A former mental health patient at the NHS trust which treated paranoid schizophrenic Valdo Calocane fatally attacked someone less than a year before the Nottingham killings, an inquiry has heard.
Paul Devlin, who was chairman of Nottinghamshire Healthcare NHS Foundation Trust until December last year, said there was a “missed opportunity” to take steps that could have prevented Calocane’s violent rampage.
Calocane, who was under the care of the trust from 2020 until he was discharged in 2022, had a rucksack of weapons when he stabbed to death students Barnaby Webber and Grace O’Malley-Kumar, both 19, and caretaker Ian Coates, 65, in the early hours of June 13, 2023.
He then attempted to murder three pedestrians in Nottingham city centre using a van he stole from Mr Coates.
The inquiry, which is examining events leading up to Calocane’s killings, heard on Tuesday that a fatal attack was carried out in August 2022 by someone who “previously had contact with the trust’s mental health services”.
The patient was not named and the circumstances of the killing were not shared in evidence.
James Weston, counsel to the inquiry, said: “From a board level, not enough was done in relation to this incident in August 2022.”
Mr Devlin said: “I accept that.”
Mr Weston added: “We’re a few weeks before VC’s (Valdo Calocane) 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?”
Mr Devlin replied: “Yes it was.”
The former chairman, who held the role for nearly five years, said the board was told of the incident in September 2022 but the trust’s investigation could not take place until after a police investigation had concluded.
The inquiry heard an action plan in relation to the fatal attack was only approved in May 2025.
Asked if the trust was not doing anything while the police were investigating, Mr Devlin said: “I don’t know if that is fair. I think there will have been a lot of looking at the circumstances of that from an operational team perspective.
“The formal investigative route, however, was regarded as having to be on hold because of that police investigation.”
Mr Weston asked if there had been an audit of “unsafe discharges” in September 2022 after this incident, it would have picked up Calocane’s case.
Mr Devlin replied: “It may well have done, yes.”
The lawyer continued: “And steps could have been taken to avoid the attacks in June of 2023?”
The former chairman replied: “It may be the case, yes.”
The inquiry heard the trust’s board was told of another fatal incident involving a mental health patient in February 2023 while a separate non-fatal attack was documented in April of that year.
Calocane, who admitted manslaughter and three counts of attempted murder, is detained indefinitely in a high-security hospital after prosecutors accepted his not guilty pleas to murder.
The inquiry continues.
