THE CHRISTOPHER CLUNIS STORY 1963 - 1980 Born 1963 in London, both parents from Jamaica. Large extended family. Father a factory worker. Left school with 'O' levels. Started study of economics and sociology 'A' levels but dropped out to be a Jazz Guitarist. 1980 - 1985 Played with the "Aqua Vita Showband". Mother had CVA in 1980, parents returned to Jamaica. Mother died in 1985. In July 1984 he registered with a GP, but that GP never received any information at all about Christopher Clunis' psychiatric problems, despite his many admissions thereafter. 1986 Started to behave oddly. Dressed innappropriately. Rambling. Threatened to hit niece for no real reason. Sent to join his father in Jamaica. Admitted to Bellevue Hospital, Kingston, Jamaica, diagnosis of paranoid schizophrenia. Discharged to care of father, but when father became ill, returned to England. 1987 Initially stayed with a sister in Birmingham, but he suddenly left without a forwarding address. By June he was back in contact with another sister, who thereafter stayed in touch with him, visiting and supporting him. She herself never received any help or support with this task. That June his sister took him in because he was in a terrible state. He stood, gazing a nothing for long periods of time. Sat in back room, with curtains drawn, smoking. Collected rubbish in a black sack and sat with it. 29 June 1987 - 1 July 1987 Sister took him to A & E at Chase Farm Hospital, Middlesex on 29 June 1987. Filthy, underweight, uncommunicative, confused, disorientated, staring into space, laughing and giggling to himself. Assessed by duty psychiatrist who diagnosed schizophrenia, and sent home to wait for an urgent assessment by the psychiatric team. Seen at home by CPN that day and on 1 July 1987. Sister says she is under strain and is worried about him being aggressive. 2 July 1987 - 27 July 1987 Seen again by the duty psychiatrist at Chase Farm Hospital, following fall and loss of consciousness. This time judged unable to care for himself, and admitted. With treatment condition improved rapidly. On 21 July went AWOL, and on return was noted to be elated and vague. Thought he may have been using drugs and therefore suffering drug induced psychosis. Drug screen was negative. On 24 July was over-familiar and rude to female patients and staff. Decision made to discharge. No OP appointment given. Said to have no GP. No arrangement for follow up care. A letter to the local h ousing department was written to support his rehousing. 13 December 1987 - 17 December 1987 Brought to A & E again by sister and duty social worker. Had lost his accommodation 2 weeks before. Deteriorated, dirty and unkempt. Bedspread over one shoulder and tyre over the other. Said he had n ot slept for days. Admitted. Settled with no psychotic symptoms by 17 December, and was discharged. Diagnosis of transient psychotic state brought about by drugs or situational crisis. Refused social work help. No contact made w ith family. No OP appointment made. Still thought not to have a GP, so no follow up care. 1 January 1988 - 4 January 1988 Admitted under sec. 136. Refused to comply with investigations. Attacked two other patients. Improved rapidly on medication. Discharged himself AMA on 4 January. No further action taken. 4 February 1988 - 8 February 1988 Presented himself at A & E. Dirty clothing, flat affect, poverty of speech. Wanted a bed for the night. Admitted. Refused to answer questions on the ward and gave no evidence of psychiatric illness. Quietly cooperative. Hospital SW helped him find accommodation and he was discharged without any follow up (again). 15 March 1988 He was in Brixton Prison on this date, but the records have been lost. Nobody now knows why or how. 29 March 1988 Self presented at A & E, asking to be admitted because he had nowhere to live. Refused physical examination or to provide urine sample. Was not admitted but duty psychiatrist did try to contact duty social worker. Allowed to sat in A & E visiting room overnight, then sent on his way with the address of the local DHSS office. No contact attempted with GP or with family. 26 April 1988 - 3 May 1988 Arrested after stealing two loaves of bread which he had tried to stuff down his trousers. Appeared in Magistrate's Court. Remanded to bail hostel. No room. Sent to a probation hostel on the other si de of London. His PO immediately took him to the Emergency Clinic at King's College Hospital. He was talking to himself, laughing, refusing to eat or drink, making innappropriate contact with females and exposing himself. Refused to answer questions. Considered to need admission, but no bed was available. Discharged back to the hostel on medication, and seen daily in the Emergency Clinic for a w hile. Eventually the PO told the Emergency Clinic that unless they admitted Mr Clunis, he would end up in jail. Therefore following his court appearance on 3 May 1988, he was admitted to Dulwich Nort h Hospital. 