Christopher Clunis Report: Lack of cash played key part in tragedy: Inquiry says care policies and agencies must share blame for mistakes that ended in stabbing

LACK OF resources played a key part, though not the whole part, in the failure to care for Christopher Clunis, the inquiry chaired by Jean Ritchie QC, found.

'A considerable injection of funds for the mentally ill' is needed, the report warns. 'If proper care is to be provided, then the only answer, in our view, is to meet the deficiencies identified.'

The failures found in the Clunis case 'may well be reproduced all over the country, in particular in poor inner-city areas'. The NHS funding formula does not take sufficient account of social deprivation in inner cities, and the strain caused by substantial prison populations, in the allocations given to health authorities. It says there is an 'urgent' need for more secure beds, and more general psychiatric beds in inner London after it found bed occupancy levels of 110, 120 and even 130 per cent.

Ms Ritchie said: 'It is clear that there are not enough beds for the number of people who need them, and there are also people who cannot get into a bed until they have done something really pretty drastic. That worried us a great deal.'

It means an increase of more than 20 per cent in general beds, as well as a sharp rise in medium secure-unit places.

The bed shortage means some patients are having to be admitted to costly private hospitals, often in an areas far from their homes, the report says. 'We do not consider that is in either the patient's or the public's best interest.'

It adds: 'We have the impression that the public would consider that money spent on keeping the mentally ill well, and the public safe, would be money well spent. The admission or ongoing treatment of patients who present clear risks to themselves or the public should not be determined by the economics of the market place.' There was almost no measure of the quality of service provided, and 'there seem to have been no consequences whether the work was done well or done badly . . . it has been difficult to understand the objectives of services other than to achieve ever more rapid turnover of patients'.

The report continues: 'In current terms, purchasers do not know what they are buying, nor do the providers know what they are selling. No one has a means of telling whether the community service provided is effective or an efficient use of resources. The old certainties and principles of care within traditional institutions which might have been too rigid have disappeared and have not been replaced.'

It is, the team says, 'essential' that the Department of Health sets up effective monitoring of psychiatric services, laying down minimum standards in manpower and facilities which health authorities will be 'required' to buy.

Hospitals and units should then have a contractual duty 'to satisfy an external inspecting or accrediting body that they have currently achieved published standards of services and facilities'. Community health services should be inspected every three years so national standards may be maintained and improved on.

Ms Ritchie stressed that the inquiry team believed that care in the community was 'the right answer. Nobody wants to go back to the old mental health institutions with locked wards and impersonal care and treatment'. But there was a need for long or short-stay 'haven-type' or 'asylum-type' accommodation, for those mentally ill people who could not cope in the commmunity.

The committee's detailed recommendations for a supervised discharge order say that England should follow Scottish practice so that a patient could be recalled to hospital during the first six months of an order, and thereafter during each subsequent 12 months. It would be possible to detain the patient, or not. 'Only by permitting such power of recall will the patient be likely to comply with the treatment plans,' the inquiry team said.

The system should also identify a special group of mental patients who require much closer supervision and support. They would be selected for specialist support by multi-disciplinary teams if they fulfill two out of four criteria. These would be: patients who have been detained more than once; have a history of violent or persistent offending; have failed to respond to treatment; or who are homeless. The inquiry believes there are up to 4,000 such patients nationwide.

----------------------------------------------------------------- MAIN POINTS OF THE REPORT ----------------------------------------------------------------- THE inquiry called for these innovations: National register of compulsorily detained patients. Supervised discharge order to allow patients to be recalled if they fail to comply with treatment. Special supervision teams to care for and follow the 3,000 to 4,000 most difficult and disturbed patients. Community psychiatric nurses should follow patients across health boundaries until responsibility is firmly transferred to another team. More medium secure beds, and many more general psychiatric beds, are needed 'urgently' in London. 'Haven-type' accommodation 'for those who cannot cope in the community'. Proper training for the police in dealing with the mentally ill. The Department of Health to set minimum standards of manpower and facilities for services. Volunteer 'befrienders' should be sought to 'keep in touch' with discharged patients. -----------------------------------------------------------------

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