A report into the care received by Nottingham triple killer Valdo Calocane shows he may have been “spared prison on the basis of incomplete evidence”, his victims’ families have said.

Calocane, who had been diagnosed with paranoid schizophrenia, was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O’Malley-Kumar and 65-year-old caretaker Ian Coates before attempting to kill three other people, in a spate of attacks in Nottingham in June 2023.

The families of the three murder victims said the independent review, published on Wednesday, showed the killer was “responsible for his actions and was allowed to make these decisions by his treating teams”, and added that “when he came to court, we were told a very different story”.

The report said Calocane was not forced to have long-lasting antipsychotic medication because he did not like needles.

The review also said other patients cared for by Nottinghamshire Healthcare NHS Foundation Trust also committed “extremely serious” acts of violence including stabbings between 2019 and 2023.

In a statement released after the report’s publication, the families of the three murder victims said: “This is now a matter which must now be dealt with as a matter of urgency.

“This latest report suggests the court may not have been given the full picture, potentially leading to an injustice of the highest order.

“He may have been spared prison on the basis of incomplete evidence.

“We have now seen report after report highlighting the failings of police forces and the health services.

“These repeated failings led to this man being in the community and able to take our loved ones from us, and now we see evidence that he may have been sentenced in court on the wrong basis.”

NHS England commissioned Theemis Consulting to carry out an independent investigation into the care and treatment provided to Calocane by NHS services.

It detailed four hospital admissions between 2020 and 2022 and multiple contacts with community teams before he was discharged to his GP because of a lack of interaction with mental health services.

Investigators found that “the offer of care and treatment available for VC (Valdo Calocane) was not always sufficient to meet his needs” and this was “not unique” to his case.

Health officials have admitted it is “clear the system got it wrong”.

The families’ statement continued: “The picture presented to the court with regards to his mental capacity was very different to the one in the notes of those treating him.

“This was a man who actively avoided his medication and treatment, knowing when he didn’t take his medication that he would become paranoid and violent.

“He was responsible for his actions and was allowed to make these decisions by his treating teams, but yet when he came to court, we were told a very different story.

“The court, the general public and us as families were all potentially misled, and this needs full scrutiny now, as we face the prospect of seeing him walk back into society again if he responds well to treatment in hospital, which again this report demonstrates he has always done in the past.

“If we don’t act to make real change now, change which can prevent these horrific events in our society, then we will remain in the same situation we have for decades, reacting to tragic, avoidable loss of life, and making false promises that it won’t happen again.

“There are similar incidents week after week and it has to stop.

“That is why the full statutory inquiry must now happen as soon as possible, not only examining what happened to our loved ones, but also the wider failings in the care, treatment and sectioning of those with mental illnesses, as we cannot keep allowing innocent people and communities to be left at risk.”

NHS officials published the report in full after initially saying they would only publish a summary due to data protection laws.

Dr Jessica Sokolov, regional medical director at NHS England (Midlands), said: “It’s clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.

“This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place.”

Claire Murdoch, NHS England’s national mental health director, said: “It is clear there were failings in the care provided to Valdo Calocane which is why the trust responsible was placed in our highest oversight and support programme, which has seen them overhaul their risk assessment processes.

“Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police.

“And we’ve instructed trusts not to discharge people if they do not attend appointments.”

Ifti Majid, chief executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “We apologise unreservedly for the opportunities we missed in the care of Valdo Calocane and accept the Theemis report in its entirety including its findings and recommendations.

“We are making clear progress with a Trust-wide plan, which is already delivering key improvements in areas such as risk assessment and discharge processes.

“We are also improving the way we listen and engage with patients, families, our colleagues, and local partners – to make sure concerns are acted on as quickly as possible.

“I know that this will never undo the catastrophic damage caused by these events – when three lives were tragically lost, and others changed irreparably.

“But we will do everything possible to prevent similar incidents happening again and remain totally committed to improving services for the communities we serve.”