Calocane and Saadallah cases expose vulnerability in NHS mental health services

Mr Streeting’s comments were in reaction to the recently published Care Quality Commission (CQC) report into the care of Calocane by Nottinghamshire Healthcare NHS Foundations Trust. The report highlighted a series of errors, omissions, and misjudgements in his care, and found that risk assessments minimised key details such as the seriousness of Calocane’s risk to others.

Calocane was diagnosed with paranoid schizophrenia three years before the attack. He regularly refused to take his medication and was having ongoing and persistent symptoms of psychosis. His increasingly violent behaviour was documented, but despite clear red flags, the risks he posed were minimised by NHS mental health services.   

Mr Streeting highlighted that there was no single point of failure in the care but said “multiple and fundamental failures on the part of the NHS to manage Calocane’s treatment in a way that not only kept him safe, but most importantly, kept others safe.” 

Following publication of the report, the Prime Minister, Sir Keir Starmer is said to be “actively considering” how best to set up a judge-led inquiry into the case, in order to deliver the accountability to the Coates, Webber and O’Malley-Kumar families.  

The concerns highlight a growing area of vulnerability within the NHS. Complex patients are often the most difficult to treat, but also pose the most risk to themselves and others if that treatment is not provided. That risk cannot and should not be ignored. 

Calocane’s care highlights the importance of proper risk assessment and care planning by NHS mental health services when it comes to such patients, and of this information being appropriately fed into other contact agencies who have a duty to ensure the safety of the public. 

Specifically, there should be risk assessments that take into account all available information relevant to a patient’s risk and include the assessment of risk to themselves and others if they fail to engage, as well as a care plan that addresses that risk with a focus on achieving engagement and a plan if that is not achieved. 

Leigh Day represented the families of James Furlong, Joseph Ritchie-Bennett and David Wails, who were murdered by Khairi Saadallah in the Forbury Gardens terror attack on 20 June 2020, in the judge-led inquest into their deaths. 

Saadallah had a personality disorder and symptoms of Post-Traumatic Stress Disorder and had multiple contact with NHS mental health services in the years leading up to the attack.   

The inquest held early this year heard evidence that information relevant to Saadallah’s risk was not properly shared with other contact agencies by NHS mental health services, and that they failed to provide him the support to engage with the services.   

In his findings, the Judge Coroner found that consistent case-management and long-term therapy had a real potential to reduce Saadallah’s aggressivity, impulsivity and substance misuse, and thereby his risk to the public. 

The tragic deaths at the hands of Calocane and Saadallah show the important part that NHS mental health services play in keeping the public safe and raise serious concerns about how they are performing that function, with the need for urgent improvements to prevent similar such tragedies occurring in the future. 

Leigh Day currently represents other families who have lost loved ones in circumstances with similarities to those perpetrated by Calocane and Saadallah.