Before HM Coroner Louise Hunt and a jury
Birmingham and Solihull Coroner’s Court
4 – 21 April 2022

Matthew Caseby was 23 years old when he died after being struck by a train on 8 September 2020. He had absconded from the Priory Hospital Woodbourne in Birmingham, where he was a detained NHS funded mental health patient.

An inquest jury has today concluded that neglect contributed Matthew’s his death, with a narrative conclusion describing a series of failures in the care he received at The Priory.

The courtyard fence which Matthew absconded over was 2.3m high. The low height of the fence was a known risk, with previous escapes over it both in 2018 and 2019. Yet no action was taken. Another patient escaped over the same fence during the course of the inquest.

The coroner will be making multiple reports to prevent future deaths, with recommendations to address seven ongoing issues (detailed below).

Background and circumstances

Matthew was from London. He was a personal trainer who graduated from Birmingham University with a first in History. He was a talented footballer and as a teenager had trials with Charlton Athletic FC. He was much loved by his parents and two older sisters.

On 3 September 2020, Matthew was detained by Thames Valley police under the Mental Health Act (Section 136) at a village north of Oxford, following reports of a man running on the railway tracks. After an assessment at Warneford Hospital in Oxford, doctors decided to section him there in the Vaughan Thomas mental health ward, for his own safety (under Section 2).

Matthew was assessed as high risk and put under 1:1 constant observation whilst waiting for a bed to be found. Matthew’s last registered GP was in Birmingham. He was therefore sent there, almost 80 miles away, to an available bed in the Beech ward at Priory Hospital Woodbourne.

Upon arrival on 5 September, Matthew was assessed by Priory staff and found to have a low risk of suicide and self-harm, and medium risk over all. The level of observations was set to four checks per hour (level two). Notes recorded by staff later that day show that he presented as anxious and delusional, and was at risk of absconsion.

The following day, a Healthcare Assistant observed Matthew in the courtyard looking at the fence. She gave evidence to the inquest that she had been concerned that he would try to abscond. To mitigate this, she stood in the way of the lower part of the fence, and verbally made a colleague aware of her concerns.

A handwritten handover note recorded this concern but was incomplete. The risk of absconsion was not captured on electronic notes, which are relied upon by doctors completing ward rounds. Indeed, doctors completing a round that afternoon did not see the handwritten note.

Following the round, a nurse informed the doctors that Matthew would be able to scale the fence. However, no additional risk assessment was undertaken or measures put in place. Both doctors told the inquest they had assumed Matthew would be supervised at all times in the courtyard, despite there being no official policy.

Later, Matthew attempted to leave the ward by taking a bin bag of rubbish to the exit door but was stopped.

On 7 September, the day after the previous attempt to leave, Matthew entered the courtyard at 4.40pm with a member of staff. After 15 minutes, Matthew refused to come back inside. He was then left unattended while staff supervised other patients.

Initially he was left for 1 minute 40 seconds, then after briefly viewing Matthew through the window the Healthcare Assistant was called away to an emergency. This meant Matthew was left for a further five minutes. No other staff member was informed of this.

The jury commented in their summary of facts that Matthew was inappropriately unattended in the courtyard. There was no official policy or guidance on supervision there, or relevant risk assessment. 

Matthew was able to abscond over a low section of the fence that was 2.3 metres high. The police were alerted but Matthew was not found.

The inquest heard that there had been numerous previous incidents involving patients absconding over this fence, but this had not been addressed. During the hearing another patient absconded over the same fence.

Jury conclusions

After hearing more than two weeks of evidence from witnesses and experts, the inquest jury concluded finding that Matthew’s death was contributed to by neglect. The cause of death was a head injury, high impact collision with a train, alongside a psychotic episode.

The jury gave a detailed narrative conclusion finding that Matthew “became acutely unwell with a psychotic illness” on 3 September 2019. They found that when he died Matthew “did not have the capacity to form any intention to end his life”.

The jury narrative included the following issues:

• It was inappropriate and unsafe for Matthew to be left unattended in the courtyard.
• The recording processes were inadequate, resulting in communication to staff involved in Matthews care being “lacking”.
• As a result of risks not being fully recorded, Matthew’s risk assessment was not adequate.
• There were shortcomings in the Priory processes for recording and sharing information between staff.

