Mental health ward staff ‘failed’ man who was strangled by fellow patient
Judge criticises ‘sloppy procedures’ at centre after 46-year-old was found dead in his room
10 December, 2020 — By Bronwen Weatherby
Carl Thorpe who was killed last year
A JUDGE presiding over the trial of a man found to have killed a fellow patient on a mental health ward in Camden has said both were “failed” by staff at the facility and that changes were needed to prevent further tragedies.
His Honour Judge Hillen made the comments last Thursday at the Old Bailey as he ordered Jordan Bramble be detained under the Mental Health Act at Broadmoor Hospital for an indeterminate amount of time.
The court heard how Mr Bramble, 22, attacked Carl Thorpe while both men were in the care of Highgate Mental Health Centre’s Coral Ward.
The 46-year-old was discovered dead in his room on February 3 last year having been beaten, strangled and set alight.
Mr Thorpe, who suffered from schizophrenia, had been admitted just two days earlier.
Inpatients of the secure psychiatric intensive care unit are supposed to be monitored closely.
Jordan Bramble has been detained at Broadmoor Hospital indefinitely
On the night Mr Thorpe died, Mr Bramble should have been kept under constant watch.
Mr Bramble, who has paranoid schizophrenia, was deemed unfit to stand trial and was instead made the subject of a “trial of the facts”.
Judge Hillen said: “You [Mr Bramble] and Carl were ill-served by the nurses and care assistants whose duty was to keep you, Carl and others safe. They failed to do so. Over several days the jury listened to a catalogue of instances of poor management, sloppy procedures, failure to keep records and even the falsification of records.”
He added: “Most significantly, Carl was meant to be observed four times an hour, and you were meant to be on one-to-one observation – meaning that you should not have been let out of the sight of a care assistant at any time.
“Had you been under the supervision which was required, in all likelihood you would not have done or been able to do what you did, and Carl Thorpe would not have died that day.”
CCTV footage viewed in court showed Mr Bramble wandering around the ward unsupervised, entering Mr Thorpe’s room on a number of occasions, which was not allowed.
Both men were in the care of Camden and Islington NHS Trust
Mr Bramble is seen pushing Mr Thorpe inside his room and following him inside where he attacked him. Staff were only alerted after seeing smoke coming out of the room.
Mr Thorpe suffered injuries to his face and head, prolonged compression of the neck, and burns to parts of his body.
Mr Bramble later confessed to the killing, saying he did not like Mr Thorpe because he was gay.
He had spent three years in mental health units between 2014 and 2018 and had previously broken the nose of a staff member and punched a sleeping patient.
Camden and Islington NHS Foundation Trust have already carried out a disciplinary investigation into Mr Thorpe’s death which resulted in two nurses and two healthcare assistants being dismissed.
Judge Hillen said he hoped that “a full inquiry [by the NHS] will be able to assess what changes need to be made, if they have not already been made, into the management of secure wards such as the Coral Ward”.
But he added that “no change in procedures in the future, however, can bring Carl back”.
Mr Thorpe’s auntie said in a victim impact statement: “Carl was a vulnerable individual and he was supposed to be looked after, but his safety was compromised on so many levels by professionals who were trusted to take care of him and manage any risk to him.”
Mr Thorpe’s family described him as a “smiley, football-loving man”.
A spokesperson for Camden and Islington NHS Trust said: “This was an isolated incident of completely unacceptable failures in professional practice and conduct and we are deeply sorry that we did not provide a safe and protective environment to these vulnerable patients in our care.
“Following the incident, we commissioned a high-level independent investigation and have worked hard to ensure that we have acted fully on all of its recommendations so nothing like this ever happens again.”