The NHS has been called upon to stop sending patients to Priory-run mental health hospitals after a patient who escaped from a facility died after being hit by a train.
Matthew Casey, 23, died in September 2020 after fleeing over the fence of Priory Hospital Woodbourn in Birmingham. He later died of head injuries after being hit by a train.
After a two-week investigation, jurors ruled Thursday that a series of mistakes by the hospital led to his leaving unattended, which contributed to his death.
Matthew’s father, Richard Casby, has called on the NHS in England to reconsider its policy of sending patients to private units such as the Priory Group.
The organization is one of the largest providers of inpatient mental health services in the United Kingdom with hundreds of millions spent on sending NHS patients to their hospitals each year.
According to an analysis by the charity Inquest, there are at least 21 deaths of patients in Priory Group facilities – a figure that has previously been criticized by forensic doctors.
Following the investigation into the deaths of Mr Casey, senior coroner for Birmingham and Solihull, Louise Hunt will issue a report on the prevention of future deaths to the Priory Group and to Secretary of State for Health and Welfare Sajid Javid.
The report will say that there must be national safety guidelines in acute mental health wards, especially with regard to the height of fences.
On September 3, 2020, Matthew Cassby suffered a mental crisis and was detained by the Thames Valley Police in Oxford. Two days later, he was sent 80 miles to Priory Hospital in Birmingham.
The investigation found that before leaving the hospital, he was left unattended in the yard by staff – a move deemed “inappropriate and dangerous.”
Staff expressed concern that he might climb the fence and leave the hospital, but there was no evidence that those worried had been tracked down or recorded.
When he was admitted to the hospital, he was assessed as having a low risk of suicide and self-harm, but later in the day it was noted that he was at risk of escaping.
The investigation found that the hospital’s admission processes were inadequate, leading to a lack of communication from the staff caring for Mr Casey.
There was no policy for the required level of surveillance in the hospital yard, which made it “unsuitable for patients”.
The investigation also highlighted that despite staff concerns about the height of the fence, they had not been raised officially. This was despite the fact that senior managers were aware of incidents that occurred before Mr. Casey’s death.
“Handsome, gentle young man”
Speaking at the end of the investigation, Richard Casey said: “Matthew was a handsome, gentle and intelligent young man whose ambition was to help everyone live a better life through exercise. He was loved by his family and had so many promises …
“In a series of failures, the Woodborn Priory has failed to assess the risk of Matthew’s absconding when it should be high. It also misjudged him as a low risk of suicide, although he was diagnosed as psychotic and was initially detained for his own safety as he traveled by train.
“The hospital knew about previous escapes through the same low fence and yet did nothing to improve security.
He added that the NHS trust, which sent his son to Preor Hospital, the Birmingham Women’s and Children’s Foundation, had failed to conduct any assurance visits in the two years before his death.
“The trust needed to have much better oversight of patient safety. The investigation heard expert evidence that the Trust also did not take all reasonable steps to prevent Matthew’s injury. “To prevent such tragedies from happening again, NHS England needs to review its national policy on outsourcing mental health beds to a provider like Priory, which has consistently failed to protect patients,” he said.
Deborah Coles, director of the Inquest charity, said: “Inquest is deeply concerned about the number of deaths in the mental health departments run by Priory nationwide. The issues raised during this investigation regarding risk assessment, monitoring and dealing with known hazards are recurring. However, no action shall be taken. ”
A Priory Group 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.
“We have already made changes to policies, procedures and the hospital environment, but we will now carefully examine the coroner’s findings.
An NHS spokesman said: “Our thoughts and deepest sympathies are with Matthew Cassby’s family and friends.
He added that the NHS expects all services to provide safe and high-quality care and continues to work with the Care Quality Commission to monitor this.
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