Serious failings contributed to death of man at Broadmoor hospital

Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has been found.

Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognize and reduce the risks acutely unwell patient Aaron Clamp presented to himself, in the minutes leading up to his death.

Mr Clamp died on 4 January 2021 after choking within his room at the NHS run high secure mental health hospital Broadmoor.

In the weeks prior to his death, Mr Clamp’s mental health had deteriorated and he was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long term segregation.

A summary of the jury’s findings, shared with The Independenthas found there was “a serious failure in the timely manner to recognize and reduce the level of risk, and a serious failure to recognize and execute the steps to remove the item of fabric” from Mr Clamp.

“This omission probably contributed to death,” the jury said.

It was also found that at the time of his death there was “insufficient” recording, by the trust, of previous incidents of self-asphyxiation by Mr Clamp.

Jurors said the plan for staff to carry out constant eyesight observations was appropriate, however not all aspects of the plan were adequately followed by staff members.

Aaron Clamp, died January 4, 2021,

(Christopher Clamp)

During a summing up last week the coroner referred to evidence which showed staff were having a conversation outside of Mr Clamp’s room whilst one was supposed to be carrying out observations. The staff member admitted they did not have direct eyesight into his room from him at all points.

On Friday a jury concluded: “Staff should have considered that in the 35 minutes before 11.05, Aaron Clamp posed a risk to his own life. There were failings to recognize the risk posed by repeated uncharacteristic behaviour-repeated instances of Aaron putting fabric in his mouth-, that could cause him a risk to his own life, and this omission probably contributed to his death.

Aaron’s father, Mr Christopher Clamp said in a statement to The Independent he is grateful for the care taken by the jury who deliberated for two days to reach their unanimous conclusions.

He said he agreed with the jury, and observes that although the policies in place at the time of Aaron’s death were appropriate to manage the risks, failure by staff to correctly implement trust policy tragically did not keep Aaron safe.

“The observing nurse was given the sole task for up to two hours to continually watch Aaron. The policy stated the service user should be kept within eyesight of one member of staff and be physically accessible at all times….If deemed necessary, any tools, instruments, or ligatures that could be used to cause harm….should be removed.”

“It is expected that the West London NHS Trust shall diligently take forward learning from this inquiry to prevent future deaths as the identified shortcomings in Aaron’s case have wider implications for inpatient service users,” he said.

Mr Clamp was represented by Oliver Lewis, Doughty Street instructed by Kate Luscombe of Abbotstone Law.

West London Trust confirmed it had carried out its own serious incident investigation following Mr Clamp’s death. However, the trust did confirm what the outcome of this investigation when asked by The Independent.

A spokesperson for the trust said: “We extend our condolences to the family and friends of Aaron for their sad loss. The trust is always learning to ensure we deliver the best possible care to our patients and we will be looking at all training protocols for our staff who may be faced with similar issues to the ones raised through this inquest”.

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George Holan

George Holan is chief editor at Plainsmen Post and has articles published in many notable publications in the last decade.

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