The Clunis Case: Passing the buck carried on until an innocent man died: The Independent's own investigation of events that led to a random killing

It was to be Jonathan Zito's first Christmas with his new wife, Jayne. His mother and father had flown into Gatwick airport from Italy, and his brother Christopher from New York, to complete the family celebration. By the time his parents and their baggage had been loaded into the car, there was barely enough room for Jayne to drive, so Jonathan and Christopher took the train back to the home in Hornsey, north London.

The brothers were waiting for a connection at Finsbury Park station when Christopher Clunis wandered on to the platform. Several passengers became alarmed by his size (he was more than 6ft tall and 18 stone), sloppy appearance and erratic, unnerving behaviour. Christopher anxiously motioned his brother to move, but he took no notice. In that moment, Clunis attacked Jonathan from behind with a knife, pulling him round and stabbing him in the face three times. The fatal cut entered the right upper eyelid and pierced his brain. Jonathan collapsed into his brother's arms.

One witness heard a thud and looked round to see Clunis withdrawing the knife and growling: 'Come on then.' Clunis fixed his eyes on Christopher, as if to say: 'You want some too?' He then calmly stepped on to the waiting train and sat down. Witnesses said he showed little concern, hurry or remorse. A woman knelt over Jonathan, fighting to clear his air passages and stem the flow of blood. He died at Whittington Hospital in north London, two hours later on 17 December 1992.

After being arrested, Clunis told a police officer at Holloway Road station: 'I've murdered someone, haven't I?'

It became apparent while Clunis was in custody that he was seriously mentally disturbed, and repeated attempts were made to find a psychiatrist to examine him before he could be interviewed. Extracts from the custody record reveal that several psychiatric hospitals had had dealings with Clunis, but each was reluctant to accept responsibility for him.

The log reads: '18 December. 10am. custody officer informed that Clunis's consultant, Dr (Janet) Sergeant of Friern (Barnet) hospital, had been requested to attend for psychiatric assessment.

'11.25am. Custody officer informed that Dr Sergeant will not attend. He is apparently an out-patient at Friern hospital, having recently been discharged from Guy's Hospital and Dr Sergeant had no personal knowledge of Clunis. Guy's Hospital contacted and (Dr Kamal Gupta) declined to attend the police station; as far as their (sic) concerned the case was closed.'

Eventually a Dr Taylor, a locum consultant psychiatrist from Friern Barnet hospital, agreed that Clunis was her hospital's responsibility. Dr Sergeant had not seen Clunis because he failed to attend appointments but she was the key worker appointed to supervise his care and had seen the case notes from Guy's.

Dr Taylor agreed to go to the station and at 3pm she informed the custody officer that any interview would be inappropriate as answers given would be unreliable. At 3.45pm he was charged with murder.

The initial buck-passing evident from these notes is the first indication that a deranged and very dangerous man with a history of mental illness appeared to have slipped through the net. Why was he not detained in hospital? If he was being treated under the Government's 'Care in the Community' policy, who was supposed to be caring for him? How could the killing of Jonathan Zito have been allowed to happen? And could it have been prevented?

Christopher Allajah Clunis, born on 18 May 1963, came from a large Jamaican family which is scattered mostly over England and the United States.

Little is known about his early life other than the fact that he was a jazz musician. His first encounter with the medical authorities was when he was committed to Bellevue psychiatric hospital in Kingston, Jamaica, in April 1986, and diagnosed a paranoid schizophrenic. He had been visting his father. His mother had died from strokes and accompanying pre-senile dementia the previous year, an event which seems to have triggered his breakdown.

After his discharge, in June 1986, he returned to England. He became ill again and in December 1987 he was admitted to Chase Farm Hospital in Enfield, north London, after leaving his relatives in Birmingham. He had become destitute and was living rough before going to his sister in London. He discharged himself after his mental state improved rapidly with medication.