3 May 1988 - 12 May 1988 On admission refused to answer questions or give a history. Dirty, puzzled, suspicious, bewildered, poor eye contact and rapport. Obviously psychotic. On 5 May 1988 one of the doctors made some effort to discover Mr Clunis' history. She contacted Chase Farm Hospital who told her they didn't think he suffered from schizophrenia, and that he was just manipulative in order to get a bed. They refused to take responsibility for him. 6 May. Agitated. Nursing staff found a hospital cutlery knife in his pocket. Argumentative and irritable over the next few days. Abusive and threatening to nursing staff. Attacked another patient. Me ntal State normal, so these were considered to be behavioural problems. 12 May considered fit for discharge. Discharged the following day with a letter in his pocket from the hospital social worker to the local homeless persons unit. OP appointment made for 13 July 1988. No contact with family or GP, or Chase Farm Hospital. 25 May 1988 - 9 September 1988 Broke into the home of an elderly woman and was found in her bathroom. Arrested and charged with criminal damage to her front door. Remanded in custody. Visited in HMP Brixton by his Consultant Psychiatrist from Dulwich North Hospital. Diagnosed paranoid schizophrenia with unusual personality. Recommended Hospital Order under Sec 37 MHA, and offered to provide a bed. 26 July Admitted to hospital under sec 37. During this admission, copies of the notes from Chase Farm Hospital were obtained, but they were not to be found in his Dulwich case notes by the time of the inquiry. On admission he was frankly psychotic. Deluded and without insight. Improved rapidly on medication, Discharged to bed and breakfast accommodation on 11 August. Given OP appointment and arrangements m ade for him to attend a depot clinic. Although the GP's name and address was now known to the hospital, the GP has no copy of the discharge summary. His accommodation was arranged by a SW. The SW wrote to the Housing Dept. saying he had no behaviour problems. He also contacted and spoke to the sister. When Mr Clunis came back for his first depot injection he also saw the SW who discharged him as 'there is no focus of work at present'. September 1988 - April 1989 No one knows where Mr Clunis was during this period. Completely lost to follow up. A consequence probably of lack of home visiting and negotiation of intervention with Mr Clunis and his sister. 20 April 1989 - 9 June 1989 Seen at bed and breakfast accommodation by a Special Needs Housing Officer from Lambeth Council. Because of the last SW's report she believed he had no history of violence. She referred him to a host el, where he was interviewed and accepted. However he turned the place down. He was becoming increasingly psychotic. Deluded, hearing voices, laughing innappropriately. Other residents were becoming frightened of him. After some discussion Officers of the Housing Dept. decided he needed urgent assessment by the psychiatric services , ie a DV. They requested this on the 23 May from St Charles' Hospital. Doctors fro m St Charles' Hospital made two attempts to see Mr Clunis at home, but on both occasions he was out. Before they managed to catch up with him, he was arrested. What happened was this. Lambeth Council had to do some work on the Bed and Breakfast accommodation because of fire regulations. Mr Clunis refused to leave his room. Several people, members of staff a nd the manager tried to remove him and were attacked (other residents were objecting at the time too). Eventually the police were called. Mr Clunis attacked them with a knife, and he was arrested, ta ken to St Mary's Hospital, under a Sec 136, where he was assessed and held under a Sec 2. Diagnosed relapse of schizophrenia. Transferred to St Charles' hospital the next day, 9 June 1989. 9 June 1989 - 14 November 1989 On admission deluded, paranoid, threatening to staff. Aggressive, verbally hostile, rude and abusive. History obtained from Dulwich North Hospital and associated Social Services staff. 