Key points are not available for this paper at this time.
he purpose of an inquiry is to improve practice and secure the future safety of patients and the public through the translation of findings into improved practice. In December 1992, Christopher Clunis killed Jonathan Zito, a young musician, at London’s Finsbury Park tube station. The subsequent trial was front-page news, and when Christopher Clunis was sentenced and committed to Rampton Hospital, Jonathan Zito’s widow, Jayne, called for a public inquiry. Subsequently the two regional health authorities concerned commissioned an independent inquiry in which I was involved. The inquiry, although not held in public, generated a vast amount of publicity and resulted in the Department of Health issuing guidance, HSG(94/27), which is still extant. The whole process led to a change in attitudes to mental health services for everyone and also heralded a more open approach to working with families. Since then I have been involved in almost 30 such inquiries and have had the privilege to chair some of them. This article is a result of this work; I have set in context the process adopted and attempted to draw out the findings and implications for the delivery of mental health services.
Jane Mackay (Tue,) studied this question.