i think when change happens, it has to come from the top. and this doesn't go any higher than the government, that run the departments, that run the agencies. i'm heartened by... i've met met with wes streeting three times now. the first time last week in position as the health secretary. and so i do have confidence that it is going to be addressed. but i won't stop until i can put my head down on the pillow and go, "did everything we could. "and change is happening." but one example that's happened as a result of of this horror is every single mental health trust has now been instructed that they must not discharge without a full risk assessment, which is common sense, surely. anyway, that's now been sent to every health trust in this country. you know, that's one thing that could potentially make a huge difference. it's not for me to be

a politician or a medical professional, but more of that needs to happen. and as well as meeting wes, we also met before with the new attorney general. it was a very productive meeting, and i'm so pleased he opened it with, "the boss has confirmed that we will be "having a public inquiry," which is great. we now need to draw that down into detail. timings, it needs to be statutory, must bejudge—led. because what we're seeing with all of the different investigations and agencies that some are much more comprehensive than others and some you know, some are poor. we were very disappointed with the cps review. the iopc was struggling to get them to agree what we perceive as acceptable terms of reference. so without public inquiry, all of these different strands will become silos and there won't be

that comprehensive, you know, where all of the questions are answered properly. and there's full accountability. but most importantly, we have a picture where things went so badly wrong and what we can do to try and fix some, if not all of it. let's speak to dr richard taylor consultant forensic psychiatrist who has worked in psychiatry over 31 years and been an expert witness in more than 150 cases. thanks forjoining us. how optimistic do you think it is wise to be that this may be the case that brings about the change the families are talking about? it is brings about the change the families are talking about?— are talking about? it is obviously such a tragic and dramatic- are talking about? it is obviously such a tragic and dramatic case, | such a tragic and dramatic case, that thejudge led such a tragic and dramatic case, that the judge led inquiry, such a tragic and dramatic case, that thejudge led inquiry, we must hope that something can come out of this. i think there are systemic issues and practices that need to be

reviewed, and a judge led inquiry can look at what happened in this individual case, but i think certain issues like discharging to a gp for a patient not engaging, with an established history of violence, that has got to stop, and i'm that risk assessments are being made in mandatory cases. patients have sometimes disengage and they receive a letter on the doormat and that might work for some up but for a patient who is delusional or suspicious, that is another practice we need to review for this group. there are a number of other complex issues around medication and this was a case that had crossed the threshold where a long acting injection was the most appropriate treatment, and the point at which we move from asking a patient to

consent and working with them on the medication that does not have side effects, the point at which we say, we have tried that a few times, now we have tried that a few times, now we are going to have to move to a different choice, that's a tough decision but we need a discussion about the threshold for doing that. what needs to be done about the involvement of a patient�*s family where they have expressed concern about the state that someone is in and the care they are getting or not getting? you have got to balance that with the confidentiality of the patient. that with the confidentiality of the atient. , . ., ., , patient. yes, a patient that has mental capacity _ patient. yes, a patient that has mental capacity to _ patient. yes, a patient that has mental capacity to make - patient. yes, a patient that has i mental capacity to make decisions about family involvement, that has to be respected, but we do have patients who are really unwell and who are delusional, and the contact with the family may be part of the illness, and so the cqc said we needed to revisit the issue of family, and a patient may refuse initially but that might change. the

other thing, initially but that might change. the otherthing, many initially but that might change. the other thing, many years ago there was robust evidence that engaging the family in the form of family therapy for those with schizophrenia actually reduced the relapse rate, and unfortunately that was never really funded or implemented, and so yes, we have to try harder and review the refusal of patients to involve family and think carefully about at what point a patient might be lacking capacity because they are so unwell and they have incorporated family into delusions.— family into delusions. thanks for “oininu family into delusions. thanks for joining us- _ family into delusions. thanks for joining us- we — family into delusions. thanks for joining us. we will _ family into delusions. thanks for joining us. we will come - family into delusions. thanks for joining us. we will come back. family into delusions. thanks for joining us. we will come back to | family into delusions. thanks for - joining us. we will come back to you in a moment. chris dzikiti, the cqc�*s chief inspector of healthcare, was asked if the nottingham killings could have been prevented if all the authorities had behaved as they should have done. he's been speaking tojustin webb on the radio 4 today programme. the damage cannot be undone.

however, there is action that can be and must be taken to better support people with serious mental health needs and provide better protection for the public now and the future. while it is not possible to say that the devastating events of last year would not have taken place, had calocane received that support. what is clear is that the risk he presented to the public was not managed well, and that opportunities to mitigate that risk were missed. there's a really striking section of your report where you talk about doctors considering giving him a long lasting antipsychotic injection, but choosing not to because he preferred oral medication. in other words, they went with what he wanted, not what might be deemed to be safer to the public. and as part of our review, there were so many missed opportunities. and we talk about the inadequate

approaches to risk assessments, which minimised or omitted key details and did not outline the seriousness and the immediate threat of the risks and known issues that would increase the risk that he presented. and that minimised information also added possibly to how the medication was managed. and we felt and concluded that they didn't optimise the use of medication. so like you said, the use of depo would have definitely ensured that calocane was taking his medication when he was in the community because it's a form of injection administered by members of staff that would have made sure that he was taking his medication. do you answer the question why the professionals behaved as they did? i think as part of this review,

we looked and we saw these gaps. we saw the shortcomings of the decisions which were made by the treating team. so we talk about the risk assessments, we talk about the poor care planning, which was really poor care planning. but why? i suppose the question people will be asking is, yes, you can go through your report and you outline in great detail the things that were not done that should have been done. but what people will want to know is why, in these cases, actions were not taken? what we were commissioned to do, so what we were asked to do, was to review the care and treatment that calocane received from nottingham healthcare nhs foundation trust, but we went even further in publishing today the recommendations we are expecting that the trust should take. we have also made recommendations for other national bodies in order to ensure people are receiving the care and treatment they deserve whilst they are in the community.

