Leading Article: A suitable case for an inquiry

THE KILLING of Jonathan Zito by Christopher Clunis, a paranoid schizophrenic, could have been prevented. On a number of occasions, professionals might have intervened to halt his decline into madness or to confine him for his own safety and others'. But such decisive action never took place. Somebody has to tell Jayne, Mr Zito's widow, as she demands, 'why Christopher Clunis was on the platform that day and murdered my husband'.

There will be no public inquiry, according to Virginia Bottomley, Secretary of State for Health. This is despite a string of failures by hospitals, police, social workers and hostels over seven years to stop a tragedy. The victims of those failures, and others who will encounter the mental health system and expect it to protect them, deserve something more from Mrs Bottomley.

Mr Zito's death might have been prevented if the police had arrested Clunis after he threatened passers- by with a screwdriver and a breadknife, an incident reported to police eight days before the killing. Alternatively, in the past at least, Clunis would not have had the opportunity to stab this innocent stranger on a railway station: a psychiatric hospital probably would already have detained him. Times have changed. Successive governments have pursued a policy of closing asylums and caring for mentally ill people in the community rather than hospital.

But that policy was not itself a death sentence for Jonathan Zito. Under a well-run community care system, Clunis would never have been allowed to deteriorate to such a murderous state. He would have received adequate support and supervision as he pursued his life in the community. He would have been kept in hospital on those occasions when he really needed inpatient care. But the professionals failed to ensure his proper care, instead passing the buck as Clunis drifted between institutions.

Even if the professionals had acted more conscientiously, the necessary resources were not available. Where were the hospital beds to ensure doctors were not pressured into discharging him too soon? Where were the specialist half-way house hostels to cope with difficult and challenging patients such as Clunis? Where was the supervision to spot when he became ill and increasingly prone to violence? The answer is that mental health services are overstretched. Psychiatrists are daily discharging patients who run the risk of suicide and violent crime because of continuing pressure on bed space.

After this string of failures one would hope that Mrs Bottomley would do her utmost at least to ensure that the lessons were learnt. Whether any individual was negligent or culpable and whether the system was fundamentally at fault could only be satisfactorily decided after a full public inquiry. But Mrs Bottomley has ruled out such an investigation, despite a personal plea by Jayne Zito. The Health Secretary has instead settled for a private inquiry by two health authorities that were involved during only the final six months before Clunis killed Mr Zito. This will not uncover the full facts: even after a death the authorities seem unwilling to face all the issues.

The Clunis case is not just an aberration. The violent killing may be rare, but the pattern of health and social services offered was typical: inadequate tracking of a patient whom bureaucracies appeared unable to deal with. It seems as if only half the community care policy has been properly put into practice, that of closing long-stay psychiatric hospitals. They were closed after the publication of devastating critiques such as Erving Goffman's book Asylums, which described how both staff and patients became institutionalised. The film One Flew Over The Cuckoo's Nest graphically illustrated the sort of horrors. So the patients were discharged. Unfortunately, staff still seem to be institutionalised, busy keeping their hospitals running in ways that are often out of touch with the lives patients now lead. Social services, police and community psychiatric nurses seem unable to take up the burden.

The Government has undoubtedly long been aware of the problems thrown up by the Clunis case. A code of practice springing from the 1983 Mental Health Act is very specific about the need for proper aftercare for former psychiatric patients. That code was tightened in 1991 after a series of scandals. The problem is not a lack of guidance, it is that the rules are being flouted.

Mrs Bottomley must also sort out the law. Professionals are split about whether current legislation gives them sufficient powers to detain people who may be too ill to live outside hospital. What is clear, however, is the paralysis that some doctors feel about their ability to detain a dangerous individual. Mrs Bottomley should clarify the law, or change it if necessary.

A public inquiry could address many of these issues relating to the police, doctors, social workers, the law and resources. The Independent's investigation has raised important questions but a newspaper can go only so far in establishing what happened and why. Jayne Zito and indeed Christopher Clunis, who faces a lifetime of confinement and perhaps regret for his actions, are entitled to authoritative answers. They are unlikely to be gained during a narrow investigation held behind closed doors. The inquiry must be independent and public.