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, 0 11 701798 1
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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, 0 901944 17 3
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Finding a Place: A Review of Mental Health Services for Adults 
HMSO, 94 pp., £11, November 1994, 0 11 886143 3Show More
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, 0 7156 2662 0
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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.

According to the Audit Commission, an area with a large number of homeless people can have admission rates twenty times higher than a suburban or rural area. In one Inner London hospital homeless men constitute 10 per cent of admissions to psychiatric wards. In consequence, the Ritchie panel was told, ‘the threshold for getting into mental health services in London is starting to get higher and higher.’ The occupancy rates in general psychiatric wards in London are very high, commonly up to 130 per cent, and the average stay very short, 18 days at Guy’s, for example.

The number of mental health beds has been falling since 1955 – there are now around fifty thousand in England and Wales, compared with one hundred and fifty thousand in 1955 – as has the mental health budget as a percentage of the NHS hospital and community health services budget, largely thanks to the policy, enshrined in the 1959 Mental Health Act, of closing the large Victorian mental hospitals found on the edges of most conurbations in Britain (relatively few have as yet been completely closed). Both the Mental Heath Foundation and the Audit Commission make the point that the money saved by the closures seems to have ‘leaked’ to other areas of the NHS budget. The disappearance of long-stay beds in mental institutions has put pressure on beds in acute wards and has led to an inability to admit people in crises, to premature discharge and to a repetition of the problems which led to hospital admission in the first place. Bed closures have not been matched by an increase in community services and 90 per cent of the NHS mental illness budget is still spent on hospital-based care, even though acute beds cost almost twice as much as the most expensive community care, 24-hour staffed accommodation. The Audit Commission estimates that if only acute patients were admitted to psychiatric wards £100 million would be released to be spent on community care, since between a third and a half of those now spending several months on acute wards are there mainly because there is no suitable place for them to live or because alternatives to admission weren’t considered or are not available.

On discharge from Dulwich North, Christopher Clunis was given a letter to take to Lambeth Homeless Persons’ Unit. There was no attempt to contact his GP, his family or social services in North London: Clunis complained about this when the panel of the Ritchie Report visited him in Rampton Hospital. ‘A person in my position,’ he said, ‘has not got the availability of choice.’ Less than a fortnight later, on 25 May, Clunis broke into an old woman’s house, was found in her bathroom, charged with criminal damage to her front door and on 26 July re-admitted to Dulwich North Hospital under Section 37 of the Mental Health Act, which allows the Courts to send mentally-ill defendants to hospital. He was discharged on 11 August to bed and breakfast accommodation in Paddington. On discharge he was described as ‘vulnerable’, with a ‘poor prognosis’, but said to have no behavioural problems, despite mention in the nursing records that he was ‘rude and abusive’. Again there was no attempt to return him to North London and no plan was made for him under Section 117 of the Mental Health Act.

Section 117 concerns the aftercare (the jargon still assumes that hospitals are the main locus of care) of people detained under the Act. Its object is to provide a comprehensive plan for meeting patients’ social and medical needs after they go home – for a start, those involved should make sure that the patient has somewhere suitable to go home to. State benefits, day-care, education, medication and alertness to the patient’s mental state and the possibility of relapse should all come within the purview of Section 117. One person, usually a CPN or social worker, known as a keyworker, should co-ordinate action and be available to the ‘user’ and to the friend or relative who acts as his ‘advocate’. This sounds admirable, but implementation has been patchy and very few plans get anywhere near providing adequate help with the patient’s housing, social and financial needs.

The 1994 Queen’s Speech included a measure which will make those under S117 care subject to a Supervised Discharge Order: this will probably mean that it will be legal to recall people to hospital if they don’t accept the treatment laid down in their care plan, or in the interests of the health and safety of the patient or of others – a measure motivated at least in part by cases such as Clunis’s and that of Andrew Robinson, a schizophrenic who murdered Georgina Robinson, an occupational therapist in the unit where he was an inmate. The Falling Shadow, the report of the official inquiry into her murder, contends that the under-used Guardianship Order (which was used to treat Robinson) covers much the same ground as the Supervised Discharge Order. Neither measure compels the patient to accept medication, and rather than new legislation still lacking any power of enforcement Louis Blom-Cooper and his co-authors support the inclusion of compulsory medical treatment in comprehensive care plans.

