Patient ‘tormented’ by criminal and mental health system dies in Broadmoor

Exclusive: Aaron Clamp was ‘tormented’ by the criminal justice and mental health system, says his father

Broadmoor high-security hospital in Berkshire (Rex)

A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard.

Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room.

The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019.

According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room.

Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.”

He said his son was “deprived of his liberty in a high secure hospital for seven years and with no release date or realistic prospect of moving on, Aaron quite simply lost hope.”

“Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation.  Psychiatric treatment is conventionally centred on medication to manage symptoms and risk.”

Mr Clamp was convicted of a serious offence 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 too unwell” and that the opportunity for participation in occupation activities was limited due to Covid restrictions.

He said the “highly restrictive and isolating regime of Broadmoor Hospital compounded Aaron’s feelings of loneliness, boredom and despair.”

He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given.

While at Broadmoor Hospital Mr Clamp was on Stratford ward in the months prior to his death - a ward described during the inquest as having “the most difficult to manage patients.”

In a summary of evidence on Wednesday, a jury at Reading Coroner’s Court heard that one of the nurses responsible for Mr Clamp was talking with a healthcare assistant whilst he was supposed to be carrying out “continuous eyesight observations.”

The nurse confirmed another staff member had come up to him for a conversation but said when on continuous observations “you use all your senses and even if not looking in, I can hear him. I know how he is.”

When challenged about having a conversation with his colleague the nurse said “the policy says not to be disturbed. But sometimes people come with coffee or something. I have not completely abandoned what I am doing. I agree that for the bulk of the time, I’m not looking directly into the window. I knew he had a t-shirt in his mouth. But I don’t know where I missed it.”

He added the other healthcare assistant was also leaning into the room and looking at Mr Clamp.

“I would say I was informed about what was happening in the room”, he said.

During evidence given the deputy director of nursing for Broadmoor, Jimmy Noak, said when another member of staff is observing they “should not be engaging in conversations with staff but maybe getting information or checking something out. I don’t know the nature of the conversations.”

When asked if the actions of the staff member were okay he said: “I don’t think it was okay. It could have distracted the member of staff. If I was teaching observations, I would advocate again it’s been distracted at any point. If you’re looking away for a period, you’re not looking at the person not looking as fully at the person as expected.”

The court head that in the morning of his death Mr Clamp was “agitated in his room, pacing, running, and bouncing off the walls.”

In a summary of CCTV evidence the coroner said there were periods where the nurses were “looking more intently into the room, interspersed with times when the observation is less intense, or the family say when he wasn’t really watching at all.”

The inquest continues and is due to reach a conclusion this week.