In January 1988, Clunis was admitted again to Chase Farm Hospital after his place in temporary accommodation broke down, and having been homeless for about two weeks. On admission he was reported to be behaving in a bizarre manner, walking around with a bedspread draped over one shoulder and a motorcycle tyre over the other. He was diagnosed by doctors as being in a 'transient psychotic state' and discharged himself after responding to treatment.

In February, he frequently turned up at Chase Farm casualty department, either because police referred him there or he took himself there because he was homeless.

In July 1988, he was remanded to Brixton prison on a charge of criminal damage after entering the home of an 80-year-old woman. At his Old Bailey trial he was ordered to be detained in hospital under section 37 of the Mental Health Act, under which courts transfer mentally disordered offenders to hospital. He was sent to Dulwich North Hospital, part of King's College Hospital, where he stayed until mid-August.

Correspondence shows there was a dispute between Dulwich North and Chase Farm hospitals over responsibility for Clunis. In a letter on 12 July to Brixton prison, Dr Gaius Davies, from King's College Hospital, wrote: 'Clunis suffers from paranoid schizophrenia and he has perhaps not been given the full benefits of community care (our italics).

'When he became an in-patient (at Dulwich) it became apparent that he was well known to psychiatrists at Chase Farm. The information from Chase Farm seems somewhat contradictory. We were told first he would be going back there because it was less than six months since he was discharged. On another occasion they were unwilling to accept him because they did not think he had a psychiatric problem.'

Replying to Dr Davies on 20 July, Dr Susan Fernando, a consultant psychiatrist at Chase Farm, wrote: 'I agree he does need some assessment and care. He has never actually lived in our catchment area and the general policy is that we do deal with catchment area. It seems to me this obligation falls on your unit.'

By spring 1989, Lambeth social services department in south London had housed Clunis in a bed and breakfast hotel outside the borough. In June, environmental health officers evacuated the hotel for examination but Clunis barricaded himself in his room and the police were called. He rushed out brandishing a knife and attempted to stab a police officer. This first threat marked his descent into increasingly violent behaviour.

Clunis was admitted to St Mary's Hospital in Paddington, west London, and a few days later transferred to St Charles Hospital in Westbourne Grove, where he was eventually detained under section 3 of the Mental Health Act, which provides for six months' hospital care and an after- care programme.

On arrival at St Charles, he was rambling, and looked dishevelled and unkempt. Once again diagnosed as a paranoid schizophrenic, he responded well to treatment, but before it could take effect, he attempted to stab a fellow patient with a knife. He was transferred to a locked ward in a medium secure unit where, after three weeks, he seemed to settle. He was sent back to St Charles, where he made good progress and was discharged in November after a meeting to arrange after-care.

The care programme included being sent by Lambeth social services to Rosemead residential hostel, in south-west London, a 24-hour supervised rehabilitation home with experienced staff who administer drugs as well as ensuring patients see doctors and keep hospital appointments.

He was allocated a community psychiatric nurse, from whom he received anti-psychotic medication by a 'depot' injection (which releases the drug gradually into the bloodstream) every three weeks. Initially he made good progress, commencing a government Remploy scheme. However, as Clunis felt recovered, he began to challenge the regime and he was evicted in October 1990 because of his 'non-compliant behaviour' - he was abusive to other residents, uncooperative with staff and disruptive. The Remploy scheme ended after he threatened a colleague, an incident to which were the police called.

Lambeth found him a place at a reception centre for homeless people with specialist staff, including occupational therapists and housing needs officers. But again he was evicted in March 1991 after an incident at the hostel, reportedly involving a knife, for which he was bound over to keep the peace at South Western magistrates' court.

By now Clunis started to refuse injections and failed to keep psychiatric out-patient appointments. After the hostel place broke down, Lambeth housing department arranged bed and breakfast accommodation. Social workers visited him several times, but say they found it increasingly difficult to keep up with his movements, and they eventually lost contact.