The Ritchie Report also recommends that a register be kept of those with severe mental illness. They estimate it would include between three and four thousand people. ‘If the needs of that small group are not properly met,’ the Report says, ‘care in the community will be discredited ... We do not think that as a society we can afford to let that happen.’ The Mental Health Foundation, however, disagrees, largely because it thinks that such registers will merely duplicate work and is concerned about the implications for the patient’s civil liberties. The MHF also makes the point that, because of cases such as Clunis’s, it will be assumed that everyone on the register is listed because they pose a danger to others.

Clunis disappeared – which is what S117 is supposed to prevent – until April 1989, when he was visited by Jenny Norville, a special needs housing officer from Lambeth Social Services, at Manor Court Chambers, a bed and breakfast in Notting Hill described by his sister as ‘just terrible’. In May, Norville and her colleague Hugh Murray, from Lambeth’s Homeless Single Persons’ Team, were told that Clunis was becoming violent and that other tenants were afraid of him. Ten days later they saw Clunis and, believing he was ‘obviously ill’ but not sectionable, tried to arrange for a psychiatrist from St Charles’ Hospital in North Kensington to do a domiciliary visit. Two doctors told the Inquiry that they had tried and failed to see Clunis. They were to return on 9 June.

On 6 June, however, all the tenants were told that they were going to be rehoused because work – which seems to have become necessary rather suddenly – had to be done on the building. Clunis first bolted himself in his room, then came out only to attack the manager, putting his hands round the man’s throat. Police were called twice the next day, the second time because Clunis had once more refused to leave his room. When they arrived, Clunis ‘rushed out at the officers, grasping a table knife which three policemen had to wrestle from his hand’. He was detained under the Mental Health Act and taken to St Mary’s Hospital in Paddington under Section 2 (for assessment in hospital of up to 28 days). He was not charged. The Ritchie Report suggests that the minimising of Clunis’s violent episodes, manifested both in the police’s reluctance to charge him and in the omission of such events from his records, while intended to ‘help him and perhaps not to stigmatise him’, acted to his ‘ultimate disservice’. It certainly didn’t help those who had to look after him.

Clunis was transferred to St Charles’ on 9 June. He was described as ‘aggressive and verbally hostile’ and as upsetting female patients – ‘overfamiliarity’ and ‘exposure’ to women was a recurring feature of Clunis’s illness. On 2 July he had an argument with a fellow patient, whom he threatened to stab in the genitals. Nursing staff intervened, but the next night he stabbed the same man six times as he lay in bed. The police were not informed about either incident, but nurses asked that Clunis be moved to more secure accommodation. Clunis was transferred to Section 3 of the Mental Health Act, which is intended for long-term hospital treatment of severe mental illness.

After two days during which he received very high doses of medication, a bed was found for him – ‘probably’, in the words of the Ritchie Report, ‘at the expense of another patient’s welfare’ – at Horton Hospital, a psychiatric hospital in Surrey. He was transferred back to St Charles’ on 27 July, and still showing signs of disinhibited behaviour was discharged on 14 November, having been offered a place in Rosemead Hostel in Balham – the only hostel in Lambeth with psychiatric supervision. He was given an out-patient appointment (as far as the Ritchie Report was able to establish, Clunis kept none of the out-patient appointments he was given). No S117 plan was made – the consultant at St Charles’, Dr Higgitt, said that procedures for S117 discharge weren’t in place until after the Royal College of Psychiatrists published guidelines in 1990, seven years after the Act became law.

The medical officer at Rosemead was sent Clunis’s discharge summary. This did say something about his propensity to violence, but didn’t mention his out-patient appointment, nor the fact that St Charles’ wanted to follow him up for three months. No arrangement was made for him to receive depot injections, in which medication is released gradually into the bloodstream, and this was rectified only because Hugh Murray noticed the omission. Dr Higgitt’s clinical assistant visited him in January, thought him well and transferred him to the care of South Western Hospital, but this hospital has no record of him and Clunis didn’t see a consultant psychiatrist again until July 1991. In October 1990, he was finally asked to leave Rosemead because again there was concern about his behaviour towards women, his challenging of staff decisions and general aggression. The staff, it seems, didn’t fully appreciate how much of Clunis’s behaviour was due to his illness – which suggests a lack of communication with the health services. The overall impression, as they say, is that all the people trying to help Clunis were doing so in isolation.

