'Serious concerns' about mental health unit where vulnerable patient absconded and died

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.

Birmingham and Solihull senior coroner Louise Hunt said after the hearing that she remained concerned at record-keeping quality, how risk assessments were completed, other incidents and the safety of the fence at the city's Priory Hospital Woodbourne.

Mr Caseby's father Richard, 61, has 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, i.e. 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 courtyard 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, who was provided with a copy of the coroner's PFD report on Monday, said: "The coroner is right to urge the Department of Health to make a ruling on the minimum height of fences at acute mental health units.

"However, 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 also 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".

The Priory Group has apologised unreservedly for the shortcomings in care identified during both the investigation process and the inquest.

In a statement issued following the inquest, the group said: "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 also stated that it had invested more than £122 million in its facilities over the last three years, of which more than £40 million was invested in improving and enhancing safety.