Priory Healthcare admits safety failing linked to death of mental health patient

Care provider Priory Healthcare has pleaded guilty to a criminal safety failing 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”.

A second charge brought under the same legislation was withdrawn.

Priory Healthcare’s barrister, Paul Greaney KC, entered the guilty plea on behalf of the company.

The London-based provider, which was charged after an investigation into the death of Mr Caseby conducted by the Care Quality Commission (CQC), now faces an unlimited fine.

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”.

Following the verdict, Birmingham and Solihull senior coroner Louise Hunt urged health chiefs to consider imposing minimum standards for perimeter fences at acute mental health units.

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 other patients had absconded from the ward on previous occasions.

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.

“The prosecution do not suggest that the defendant is to be sentenced on the basis that it has caused the death of Matthew.”

In a victim impact statement that he read to District Judge Shamim Qureshi, Mr Caseby’s father, Richard Caseby, said: “Five days before his death, Matthew had been diagnosed as suffering from a psychotic episode.

“He had lost contact with reality.”

After describing his son as a sensitive, gentle and intelligent soul, Mr Caseby said that his ability to grieve had been stunted for years by Priory Healthcare’s attempts to “hide the facts” about his son’s death and “evade accountability for its gross failures.”

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

Mr Caseby said his son had died needlessly and in the aftermath, Priory Healthcare had made the family’s lives “indescribably more painful”.

Mitigating for Priory Healthcare, whose chief executive Rebekah Cresswell attended the court hearing, Mr Greaney 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.

Stressing that Priory Healthcare was making efforts to tackle the problem of patients absconding, Mr Greaney added: “It is a fact that the company was working hard to address the issue.

“It certainly was not a company that didn’t care.”

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 have been installed.

Sentence in the case is expected to be passed later on Friday.