On 3 September 2009, the report of an independent inquiry commissioned in 2005 by Strategic Health Authority NHS London, published today, concludes that individual and systemic failings led to the homicide in April 2004 of Richard Loudwell by Peter Bryan on the male admissions ward (Luton Ward) at Broadmoor Hospital.
The inquiry found deficiencies in many aspects of the care provided to both Richard Loudwell and Peter Bryan and shortcomings at every level within the Trust.
Richard was a vulnerable detained patient who died at the hands of a highly dangerous and mentally disordered fellow patient. An accumulation of individual and managerial failings left these two patients unsupervised on the afternoon of 25 April 2004, when Peter Bryan mounted a sustained and prolonged attack on Richard that staff failed to notice or stop. Richard never regained consciousness and died on 5 June 2004.