The NHS should stop sending patients to Priory-run mental health hospitals after a patient who fled a facility died when he was hit by a train, the victim’s father has said.
Matthew Caseby, 23, died from head injuries in September 2020 after he escaped over a fence from the Priory Hospital Woodbourne in Birmingham and was later struck by a train.
Following a two-week inquest, jurors ruled on Thursday that a series of failings by the hospital led to him leaving the unit unattended, which contributed to his death.
His father, Richard Caseby, has called for NHS England to review its policy of sending patients to private units such as the Priory Group.
The organisation is one of the largest providers of mental health inpatient services in the UK with hundreds of millions spent on sending NHS patients to its hospitals each year.
According to analysis by the charity Inquest, there have been at least 21 patient deaths at Priory Group facilities - a figure previously criticised by coroners.
Following the inquest into Mr Caseby’s death, senior coroner for Birmingham and Solihull, Louise Hunt, will issue a prevention of future deaths report to the Priory Group and to the Secretary of State for Health and Social Care, Sajid Javid.
The report will say there should be national guidelines on security in acute mental health units, particularly in relation to the height of fences.
Mr Caseby suffered a mental health crisis on 3 September 2020 and was detained by Thames Valley police in Oxford. Two days later he was sent 80 miles away to the Priory Hospital in Birmingham.
The inquest found that prior to him leaving the hospital, he was left unattended in a courtyard by staff, a move deemed “inappropriate and unsafe”.
Staff had raised concerns he might climb the fence and leave the hospital, however there was no evidence those concerns were followed up or recorded.
Upon being admitted to the hospital, he was assessed as being at low risk of suicide and self harm, but later in the day it was noted he was at risk of fleeing.
The inquest heard the hospital’s recording processes were inadequate, resulting in a lack of communication by staff caring for Mr Caseby.
There was no policy in place for the level of observations needed within the hospital’s courtyard, which made it “unsuitable for patients”.
The inquest also highlighted that despite staff having concerns over the height of the fence, they were not raised officially. That was despite senior managers being aware of incidents occurring before Mr Caseby’s death.
‘A beautiful, gentle young man’
Speaking after the inquest concluded, Richard Caseby said: “Matthew was a beautiful, gentle and intelligent young man whose ambition was to help everyone live a better life through exercise. He was loved by his family and he had so much promise.
“In a litany of failings, the Woodbourne Priory failed to assess Matthew’s risk of absconsion when it should have been high. It also wrongly assessed him as a low suicide risk even though he was diagnosed as psychotic and had been originally detained for his own safety because he had been running on train lines.
“The hospital was aware of previous escapes over the same low fence and yet had done nothing to improve security.”
He added that the NHS trust that sent his son to the Priory Hospital, Birmingham Women’s and Children’s Foundation Trust, had failed to conduct any assurance visits over the two years before his death.
“The trust should have had far better oversight in respect of patients’ safety. The inquest heard expert evidence that the trust had also failed to take all reasonable measures to prevent harm to Matthew. To prevent such tragedies ever happening again, NHS England should review its national policy of outsourcing mental health beds to a supplier like the Priory, which consistently fails to keep patients safe,” he said.
Deborah Coles, director of the charity Inquest, said: “Inquest is deeply concerned by the number of deaths occurring at Priory-run mental health units nationally. Issues raised at this inquest around risk assessment, observations, and addressing known dangers are occurring time and time again. Yet no action is taken.”
A Priory Group spokesman said: “We would like to say how deeply sorry we are to Matthew’s family, and we apologise unreservedly for the shortcomings in care identified during both the investigation process and the inquest.
“We accept that the care provided at Woodbourne in this instance fell below the high standard patients and their families rightly expect from us, and we fully recognise that improvements are needed to the service.
“We have already implemented changes in relation to policies, procedures and the hospital environment, but we will now carefully study the coroner’s findings.”
An NHS spokesperson said: “Our thoughts and deepest sympathies are with the family and friends of Matthew Caseby.”
It added the NHS expected all services to provide safe and high-quality care and it continues to work with the Care Quality Commission to monitor this.