23 days after admission threatened to stab another patient but was restrained. The next day stabbed the same patient five times late at night while he was in bed. Superficial wounds only. Placed on Section 3 and transferred to (psychiatric) Intensive Care Unit at Horton Hospital. There was some delay because a bed was not immediately available. Evasive, argumentative and abusive. Improved on medication. Transferred back to St Charles Hospital on 27 July. Still thought disordered and deluded. Plans for discharge to Lambeth commence, the work er from their housing dept being contacted who organised a place in a supervised psychiatric rehabilitation hostel. Prior to Mr Clunis discharge there were three further occasions on which he punched another patient and one in which he was relieved of a knife after threatening to stab another patient in the eye. After an assessment at the hostel in October he was discharged there on the 14 Novem ber. He was given an OP appointment which he did not keep. The appropriate hospital was not informed about his residence in their area, as St Charles intended to follow him up for 3 months, not being sure he would stay there. The staff at the hostel were not aware of this arrangement. No Sec 117 plan was made. November 1989 - February 1990 Although the hostel received an application on Mr Clunis' behalf from a SW accompanied by a social report from the Consultant Psychiatrist, and the hostel staff made their own assessment, nowhere is it recorded that Mr Clunis has a history of violence and aggression. In fact the hostel assessment explicitly says there was no risk. A discharge summary was sent to the GP who was Medical Officer to the hostel, and this did mention the history of violence. None of this paperwork mentions the OP appointment for St Charles Hospital of the fact that they would follow Mr Clunis up for three months. As St Charles had made no arrangements at all for him to have his depot, the Lambeth Housing worker sorted this out with CPNs from Tooting Bec Hospital. The GP provided the prescription. He slowly settled in at the hostel, with the Housing Worker becoming a sort of keyworker/Care Co-ordinator. The Housing worker helped him sort out his benefits and a bus pass. He visited regularly, a ttended review meetings, talked to the staff whom he expected to keep him fully informed. There were difficulties. At times he was dirty and neglected himself and hid room. He harassed female staff. He could be rude and demanding, and he lost a place at a sheltered workshop due to this. The depot was given on three weekly home visits by a Tooting Bec Hospital CPN who saw his role as administration of depot and monitoring of mental state and side effects. In January the Consultant from St Charles visited him, but kept no records of the visit. He judged everything was OK. He then wrote to a Consultant at South Western Hospital, enclosing a full history and discharge summaries from all hospitals, handing over his care. South Western Hospital has no record of Mr Clunis at all. February 1990 - October 1990 From February onwards Mr Clunis had a period of working a Remploy. Following an aggressive incident in May he did not return, and was finally sacked for absenteeism in July. Apparently there were a n umber of aggressive and violent incidents at Remploy. During June he was also threatening and verbally insulting to staff and residents at the hostel. Meanwhile, although the CPN continued to visit, he apparently knew nothing about all this. At the end of July the staff of the hostel called an emergency case conference. They wanted to discharge Mr Clunis because of his intolerable behaviour. only pleas from the Housing Officer stopped th em from giving him two weeks notice to quit. They agreed to keep him until alternative accommodation could be found. In September his CPN left, and another one took over. She claims she was not even informed about Mr Clunis approaching transfer of accommodation. By this time he had no seen a Consultant Psychiatrist for 9 months and was not taking his oral medication. On the 4 October he was transferred to another hostel. October 1990 - March 1991 The new hostel was staffed but was not a specialist psychiatric hospital. The Housing Officer arranged this placement and kept in touch. The CPN attempted to get him to attend a depot clinic, but this failed and home visits continued. Still nobody made an effective OP appointment to see a psychiatrist. In February Mr Clunis refused to have his depot unless he was given an OP appointment. His CPN made one, but it wasn't until April. Mr Clunis said that was too long to wait and continued to refuse. T he CPN therefore made another appointment for the 14 March, told the Hostel staff about it. One further futile attempt was made by the Housing Officer and the CPN to persuade Mr Clunis to have his de pot. It failed. The CPN assumed that the hostel staff would take Mr Clunis to his OP appointment and would keep her informed. She did nothing further until she realised she had heard nothing by 2 April. She then con tacted the Housing Officer who told her Mr Clunis had been evicted and nobody knew where he was. She discharged him from her caseload. March 1991 On the 12 March Police called to the Hostel, as Mr Clunis was chasing the residents round with a carving knife. The Officer who attended had to call for further assistance before he would