Private mental health care provider Priory Healthcase fined £650k after 'avoidable' death of patient

A private mental health care provider has been fined £650,000, after the death of a patient who escaped hospital, climbed over a fence and was hit by a train in Birmingham.

Personal trainer Matthew Caseby, 23, escaped from Birmingham’s Priory Hospital Woodbourne by climbing a 2.3metre fence, 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”.

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.

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

District Judge Shamim Qureshi said dealing with patients detained under the Mental Health Act was a very difficult area for care providers.

The judge, who also made an order for prosecution costs of more than £43,000, said the company had to care for patients “who are vulnerable and need protection from themselves”.

He said the firm’s culpability was high and the risk of harm posed by the offence had been in the medium category under the sentencing guidelines.

During his remarks, Mr Qureshi observed that Matthew Caseby’s father, Richard Caseby, felt that he had to “fight tooth and nail” for the investigation carried out by the coroner’s court and the Care Quality Commission.

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