Even so, Clunis’s time at Rosemead represents his ‘longest period of stability’ and for much of this period he also had a job – the only employment he had after the onset of his illness. Rosemead had wanted to discharge him at the end of July but staff were persuaded by the Homeless Persons’ Unit to let him stay until appropriate housing could be found. Clunis’s behaviour and his ability to take care of himself were deteriorating; he had lost his job; his CPN had left his job; he had stopped taking oral medication and now he was about to lose his home.

One of the most obvious shortcomings of the care in the community programme is the lack of attention to the housing needs of mental health patients. Some local authorities have schemes for the mentally-ill, but most psychiatric patients have to queue up for public housing with everybody else, clogging up places in hospitals and short-stay hostels while they wait. Conflicting government policies exacerbate the problem: while the Department of Health is encouraging the move from hospital into the community, the Department of the Environment has banned the building of supported housing with Housing Corporation funds. Most care plans don’t specify the recipient’s housing needs or how they might be met, and social service departments find it difficult to work with local housing authorities, who often feel that social care isn’t their problem. Compulsory Competitive Tendering for housing management – which puts council housing departments out to tender, the contract usually going to the cheapest bidder – will mean even less attention to any social function. While those with mental problems are more likely to become homeless, the increase in the number of people sleeping rough does not – contrary to popular opinion – appear to be connected with the closure of long-stay mental asylums. In a survey of 1518 homeless people in London in 1992 two-thirds had had some contact with psychiatric services but only 2 percent had been long-stay patients.

On 4 October 1990 Clunis moved to Jeffrey’s Road Hostel in Clapham, which was staffed by a social worker and an occupational therapist. In December he told his new CPN, Bala Sivakumar, that he wanted to see a consultant because he was getting side-effects from his depot injections. In February he asked again and was given an out-patient appointment, which as usual he did not keep. Later that month he refused his injection, saying he wouldn’t have it unless he got another appointment. Sivakumar made one for 12 April but Clunis said it was too far away. It was moved forward to 14 March, and the hostel, but not Clunis himself, was notified of the change. Sivakumar didn’t see Clunis again – in the meantime he was taking no medication at all – and didn’t try to find out what had happened at the hospital until nearly a month after Clunis should have attended his appointment. Virginia Bottomley frequently speaks of having quadrupled the number of CPNs, but a quarter of them don’t have any schizophrenics on their caseload – at least in part because, like Clunis, they are difficult and uncommunicative and seem unrewarding to treat.

Clunis didn’t turn up for the 14 March appointment because he had been arrested on 12 March, having chased one of the other residents round the hostel with a large knife. When the police arrived he raised the knife at one of them. A magistrate bound him over for a year for breach of the peace; he was not referred to hospital. Clunis would have received more help, the Ritchie Report suggests, under a hospital order or through the Probation Services. In the Report’s view, victims should be encouraged to press charges in such situations.

Having exhausted Lambeth’s meagre supply of supervised housing, Clunis was given a room in a bed and breakfast hostel in Streatham. Hugh Murray saw him there, was worried that Clunis ‘would not wash or feed himself’ and tried to find somewhere else for him to live, but Clunis moved on after less than a fortnight in Streatham and disappeared from view. He resurfaced in July when he was found by the police outside a Co-Op in Brixton, from which he had stolen some sweets. He was sucking a dummy. After being assessed he was admitted as a voluntary patient to St Thomas’s. Again, nursing staff, concerned about his behaviour, asked that he be transferred to the local intensive therapy unit, but it was full and Clunis stayed where he was, receiving very high doses of medication which the staff nurse on the ward described as ‘putting him in a chemical straitjacket’; the consultant denied this, but admitted that Clunis had received the highest dose of Chlorpromazine he had ever prescribed. Clunis remained aggressive and objected do the medication. ‘If you give me any more of that stuff I’ll beat you up,’ his notes record him as saying. On 17 August he left the ward without permission and was discharged in his absence a few days later.

