The inquiry blamed no one person, service or agency. However, it said police, psychiatrists, social workers, the Crown Prosecution Service, hostel staff, the probation service and the private sector must all share the blame for their failure to prevent Clunis killing Jonathan Zito at Finsbury Park tube station, north London, on 17 December 1992. 'It was one failure or missed opportunity on top of another.'
The inquiry, chaired by Jean Ritchie QC, found that 'the more disturbed Christopher Clunis became, the less effective was the care he received.' Its report added that the police, among others, failed to protect the public; they tended 'to overlook or minimise violent incidents' involving the mentally ill.
The inquiry stated bluntly that lack of resources and psychiatric beds was only part of the story; for deficiencies to be made good 'a considerable injection of funds' was 'the only answer'.
It also warned that 'we have heard time and again . . . Christopher Clunis is not alone, that there are many more like him living in the community who are
a risk either to themselves or others'.
While backing the community care policy, it warned that some patients will always require long-term 'haven-type' care. The more than 50 recommendations include providing: special teams funded with earmarked money to supervise and support an estimated 3,000-4,000 most disturbed and difficult patients; a national register of those compulsorily detained in hospital; and a supervised discharge order so patients who fail to take medication or comply with treatment can be recalled to hospital. The Department of Health must require health authorities to set minimum standards of manpower and facilities.
Mrs Bottomley yesterday said she had anticipated many of the recommendations, with supervision registers starting in April, the supervision of those discharged having been agreed, but not legislated for, and a pounds 45m plan in place to provide 1,000 more medium secure beds by 1995-96.
She announced an extra pounds 10m for community-based mental health services in London from next year.
Her moves do not set nationally enforceable minimum standards or create special supervision teams or meet Ms Ritchie's estimate that an increase of more than 20 to 30 per cent in inner London psychiatric beds is needed. Mrs Bottomley said she would now 'urgently consider' further action. The inquiry said 'only if the whole package is provided (will) care in the community work effectively'.
Jayne Zito, Mr Zito's widow, said unless all recommendations were implemented 'we cannot call ourselves a civilised society and Jonathan's murder was in vain'.
The report was welcomed by Marjorie Wallace, chief executive of the mental health charity Sane, for 'acknowledging care in the community is failing'. The National Schizophrenia Fellowship said the pounds 2bn spent on mental illness services needed to be raised by pounds 500m a year.
Analysis, page 5
Leading article, page 17Reuse content