On Thursday, Valdo Calocane, an engineering graduate diagnosed with paranoid schizophrenia, was sentenced to a hospital order with restrictions for killing three people and attempting to kill three others in a violent spree across Nottingham. The decision enraged the families of his victims, who believe he should have been prosecuted for murder, with one saying they were “railroaded” into accepting Calocane’s plea to the lesser charge of manslaughter. Here is a breakdown of the sentencing – and what could happen next. Could Calocane’s sentence be changed? The attorney general is looking at Calocane’s sentence after it was referred for being “unduly lenient”. This is a process that can be triggered by just one referral from an individual or institution. The situation is complicated because the attorney general is unable to look at Calocane’s charge: he was originally charged with murder but this was converted to manslaughter on the grounds of diminished responsibility because of severely poor mental health, to which he pleaded guilty. The restricted hospital order was handed down by the judge based on the medical evidence provided by doctors on Calocane’s condition, schizophrenia. A more severe sentence would presumably be a prison sentence, in which case if the attorney general were to progress the case, they would have to argue that Calocane’s condition was not as severe as presented by the doctors, which is a highly unlikely scenario. What is a hospital order with restrictions? If a person is found guilty of a crime that can be punishable with a prison sentence, the courts can send them to a hospital instead. The judge can do this under section 37 of the Mental Health Act. If the judge believes the person is a risk to the public, they can add a restriction to the hospital order under section 41 of the same act. The restriction means that the person subject to the order can only be discharged from hospital if the justice secretary agrees. How do the courts issue hospital orders? Before the courts issue a hospital order under section 37, two doctors need to assess the defendant. They must agree that they have a mental disorder that means they should be in hospital. One of these doctors should be from the hospital where the person will be staying. In order to add a restriction under section 41, one of the doctors who assessed the person must speak in court to give evidence about their condition. How long does a hospital order last? Since 2007, a restricted hospital order does not have a time limit. This means the hospital order does not have a fixed end date and does not need to be renewed. The responsible clinician will decide when a person is well enough to leave hospital and the Ministry of Justice must agree for them to be discharged. What are conditions like in a high-security hospital? According to the NHS, high-security hospitals’ physical security arrangements are equivalent to those of a category B prison, although they are able to treat individuals who in a prison setting would be in a category A environment. An inpatient can be given treatment without their consent for the first three months, and can then be treated without consent only if a second doctor agrees. Where are the high-security hospitals? There are three in England. Perhaps the most well known is Broadmoor hospital in Crowthorne, Berkshire. The other two are Ashworth hospital near Liverpool and Rampton secure hospital in Nottinghamshire. Who else has been sentenced to a hospital order and what happened to them? According to the most recent data, there were 7,796 restricted patients as of 31 December 2022. There were 1,524 disposals and discharges in that year, a 1% decrease from the previous year. The annual number of discharges and disposals has fluctuated between 1,350 and 1,550 since 2011. There have been many well-known inpatients of high-security hospitals, including the Moors murderer Ian Brady, who died in hospital; the Yorkshire Ripper, Peter Sutcliffe, who was transferred to prison later in life and died behind bars; and the London gangster Ronnie Kray, who died in Broadmoor in 1995.