It was an atrocity that shook the nation. In June last year, Valdo Calocane stabbed to death 19-year-old students Barnaby Webber and Grace O’Malley-Kumar in Nottingham, going on to kill 65-year-old Ian Coates. Calocane then stole Mr Coates’ van and used it to seriously injure three more people by mowing them down in the street before police apprehended him.
The attack had all the hallmarks of a terrorist incident, and the people of Nottingham and far beyond certainly felt terrorised in the initial hours and days after the event. The courts decided that Calocane was guilty of manslaughter through diminished responsibility, a decision bitterly resented by the bereaved families. It is likely he will never be released from a secure hospital where he is now detained.
The brutal trajectory of this attack was laid out in court, so the how of these killings is easy to determine. It’s much harder to work out the why of such events, and certainly less comfortable. What is emerging now, with depressing inevitability, is that the processes that were already available and should have kept us safe from this man failed spectacularly. Calocane was discharged by the Nottinghamshire NHS Trust to the community despite clear evidence that his mental illness could lead him to harm or even kill someone.
Inspectors from the legal regulator, the Care Quality Commission, walked into the trust just 13 days after Calocane’s murder spree. At that point, they found an organisation that ‘required improvement’ overall, but was doing reasonably well. It did, however, identify organisational risk management as a particular weakness, stating: ‘There were not always robust arrangements for identifying risk, issues and mitigating actions. We did not see where high risks had been challenged and validated’.
Of the people whose literal job it was to challenge risk management and be the organisation’s canary in the coal mine, it had this to say:
There was widespread praise from the non-executive directors about how the chair had brought a sense of order and calm to the board. He had sought to increase the diversity of the board through the appointment of associate non-executive directors and had increased focus on equality and diversity.
The self-congratulation over this focus did not survive the next visit by the CQC earlier this year. This time, it was specifically to look at how the trust’s mental health service had operated in the light of the Nottingham attack by a man under their supervision. The resultant charge sheet is woefully familiar to those of us who spend our working lives trying to prevent harm.
Risk assessments were inconsistent and left out key details of the threat Calocane posed. His care plans were inadequate and failed to use available relevant powers to compel treatment. Record keeping of whether and when he took medication was chaotic or non-existent. The trust minimised or failed to understand how his previous behaviour could impact his future actions. And, most importantly from the perspective of why the Nottingham NHS Trust failed his victims, an entrenched ideological belief that severely ill and dangerous people can almost always be managed in the community. This default killed people.
This last failure starts to explain why changing the culture in organisations that fail is arguably more important than additional processes, protocols and reports. However, this is also notoriously hard to do. I have spent much of my professional life looking at risk management, from boardroom to court room. Invariably, catastrophic outcomes are caused by a failure of people to properly use existing systems not for want of new ones.
This pathology manifests itself in tired, isolated, beleaguered and secretive organisations where people are stopped from critically examining their own practice. Lack of time, poor front-line morale, lack of training, lack of transparency, senior leadership arrogance and hubris, lack of resources, poor shop floor supervision, fear of repercussions, putting personal and organisational reputation above ethical priorities. Some or all of these things operate within high-risk organisations to fashion an internalised ‘groupthink’ that is occasionally ruinous to public protection.
Nottingham NHS trust had all the bells and whistles of theoretical risk management in place. It had ‘governance’ structures coming out of its ears. All the rotten architecture of bureaucracy was in place before someone decided a floridly mentally ill man was suitable to be managed in the community with a light touch. Calocane converted that inexcusable leeway into homicide. All of these predictive factors for organisational disaster can be halted and reversed. But it takes huge commitment from C-suite to basement to make it happen. It also requires rigorous independent scrutiny of progress which the current crop of non-exec directors have not shown themselves capable of.
Can we fix organisations like this foundation NHS Trust? Nottingham was the first trust with a high security hospital within its purview to be given that vaunted status in 2015. What a grotesque irony. One of the benefits of trust status is that the organisation can behave with greater autonomy and in a more business-like way. If that were true in a commercial environment, we would see the share price crash and the board depart along with senior executives. But it’s dead people we are talking about here, not widgets.
It must fall to Wes Streeting who has declared himself ‘shocked’ by the latest revelations to act. A judge-led enquiry, while welcome, cannot provide the reassurance that the country needs now that a recurrence of this failure is made as close to impossible as can be, not ‘fingers crossed’. The families robbed of children and a grandfather cannot ever be compensated for the harm done. But swift and decisive intervention can make some sense of the grievous loss they have suffered at the hands of the state.
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