What happened
Aaron Clamp, 30, had a diagnosis of schizoaffective disorder. He was convicted of a serious violent offence in 2013, and while serving that sentence his mental health deteriorated and he was transferred to Broadmoor. He spent more than seven years there with no release date.
Weeks before his death he was moved to the intensive care ward, under long-term segregation and continuous eyesight observations for a high risk of self-harm. On 4 January 2021 he was agitated in his room, pacing and bouncing off the walls. CCTV showed him repeatedly putting fabric in his mouth and then launching himself face down onto his mattress.
The nurse responsible for the continuous eyesight observations was in conversation with a healthcare assistant outside the room. In evidence he said that for the bulk of the time he was not looking directly through the window, that he knew there was a t-shirt in his mouth, and that he did not know where he had missed it. Resuscitation began about 17 minutes later. He died the same day.
The outcome
A jury at Reading Coroner’s Court returned a unanimous narrative conclusion on 4 March 2022, finding serious failures in keeping him safe.
Previous incidents of self-asphyxiation were insufficiently documented in his segregation application, risk assessment and care plan, which probably contributed to the death. Staff failed to recognise escalating risk and to remove the fabric, which probably contributed. Continuous observation was not followed adequately, which possibly contributed.
No prosecution or regulatory action is recorded in the sources opened.
What went wrong
The risk history existed and did not travel with him. What he had done before was not written into the document that authorised his segregation, nor into the risk assessment or care plan the staff worked from. The observation was therefore set up as a task rather than as a response to a known behaviour.
The observer was present, conversant, and sure he would hear trouble. The jury found the observation inadequate anyway. The trust’s deputy director of nursing told the inquest that staff on observation should not be engaging in conversation, and that if you look away you are not looking as fully as expected. The coroner described stretches of less intense observation, which the family said was sometimes no watching at all.
What it teaches
Long-term segregation with continuous observation is a clinical intervention, not a staffing task. The person watching needs to know what this patient has done before, what the warning signs look like, and that a colleague arriving for a chat is a threat to the plan.
Three things make the difference: the risk history goes into the paperwork that authorises the observation, the observation has a defined field of view and interval, and saying “I can’t talk, I’m observing” is normal, including to a senior colleague.
Questions for the room
- He had put fabric in his mouth before. Where should that have been written down, and who should have read it?
- You are the nurse on continuous observation and a colleague arrives to talk. What do you say?
- The ward was described at the inquest as having the most difficult patients to manage. What does a manager owe an observer there?
Evidence and limits
Confidence: confirmed, but on one readable source.
The Doughty Street Chambers report of the inquest returned an access error and could not be read. The jury’s findings here are carried from the vault record. The Independent’s reporting of the hearing covers the evidence given, not the verdict. So the conclusion is as the record summarises it, and it has not been checked against the coroner’s own wording.
Proceedings concluded on 4 March 2022, so the page may be cited outward with that stated. No member of staff is named and no finding is made about any individual.
Our vulnerable and volatile persons training covers acute behavioural disturbance and what to do before hands are used.
Sources
- Doughty Street Chambers, March 2022 · https://www.doughtystreet.co.uk/news/inquest-jury-finds-serious-failures-broadmoor-hospital
Reviewed 20 October 2026.