Report into troubled NHS trust 'deeply worrying'

The survivors and bereaved families of the Nottingham attacks say they are disappointed following a report into the leadership of a mental health NHS trust.

A report by the Care Quality Commission (CQC) into the Nottinghamshire Healthcare NHS Foundation Trust, published on Wednesday, found leaders had not been proactive in making changes.

The trust had discharged Valdo Calocane months before he stabbed to death Ian Coates, Barnaby Webber and Grace O'Malley Kumar -and injured three others - on 13 June 2023.

Ifti Majid, the chief executive of the trust said in response to the report that changes had been made but admitted there was more to do.

The review follows, but is separate from, a programme of expedited inspections into the trust - which was part of recommendations the CQC made during its formal review, commissioned by the Secretary of State for Health and Social Care - following the 2023 attacks.

It was an overall review of leadership at the trust.

The review found leaders did not have full oversight of the Mental Health Act and did not have a "shared vision or strategy" on the trust's goals for making change.

Staff also told inspectors there was a "disconnect" between them and leadership and felt leaders "communicated poorly".

The CQC said in the report there had been breaches of regulation in the way the trust was run and called on the trust to submit an action plan showing what measures it was taking in response.

Barnaby Webber's mother, Emma Webber, said it "beggars belief" that there was not proper understanding of the Mental Health Act among the leadership.

She added: "It's alarming, concerning and just disappointing that despite everything that's happened, it doesn't appear that anything really drastically has changed."

While she said she recognised there were some "amazing staff" in the trust, Webber added changes were needed within leadership.

The trust announced in November that Majid was set to retire in June 2026, remaining in post for the public inquiry due to start in February.

However, Webber said retiring was not the change she believed was necessary.

She said: "How there hasn't been a fundamental change in the leadership of the mental health trust is beyond me - I do not understand it.

"What more do we need to do? A national tragedy, three lives lost, three lives changed forever as well."

Greg Almond a solicitor representing two of the survivors, Wayne Birkett and Sharon Miller, said it was clear that a "significant amount of work" needed to be done.

He said in a statement: "For the survivors, who deserve to have faith in the mental health provisions in Nottinghamshire, this is a deeply worrying assessment and they can't help but be left with the feeling that nothing has been done to prevent a reoccurrence."

Almond said despite the scrutiny the trust had been under since June 2023, there remained "significant and glaring problems within the mental health provision in Nottinghamshire".

He added the survivors had not been consulted by the CQC about the report or given advance notice of it, claiming there had been a "lack of communication with the surviving victims".

A spokesperson for the CQC said: "We continue to extend our deepest sympathies to everyone affected by the devastating attack that took place in Nottingham in June 2023.

"The report published [on Wednesday] is on our findings from a trust-wide, well-led review in September 2025 to assess the leadership at Nottinghamshire Healthcare NHS Trust.

"This follows a programme of assessments recommended by our review of the trust published in 2024."

The mental health trust boss, Majid said: "We are committed to providing high quality, effective and safe care to those people who need it most.

"We accept the CQC's findings and recognise where improvement is needed.

"We have already made significant improvements since the CQC's last inspection but fully appreciate there is still more to do.

"We will be addressing all areas identified in the report."

A separate NHS review into Calocane's care published in February 2025, laid out how the killer, who has paranoid schizophrenia, had no contact with mental health services or his GP for about nine months prior to the killings - after he was discharged when he repeatedly failed to engage with them.

Calocane was sentenced to a hospital order in January 2024 after admitting manslaughter on the grounds of diminished responsibility, and pleading guilty to three counts of attempted murder.

The decision to discharge him from mental health services will be among the decisions and actions scrutinised in a public inquiry into the attacks beginning on 23 February.

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