Who Cares?
Jean McNicol
- The Report of the Inquiry into the Care and Treatment of Christopher Clunis by Jean Ritchie, Donald Dick and Richard Lingham
HMSO, 146 pp, £9.50, February 1994, ISBN 0 11 701798 1
- Creating Community Care: Report of the Mental Health Foundation into Community Care for People with Severe Mental Illness by William Utting
Mental Health Foundation, 76 pp, £9.50, September 1994, ISBN 0 901944 17 3
- Finding a Place: A Review of Mental Health Services for Adults
HMSO, 94 pp, £11.00, November 1994, ISBN 0 11 886143 3
- The Falling Shadow: One Patient’s Mental Health Care. Report of the Committee of Inquiry into the Events Leading up to and Surrounding the Fatal Incident at the Edith Morgan Centre, Torbay, on 1 September 1993 by Louis Blom-Cooper, Helen Hally and Elaine Murphy
Duckworth, 230 pp, £12.99, January 1995, ISBN 0 7156 2662 0
At around 9 p.m. on 9 December 1992 Nigel Bartlett was walking down a quiet suburban street near Wood Green in North London when a man began to follow him. The man – Bartlett said he looked ‘like the Michelin man’ – started walking backwards in front of him and asked him if he was the devil, and then if he was happy. He had something in his hand; Bartlett thought it was a knife as it glinted in the streetlights, but then realised it was a screwdriver. The man waved it around and then hit Bartlett on the bridge of the nose, probably with his fist. As Bartlett lay in the road shouting for help his assailant walked away. The policeman who eventually arrived said that he thought he knew who the culprit was, that he lived locally and that he was mentally-ill – and so was unlikely to be prosecuted. The policeman, a PC Sullivan, seems to have made the connection between Bartlett’s attacker and the elusive subject of an abortive Mental Health Assessment he had attended the week before. He later, rather unconvincingly, denied all this and claimed that he had had no idea who attacked Nigel Bartlett.
About half an hour later, Susan Parashar, who lived nearby in Whittington Road, bumped into her son and his friends while she was taking her dogs for a walk. A large man came up and began, incoherently, to talk to them. He tried to pat one of her dogs, but it growled at him and the man became abusive. Mrs Parashar walked off with her dogs. The man chased the children in between the cars parked in the street, again waving a screwdriver.
Mrs Parashar rang the police, as did one of the boys and a local shopkeeper. Parashar spoke to an officer at Edmonton Police Station, who asked for a description and then said: ‘I think we know who that is.’ The man, meanwhile, had gone into a house on Marlborough Road – a side street pretty much parallel to Whittington Road, which is split between two police divisions and two local authorities. When the police finally arrived no one was asked to give a statement. The next day one of the boys saw the man again, followed him home and went to the local police station and told them the address – 112 Marlborough Road. That evening Susan Parashar rang Edmonton Police Station again and was told by the woman she had spoken to the previous night that they already knew the address because the police had been present at an attempted Mental Health Assessment there the previous week, but that they couldn’t ‘just go and arrest him’.
The case was transferred to Winchmore Hill Police Station on 12 December; on the 15th an Inspector Gill told Mrs Parashar that everything was in hand. He also contacted Haringey Social Services and told a social worker there that one of their clients had been chasing children and asking people if they were the devil. The man, she said, had an appointment with them for 24 December; Gill seemed satisfied with this. (Like PC Sullivan, Gill denied that he had known who the man was when he gave evidence to the Inquiry, but a record of the conversation was entered in the relevant file.)
Another social worker phoned the man’s consultant psychiatrist (who had never seen him) on 17 December and after some wrangling about whose responsibility he was – which hospital and which social services department – the two decided that an emergency Mental Health Assessment should be organised for the following day. That afternoon Ursula Robson, the duty Approved Social Worker – ASWs have training in mental health, and become involved if there is a possibility that a client will be committed – was given his file. Alarmed by the history of violence it contained, she decided to call at his address that evening. He wasn’t there, so she left a note asking him to come and see her the next morning. She and her colleagues were waiting for him to turn up when they were told that he had been arrested for murder the previous day.
It was not until the following June that Susan Parashar realised that the man who had frightened her was Christopher Clunis, on trial at the Old Bailey for murdering Jonathan Zito on the northbound Piccadilly Line platform at Finsbury Park tube station on 17 December 1992.
