Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust: Part 2

Scope of our report

Under section 48 of the Health and Social Care Act 2008, we have the power to carry out a thematic review of the care provided by NHS and adult care services. As a result, the scope of our review was limited to the care Valdo Calocane (VC) received from NHFT mental health services, from his first point of contact in May 2020 to his discharge back to his GP in September 2022.

It does not look more widely at how services across the system, including for example the police or social care services, worked together. In addition, it does not comment on VC’s interactions with the police, other than where this intersects with the care provided by NHFT.

In order to identify any failings in care, as well as wider issues with mental health services in Nottinghamshire, we have reviewed VC’s care records alongside 10 other cases receiving care from NHFT (to enable benchmarking) and evidence from our wider review of NHFT. While we have reviewed VC’s care records, our report focuses on the quality of care provided by the trust.

As part of our review, we have engaged with the families of VC and the victims, but we have not interviewed or spoken with any members of NHFT staff involved in VC’s care as part of the review.

Methodology

For this part of our section 48 review, we commissioned 2 consultant psychiatrists with experience of community mental health teams and early intervention in psychosis services to review VC’s medical records for the entire duration he was under the care of the trust, including the records from the time he spent under the care of the independent hospital.

We also commissioned 2 senior community mental health nurses, who have experience in early intervention in psychosis teams, to carry out a review of all medical records of 10 cases for benchmarking.

The 10 cases were selected from a list of 2,528 patients who had been patients of the early intervention in psychosis services at NHFT between April 2020 and February 2024. Cases were selected at random to ensure that records reviewed covered a cross section of the entire period. Of the 10 cases selected, 6 were closed and had been discharged from the trust, and 4 cases were still open to trust services.

For both VC and the benchmarking cases, reviewers looked at all interactions that patients had with the trust including, but not limited to:

• observations
• risk assessments
• care plans
• discharge plans
• Mental Health Act assessments
• multidisciplinary team meeting notes.

Reviews were completed following a template of best practice guidelines, the trust’s policies and procedures and national guidance, to form a judgement about the care and treatment delivered. VC’s care and treatment and the benchmarking cases were compared against each other to identify if any themes and trends existed between them. These were further compared against the wider review of the trust completed previously to identify any similarities.

Context

VC first came into contact with NHFT mental health services in May 2020. At the time, he was a student at Nottingham University.

VC’s first contact with mental health services occurred during the COVID-19 pandemic when the country was in its first lockdown.

It is clear from his records that VC was acutely unwell throughout the 2 years he was under the care of NHFT. Following his first arrest and mental health assessment it was concluded that VC was psychotic and suffering from paranoid delusions. He was later given a diagnosis of paranoid schizophrenia in July 2020. See the timeline for a chronology of his interactions with NHFT mental health services.

The way in which symptoms of psychosis present will be unique to each person and there will be a range of symptoms that differ in both presentation and severity. The 3 main symptoms of psychosis include:

• hallucinations
• delusions
• confused and disturbed thoughts.

People with psychosis can present as hostile and guarded, or demonstrate uneasiness with others. Records indicate that VC showed evidence of these symptoms throughout his care under NHFT.

During his care, VC also showed little understanding or acceptance of his condition. Lack of insight is a common, but not predictable, feature of someone with psychosis or schizophrenia. While some people will have insight, many won’t.

People experiencing delusions or hallucinations genuinely believe that what they are experiencing is happening to them. This is exacerbated when someone is paranoid, as their paranoia will increase their suspicions and distrust of people and organisations.

Evidence-based practice has demonstrated that psychoeducation and psychological therapies can help people gain insight into their illness and understand the importance of taking their medicine. However, it cannot always be guaranteed to work. In some cases, people do not engage with other therapies and will only take medicine to help them live with and manage their symptoms.

It is evident that VC’s risk of violence, and in turn the risk this posed to others, increased when his psychosis was not managed by medicine. However, it appears that VC did not engage with therapies that could help him manage his condition and problems with him taking his medicine were recorded from early on.

VC’s engagement with care services fluctuated throughout the 2 years. While there is evidence that some health professionals were proactive in maintaining contact, VC was consistently hard to engage. Towards the end of the 2-year period VC became more unwell and increasingly disengaged from care services