Written evidence submitted by Mr Richard Caseby (TCS0046)
My name is Richard Caseby. I am the father of Matthew Caseby, who was sectioned under the Mental Health Act, and who was killed after escaping from the Woodbourne Priory psychiatric hospital, in Birmingham, three days after being detained there in 2020.
He escaped over a dangerously low fence, over which previous patients had escaped before. The Priory had done nothing to make the fence safe at the time of Matthew’s own escape. Hours after leaving the hospital he stood in front of a train on September 8, 2020.
The Coroner at Matthew’s inquest issued a Prevention of Future Deaths report which made a number of recommendations for the Priory and the Department of Health and Social Care (DHSC), including about the height of fences in psychiatric hospitals in England and Wales.
If a coroner is so disturbed by evidence of failures that led to the death of your child, they will issue a Prevention of Future Deaths (PFD) report - a list of recommendations that may save the lives of others.
The systemic scandal here is that there is absolutely no guarantee that any changes will be made because the coroner has no legal powers of enforcement.
To this day, three years later, I have no idea whether anything has been done to ensure that no other family suffers the same devastation from the same hospital and government failures as my family.
I have submitted a Freedom of Information request to the DHSC and, at the time of writing this submission, I am still waiting to hear whether the department has acted upon the Coroner’s recommendations.
Is this the treatment that bereaved families should expect – to be blanked, ignored and marginalised? All the while, the sons and daughters of other families remain in danger.
And when someone else’s child dies from the very same failures of care, the whole merry-go-round of investigations and search for accountability will kick off again only to reach the same conclusions.
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My son Matthew, a 23 year-old personal trainer with a first-class history degree, was a smart, sensitive and loving boy.
As a child he was affectionate, playful and good-humoured. As a teenager and young man, he continued to be demonstrative. On any occasion we said hello or goodbye, we would hug and we would always say we loved each other.
Although he had become more withdrawn during the pandemic lockdown, particularly in the months before his death, Matthew had never had a medical diagnosis or treatment for any mental health issue. He never drank alcohol or took drugs.
His sudden crisis occurred as he was taking a train to visit a friend outside London in autumn 2020 just as the first lockdown was lifting, life seemed more positive and there was hope of everyone returning to work.
After reports of him running on railway lines at a village, near Oxford, Matthew was detained by police and doctors diagnosed him as suffering from a psychotic episode. He was assessed as a suicide risk and sectioned under the Mental Health Act for his own safety.
It was a total shock when the police called us to say he had been picked up and taken to hospital for assessment. Within two days Matthew was despatched as an NHS patient to the Woodbourne Priory hospital in Birmingham, the city where he had attended university and was last registered with a GP.
Over three days Matthew made three attempts to escape from the Priory and succeeded when he was left unsupervised in an external courtyard with a dangerously low fence over which other patients had escaped before.
Although senior staff had repeatedly raised concerns about the fence, the Priory had done nothing to make it safe. Within 14 hours Matthew was dead.
On first learning of his escape from a nurse at the Priory, I raced from London to Birmingham to mount a search and was 200 yards away from him when he was hit by a train near his old university residence, just two miles from the hospital. Mercifully, I didn’t see it happen because the rail line is in a culvert.
As a former journalist of 40 years’ experience, I devoted myself to investigating Matthew’s death and lobbied the NHS for 100 days to get an independent investigation report by Prof Jenny Shaw, one of the UK’s leading psychiatric investigators. Her conclusions were devastating.
In just three days the Priory had been so negligent it was responsible for two fundamental causes of Matthew’s death and 29 contributory factors. In a career spanning two decades, Prof Shaw had never before investigated a death where there were so many contributory factors.
It was a litany of failure and negligence by the Priory, from dire record-keeping and utterly inadequate risk assessments through to a gross failure to respond after previous security breaches. The Woodbourne Priory hospital was a danger to anyone who had the misfortune to be put there. I could go on....
At the three-week inquest in 2022, the jury found that Matthew’s death was “contributed to by negligence” by the Priory - the most damning judgement available short of unlawful killing. The Coroner issued a Prevention of Future Deaths (PFD) report and made six recommendations for the Priory and the Department of Health.
At the inquest the Priory was in such aggressive denial that their barrister had the temerity to argue that the Coroner should not issue a PFD even though another patient had escaped from the same hospital, from the same courtyard over the same fence during the inquest.
The Priory knows that a bereaved family is crippled by grief and takes every advantage of this inequality of arms to protect their reputation with its army of lawyers. The company will delay, mislead and obfuscate. Any tactic to hide the truth.
It takes huge resilience for a family to drag the Priory kicking and screaming to face the hard evidence of its shortcomings at an inquest. And even when you do, they’ll still try to deny it.
The PFD recommendation for the Department of Health and Social Care (DHSC) was that it should consider issuing national guidelines for perimeter fences and outside areas in acute mental health units. No such guidance currently exists.
Using Freedom of Information requests, I reviewed fence heights in a sample of 14 NHS mental health units, sent the department my findings and also met with the then Minister for Mental Health, Gillian Keegan.
Has anything been done? I have no idea despite repeated requests of the department. Silence. A cliff edge. I
I have recently submitted another Freedom of Information request and await as to whether a minister or civil servant will produce an answer.
After a year’s work and a blitzkrieg of Freedom of Information Requests and Subject Access Requests, that’s where we are. And if I cannot find an answer as a privileged, middle-class professional, then God help a single mother working all hours on a minimum wage doing her best to raise her surviving children at the same time.
This is precisely where the PFD regime falls down. Unless a family, lawyer or charity makes enough noise and impact, there is absolutely no guarantee of any change. Culpable organisations and individuals just slide away from their responsibilities.
