Patient fled to his death due to ‘hospital neglect’
Coroner critical of Priory failings after man killed by train
ACORONER has urged health chiefs to consider imposing minimum standards for perimeter fences at acute mental health units after neglect was found to have contributed to the death of a vulnerable patient.
An inquest jury ruled last week that Matthew Caseby, a 23-year-old being treated at a Priory hospital, was left “inappropriately unattended” for several minutes before he climbed over a 2.3 metre-high courtyard fence at Priory Hospital Woodbourne, in Woodbourne Road, Harborne.
Birmingham senior coroner Louise Hunt said after the hearing that she remained concerned at recordkeeping quality, how risk assessments were completed, other incidents and the safety of the fence.
Mr Caseby’s father Richard, 61, said the hospital “failed profoundly to prevent harm” to his son, who was hit by a train while suffering a psychotic episode in September 2020.
In a Prevention of Future Deaths (PFD) report sent by the coroner to the Priory Group, NHS England, and the Department of Health and Social Care, Mrs Hunt expressed “serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients”.
The coroner added: “The inquest heard evidence that a previous absconsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focused on why the patient absconded, ie to have a cigarette.
“I have serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time.”
Addressing her concern over the safety of the courtyard fence, she went on: “A patient absconded over the courtyard fence during the inquest which indicates the court
yard area is not safe. I have serious concerns that an urgent review of the courtyard is required.
“Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe, especially if a patient needed to be restrained.”
Addressing issues to be examined by the Department of Health related to national guidelines for perimeter fences and security in the grounds of acute mental health units, Mrs Hunt went on: “The inquest heard evidence from Professor Shaw, a specialist in safety in Mental Health settings, that it would be useful for there to be standard guidelines for the requirements of perimeter fences and security for outside areas in acute Mental Health units as no such guidance is in place.
“This would ensure the correct level of security for some of the most vulnerable patients whilst maintaining a therapeutic setting.
“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”
Current guidance for adult acute mental heath units states that all facilities should “prevent the unauthorised exit or entry of people” but does not stipulate a minimum fence height.
Richard Caseby said: “It is disturbing that 20 months after Matthew’s death, the Priory Group is still so complacent that it has failed to make the necessary improvements to safety and security. The coroner’s report is clear. Today the Woodbourne Priory hospital is dangerous for any patient who has the misfortune to be detained there.”
Mr Caseby called on Birmingham Women’s and Children’s NHS Trust to stop sending NHS patients to the Priory Hospital Woodbourne “while it remains a threat to their safety”.