Mr Zito, a musician, was stabbed to death by Clunis at Finsbury Park Tube station in December 1992. Clunis admitted manslaughter on the grounds of diminished responsibility and was ordered to be detained indefinitely in a maximum security hospital.
'We do not single out just one person, service or agency for particular blame,' the inquiry report said - although it found that two police officers had lied to it. 'In our view the problem was cumulative; it was one failure or missed opportunity after another.'
The inquiry found that hospitals and social services failed to contact his family or GP, repeatedly treated admissions as separate incidents, failed to check his false claims that he abused drugs, and discharged him from hospital when he was not ready because of pressure on beds, or to save money.
The report catalogues 'a whole series of violent attacks' by Clunis over four years, often involving knives or cutlery. Just eight days before he killed Mr Zito, he attacked and injured a man with a screwdriver in north London and later the same day terrified a group of adults and children by chasing them round a street brandishing a screwdriver.
In the whole of six years when he was mentally ill, Clunis did not once keep an out-patient appointment, and went through repeated admissions to a string of hospital psychiatric units. 'Each lost contact with him,' the inquiry found.
In August 1992, he was sent to Kneesworth House, a private psychiatric hospital in Hertfordshire from which he was rapidly transferred to Guy's Hospital - a decision probably made 'in the interests of saving money'. Guy's then discharged him with an aftercare plan that was 'virtually non-existent'.
'Wholly inadequate' information was provided by Guy's to Haringey social services. But in north London, the social services department in turn spent too long attempting to arrange a mental health assessment. When the team finally arrived, on 30 November, Clunis walked into his home and out again. No one on the mental health assessment team stopped him, because no one knew what he looked like.
Haringey Social Services displayed 'indecision and procrastination', while the police's failure to act effectively on information they had, and on calls from the public, meant 'they were not properly protecting the public from potential harm', the inquiry found.Reuse content