The death of a 23-year-old man who ran away from a Priory mental health hospital and was killed by a train was “contributed to by neglect” on the part of the institution, an inquest has concluded.
After a two-week inquest at Birmingham coroner’s court, the jury found it was not safe for Matthew Caseby to be left unattended in the courtyard where he jumped over a low fence, and staff had “missed an opportunity” to improve the area’s security after previous patients had absconded.
They also highlighted poor record-keeping, inadequate risk assessments and the absence of a policy on observation of the courtyard.
In a statement, Matthew’s father, Richard Caseby, said the inquest had shown “a litany of failings” at the hospital: “The Priory Group were accountable for Matthew’s care and safety yet they failed profoundly to prevent harm to him.
“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.”
Just 60 hours after being admitted, Matthew absconded from the Priory Woodbourne in Birmingham when left unsupervised in a courtyard.
He had been sectioned as an NHS patient under the Mental Health Act after being found running along a railway line and telling doctors he was hearing voices.
His father, Richard Caseby, told the inquest he raced up to Birmingham from London to help search for Matthew, and was just 200 yards away from his son when he was hit by a train near University station.
He said Priory staff told him patients absconded “all the time”, and that Matthew had been deemed a low suicide risk, even though he was diagnosed as psychotic.
Forensic psychiatrist Prof Jennifer Shaw, who carried out an independent investigation into Matthew’s case, told the inquest he was at high risk of absconding, having previously tailgated staff and “eyed up” the fence, but was still left unattended.
She said other patients had previously absconded from the hospital and staff had “raised concerns […] that they felt hadn’t been listened to”.
She said it wasn’t until another patient absconded on 19 November 2020, two months after Matthew’s death, “that there was any change in the physical security of that courtyard”.
During the inquest another patient escaped from the Woodbourne hospital over the same fence in the courtyard.
Deborah Coles, director of Inquest, said the charity was “deeply concerned by the number of deaths occurring at Priory-run mental health units nationally”.
“Neglect contributing to the premature and preventable death of Matthew, a young man who had his life ahead of him, once again demonstrates the inability of these services to change,” she said. “How many more people must die before the NHS and government reconsider commissioning services from a company that puts profit over patient safety?”
The inquest also heard that, 42 days after Matthew’s death, staff at Birmingham Women’s and Children’s NHS Trust (BWC) insisted to his father that he was still alive and being cared for.
Richard said this showed how the trust was “dangerously disconnected from the care of their NHS patients at the hospital”.
Dr Fiona Reynolds, the chief medical officer at BWC – which contracts out mental health services to the Priory, including Matthew’s treatment – said the misinformation should not have happened. “I am appalled and I have apologised … Mr Caseby should not have been subjected to that and I am very sorry.”
Matthew, a personal trainer who had a first-class degree in history from Birmingham University, began seeing a counsellor in 2019 and his mental health deteriorated during lockdown.
His family described him as “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,” Richard said. “After a long campaign, we are pleased that the truth has finally been heard.”
A Priory spokesperson 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.”
They added changes to policies and procedures at the hospital have already been implemented, but they would study the coroner’s findings to ensure all steps are taken to improve patient safety.
Reynolds said on behalf of BWC that Matthew “tragically did not receive the standard of care [from the Priory] he deserved when he was at his most vulnerable”.
“This is why we commissioned both an independent investigation into the circumstances surrounding his death and a comprehensive review of contracting arrangements with the Priory Group. The recommendations of both of these reviews have already been implemented.”
• This article was amended on 22 April 2022 to clarify that the Birmingham Women’s and Children’s NHS Trust has a contract with the Priory to provide mental health services.