According to his solicitor, Christopher Clunis, who was found guilty of manslaughter and sent to Rampton Hospital, is ‘contemplating’ suing North East Thames and/or South East Thames Regional Health Authorities for negligence in releasing him into the community without support. Jayne Zito, his victim’s widow, is said by the Guardian to support him in this. Jayne Zito had worked with the mentally-ill and was on a postgraduate course in social work and social studies at Middlesex University when her husband was killed. Her vehement disagreements with the Health Minister Virginia Bottomley about the degree of responsibility the care in the community programme bears for her husband’s murder have been widely reported. The two women met at the end of Clunis’s trial and Zito tried unsuccessfully to persuade Bottomley to hold a public inquiry. The politicians, she said afterwards, ‘tried to turn this into my personal tragedy instead of tackling the questions that need to be answered about care in the community’. In their view a closed inquiry by the two health authorities responsible for Clunis’s care in the six months before the murder, and investigating his care only during this period, would be adequate. Zito doubted this. Jean Ritchie, the QC engaged to chair the Inquiry, seems to have shared Zito’s feelings, and the two health authorities were persuaded that the Inquiry should investigate Clunis’s case back as far as 1986. The resulting report approximates in scope to the public inquiry for which Jayne Zito originally pressed and also comes close to endorsing her explanation of the causes of the murder.
Clunis was born in 1963 in Muswell Hill, North London of Jamaican parents and went to school in Luton where his father worked at the Vauxhall car plant. He did quite well academically but left before sitting A-levels: he wanted to be a jazz guitarist. He joined the Aqua Vita Showband; in 1985, while he was touring with the band, his mother died – she had had a stroke in 1980 and his parents had gone back to Jamaica. Clunis and his family seem to date the onset of his illness to this period. His father was worried and suggested that Clunis join him in Jamaica. It was there in 1986 that schizophrenia was first diagnosed.
He came back to England in 1987 when his father became ill. On 27 June one of his sisters found him in a ‘terrible state ... uncommunicative, confused, disoriented, staring into space, laughing and giggling to himself’ and took him to the A & E department at Chase Farm Hospital in Enfield. This was his first admission to hospital in this country and he was seen at Chase Farm another five times in the following eight months; and each time, according to the Ritchie Report, was treated ‘almost as though he were a new patient’. There was no investigation of his circumstances or any attempt to check the inaccurate statements he made about them. For example, his claims to have abused drugs were often taken on trust – the Ritchie Report suggests that because Clunis was black there was an undue willingness to believe that his illness was a drug-induced psychosis. Admitted the day after a Community Psychiatric Nurse (or CPN) had visited him at the house of his sister, where he was living, he was described as ‘homeless’. His GP and family weren’t officially informed of the majority of his spells in hospital. This pattern continued: the family’s lack of formal involvement in Clunis’s care over the years was such that the Inquiry was ‘surprised’ to hear from his sister that she had remained in touch with her brother. She was only rarely informed of his discharge from hospital and no member of the family was ever contacted when he was compulsorily detained, despite their statutory right under the 1983 Mental Health Act. Clunis was treated as an itinerant, homeless man, a model which he came more and more to approach.
On 26 April 1988, less than a month after he was last seen at Chase Farm, Clunis was arrested in Tottenham for stealing two loaves of bread, which he had tried to hide by stuffing them down his trousers, and remanded to a bail hostel. Because there was no space in the local hostel he was taken to one in Tulse Hill in South London, troublingly unfamiliar territory. He was clearly disturbed, and a probation officer from the hostel took him to King’s College Hospital. But there were no beds available and he was seen as an out-patient every day until his trial on 3 May, at which point a bed was found for him in Dulwich North Hospital. He was remanded on bail on condition that he went to hospital – if a bed had not become available he would have gone to prison. There have been several cases recently in which High Court judges have threatened to call Virginia Bottomley before them to explain why secure beds could not be found for mentally-ill defendants.
A doctor from Dulwich North contacted Chase Farm and was told that Christopher Clunis was ‘a difficult young man who just wanted a bed’, that Chase Farm doubted the diagnosis of schizophrenia and refused to accept any responsibility for him. On 6 May a nurse at Dulwich North noted that he was carrying a cutlery knife around. On 12 May, having been described as violent and threatening on several occasions, he was discharged. The consultant psychiatrist at Dulwich North, Dr Davies, told the Inquiry that the ‘ward was old and Dickensian and that violence was commonplace’. Its unsuitability, he added, meant that patients were discharged earlier than they should have been.
