Preventable Suicides - The Priory Group Failings

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05 July, 2022

Leonie Millard

The Priory Group is the country's biggest independent provider of psychiatric services and obtains thousands of referrals from the NHS every year.

Over the years the Priory Group has been continuously criticised by coroners and inquest juries for failing to keep patients safe. Following an investigation conducted by the Care Quality Commission it was reported that the Priory Group's care had been criticised in respect of at least 30 patient deaths.

One of these being Matthew Caseby. Matthew who at the age of 23, was sectioned under the Mental Health Act in September 2020 after being found "running on train lines" and telling doctors that he was hearing voices. Matthew was sent by the NHS to Priory Woodbourne hospital, a hospital owned by the Priory Group. Four days after his admission, Matthew was found dead after escaping from the hospital over a low-rise fence whilst unsupervised and being hit by a train. The inquest into Matthew's death found that the Priory Group had inadequate record-keeping and risk assessments. The inquest heard that patients had escaped over the same 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. The jury at the inquest concluded that Matthew's death was contributed to by neglect on the part of the treating hospital.

Another matter involved Gary Mavin. Gary was voluntarily admitted to Priory Hospital Arnold on 31 August 2020 after displaying paranoid thoughts and poor mental health and attempting to end his own life. On admission Gary was placed on anti-depressants that were discontinued only one week later due to side effects, without any alternative being considered or provided to him. Following an incident on 13 September 2020, staff become concerned about the behaviour Gary was exhibiting and following a search of hit room, they discovered a self-made ligature. He was temporarily detained under section 5(2) of the Mental Health Act for a maximum of 72 hours pending a formal Mental Health Act assessment. He was reviewed at a multidisciplinary team meeting the next day and the decision was made not to proceed with a formal assessment. A week later, during the night of 20 September, Gary was discovered to be missing from his bedroom and later found hanging in the en-suite bathroom attached to his room. The coroner concluded that there were "serious and inexplicable omissions in care" and that "Gary's case is one of the worst examples of care provided to a vulnerable, mentally ill patient" and that the care he received was "seriously flawed" and that neglect contributed to his death.

There are many cases like Matthew's and Gary's, where people suffering from mental illness are let down by the mental health system, whether it be whilst at an institution like a Priory Group hospital, in prison or whilst under the care of mental health professionals as an outpatient.

At Forbes, our expert team of solicitors can provide legal advice and support for families dealing with the aftermath of preventable suicide and give advice in a number of areas, including:

  • Failure to identify and react quickly to signs of distress or requests for help
  • Misdiagnosis of mental health illnesses
  • Failure to refer or make supervision arrangements for an individual that is considered 'at-risk'
  • Allowing an individual that is considered 'at-risk' access to materials that may harm them
  • Discharging 'at risk' individuals from hospital before the treatment is complete
  • Failure to ensure appropriate treatment or medication

If you wish to seek advice in relation to a loved one's death, please contact Leonie Millard in our Medical Negligence department by emailing Leonie Millard or by phoning 01254770517.

For more information contact Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

Learn more about our Clinical Negligence department here

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