Source · Prevention of Future Deaths

Matthew Caseby

Ref: 2022-0116 Date: 22 Apr 2022 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 2 / 2 View PDF

Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Date 22 Apr 2022

56-day deadline 17 Jun 2022

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Railway related deaths

Coroner's concerns

AI summary

View full coroner's concerns

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. I have 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. I 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 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. I have 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. I have 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. I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from 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 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.

Responses

2 respondents

Gillian Keegan MP

22 Apr 2022 PDF

Action Planned

The Department of Health and Social Care will collect data on ward perimeters and review the evidence base and patient and family feedback regarding national guidelines for perimeter fences and security in acute mental health unit outside areas. (AI summary)

View full response

Dear Mrs Hunt,

Thank you for your letter of 22 April 2022 to then Secretary of State for Health and Social Care, Sajid Javid, about the death of Matthew Caseby.

I would like to say how saddened I was to read of the circumstances of Matthew’s death and offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

In preparing this response, Departmental officials have made enquiries with NHS England and NHS Improvement.

Beech ward at the Priory Hospital Woodbourne in Edgbaston is an adult acute service. The adult acute Health Building Note (HBN) 03-011 is mute on the specifics of fence heights that should be appropriately employed within this service as Professor raised.

In terms of acuity levels, the next step on from an adult acute mental health unit is a Psychiatric Intensive Care Unit (PICU). There is no HBN covering this, but in 2017 the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) published design guidance2 and recommendations for commissioners - the minimum height should be 3m.

PICU’s are often in the same building or campus as adult acute services (Woodbourne hospital has one) and a patient is moved from a general adult ward here when their care cannot be safely managed in a general ward setting, this could include the risk of absconding.

1 https://www.england.nhs.uk/wp-content/uploads/2021/05/HBN_03-01_Final.pdf 2 https://napicu.org.uk/wp-content/uploads/2017/05/Design-Guidance-for-Psychiatric-Intensive-Care- Units-2017.pdf

As you move up the acuity levels in mental health into secure accommodation there are prescriptive standards for fence heights that must be met on the basis of:

• Low secure services provide care and treatment who present a significant risk of harm to others and whose escape from hospital must be impeded (3m fence);
• Medium secure services provide care and treatment to those adults who present a serious risk of harm to others and whose escape from hospital must be prevented (5.2m fence); and
• High Secure services provide care and treatment to those adults who present a grave and immediate risk to the public and who must not be able to escape from hospital.

Therefore, services with increased security levels are available if there is clinical indication that the person needs to be supported in a more restrictive and secure setting. However, acute mental health wards remain the least restrictive inpatient setting for a person to be supported in.

I have asked my officials to look into your recommendation for national guidelines for perimeter fences and security in acute mental health unit outside areas. They will collect data on ward perimeters and review the evidence base and patient and family feedback.

More generally, the Government is committed to improving mental health outcomes through the NHS Long Term Plan, which will see mental health services across England supported by and additional £2.3 billion a year by 2023/24.

We will be publishing a new long-term plan for suicide prevention as well as a new cross government ten-year plan for mental health as part of our commitment to ‘level up’ and improve unequal outcomes and life chances across the country.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

GILLIAN KEEGAN

Priory Group Private Sector

14 Jun 2022 PDF

Action Taken

The Priory Hospital Woodbourne issued bulletins on record keeping and shift handovers, is installing software to enable daily data transfer from handover sheets to electronic records, excavated the Beech ward courtyard to eliminate banking adjacent to the fence, and upgraded the CCTV system to ensure full visibility. (AI summary)

View full response

Dear Ms Hunt

Matthew Alexander Caseby – Response to Regulation 28 Report

I write in response to the Regulation 28 Report dated Thursday 22 April 2022 which was issued following the Inquest touching the death of Mr Matthew Caseby. You have raised five matters of concern that relate to the Priory Hospital Woodbourne and one matter of concern that has been raised with the Department of Health. The responses to the matters of concern that relate to Woodbourne are as follows below. Please note that each concern has been raised and discussed directly with the Woodbourne Senior Management Team (SMT) in order for them to reflect on the issues and take appropriate remedial actions.

1. Record Keeping

You have raised a concern that there is potential for there to be different information contained in the patient electronic records (CareNotes) and the hand-written handover sheets.

