Executive medical director and deputy chief executive of Nottingham Healthcare NHS Foundation Trust, Dr Susan Elcock, was speaking during evidence to The Nottingham Inquiry.

When asked if the killings of Barnaby Webber, Grace O'Malley-Kumar and Ian Coates on 13 June 2023, nine months after Calocane's discharge, could have been prevented, Dr Elcock said: ‘I think there are clearly a number of errors, and missed opportunities in terms of care and oversight, which might have meant that his care had been delivered in a different way.

‘In terms of then going on to whether it could have been predicted, the levels of risk and the risk incidents as such, from my clinical perspective, it would be very difficult to link, in terms of predicting the level of future violence and the tragic outcomes.

‘In terms of the totality of missed opportunities in a whole variety, as I've heard, across the entirety of the inquiry, again, leads to questions about whether or not there were errors such that it could have been preventable. I think it's a very difficult, fine question.'

Dr Elcock said the trust had made no referrals to the regulator regarding disciplinary action, although one doctor who self-referred was not considered to have met the GMC's criteria.

When asked if the trust would revisit questions of disciplinary action, Dr Elcock said: ‘We've already agreed the process which is what we've done before in terms of the professional practice reviews. So all evidence that has been heard to date for clinicians, both nursing and doctors, will be reconsidered through that process.'