A PATIENT at top security Broadmoor Hospital died days after seriously harming his own genitals in order to leave his secure ward, an inquest has heard.

Christopher Brand, imprisoned for life in 2012 after drowning another man in a bath, carried out a deliberate act of self-harm in order to temporarily leave his secure ward, coroner Peter Bedford was told on April 11 and 12.

The inquest heard the 53-year-old suffered from dissocial personality disorder, an emotionally unstable personality disorder and paranoid personality disorder and was considered at high risk of self-harm, but not a high suicide risk. 

He was taken to Frimley Park on June 29 having harmed himself four days earlier and after a failed operation to mend his injuries he was given a cocktail of drugs. 

However, hours after he was readmitted to Broadmoor, Brand was found unresponsive in a secure isolated bedroom in the hospital's Chepstow ward despite being under constant supervision throughout the night. 

Nursing staff at the hospital insisted at the inquest that they had no concerns over Brand's welfare.

Thamsanqa Zindela, a healthcare assistant at Broadmoor assigned to observe Brand, said: "When he came to the ward he looked sleepy and tired but he was standing and walking. He was talking and wasn't slurring.

"He appeared to be asleep. There were no concerns that maybe there was something wrong."

A clear plastic window that allowed staff to see into the room was scratched and "relatively opaque", affecting visibility, the inquest heard. Mr Zindela admitted that he had difficulty observing Brand.

Two healthcare assistants took over observation of Brand at 7.15am on July 1 but after 10 minutes became concerned he was not responsive. 

Hospital staff tried to resuscitate Brand until paramedics arrived to take over but they were unable to revive him and declared him dead.

Police officers sent to investigate Brand's death found an empty cup containing the residue of a pink liquid in Brand's room. Tests later showed it was an anti depressant that he had not been prescribed.

In the post mortem examination and toxicology report read out at the inquest, which was attended by Brand's family, pathologist Dr Ashley Fegan-Earl said: "There was no sign of heart attack or respiratory problems.
"The cause of death was given as natural causes."

Although the inquest heard that the toxicology report found a cocktail of medication in his blood the coroner ruled this had not caused his death.

Mr Bedford said: "Mr Brand died on July 1 2013 while a patient at Broadmoor Hospital from a cardiac condition that caused ventricular arrhythmia.

"Mr Brand was in a seclusion room at Broadmoor and put under observation. I accept that those eye observations were not performed in line with the hospital's policy between the hours of 6.35am and 7.35am."

Mr Bedford confirmed he would make two section 28 reports to prevent future deaths ordering Broadmoor Hospital to investigate and improve its observation and CPR procedures.