Communications to staff: During May 2022 two bulletins were issued to all colleagues in the Healthcare Division via the Priory intranet. The first bulletin, issued as part of the monthly Safety First initiative, emphasised the importance of accurate and detailed record keeping. The second bulletin detailed the importance of conducting thorough and comprehensive shift handovers. The bulletins each emphasise that the content of the daily care record must correspond with the content of the handover record. The bulletins have been discussed at Woodbourne governance meetings and in staff supervision.

Changes to the IT system: We are currently installing software in the Healthcare Division to enable the Datix incident reports to upload directly to the patient’s CareNotes record (i.e. staff will only have to record the incident on Datix and the information will automatically be copied across to the patient record). We expect this to go “live” from July 2022. This will enable colleagues to have ease of access to the incident reports via CareNotes which will facilitate preparing for and writing up shift handover documentation.

Changes to Documentation: A trial is underway within the Healthcare Division of a shift handover template with the finalised version likely to be introduced at the beginning of July 2022. The shift handover template specifically contains a requirement for colleagues to refer to recent incidents and communicate the patient’s current risk to colleagues on the incoming shift. Colleagues will sign to confirm that the handover has been received.

Monitoring: Implementation of these actions will be monitored by the following means:

 The internal compliance team will check for the consistency between patient records and handover notes as part of their monitoring audits: they routinely ‘sit in’ on handovers and review the content of patient CareNotes records.

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 The monthly Quality Walk Round template has been updated so that patient records and handover notes will be assessed for consistency. A Quality Walk Round involves a senior member of the hospital team scrutinising particular areas of ward practice using sampling methodology.

2. Record Keeping Quality

You have identified that there were inaccuracies in Mr Caseby’s medical records.

Communications to staff: The importance of keeping accurate records has been raised with all relevant staff at Woodbourne. This will be monitored on an ongoing basis as part of staff supervision and where necessary their appraisals. The importance of accurate record keeping was outlined as part of the Safety First initiative referred to above. The bulletin also made it clear that “cutting and pasting” is not acceptable clinical practice.

Changes to Policy: Policy H62 Healthcare Records has been reviewed and re-issued. The policy also makes reference to the fact that “cutting and pasting” between patient records is not acceptable.

Monitoring: The following checks are being undertaken to ensure that records are accurate:

 The internal compliance team will continue to undertake reviews of patient CareNotes records during their inspections. The reports arising from three recent internal compliance audits have been reviewed and we can confirm that patient notes were reviewed for accuracy as part of that process.

 The monthly documentation Quality Walk Round template has been updated and includes a requirement for accuracy checks to be carried out on CareNotes records (including ensuring there is no “cutting and pasting” between patient records).

3. Risk Assessments

You have identified that Mr Caseby’s risk assessment was not updated when the risk of absconding materialised.

Communications to staff: All colleagues at Woodbourne have been reminded about the requirement to complete contemporaneous risk assessments. This has also been raised with colleagues as part of supervision and where necessary, appraisals.

Checks by Ward Staff: At Woodbourne, the nurse in charge of the ward (or the on-site manager during weekends and “out-of-hours”) checks reported incidents and triangulates these with the patient risk assessments and risk management plans. Similarly, all incidents that have occurred in the previous 24 hours are highlighted during the morning ‘flash’ meeting (these meetings take place Monday to Friday and are attended by the SMT together with representatives from each ward). The meetings act as a prompt to ward managers to check that such incidents have been reported on Datix and CareNotes and considered within the patient’s risk assessment and care plan. This is then confirmed the following day at the next flash meeting.

Changes to Policy: During May 2022, we incorporated the issues learned from the inquest into Policy H35 Clinical Risk Assessment which has been updated and re-issued. For example, there is now a reference to the risk assessment and risk management plan being reviewed by the senior member of the team as soon as practicable after an incident and this review must be completed before the end of the current shift. The outcome of the risk assessment and any subsequent changes to the care plan (which may include an increase in observation levels) must be communicated to the next shift at handover.

Changes to Datix: The Datix incident reporting system now has a prompt in place asking the staff member reporting the incident to confirm whether the patient’s risk assessment and associated care plans have been reviewed in response to the incident.

Monitoring: The following checks are being undertaken to assess whether risk assessments and risk management plans are accurate:

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 Woodbourne is undertaking a weekly audit of a sample of incident reports which are checked against risk assessments and care plans. Results are reviewed at the weekly hospital governance meetings.

 The internal compliance team will continue to review patient risk assessments (which form part of the CareNotes records) against incident reports during their inspections.

