Services that cared for Nottingham knife attacker Valdo Calocane before he stabbed three people to death have been accused of having "blood on their hands".
It comes after it emerged in a new report that Nottinghamshire Healthcare NHS Foundation Trust (NHFT) "minimised or omitted" key details of the serious risk he posed to others.
Calocane - who has paranoid schizophrenia - fatally stabbed 19-year-old students Barnaby Webber and Grace O'Malley-Kumar before killing 65-year-old caretaker Ian Coates in June 2023.
He was detained in a high-security hospital - "very probably for the rest of his life" - in January after prosecutors accepted a manslaughter plea on the basis of diminished responsibility.
NHFT said it "acknowledged and accepted" the conclusions of the report and had "significantly improved processes".
'Omitted key details'
The second part of a review by the Care Quality Commission (CQC) has examined how NHFT handled the care of 32-year-old Calocane before the killings.
It found that from May 2020 until September 2022, risk assessments by the trust played down the fact Calocane was refusing to take his medication and having ongoing and persistent symptoms of psychosis.
The regulator said that while some risks were highlighted, other assessments "minimised or omitted key details".
It added that a decision to discharge the attacker back to his GP in 2022 was made despite there being evidence beyond any real doubt that Calocane would "relapse into distressing symptoms and potentially aggressive behaviour".
It was also revealed Calocane had been detained in hospital four times under mental health laws before the attacks.
Grace's mother and father, Dr Sinead O'Malley and Dr Sanjoy Kumar, told Sky News they had been left "devastated" by the report.
Dr Kumar continued: "We had a simple case, a simple case of a culpable person who did not take his medication.
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"All of this is devastating to read. It was so basic.
"The errors were not technical, they were basic, basic errors... there were so many chances to change the course of Calocane but none of those opportunities were taken by any of the doctors.
"The doctor who actually discharged him, that was the most irresponsible thing to do knowing that... a doctor had put in the notes he had the potential to murder someone."
He added: "Any psychiatrist that puts a dangerous person on our streets has to be held responsible for putting that patient out."
The CQC said there appeared to have been "a series of errors, omissions and misjudgements" in Calocane's care.
Chris Dzikiti, the watchdog's interim chief inspector of healthcare, said: "This review identifies points where poor decision-making, omissions and errors of judgements contributed to a situation where a patient with very serious mental health issues did not receive the support and follow up he needed."
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He said while it was not possible to say that the events in June last year would not have taken place if Calocane had received the support he needed, it is clear "that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed".
"For the individuals involved, their families and loved ones, the damage cannot be undone," Mr Dzikiti added.
'Gross, systemic failures'
The CQC questioned how well the trust engaged with Calocane's family, who raised concerns about his mental state on a number of occasions.
The victims' families said the review's findings make for "devastating reading".
"This report demonstrates gross, systemic failures in the mental health trust in their dealings with Calocane; from beginning to end," they said in a joint statement.
"We were failed by multiple organisations pre- and post-June 2023. Along with the Leicestershire and Nottinghamshire police forces, these departments and individual professionals have blood on their hands.
"Alarmingly, there seems to be little or no accountability amongst the senior management team within the mental health trust. We question how and why these people are still in position."
'Horrifying stories of a system unable to cope'
Ashish Joshi
Health correspondent
"Lessons must be learned". There is no doubt the health secretary is well-intentioned and honest when he repeats this phrase. But it is used after every mental health tragedy.
Including the Nottingham case, there have been five deaths involving a killer who is mentally ill since 2020. Accurate figures are hard to obtain as the NHS funding of this research was cancelled in 2019.
But research by charities helping those impacted by so-called patient homicides says that of about 600 homicides in the UK each year, about 10-20% on average involve a killer who is mentally ill.
A study of 50 homicides by London's violence reduction unit found mental illness was a "key factor" in 29 cases. NHSE own research found 111 patient homicides in 2018-2019.
Clearly, lessons are not being learned.
NHS England mental health services are in crisis. There is no capacity in the system resulting in too few beds and too few staff to diagnose and treat rising patient waiting lists.
Speak to any family trying to access NHS mental care and they will share horrifying stories of a system unable to cope.
That means every time there is another shocking case, it must be remembered it is a catastrophic double failure. Failure to protect communities from violent patients and the failure to care for our most seriously ill.
The families confirmed that a public inquiry will be held to examine the events which led to the attack, after they met with Health Secretary Wes Streeting and Attorney General Richard Hermer.
The special review of mental health services at NHFT was ordered by then health secretary Victoria Atkins in January after Calocane was convicted.
In the findings published on Tuesday, the CQC said from when Calocane was under the care of the trust, it was "clear that he was acutely unwell".
He presented with symptoms of psychosis, appeared to have little understanding or acceptance of his condition and issues with taking his medication were recorded early on, the CQC reported.
Read more:
Warning years before attack 'another kick to teeth'
Victims' families 'fuelled by anger' a year on
Calocane's sentence ruled not 'unduly lenient'
The CQC also found that if Calocane had been treated under section 3 of the Mental Health Act following his fourth admission to hospital, healthcare professionals could have administered longer-lasting medication, even against his will, or considered placing him under a community treatment order - which allows treatment to be carried out in the community, instead of in hospital.
Instead, Calocane was placed under section 2 of the act, which is typically used for people not known to mental health services.
Be the first to get Breaking News Install the Sky News app for freeMr Streeting said the report "makes for distressing reading, especially for those living with the consequences of their loss in the knowledge that their untimely deaths were avoidable".
"I want to assure myself and the country that the failures identified in Nottinghamshire are not being repeated elsewhere," he added.
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A NHFT spokesperson said: "We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out."
The handling of the Calocane case prompted outcry and led to numerous inquiries into the public bodies involved, including Nottinghamshire Police and Leicestershire Police.