Ten days after Clunis disappeared, a psychiatric nurse from Spur House in Lewisham, a DSS resettlement unit for homeless single people, called the ward, said that Clunis was living there and asked about his medication. The staff nurse does not seem to have made it clear that Clunis was wanted back on the ward, and didn’t tell the consultant about the episode. Spur House and its sister units – which are now being closed down or transferred to the private sector – offered a very basic level of support. The members of the Inquiry found the hostel dirty and unsuitable for the care of the mentally-ill (about 30 per cent of the inmates). Clunis didn’t stay there long: on the same day that the nurse rang St Thomas’s, he attacked another resident, who again didn’t want to bring charges, and was told to leave. The Manager arranged, however, for him to move to another Resettlement Unit, Lancelot Andrewes House in Southwark.

This unit can accommodate 72 men in dormitories: around thirty stay for a considerable period but others only for a night – ‘several thousand’ pass through during a year. There are many violent incidents and problems with drugs, alcohol and, increasingly, with mental illness. The manager admitted to the Inquiry that they were ill-equipped to deal with the mentally-ill, in part because confidentiality rules meant that they weren’t told inmates’ histories, but added that, although he wouldn’t have admitted Clunis had he known his history, he wouldn’t disclose a similar case to another hostel. The hostel contacted Hugh Murray after Clunis told a worker that he’d lived at Jeffrey’s Road, and Murray gave the nurse Clunis’s history; but the duty of confidentiality meant that this information wasn’t passed on to other staff.

In December Clunis was seen by a social worker from the local authority Mental Health Team. Clunis told the social worker, David Purse, that he was on medication because of drug abuse, had no psychiatric problems and wanted help only with housing. He was taken at his word: Purse told the Inquiry that he ‘could only go on the information he was given’, and that he thought Clunis was a ‘gentle giant’. Social workers cannot coerce people into accepting their help nor are they allowed to contact hospitals for details of previous admissions unless given written permission by the person concerned. When Clunis asked to see him the following February, Purse refused, saying his problems were not mental health ones, to the amazement of the staff at Lancelot Andrewes House.

On 3 May 1992 Clunis paced around his dormitory all day and at night set fire to a Bible. Normally he spent the day in bed and the sudden change in his behaviour worried the staff, who arranged for him to see the visiting medical officer. But that night he stabbed another resident in the neck. The man was taken to Guy’s Hospital; Clunis was arrested and charged with wounding with intent. Only one staff member was interviewed; he was later told the date of the trial, but never heard from the police whether or not they wanted him to attend it. The victim returned to the hostel for a week after being discharged from Guy’s, but the police don’t seem to have made any attempt to trace him or to obtain the medical records relating to the incident. They probably couldn’t be bothered. After all, as the Ritchie Report puts it, ‘the attack had been perpetrated by someone who was mentally-ill on a person who was homeless.’

Clunis was seen by psychiatrists at HMP Belmarsh and at Tower Hill Magistrates’ Court. The two doctors agreed that he should be sent to the Regional Medium Secure Unit in the grounds of Bexley Hospital, but there was no bed available. The unit serves 850,000 people and has 15 beds: staff estimate that they need another ten. One result of the shortage of secure beds is that people often have to be treated, if funding can be obtained, at expensive private hospitals which can be anywhere in the country. The expense tends to mean that people don’t spend as long as they ought to in these hospitals and the geographical position leads to problems with follow-up. There is no requirement for NHS staff to keep in touch with a patient once he has been moved to the private sector. Clunis was sent to Kneesworth House, a private hospital in Hertfordshire, on 28 May. He wasn’t sorry, he said, about the stabbing and although he improved slowly, the hospital’s recommendation to the court was that ‘he would not co-operate with treatment outside hospital and ... could again act in a dangerous way if he becomes floridly psychotic.’

