Tonight:
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Peter Bryan, left, killed inmate. Simon Crawford, right, resigned as chief executive
Broadmoor Hospital — condemned for serious failings putting patients at risk of murder and suicide — was forbidden to remove window bars that patients could use to hang themselves because it is a listed building.
Other “ligature points” such as hooks and curtain rails were also protected, significantly raising the risk of suicide.
The hospital in Berkshire houses about 260 of the country's most dangerous psychiatric patients. A Care Quality Commission report into the West London Mental Health Trust which runs the former Victorian asylum said that between 2001 and last year there were eight suicides at Broadmoor, five by hanging — while at two other high-security mental hospitals in England there was only one in the same period.
Studies have shown that removing the ligature points significantly reduces suicide rates, but Broadmoor has been prevented from doing the work because some buildings are Grade II-listed.
The damning report also attacked managers for leaving patients in overcrowded, dangerous wards.
It came after Broadmoor patient Richard Loudwell, 59, was strangled with a pyjama cord and had his head smashed on a table by fellow inmate Peter Bryan, 36, who was awaiting trial for a cannibalistic murder.
The trust's chief executive, Simon Crawford, resigned last week after four years in the job as an inquest opened into the death. He will join NHS London, where he will be given a role helping to improve standards in hospitals.
Today's report looked into 95 serious incidents including suicides, attempted suicides and killings at Broadmoor and other centres from 2005 to 2007. It found bosses in Hounslow, Ealing and Hammersmith & Fulham had failed to investigate incidents properly. Patients had been left in “sub-standard” accommodation and sleeping on sofas because wards were overcrowded.
Commission chairwoman Barbara Young said: “Patients were considered to be at greater risk of harming themselves or others because the trust's systems to manage risk were seriously flawed.
“This trust cares for some of the most seriously unwell patients ... the organisation should be leading the way in managing risks, yet in some instances they tolerated poor and mediocre practices.” The commission said the trust's board lacked “vitality and vigour” and was “good at writing policies, but not good at putting them into action”.
There was also a lack of adequate procedures to report and investigate deaths. Investigations took nine months on average and in one case almost two years. The trust was aware of the delays but did nothing to improve the process and there was little to learn from the findings, the commission found.
It said the Broadmoor building, built in 1963, was still “totally unfit for purpose”, as described in 2003 by a regulator. Modernisation is not due to be completed until 2016. St Bernard's Hospital in Ealing, which dates back to 1830, also needs urgent work.
Staff shortages were endemic, reaching 22 per cent on some Broadmoor wards. One ward in Hounslow had 36 per cent fewer staff than required.
Peter Cubbon, new chief executive of the West London trust, said: “There are lessons to be learned. The trust has already made progress in implementing a number of recommendations and I am committed to making sure action is taken to address outstanding issues.”
Reader views (4)
in reply to P. Stalker's harsh comments, yes thank God some of us do care what happens to these people, they are in the main, some of the most vulnerable and unwell people at the time of their offences. This is by no means condoning what crimes they have commited, nor minimising the hurt and grief of their victims and families, but what please tell me is the alternative. They are placed in a hospital for treatment, and as such, at least deserve to be kept safe and looked after, I really do not believe that most decent people would not care if they were all left to kill themselves and each other as the previous author suggested.
- K Phillips, bracknell berks
If someone really wants to commit suicide they will find a way.
- Clare Connell, London
If they are going to commit suicide, the means they use cannot be blamed, just the reasons - real or imagined. If the bars had not been there they would have used something else - someone determined to die will always find a way. That is the reality of it all. This blaming of the bars is hobby-horse material and blame shifting, nothing more.
- Rogan, Irving
Before anyone sheds a tear for Richard Loudwell aged 59, who was killed by Peter Bryan, pictured in the article, remember he:-
Strangled a woman of 82 and left her naked body covered in bites and cigarette burns, and had also just raped another man.
Does anyone really care if these monsters are able to committ suicide or kill each other in Broadmoor?
- P Staker, London
