Matthew Caseby death contributed to by neglect of the Priory

Matthew Caseby was 23 years old when he died after being struck by a train on 8 September 2020. He had absconded from the Priory Woodbourne hospital in Birmingham, where he was a detained NHS funded mental health patient.

Senior Coroner for Birmingham and Solihull Mrs Louise Hunt sat with a jury between 4 and 21 April 2022 to conduct the inquest into Matthew's death, and issued a prevention of future deaths report on 25 April 2022. The jury found that neglect contributed to Matthew’s death and published a narrative conclusion describing a series of failures in the care he received at the Priory.


Matthew was from London. He was a personal trainer who graduated from Birmingham University with a first in History. He was much loved by his parents and two older sisters.

On 3 September 2020, Matthew was detained under the Mental Health Act by police in a village in Oxfordshire, following reports of a man running on the railway tracks. After a mental health assessment, doctors detained him under s.2 Mental Health Act. He was guarded and could not explain what he was doing on live railway lines. Matthew’s last registered GP was in at his university in Birmingham, so he was sent there to a bed in the Beech ward at Priory Hospital Woodbourne. The local Trust - Birmingham Women's and Children's NHS Foundation Trust - contracted with the Priory to provide inpatient mental health services to 18-25 year olds.

On admission in the early hours of Saturday 5 September 2020, Matthew was assessed by a non-psychiatrist doctor who recorded a low risk of suicide on the basis that he had no active suicide plans. The doctor told the inquest that this assessment was incorrect. Matthew was placed on 15-minute observations. Notes recorded by staff later that day show that he presented as anxious, guarded and responding to unseen stimuli. Handwritten nursing handover notes during the weekend recorded "risk of absconsion".

A healthcare assistant observed Matthew in the courtyard over the weekend looking up at the fence, but this was not recorded. She was concerned that he would try to abscond over the fence, so she stood at the top of the steps where the fence was 2.3 metres.

A consultant psychiatrist reviewed Matthew in ward round on Monday 7 September 2020. The psychiatrist was not aware of the absconsion risk, because the nursing handover notes were not available to him and nor had this information been recorded in the electronic notes. The risk assessment carried out by the non-psychiatrist doctor was not reviewed. The nurse in charge told the psychiatrist of her concerns of Matthew's absconsion risk, but the psychiatrist did not assess absconsion risk or put in place any mitigating measures. The psychiatrist told the inquest he thought Matthew would be supervised in the courtyard, because despite there being no written policy of the status of the courtyard or how patients are to be observed there, that was what he thought usually happened.

Matthew went into the courtyard at 4.40pm with a member of staff, and after 15 minutes, he refused to come back inside. He was then left unattended while staff attended to other patients. He scaled the fence and ran out of the hospital grounds. The police were alerted but Matthew was not found. Very sadly, he was hit by a train at 8:40am the following morning and died.

Matthew was able to abscond over a low section of the fence that was 2.3 metres high. The inquest heard that patients had escaped over the courtyard the fence in 2018 and in 2019. Contrary to the NHS Serious Incident Framework, the Priory had not considered these escapes to be security breaches/concerns, and had not notified the commissioning NHS Trust of them. It carried out no analysis of the escapes and took no action to make the courtyard more secure.

Jury conclusions

After hearing evidence from witnesses and two independent experts, the jury formed 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 recorded that "Matthew was inappropriately unattended in the courtyard. This was in contrast to what the majority of staff reported to be standard practice during their evidence. There was no official written policy or guidance on supervision or observation in the courtyard and there was no risk assessment in place."

The jury noted that, although staff had concerns regarding the height of the fence, there is no evidence that the issue had been raised in any written or official way. However, senior hospital management were aware of previous incidents. The jury found there was therefore a missed opportunity to review the physical security of the area.

The jury found that, "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." and that "his death was contributed to by neglect on the part of the treating hospital."

Prevention of future deaths 

On 25 April 2022, the Senior Coroner Mrs Louise Hunt issued prevention of future deaths reports.

To the Secretary of State for Health and Social Care, the Coroner noted that there are no national guidelines for perimeter fences and security in the outside areas of acute mental health units. (The inquest heard that although there are security specifications for low secure including psychiatric intensive care, medium secure and high secure settings, there are none for general mental health units).  

To the Priory, the Coroner expressed concerns about six items.

1. Record keeping. The parallel system of paper and electronic records, which "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, leading the Coroner to "have 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 Coroner raised "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 lack of analysis by the Priory of previous absconsions over the courtyard led the Coroner to express "serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time"; and

5. Courtyard fence. During the course of the inquest, the Coroner was informed that another patient had absconded over the courtyard fence, "which indicates the courtyard area is not safe". The Coroner expressed, "serious concerns that an urgent review of the courtyard is required."


Oliver Lewis represented Matthew's father Richard Caseby. He was instructed by Craig Court of Harding Evans Solicitors. Oliver is clerked in inquests by Grace Walton.


The inquest was reported in The Sun on 4 April and 22 April, The Telegraph on 4 April and 22 April, The Times on 22 April and 23 AprilThe GuardianMail OnlineITV NewsThe IndependentOxford Mail and Birmingham Live.

INQUEST's press release is here

Who to contact if you or someone you know needs help

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Mind also offer mental health support between 9am and 6pm, Monday to Friday. You can call them on 0300 123 3393 or text them on 86463. There is also lots of information available on their website.

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