07 Mar 22

Inquest jury finds serious failures by Broadmoor Hospital

On Friday 4 March 2022, a jury at Reading Coroner's Court returned its conclusions in the inquest concerning Aaron Clamp, who died in Broadmoor Hospital on 4 January 2021. At the end of the two-week inquest, the jury deliberated for two days before returning a unanimous conclusion that found serious failures in keeping Aaron safe. Oliver Lewis represented Aaron's father Christopher Clamp in the inquest, instructed by Kate Luscombe of Abbotstone Law.

At the time of his death, Aaron was 30 years old and had been a patient in Broadmoor Hospital for over seven years. In the weeks prior to his death, his mental health had deteriorated, necessitating his transfer to the intensive care ward. He was subject to “Long Term Segregation” as he was assessed to pose a high risk of self-harm. This meant that his risks could only be managed by continuous eyesight observations: a staff person was positioned outside the room and was supposed to look into Aaron's bedroom though the window in the door at all times, to make sure Aaron was safe.

The relevant 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.”

CCTV footage of the corridor showed the observing nurse talking to a colleague, and not paying attention to Aaron for much of the time when Aaron was inserting fabric into his mouth and throat. The jury described "the repeated instances of Aaron putting fabric in his mouth" as "an escalation of risk behaviours."

Commenting on the quality of the observations, the jury found that, “Not all aspects of the continuous observation were followed adequately”. The jury determined that this omission possibly contributed to Aaron’s death. The jury found that "the previous incidences of self-asphyxiation were insufficiently documented in Aaron’s LTS [long term segregation] application, Aaron’s risk assessment and care plan" and that "this omission probably contributed to the death".

The jury found that, "There were failings to recognise the risk posed by repeated uncharacteristic behaviour (repeated instances of Aaron putting fabric in his mouth) that could cause a risk to his own life". The jury said that this omission "probably contributed to the death."

At 10:49 hrs on 4 January 2021, having run around his room with fabric in his mouth - visible from the CCTV footage - Aaron launched himself face-down onto the mattress in his room for the final time. The observing nurse did not remove the t-shirt. At 11:06 hrs, some 17 minutes after Aaron had launched himself onto the mattress, staff begun resuscitation. The jury concluded that, "there was a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric. This omission probably contributed to the death."

Commenting on the inquest process, Christopher Clamp's solicitor Kate Luscombe said:

"The position of West London NHS Trust was that staff had adhered to the hospital’s care plan and policies and Aaron’s death was not preventable. The jury's conclusions suggest that Aaron's death was in fact preventable had staff adequately assessed risk and carried out their duties properly.

Aaron's father thanks the jury for their careful evaluation of the evidence and hopes that the West London NHS Trust recognises, accepts and apologises for its failure to prevent Aaron’s death. He expects that the Trust will diligently take forward learning from this inquest to prevent future deaths, as the identified shortcomings in Aaron’s case have wider implications for inpatient service users."

The case was reported in The Independent, on 3 March and 7 March 2022.

APPENDIX: JURY'S CONCLUSIONS

Assistant Coroner Mr Alan Blake directed the jury to answer ten questions and that they should return a narrative conclusion. Below is the jury's conclusion in full.

At the time of his death, was Aaron Clamp’s risk of causing harm to himself appropriately assessed?

Broadly yes, however, the previous incidences of self-asphyxiation were insufficient documented in Aaron’s LTS [long term segregation] application, Aaron’s risk assessment and care plan, which the jury believe that this omission probably contributed to the death.

At the time of his death, did Aaron’s care plan supported by the Continuous Therapeutic Engagement and Supportive (TESO) procedure represent an appropriate plan to manage Aaron’s risk to himself?

Aaron’s care plan supported by the TESO policy did represent an appropriate plan to manage Aaron’s risk to himself. However, the previous incidences of self-asphyxiation were insufficiently documented, which the jury believe that this omission probably contributed to the death.

Was the staff member who took over at 10.30am given an adequate handover?

Yes, the staff member who took over at 10.30am was given an adequate handover.

Did Aaron Clamp's presentation on the morning of 4th January 2021 prior to 10.40 constitute an increased risk of self harm?

Aaron Clamp’s presentation on the morning of 4th January 2021 prior to 10.40am did constitute an increased risk of self harm.

Did repeated instances of Aaron putting fabric in his mouth after 10.40 represent an escalation of risk behaviours?

The repeated instances of Aaron putting fabric in his mouth after 10.40am did represent an escalation of risk behaviours.

Were there any failings in the delivery of the one to one observations on the morning of 4thJanuary 2021 [In relation to this question the jury may, if they wish, indicate if there was an act or omission that possibly, rather than probably, contributed to the death.]

Yes, in relation to TESO policy 1, paragraph 4.4, whereby the jury believe that not all aspects of the continuous observation were followed adequately, and therefore, this omission possibly contributed to the death.

Should staff have considered that in the 35 minutes before 11.05 hrs, Aaron Clamp posed a risk to his own life? [In relation to this question the jury may, if they wish, indicate if there was an act or omission that possibly, rather than probably, contributed to the death.]

Staff should have considered that in the 35 minutes before 11.05 hrs, Aaron Clamp posed a risk to his own life. There were failings to recognise the risk posed by repeated uncharacteristic behaviour (repeated instances of Aaron putting fabric in his mouth), that could cause a risk to his own life, and this omission probably contributed to the death.

Were timely and appropriate steps taken to reduce the level of risk which Aaron Clamp posed to himself on that morning? [In relation to this question the jury may, if they wish, indicate if there was an act or omission that possibly, rather than probably, contributed to the death].

The steps were reasonably appropriate based on Aaron’s care plan to verbally de-escalate and offer PRN medication. However, there was a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric. This omission probably contributed to the death.

At the time of his death, was there a policy that clearly identified the circumstances in which, and the procedure by which, staff should enter Aaron’s locked room if there was a concern for his welfare?

There was a policy that clearly identified the circumstances in which, and the procedure by which, staff should enter Aaron’s locked room if there was a concern for his welfare.