Dr Jessica Sokolov, regional medical director at NHS England (Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.
“This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”
Claire Murdoch, NHS England’s national mental health director, added: “Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police.
“And we’ve instructed trusts not to discharge people if they do not attend appointments.”
Marjorie Wallace, chief executive of mental health charity Sane, said the publication of the review “should act as a watershed moment revealing the truth and honouring the needs of the families of victims of homicides by people with mental illness or disorder”.
“We have been involved in and supported the families of both victims and perpetrators in over 100 such inquiries in the last 30 years,” Ms Wallace said.
“Today’s findings expose the same flaws and fault lines that have resulted in tragedies, yet little seems to have changed: basic failings of communication, inadequacies in assessing risk, and in over half the cases we analysed, not heeding the warnings of families or those close to the patient. As in this case, it is too often cited that it was the individual’s choice to ‘disengage with services’ as a reason for the lack of effective follow-up and care.”