In November 2023, months after the attacks, the inquiry heard a review was undertaken of the Early Intervention in Psychosis (EIP) team - which involved an audit of 15 clinical samples.

The report stated absence of specialist staff had a "detrimental impact" on the care of patients.

When asked by Rachel Langdale - counsel to the inquiry - whether the recommendations from the review had been implemented, Ifti Majid said the trust had "partially implemented" all recommendations, but said there was "more work" to do.

Nottinghamshire Healthcare NHS Foundation Trust has been under close scrutiny since the Nottingham attacks, and has come under fire for the failings that emerged in the aftermath.

In January 2024, the trust suspended more than 30 members of its staff over allegations around staff conduct at Highbury Hospital - where Calocane had been admitted on a number of occasions.

The allegations, according to a report, included falsifying mental health observations, as well as maltreatment of patients.

Rampton Hospital, which is also run by the trust, was rated "inadequate" by the Care Quality Commission (CQC) in the same month.

At an annual general meeting of the trust in September 2024, Majid said the trust had "let down" patients and families.

"No-one should have to go through this, and I offer my heartfelt apologies for the opportunities we missed in the care and treatment of Valdo Calocane, to all of those who continue to be affected by what happened on that dreadful day," he said previously.

In February 2025, Majid admitted he owed an apology to the killer's family, following an NHS review into Calocane's care which found a catalogue of failings.

That review found the killer's risk was not "fully understood, managed, documented or communicated", and that there were missed opportunities to take more assertive action towards his care.

In May 2025, the BBC found two men with paranoid schizophrenia under the trust's care had stabbed members of the public in separate attacks - weeks before Calocane's killings.

The trust was told it needed to make "significant improvements" following a review of its leadership, which was published in January this year.

We know Valdo Calocane was responsible for the deaths of Barnaby Webber, Grace O'Malley-Kumar and Ian Coates. But what else do we know about the perpetrator of the Nottingham attacks?

Calocane, who has referred to himself as Adam Mendes, was born in Guinea-Bissau on 4 September 1991.

His family moved to Portugal when he was three, before coming to the UK in 2007 when he was 16 years old.

The triple killer completed a degree in mechanical engineering at the University of Nottingham, graduating in June 2022, when he was aged 30.

At Calocane's sentencing hearing, the court was told he had no previous convictions.

However, the inquiry has heard he had a history of police interactions linked to violent incidents, including the assault on Nottinghamshire Police officer PC Barnaby Pritchard.

In May 2020, Calocane was experiencing a psychotic episode when he kicked in the door of a woman's flat at Brook Court in Radford.

The woman fell from a window as she attempted to flee and was left needing metalwork and screws surgically fitted to her spine.

In July 2021, while he was a student at the University of Nottingham, Calocane suddenly grabbed his housemate, Sebastian, by the shirt and held him up against a wall. Sebastian also reported being followed home by Calocane in 2022.

In January 2022, while living at different accommodation, Calocane put his flatmate, Christopher, into a headlock following a confrontation about cleaning.

Weeks before the attacks, in May 2023, Calocane violently assaulted two colleagues at a warehouse in Leicestershire.

Image source, Helen Tipper

The inquiry has heard after serious incidents, including attempted homicide involving patients, reviews were carried out.

Langdale told the hearing the reviews identified "missed" opportunities to provide support to patients.

When asked whether changes could have been brought about "more quickly", Majid agreed.

Majid said since mid-2023, there had been "more than 90 visits from the CQC, more than 60 inspections".

"Each of those drive separate actions plans.

"So there is a real tension in my mind, between regulatory activity and sustainable learning that drives improvements," he said.

Majid said actions plans tended to "drive" policies that should be in place. But he said it was not just about the policy.

He said: "It's the person. How we support the person?

"How do we check that the person does what they should be doing? How do we support them with any queries?"

A report by the trust found that duty of candour intelligence training was not rolled out to the appropriate personnel at all levels in the trust.

Duty of candour requires clinicians to make people aware or alert them of failings or potential failings in care.

Majid added this was one of the things that the trust changed when it was developing and enhancing its patient safety functions.

The inquiry heard Majid had asked for comparative data on the number of "serious incidents", which took place regarding other mental health trusts.

When asked why by Langdale, Majid said a "concern" of his was how the trust managed serious incidents.

He told the inquiry he was trying to understand for an organisation the size of the trust, and considering the demographics, was there a "benchmark" figure?

Majid added he was told the information he requested was not available.

The inquiry heard an internal report identified a number of areas for learning at the trust, including:

• Poor risk assessments
• Poor quality of care plans
• Lack of crisis plans
• Missing documentation
• Lack of communication or understanding of processes with other agencies
• Lack of medical liaison at times
• Lack of adherence to local procedures

Majid agreed these were not just areas of learning, but "failings" in the provision of care.

The chief executive said he was aware the trust had been rated "requires improvement" since 2019 when he started in the role.

Asked who was responsible for ensuring improvement, Majid said: "From the point that I take up post, that would be my responsibility."

The inquiry heard in 2022, before Ifti Majid was appointed CEO of the trust, the body was rated "requires improvement" by the CQC.