The case came to court on 17 August but in the absence of both the victim and of the medical records the CPS decided to offer no evidence. The judge now regrets that he did not adjourn the case so that efforts could be made to trace the victim. Clunis’s barrister, Anthony Rimmer, was worried about the prospect of his client getting no further medical treatment, and having established that Clunis ‘was not troubled’ by Kneesworth, decided for the only time in his career not to ask for his client to be discharged from the dock.

Clunis returned to Kneesworth as an informal patient, but two doctors and a social worker recommended compulsory detention under S3. All three thought Clunks was still potentially dangerous. But only three days after the trial, Dr McCarthy, a consultant psychiatrist at Guy’s, rang Kneesworth and told the doctors there that Clunis was to be immediately transferred to a general psychiatric ward at Guy’s. Dr McCarthy insists that he was told Clunis was almost well; his counterpart at Kneesworth denies this. The decision seems to have been made to save money now that he was no longer detained under a forensic section of the Mental Health Act. He was transferred to Guy’s on 21 August; from 13 September he was given leave from the ward so that he could find somewhere to live – having given a false address in Haringey he finally succeeded in returning to North London – and sort out his benefits.

This is always a difficult process for the mentally-ill and will be made more so by the Social Security (Incapacity for Work) Bill, which comes into force this year. This system will use a self-assessment form – a singularly inappropriate method – to work out eligibility for the slightly higher benefit available to the mentally and physically disabled, but will judge psychological incapacity on what the MHF describes as ‘strikingly more limited scales’ than physical disability. The higher levels of payment must be ‘requalified’ for with every episode of illness and fall to ‘pocket-money’ levels during any period in hospital longer than six weeks, making it hard for people to keep up with financial responsibilities.

Clunis was discharged on 24 September 1992 and described as being ‘completely well’: Dr McCarthy told the Inquiry that Clunis’s continuing aggressiveness was part of his ‘underlying personality’ and not due to his schizophrenia. Nevertheless, because of it medical staff at Guy’s thought he should be seen by a forensic psychiatrist at Friern Hospital (a psychiatric hospital which was closed in 1993). But having made an unorthodox telephone request to this effect, they were told that patients should initially be referred to a general psychiatrist and an appointment was made for Clunis with a Dr Seargeant.

No one from Friern or from Haringey Social Services attended Clunis’s S117 meeting on 24 September. Dr Gupta, Dr McCarthy’s Research Fellow, told the Inquiry that a care plan was made for Clunis, but nothing was written down, and if there was a plan it was not divulged to any of the organisations about to become responsible for him. Ann Witham, the social worker on the psychiatric ward, wrote to Haringey Social Services saying that Clunis was ‘quite capable of self-care and should be able to cope with independent living’. (She was surprised when told by the Inquiry that he hadn’t known how to open a bank account in which to put his DSS cheque.) She accepted without checking Clunis’s wildly inaccurate account of his history and relied on him to supply details of names and addresses for his S117 form (his new address is recorded there as ‘5 Malbro Rd’). The Ritchie Report concludes that Witham gave ‘groundless reassurance which contributed crucially to subsequent doubt, delay and under-reaction’. The discharge summary from Guy’s, which might possibly have alerted doctors to the need for prompt action, didn’t arrive at Fniern Hospital until 6 November. An internal inquiry at Guy’s into Clunis’s treatment and discharge found both to be ‘exemplary’.

Clunis went to Haringey’s Emergency Housing Group armed with a letter from Ann Witham giving his made-up story and on the strength of it was given bed and breakfast accommodation at the much misspelled Marl-borough Road. The house is described by the Ritchie Report as ‘well-organised and maintained’; a manager is present three times a week and there is a 24-hour emergency service. Staff were not told of Clunis’s history because Haringey Social Services didn’t know of it themselves, but although the owner thought Clunis untidy and lonely, he didn’t have any worries about him. His sister visited him there a few times, the last time a week or so before the murder.

