This year marks 25 years since Jonathan Zito was killed in London by mentally ill Christopher Clunis.

The subsequent inquiry into the case was influential and marked the start of the current system of independent investigations of homicides by patients with mental illness.

The report found certain deficiencies in the care of Christopher Clunis – which certainly merit re-reading today.

Some things have changed, but arguably many have not.

Clunis Inquiry – Matters of particular Concern

There were important failures in the following respects:

1. to communicate, pass information and liaise between all those who were or should have been concerned with Christopher Clunis’ care in the widest sense of the word; Consultant Psychiatrists and members of the Consultant Team; Nursing Staff; General Practitioners; Community Psychiatric Nurses; Social Workers; the Police; the Crown Prosecution Service; the Probation Service; hostel staff; people who provided care from the private sector; and Christopher Clunis’ family. Without proper communication and liaison, there cannot be effective care either in hospital or in the community.

2. to contact and involve the patient’s family and General Practioner in the provision of care.

3. to obtain an accurate history, or to verify it

4. to consider or assess Christopher Clunis’ past history of violence and to assess his propensity for violence in the future.

5. To plan, provide or monitor S 117 Mental Health Act 1983 aftercare

6. To manage or oversee provision of health and social services for the patient/client

7. To provide assertive care when the patient is living in the community and to note and act upon warning signs and symptoms to prevent a relapse.

8. To identify the particular needs of homeless itinerany mentally ill patients on discharge from hospital, to keep track of such persons and to provide for their care even when they cross geographical boundaries

9. To provide qualified social workers, including sufficient numbers of Approved Social Workers, to assess all new referrals and to provide supervision and leadership.

10. Of the Police adequately to recognise and deal appropriately with mentally ill people.

11. To conduct an internal inquiry that was fair, objective and independent.

There was a shortage of the following important resources:

12. Of beds in Regional Medium Secure Units for the population in London Inner City area.
13. Of beds in general psychiatric wards for the population in the London Inner City area

14. Of a range of health service accommodation, for those patients who require rehabilitation or for those patients who cannot cope in the community on their own.

15. Of a range of accommodation, providing varying degrees of care and supervision for patients on discharge from hospital or for patients who would otherwise relapse and then require hospital admission.

16. Of sufficient numbers of Doctors who are approved under S 12 Mental Health Act 1983

17. Of sufficient numbers of social workers trained and experienced in mental illness

18. To overlook or minimise violent incidents

The following tendencies were noted repeatedly:

19. To care and treat the acute episode of illness without also providing long term care.

20. To allow geographical boundaries to interfere with or curtail provision of care.
21. To postpone decisions or action when difficulty was encountered or perhaps because the patient was threatening , and intimidating, and possibly because he was big and black.

(from Pages 105 – 107)