‘SERIOUS failings’ contributed to the death of a patient who died at Broadmoor, a jury has found.

Aaron Clamp died at the high-security Crowthorne hospital on January 4, 2021, after he stopped breathing due to a ‘fatal obstruction to his airway’.

During a two-week inquest trial at Reading Coroner’s Court, a jury heard how Clamp, who was 30 at the time of his death, choked in his room.

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After being presented with evidence, the jury found that in the 35 minutes before Clamp died, the Broadmoor patient ‘posed a risk to his own life’.

The conclusion added: “There were failings to recognise the risk posed by repeated uncharacteristic behaviour (repeated instances of Aaron putting fabric in his mouth) that could cause a risk to his own life and this omission probably contributed to his death.”

The jury also found there was a “serious failure” in staff’s response to recognise and reduce Clamp’s level of risk to himself, and a “serious failure” to remove the clothing from him prior to his death.

And in the 15 minutes before his death, the steps taken by Broadmoor staff to address Clamp’s risk to himself “were not timely nor appropriate”.

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The jury also concluded:

  • Previous incidents of self-asphyxiation were ‘insufficiently documented’ in Clamp’s risk assessment and care plan, which ‘probably contributed to his death’
  • Not all aspects of staff’s observation of Clamp were followed adequately, which ‘possibly’ contributed to his death
  • Repeated incidents of Clamp putting fabric in his mouth on the morning of his death ‘represented an escalation’ of risk of death.

The inquest into the death of Aaron Clamp, who was born in Milton Keynes, came to a conclusion at Reading Coroner’s Court on Friday, March 4.