The Coroner’s guidance states: “PFDs are vitally important if society is to learn from deaths…a bereaved family wants to be able to say: “His death was tragic and terrible but at least it shouldn’t happen to somebody else.”
Through working with the Inquest charity, I have been horrified to meet so many other parents who have lost their children after experiencing the same Priory failings that led to Matthew’s death. This scandal has gone on for years.
The current system results in fragmented, piecemeal and ad hoc initiatives to act on recommendations. To the extent that change is achieved, it is often not sustained. Actions peter out only to be raised again several years later, often when there have been further preventable deaths.
For years inspections, investigations and inquests have exposed the same failings and harmful practices at the Priory: poor risk assessments; lack of observations; ligature points; negligent record-keeping; poor communication and unsafe environments.
Under the Coroner’s and Justice Act 2009, a Coroner is required to make a report where evidence suggests future deaths might be prevented.
The problem is that although the recipient of the report is under a legal duty to consider and respond, there is no sanction if they don’t - or even if they don’t bother to respond at all. There is a complete lack of transparency.
In 2021 there were 440 PFDs issued across England and Wales but, as the Commons Justice Select Committee itself observed: “There is no follow-up to see if coroner’s reports have had the desired impact”.
Bereaved families know all too well the blackhole emptiness of the mantra “lessons will be learned”. It is the same problem at public inquiries, where there is no legal mechanism to require consideration or reasoned rejection of recommendations.
There is, though, a simple answer. A highly focused official supported by a small office is urgently needed to ensure proper follow up of these reports otherwise more people will die needlessly. I would call them the Commissioner for the Prevention of Future Deaths, if you will.
The Inquest charity is campaigning to establish this independent oversight body which would close the gap in accountability from recommendations made to actions completed. It would also audit and analyse the changes required at a national level to ensure continuity and consistency.
Investigatory processes drag on for years and organisational memory is lost. Even when there is a goodwill, people move on and previous promises to act are all too easily forgotten.
The first weapon in the Commissioner’s armoury would be the power of embarrassment at inquiries, select committees and, of course, in the media. Never under-estimate the effect of a public shaming on reputation and share price. Defy the Commissioner at your peril, lazy and dangerous hospitals and prisons.
Some accountability, of course, can be forced if a family is dogged enough. After much prodding by me, the Care Quality Commission launched a criminal investigation into the Priory Healthcare Ltd. The company is now pleading guilty to exposing Matthew to serious risk of harm and will be sentenced by a district judge in March. The Priory faces the penalty of an unlimited fine.
Meanwhile, the Birmingham Women’s and Children’s NHS Trust continues to send its vulnerable NHS patients to the Woodbourne Priory, a hospital branded as “inadequate” by the health regulator. Why? Because the Priory has been allowed to corner the market in NHS mental health beds.
Today the Prevention of Future Deaths report issued after Matthew’s death lies gathering dust on a shelf somewhere in the Department of Health and Social Care and there is still no recommended minimum height for a fence in any acute psychiatric unit in England or Wales.
Today, no criminal inquiry or inquest guarantees that the necessary changes to prevent new tragedies will be made promptly - and be seen to be done. That will only happen when there is a Commissioner for the Prevention of Future Deaths.
Others are finally acknowledging this blinding truth.
Last year the Independent Advisory Panel on Deaths in Custody (IAPDC) suggested the government should consider setting up this new body to audit, follow up and collate PFD report recommendations.
The IAPDC report found that “the preventative potential of PFD reports is not currently being fully realised, with families criticising the current system as “nothing more than a paper exercise”.
It said both coroners and families express “deep frustration” that further deaths take place under the very circumstances they have previously warned about or experienced
It also highlighted that coroners’ concerns are often “only cursorily addressed by respondents, or simply not addressed at all” and it noted that recipients of a PFD report are under a legal duty to consider and respond but there is no sanction if they do not.
The panel also found that the PFD reports vary greatly in quality, limiting their impact, are often published long after the inquest and may not be sent to the organisations that are best placed to ensure changes are made, with no central research system available to co-ordinate the report.
Most important of all, the panel said that the government should consider setting up a new body to audit, follow up on and report on PFD reports.
The IAPDC said the Department of Health and Social Care (DHSC) should also give “serious consideration” to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings.”
Finally, in its 2021 report on the Coroner Service, the Justice Committee expressed concern about whether families were really put at the heart of the Coronial process. The government has repeatedly stated that they are. Given my experience and that of other families I have met, they most certainly are not.
Families usually enter the coronial arena innocently believing that everybody present is only concerned in discovering the truth about their relative’s death. Nothing could be further from the truth. There is absolutely no equality of arms.
Public bodies like NHS Trusts and the police and private sector health suppliers all turn up to inquests fully armed with battalions of highly-paid lawyers - most of them funded out of taxpayers’ money.
Their single concern is to protect the reputations of their clients by deflecting any hint of accountability. They behaviour is shocking. In my experience these lawyers are manipulative, obfuscating, defensive and aggressively adversarial towards families who are already traumatised.
There have been two significant reforms. In January 2022 the rules for Exceptional Case Funding for inquests were changed to remove the means test and in May 2023 the government said it would remove the means test for inquests involving a potential breach of rights under the European Convention on Human Rights.
Those are steps in the right direction. In fact, I was one of the very first beneficiaries of the change in rules in January 2022 - a change that the INQUEST charity campaigned so hard to deliver.
However, to guarantee true equality of arms, all inquests where the state is represented should be publicly funded.
ENDS
January 2024