Another Report on Crowthornes Broadmoor

In Addition to the July report on Broadmoor detailed in Bracknell Blog here, Yesterday a new report was published my NHS London into the death of a patient at Broadmoor Hospital.

The report concluded that "a collective failure at all levels" the report was investigating the killing of a patient by Peter Bryan sent there for murdering his friend Richard Loudwell and eating parts of his brain.

The report accused Broadmoors management of a lack of leadership at most levels and little common purpose within to deliver a first class service to patients and the public'.

The report also highlights severe organisational failings at Broadmoor which contributed to the killing. These failing include, No risk assessment carried out on Peter Bryan, On the day of the incident 6 of 9 staff on duty were in their offices with doors shut, for over several months there were repeated failures to take seriously complaints made by Richard Loudwell.

Some people would say let them die but what they forget is that we live in a caring society, they also forget that suffering from severe mental illness is not the fault of the individual and most of the patients have not committed murder but did commit a very serious crime. Others are there because they were found unfit to plead in a trial.

NHS London published two separate independent reports into the care and treatment of Peter Bryan by East London NHS Foundation Trust and West London Mental Health Trust.
NHS London press release and report on Broadmoor Hospital (Opens in a new window)

West London Mental Health NHS response to the London NHS report
http://www.cqc.org.uk/newsandevents/newsstories.cfm?cit_id=35282&FAArea1=customWidgets.content_view_1&usecache=false

Press release: CQC reaction to NHS London report on PBRL report

CQC investigation report into West London Mental Health NHS Trust

Crowthornes Broadmoor Reported as Unfit for it's Purpose.

A report by the Care Quality Commission in July criticised West London Mental Health NHS Trust for ‘failing to tackle a series of shortcomings’. Broadmoor high security hospital is home to 260 patients, which include the Yorkshire Ripper and Stockwell Strangler. Eight of its residents have killed themselves in the last eight years.

One reason for Broadmoors high suicide rate is opportunities that patients have to hang themselves as Broadmore still has window bars. Broadmoor is a listed building which means that it currently can not remove curtain rails and hooks and window bars. The other reasons stated by the report include lack of supervision, management of risks, sub-standard buildings, bed shortages, health care and not enough staff with the right training.

West London Mental Health Trust has been in communication with English Heritage however English Heritage claims that this subject has not been approached (As reported by the BBC here). It would appear that West London Mental Health Trust need to make this point to a English Heritage as strong as they can as keeping these hook points there is in itself madness. The listed status does not mean that no alterations can take place; it simply means that alterations have to be given listed building consent so minor works can be done.

Of course all this can be improved by the planned redevelopment of Broadmoor which was built in 1863! Broadmoor in other words is simply out-of-date. Mental Health practices in the 1900’s were very different to how they are now (This has been well documented see here for example). Redevelopment was approved by the Secretary of State in November 2005.

The trust is currently reviewing four short listed options. This need to happen as soon as possible as a redevelopment of the hospital has been urgently needed for many years and would help lead towards better treatment and rehabilitation. In the mean time management need to take on board the findings of the report and make changes in both practice and some physical changes to the building itself.

Read more: http://www.bdonline.co.uk/story.asp?storycode=3145391#ixzz0PkWZumRi

However English Heritage is not the only organisation at fault.
http://www.bdonline.co.uk/story.asp?storycode=3145391#ixzz0PkVBCGPT

Broad moor redevelopment plans http://www.wlmht.nhs.uk/services/b/broadmoor/redevelopment.html

West London Mental Health Trust response to the report http://www.wlmht.nhs.uk/news/press_releases/2009/06_statement_CQC.pdf