In July 1991, Clunis was found by police wandering around Brixton market eating sweets and sucking a dummy. He was 'distressed, dishevelled, unshaven' fidgeting and 'speaking in a bizarre manner'. He was admitted to St Thomas's Hospital under section 136 of the Mental Health Act, which allows the police to remove a person to a place of safety for further mental health assessment.

By mid-August his mental state was felt to be good enough for him to be discharged to a hostel. However, before this could be arranged he left the ward without permission and, later that month, he was discharged in his absence.

In September 1991, Clunis booked himself into Lancelot Andrews House, a Department of Social Security hostel for the homeless in Southwark with no supervision from doctors or social workers. He remained there until May 1992, when he was arrested for allegedly stabbing a room- mate. He was remanded to Belmarsh Prison in south-east London.

On 29 May 1992, while awaiting trial, he was ordered to be detained at Kneesworth House, a private mental hospital in Hertfordshire, under section 48 of the Mental Health Act.

On 17 August, the case against him collapsed after the prosecution offered no evidence because the complainant did not turn up. A big question arises here over why, after a serious stabbing incident (the third), the Crown Prosecution Service did not adjourn the case until the witness could be found, in the interests of public safety.

He returned to Kneesworth House Hospital first as an informal patient, but on 21 August 1992 was transferred to the York Clinic at Guy's Hospital and detained under section 3 of the Mental Health Act.

Here, accounts conflict. According to Adrian Fulford, Clunis's barrister, when he was convicted in court last month: 'For most of the time, he showed little or no insight into his behaviour.' But 'by 23 September, he was considered to have an appropriate mental state'.

However, Peter Reading, head of Guy's mental health unit, stated: 'It was evident to us that immediately he was admitted to Guy's he no longer fulfilled the criteria to be detained under any section of the Mental Health Act. He was completely asymptomatic. He had insight into his condition and had a normal mental state and was agreeable to take oral medication.'

Clunis was discharged on 24 September, after a meeting to arrange after-care by Haringey social services and referred to Friern Barnet Hospital as an out-patient. He apparently wished to return to Haringey where he had lived as a child.

Dr Kamal Gupta, a senior registrar at Guy's, wrote to Haringey housing department on 14 September saying that Clunis was 'compliant with his medication and is fit for discharge as soon as housing becomes available'.

According to Mr Reading, on 21 September, Dr Gupta telephoned the forensic psychiatry team at Friern Barnet - a Dr Kennedy and his registrar, a Dr Dedoranda - and gave them a full history of the case. He said that the team decided Clunis did not need to be examined by a forensic psychiatrist but should be dealt with by general psychiatric services. Dr Janet Sergeant was to supervise him and was also appointed his key worker with overall responsibility for him.

According to a letter from Dr Sergeant, she was telephoned by Dr Gupta a few days before Clunis's discharge and given a brief summary of his condition which stated he was 'compliant with medication and appeared quite well'.

On 23 September Ann Witham, a social worker from Southwark social services who worked at Guy's, wrote to Haringey social services, saying: 'I do not feel there is a need for social work intervention with Mr Clunis at present.'

On the same day Haringey social services also received a letter from the social work department at the York Clinic saying there was 'no need for social work intervention'. It said Clunis should be able to cope well with independent living and he had been given details of social services should he need them. Haringey council now says neither of the letters suggested Clunis was a danger to himself or to others.

Several crucial questions arise over the transfer arrangements from Guy's to Friern Barnet hospital. Why, having been admitted following the latest in a series of stabbings, was he considered, a month later, to be harmless enough to be released with an out-patient's appointment arranged for three weeks later? Why was there no forensic psychiatric follow-up normally given to patients with histories of violence? Why was he not allocated a social worker? Was Dr Sergeant told of Clunis's history of violence as well as his medical history? It emerged in court that the discharge notes from Guy's and Kneesworth House, which detailed his violent past, did not arrive at Friern Barnet until 9 November, six weeks after his discharge.