 The monthly Quality Walk Round template has been updated and includes reference to checks being made on CareNotes that the risk assessment accords with the patient’s incident profile.

Training: We have initiated a review of our risk assessment and risk management training e-learning module and this will be updated and rolled out during H2 of 2022. The module will include a requirement to ensure that risk assessments and risk management plans are contemporaneous and accurate and that patient risk is shared in “real-time” with all colleagues.

4. Serious Incidents

You have concerns that the system of investigation in place means that critical lessons are not learnt at the appropriate time.

Changes to Datix: A review has been completed of the absconding categories on Datix which will ensure more accurate reporting. For example, the categories now clearly define whether the patient has absconded from the ward or whether the patient is absent from the ward (i.e. has not returned from planned leave). A ‘pop up’ prompt has also been added to Datix to advise that in the event of a patient absconding from within the ward garden/courtyard, an environmental risk assessment of the garden/courtyard must be completed.

72-Hour Reports: Priory has amended the 72-hour incident report and team incident reporting system to ensure that these document in more detail the lessons learnt from incidents and the actions taken to prevent a re-occurrence of such incidents.

Changes to Investigations: Priory is adopting the NHS Patient Safety Incident Review Framework (PSIRF) which is likely to be rolled out by the NHS during 2022. This will facilitate the carrying out of proportionate and detailed investigations in response to serious incidents (including where patients abscond). Colleagues will also be reminded of the requirement that prompt and appropriate actions are taken in response to all incidents and near misses. More specifically, Priory has determined that any incidents involving a patient absconding from within a ward garden/courtyard will be subject to a full PSRIF investigation to ensure lessons are learned. All Hospital Directors will receive updated serious incident investigation training in the next 2-3 months.

Monitoring: The following checks are being undertaken to ensure that there is an appropriate response to incidents:

 The divisional Quality Improvement Leads will undertake a review of incident reports and the actions taken in response to those incidents. Where there are concerns about a lack of action these will be escalated through the divisional management structure.

 Absconding incidents will be reviewed by the divisional senior management team on a monthly basis with a check made that an environmental risk assessment of the garden/courtyard has been completed and where necessary local risk management procedures have been updated.

5. Courtyard Fence

You have raised concerns about the safety of the Beech ward courtyard area as an absconding risk and the potential for the fence to be used as a ligature point.

Ongoing Works: Excavations of the Beech ward courtyard, to include levelling off and landscaping, began shortly after the conclusion of the Inquest. These works were finished on 10 June 2022 and will eliminate the areas where there is banking adjacent to the fence: i.e. the courtyard mesh fence will be

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a minimum of 3.2 metres in height with anti-climb roller bars also in place. A CCTV survey has been completed and the system has been upgraded to ensure that there is full visibility of the environment.

Management Procedures: The existing Beech ward courtyard/garden risk management procedures will be reviewed and updated upon completion of the excavation works. It is expected that the procedures will be re-issued during week commencing Monday 21 June 2022.

Ligature Risk: The ligature point risk presented by the fencing had already been recognised and formed a part of the external environment ligature point audits which are completed on no less than an annual basis. Colleagues are aware of the risk of patients using a ligature and this is considered as part of the patient risk assessment process with patient observation levels adjusted accordingly.

Please note there have been no further incidents of absconding from the Beech ward courtyard since the incident that was reported to you during the inquest.

6. National Guidelines for Perimeter Fencing

Although your concerns were addressed to the Department of Health, I can confirm that following an internal review, we have concluded that the appropriate height for courtyard and garden fencing at our acute units is not less than 3.2 metres and we are currently implementing a programme of works to increase fence heights where required. This is expected to be carried out over the next 12 months. We also consider it appropriate for anti-climb roller bars to be fitted at the top of each fence.

I trust that the actions outlined above will provide the assurances you seek in respect of this matter.

