17 April 2019

The Priory Group have today been found guilty of breaching Section 3 (1) of the Health and Safety Act, following the death of 14 year old Amy El-Keria in one of its hospitals in 2012. This is understood to be the first prosecution of its kind and is a historic moment in terms of accountability following deaths of children in private mental health settings.

The Priory pleaded guilty to the charges in January 2019 and the case was sent from the Magistrates to the Crown Court. Though they pleaded guilty, the Priory did not accept that these health and safety failures caused Amy’s death. As a result a hearing was held at Lewes Crown Court this week for the trial judge to decide on the level of fine to which The Priory Group should be sentenced, in view of the available evidence concerning causation. The judge, the Hon. Mr Justice Dingemans, today made the sentencing decision to fine the Priory £300,000.

When imposing the fine, the judge said he took into account the company's "good" health and safety record, guilty plea and steps made to improve the service. Priory Healthcare had a turnover of £133m in 2017, with an operating profit of £2m. It must also pay the Health and Safety Executive's (HSE) costs of £65,800 and a victim surcharge of £120.

Amy was a child with complex needs associated with multiple mental health diagnoses. She died whilst an NHS funded patient in a specialist children’s unit at Ticehurst House in East Sussex, a private psychiatric hospital run by the Priory Group. She was found unresponsive with a ligature in her locked hospital room on 12 November 2012 and was pronounced dead the following day.

An inquest jury in 2016 found that neglect (i.e. gross negligence) and failures by the Priory contributed to Amy’s death, identifying failures across all aspects of the care and treatment provided to Amy during her three month admission. The HSE commenced a criminal investigation as a result of the evidence revealed by the inquest.

Amy’s death is one of several concerning cases involving failures in mental health care by the Priory Group, which still runs Ticehurst House and numerous other specialist services for children and young people. For the past 18 months, ITV's 'Exposure' has been making a documentary about Amy El-Keria and conditions inside the specialist unit at Ticehurst House. The film, to which the El-Keria family and INQUEST have contributed, and which contains harrowing scenes, has been delayed because of the Health and Safety Prosecution, but is due to broadcast on Thursday 18 April.

There is a lack of transparency surrounding deaths of children in both NHS and privately run mental health settings, in addition to the lack of pre-inquest independent investigations into these deaths despite higher standards in other detention settings. The Priory are currently under an ongoing Health and Safety investigation into the death of 21 year old Francesca Wyatt in their Roehampton hospital in 2013.

Responding to the sentencing, Amy’s mother Tania El-Keria said: “Today is a historic day in my fight for justice for Amy. The public's eyes have finally been opened to what the Priory really stand for. Profit over safety.

Our Amy died in what we now know to be a criminally unsafe hospital being run by the Priory. This was Amy’s first ever hospital admission. She was alone, far from her home and her family. By day two she had been restrained by staff. She went on to be restrained many more times including on the day before her death, with forced sedative injections applied against her will.

The night Amy was found staff didn’t have a key to open her locked door. A healthcare assistant entered but didn’t have a radio and ran out leaving her hanging. Staff were not trained in basic life support and for 10 minutes she was left lying on the floor until the duty doctor arrived and started CPR.

My 14 year old Amy was put alone, unconscious in an ambulance. No-one went with her to hospital and no-one bothered to tell her family what was going on until many hours later. This is not what care looks like.

Amy loved life and I know she wanted to live. That her precious life should have ended in a place so devoid of care is something that will forever haunt me. This whole painful process has been marked by the Priory’s long and bitter failure to show any level of remorse or acceptance of responsibility. 

To me the Priory are a morally bankrupt company. They continue to take large sums of public money, allowing our children to suffer by placing profit over safety. This cannot be allowed to continue, and I will not stop fighting until this stops.

I would like to thank The Hon. Mr Justice Dingemans, Tony Murphy of Bhatt Murphy, Raj Desai of Matrix Chambers, the HSE’s Michelle Canning, Dave Rothery, Julia Thomas and Sarah Lefevre, Victoria McNally and the INQUEST team for getting us to this point.”

Victoria McNally, Senior Caseworker at INQUEST who has supported the family since 2012, said: “Today's historic decision is the achievement of Amy's family and their brave fight for justice in her name. 

