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.
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.
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.
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.
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’.
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.
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.
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.
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.
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.’
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.
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.