The jury also found that there was no written policy on observation levels in the courtyard, the omission of which led to a lack of consistent understanding by staff as to what should happen. This made the courtyard unsuitable for use by patients.

The jury noted that, although staff had concerns regarding the height of the fence, there is no evidence that the issue had been raised in any written or official way. However, senior hospital management were aware of previous incidents. The jury found there was therefore a missed opportunity to review the physical security of the area.

The coroner will be making reports to prevent future deaths on seven issues, six addressed to The Priory Group and one addressed to the Secretary of State for Health and Social Care.

Recommendations to The Priory relate to issues of record keeping, risk assessment, the safety of the fence and courtyard, and the organisation’s response to serious incidents (such as the previous incidents involving the low fence) which the coroner calls on them to review.

The report to the Secretary of State recommends national guidelines on security in acute mental health units, particularly relating to the issue that there is currently no national standard for the height of fences in acute mental health wards.

Richard Caseby, Matthew’s father said on behalf of the family: “Matthew was a beautiful, gentle and intelligent young man whose ambition was to help everyone live a better life through exercise. He was loved by his family and he had so much promise.

After a long campaign, we are pleased that the truth has finally been heard. We thank the coroner for being so forensic and sensitive in her investigation into our son's death.

Unknown to his family, Matthew was suffering his first mental health crisis. He was sectioned as an NHS patient under the Mental Health Act for his own safety and we were assured that the Woodbourne Priory Hospital, Birmingham, was the best place for him.

But in a litany of failings, the Woodbourne Priory failed to assess Matthew's risk of absconsion when it should have been high. It also wrongly assessed him as a low suicide risk even though he was diagnosed as psychotic and had been originally detained for his own safety because he had been running on train lines.

Matthew escaped over a low fence when left unsupervised in a courtyard just 60 hours after admission and died shortly afterwards. The hospital was aware of previous escapes over the same low fence and yet had done nothing to improve security.

The Priory Group were accountable for Matthew’s care and safety yet they failed profoundly to prevent harm to him.

We can never bring Matthew back but we can prevent this ever happening again. Matthew was sent to the Woodbourne Priory by the Birmingham Women's and Children's NHS Foundation Trust, which outsources all NHS mental health care for young adults.

The Trust’s failure to conduct any assurance visits for over two years before Matthew's death resulted in them being dangerously disconnected from the care of their NHS patients at the hospital.

The Trust should have had far better oversight in respect of patients’ safety. The inquest heard expert evidence that the Trust had also failed to take all reasonable measures to prevent harm to Matthew.

To prevent such tragedies ever happening again, NHS England should review its national policy of outsourcing mental health beds to a supplier like the Priory, which consistently fails to keep patients safe.”

Deborah Coles, Director of INQUEST, said: “INQUEST is deeply concerned by the number of deaths occurring at Priory run mental health units nationally. Issues raised at this inquest around risk assessment, observations, and addressing known dangers are occurring time and time again. Yet no action is taken.

Neglect contributing to the premature and preventable death of Matthew, a young man who had his life ahead of him, once again demonstrates the inability of these services to change. We repeat the question, how many more people must die before the NHS and government reconsider commissioning services from a company that puts profit over patient safety?”

Craig Court of Harding Evans solicitors, who represent the family, said: “Matthew’s family have shown incredible strength through this inquest process. The jury’s conclusion highlights the significant failings in Matthew’s care. Inadequate and unsafe practices meant that Matthew was able to abscond from the hospital that should have been keeping him safe in his time of need.

The jury’s finding that Matthew’s death was contributed to by neglect will be little comfort for Matthew’s family but it is important that significant lessons are learned in the hope that it will prevent another family going through such an ordeal.”

ENDS

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

Matthew’s family are represented by INQUEST Lawyers Group members Craig Court of Harding Evans Solicitors, and Dr Oliver Lewis of Doughty Street Chambers. They are supported by INQUEST caseworker Caroline Finney.

Other Interested persons represented are The Priory Group, West Midlands Police, British Transport Police, Birmingham and Solihull CCG, Birmingham Women’s and Children’s NHS Foundation Trust.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.