but i suppose the point is, sorry to interrupt, but i suppose the point is that you can make any number of recommendations, but if you don't know why people are not following the obvious principles in some cases, for instance, why it was that in the end they discharged him in the last time he was in hospital, the final missed opportunity. he was discharged to a gp that then lost touch with him, and the discharging seems to have been done without any thought to what would happen next, although they knew him to be potentially dangerous. again, the question is why they did that, is it a lack of resources? is it a lack of money? is it cultural? what is it? so when we published our first report in march 2024, we made clear recommendations because we were responding to the gaps we had found out. so there were pressures in terms of staffing. there were shortages of staffing.

and also in our previous reports, for example, in our state of care, we highlighted the challenges mental health services are facing. for example, shortages of staff. for example, in mental health nurses and consultant psychiatrist. also we also highlighted the issues around skilled staffing, which are needed to support people in the community. so those are some of the challenges that mental health services are facing at this given time. the chief inspector of health care at the cqc. dr richard taylor is still here. how important do you think it is to establish why the professionals involved behaved in the way they did which was the point the interviewer was trying to get out? it is which was the point the interviewer was trying to get out?— was trying to get out? it is very important _ was trying to get out? it is very important and _ was trying to get out? it is very important and clearly _ was trying to get out? it is very important and clearly there - was trying to get out? it is very important and clearly there are | important and clearly there are individual decisions that will be looked at by a judge led inquiry about they are systemic issues

around consent. it is reasonable to aim to get a patient to consent to a medication that helps them and makes them better and treats their delusions does not give them side—effects, but at what point do we move beyond that to compulsory treatment? i do not think that is clear and that is a matter of professionaljudgment. by the time we got to the fort admission in this case, a nurse was recommending or suggesting a long acting anti—psychotic —— fourth admission. clearly at that point the threshold had been crossed for what we call compulsory treatment, and it is not an easy thing to do, working with a patient in hospital, insisting they have medication, essentially forcing it on them, which they do not want to take, that is not easy. the other issue, and this does come down to resources, there has been a tendency to discharge to gp, and it sounds

strange, but it is common practice, when a patient is not engaging, to take them off the caseload, and it is not fair on the gps who have a lot of other work to do, in picking up lot of other work to do, in picking up these complex cases, and it is not fair on the patients and on the public. so discharge to gp for someone who is not engaging and has a history of violence and not taking medication, that really does need to be reviewed. medication, that really does need to be reviewed-— be reviewed. very briefly, and i do mean very — be reviewed. very briefly, and i do mean very briefly, _ be reviewed. very briefly, and i do mean very briefly, how— be reviewed. very briefly, and i do mean very briefly, how much - be reviewed. very briefly, and i do mean very briefly, how much of. be reviewed. very briefly, and i do | mean very briefly, how much of this is down to more resources being needed? we is down to more resources being needed? ~ ., .,. is down to more resources being needed? ~ ., . , , needed? we need more acute crisis beds and patients _ needed? we need more acute crisis beds and patients are _ needed? we need more acute crisis beds and patients are being - needed? we need more acute crisis beds and patients are being moved| beds and patients are being moved across the country when they are not beds available and it is short—term admissions that may be under the mental health act detention, and if we could find acute crisis beds and i think we needed several thousand of them around the country.- of them around the country. doctor richard taylor, _ of them around the country. doctor richard taylor, we _ of them around the country. doctor richard taylor, we appreciate - of them around the country. doctor richard taylor, we appreciate you | richard taylor, we appreciate you talking to us. much more on the nottingham attacks and the failure

of the care of valdo calocane and the families of barnaby webber, grace o'malley kumar and ian coates, thatis grace o'malley kumar and ian coates, that is all on the bbc news website and on the app and you can also watch the panorama programme from last night on the bbc iplayer. you are watching bbc news.

live from london. this is bbc news. ukraine says it is not interested in taking russian territory, a week on from its surprise incursion into the kursk region. in a public conversation plagued by technical problems, elon musk and donald trump discuss everything from global warming to the assassination attempt. i also heard people shout, "bullets, bullets! get down, get down!" because i moved out pretty nicely, pretty quickly. a public health emergency is declared in africa over the spread of a new strain

of the mpox disease. a man appears in court charged with attempted murder after an 11—year old girl was stabbed in london's leicester square. and banksy unveils his ninth animal artwork in as many days, this time at london zoo. hello, i'm annita mcveigh. welcome to verified live, three hours of checking out the days main stories and the facts behind them. a week after it launched its surprise cross—border offensive, ukraine says it has no interest in occupying territory in russia's kursk region. it says the incursion will complicate russian military logistics, including russia's ability to fight in the east of ukraine.

russia, meanwhile, says its forces have foiled new attacks