There were “multiple and fundamental failures” with the NHS’s management of Nottingham killer Valdo Calocane’s mental health treatment, the health secretary has said.

Speaking after a Care Quality Commission (CQC) report found paranoid schizophrenic Calocane’s condition was downplayed by the NHS, Wes Streeting said the report’s findings were “deeply distressing”.

Calocane fatally stabbed students Grace O’Malley-Kumar and Barnaby Webber, and caretaker Ian Coates, in June 2023.

He was detained in a high security hospital in January – “very probably” for the rest of his life – after prosecutors accepted a manslaughter plea on the basis of diminished responsibility.

Mr Streeting said: “I think what’s so shocking about the Care Quality Commission’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, the fact he was discharged for not attending when actually, non-attendance should have provoked closer supervision.”

Mr Streeting said Nottinghamshire NHS Trust, which was responsible for Calocane’s care, was shown the report’s findings ahead of its publication and “have already been acting to implement some of its findings”.

And he said the NHS, across England, has already been instructed not to discharge mental health patients who do not attend appointments.

“There’ll be further action and I’ll be seeking regular updates because we’ve heard so many times before, lessons are learned,” he said.

“Actually, what we need to see is lessons acted upon, not just for the benefit of people in Nottinghamshire, but right across the country.”

The health secretary confirmed a judge-led inquiry into what happened with Calocane’s care by the NHS will be held.

He said Prime Minister Sir Keir Starmer is “actively considering” how best to set up the inquiry so it delivers “both the accountability and the answers that the families are looking for”.

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Mr Streeting added that he he cannot “imagine the unbearable grief” the families are going through, especially knowing from the report that they were preventable “if the NHS had been there when it should have been”.

The CQC’s review, published on Tuesday, examined how the Nottinghamshire Healthcare NHS Foundation Trust (NHFT) handled the care of 32-year-old Calocane before the killings.

It found that from May 2020 until September 2022, risk assessments by the trust played down the fact Calocane was refusing to take his medication and having ongoing and persistent symptoms of psychosis.

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The regulator said that while some risks were highlighted, other assessments “minimised or omitted key details”.

It added that a decision to discharge the attacker back to his GP in 2022 was made despite there being evidence beyond any real doubt that Calocane would “relapse into distressing symptoms and potentially aggressive behaviour”.

It was also revealed Calocane had been detained in hospital four times under mental health laws before the attacks.

Ms O’Malley-Kumar’s mother and father, Dr Sinead O’Malley and Dr Sanjoy Kumar, told Sky News they had been left “devastated” by the report.

Dr Kumar continued: “We had a simple case, a simple case of a culpable person who did not take his medication.

“All of this is devastating to read. It was so basic.

“The errors were not technical, they were basic, basic errors … there were so many chances to change the course of Calocane but none of those opportunities were taken by any of the doctors.

“The doctor who actually discharged him, that was the most irresponsible thing to do knowing that… a doctor had put in the notes he had the potential to murder someone.”

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Chris Dzikiti, the CQC’s interim chief inspector of healthcare said while it is not possible to say the events would not have taken place if Calocane had received the support he needed, it is clear “that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed”.

“For the individuals involved, their families and loved ones, the damage cannot be undone,” Mr Dzikiti added.

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