Damning verdict on student's death amid worrying pattern at the Priory

Is the Priory fit for purpose? Thousands of NHS patients are sent to its lucrative private mental health clinics every year. But after a coroner’s damning verdict on a 23-year-old student’s death, the Mail’s dossier exposes a deeply worrying pattern

  • The Priory is now the biggest provider of mental health services in the country
  •  A coroner has slammed the provider for the death of patient Matthew Caseby 
  • The 23-year-old was hit by a train after climbing over a fence at one if its centres
  • An investigation by the Daily Mail reveals a deeply worrying pattern of deaths
  • A charity supporting bereaved families, has identified more than 20 such cases
  • Samaritans offers confidential support – call 116123 or visit www.samaritans.org

Matthew Caseby graduated from Birmingham University with a first-class degree in history. 

Apart from being academically gifted, he also excelled at sport, particularly football. As a teenager, he had trials with Charlton Athletic FC. 

Most recently, he was preparing to start his own fitness business after qualifying as a personal trainer.

Matthew, who was 23, was much loved in the same way all the other faces staring out from this page were.

Matthew Caseby, 23, was a promising student and sportsman. Matthew was struck by a train after climbing over a low fence in the courtyard of the Priory Woodbourne Hospital in Birmingham in September 2020, where he had been left unattended

Failure: The Priory Woodbourne, in Birmingham, at which Matthew Caseby was being treated

Behind each face is a grieving family and a shocking story of failings in the care they received. All of them have something else in common. They were all being treated by the Priory when they died.

The Priory has become synonymous with celebrities recovering from drink or drug addiction at the brand’s flagship hospital in Roehampton.

But the majority of patients at more than 300 Priory clinics all over Britain are paid for by the NHS; the taxpayer, in other words. 

The Priory, which gets at least £400 million a year in lucrative NHS contracts, is now the biggest provider of mental health services in the country.

Keep that in mind when you read what happened to the people in these photographs: husbands, wives, sons, daughters. Let’s start with Matthew.

Matthew was struck by a train after climbing over a low fence in the courtyard of the Priory Woodbourne Hospital in Birmingham in September 2020, where he had been left unattended.

Francesca Whyatt, 21, made nine suicide attempts after her admission to the Personality Disorder Unit at the Priory Roehampton. No one noticed when, in September 2013, she climbed from the basement, through supposedly locked doors, to the top floor lounge where she strangled herself. Coroner Karon Monaghan QC said she was at known risk, and should not have had the means to kill herself this way.

The death of a troubled young man in such circumstances rarely makes the news. These tragedies happen from time to time, is the usual reaction. But at Matthew’s recent inquest a very different narrative emerged.

It was not the first time that a patient had absconded from Woodbourne by climbing over the same fence as Matthew, nor the second time, but the third.

In fact, the same fence was breached on a fourth occasion after he died. Only at that point was the height raised to 9ft 10in (3 m) from 7ft 6in (2.3 m).

The findings were contained in an independent report, commissioned following pressure from Matthew’s parents to uncover the truth, which also listed an additional 32 ‘contributory factors’ — bad practice to put it bluntly — that played a part in his death and amounted, said the coroner, to ‘neglect’.

How many other Matthew Casebys are there? The answer is far too many.

William Jordan, 16, was left unattended in the hours leading up to his death in January 2018 at the Priory North London, despite clear instructions that he required checking four times an hour. Staff then falsified logs to appear as if they had done so. At his inquest, coroner Andrew Walker condemned the ‘really serious failure’ of staff to adequately monitor the teenager, who was found hanged in his room.

The charity Inquest, an organisation supporting bereaved families, has identified more than 20 such cases since 2012 and there are surely many more that we haven’t heard about.

Matthew’s family, remember, had to fight to find out what happened to him.

Since 2019, four Priory hospitals have been forced to shut following damning inspections by the Care Quality Commission (CQC), the NHS regulator, due to a shortage of staff, who often lacked the skills to deal with the complex needs of patients.

