Grade II-listed window bars are blamed for Broadmoor suicides

Rashid Razaq
21 Jul 2009

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.”