A catalogue of “failures” led to the death of a vulnerable man at Highgate Mental Health Centre in February 2019, said a judge at the Old Bailey.
Carl Thorpe, 46, was beaten, strangled and then set alight by a fellow patient on a secure mental health ward at the unit.
Jordan Bramble, 22, was able to kill him even though he was supposed to have been kept under constant watch on Coral Ward at the centre in Dartmouth Park Hill.
Mr Thorpe had only been admitted to the ward on February 1, less than two days before his death.
Bramble, who has paranoid schizophrenia and a history of violence, was unfit to stand trial for Mr Thorpe’s murder but was found by a jury to have committed the act.
In a statement, the victim’s aunt, Lenora Thorpe, said: “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.”
On Thursday, Judge John Hillen QC ordered that Bramble be detained under the Mental Health Act for an unlimited amount of time.
The judge told him: “You 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.
“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.
“During the 23 minutes of CCTV which the jury and I watched, you were wandering unsupervised around the ward, entering Carl’s room, which you were not allowed to do.
“You had the means to set a fire, which could have endangered the disturbed patients on that ward.
“Once, during the images we watched, a member of staff was glimpsed in the distance.”
The judge said the jury had been concerned by the “obvious laxity of the management of Coral Ward”.
He added that if Bramble had been supervised as required, Mr Thorpe, in all likelihood, would not have died that day.
Bramble had spent three years in mental health units from 2014 to August 2018 and during that time had broken the nose of a staff member and punched a sleeping patient.
At 6.27am on February 3 last year, staff were alerted to smoke and flames coming from the victim’s room after the fire alarm sounded.
Mr Thorpe’s body, wrapped in a sheet or towel, was pulled out, with the material still on fire.
A workforce investigation dated June 29 2019 made findings and a support worker was summarily dismissed on July 31 2019 along with others, jurors were told.
READ MORE: Vulnerable patient killed at Highgate Mental Health Centre ‘was badly let down’
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