Failings amounting to neglect contributed to the death of a vulnerable man who was hit by a train after absconding from a mental health hospital, a jury has ruled.
Personal trainer Matthew Caseby, 23, was able to leave Birmingham’s Priory Hospital Woodbourne, where he was an NHS-funded patient, by climbing over a courtyard fence, in September 2020, the city’s coroner’s court heard.
The inquest jury, which heard that the University of Birmingham graduate should have been under constant observation, but was left unattended, reached a conclusion that death “was contributed to by neglect”.
The narrative verdict, delivered on Thursday after jurors heard two weeks of evidence, said that Mr Caseby had been left “inappropriately unattended” in the courtyard, first for a period of 100 seconds and then for five minutes.
As well as noting that the courtyard was “not suitable for patients to use” due to the lack of risk assessment, the jury concluded: “As a result of risks not being fully recorded, Matthew’s risk assessment was not adequate, as it was not based on all the available information.
“There were shortcomings in the Priory processes for recording and sharing information between staff.
“When reviewing (previous absconsions) there was insufficient attention paid to the physical security of the area.
“This was a missed opportunity. Overall the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard, means that the courtyard was not safe for Matthew to use unattended.
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
Richard Caseby, the father of Matthew Caseby
“His death was contributed to by neglect on the part of the treating hospital.”
The inquest was told Mr Caseby was hit by a train near Birmingham’s University station on September 8 2020, a day after he was seen leaving the hospital.
Birmingham Coroner’s Court also heard Mr Caseby, who lived in London, was originally detained under the Mental Health Act following reports of a man running on to railway tracks near Oxford on September 3.
In a statement issued after the inquest, Mr Caseby’s father, Richard Caseby, 61, 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.
“After a long campaign, we are pleased that the truth has finally been heard. We thank the coroner for being so forensic and sensitive in her investigation into our son’s death.”
His statement added: “Unknown to his family, Matthew was suffering his first mental health crisis.
“He was sectioned as an NHS patient under the Mental Health Act for his own safety and we were assured that the Woodbourne Priory Hospital, Birmingham, was the best place for him.
The jury’s finding that Matthew’s death was contributed to by neglect by the treating hospital will be little comfort for Matthew’s family, but it is important that significant lessons are learned in the hope that it will prevent another family going through such an ordeal
Craig Court, Harding Evans
“But 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.
“Matthew escaped over a low fence when left unsupervised in a courtyard just 60 hours after admission, and died shortly afterwards. The hospital was aware of previous escapes over the same low fence and yet had done nothing to improve security.”
Consultant forensic psychiatrist Professor Jennifer Shaw, who carried out an independent investigation into his care, told the inquest Mr Caseby was “said to be eyeing up the fence” in a courtyard area at the hospital in the days before he absconded.
She said he had also previously “tried to tailgate staff” and was seen with a binbag “walking as if to take it out”, meaning he should have been assessed as at a high risk of absconding.
The Priory Group “were accountable for Matthew’s care and safety yet they failed profoundly to prevent harm to him”, his father said, adding: “We can never bring Matthew back but we can prevent this ever happening again.
“Matthew was sent to the Woodbourne Priory by the Birmingham Women’s and Children’s NHS Foundation Trust, which outsources all NHS mental health care for young adults.
“The Trust’s failure to conduct any assurance visits for over two years before Matthew’s death resulted in them being dangerously disconnected from the care of their NHS patients at the hospital.
We accept that the care provided at Woodbourne in this instance fell below the high standard patients and their families rightly expect from us,
Priory Hospital Woodbourne
“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.”
After the verdict, the senior coroner for Birmingham and Solihull, Louise Hunt, said there were several areas of the evidence which left her concerned, including staff recording information in two different places.
The coroner said she was also concerned that the fence still may not be safe, while the courtyard might not be safe in the event of a patient needing to be restrained.
Ms Hunt added that she intended to write to the Department of Health and Social Care with regard to national guidelines covering mental health units.
Craig Court, of Harding Evans solicitors, who represent the Caseby family, said: “The jury’s finding that Matthew’s death was contributed to by neglect by the treating hospital will be little comfort for Matthew’s family, but it is important that significant lessons are learned in the hope that it will prevent another family going through such an ordeal.”
A spokesman for the Priory Hospital Woodbourne 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 to ensure that we take all necessary measures to improve patient safety at Woodbourne, including carrying out an urgent review of the environmental safety arrangements on Beech Ward.
“Though the hospital was rated ‘good’ overall by CQC inspectors in their February 2022 report, we remain absolutely committed to continually learning and improving from incidents, and are determined to implement whatever changes are needed for the safety and welfare of all our patients.
“We would welcome national guidance on how best to achieve the most appropriate level of security in acute mental health units, while balancing the need for these to remain therapeutic and rehabilitative environments.”
The Priory spokesman added: “Priory has invested more than £122m in its facilities (hospitals and homes) over the last three years, of which more than £40m was invested in improving and enhancing safety.
“It safely and successfully treats over 30,000 patients a year, many of whom have very complex conditions, and it remains fully committed to providing high-quality and safe care.
“Priory undergoes regular scrutiny of its services by external agencies including the NHS and the CQC and the overwhelming majority of Priory sites are rated ‘good’ or better by UK independent regulators.”