Sara Green, 17, began self-harming after being bullied. Because of a shortage of beds, Sara was sent to the Priory Cheadle Royal, South Manchester, more than 100 miles from where she lived. In March 2014, she hanged herself in her room at the hospital. Earlier, she had asked her suicide watch to be changed from every five minutes to every 15 minutes and staff agreed.

One of those hospitals was being run by the same senior Priory executive responsible for Woodbourne where Matthew spent his last days.

It is impossible to say how many patients like Matthew, among them five teenagers, would be still alive if they had received better care. 

In some cases the coroner said death was ‘preventable’. In others, there were ‘missed opportunities’ which might have resulted in saving someone.

One of Britain’s top town planners, Keith Hearn, 58, checked into the Priory Roehampton in 2015 after becoming depressed about not being able to work following a hip operation. Shortly afterwards, the father-of-two was caught trying to kill himself. The next day he was found hanged. Coroner Bernard Richmond QC ruled his death was ‘preventable’ and he should have been placed ‘on one-to-one observation’.

People with mental illness, it is true, are, by their very nature, often difficult, unpredictable and sometimes violent; there surely can’t be many more challenging environments than an acute mental health unit. 

But the very least families like Matthew’s expected when their loved ones entered the Priory was a proper standard of care to help them live with their illness.

They didn’t get it.

Matthew himself, who didn’t smoke, drink alcohol or take drugs, had no previous history of serious mental health issues before suffering a ‘psychotic episode’ so, in different circumstances, he could well have made a full recovery.

In 2019, the Priory Group was fined £300,000 after pleading guilty to charges brought over Amy El-Keria’s death. The 14-year-old was being treated at the Priory’s Ticehurst House Hospital in East Sussex when she hanged herself in November 2012. Staff failed to dial 999 or call a doctor quickly enough and the jury at her inquest agreed Amy may have lived if she had received the care she deserved.

‘I’m convinced Matthew would have,’ said Mr Caseby, 61, who runs a communications business. 

‘He should be still with us. He was loved by his family and he had so much promise.’

The same criticisms at Priory-run establishments crop up again and again at inquests which suggest lessons are not being learnt: inadequate risk assessments, lack of staff training or expertise, failure to carry out appropriate observations and address known ligature points, mishandled discharges and negligent record-keeping, including two instances where staff deliberately falsified records. 

Evelina Alksne, 22, was a victim of a catalogue of errors when the Recovery First Hospital, Widnes, was run by the Priory. In 2015, soon after Evelina arrived there, she killed herself using a bandage that staff had failed to identify as a risk. They did not act when alerted to her declining mental state and also failed to transfer all her medical history from a previous hospital. The inquest also revealed supervision levels for inexperienced staff was ‘unsatisfactory’.

Only last month, a few days after Matthew’s inquest, another inquest heard a 20-year-old student was found hanged from a known ligature point in her room which was supposed to have been removed.

Three families are also in the process of taking legal action against the Priory.

If there is a single issue that unites bereaved families — we have spoken to a number over the past few weeks — it is the continued ‘outsourcing’ of mental health services to companies such as the Priory, which has been accused of putting ‘profits before patients’.

Pippa McManus, 15, who was severely anorexic, died after stepping in front of a train after being granted home leave from the Priory Hospital Altrincham before the completion of the formal discharge process. In 2017, an inquest jury said that the lack of support provided to her family and delays in implementing a care plan could have been contributing factors in her death two years earlier.

The Priory Group is owned by a Dutch private equity firm, which bought the business for more than £1 billion from its U.S. owners in 2020. 

There are, of course, good private equity companies and bad ones. 

Some are seen as the sharks of the financial world, buying up established businesses with borrowed cash before ‘restructuring’ them — usually by selling off existing assets and shedding jobs — to maximise the bottom line.

Nevertheless, children with autism, teenagers with eating disorders, adults with learning disabilities as well as dementia sufferers and people in psychological distress are all farmed out to the Priory because the NHS doesn’t have either the staff or resources to do this work itself.

