Retired Judge to Lead Public Inquiry into Nottinghams Attacks: A Deep Dive into Oversight and Systemic Failures

A retired senior judge, Her Honour Deborah Taylor, has been appointed to chair a public inquiry into the devastating Nottingham attacks of June 13, 2023, which resulted in the deaths of three individuals: Barnaby Webber, Grace O’Malley-Kumar, and Ian Coates. The inquiry, mandated by Justice Secretary Shabana Mahmood, will thoroughly investigate the events leading up to the killings and assess the response from various agencies involved. Ms. Taylor, formerly a resident judge at Southwark Crown Court and the recorder of Westminster, is expected to lead the investigation with “at pace” and prioritize delivering findings as swiftly as possible.

The attacks occurred when Valdo Calocane, diagnosed with paranoid schizophrenia three years prior, stabbed Webber and O’Malley-Kumar in Ilkeston Road while driving Coates’s van. In a shocking turn of events, Calocane then used the same vehicle to intentionally strike Wayne Birkett, Marcin Gawronski, and Sharon Miller in the city center, causing serious injuries and tragically leading to Birkett’s death.

The families of Webber, O’Malley-Kumar, and Coates have expressed significant criticism regarding the handling of the case by authorities. Following the sentencing of Calocane to a hospital order in January 2024 for manslaughter on diminished responsibility grounds – and attempted murder charges – Mrs. Webber stated that “true justice has not been served.”

The inquiry’s scope extends beyond simply investigating Calocane, with multiple reviews launched following the tragedy. A comprehensive review commissioned by NHS England examined the treatment provided to Calocane by Nottinghamshire Healthcare NHS Foundation Trust, as well as the broader interactions between the trust and other agencies involved in his care. The independent review revealed critical systemic failings, concluding that “the system had got it wrong,” citing inadequate risk assessment, management, documentation, and communication related to Calocane’s potential for violence. NHS England and the healthcare trust have since issued apologies for these shortcomings.

Furthermore, a review by the Crown Prosecution Service (CPS) acknowledged areas where the prosecution could have been more effective in presenting the case for diminished responsibility. Judges subsequently ruled that Calocane’s sentence was not unduly lenient. The Independent Office for Police Conduct (IOPC) is also conducting an investigation into prior contact between Leicestershire and Nottinghamshire police forces and Calocane, seeking to understand if any warning signs were overlooked.

The families of the victims have been actively involved in shaping the inquiry’s direction. In February, they met with Prime Minister Keir Starmer to discuss plans for the public inquiry, which is expected to commence within weeks. Draft terms of reference have been presented to the families for amendment, highlighting their desire for a comprehensive investigation into all relevant agencies.

The inquiry will likely scrutinize not only Calocane’s mental health care but also the processes and procedures followed by police, healthcare providers, and the CPS, seeking to identify systemic weaknesses that contributed to the tragic outcome. The full terms of reference are slated to be released to both Houses of Parliament at the earliest opportunity.