Letters
Vol. 17 No. 7 · 6 April 1995
From Trevor Turner; Michael Neve
Several points need to be made in response to Jean McNicol’s admirable piece about the current crisis in community care for the mentally ill (LRB, 9 February). For example, it is not correct that acute psychiatric beds cost ‘almost twice as much as less expensive community care’. In essence it is all about paying people to look after people and if those carers are skilled nurses they will cost more than good-hearted but amateur ‘care attendants’. Of course, an acute psychiatric ward also has to have additional staff for the more disturbed patients, and requires medical and other support personnel, and one has to be prepared to take anyone for whom admission is required. Ex-patients who were once in hospital for many years, by contrast, require little in the way of support – perhaps a visit once a day to help keep a house tidy. But more dependent patients, with limited self-care skills, may require intensive help, perhaps up to eight carers for four patients. Even in the old asylums there were the ‘refractory wards’, that needed many more nurses than the rather indolent ‘chronic’ wards. In fact, it may well be that asylums are cheaper overall than community care, because of the economies of scale. Such economies are not available in many typical community hostels or residential houses, the average size of which varies between six and ten people. It is, however, generally accepted, and ‘user’ (to use the correct language) questionnaires seem to support this, that living in a relatively small building is more human and more humane. Simple things like the curtains in your room, the time of getting up, and when you eat are not institutionally rostered. But such choices come with a cost.
On the other hand, many patients refuse to go to hostels because they know they will only receive £10-£12 per week in pocket-money once all expenses have been met. They would much prefer to live in their own flat, possibly accumulating rent arrears and bills, but at least enjoying their own lifestyle. This may be unrealistic, but the desperation of mental illness makes it hard to plan ahead. In such circumstances going back into an acute psychiatric ward can be a considerable relief, not only because one may be treated for unpleasant symptoms, but because one continues on full benefit for a number of weeks, and bills may be paid off. An acute 20-bed ward in London costs between £500,000 and £600,000 a year to run, at least in terms of staffing, while a high-dependency hostel for eight people costs about £200,000. Simple arithmetic shows that 20 divided by 8 makes 2.5, and that 2.5 multiplied by 200,000 makes half a million. But community care needs the ward as well as respite care, for the inevitable relapses: should one charge those costs to the costs of the hostel or not? In the end there is little difference, and compared to the revenue-saving device of making someone homeless both are grossly expensive.
The Government’s response to all this has been that of the classic desk-wallah, organising ‘care plans’, in which the careful documentation and the continual meetings of many people are seen as the key facts. Thus the Care Programme Approach insists that all individuals brought into hospital with severe mental illness should have their needs identified, a key worker nominated and an aftercare plan drawn up to deal with those needs. This approach is formalised under Section 117 of the Mental Health Act, in which such meetings and plans are a statutory duty. Of course, if there is no ward clerk to organise the paperwork, and no spare key worker to take on yet another severely disabled individual, all the planning in the world will not help. How many patients/clients can one individual key worker take on, particularly in the inner city? It is thought that perhaps ten to fifteen people with chronic severe illnesses, liable to relapse, is a reasonable caseload, but even formally documented demand does not generate additional resources. Community nurses in areas like Hackney may thus accumulate fifty or more clients and crisis work overwhelms any continuing care.
Most recently in this regard the Government has decided to set up Supervision Registers. These are a kind of Schindler’s List in reverse, a form of stigmatisation of those most in need of confidentiality. Patients must be included on these Registers if it is felt that they are suffering from a severe mental illness and ‘are, or are liable to be, at significant risk of committing serious violence or suicide, or of severe self-neglect in some foreseeable circumstances which it is felt might well arise in this particular case’. The decision to put someone on the Register has to be taken by the responsible medical officer (that is, the consultant psychiatrist in charge of the case) after consultation with the mutli-disciplinary team. There is no formal mechanism of appeal, and again no additional resources can be identified by this procedure. Apart from begging the question of what is meant by the term ‘severe’ or ‘serious’ in this context, these Registers are liable to provoke considerable argument among all those involved. Patients or their families may well object to the processes of labelling, and stigma will be reinforced. Nothing else will have been achieved practically.
The most obvious answer, the community treatment order, is already working in Australia, New Zealand and some of the United States. In the latter it is called ‘outpatient commitment’, requiring a court order for its implementation. However, it seems that in Great Britain the European Convention of Human Rights may make such an order impossible to put into force, since to interfere with anyone’s liberty against their will, unless they are deemed to be actively insane, is regarded as illegal. Yet keeping someone stable in the community can only be guaranteed if regular medication is part of that process. Since the Sixties the basis of community care has been the availability of effective medication, the sine qua non of the business. Which does not mean that social support, personal relationships, and a psychological understanding are not also vital in psychiatric care, but if the patient/client suffers from formal thought disorder, secondary to impaired dopamine pathways, little can be done by the comforts of talking.
