01633 244233 Contact us

22 Apr 2022

Actions against public authorities


Public Law and Private Client

Inquest into the death of Matthew Caseby

Following the inquest into the death of Matthew Caseby, the jury have found that Matthew’s death was contributed to by neglect from the Birmingham Priory hospital.

Matthew Caseby was a 23-year-old personal trainer, who graduated from Birmingham University with a First-Class Honours in History. He was loved by his parents and two sisters, with his father describing him as a gentle and intelligent young man. The tragic nature of Matthew’s death is further emphasised with Matthew being a talented individual with so much of his life ahead of him.

On 3 September 2022, Thames Valley Police detained Matthew under the Mental Health Act (Section 136) following reports of a man running on the railway tracks. An assessment was carried out at Warneford Hospital in Oxford. The acting doctors decided to section Matthew, for his safety, in the Vaughan Thomas mental health ward under Section 2. Matthew was assessed as high risk and was put under 1:1 constant observation while waiting for a bed.

As Matthew’s registered GP was in Birmingham, he was sent there to occupy an available bed in the Beech ward at Priory Hospital Woodbourne. An assessment by staff confirmed that he had a low risk of suicide and self-harm, and a medium risk overall.

A day after his initial assessment, a Healthcare Assistant noticed Matthew looking at the fence in the courtyard. She told the inquest about this and said she had been concerned, so she stood in the way of the lower part of the fence, and verbally made a colleague aware of her concerns. There was a handwritten handover note recorded of this concern, but the note was incomplete and the risk of absconding was not captured on electronic notes. Electronic notes are relied upon by doctors completing ward rounds, so the doctors did not see the handwritten note and were therefore unaware of the Healthcare Assistant’s observation.

After the round was complete, a nurse informed the doctors that Matthew would be able to scale the fence. Despite this, no additional measures or risk assessments were put in place. Both doctors told the inquest that they had assumed Matthew would be supervised at all times in the courtyard. Later that day, Matthew attempted to leave the ward by taking a bin bag of rubbish to the exit but was stopped from leaving by members of staff.

On 7 September, the day after the previous attempt to leave, Matthew and a member of staff entered the Courtyard at 4:40 pm. Matthew then refused to leave the courtyard and was left unattended while staff supervised other patients.

Initially, he was left for 1 minute 40 seconds, then after briefly viewing Matthew through the window, the Healthcare Assistant was called away to an emergency. This meant Matthew was left for a further five minutes. Unfortunately, no other staff member was informed of this.

Matthew absconded over a low section of the fence, which was 2.3 meters high. The police were alerted but Matthew could not be found. The inquest heard that there had been other previous incidents involving patients absconding over the fence, which highlights there was a need for this issue to be addressed.  Alarmingly, a further patient was able to abscond over the fence whilst this inquest was being heard.

Neglect concluded as the main contributory factor to Matthew’s Death

After hearing over two weeks of evidence, the jury concluded that Matthew’s death was contributed to by neglect. Matthew’s cause of death was stated as a head injury after colliding with a train, alongside a psychotic episode. The jury gave a detailed narrative conclusion finding that Matthew “became acutely unwell with a psychotic illness” on 3 September 2019. They found that when he died, Matthew “did not have the capacity to form any intention to end his life”.

The jury narrative included that it was inappropriate and unsafe for Matthew to be left unattended in the courtyard. They also believed that the communication between staff was ‘lacking’ and Matthew’s risk assessments were inadequate.

Craig Court, a Partner in our Dispute Resolution team, who represents Matthew’s family, issued the following statement.

“Matthew’s family have shown incredible strength throughout this inquest process. The jury’s conclusion highlights the significant failings in Matthew’s care. Inadequate and unsafe practices meant that Matthew was able to abscond from the hospital which should have been keeping him safe in his time of need.

The jury’s finding that Matthew’s death was contributed to by neglect will be little comfort for Matthew’s family but it is important that significant lessons are learned in the hope that it will prevent another family going through such an ordeal.

To help ensure that similar situations are avoided in the future, the coroner will be implementing a ‘Prevention of Future Deaths’ (PFD) report. This will include seven issues that need to be addressed, six of which being directed to The Priory Group, with the remaining issue concerning guidelines for mental health units. The coroner has indicated an intention to write to the Department of Health & Social Care regarding this issue.

Mr Court commented “The PFD report highlights the shortcomings in the care provided to Matthew. Matthew’s death was preventable and these issues must be urgently addressed”.

The family were represented at the inquest by Craig Court and Dr Oliver Lewis of Doughty Street Chambers. They have also been supported by INQUEST caseworker Caroline Finney.

For press enquiries, please contact Craig Court at courtc@hevans.com

Share post