As the Nottingham Inquiry, established following the attacks carried out by Valdo Calocane in June 2023, concludes its hearings, our thoughts remain with the families of Barnaby Webber, Grace O'Malley-Kumar and Ian Coates, and with everyone whose lives have been forever changed by these devastating events.
 
The purpose of the Inquiry is to understand what happened, what went wrong, and what must change to help prevent such a tragedy from happening again. It is right that those questions are examined thoroughly and independently. 
 
Throughout the Inquiry, the families and others directly affected have had to revisit events that no one should ever have to endure.  The wider public discussion around it has also been difficult for many people living with severe mental illness and their families, who know first-hand the consequences of a mental health system that too often fails to provide timely, effective and joined-up care.
 
As the Inquiry draws to a close, it is important that we hold on to two truths at the same time. The first is the devastating impact that violence has on victims, families and communities. The second is that the overwhelming majority of people living with mental illness are not violent and are far more likely to experience harm themselves than to harm others. Both of these realities matter, and neither should be overlooked.
 
Good quality mental healthcare saves lives. It helps people recover, supports families, reduces risk and contributes to safer communities. That is why we continue to call for people living with the most severe mental illnesses to receive the right care, at the right time, for as long as it is needed. When care is delayed, fragmented or unavailable, the consequences can be profound for individuals, families and society.
 
When the Inquiry reports, the focus must be on learning lessons, implementing recommendations and ensuring accountability for change. Too often, serious incidents, investigations, reviews and inquiries identify important improvements, only for recommendations to be implemented inconsistently, duplicated across different processes, or not acted upon at all.
 
The Health Services Safety Investigations Body (HSSIB) has highlighted concerns about the volume of recommendations relating to mental health services, the lack of clear ownership for implementation, and the absence of effective oversight of whether change is actually delivered. 

As we have argued through our Better Care = Safer Care campaign, there is a strong case for a national system to coordinate, prioritise, monitor and report on mental health safety recommendations, building on approaches already used elsewhere in healthcare. This would help ensure that lessons identified through inquiries, investigations and reviews are translated into meaningful improvements in care and safety.
 
The findings of the Nottingham Inquiry must be considered carefully and in full. Whatever conclusions it reaches, the families affected by this tragedy, alongside patients, carers and the wider public, deserve confidence that when serious failings are identified, lessons are learned, action is taken, and meaningful change follows.