Friern Barnet Hospital closed in March this year and all inquiries were referred to North East Thames Regional Health Authority, which refused to comment on the Clunis case until the joint health authorities' inquiry is complete. Dr Sergeant also declined to comment.

On 9 October 1992, Clunis failed to keep his out-patient appointment at Friern Barnet with Dr Taylor, a locum consultant psychiatrist.

Doctors there contacted Clunis's general practitioner to see if he was taking his medication. The GP apparently said that Clunis visited him once shortly after his discharge from Guy's in September, but behaved aggressively so he removed him from his list in October. Enfield Family Health Services Authority said the doctor was entitled to do this and informed the relevant authorities.

On 29 October, Clunis arranged another GP, a Dr Sivananthan, in Muswell Hill, north London, who gave him medication - chlopromazine.

On 9 November, Jonathan Zito arrived in London to begin a new life with Jayne, his wife of three months. On this day the medical notes and papers detailing Clunis's violent past arrived at Friern Barnet, six weeks after his discharge from Guy's.

Eight days later, on 17 November, Dr Sergeant rang Haringey social services to say that Clunis had not made an appointment and requested that a mental health assessment team be assembled to visit him.

On 30 November, two social workers, Dr Sergeant, another doctor and two police officers went to his home in Wood Green to assess him. Clunis was out, but a card was left by a social worker and doctor telling him to go to Wood Green district social services next day.

Clunis turned up for his appointment and despite the fact that just a day earlier an emergency team had visited his house, the social workers at Wood Green decided he appeared 'fine and friendly'. They made an out-patient's appointment with a psychiatrist for 10 December.

But just eight days later, Clunis no longer appeared friendly. On 9 December at 9.35pm, Susan Parashar was out walking her two dogs in Bowes Park, Bounds Green, north London, when she met her son and his friend. She said Clunis approached them 'looking menacing' and after her younger dog growled at him, Clunis mumbled something to her son. After she walked off, Clunis shouted insults at her and then, without warning, took a screwdriver from inside his jacket and chased the boys.

As they ran into a grocery shop, Clunis turned on two other teenage boys in the street and they tried to seek refuge in a telephone kiosk. Clunis ran into the shop, produced a breadknife from his jacket and threatened a couple. The shop owner rang the police. The two boys rang the police and Mrs Parashar also called the police.

Officers arrived at her house just before 10pm and by then her son and his friend were there. Mrs Parashar said she assumed they had then gone in search of Clunis to arrest him. But the next day her son's friend saw Clunis in the street and followed him to discover where he lived. The house was just a few yards from Mrs Parashar. Horrified that Clunis was still at large, she rang Edmonton police to tell them where Clunis lived and to ask them to arrest him. She said a woman police officer told her that a week earlier the police joined a mental health assessment team in visiting his home, but he was out.

On 10 December, Clunis failed to turn up for his appointment with the psychiatrist at Friern Barnet. According to Haringey council, a doctor rang the housing emergency group 'expressing concern about a lack of controlled medication and the fact that they thought he was discharged too early from Guy's'.

Over the next week Mrs Parashar rang the police on several occasions and enlisted the help of a woman magistrate she knew, Angela Espos ito, who said she also called several times, to ask when this highly dangerous man was to be taken off the streets. Edmonton police told them the case was being transferred to Southgate police, who a few days later passed it on to an Inspector Gill at Winchmore Hill station.

The police now say they did not know Clunis's identity and the fact that he was suspected to be suffering from a mental illness until 12 December. They said that on 14 December police from Winchmore Hill mistakenly contacted Enfield social services, and the following day Haringey social services, who were told in an answerphone message of the screwdriver and breadknife incident. Haringey picked up the message on 16 December and Friern Barnet Hospital was alerted on 17 December.

Immediately an emergency mental health assessment team was assembled, for the second time, and twice that day they called at Clunis's house. But he was not there. Again they left a card saying: 'Come and see us straight away. We are worried about you.' Their concern came too late for Jonathan Zito.

Leading article, page 17

(Photograph omitted)