put the kni fe down. He was arrested, spent the night in the cells, appeared in Magistrate's Court the next morning charged with Breach of the Peace Went to Bed and Breakfast accommodation. Did not keep his OP appointment. Lost all contact with the services until July. July 1991 - August 1991 On 23 July, Mr Clunis stole some sweets from the Co-op and was admitted to St Thomas' Hospital under a Sec. 136. Full histories were obtained from previous hospitals involved and from the Housing Off icer. He was overtly psychotic. A series of violent incidents occurred during this admission; punch ups and other fights, breaking of windows etc. He was controlled on very high doses of CPZ (2.7g daily) - beds on the secure ward were not available. He remained an informal patient and on 17 August absconded with his belongings. On 27 August the SN on the ward received a phone call from Spur House ( a Hostel for the Homeless) asking for details on Mr Clunis' medication. These were provided. Mr Clunis had been there since abs conding. he was seen there by a psychiatric nurse and by a medical officer. He attacked another resident while there and was kicked out. 28th August 1991 - May 1992 Moved to a large 72 bed resettlement unit for homeless men, Lancelot Andrews House. Mostly used by a transient population, many of whom have problems with drug or alcohol abuse, or who are mentally i ll. The staff there said that if they had known of Mr Clunis' violent history, they would not have accepted him. However, they also said that if they sent him on to another hostel they would not reve al his violent history because that would jeopardise his getting a place. While resident there the medical officer and the nurse of the hostel discovered most of Mr Clunis history and prescribed medication for him. They did not tell the other staff of the hostel of his his tory of violence because of breaching confidentiality. While at the hostel Mr Clunis neglected himself and his bed space, spent all day in bed in his clothes, and punched another resident in the face causing considerable facial injury. A representative o f the Mental Health Team for Single Homeless People saw him in November and February. Nobody gave this rep. any information about Mr Clunis' past psychiatric history, and Mr Clunis claimed his proble ms were due to drug use. On the grounds that this was no a mental health problem, the team declined to help. In May Mr Clunis started to become agitated, walking round the dormitory all night, staring at walls, burnt a bible. The next night he attacked another resident with a knife. The victim required trea tment in hospital and was left with some cervical nerve damage. 5 May 1992 - 21 August 1992 Following the stabbing Mr Clunis was arrested. In the cells he was seen by an ASW and a doctor. Following several court appearances and assessments by psychiatrists, it was recommended he be admitted to the local RSU. As no beds were available, he was transferred to a private facility in Hertfordshire under Sec 48 and 49 of the MHA. Although he made some progress during this admission, he remained without insight and was considered unlikely to co-operate with OP care. The case came up at Crown Court on 17 August 1992. It then emerged that the Police had neither secured medical evidence on the injury done to the victim, or managed to trace the victim himself to giv e evidence. The report hints that the case was not taken terribly seriously by the police because both attacker and victim were homeless. As no evidence was offered, a verdict of not guilty was recor ded. Mr Clunis agreed to go back to the private RSU as an informal patient, and was immediately placed on a Sec 3, as he was still considered to be dangerous. On 21 August Mr Clunis was transferred to an NHS psychiatric ward at Guy's Hospital. The records are unclear as to why this transfer occurred so rapidly. 21 August 1992 - 24 September 1992 During his stay at Guy's Mr Clunis was assertive and at times irritable and aggressive in manner, but otherwise behaved well. When given a few days leave he arranged his own accommodation outside tha t hospital's catchment area. He then returned for a Sec 117 meeting and was then discharged on 24 September. That meeting appointed a Clinical Assistant in the receiving Health Authority as Key Worke r without discussing this with her or informing her until 6 weeks afterwards. The meeting also decided Mr Clunis needed forensic follow up. A doctor tried to arrange this by telephone at a later date , but was told that the general consultant psychiatrist in the receiving authority should make the referral. The Guy's Hospital Social Worker did make an assessment of his follow up needs, but consid ered them to be zero, stating that he was capable of independent living. She did not inform this newly responsible Housing Dept. of his past history of violence. An OP appointment with the new Clinic al Assistant was arranged. 