Recipient

Broadmoor Hospital

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First report 21 Apr 2016•Latest report 21 Apr 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Broadmoor Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Christopher Harold Brand · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Harold Brand, a 53-year-old patient at Broadmoor Hospital, became unresponsive after returning from treatment at Frimley Park Hospital and could not be revived despite resuscitation attempts. Concerns included failures to follow observation procedures, failure to check that he was alive when his room was unlocked, and a delay in starting CPR.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Broadmoor Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out hospital observation checks correctly and ensure patient safety

    Wider context from the report

    “(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Broadmoor Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in commencing CPR for unresponsive patients

    Wider context from the report

    “(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Broadmoor Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check that patients are alive and well when room doors are unlocked

    Wider context from the report

    “(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026