As McNicol has correctly pointed out, the homeless are not those individuals who have been long-stay patients in asylums: only 2 percent, approximately, of homeless individuals in London have been long-stay patients. However, while the asylum closures have not led to any deterioration in care for those transferred to support in the community, a whole population of ‘new long-stay’ has never got into the regular asylum system. These are the ‘revolving-door’ people, who have responded well to treatment, have been discharged, but have deteriorated once more. Usually this is due to a mixture of limited aftercare, lack of insight, and a refusal to accept continuing medication. Their numbers have gradually increased over the last ten to fifteen years, and Christopher Clunis was certainly representative of them. Asylum care is no longer available, so they wander around the system, a stage army of troubled individuals, hiding in the woodwork so to speak, and re-emerging when their behaviour becomes socially unacceptable. The overflowing acute psychiatric wards of the inner city are sad reminders of their plight.
Another aspect of the Clunis affair is the difficulty of clarifying a past history, when issues of confidentiality and a differential understanding as to the nature of mental illness pervade the processes of mental health work. Clunis told his social worker that he was on medication ‘because of drug abuse’. Understandably the social worker informed the Inquiry that he could ‘only go on the information he was given’, and was constrained by his inability to contact hospitals about any previous history. It is not uncommon for individuals to give different stories to different workers, depending on that worker’s background. This dichotomy is clearly signalled by the difference between the terms ‘client’ and ‘patient’.
Finally, there is considerable difficulty in keeping people in facilities deemed ‘medium secure’, a broad-church concept that involves everything between maximum security (i.e. Broadmoor) and the general acute psychiatric wards. The sheer expense of these beds creates pressure to move people downmarket – i.e. out of the acute ward. There is always another more acutely psychotic patient (or client) at the doorway, and nurses ruefully describe the dilemma of having to discharge patients as soon as they are coherent enough to be receptive to counselling and more interactive nursing care. These pressures are exacerbated by the requirement of the ‘catchment area’, whereby any hospital team has to concentrate on those who live in their particular district. Arguments between doctors and nurses about addresses absorb ridiculous amounts of professional time. Paranoid wanderers such as Clunis, who as soon as they are well disappear once more into the anonymity of urban life, are a common feature of psychiatric wards. In fact, the ordinariness of the peregrinations of Christopher Clunis is in itself terrifying.
McNicol has pointed out that ‘properly organised and funded community care should be able to protect the public and to treat and control a patient.’ Yet without the basic premise of regular medication such extra-institutional care is a shibboleth. Fears of mandatory community treatment revolve around images of men in white coats forcibly injecting people on the kitchen table, even though the Mental Health Act still insists that this can only be carried out in hospital. And most patients, once in hospital, accept the verdict of the law and are compliant with medication. Given a choice between living in their own home and being in hospital, the great majority would prefer to be out of hospital: if it is laid down by appropriate legal statute that they have to receive regular medication then that would become part of the deal. At present this can only be done for a month or two when the patient is on leave from the hospital.
Yet a kind of community treatment order does in effect exist. It is the restriction order, outlined in Section 41 of the Mental Health Act. A number of individuals already live in the community under this order, which can only be imposed by a judge in a Crown Court. Like Christopher Clunis, however, one has to have done something seriously dangerous to be the subject of such an order. It is a classic case of after the horse has bolted. Christopher Clunis, now reasonably clear-headed and under appropriate treatment, is locked up in Rampton but he would not have been a danger to the public at all if he had received regular medication. The outdated nature of the 1983 Mental Health Act is well brought out in The Falling Shadow, but getting a new Act will be extraordinarily difficult.
There is a general reluctance in Parliament to spend time debating issues of mental health. It takes twenty to twenty-five years for a new Act to come into force (in this century, 1930, 1959 and 1983), partly because of fears about civil liberty. In fact, MPs have included a special section (Section 141) for their own protection, whereby the Speaker of the House of Commons has to be notified, and a special report obtained from eminent physicians appointed by the President of the Royal College of Psychiatrists, if any Member of Parliament is ‘detained’.
Trevor Turner; Michael Neve
Consultant Psychiatrist, St Bartholomew’s Hospital, London EC1; Wellcome Institute for the History of Medicine, London NW1
