When I became Health and Social Secretary I declared the NHS to be failing.
But the families of Barnaby, Grace and Ian have been victims of a broken system in the most tragic and cruel ways.
Vardo Kalokane’s violence took the lives of three innocent people and has claimed the lives of many more.
What’s worse, if they had been more careful, this could have been prevented.
Kalokane’s crimes exposed the flaws in a broken system that meant he was able to roam the streets of Nottingham and commit heinous acts of violence.
An investigation by the Care Quality Commission found there were unacceptable failings in staffing and leadership at a local level.
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And today we learned about the national changes that need to be made, with Government’s help, to better protect people with serious mental health problems from themselves and others.
It is now painfully clear that he was discharged too early and there was no follow-up when he failed to turn up for an appointment with the local community mental health team.
I welcome the improvements the NHS has quickly made in response to the initial findings of this review, including tightening discharge procedures and improving data collection.
But much more must be done.
The NHS has also commissioned an independent investigation into the failings, the findings of which are due to be published before the end of the year and the NHS will no doubt act on its findings.
And now is the time to prioritise mental health, so we will reform our mental health law to bring care into the 21st century, ensuring that care is appropriate, proportionate and compassionate, while ensuring public safety.
I have also spoken to the families of Barnaby, Grace and Ian and reiterated the Premier’s commitment to a judge-led investigation to ensure accountability.
This Government wants to ensure that no family has to suffer the unspeakable horrors of that day because of failings in the system.