Priory hospital neglect contributed to death of patient, jury finds


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 the 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”.

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 his son’s death, Richard was told by NHS staff that Matthew was still alive and being cared for.

Fiona Reynolds, chief medical officer at Birmingham Women’s and Children’s (BWC) NHS Trust which outsourced Matthew’s treatment to the Priory, said: “I am appalled and I have apologised. It should not have happened. 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.

“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.”

The Priory Group and BWC NHS trust have been contacted for comment.



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