Lessons learned?

Following the announcement of a planned statutory inquiry into the 2023 Nottingham killings, Chartered Legal Executive Simon Parsons considers how effective the inquiry is likely to be in preventing future harms 

On the 12 February, Prime Minister Keir Starmer announced a judge-led statutory public inquiry into the tragic deaths of Barnaby Webber, Grace O'Malley-Kumar and Ian Coates, who were brutally stabbed to death by Valdo Calocane in Nottingham in June 2023.

Statutory public inquiries are held under the Inquiries Act 2005 and are set up to consider incidents of major public concern. They are aimed at learning lessons, determining accountability and restoring public confidence. At present, there are 14 statutory inquiries being undertaken under the 2005 Act.

The government can set up other types of investigation, such as a non-statutory inquiry, a royal commission or a departmental inquiry. There is currently a non-statutory inquiry into the rape and murder of Sarah Everard by serving police officer Wayne Couzens, for example. Such inquiries offer various benefits, including the ability to provide more appropriate treatment for victims and survivors, as well as increased procedural flexibility. Proceedings can be in private if the evidence is sensitive for national security reasons.

Statutory inquiries must comply with the provisions of the 2005 Act and the Inquiry Rules 2006. The advantage is that witnesses can be compelled to give evidence under oath and can face perjury charges for lying. This is not possible under non-statutory inquiries.

This can result in a complete picture of the facts, as has been shown by the Post Office Horizon IT inquiry, which revealed a management culture of denial by Post Office managers which led to a conspiracy to wrongly prosecute sub-postmasters for dishonesty offences. Over 700 sub-postmasters and postmistresses were prosecuted and convicted between 1999 and 2015, and the Post Office (Horizon System) Offences Act 2024 was needed to quash most of the convictions – a unique constitutional step for Parliament to take.

Time and expense

Concerns frequently arise regarding the duration and expense associated with statutory inquiries. Over £1bn has been spent on public inquiries since 1990. The Bloody Sunday inquiry alone cost £272m and took over 12 years to report.

“Of the 88 public inquiries that took place between 1990 and 2024, only six have been followed up by parliamentary select committees to see what the government did as a result” 

Another issue is that there is no process for following up recommendations for improvement. Of the 88 public inquiries that took place between 1990 and 2024, only six have been followed up by parliamentary select committees to see what the government did as a result.

That said, many inquiries have achieved significant lasting change. For example, the public inquiry into the shootings at Dunblane Primary School led to an overhaul of the laws controlling the ownership of handguns.

Manslaughter conviction

The Nottingham victims’ families have been asking for a statutory inquiry so that witnesses can be compelled to give evidence. The relatives have said that getting one was a great day and a watershed moment.

It should be noted, however, that one thing the inquiry will not do is ask why Calocane was not convicted of murder. This is because it is clear he was suffering from a recognised medical condition (paranoid schizophrenia, as confirmed by four psychiatrists) that caused an irrational delusion that if he did not kill, his family would be harmed, in turn causing an irresistible impulse to kill. Thus, when he killed, Calocane was suffering from abnormality of mental functioning and the prosecution was right to accept his plea of guilty to three counts of manslaughter on the grounds of diminished responsibility.

Calocane was sentenced to an indefinite hospital order. The Court of Appeal has ruled that the hospital order was not unduly lenient. The Crown Prosecution Service Inspectorate also investigated how the Crown Prosecution Service handled the case, following complaints by the victims' families. It found that, while prosecutors had been right to accept Calocane's pleas of guilty to manslaughter because of diminished responsibility, they could have handled the case better.

Errors, omissions, and misjudgements

The inquiry must determine why Calocane's abnormality of mental functioning was not identified as a potential danger to society before the killings occurred. A review by the Care Quality Commission found that there had been a series of errors, omissions and misjudgements by mental health professionals.

The independent mental health homicide report into his treatment found there had been a catalogue of failings, including that Calocane's risk "was not fully understood, managed, documented or communicated”. There were missed opportunities to take more assertive action towards his care. The voice of Calocane's family "was not effectively considered to support the dynamic evaluation of risk" during his treatment. When sectioned, he was not required to take anti-psychotic drugs because he was afraid of needles. He had no contact with mental health services or his GP for about nine months prior to the killings.

The inquiry will have to deal with these important issues and, it is hoped, will report within two years. The inquiry will most likely find that the severe underfunding of NHS mental health services was the underlying cause of these tragic killings. But the question is, will that finding be acted on in this time of cuts to public services?

Simon Parsons is a Chartered Legal Executive and teaching fellow in law at Bath Spa University