Priory Healthcare fined £650,000 after probe into death of mental health patient

Care provider Priory Healthcare has been fined £650,000 for safety failings linked to the death of a patient who was hit by a train after absconding from a mental health hospital.

Personal trainer Matthew Caseby, 23, was able to leave Birmingham’s Priory Hospital Woodbourne after being “inappropriately unattended” for several minutes in September 2020, an inquest jury ruled in 2022.

Priory Healthcare Ltd admitted breaching the 2008 Health and Social Care Act at Birmingham Magistrates’ Court on Friday, by failing to provide safe care and treatment “resulting in Matthew Caseby and other service users being exposed to a significant risk of avoidable harm”.

In a victim personal statement read to the court prior to sentence, Mr Caseby’s father, Richard Caseby, said in his experience Priory Healthcare Ltd was a “calculating, cruel and fundamentally dangerous company” which had not learned from its mistakes.

“Matthew died needlessly and, in the aftermath of that most devastating loss, Priory Healthcare Ltd chose to make our lives indescribably more painful,” he said.

After describing his son as a sensitive, gentle and intelligent soul, Mr Caseby said that his ability to grieve had been affected by Priory Healthcare’s response to his son’s death.

Mr Caseby also told the court that the firm “had been dragged kicking and screaming” to face hard evidence of its shortcomings.

The 63-year-old added: “Five days before his death, Matthew had been diagnosed as suffering from a psychotic episode.

“He had lost contact with reality.

“My own ability to grieve has been stunted for years by the way Priory Healthcare Ltd, the company that had a solemn legal duty to care for Matthew and keep him safe, tried to hide the facts about his death and evade accountability for its gross failures.”

Priory Healthcare, which was charged after an investigation into the death conducted by the Care Quality Commission (CQC), pleaded guilty through its barrister.

An inquest held in April 2022 was told Mr Caseby was able to leave the hospital, where he was an NHS-funded patient, by climbing over a 2.3-metre-high courtyard fence.

The inquest jury, which heard 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”.

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 five days before his death.

Opening the case against Priory Healthcare at the magistrates’ court hearing, CQC barrister James Marsland said three other patients had absconded from the ward before Mr Caseby’s death.

Mr Marsland said: “There was a courtyard (on the ward) which service users were able to access. Part of the perimeter was a fence, which at its shortest was 2.3 metres tall.

“The prosecution say that they failed to provide safe care and treatment in that they failed to properly assess the risk.”

Mitigating for Priory Healthcare, whose chief executive Rebekah Cresswell attended the court hearing, Paul Greaney KC said: “The company’s conduct in relation to this prosecution has been wholly co-operative and responsible.

“It should be publicly understood that the company has not admitted any charge alleging it caused Mr Caseby’s death.”

The defence lawyer added that the company had pleaded guilty on the basis that it had exposed service users to a risk of avoidable harm by not carrying out a full review of three previous abscondments from the ward, not all of which took place over the same fence.

The first two of three incidents in 2018, 2019 and 2020 saw patients suffer no injury.

But the third incident on July 17 2020 saw a male patient, who visited a supermarket, suffering a cut to the leg.

At the time of the incident there was “no industry standard or guidance” on minimum fencing height for outdoor space attached to wards of the type involved, Mr Greaney told the court.

Lessons had been learned, Mr Greaney said, as part of a continuing drive to ensure patient safety, while the fence height had been twice raised and anti-climb roller-bars had been installed.

Passing sentence, District Judge Shamim Qureshi said dealing with patients detained under the Mental Health Act was a very difficult area for care providers.

The judge, who also made an order for prosecution costs of more than £43,000, said the company had to care for patients “who are vulnerable and need protection from themselves”.

He said the firm’s culpability was high and the risk of harm posed by the offence had been in the medium category under the sentencing guidelines.

Speaking after the sentence was passed, Mr Caseby said: “My family is relieved that the Priory has finally been held to account for its criminal neglect after our three-year campaign for the truth.

“However, the prosecution over Matthew’s death brings no real satisfaction because, of course, nothing can bring our dear son back.”

Referring to the deaths of Amy El-Keria, 14, over which the Priory was fined £300,000 after admitting breaching health and safety law, and 21-year-old Francesca Whyatt, following which the company was fined £140,000, Mr Caseby called on the Government to end NHS outsourcing of mental health services to the firm.

A Priory spokesperson said: “We would like to repeat how deeply sorry we are to Matthew’s family, and once again apologise unreservedly for the shortcomings in the care provided to Matthew in 2020.

“We take our responsibilities extremely seriously and have implemented all the recommendations identified during the investigation process and the inquest into Matthew’s death.

“These include raising the height of the courtyard fencing at Woodbourne Hospital to 3.2m. There are no national standards for fence heights in adult acute mental health services as provided at Woodbourne, but we have now installed 3.2m fencing in 15 of our facilities across 24 wards.

“We co-operated fully and transparently with the CQC’s investigation, recognising the shortcomings in care and entering a guilty plea at the earliest opportunity.

“We have cared for over 100,000 people in the last five years and remain committed to balancing the need to keep patients safe, with the need for patients to receive the least restrictive care in therapeutic environments which promote their recovery.”