Classification: Official
Publication reference: PRN01844

To:

• Integrated care boards (ICBs):
  • chief executives
  • chairs
  • accountable officers
  • mental health leads
• NHS mental health trust:
  • chief executives
  • medical directors

cc.

• Regional:
  • directors
  • mental health leads

Dear colleagues

Independent Mental Health Homicide Review into the tragedies in Nottingham

Thank you for the work you are taking forward to improve intensive and assertive community treatment for people with serious mental illnesses. As you will be aware, national focus on this service provision is necessary in light of learnings from the tragic incidents in Nottingham when Barnaby Webber, Grace O’Malley-Kumar and Ian Coates lost their lives in June 2023. These horrific events have resulted in unimaginable loss and grief for the families of Barnaby, Grace and Ian and all who knew and loved them.

Today, NHS England has published an Independent Mental Health Homicide Investigation into these events, which we request you and your teams all read. The report highlights instances where Mr Valdo Calocane, a patient experiencing serious mental illness, was failed by mental health services, which had devastating consequences.

While much of the improvement required to prevent such failures occurring again is taking place locally, improvements are required across the sector, as highlighted in the review. We recognise the significant work you have undertaken to date, having already reviewed the level of care and treatment available locally for patients who require intensive and assertive community treatment, alongside your policies for engagement and disengagement.

Next steps

In line with your commitment to keep these plans under regular review, we now ask that you review your local action plans, ensuring they address the issues identified in the independent review with particular attention to:

• personalised assessment of risk across community and inpatient teams
• joint discharge planning arrangements between the person, their family, the inpatient and community team (alongside other involved agencies)
• multi-agency working and information sharing
• working closely with families
• eliminating Out of Area Placements in line with ICB 3-year plans

Requirements of trust and ICB boards

ICB plans should be updated to reflect the outcomes of your reviews and any actions you identify to make improvements locally.

Updated action plans should be discussed in both trust and ICB public board meetings no later than 30 June 2025. This date aligns with your planned review of your existing action plan and you will be supported by NHS England regional colleagues as part of this process. Progress against plans should be regularly reported to your boards. We will continue to support you through the development of local guidance and sharing of best practice.

NHS England has accepted the national recommendations in the report in full and has already taken steps to implement the 2 national recommendations from the independent review.

We are keen to hear feedback and reflections from ICBs and trusts, via regional mental health leads, on the progress of your existing plans and your reflections from consideration of this critical report.

Thank you for your continued focus, support and effort in this important area. It is hugely appreciated, and we are here to help if you have any questions.

Yours sincerely,

Claire Murdoch CBE, National Director for Mental Health, Learning Disabilities and Autism, NHS England
Dr Adrian James, Medical Director for Mental Health and Neurodiversity, NHS England