Report sections

Investigation and inquest

On 9 October 2020 I commenced an investigation into the death of Matthew Alexander CASEBY. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Matthew Caseby became acutely unwell with a psychotic illness on 03/09/20. Following his admission and subsequent absconsion from the Priory Hospital in Edgbaston, Matthew stepped in front of a train on 08/09/20 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 on 07/09/20. He absconded 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. There were shortcomings in the Priory processes for recording and sharing information between staff. Matthew was not on any specific observations in the courtyard to avoid his risk of absconsion. There was no written policy on observation levels in the courtyard, the omission of which led to a lack of consistent understanding by staff as to what should happen in the area. This made the courtyard area unsuitable for use by patients. The Priory staff did have concerns regarding the height of the fence in the courtyard at a ward level but there is no evidence that there was a formal raising or escalation of this issue to a senior level which was a missed opportunity. However senior hospital management were aware of previous absconsions over the courtyard fence. When reviewing these incidents there was insufficient attention paid to the physical security of the area, with the focus being on the reasons why the patient absconded rather than how they absconded. This was a missed opportunity. 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.

Circumstances of the death

Following calls to the Police from members of the public reporting sightings of a male on the railway lines and in a school playground, Matthew Caseby was found by Oxfordshire Police in a playground in Islip in Oxfordshire on 03/09/20. Following a conversation with Matthew, the Police officers took the decision to detain him under Section 136 of the Mental Health Act.

