then I honestly think Barnaby would still be here today - so would Grace.
"He and Grace might be off on holiday together. Ian would have been off fishing enjoying his retirement that he jolly well earned. But, they're not."
"It's systemic," she added. "It's not just one mental health trust.
"It's uncovered and highlighted the urgency for conversation and change.
"It's not a witch hunt, but we do expect accountability."
Last year, Calocane went on a rampage through the streets of Nottingham, killing students Mr Webber and Ms O'Malley-Kumar with a knife as they returned from a night out, before stabbing Mr Coates to death near the school where he worked as a caretaker.
He then stole Mr Coates's van and drove into pedestrians Wayne Birkett, Marcin Gawronski and Sharon Miller, inflicting serious injuries.
He was sentenced to a hospital order in January and told he would be in a high-security facility "very probably" for the rest of his life.
Tuesday's report looked into Calocane's care by Nottinghamshire Healthcare NHS Foundation Trust from May 2020 to September 2022.
The victims' families - who have repeatedly called for a public inquiry into the case - said they were failed by multiple organisations before and after the attacks.
In a joint statement, they said: "This report demonstrates gross, systemic failures in the mental health trust in their dealings with Calocane, from beginning to end.
"Clinicians involved at every stage of Calocane’s care must bear a heavy burden of responsibility for their failures and poor decision making.
"Sadly, this is the first of what we expect to be a series of damning reports concerning failures by public bodies in the lead up to the killings of our loved ones, and beyond.
"Along with the Leicestershire and Nottinghamshire police forces, these departments and individual professionals have blood on their hands."
They added: "Progress is slowly being made and we will continue in our fight to ensure there is full organisational and individual accountability for the horrific events of 13 June 2023.
"We will also fight to ensure that appropriate changes and improvements to our systems and laws are made, so as to ensure that a tragedy of this level is prevented from ever happening again."
Dr Sanjoy Kumar, Ms O'Malley-Kumar's father, told the BBC that the families would like the scope of the inquiry to be "as wide as possible".
"We would like it to be a statutory public inquiry led by a judge, and one that has real teeth to make a difference and change things in our country," he added.
"We have to concentrate on Nottingham first and learn from what went wrong because these systems are parallel across the country."
In compiling its report, the CQC reviewed Calocane's records alongside 10 other cases "to enable benchmarking".
The CQC said it had "engaged" with the families of Calocane and the victims, but the watchdog did not interview or speak to any staff members involved in the offender's care at the trust.
The report found the 32-year-old - a former University of Nottingham student - had first come into contact with the trust in May 2020 during the first Covid-19 lockdown.
Documents showed he was "acutely unwell", and was diagnosed with paranoid schizophrenia and sectioned four times in less than two years.
But the report said "key" risks had either been missed or omitted, including the refusal of medicine, ongoing and persistent symptoms of psychosis, levels of violence against others when his psychosis was not managed well, and Calocane's escalation of violence towards others in the later stages of his care under the trust.
It also found "poor planning and engagement" with the killer and his family, who raised concerns about his mental state with the trust and to BBC Panorama in their first interview.
"It is clear that after four admissions in two years, and repeated disengagement and refusal to take medicine, [Calocane] required a much more robust package of care," the report said.
"More assertive engagement and restrictive measures were crucial to managing his illness and the risk he posed to others when unwell."
The CQC issued five recommendations to the trust, including ensuring that staff were aware of the importance of involving and engaging patients' families, and implementing "robust discharge policy and processes".
Responding to the review, the Health Secretary said: “What the CQC has uncovered is deeply distressing. Mostly for the families of Grace, Barnaby and Ian, who in addition to having to deal with the unbearable and unimaginable grief they are going through, are doing so in the knowledge that this could’ve been prevented.
“What's so shocking about the CQC’s report is that there were so many failures and fundamental failures; in terms of the supervision of Valdo Calocane, the provision of medication and what happened when he wasn’t taking his medication, and then shockingly he was discharged for not attending when actually non-attendance should've provoked closer supervision.
“The hard truth here… is that had the NHS done its job, had there not been multiple fundamental failures, three innocent people might still be alive… that’s why I totally understand why they [the victim’s families] have accused the NHS of having blood on its hands.
"It is a hard criticism to hear but one the NHS has to take on the chin. Most importantly we need to do ensure two things - firstly that there is accountability, and secondly to make sure that the factors that led to the preventable deaths of three innocent people are eliminated as risk factors right across the country."
'More detailed scrutiny'
"I’m reassured Nottinghamshire Trust is already acting. I’m reassured that the NHS nationally is also acting and I will hold them to account by demanding regular progress reports so we don’t have the usual mantra of lessons must be learnt, we instead have the reassurance of action is and will be taken to make sure other families don’t have to go through the unbearable grief that these families are going through today.”
Mr Streeting also said the Prime Minister and Attorney General were "actively considering" how best to set up an inquiry that delivered "both the accountability and the answers that the families of the victims are looking for".
In its report, the CQC said NHS England would be carrying out "more detailed scrutiny" of Calocane's wider interaction with mental health services in its "independent homicide review".
