The death of a 23-year-old man who escaped from a mental health hospital in Priory and was killed by a train was “contributed by negligence” by the institution, the investigation concluded.
After a two-week investigation in the Birmingham Coroner’s Court, the jury found it unsafe to leave Matthew Casey unattended in the courtyard, where he jumped a low fence, and officials “missed an opportunity” to improve security in the area after previous patients sheltered.
They also highlighted poor record keeping, inadequate risk assessments and a lack of yard monitoring policy.
In a statement, Matthew’s father, Richard Cassby, said the investigation showed “failures” at the hospital: “Priory’s team is responsible for Matthew’s care and safety, but failed to deeply prevent his injury.
“To prevent such tragedies from happening again, the NHS in England needs to review its national policy on outsourcing mental health beds to a provider like Priory, which has consistently failed to protect patients.
Just 60 hours after his admission, Matthew was hiding from the Priory Woodbourne in Birmingham when he was left unattended in the courtyard.
He was separated as an NHS patient under the Mental Health Act after being found running on a railroad track and telling doctors he heard voices.
His father, Richard Casey, told investigators he ran to Birmingham from London to help search for Matthew, and was just 200 meters from his son when he was hit by a train near University Station.
He said Priory staff had told him that patients were hiding “all the time” and that Matthew was considered a low risk of suicide, even though he had been diagnosed as a psychopath.
Forensic psychiatrist Prof. Jennifer Shaw, who conducted an independent investigation into Matthew’s case, told the investigation that he was at high risk of absconding after detaining staff and “inspecting” the fence, but was still left behind. without supervision.
She said other patients had previously fled the hospital and staff had “shown concern […] who feel they have not been heard. “
She said that only another patient took refuge on November 19, 2020, two months after Matthew’s death, “there is some change in the physical security of this yard.”
Deborah Coles, director of Inquest, said the charity was “deeply concerned about the number of deaths in the mental health departments run by Priory nationwide.”
“The neglect that contributed to the untimely and preventable death of Matthew, a young man who had a life ahead of him, once again demonstrates the inability of these services to change,” she said. “How many more people have to die before the NHS and the government reconsider outsourcing a company that puts profit above patient safety?”
The investigation also found that 42 days after his son’s death, NHS officials told Richard that Matthew was still alive and caring for him.
Fiona Reynolds, chief medical officer at the NHS Trust for Women and Children in Birmingham (BWCH), who commissioned Matthew’s treatment at the Priory, said: “I’m horrified and I apologize. It shouldn’t have happened. Mr Casey did not have to be subjected to this, and I am very sorry.
Matthew, a personal trainer with a first-degree degree in history from the University of Birmingham, began meeting with a counselor in 2019 and his mental health deteriorated during the blockade.
“He was loved by his family and had so many promises,” Richard said. “After a long campaign, we are pleased that the truth has finally been heard.”
A Priory spokesman said: “We would like to say how deeply we feel sorry for Matthew’s family and apologize unreservedly for the shortcomings in care identified during both the investigation and the investigation.
“We accept that the care provided at Woodbourne in this case has fallen below the high standard that patients and their families rightly expect from us, and we fully recognize that improvements in the service are needed.
They added that changes to hospital policies and procedures have already been implemented, but they will examine the coroner’s findings to ensure that all steps are taken to improve patient safety.
Reynolds said on behalf of BWCH that Matthew “tragically did not receive standard care [from the Priory] he deserved it when he was most vulnerable. “
“That is why we have commissioned both an independent investigation into the circumstances surrounding his death and a comprehensive review of the arrangements with The Priory Group. Recommendations from both reviews have already been implemented. “
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