Surrounded by all the detritus of family life with two teenage sons, it is a silent yet resounding reminder of her first husband, Jonathan Zito, who was stabbed to death by a paranoid schizophrenic at Finsbury Park tube station in London, 23 years ago, just months after they were married. The police, but no one else. It took years for people to say they were sorry. Daley, a year-old former architecture student, had a decade-long history of mental illness, during which his family begged for him to be sectioned , warning of their fears that he might harm or even kill someone.
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Duckworth, pp. 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.
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.
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 — Marlborough Road. 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. 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. 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 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.
Zito doubted this. 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 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 , while he was touring with the band, his mother died — she had had a stroke in 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 that schizophrenia was first diagnosed. He came back to England in when his father became ill. 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.
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 Mental Health Act. Clunis was treated as an itinerant, homeless man, a model which he came more and more to approach. On 26 April , 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. 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. 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. 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. The number of mental health beds has been falling since — there are now around fifty thousand in England and Wales, compared with one hundred and fifty thousand in — 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 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.
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, hour staffed accommodation.
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. He was discharged on 11 August to bed and breakfast accommodation in Paddington. Again there was no attempt to return him to North London and no plan was made for him under Section of the Mental Health Act. Section concerns the aftercare the jargon still assumes that hospitals are the main locus of care of people detained under the Act.
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. We do not think that as a society we can afford to let that happen.
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. Police were called twice the next day, the second time because Clunis had once more refused to leave his room.
He was not charged. 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. 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 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. In October , 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 overall impression, as they say, is that all the people trying to help Clunis were doing so in isolation. 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. 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 homeless people in London in two-thirds had had some contact with psychiatric services but only 2 percent had been long-stay patients. 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. 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.
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. 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. Clunis remained aggressive and objected do the medication. 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. 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. There are many violent incidents and problems with drugs, alcohol and, increasingly, with mental illness.
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.
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 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. 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 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.
CLUNIS REPORT PDF
Meztigor Who Cares? Surrounded by all the detritus of family life with two teenage sons, it is relort silent yet resounding reminder of her first husband, Jonathan Zito, who was stabbed to death by a paranoid schizophrenic at Finsbury Park xlunis station in London, 23 years ago, just months after they were married. Mrs Parashar rang the police, as did one of the boys and a local shopkeeper. We rely on advertising to help fund our award-winning journalism. 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.
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