Terms of Reference

Introduction

On 13 June 2023, Valdo Calocane (VC) brutally killed Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham city centre, before driving into and seriously injuring three pedestrians, Wayne Birkett, Sharon Miller and Marcin Gawronski.

Prior to the attacks in June 2023 VC interacted with health services for management of mental health conditions, and with the police.

In November 2023, VC pleaded guilty to manslaughter by reason of diminished responsibility in relation to each of the three killings. He also pleaded guilty to attempted murder for the three further attacks. On 25 January 2024, VC was sentenced to a hospital order and restriction under s37 and s.41 of the Mental Health Act 1983 on each offence to run concurrently.

Scope and aims of the Inquiry

The purpose of the Inquiry is to build a clear understanding of the events, acts and omissions that led up to VC carrying out these brutal attacks. The Inquiry will provide a Report and recommendations so that lessons can be learned to prevent similar attacks.

The Inquiry will take account of the following reviews (“the reviews”) carried out or commissioned by agencies into the actions of the Nottinghamshire Healthcare NHS Foundation Trust, Nottinghamshire and Leicestershire Police and the Crown Prosecution Service (CPS) concerning VC, and the attacks of 13 June 2023:

• The Care Quality Commission.
• Theemis Consulting Ltd, instructed by National Health Service England
• His Majesty’s Crown Prosecution Service Inspectorate.
• The Independent Office for Police Conduct (IOPC).
• Nottinghamshire Healthcare NHS Foundation Trust.

The Inquiry will avoid duplication but use and build upon the work undertaken in the reviews. The Inquiry will, as necessary, identify and address any relevant materials, issues or investigations not addressed or insufficiently addressed in the reviews, and obtain its own written and oral evidence. Whereas the reviews have been focussed on the involvement and actions of individual agencies, the Inquiry will provide a holistic view.

The Inquiry will not consider any independent judicial decisions (including sentencing decisions), nor revisit misconduct outcomes. The Inquiry cannot determine criminal or civil liability and matters of professional conduct will be referred to the appropriate statutory regulatory body. The Inquiry will avoid any action that could prejudice any criminal or police misconduct investigations or proceedings.

The Inquiry will not consider reform of the law relating to homicide as this is the subject of a Law Commission Review.

Terms of reference

The Inquiry will cover the following broad areas:

1. Produce and review a detailed multi-factorial timeline of VC’s interactions with health services, social services, Nottingham University, the police and the wider criminal justice system between his first presentation with mental health issues in 2019 and the attacks on 13 June 2023 (“the timeline period”). If and where relevant, any expressed concerns as to VC’s mental health and any instances of violence prior to 2019 (but only when VC was in the UK) will also be included.
   
   The timeline will also include any contact relevant to VC’s risk to others and risk of offending between VC’s immediate family and health services, social services, Nottingham University, the police and wider criminal justice system, and contact between VC and his immediate family in the timeline period and where relevant, prior to 2019 (but only when VC was in the UK).

(Timeline)

2. Produce and review a timeline of the sequence and timing of events on 13 June 2023 prior to arrest including reports to, and the response of the police and emergency services to each of the attacks.

(Events and response on 13 June 2023)

3. Produce and review a timeline of the unauthorised access and disclosure of case files and evidence following VC’s arrest that took place in the NHS, the police, Nottingham City council, HMPPS and HMCTS, including the handling of and communications with the survivors and bereaved families.

(Unauthorised access and disclosure)

4. Review the understanding, assessment and management of the risk of VC to others and his risk of offending between 2019 and 13 June 2023, to identify and address any issues with regard to decisions, actions or omissions of agencies, professional bodies or individuals relevant to the treatment of VC, and the management of his risk to others including whether the relevant guidance was followed appropriately.

(Understanding, assessment and management of risk)

5. Review the effectiveness of national and local multi-agency working and information sharing, as appropriate, by health and social services, police and the wider criminal justice system
   1. providing appropriate care for and monitoring of VC’s mental health conditions,
   2. the identification assessment and management of his risk to others and risk of offending between 2019 and 13 June 2023, and
   3. information sharing prior to 13 June 2023 (but only when VC was in the UK).

(Multi Agency working)

6. Review the adequacy and appropriateness of care and monitoring of VC including actions, policies and procedures, when VC was in police custody after arrest between 13 – 17 June 2023 to include:
   1. Any assessment of medical and mental health issues and drug testing, and provision of appropriate medical support.
   2. The forensic strategy (e.g., conducting specific lines of inquiry relating to toxicology or decisions with regards to taking samples as required).
   3. Handling of and communications with other agencies, the media, the survivors of the attacks and all bereaved families.

(Care, actions, policy and procedures in custody)

7. Consider handling by the Crown Prosecution Service of the case between 13 June 2023 and the commencement of the Sentencing hearing on 23 January 2024. Using and building on His Majesty’s Crown Prosecution Service Inspectorate (HMCPSI) report, the Inquiry will further consider concerns raised by families about CPS decision-making, including:
   1. as to charging and acceptance of pleas;
   2. seeking the relevant information to inform decisions; and
   3. handling of and communications with the survivors and bereaved families.

(CPS handling of the case)

8. Provide Recommendations to ensure lessons are learned and prevent similar attacks in the future.

(Recommendations)

Procedure

The inquiry will operate within the legal framework of the Inquiries Act 2005. The procedure and conduct of the inquiry will be directed by the Chair. The Terms of Reference are decided by the Lord Chancellor after consultation with the Chair.

Report and recommendations

The Chair will provide a final report to the Lord Chancellor without undue delay, and within 2 years of commencement. The Chair may make recommendations as she considers appropriate.