a patient in broadmoor hospital He died after suffocating while staff were chatting outside his room, according to an investigation.
Aaron Clamp, a notorious high security patient mental health Broadmoor Hospital, died on January 4, 2021 after suffocating while in his room.
the independent understands that Mr Clamp’s death may have been the first “unnatural” death since the new Broadmoor Hospital, run by the West London Trust, opened in December 2019.
According to evidence heard at the investigation, the staff who were to conduct continuous “sight” observations on Mr. Clamp were having a conversation without directly seeing his room.
Mr. Clamp’s father told him the independent was “tormented” by the criminal justice and mental health system that resulted in his “indefinite imprisonment.”
He said his son was “deprived of his liberty in a high-security hospital for seven years and with no release date or realistic prospect of moving forward, Aaron just gave up hope.”
“Diagnosed of a mental illness, schizoaffective disorder, the end of the treatment was rehabilitation. Psychiatric treatment conventionally focuses on medication to control symptoms and risk.
Mr Clamp was convicted of a felony of violence in 2013, while serving this sentence his mental health deteriorated and he was transferred to Broadmoor Hospital for medical treatment.
During his time at Broadmoor Hospital, Mr Clamp’s father said there was “limited psychological input because he was said to be unwell” and the opportunity to engage in occupation activities was limited due to Covid restrictions.
He said Broadmoor Hospital’s “highly restrictive and isolating regimen compounded Aaron’s feelings of loneliness, boredom and despair.”
He acknowledged that a balance needs to be struck between risk management and patient restraint, but more attention needs to be paid to holistic compassionate care.
While at Broadmoor Hospital, Mr Clamp was on the Stratford ward in the months before his death, a ward described during the inquest as having “the most difficult patients to manage”.
In an evidence summary on Wednesday, a jury at Reading Coroner’s Court heard that one of the nurses responsible for Mr. Clamp was talking to a health care assistant while she was supposed to perform “continuous eye observations.”
The nurse confirmed that another member of staff had approached him for a chat, but said that in ongoing observations “you use all your senses and even if you don’t look in, I can hear it. I know how he is.
When asked about having a conversation with her colleague, the nurse said, “policy says don’t bother. But sometimes people come with coffee or something. I haven’t completely abandoned what I’m doing. I agree that most of the time I don’t look directly out the window. I knew she had a t-shirt in her mouth. But I don’t know where I missed it.”
He added that the other health care attendant was also leaning into the room and looking at Mr. Clamp.
“I would say that he was aware of what was going on in the room,” he said.
During the evidence presented, Broadmoor’s Assistant Director of Nursing, Jimmy Noak, said that when another staff member is watching, “they shouldn’t be engaging in conversations with staff, but maybe getting information or checking something. I don’t know the nature of the conversations.”
When asked if the staff member’s actions were okay, he said, “I don’t think it was okay. Could have distracted the staff member. If you were teaching observations, I would again recommend that you have been distracted at some point. If you’re looking away for a period, you’re not looking at the person who isn’t looking as fully at the person as expected.”
The court ruled that on the morning of his death, Mr Clamp was “agitated in his room, pacing, running and bouncing off the walls”.
In a summary of the CCTV evidence, the coroner said there were periods when the nurses “looked more intently at the room, interspersed with times when the observation is less intense, or the family says he wasn’t really looking.” .
The investigation continues and should reach a conclusion this week.
