Serious failures led to the death of a man at Broadmoor Hospital

Serious deficiencies by healthcare personnel Broadmoor Hospital Presumably contributed by a Patient The jury ruled out self-mutilation.

After two weeks Investigation Jurors at Reading Coroner’s Court found that staff were unaware of and reduced the risks that critically ill patient Aaron Clamp posed to himself in the minutes leading up to his death.

Mr. Clamp died on January 4, 2021, after drowning in his own room NHS-Produces Broadmore Hospital Highly Safe Mental Health.

A few weeks before his death, Mr. Clamp’s mental health deteriorated. He was transferred to Broadmoor Hospital in the “Psychiatric Intensive Care Unit” and placed in long-term segregation.

Summary of jury conclusions shared Independent Found that there was a “serious failure to identify and reduce the level of risk in a timely manner, and a serious failure to identify and perform the steps to retrieve the item” that Mr. Clamp had strangled.

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

It was also found that the record was “insufficient” in the confidence of Mr. Clamp in previous incidents of self-mutilation when he died.

The jurors stated that the plan of permanent surveillance personnel was appropriate but all aspects of the plan were not adequately protected by the staff.

Aaron Clamp’s health deteriorated a few weeks before his death and he was transferred to the “Psychiatric Intensive Care Unit” in Broadmoor.

(Christopher Clamp)

In last week’s summary, the court cited evidence that showed staff talking outside Mr. Clamp’s room while one was supposed to conduct an observation.

The employee admitted that they did not have constant direct vision in his room.

The jury concluded on Friday: “Employees should have considered that Aaron Clamp was in danger of losing his life for 35 minutes before 11.05am. The risk of repetitive uncharacteristic behavior could not be identified – repeated instances of Aaron’s tissue being inserted into the mouth – which could have endangered his life, and this omission could have contributed to his death.

Aaron’s father, Mr. Christopher Clamp, said in a statement Independent That he is grateful for the care of the jurors, who spent two days arguing for a unanimous conclusion.

He said he agrees with the jurors and notes that although the policy in place at Aaron’s death was to manage the relevant risks, the failure of staff to properly implement the trust policy could not keep Aaron safe.

“The observer nurse was given the only task for two hours to keep an eye on Aaron. The policy states that the user of the service must be under the supervision of one member of staff and be physically accessible at all times … If necessary, any tools, equipment or ligatures that may be used to cause harm must be removed.

“It is likely that the NHS Trust in West London will diligently learn from this investigation to prevent future deaths, as the shortcomings identified in Aaron’s case will have a wider impact on inpatient service users,” he said.

Mr. Clamp was represented by Oliver Lewis on Doute Street, taught by Kate Luscom of Abbotstone Law.

The West London Trust has confirmed that it has been investigating its own serious incident since Mr Clamp’s death. However, Confidence confirmed the outcome of this investigation when asked Independent.

A spokesman for the trust said: “We mourn Aaron’s family and friends for their sad loss. Trust always learns to ensure that we provide the best care to our patients and we review all training protocols for our staff that may encounter similar issues as raised during this investigation.

Serious failures led to the death of a man at Broadmoor Hospital

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