Clunis joined a GP’s list, mainly to get a certificate so that he could claim benefits, but when the GP wouldn’t backdate it he became abusive and violent and was removed from the doctor’s list. He didn’t go to his 9 October outpatient appointment at Friern, and his notes didn’t arrive at the hospital until just before the rearranged appointment on 13 November. When she looked at the S117 form, Dr Seargeant was surprised to see herself named as the key worker, a job more commonly taken by a social worker or CPN. When Clunis failed to attend on 13 November Dr Seargeant rang the GP, discovered that he had been removed from the doctor’s list, and then spoke to Haringey Social Services, and was told that they had been informed that he was not in need of help. Dr Seargeant decided that a Mental Health Assessment Team should see Clunis and a date of 30 November was set. Dr Gupta at Guy’s advised her to ask the police to attend.

In many areas Clunis’s case would have gone straight to a specialist mental health team, but in Haringey the Advice and Assessment Team dealt with all new cases. This team was formed in July 1992 and from the start was seriously understaffed: there were around half the number of social workers intended; all of them were inexperienced and none was an ASW. They were thus especially dependent on the two team leaders – but one was off work for eight months from August 1992 and temporarily replaced only in October. The second team leader was off work for a fortnight at the start of December. This meant that staff were not adequately supervised – cases were reviewed every six weeks instead of every fortnight – and files were passed from one member of staff to another. A different ASW was on call each day should assessments become necessary, but had no obligation to continue dealing with a problem when no longer on call.

On 30 November, while the assessment team waited for one of their (unwieldily large) lumber to arrive, Clunis returned to his flat and then left again: nobody stopped him because nobody knew what he looked like. The next day he turned up at Wood Green Social Services seeking help with his benefits and promised to keep a new appointment with Dr Seargeant on 10 December. His behaviour reassured the social workers who saw him: the Ritchie Report notes that Clunis can seem quite normal – as he did at first to the Inquiry’s members when they visited him – if seen only briefly or by those not fully acquainted with his story. Clunis again didn’t keep his appointment, and after some discussion, Social Services wrote asking him to come in on Christmas Eve. The social worker who did this might have misunderstood her instructions, but no body picked up on this: ‘indecision and procrastination’, according to the Ritchie Report, characterised Haringey’s handling of the case. They also criticise Dr Seargeant – she was, however unusually or unwillingly, the key worker, and as such had a responsibility to Clunis, one she knew no one else would fulfil. Nothing advanced until Ursula Robson’s intervention on 17 December, the same day that Christopher Clunis committed murder.

Jonathan Zito was on his way home from Gatwick Airport, where he had met his parents and his brother who had come to Britain to spend Christmas with him and his new wife. Since they couldn’t fit everyone into a friend’s car, Zito and his brother Christopher went home by train and tube. The last stage of their journey was the change from the Victoria to the Piccadilly Line at Finsbury Park before the final two stops back to Turnpike Lane. As they waited on the platform, Christopher Zito noticed that Clunis was standing right behind him and moved away. He was motioning his brother to do the same when Clunis stabbed Jonathan in the face: all the witnesses described only one blow, but three entry wounds were found. One of the blows penetrated the brain, causing haemorrhage. The driver of an approaching train saw Jonathan Zito collapse as he drew into the station and, realising that he was seriously injured, radioed his controller. Clunis got onto the train, but the driver had been told to hold it in the station and close the doors. When the police arrived a witness identified Clunis: the knife was in his pocket.

Virginia Bottomley said that the conclusions of the Ritchie Report showed that ‘the pendulum has swung too far’, that too much attention is paid to the civil liberties of the mentally-ill, and not enough to the security of the public. This statement seems not merely to undermine the principle on which her department’s policy is founded, but to suggest that it lias had the effect of letting loose hundreds of homicidal madmen to roam the streets unchecked. (In the last twenty years the number of homicides committed by mentally-ill people has remained the same; the number committed by the rest of the population has more than doubled.) In fact, Bottomley’s pendulum hasn’t swung far enough. Hospitals still consume most of the money intended for the care of the mentally-ill and, as The Falling Shadow puts it, the 1983 Act still assumes that ‘incarceration is a necessary precondition for effective care.’ Properly organised and funded community care should be able both to protect the public and to treat and control the patient. It should also be able to offer him a better life. The law as it now stands seems incapable of ensuring any of this.

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Vol. 17 No. 7 · 6 April 1995

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

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