Gross failings contributed to death of Broadmoor patient

The jury also found a “gross failure to provide basic attention” by West London Mental Health NHS Trust and Broadmoor staff to Darren who, as an inpatient, was entirely dependent on them to provide it.

Darren Linfoot originally from Sussex died on 18 December 2011 while a patient at Broadmoor Hospital.  He had a history of mental health problems and had spent most of his adult life in and out of prison.

The inquest heard that Darren had been in his bedroom for most of the day on 17 December 2011. The duty doctor had assessed his health that morning and requested clinical observations be repeated that afternoon to check how he was doing.

The Nurse in Charge on the morning shift asked Darren to stay in communal areas where she could keep an eye on him due to his health.

However, later that day, after a shift change, Darren was sent to his bedroom.

It was not until a friend and fellow patient went to check in on Darren shortly before 2100, that he was found to be unresponsive and the alarm raised.

It took several minutes before staff entered the room and it took approximately 25 minutes for the duty doctor to arrive.

The Post Mortem report concluded that Darren had died of Lobar Pneumonia contributed to by Dihydrocodeine toxicity, a drug Darren was receiving for dental problems. Lawyers for his family had asked the inquest to examine how Darren could have obtained a fatal dose of his medication.

Giving their verdict at Berkshire Coroner’s Court the Jury found that:

There was a continuous failure to arrange a dental appointment to resolve Darren’s dental problems.

There was a failure by nurses to carry out clinical observations which the doctor had requested.

Handover between nursing staff failed to include “crucial details pertinent to Darren’s health”.

The CCTV footage showed no observations were carried out between 1654 & 1802 and 1854 and 2044, despite staff having signed the observation sheet.

The Observations that were done were “grossly inadequate” as these did not include actually entering Darren’s bedroom, specifically when he could not be roused for his teatime meal and routine medications, despite the fact he showed signs of being unwell during the day.

The Jury concluded “any of these could have triggered further investigations”.

The Coroner, Mr Peter Bedford, has now sent a Report to Prevent Future Deaths to West London Mental Health NHS Trust, which requires the Trust to confirm what action will be taken to minimize the risk of a similar avoidable death reoccurring.

In addition to the concerns noted by the Jury, the Coroner specifically states a concern regarding the monitoring of opiate drugs in Broadmoor, such as DiHydrocodiene, as it became clear in the Inquest that medication could not be accounted for.

Merry Varney, solicitor for Darren’s mother, Rosemary Benham, said:

“This was a really sad case involving the death of a troubled young man who was looking to take responsibility for his past and we are very grateful to the Legal Aid Agency for supporting it.

“Patients at Broadmoor are hugely dependent on the staff caring for them and Darren was let down with the most devastating of consequences.

“The Jury’s Conclusions and the Coroner’s Report are welcome acknowledgments of the wrongs Darren suffered and the need for the Trust to learn from its mistakes so that no other preventable death occurs.”
Rosemary Benham said:

“Since Darren’s death I have felt I could not let him go. I have carried him painfully with me. Now that the truth that Darren was neglected has been acknowledged I feel I can finally move on and that he can rest in peace.

“Nothing can bring Darren back but I hope lessons are now learnt from his death so no other family has to go through this.”