I’ve Met Many Valdo Calocanes. This Is How A Mental Health Crisis Can Lead To Tragedy | Jeremy Walker
I have met dozens of Valdo Calocanes. What he did in Nottingham just over a year ago 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 me.
On a summer evening in 2023, Calocane randomly murdered three strangers in Nottingham while suffering intense delusions stemming from his untreated psychotic illness. He had been in contact with his local NHS care home on and off for two years, some of it while in hospital under the Mental Health Act. However, he was discharged from community service nine months before the murders and returned to his GP, on the grounds that he had broken off contact with his mental health team. Criticism of Calocane’s management by the home’s staff, led by the recent Care Quality Commission report, has been damning and almost universal.
I am certain that these deaths would not have occurred if there had been a much more interventionist and rigorous approach to Calocane’s care. Objectively, the responses to his devastating illness were grossly inadequate.
However, diagnosing and subsequently treating someone with serious mental health issues is an extremely difficult process. Community mental health, especially in the inner city, struggles daily with challenges like those faced by Calocane.
During the early stages of care, clinical uncertainty and missed opportunities for early and effective treatment are in some way inevitable. Early on, it is common for there to be clinical disagreement about whether a patient’s symptoms are due to an emerging illness, the use of medications, or an underlying antisocial personality. And it often takes years before the optimal pharmacological treatment for a patient is achieved. This is not incompetence. It is the reality of working with severe psychotic disorders such as paranoid schizophrenia.
Follow-up of this group of patients is often haphazard. This is generally because patients actively resist becoming a “patient”, with all its consequences, and are determined to avoid contact with services out of desperation to maintain the identity they know and feel safe with. Suicide, rather than harm to others, is often a response to the catastrophic loss of authenticity felt at this stage.
Other organizational and cultural factors quickly come into play. Survivors, who almost always understand best the extent and risks of their loved one’s illness, are gradually pushed to the margins of their care. As a caregiver of someone with serious mental health problems, I know firsthand that it takes confidence to insist that you will be listened to and fully involved in decisions about discharge and aftercare.
But there is a sad truth that I have seen so often in my various roles. I believe that many mental health services in England are anti-family, and that this has been institutionalised. Staff do not intend to behave in this way, and trust policies may well say otherwise, but there is often a reluctance to involve family members actively and supportively in the decision-making process.
Confidentiality is often cited as a reason for not working closely with family members, and it appears that Calocane told staff not to have any more contact with his family. Ignoring this may have alienated him further, but a patient’s consent is not required to simply have contact with family members and listen to their wishes and concerns. In any case, the need for consent to provide information to others can be ignored if there is a risk of death or serious injury. When it comes to risk, the patient is not your only client.
Two other powerful cultural factors stand out in what we know about Calocane’s case. Sending him back to his GP for uncooperative behaviour was indeed a blatant and crucial mistake – the failure to work with healthcare professionals is often a symptom of psychotic illness rather than a reason for discharge. But such practices are driven by a pervasive but hidden organisational imperative, namely to keep people off the trust’s caseload and, above all, out of hospital where possible – even when it is objectively clear that hospitalisation is exactly what a patient needs.
All the behaviours and all the structures point in this direction. As a manager of an NHS trust community assessment service for eight years, receiving referrals from GPs and numerous other agencies, I am ashamed to say that my first instinct was to find reasons not to accept or to delay a referral. Where earlier in my career there was a general eagerness to provide a responsive service, later the whole engine of the organisation I worked in was geared towards deflecting potential patients and sending them back to primary care where possible.
Another important factor is that mental health services are trusted are focused on dealing with immediate or short-term risks, not long-term risks, which are much harder to manage. The media seized on a doctor’s prediction that Calocane would kill someone, but this was a fear we all have in our community mental health teams about a large group of patients. A few years ago I wrote in a report to a mental health court that I believed a patient would kill someone, even specifying the circumstances and the weapon – and this is exactly what happened the following year.
Long-term risks are much easier to manage in a forensic mental health service, which deals exclusively with patients who have committed serious crimes. Caseloads here are stable and low, and the Mental Health Act restriction orders (whereby every decision about a patient must be ratified by the Home Office) help staff to be steadfast and consistent over many years. The tragedy, and perhaps the absurdity, of this situation is that patients like Calocane only receive the rigorous treatment and management they have always needed after they have committed their crime.
I worry about further inquiries and commissions. Like every inquiry going back to the murder of Jonathan Zito by Christopher Clunis in 1992, they will not find new failings. They will come up with a barrage of recommendations and structural changes that will demoralise staff, sap clinical energy and ensure that the most capable staff spend their time managing change when they should be managing disease and treatment.
We need very simple structures, rather than the fragmented, cellular system that trusts currently have, which fails to provide the real continuity and consistency of community care that patients like Calocane need from the outset. But above all, we need this care to be delivered by staff who have the tenacity, experience, qualities and interpersonal skills needed to engage fully with patients and their families. The focus should not be on what went wrong in one particular case, but on the attitudes and deep organisational factors that cause things to go wrong so often and in the same way.