The government said measures the NHS had already taken included issuing guidance to trusts - reiterating instructions not to discharge patients with serious mental health issues if they did not attend appointments - and ensuring every service provider had "clear policies and practice in place to treat patients".
Chris Dzikiti, interim chief inspector of healthcare at the CQC, added: "The issues we have identified at Nottinghamshire Healthcare NHS Foundation Trust are not unique.
"We found systemic issues with community mental health care, including a shortage of mental health staff, a lack of integration between mental health services and other healthcare... and support services, including the police.
"Without action, this will continue to pose an inherent risk to patient and public safety."
Timeline of Valdo Calocane's contact with the trust
The CQC has released a timeline of Calocane's contact with the local NHS trust. It said:
- 24 May 2020 - Calocane is arrested for the first time. He is sent home after a mental health assessment but is re-arrested an hour later
- 25 May 2020 - Officials section Calocane for the first time at Highbury Hospital in Nottingham
- 14 July 2020 - Calocane is involved in a police incident and sectioned for the second time
- 3 September 2021 - Calocane is sectioned for the third time and taken to an independent hospital
- 18 January 2022 - Calocane is detained after an assault on another student
- 28 January 2022 - He is sectioned for the fourth time
- 23 September 2022 - Calocane is discharged to a GP due to non-engagement
Mr Dzikiti added "poor decision-making, omissions and errors of judgement" had contributed to a situation in which a patient with "very serious mental health issues did not receive the support and follow-up he needed".
"While it is not possible to say that the devastating events of 13 June 2023 would not have taken place had Valdo Calocane received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed," he said.
"There is action that can, and must, be taken to better support people with serious mental health issues and provide better protection for the public in the future."
Marjorie Wallace, founder and chief executive of mental health charity SANE, described the report as "one of the most damning" she had ever read.
She told BBC Breakfast: “Sadly… the same kinds of things are happening all the time, not always leading to headline tragedies.
“The problem is that we have nowhere for people to go. We actually have half the number of adult psychiatric beds since 2000. We’ve only got about 18,000 left in the country.
“Where a person does pose a risk, the tendency is to say they aren’t sufficient risk and therefore they can go back and live in the community.
“What worries us in this case, is it seems to be Valdo Calocane’s right to refuse taking medication – the anti-psychotic medication which might have kept the voices in his head at bay and might not have got him to a state of deterioration.
“This right to choose not to engage with services, well that seems extraordinary."
She added: “This report exposes the psychiatric services are not only in crisis, they are in breakdown."
Panorama - The Nottingham Attacks: A Search for Answers
In June 2023, Barnaby Webber, Grace O'Malley-Kumar and Ian Coates were stabbed to death by Valdo Calocane. Reporter Navtej Johal investigates his history of mental ill health and the care he received.
Ifti Majid, chief executive of the NHS trust, offered his "sincere apologies" to the families of the victims.
"We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out," he said.
"Our teams have much more contact with people waiting to be seen in the community to agree crisis plans and ensure they have an up-to-date risk assessment even when they are struggling to engage with our services or primary care.
"We have a clear plan to address the issues highlighted and are doing everything in our power to understand where we missed opportunities and learn from them."
The report is the latest of a series of reviews, including by the Independent Office for Police Conduct (IOPC) into both Leicestershire and Nottinghamshire Police.
A review into the Crown Prosecution Service (CPS) found that while prosecutors had been right to accept Calocane's pleas of manslaughter on the basis of diminished responsibility, they could have handled the case better.
And in May, a judge ruled Calocane's sentence was not unduly lenient, following a referral from the attorney general.
Analysis
By Navtej Johal, BBC Panorama
There are several points mentioned in this review which support the view of Calocane’s family that opportunities to provide him with the care he needed before the tragic events in Nottingham in 2023 were missed.
In their first interview, Elias and Celeste, Calocane’s brother and mother, told me that they believed the mental health system was “broken” and “not fit for purpose”.
One of many examples of the problems in his care highlighted by the CQC is the decision to discharge him to his GP for not engaging with mental health services nine months before the killings.
The review says that decision “did not adequately consider or mitigate the risks of relapse”.
Celeste Calocane said she felt that at that moment, the community mental health team “wash their hands and say, 'OK, that's it’.”
They will be hoping that the recommendation to strengthen policy and processes that “consider the circumstances surrounding discharge and whether discharge is appropriate” are among many that are acted upon.
The CQC report was released the day after BBC Panorama interviewed the family of Valdo Calocane for the first time.
Mrs Webber said she was "very disappointed" that the victims' families were not asked to take part in the documentary, which aired on Monday.
"I don't think they acted with proper duty of care to us, but we've got other things to concentrate on now and there are elements of that programme that of course just further what's come out in much more detail in the CQC report and it will with the NHS," she said.
A BBC spokesperson said: "We have the deepest sympathy for the families, and the Panorama team has been extremely mindful of the sensitivities in handling this programme.
"They have been in contact with the bereaved families to tell them about the programme and to provide an outline of its editorial focus."