NHS trust boss tells inquiry of ‘missed opportunity’ to stop Nottingham killings
Valdo Calocane, a former mental health patient who treated paranoid schizophrenia at the NHS trust, fatally attacked someone less than a year before the Nottingham murders, an inquest heard.
Paul Devlin, who was chairman of Nottinghamshire Healthcare NHS Foundation Trust until December last year, said it was a “missed opportunity” to take steps that could have prevented Calocane’s violent rampage.
Calocane, who was under the care of the trust from 2020 until his discharge in 2022, was carrying a gun in a backpack in the early hours of June 13, 2023, when he stabbed students Barnaby Webber and Grace O’Malley-Kumar, both 19, and caretaker Ian Coates, 65, to death.
He then attempted to kill three pedestrians in Nottingham city center using the van he stole from Mr Coates.
The inquest examining the events leading up to Calocane’s murder heard on Tuesday that a fatal attack was carried out in August 2022 by someone with “previous links to the trust’s mental health services”.
The patient’s name was not given and the circumstances of the murder were not shared as evidence.
Inquiry lawyer James Weston said: “At board level, not enough has been done in relation to this incident in August 2022.”
Mr Devlin said: “I accept that.”
Mr Weston added: “We are a few weeks before the demobilization of the VC (Valdo Calocane), at which time the GP was demobilized from his trust.
“We have a case here involving a former patient and there are some issues regarding discharge, but no meaningful action is being taken by the board at this stage.
“This was a missed opportunity, wasn’t it?”
Mr Devlin replied: “Yes it was.”
The former president, who has held this position for about five years, said that the incident was reported to the board of directors in September 2022, but the foundation’s investigation could not be carried out until the police investigation was concluded.
The inquest heard that a plan of action regarding the deadly attack was only approved in May 2025.
Asked whether the trust had done anything during the police investigation, Mr Devlin said: “I don’t know if it’s fair or not. I think this will be looked at very much from an operational team perspective.”
“However, it was felt that the official investigation route should be suspended due to the police investigation.”
Mr Weston asked if Calocane’s case would have been considered if an audit of “unsafe evictions” had been carried out in September 2022 after this incident.
Mr Devlin replied: “Yes, that may have been the case.”
The lawyer continued: “So, could steps have been taken to prevent the attacks in June 2023?”
The former president replied: “It could be so, yes.”
The inquest heard that the trust’s board was notified of another fatal incident involving a mental health patient in February 2023, while a separate non-fatal attack was documented in April the same year.
Calocane, who pleaded guilty to manslaughter and three counts of attempted murder, was detained indefinitely at a high-security hospital after prosecutors pleaded not guilty to the murder.
The investigation continues.
