I have met dozens of Valdo Carrocanes. What he did in Nottingham a little over a year ago was bizarre, but he was not an unusual patient. His symptoms, his elusiveness and his pattern of early contact with services are all too familiar to people like me.
On a summer night in 2023, Kalokane randomly murdered three strangers in Nottingham while suffering from intense delusions resulting from untreated mental illness. The suspect had been in intermittent contact with the local NHS healthcare trust for two years, some of which was spent in hospital detention under the Mental Health Act. However, nine months before the murders, he was discharged from community services and returned to his GP on the grounds that he had lost contact with the mental health team. Criticism of Kalokane's management by trust officials, sparked by a recent Care Quality Commission report, has been scathing and almost universal.
I am convinced that had a more interventionist and rigorous approach been taken in Mr Kalokane's treatment, these deaths would not have occurred. Objectively, the response to his devastating illness was woefully inadequate.
But the process of diagnosing and treating people with serious mental illness is incredibly difficult, and community mental health services, particularly in inner-city areas, are faced with challenges like those faced by Kalokane every day.
In the early stages of treatment, clinical uncertainty and missed opportunities for rapid and effective treatment are in some sense inevitable. In the early stages, there is often clinical disagreement as to whether a patient's symptoms are due to an emerging illness, to drug use, or to an underlying antisocial personality. It also often takes years to find the optimal drug treatment for a patient. This is not incompetence; it is the reality of dealing with a serious mental illness such as paranoid schizophrenia.
Vardo Karokane's victims Ian Coates, Barnaby Webber and Grace O'Malley Kumar. Photo: Nottinghamshire Police/PA
Follow-up with this group of patients is often haphazard. Typically this is because they actively resist becoming a “patient” and all that entails, and try to avoid contact with services in a desperate attempt to protect a familiar and comforting identity. Suicide is more often a response to the devastating loss of authenticity felt at this stage, rather than a desire to harm others.
Other organisational and cultural factors also come into play: although it is often relatives who are most aware of the extent and risks of their loved one's illness, they are increasingly withdrawn from caregiving. As a carer for someone with a serious mental illness myself, I know firsthand the confidence required to be listened to and fully involved in decisions about discharge and aftercare.
But here's a sad truth that I have witnessed time and time again in my various roles: many mental health services in England are anti-family, and I believe this is institutionalised. Staff may not be intentionally doing so, and trust policies may profess to say otherwise, but there is generally a reluctance to actively and collaboratively include relatives in decision-making circles.
The dynamics of the organisation where I worked were geared towards scaring away potential patients.
Confidentiality is often cited as a reason for not working closely with relatives, and Kalokane appears to have instructed his staff to cease contact with the family. Ignoring this may have led to further estrangement, but simply contacting relatives and listening to their wishes and concerns does not require the patient's consent. In any case, where there is a risk of death or serious injury, the need for consent to disclose information to others may be ignored. If risk is a concern, the patient is not your only client.
From what we know about Kalokane's case, two further powerful cultural factors emerge. Discharging him to his GP for being uncooperative was certainly a huge and serious error, as inability to cooperate with medical professionals is often a symptom of mental illness rather than a reason for discharge. But such practices stem from a ubiquitous yet hidden institutional imperative to keep people out of the Trust's cases, and especially out of hospital wherever possible, even when it is objectively clear that admission is exactly what the patient needed.
Every action and every structure points in this direction. Indeed, after eight years as manager of a community assessment service in an NHS Trust, receiving referrals from GPs and many other agencies, I am ashamed to say that my first instinct was to look for reasons not to accept or delay a referral. Early in my career there was a general enthusiasm to provide a responsive service, but later on the drive throughout the organisations in which I worked was geared towards fending off potential patients and directing them back into primary care wherever possible.
Another key factor is that mental health trust services are tailored to deal with immediate or short-term risks, rather than longer-term risks which are much harder to manage. The media jumped on the doctor's prediction that Karokane would kill someone, but this was a fear that community mental health teams had about a large cohort of patients. In fact, a few years ago I wrote in a mental health tribunal report that I believed a patient was going to kill someone, and even gave the circumstances and the weapon. And the following year that's exactly what happened.
The long-term risks are much more manageable in forensic mental health services that specialise only in patients who have committed serious crimes. Patient numbers here are stable and small, and restraining orders under the Mental Health Act (all decisions about patients must be approved by the Home Office) allow staff to remain solid and consistent over several years. The tragedy, and perhaps the absurdity, of this situation is that patients like Kalokane are only able to receive the rigorous treatment and supervision they have always needed, once they have committed a crime.
I worry about further investigations and commissions. Like all investigations going back to Christopher Clunis' murder of Jonathan Zito in 1992, they will likely find no new shortcomings. They will churn out recommendations and structural changes that will undermine staff morale, sap clinical energy, and force our most qualified staff to spend their time managing change when they should be spending their time managing illness and care.
We need a very simple structure. The fragmented cellular system currently adopted by the Trust cannot provide the true continuity and consistency of community care that patients like Caloocan need from the start. But above all, this care needs to be delivered by staff who have the tenacity, experience, qualities and interpersonal skills needed to fully engage with patients and their families. Instead of focusing on what went wrong in particular cases, we need to focus on the attitudes and deeper organisational factors that cause things to go wrong in the same way so often.
Jeremy Walker has worked in and managed NHS Community Mental Health teams for 25 years, served as an inspector for the Mental Health Act Commission (now part of the CQC) for nine years and was Chair of the committee reviewing the detention of patients under the Mental Health Act for 14 years.
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