Prevention of Future Deaths report: Matthew Caseby (27 April 2022)

Summary

An investigation started on 9 October 2020 into the death of Matthew Alexander Caseby. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on the 8 September 2020 and was fatally injured. At the time, Matthew was suffering from disorder thinking and did not have the capacity to form any intention to end his life.

Matthew absconded from Beech ward over a fence in the courtyard area and at the time of his absconsion Matthew was unattended. It was inappropriate for Matthew to be left unattended in the courtyard. There were concerns regarding Matthew absconding but the recording processes on Beech ward were inadequate which resulted in the communication to staff involved in Matthew's care being lacking. As a result of risks not being fully recorded, Matthew's risk assessment was not adequate as it was not based on all of the available information.

Overall, the inadequate risk assessment for Matthew, the inadequate documentation records, the lack of a risk assessment for the courtyard area and the absence of a policy regarding observations levels in the courtyard means that the courtyard was not safe for Matthew to use unattended. His death was contributed to by neglect on the part of the treating hospital.

Content

The Matters of Concern are as follows:

For the Priory Hospital:

1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. There are serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost.

2. Record Keeping quality: There were numerous inaccuracies in Matthew’s medical records, eg his status was written as informal when he was formal, he was described as violent when he was not and was described as "she". Staff were unable to explain how that occurred. The investigation witness from the Priory thought there was an element of cutting and pasting into the records from another patient’s records. There are serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients.

3. Risk Assessments: The inquest heard how all members of staff can update a Risk Assessment at any time. Despite this, and with clear evidence that Matthew was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised. There are serious concerns about how risk assessments are completed, when they are completed, who completes them and whether they are updated in a timely and necessary manner by suitably experienced staff.

4. Serious Incidents: The inquest heard evidence that a previous absonsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focussed on why the patient absconded ie to have a cigarette. There are serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time.

5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe. There are serious concerns that an urgent review of the courtyard is required. In addition,evidence heard from a Dr that the fence was a ligature risk. Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained.

For the Department of Health:

1. National guidelines for perimeter fences and security in acute mental health unit outside areas. The inquest heard evidence from a Professor, 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. This would ensure the correct level of security for some of the most vulnerable patients whilst maintaining a therapeutic setting.