Attacks victim's death 'potentially preventable'

The death of a student killed in the Nottingham attacks was "potentially preventable", a public inquiry has heard.

Barnaby Webber - along with Grace O'Malley-Kumar and Ian Coates - were killed by Valdo Calocane, who had been diagnosed with paranoid schizophrenia in 2020, on 13 June 2023.

On Tuesday, ahead of closing statements to the Nottingham Inquiry - which is examining the killings - the inquiry was told a "more rapid administration of blood products" could have meant Barnaby's death was "potentially preventable".

The inquiry also heard documents found in a bin at Calocane's address contained a list of explosives, which was not disclosed by Nottinghamshire Police until June this year.

A panel of medical professionals assessed the emergency medical response on the day of the attacks to assess "survivability", the inquiry was told.

In their assessment, the panel noted the hard work of the emergency responders in their care to the victims.

The panel found if blood products had been administered to Barnaby earlier and more rapidly, it could have increased his chances of getting to hospital with enough of a heartbeat to undergo surgery.

However, multiple other rapid and particular steps would have had to have taken place for him to have survived.

The inquiry heard Barnaby had a less than 50% chance of surviving his injuries, characterised as "potentially preventable", while Grace and Ian's deaths were "not preventable".

The families of the victims sobbed as the assessments were read out by counsel to the inquiry Rachel Langdale KC. Grace's father, Dr Sanjoy Kumar, left the hearing room.

Langdale said Nottinghamshire Police found the documents in a bin at Calocane's former property in Burford Road in Nottingham.

He wrote bullet points on one page about explosives under the heading "thoughts", including TNT and nitrate fertiliser.

Langdale said: "This piece of paper listing thoughts about a number of explosives was not identified or taken into account at the time."

She added it had not been made available by police to the Crown Prosecution Service (CPS) or to psychiatric experts.

Calocane was evicted from the Burford Road address on 11 June 2023 and travelled to London, before returning via to Nottingham shortly before midnight on 12 June, a day before his killings, the inquiry heard.

The Nottingham Inquiry started hearing evidence in February, with more than 100 witnesses questioned over three months.

Witnesses included police staff and officers, mental healthcare practitioners, Calocane's former flatmates and family members, the bereaved families and the survivors of the attacks.

A number of revelations emerged in evidence about errors in Calocane's care, his previous interactions with police and failings both during and in the aftermath of the attacks.

Calocane - who also seriously injured three others - is currently serving an indefinite hospital order in a high-security facility after pleading guilty to three counts of manslaughter, on the grounds of diminished responsibility, and to three counts of attempted murder.

The inquiry is currently hearing updates in evidence since the end of oral evidence earlier this year.

In her closing remarks, Langdale reiterated the evidence of former parliamentary ombudsman Sir Rob Behrens.

She said: "Too often these cases are dependent upon bereaved families campaigning at a time when they are least prepared to do so, and it is an outstanding public service that they perform."

Langdale added: "Although Sir Rob was talking generally about bereaved families, his words could have been written as a description of the bereaved families and their legal team in this inquiry. Indeed, without their efforts there would not have been a public inquiry at all.

"The evidence we have obtained has revealed one failure after another.

"There is a suggestion in some submissions that further oral evidence should be called. We submit that there's no need for further oral evidence from any source.

"Barney, Grace and Ian should be alive. And the survivors - uninjured."

Final submissions to the chair, senior judge Deborah Taylor KC, will continue on Wednesday.

Taylor said it was "disappointing" that over the break, evidence had emerged which "ought to have been identified" and disclosed earlier.

She directed core participants to provide any corrections to errors or omissions by no later than 31 December.

Langdale said Nottinghamshire Police also recovered a holdall bag belonging to Calocane - who is being referred to in the inquiry as VC - from his address in the days after the attacks.

There were three notebooks in the bag, which included a note written by Calocane saying he was a god and "was a tree that guards the key between heaven and hell".

In his closing speech, Tim Moloney KC, who represents the bereaved families, said a note made by Calocane on one of the sheets of paper appeared to say "Manchester Arena".

Calocane searched online for large venues in Nottingham and bookmarks on his web browser for the Albert Hall Conference Centre in the city and the Theatre Royal and Royal Concert Hall, the inquiry heard.

Moloney said the notebooks also revealed "relevant information including what we say was a deep-seated misogyny".

The items were not prioritised because efforts were focused on finding a bag which the killer had with him on the evening of the attacks, the inquiry heard.

"There was a failure to investigate VC's historical behaviour and actions," Moloney said.

He added "no-one asked VC why he was searching for explosives and large venues because they couldn't", referencing the police's failure to share the information.

Langdale described the failure to disclose the notebooks an "oversight by Nottinghamshire Police".

The inquiry heard further violent assaults by Calocane on colleagues at warehouses in Nottinghamshire were also not disclosed to the inquiry team until after the public hearings took place.

This included an assault on a colleague in a warehouse in Eastwood in 2021 and another in Normanton in February 2023.

Footage of the February 2023 attack, described by Moloney as "sustained attack with punches thrown", was shown to the inquiry for the first time on Tuesday.

In his closing statement, Moloneyfocused on the timeline of contact between Calocane and public services.

"We say the timeline contains a litany of unnoticed red flags, missed opportunities and individual and systemic failures," he said.

"The bereaved families firmly believe that if opportunities had been taken to effectively deal with the behaviour of VC, if there had not been so many failures by so many people in institutions between 24 May 2020 and 13 June 2023, then their loved ones would still be here today.

"They have good reason to believe that, because VC's history of contact with public agencies is one of repeated individual and systemic failures in the face of the clear and growing risk that he presented."

Moloney said there were failures by authorities to follow policies and procedures and adequately consider harm with "every incident" involving Calocane between 2022 and 2023.

"Police were too quick to let things go in the teeth of really quite serious incidents, and clinicians were too quick to adopt a least restrictive practice which ignored the rights of his victims as we say ultimately and the rights of the public," he said.

"Together, these practices diverted VC away from the criminal justice system or forensic psychiatry and he should have been going down that pathway.

"Together, these practices failed VC and the people he affected who sit in this room."

Adam Straw KC, representing Calocane's family, highlighted a list of failings by Nottinghamshire Healthcare NHS Foundation Trust throughout the duration of its care for the triple killer.

He said: "Many of the problems brought to light by this case are founded on inadequate resources.

"It was clear from many of the witnesses at every level that resources for mental health services are far too low."

Among his suggestions, he said there should be a ring-fenced "increase for mental health service generally", national guidelines on minimum staffing levels for various relevant roles and more support for patients' families.

"Had VC received full and proper treatment and management of his admission in May 2020, there is reason to think that this tragedy would have been prevented.

"The same is true of many other schizophrenic-homicides up and down the country," Straw added.

Listen to BBC Radio Nottingham on Sounds and follow BBC Nottingham on Facebook, on X, or on Instagram. Send your story ideas to eastmidsnews@bbc.co.uk or via WhatsApp on 0808 100 2210.