The Care Quality Commission’s (CQC) report into the case of Valdo Calocane, the paranoid schizophrenic who killed three and seriously injured three others in Nottingham in June last year, looks like it will impact the new government’s commitment to “modernise” the Mental Health Act (MHA). Health Secretary Wes Streeting has reportedly promised the family of Grace O’Malley-Kumar, one of the three people fatally stabbed by Calocane, that he will “slow down” the reform process. But ought it now to proceed in a very different direction?
Labour’s plans were focused on “strengthening the patient’s voice”. There was an intention to put patients’ right to be involved in planning their care on a statutory basis, including making choices about treatment, and being able to refuse it. Periods of compulsory detention under the MHA were slated to be shortened. Yet, as the CQC report describes in stark detail, these factors appear to have been major causes of the breakdown of care that led ultimately to Calocane’s horrific attacks. Calocane had four relatively short hospital admissions over the space of two years. Out in the community, he had a repeated pattern of disengaging from mental health services and not taking medication. Fortnightly injections of anti-psychotic medication were proposed but he refused them. Ultimately, his failure to engage with follow-up seems to have been respected as a personal choice, and he was discharged from the mental health service. The case seems to be strongly suggesting the government hurriedly finds its reverse gear.
The MHA contains all the powers that would have enabled Calocane to be effectively treated. His fourth admission, for example, was under Section 2 of the Act, intended to allow detention for up to 28 days to assess someone newly presenting with serious mental illness who is judged to pose a significant danger to themselves or to others. As a patient with a relapse in a diagnosed condition, Calocane ought properly to have been admitted under Section 3, which allows treatment for up to six months. Had this been invoked, Calocane could have been subject to a community treatment order, which would have empowered the community mental health team to administer regular injectable medication, and allowed recall to hospital in the event of non-compliance. And the Mental Capacity Act could have been used to assess his capacity to take decisions about his treatment. It is likely that he would not have been deemed capable of withholding consent.
The key question is why these powers were not used. To me, the CQC report implies an excessive deference to the principle of patient autonomy in Nottingham’s mental health services. The management of serious mental illness is always a matter of weight and counterweight: the rights of the individual vs the protection of themselves or others. Calocane’s care seems to have lacked an appropriate balance.
The principles of patient autonomy are already enshrined in an annex to the MHA, the Code of Practice. Labour’s desire to incorporate them into a modernised act reflects a 2019 CQC report which found that, even though the act directs professionals to have due regard to the Code of Practice, this was happening patchily. Patient autonomy is an important corrective to the ways in which people were often treated in the past. But as the Calocane case shows, if it is to be given additional weight, then the counterweight must also be bolstered.
The CQC report does not tackle the issue of resources. How much did the scarcity of inpatient beds subliminally affect admission and discharge decisions? To be effective, the counterweight of personal and public safety depends on sufficient capacity and expertise to enable the difficult balance to be appropriately struck. NHS England is due to conduct its own inquiry, and this must address the wider question of whether current mental health service provision is funded adequately to perform its vital role.
[See also: The body’s secret defence mechanism]
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