Langdale asked Majid whether he was aware not all governance processes "operated effectively" at team level, to which he agreed that he was aware.

The inquiry also heard meeting decisions were not always recorded at the time, which Langdale described as a "consistent and chronic" issue.

Majid was also asked whether he had meetings with the senior coroner when he began the role, to which he said he did not.

The outgoing CEO said "senior" members of staff such as the medical director or chief nurse would attend meetings with the senior coroner and provide feedback to him.

The inquiry has heard throughout evidence in the Nottingham Inquiry that mental health services followed a policy of using "the least restrictive practice" when dealing with its patients.

Majid said: "I think in mental health practice generally, it would be my view that least restrictive practice is what is expected to be aimed towards."

Asked if the risk a patient presents to others was adequately considered, he said: "It's a personal opinion, but my opinion would be that over recent years, the focus on safety to others, safety to the public, has reduced."

Rachel Langdale, counsel to the inquiry, asked Majid about a report that detailed there were "limited escalation mechanisms" provided at the NHS trust.

Majid told the inquiry his concern was that information about performance or "wasn't flowing up the organisation" in a way which enabled the board to understand what was happening on the front line.

He added he understood from colleagues that the previous accountability framework shared "what was positive" instead of holding to account.

When asked by Langdale whether he thought it had become an "echo chamber", Majid responded: "Yes, I would say so."

Majid has told the inquiry that when he joined the organisation, he was concerned about the relationship between the three divisions the trust's services were split into - mental health, community health and specialised services, and forensic services - all of which were led by a group director, nurse director and associate medical director.

He said colleagues told him they did not know where decisions were made.

Majid said: "I was concerned they were siloed in nature. I didn't feel there was opportunity for sharing best practice for sharing, learning and therefore improving.

"And I was also concerned that the divisions all had slightly different structures, they had slightly different governance processes."

Ifti Majid was a practising mental health nurse for the first half of his career before moving into various management and leadership roles.

He said he became the director of operations for the trust in 2010, and told the inquiry he had been in executive roles "for some 10 years".

Ifti Majid has begun giving evidence to the Nottingham Inquiry.

The CEO of the hospital trust at the time of the attacks on 13 June 2023 is being questioned by Rachel Langdale, counsel to the inquiry.

Ifti Majid, the outgoing CEO of Nottinghamshire Healthcare NHS Foundation Trust, has been sworn in and is set to begin giving evidence to the Nottingham Inquiry.

Majid joined the trust in December 2022, after Calocane was discharged. He was in post at the time of the Nottingham attacks on 13 June 2023.

Majid announced his retirement in November last year. He had intended to retire on his 60th birthday in October but the trust said at the time, he would be staying in post for the public inquiry with a view to leaving in June.

If you'd like to find out about more of the evidence heard in the Nottingham Inquiry so far, you can get up to speed with the latest as part of our Need to Know series.

Last week we heard from Valdo Calocane's brother Elias, and his mother Celeste.

This morning, we heard evidence from John Brewin, who was CEO of the Nottinghamshire Healthcare NHS Foundation Trust from January 2019 to August 2022.

This covers almost the whole period Nottingham triple killer Valdo Calocane was under the trust's care after his paranoid schizophrenia diagnosis.

Here's a recap of what we've heard at the inquiry this morning:

• Early into Brewin's tenure as CEO of the trust, there was an inspection by the the healthcare watchdog, the Care Quality Commission (CQC), which rated the service as "requires improvement"
• The inquiry heard Brewin wrote to staff about a "harrowing" meeting with managers, saying that services at the trust "are not safe"
• The inquiry was told a report prepared for a trust meeting in 2021 flagged staffing as an "urgent" issue, which Brewin said was "not unique to Nottingham by any stretch"
• Brewin told the inquiry when he started the role of CEO of the trust, he understood there were "significant concerns" about the Early Intervention in Psychosis (EIP) team

Image source, The Nottingham Inquiry

Following Calocane's sentencing in 2024, a series of failings emerged by authorities, including the police and mental health services - both of which the killer was known to - prompting calls for a statutory, public inquiry.

A statutory inquiry means witnesses who are called forward are legally compelled to give evidence under oath.

The Nottingham Inquiry, which began hearing evidence on 23 February this year, is examining the lead-up to the attacks, the investigation that followed and the aftermath.

It is being chaired by retired senior judge Deborah Taylor KC - who will listen to all the evidence and draw up her findings as part of a final report.

You can read more about how the inquiry works here.

Image source, Nottinghamshire Police

Brewin has now completed his evidence to the inquiry. His witness statement will be published later on the Nottingham Inquiry website.

The hearing has now paused for a lunch break until 13:20 BST.

Ifti Majid, the outgoing chief executive officer (CEO) and Brewin's replacement, is expected to begin his evidence after the break.

The chair of the inquiry, retired senior judge Deborah Taylor KC, has put to Brewin that audits showed the EIP team appeared to be "consistently good at physical examinations - but not in relation to mental health".

She said: "Do you agree with that? Perhaps the emphasis was on the wrong thing?"

Brewin said targets for physical assessments were "relatively easy" to meet but added "the broader church of mental health interventions is a much more challenging area".