Patrick Casey, 41, choked to death in a tragic mix up at the Priory Devon House, North London. His family said they made it clear he should never be given marshmallows, as did a speech therapist, because he had difficulty swallowing. But staff thought he could have the sweets provided they were cut into pieces. In 2019, coroner Andrew Walker said this death was avoidable and due to failures to follow his dietary requirements.

This is the reason why, after being found by police wandering along railway lines outside Oxford on the evening of September 3, 2020, Matthew was detained under the Mental Health Act and admitted to the Woodbourne Priory Hospital in Birmingham, the city where he was still registered with his university GP, instead of somewhere nearer his home in London.

There is a detailed breakdown of what happened to him in the 60 hours he was in Woodbourne from two sources. 

One is the independent report into his death by Professor Jennifer Shaw. 

The other is a prevention of future deaths (PFD) notice by coroner Louise Hunt. PFD notices are made to address concerns arising from inquests.

Things started to go wrong almost from the moment Matthew arrived. He was assessed as a low suicide risk when he should have been ‘rated as high until proven otherwise’, the coroner said.

Neil Carter, 37, an IT consultant, from Ewell, Surrey jumped to his death in front of a train in 2012. He was being treated at the Priory Roehampton for misophonia — an extreme intolerance to certain sounds — when he went missing. Coroner Dr Sean Cummings concluded: ‘There were gross failures in his care, notably the failure to perform basic observations, followed by a deliberate falsification of the record.’

Matthew was also described as violent in his medical records when ‘he was not’. Even his sex was recorded incorrectly. 

According to his notes, Matthew was a ‘she’. One witness suggested the mistake may have arisen because ‘there was an element of cutting and pasting into the records from another patient’s records’.

Furthermore, patient details were kept both on handwritten handover sheets and electronic notes which created ‘a real risk’, according to the coroner, which ‘materialised in Matthew’s case’. 

Matthew had been observed assessing the height of the courtyard fence and ‘hanging around doors and asking to go outside’.

But while this information was documented on the handover sheets, it wasn’t entered into his electronic notes and these were the ones relied on by doctors when completing the ward round.

Eliana Hanton, 20, was studying biology at university and planned to become a hearing specialist working with children. But while being treated at the Priory Hospital in Woking, she made numerous attempts to take her life. In January last year she succeeded using a known ligature point in her room which should have been removed but wasn’t. Her life support machine was switched off six weeks later, her inquest heard last week.

Moreover, CCTV didn’t cover the whole courtyard area, making it ‘unsuitable’ for patients.

They were among the 32 contributory factors culminating in Matthew’s death listed by Professor Shaw following her inquiry.

‘To put this into context, she told me that in a career spanning over two decades she has never had to author a report that contains such a high number of contributory factors to a death,’ Mr Caseby revealed.

On the evening of September 7, 2020, Matthew was left unaccompanied in the courtyard for five minutes. 

When staff next checked, he had gone. CCTV shows him walking towards the low fence before disappearing from view. Hours later he was dead.

George Werb, 15, ‘calmly’ walked in front of an express train the morning after he was allowed home for a weekend from the Priory Southampton. At an inquest in 2013, coroner Lydia Brown said: ‘Poor engagement with the family, placing him in a unit a long distance from home [in Devon], absent note-keeping and inadequate internal communications all contributed to the outcome.’

It was Mr Caseby, however, who discovered under a freedom of information request, that the fence in question had been the scene of previous ‘absconsions’, and that there had been more than 60 absconsions from other areas of the hospital in the previous five years.

This crucial evidence, he says, was not mentioned in Woodbourne’s own initial internal inquiry.

After Matthew died, Mr Caseby contacted the local health trust to discuss his son’s case. But the person at the end of the line insisted he was still alive and still being looked after at the hospital.

Matthew’s records had not been updated. By then he had been dead for 42 days.

‘Sub-standard and insensitive’ the coroner called it.

When racehorse owner Mustafa Khan, 40, was discharged from the Priory North London, after a nine-day stay in 2018, his family was told he was at ‘low risk’ of suicide. But three days later Mr Khan, 40, from Richmond, was found hanged in woodland in Horsham, West Sussex. An inquest ruled that risk assessments were ‘poor’ and did not comply with hospital policies. It found that discharge planning was ‘inadequate’.

