Care Quality Commission Section 48 Review of Nottinghamshire Healthcare NHS Foundation Trust
(Limited Text - Ministerial Extracts only)
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The Secretary of State for Health and Social Care (Wes Streeting)
On 30 January 2024, my predecessor as Secretary of State asked the Care Quality Commission to conduct a special review of mental health services in Nottinghamshire in response to the horrendous killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber.
I am grateful to the CQC for the detailed work it has undertaken on this report. My thoughts are with the families and friends of Barnaby, Grace and Ian. This report makes for distressing reading, especially for those living with this unimaginable loss in the knowledge that this tragedy could have been prevented.
The review was composed of three strands. The reports for strands 2 and 3, relating to the safety and quality of services provided by Nottinghamshire healthcare NHS foundation trust and the services provided at Rampton hospital, were published on 26 March 2024.
On 13 August, the CQC published the remaining report for strand 1 of the review into the care and treatment provided to Valdo Calocane by NHFT in the period leading up to the horrific events of June 2023. As part of this review, the CQC was also asked to determine whether its review of Valdo Calocane’s care and that of 10 other benchmarking cases indicated wider patient safety concerns or systemic issues with the provision of mental health services in Nottinghamshire.
This report identified serious failings in the care and treatment provided to Valdo Calocane by NHFT that may have contributed to these tragic killings after he was discharged from the trust’s mental health services. These failings are consistent with the CQC’s findings from strands 2 and 3 of the review, published in March, which identified issues with the safety of services and quality of care at NHFT as a whole.
While there was no single point of failure for Valdo Calocane’s care identified in the report, the strand 1 review identified serious shortcomings relating to four areas: risk assessment and record keeping, care planning and engagement, medicines management, and discharge planning.
I have met with NHS England, which has provided me with assurance that it and NHFT are taking action to address the serious failures identified in the report. I have made it clear to NHS England that I expect regular updates on progress against all the recommendations across the three strands of the review.
In advance of the publication of this report, NHFT has taken action to implement the CQC’s recommendations, specifically relating to managing patients who may be at risk of harming themselves or others. These actions include:
Changing “did not attend” policies to make sure patients are not discharged for not attending appointments.
Implementing systems to make sure staff more robustly consider risks to patients and the public.
Reviewing the approach to managing beds—there are early positive signs of a reduction in patients being placed in incorrect care settings as a result.
Putting into place a new crisis telephone system so that patients can access crisis services 24/7 without delay.
Reviewing patients waiting to access community support—the waiting list has reduced from 1,500 to 1,092.
Providing increased oversight for patients who are waiting to access care and checking medications for everyone in the community on antipsychotic medication.
I have made it clear that I also expect regular progress reports from NHFT.
I also expect these findings and recommendations to be considered and applied throughout the country. NHS England has accepted all of the CQC’s recommendations and has initiated a series of actions to ensure nationwide improvements are made.
As part of this work, NHS England has tasked every provider in England to review the policies and practices in place to ensure patients who are very unwell and who need help to engage with services do not fall through the cracks. I expect regular updates from NHS England on the progress of this review.
Other measures the NHS has already undertaken include:
Issuing guidance to trusts reiterating instructions not to discharge patients with serious mental health issues if they do not attend appointments.
Commissioning an independent investigation into the incident, which will be published by the end of 2024.
Continuing to improve data on community mental health services including developing metrics around access to psychological therapies for severe mental health problems and outcomes for people accessing community mental health services.
Establishing an expert advisory group to oversee the development of core standards for safe care in community mental health services.
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