Darren Linfoot · Prevention of Future Deaths report

On the 4th March 2015 I concluded an Inquest into the death of Darren Linfoot, a thirty-three year old detained patient at Broadmoor Hospital. The Inquest was heard before a Jury.

On the 18th December 2011 Darren Linfoot was declared deceased at Frimley Park Hospital, Surrey. He had been a patient at Broadmoor Hospital since the 17th November 2011 and he was found unresponsive in his room in the hospital by nursing staff. A post mortem examination found a cause of death of Lobar Pneumonia to which Dihydrocodeine Toxicity contributed.

(1) The evidence was that a variety of drugs and medications are dispensed from the hospital’s in-house pharmacy for use of individual patients on the individual wards. Only controlled drugs are audited and their whereabouts monitored. Among others, Opiate drugs are classed as non-controlled and therefore not audited. There is a real risk that potent medication could go unaccounted for and could end up in the possession of patients.

(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided.

(3) Nursing staff also gave inconsistent evidence about the duties of the radio nurse on the admissions ward. There appeared to be a need for consistency and appropriate training.