Nottinghamshire’s mental health trust should have responded properly to an incident just months before the Nottingham attacks
Dr Sanjoy Kumar, father of Grace O’Malley-Kumar, pictured outside Mary Ward House where the Nottingham Inquiry is held(Image: Joseph Raynor/Nottingham Post)
A former leader at an NHS trust says it could have stopped the Nottingham attacks by responding properly to another atrocity months earlier in an admission that one bereaved parent has dubbed “heartbreaking”.
Dr Sanjoy Kumar said the Nottinghamshire Healthcare NHS Foundation Trust (NHFT) are guilty of a “total failure” in their response to a fatal attack in August 2022 – less than a year before Valdo Calocane’s attacks of June 2023.
Calocane was a paranoid schizophrenic who had contact with NHFT for around two years before he killed Barnaby Webber, Grace O’Malley-Kumar and Ian Coates.
Critically, NHFT decided to discharge Calocane from their care back to his GP in September 2022 because healthcare staff had “lost” him, something that those involved in the killer’s care have acknowledged was the wrong decision.
The public inquiry into the Nottingham attacks heard on Tuesday (May 19) that steps could have been taken to “avoid” the attacks by responding properly to another incident involving an NHFT patient in August 2022.
The inquiry did not discuss the specific details of the August 2022 incident – but that month saw paranoid schizophrenic Rudi Marriott stab his father, 58-year-old Brenton Marriott, 75 times at their home in Lenton.
Mr Marriott’s family have previously told the Nottingham Post that they had tried to get Rudi help with his mental health for years, with NHFT having previously been accused of failing to take concerns seriously.
The man who served as NHFT’s chair at the time of both Mr Marriott’s death and of the Nottingham attacks has now admitted that the former incident should have been the “trigger point” for change.
Delvin Marriott, Brenton’s brother, and family friend Michael Bent pictured outside Nottingham Crown Court after the sentencing of Rudi Marriott(Image: Joseph Raynor/Nottingham Post)
The August 2022 incident referred to in the inquiry was discussed very briefly by NHFT’s board of senior leaders at a September 2022 meeting – around the time that Calocane was discharged.
Paul Devlin was the chair of that board from 2020 until 2025 and gave evidence to the Nottingham Inquiry on Tuesday, admitting a series of significant governance failures at NHFT during his tenure.
The inquiry heard about three serious incidents involving NHFT patients in the run-up to the attacks, with the second fatal incident coming to the attention of NHFT’s executive in February 2023.
A third and non-fatal attack involving a patient was then raised in April 2023, but in relation to the August 2022 fatal incident, the inquiry heard the trust did not take any immediate action for fear of influencing Nottinghamshire Police’s investigation.
James Weston, counsel to the Nottingham Inquiry, questions whether Mr Devlin asked whether anything else could have been done more informally before the police investigation concluded, to which he responded: “I don’t know whether I will have done.”
“From a board level, not enough was done in relation to this incident of August 2022”, Mr Weston said.
“I accept that”, Mr Devlin responded. Mr Weston continued: “We’re a few weeks before VC’s discharge when he was discharged from the trust to the GP.
“We’ve got a case here that involves a former patient and some issue about discharge, but no meaningful steps are being taken by the board at this stage. This was a missed opportunity wasn’t it?”
“Yes it was”, Mr Devlin admitted. An action plan on the back of the August 2022 incident did not end up being approved until May 2025.
Sanjoy Kumar, the father of Grace O’Malley-Kumar, told the Nottingham Post: “It is heartbreaking. This could have been prevented, it’s a direct correlation.
“They would have got [Calocane] and detained him, or he wouldn’t have been discharged. It is total vertical failure from the top down, I can’t actually believe the failures I’m hearing.”
Paul Devlin, the former chair of NHFT(Image: Nottingham Inquiry)
On what should have been done specifically after the August 2022 incident, Mr Weston said: “That should have been the trigger point to review the policies. That should have been the moment when an audit was undertaken to check whether discharge policies were safe, whether anyone else was potentially being discharged in an unsafe way.
“You could have asked for a review as to whether discharges in recent times had been safe. That would have been a logical piece of work when the report is of previous patients causing fatal or very serious injuries to others… are we waiting for another one?”
Such an audit in fact ended up being recommended in the conclusions of a review in August 2024, ordered after the Nottingham attacks.
Mr Devlin admitted: “The recommendations that were put forward in this piece of work, I accept that they could have been brought in at those earlier stages.”
Mr Weston asked Mr Delvin: “If there’d been an audit of unsafe discharges, as I think you agree should have happened in September of 2022, that process would have picked up VC’s case wouldn’t it?”
“It may well have done yes”, Mr Delvin replied.
“And steps could have been taken to avoid the attacks in June of 2023”, Mr Weston continued. “It may be the case yes”, Mr Delvin admitted.
The inquiry continues.