24 September 1992 - December 1992 Mr Clunis went to live a private B & B accommodation financed by the local authority. The manager of the property or his staff checked on Mr Clunis weekly, as he did with all his residents. Mr Clunis registered with a GP. He went to see him in October asking for a backdated medical certificate. When this was refused he became violent and abusive. The GP removed him from his list followi ng this incident. He did not attend two consecutive OP appointments with his new psychiatrist. When she eventually received the Sec 117 forms naming her as Key worker, she did some ringing around and discovered Mr Clu nis had been removed from his GP's list, and was not receiving any Social Work support. She decided toUse of uninitialized value in concatenation (.) or string at E:\listplex\SYSTEM\SCRIPTS\filearea.cgi line 455, line 477. set up a Mental Health Assessment Team visit (ie ASW, Sec 12 doctor, etc. All the people needed to make a section) with police support, for 30 November. There was some confusion about where he was living, but this was straightened out and the team assembled outside the house on a dark, wet evening. No one knew what Mr Clunis looked like. While they w ere waiting for the doctor outside, Mr Clunis walked out straight past them. Hence when they knocked at the door there was no reply. A letter was left asking him to contact Social Services. Mr Clunis did go in to see the Mental Health Social Workers the next day. He appeared pleasant and fine, with no apparent symptoms. The Social Workers contacted the psychiatrist, who gave them and OP appointment for 10 December to pass on to him. This they did. He did not attend. 9 December 1992 - 17 December 1992 On 9 December a ranting and raving Mr Clunis attacked with a screwdriver a man who was walking home in the evening. He escaped with a minor injury only and took refuge in a nearby house. The Police w ere called. Coincidentally, one of the policeman was had attended the abortive home assessment of Mr Clunis. When they arrived they said they knew the perpetrator who was mentally ill and lived nearb y (at a later date they denied having said this). They persuaded the victim not to prosecute. A number of Officers then went to look for the suspect, but could not find him. Later that evening Mr Clunis approached a woman who was walking her dogs. he behaved in a incoherent and abusive manner. Then he chased some boys around the street, with a screwdriver. One of them we nt into a phone box and called for the police. While he was making the call he was threatened by Mr Clunis, but some other boys distracted him, and eventually he walked off. The police searched the a rea in a car, but found no one. Members of the public in the locality were becoming very concerned. The next day the man (Mr Clunis) was seen again and this time followed home. One police station was contacted to be informed of thi s, and they said it was another police station's problem. The second police station said yes, they knew who it was an where he lived because they had been round there with an ambulance and the psychi atrist last week, but he had not answered the door. In any case, they said, they could not just go and arrest him. The lady who had been threatened by Mr Clunis while walking her dogs had a friend who was a JP. She rang the friend who over the next few days made many phone calls to various police Inspectors. Desp ite being reassured by the Police on 15 December, actually absolutely nothing had been done. On the 15 December the Police contacted Social Services to report Mr Clunis' behaviour and aggression. Despite this, nothing was done until a duty Social Worker investigated the case on 17 December. After reading the file, speaking to the psychiatrist and becoming concerned about the risk that Mr Clunis might be violent, she made a home visit by herself in the evening. By that time Mr Clunis was already under arrest. On 17 December Mr Clunis made an unprovoked attack on Mr Jonathan Zito at Finsbury Park Tube Station, stabbing him in the face with a knife three times. One wound had penetrated into the brain causin g his death. When Mr Clunis was arrested he was sitting calmly on the train in the station. 1. This is an unofficial summary of the full report. It is not claimed that this summary is 100% accurate. Anyone wishing to know the full or accurate story should consult the original document. This summary is for teaching purposes only. 2. Permission is given to reproduce this summary for teaching purposes, so long as it remains unchanged in this form. c Len Bowers Co-ordinator, Psychiatric Nursing Research and Development Unit (C)