The marketisation of our mental health system enables the Priory to put profit over the safety of children in its care. The lack of any independent system of investigation, allowing the Priory to investigate their own actions, has meant it took six and a half years for their criminally unsafe practises to be exposed. 

If we are serious about child safety and welfare, such a blatant lack of oversight and scrutiny cannot continue. The grave concerns for safety raised by Amy's and other children’s deaths must lead to an immediate intervention by the government and an urgent review of the Priory's fitness to deliver national CAMHS hospital services. 

The mental health minister has agreed to meet with Amy's family and INQUEST. These concerns will be matters for urgent discussion during that meeting.”

The family’s solicitor, Tony Murphy of Bhatt Murphy: “The question which must now be asked is whether it is safe for the NHS to continue sending vulnerable young people to The Priory.”

ENDS

NOTES TO EDITORS
For further information, please contact Lucy McKay on 020 7263 1111 or [email protected]

INQUEST has been working with the family of Amy El-Keria since shortly after her death.  Amy’s family are represented by INQUEST Lawyers Group members Tony Murphy, Bhatt Murphy solicitors and Raj Desai of Matrix Chambers.

1. The prosecution was brought by the Health and Safety Executive, the UK government agency responsible for the regulation and enforcement of workplace health, safety and welfare. Charges relate to section 3 (1) of the Health and Safety at Work Act 1974, which states “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.”
   
   
2. The inquest into Amy’s death concluded on 2nd June 2016 – see the media release for more information. The coroner wrote a Prevention of Future death report, which summarises the findings of the inquest.
   
   
3. Throughout Amy El-Keria’s case the Priory resisted scrutiny: refusing an independent investigation pre-inquest, arguing against an enhanced ‘Article 2’ inquest, opposing an inquest jury, claiming they did not carry out public functions in response to an FOI from INQUEST which sought details of possible other child deaths in their care. This conduct has exacerbated the trauma for Amy’s family, and frustrated the processes intended to keep others safe.
   
   
4. INQUEST has consistently highlighted the failures of oversight and scrutiny concerning the deaths of children in mental health settings. This was highlighted by BBC’s Panorama in 2016 with research by INQUEST.
   
   
5. Changes introduced since fail to address INQUEST’s central concerns:

• There is an absence of publicly available information about the number and circumstances of deaths of children and young people who have died while receiving in-patient mental health care from the Priory Group and other providers.  This remains in contrast to all other state detention deaths. 
  
  
• There is no system of independent investigation pre-inquest into the deaths of children who die as mental health inpatients, unlike in other detention settings. This is something which INQUEST have repeatedly called for. The mental health provider in which the death occurs remains responsible for commissioning any investigations or investigating themselves prior to the inquest. 

6. In the financial year 2017/18, the Department of Health reports that 44% of child and adolescent mental health services (CAMHS) expenditure was on services by the ‘Independent Sector’ of which the Priory is a significant recipient. Spend to Independent Sector providers in 2017/18 totalled £156.5 million. This information was published in answer to a parliamentary question by Luciana Berger.
   
   
7. Through INQUEST’s casework we are aware of the following cases involving the deaths of children and young people receiving Priory in-patient mental health care:

• Pippa ‘Pip’ McManus, 15 years old, died on 9 December 2015 while formally an inpatient of Priory Hospital Altrincham. See INQUEST media release.
• Evelina Alksne, 22 years old, died on 30 March 2015 while formally an inpatient of Priory Group’s Recovery First Hospital, Widnes.
• George Werb, 15 years old, died on 28 June 2014, in the care of Priory Hospital Southampton. See media coverage.
• Sara Green, 17 years old, died on 18 March 2014, in the care of Priory Hospital Cheadle Royal, Cheshire. See INQUEST media release.
• Francesca Wyatt, 21 years, died on 28 September 2013, in the care of Priory Hospital Roehampton. In March 2013 HM Senior Coroner for Inner West London, Dr Fiona Wilcox, issued a Regulation 28 report to prevent future deaths,  identifying her concerns about ongoing risks.
• Will Jordan, a 16 year old boy who died after he was found hanging in the Priory Hospital North London on 22 January 2018. In August an inquest highlighted serious failures in carrying out observations by Priory staff. See media coverage.