Matthew Caseby: Plea to tighten fence rules after patient's death

The inquest heard Matthew Caseby had been left unsupervised in a courtyard area

A coroner has urged health chiefs to consider imposing minimum standards for perimeter fences at acute mental health units after a patient died.

Failings amounting to neglect contributed to the death of Matthew Caseby in 2020, who fled Birmingham's Priory Hospital Woodbourne and was hit by a train, an inquest concluded.

Birmingham and Solihull senior coroner Louise Hunt said she remained concerned at record-keeping quality.

The Priory Group has apologised.

Mr Caseby, who lived in London, had been detained under the Mental Health Act by Thames Valley Police on 3 September.

He was hit by a train near Birmingham's University station on 8 September, the day after he was seen leaving the hospital.

An inquest jury ruled last week Mr Caseby, 23, a personal trainer, was left "inappropriately unattended" for several minutes before he climbed over a 2.3m (6.5ft)-high courtyard fence.

The jury was told despite concerns by members of staff about the fence and the courtyard, no action was taken to improve security in that area until another patient absconded two months after Mr Caseby's death.

In a Prevention of Future Deaths report sent to the Priory Group, NHS England and the Department of Health and Social Care, Mrs Hunt expressed "serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients".

The coroner added: "The inquest heard evidence that a previous absconsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focused on why the patient absconded."

Addressing her concern over the safety of the courtyard fence, she said: "A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe.

"I have serious concerns that an urgent review of the courtyard is required."

Mrs Hunt said: "The inquest heard evidence from Prof Shaw, a specialist in safety in Mental Health settings, that it would be useful for there to be standard guidelines for the requirements of perimeter fences and security for outside areas in acute Mental Health units as no such guidance is in place."

The Priory Group said it had already implemented changes

Mr Caseby's father, Richard, 61, said it was "disturbing that 20 months after Matthew's death, the Priory Group is still so complacent that it has failed to make the necessary improvements to safety and security".

He said: "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."

He described his son as a "beautiful, gentle and intelligent young man".

The Priory Group has apologised unreservedly for the shortcomings in care identified during both the investigation process and the inquest.

In a statement issued following the inquest, the group said: "We accept that the care provided at Woodbourne in this instance fell below the high standard patients and their families rightly expect from us, and we fully recognise that improvements are needed to the service."

It added it had already implemented changes in relation to policies, procedures and the hospital environment, but would "now carefully study the coroner's findings to ensure that we take all necessary measures to improve patient safety at Woodbourne".

The group, which said the hospital was rated good overall by CQC inspectors in their February 2022 report, stated: "We would welcome national guidance on how best to achieve the most appropriate level of security in acute mental health units, while balancing the need for these to remain therapeutic and rehabilitative environments."