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Private mental health hospitals: Care concerns raised as coroner calls for new safety standards

By Rowen Cobb, a medical negligence expert at Irwin Mitchell

A coroner has called for new security standards at acute mental health units after an inquest found that a young personal trainer died following a litany of failures at a private hospital.  

Matthew Caseby, aged 23 , was left unattended in a courtyard at Birmingham's Priory Hospital Woodbourne hospital before escaping over a low fence that had been the scene of previous incidents.

Prevention of future deaths report issued 

Senior coroner Louise Hunt has called for the Department of Health to issue guidelines for the minimum height of fences at such facilities. In a prevention of future deaths report issued because of continuing concerns raised by Matthew’s death, the coroner said the standard should be introduced alongside wider guidance on security in outside areas of acute mental health units.

An inquest concluded that neglect by the Woodbourne Priory Hospital, where history graduate Matthew had been sent by an NHS trust, had contributed to his death. Matthew was left unattended whilst suffering a psychotic episode. He took his own life in September 2020 hours after absconding from the courtyard.

Independent investigation

Professor Jennifer Shaw, a psychiatrist who carried out an independent investigation into Matthew's  case, stated that the fences should have been a minimum of 9ft tall. The fence used by Mr Caseby and other Priory patients to abscond were 7ft tall.

Staff said concerns had been raised about the fence but were ignored by hospital managers. The height of the fence was only changed after another breach two months after Matthew's death. In her report Professor Shaw referenced the lack of national guidelines as a contributory factor in Matthew's death.

NHS Guidance

A 2013 NHS guidance note into the design of adult acute mental health unit’s states "the design of all facilities should prevent the unauthorised exit or entry of people and the passing of contraband”, but does not outline heights.

In the report, sent to the Department of Health and the Priory, the senior coroner noted that another patient absconded from the courtyard during Matthew's. She said this gave rise to "serious concerns" and called for an urgent review into the hospital's external area.

The coroner has set out a number of other areas where she had concerns about whether the Priory, the largest independent provider of mental health services in the UK, was operating safely. She mentioned its response to serious incidents, including a 2019 escape over the fence, poor record keeping and concerns about patient risk assessments.

The Priory apologised unreservedly for the shortcomings in the case. After the inquest it said it would "welcome national guidance".


It's extremely worrying that concerns remain nationally around the standards at such private facilities. As this appears not an isolated incident, there needs to be strict guidelines in place at private mental health facilities to prevent further deaths in such circumstances from occurring.  

Irwin Mitchell is currently supporting families who have been affected by care issues in both private and NHS mental health hospitals. Please find more information at our dedicated medical negligence section.

A coroner has urged health chiefs to consider imposing minimum standards for perimeter fences at acute mental health units after a patient died.

Failings amounting to neglect contributed to the death of Matthew Caseby in 2020, who fled Birmingham's Priory Hospital Woodbourne and was hit by a train, an inquest concluded.”