The man who killed three people on the streets of Nottingham was allowed to avoid taking long-lasting antipsychotic medication because he did not like needles.

An independent review also reveals that Valdo Calocane punched a police officer in the face and held his flatmates “hostage”.

He frightened one neighbour so much, she jumped out of a first floor window and seriously damaged her back.

Mental health staff did not visit his home alone.

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 June 2023.

NHS England initially planned to release only a summary of the report because of data protection laws, but reversed its decision “in line with the wishes of the families”.

Those relatives say the revelation that Calocane was refusing his meds shows he may have been “spared prison on the basis of incomplete evidence”.

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Prosecutors accepted a plea of manslaughter after experts agreed his schizophrenia meant he wasn’t fully responsible for his actions.

But in a statement, the families said: “This was a man who actively avoided his medication and treatment, knowing that when he didn’t take his medication 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.”

A “theme” running through Calocane’s clinical records is that he “did not consider himself to have a mental health condition”, the review found.

That meant the importance of medication “never appeared to be understood” by him.

The report 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”.

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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, added: “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.”

The report, which found Calocane’s risk “was not fully understood, managed, documented or communicated” should be a “watershed moment”, a mental health charity boss has said.

Marjorie Wallace, chief executive of mental health charity Sane, said there had been “one hundred such inquiries in the last 30 years”.

She added: “Today’s findings expose the same flaws and fault lines that have resulted in tragedies, yet little seems to have changed.”

A panel of international medical experts has given alternative causes of death in several cases against child serial killer Lucy Letby.

It comes as her defence lawyers announced they have asked for her case to be investigated as a miscarriage of justice.

Letby, 35, the UK’s most prolific child killer of modern times, is serving fifteen whole life terms in prison after she was convicted at Manchester Crown Court of murdering seven infants and attempting to murder seven others between June 2015 and June 2016.

Various methods were used to attack the babies while Letby worked as a nurse on the neonatal unit at the Countess of Chester Hospital.

One method was air being injected into the bloodstream which caused an air embolism, blocking the bloody supply and leading to sudden and unexpected collapses.

On Tuesday, retired neonatologist Dr Shoo Lee, who co-authored an academic paper on air embolisms (bubbles) in babies in 1989 which featured prominently during her trial, chaired a panel of 14 experts to compile an “impartial evidence-based report”.

Dr Lee said he believed his findings on skin mottling were misinterpreted by the prosecution. He said in a new paper he published in December 2024 that there were no cases of skin discolouration when air was injected into the veins.

At her trial in 2023, prosecutors pointed to skin discolouration in several of the victims as evidence that air had been injected into their veins by Letby.

“The notion that these cases are air embolism because they collapsed and because there were skin rashes has no basis in evidence. Let’s be clear about that,” Dr Lee said.

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The panel laid out alternative causes of death in many of the cases, including natural causes and poor medical care at Countess of Chester Hospital.

“We did not find any murders,” Dr Lee said. “In all cases, death or injury were due to natural causes or just bad medical care.”

Asked about the Countess of Chester Hospital, Dr Lee, a retired medic from Canada, said: “I would say if this was a hospital in Canada, it would be shut down. It would not be happening.”

A spokesperson at the Countess of Chester Hospital NHS Foundation Trust said: “Due to the Thirlwall Inquiry and the ongoing police investigations, it would not be appropriate to comment further at this time.”

The Criminal Cases Review Commission (CCRC) will now review all the evidence after an application from the defence to determine if the case should be referred back to the courts.

A CCRC spokesperson said: “We are aware that there has been a great deal of speculation and commentary surrounding Lucy Letby’s case, much of it from parties with only a partial view of the evidence.

“We ask that everyone remembers the families affected by events at the Countess of Chester Hospital between June 2015 and June 2016.

“We have received a preliminary application in relation to Ms Letby’s case, and work has begun to assess the application.”

Opening the press conference, MP Sir David Davis described Letby’s convictions as “one of the major injustices of modern times”.

Last year Letby lost two bids to challenge her convictions at the Court of Appeal – in May for seven murders and seven attempted murders, and in October for the attempted murder of a baby girl, which she was convicted of by a different jury at a retrial.

In December, the former nurse’s barrister, Mark McDonald, said he would seek permission from the Court of Appeal to re-open her case on the grounds Dr Dewi Evans, the lead prosecution medical expert at her trial, was “not reliable”.

Dr Evans, a retired consultant paediatrician, said concerns regarding his evidence were “unsubstantiated, unfounded, inaccurate”.

In September a public inquiry into how Letby was able to commit her crimes began hearing evidence. Closing legal submissions are expected in March and the findings are expected to be published this autumn.

Detectives from Cheshire Constabulary are also continuing their review of the care of some 4,000 babies admitted to the Countess of Chester Hospital from January 2012 to the end of June 2016, while Letby worked as a neonatal nurse, there. It also includes two work placements at Liverpool Women’s Hospital in 2012 and 2015.

Letby has been interviewed under caution at HMP Bronzefield in Ashford, Surrey, in relation to the ongoing investigation into baby deaths and non-fatal collapses.

She maintains her innocence.

At the gates of All Saints Catholic High School in Sheffield, the tributes to Harvey Willgoose continue to arrive.

Flowers bearing notes from friends and former teachers, balloons and cards, one woman even arrived with a shirt of his beloved Sheffield United.

The school remains closed but some youngsters were allowed through the locked gates by police to lay flowers at a small garden bed outside the main entrance.

Those coming to lay flowers all spoke of their shock at Harvey’s death.

Luisa Meco’s daughter knew Harvey from when they were both in nursery school and also attended All Saints.

She said: “It’s just shocking, really sad, heartbreaking.”

Her thoughts were with Harvey’s family. She said: “Obviously we’re all putting ourselves in their shoes and thinking ‘What on earth?’. It is hard to describe, it is just unreal.”

Luisa was also concerned with how her daughter would feel returning to school when it reopens.

“I will wait and see what she says and if she’s not comfortable, I will just have to keep her off for a couple of days,” she said.

She added: “It’s not something that’s easy to get over, it’s not an easy thing even as an adult to understand, how it could happen at school, so for 14 and 15-year-olds it’s even harder.”

Flowers have also been placed at the Bramall Lane home of Sheffield United.

The club said it was aware discussions were taking place about how best to pay tribute to Harvey.

A line of flowers had also appeared outside Harvey’s family home, on a quiet housing estate five miles from All Saints.

Not far from the home, a family friend, who saw Harvey on his way to school on the tram on Monday morning, said she was “in shock” at the death of a boy she considered to be “like a brother” to her.

The 17-year-old told Sky News that Harvey was “funny, he’s cheeky, he’s caring, just a lovely boy, he’d never hurt anyone. He’s never been nasty, he’s just not a nasty person at all”.

The girl and Harvey’s family went on numerous holidays together.

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“We’re just so close. I can’t believe he has gone,” she said.

At the gates of All Saints, some families came to look at the tributes and reflect.

Brenda Bartholomew’s granddaughter witnessed the incident on Monday lunchtime.

“This should just not be happening,” she said.