The regional hospital director at the time of the tragedy was Victoria Colloby, who gave evidence at Matthew’s inquest. She said she had no knowledge of the poor security at Woodbourne or other shortcomings. 

Ms Colloby was also responsible for Priory Barnt Green hospital in Birmingham. Barnt Green is now in special measures.

The Care Quality Commission (CQC), the NHS regulator, found that the brand-new facility, which had only one ten-bed ward for adult women, could not protect patients from avoidable harm because there were not enough staff with the right training to ensure their safety.  

Some were discovered asleep on duty when, in one instance, a patient was self-harming.

Ms Colloby is now Priory Group’s director of Wellbeing Services on what is thought to be a six-figure salary.

Teacher Suzanne Greenwood, 43, from Bolton, spent four weeks as a private patient at the Priory Altrincham, where she was prescribed anti-depressants for insomnia before being allowed home. The Priory had no contact with her for 11 months before her death in 2014. Her GP reduced her medication shortly before she hanged herself. The coroner said the hospital had no system for contacting patients who missed appointments.

‘This is not a fair reflection of a career in which I have worked very hard in a complex and challenging environment to deliver improvements, which have been recognised in every position I have held,’ she said.

Woodbourne Priory Hospital itself was inspected by the CQC on October, 26, 2021 (a year after Matthew died). The results were published four months later on February 22 (two months before his inquest).

Next to the heading ‘Are patients safe’ is written: ‘Requires improvement.’ Yet Woodbourne was still rated as overall ‘Good’.

Many would argue this is a contradiction in terms and, in the light of Matthew Caseby’s death, seriously undermines any confidence we might have in the system of regulation.

In her report, Coroner Louise Hunt concluded: ‘In my opinion there is a risk that future deaths will occur unless action is taken.’

Anthony McManus, 48, was a patient at Chadwick Lodge mental health services unit in Milton Keynes when it was operated by the Priory Group. On December 8, 2015, he hanged himself. Coroner Thomas Osborne concluded that a failure to carry out proper observation checks ‘may have caused or contributed to his death’. The Priory paid the McManus family compensation following the inquest in 2016.

There could hardly be a more damning indictment.

Matthew’s father has written to Health Secretary Sajid Javid calling on him to close the hospital until her concerns have been addressed.

He has also urged him to introduce a statutory minimum height of at least 3m for perimeter fences at acute mental units and conduct a strategic review of the outsourcing of mental health services.

‘For years, inspections, investigations and inquests — like the one into the death of Matthew — have repeatedly exposed the same failings and harmful practices,’ said Mr Caseby.

The Priory has apologised for the way Matthew was treated. 

‘We would like to say how deeply sorry we are to Matthew’s family, and we apologise unreservedly for the shortcomings in his care both during the investigation process and the inquest,’ the company said in a statement.

Gary Mavin, 54, a father of three, entered the Priory Arnold, Nottinghamshire, after being diagnosed with psychosis. However, his diagnosis at another hospital was not recorded on his notes and his consultant psychiatrist was convinced he was ‘malingering’. Three weeks later, in September 2020, he hanged himself. At his inquest, the coroner said the hospital was responsible for ‘one of the worst examples of care’ provided to a vulnerable patient.

‘We accept that the care provided at Woodbourne in this instance fell below the standard patients and their families expect from us, and we fully accept that improvements are needed to the service.’

On the wider issues raised in this article, a Priory spokesman said: ‘Priory has cared for around 270,000 patients in the last decade, and saved very many lives, and remains one of the safest providers in the UK. While it is impossible to eliminate risk, patient suicides remain rare, and inpatient suicides extremely rare.’

‘Priory has seen no overall increase in inpatient suicide, despite a significant increase in patients accessing its services driven — in part — by a nationwide shortage of inpatient mental health beds. The number of deaths overall remains small and from natural causes.’

This will come as no consolation to Matthew’s father or the many other families of those who died. 

For confidential support, call the Samaritans on 116123 or visit a local Samaritans branch. See www.samaritans.org for details

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