Matthew was taken to a place of safety at Vaughan ward part of Warneford Hospital, where he was assessed and detained under Section 2 of the Mental Health Act as he was found to be suffering from a mental disorder of a nature or degree which required detention for his or other’s safety. Due to his registered GP being in Birmingham, because of him previously being a student at Birmingham University, a bed was found for Matthew at the Priory Hospital in Edgbaston, Birmingham. Matthew arrived at the Priory Hospital at 05:05 on 05/09/20. At 06:00 on 05/09/20 Matthew was assessed by the resident medical officer (RMO). The RMO completed a risk assessment in the presence of a registered nurse and a healthcare assistant. The RMO recorded that Matthew had a low suicide and self harm risk and recorded an overall medium risk on the risk assessment. The RMO determined that level 2 observations be put in place meaning that he would receive 4 checks per hour. Notes recorded by staff on 05/09/20 show that Matthew presented as guarded and delusional and that he wanted to leave the ward. Matthew was also seen to be responding to unseen stimuli. Evidence presented show that on 06/09/20 Matthew was presenting as guarded, anxious and responding to unseen stimuli. It was also recorded on the handover notes that Matthew was at risk of absconsion. It was noted that Matthew was loitering by ward exits and that he made an attempt to leave with a black bin bag. Although it was not recorded in any of the written notes a HCA gave evidence that on 06/09/20 Matthew was observed looking at the fence in the courtyard and that she was concerned that he would try to abscond. To mitigate this the HCA gave evidence that she stood at the highest point of the steps. The HCA advised that she made a colleague aware verbally but did not record this risk in any of the written notes. The handwritten handover notes do mention that Matthew was at risk of absconsion but the notes were incomplete. The information regarding Matthew’s risk of absconsion was not captured on the electronic notes which were the ones relied upon by the doctors when completing the ward round/MDT. The ward round/MDT took place and Matthew was seen by 2 doctors and 1 registered nurse at 13:30 on 07/09/20. One of the doctors reviewed the electronic notes. The handwritten notes were not present during the MDT and the contributing nurse gave evidence that she did not read these in advance as it had been a very busy shift and she did not have time. The risk assessment (initially completed by the RMO on 05/09/20) was not reviewed during the MDT. Matthew reported low mood during the MDT. The senior doctor prescribed anti-psychotic medication, but Matthew refused to take this. Following the MDT the nurse raised concerns to the doctors that Matthew was physically fit and would be able to scale the fence in the courtyard should he try to. Upon hearing the concerns no additional risk assessment was undertaken and no additional measures were put in place. Both of the doctors gave evidence that they assumed Matthew would be supervised at all times in one courtyard as was standard practice (although there was no official policy). On 07/09/20 at 16:40 Matthew asked a HCA if he could go into the courtyard and was escorted out by the HCA who remained with him initially. After 15 minutes the HCA asked Matthew to return inside but he refused. The HCA left Matthew in the courtyard under the supervision of 2 other HCAs who were supervising two other patients who were on 1:1 checks. Matthew was observed throwing something over the courtyard perimeter fence. At 17:02 one of the HCAs returned inside to flag that her and her colleague would be returning inside with their 121 patients meaning that Matthew would be left unattended in the courtyard. This was flagged to the nurse in charge and the original HCA. 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. Matthew was unattended for 1 minute and 40 seconds initially. During this time the HCA who had originally given him access to the courtyard could be observed on CCTV images in the nurse’s office and using the staff toilet. The HCA then approached the courtyard and viewed Matthew through the vestibule window. Before the HCA could rejoin Matthew in the courtyard, she was called by a colleague to assist with an emergency ligature situation. This meant that Matthew was unattended for a further 5 minutes. No staff member was informed he was unattended. CCTV showed Matthew moving towards the courtyard fence at 17:06 and he then disappeared from the view of the camera. At 17:07 a HCA on her break in the smoking area observed Matthew walking past her. She approached Matthew and asked if he was OK but he did not respond. The HCA made her way to Beech ward to inform staff of what she had seen. Another HCA was on her break and stood at the bottom of the hospital driveway. She saw and recognised Matthew and asked him where he was going. Matthew responded that he was “going home” and picked up speed as he left hospital grounds. The HCA called Beech ward to report what she had seen. The nurse in charge of the ward immediately called 999 upon realisation that Matthew had absconded. No other action was taken by the staff at the Priory. Although staff did have concerns regarding the height of the fence in the courtyard, there is no evidence that it had been raised in any written or official way or followed up, through established forums to make senior hospital management aware. Although the height of the fence did meet national guidelines the courtyard was not suitable for patients to use due to the lack of a risk assessment and the absence of any written policy specifying observations and supervision whilst the patients were using it. At 17:56 on 07/09/20 Police arrived at the Priory Hospital having already searched the local area in an attempt to find Matthew. On arrival at the ward, the officers spoke to the staff present in the nurse’s office. The Police attempted to get additional information that could assist them with finding Matthew such as next of kin, previous addresses or known contacts. The Priory staff advised Police that Matthew was very guarded and that they didn’t have this information. Police were provided with Matthew’s section paperwork from the hospital in Oxfordshire. When reviewing this paperwork once they’d left the Priory, the Police saw that Matthew had been found on railway lines, which was information that they had not previously been aware of. At 18:46 the Police made British Transport Police (BTP) aware of Matthew as a missing person. There was some confusion around where Matthew was originally picked up by the Police in Islip. Inconsistencies in paperwork showed that Matthew was found on railway lines, but it was a children’s playground where he was picked up. At 19:20 West Midlands Police (WMP) opened a missing person record for Matthew and recorded that he was a medium risk. At 19:32 , Matthew’s Father, contacted Police to raise concerns that Matthew may try to harm himself. Matthew’s risk level remained at medium. The Police gave evidence that they were in contact with Matthew’s Mother and Sister over the course of the evening. Based on information received from them a previous address and place of employment were attended. They also searched the Selly Oak triangle area of Birmingham which Matthew was familiar with, in an attempt to find him but unfortunately Matthew could not be located. At 01:27 on 08/09/20 Matthew’s case was assessed again by the Police response manager and found to be medium risk. No further search took place and the case was handed to the locate team. The locate team picked up Matthew’s case at 07:00 on 08/09/20. At this point the risk level was raised to high. Officers were allocated to try to find Matthew and a fast track action list was set out. Officers were limited with what checks they could complete due to the fact that Matthew didn’t have a debit card or mobile phone and had no contacts in the area. Evidence from British Transport Police confirmed that a collision occurred between a train and a male at 08:40 on 08/09/20. The train had departed University Station and was travelling in the direction towards Five Ways Station. The train was accelerating and was within the permitted speed limits. As the train was adjacent to Vale Campus location the driver saw Matthew appear from undergrowth. Matthew ran out and placed himself in front of the train. As soon as the driver saw Matthew, he applied the emergency brake and sounded the horn. Unfortunately, the driver was unable to stop in time and the collision took place. It was confirmed that the collision was fatal at 09:11 by the Paramedic at the scene who confirmed life extinct. It was established that Matthew was the individual who had been hit by reviewing CCTV images of Matthew. Formal identification took place using fingerprints. Between Matthew absconding from the Priory over the courtyard fence at 17:06 on 07/09/20 and the collision that took place at 08:40 on 08/09/20 there is no evidence showing Matthew’s whereabouts or activities. Following a post mortem the medical cause of death was determined to be: 1a Head Injury 1b High Impact Collision with a Train 1c II Psychotic episode CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 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. I have 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. I 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 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. I have 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. I have 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. I have serious concerns that an urgent review of the courtyard is required. In addition, I heard evidence from 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 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.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2022-0116
Date of report: 22 April 2022
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jun 2022.

Sent to

Department of Health and Social Care

Priory Group

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