A vulnerable patient who absconded from a mental health hospital by climbing over a fence before he was killed by a train should have been under constant observation, an inquest has heard.
The 23-year-old was hit by a train in Birmingham on September 8 2020, just hours after he absconded.
Honorary consultant forensic psychiatrist Professor Jennifer Shaw, who carried out an independent investigation into the incident, said Mr Caseby was ‘said to be eyeing up the fence’ in a courtyard area at the hospital in the days before he absconded.
She said he had also previously ‘tried to tailgate staff’ and was seen with a binbag ‘walking as if to take it out’.
Louise Hunt, senior coroner for Birmingham and Solihull, asked Prof Shaw: ‘In your opinion, what level of risk would that put him at in relation to absconding?’
The psychiatrist replied: ‘I think that would suggest that the risk was high.’
She said it was not safe for Mr Caseby to be left unattended in the courtyard.
Matthew Caseby swimming in the sea off Brighton beach. He was described as ‘sensitive, gentle and intelligent’ and had graduated with a first class history degree in 2018
He was able to leave Birmingham’s Priory Hospital Woodbourne, where he was an NHS patient, despite signs that he was at high risk of absconding
‘There needed to be a separate risk assessment for the courtyard in terms of his risk of absconding,’ Prof Shaw said.
‘And that should have led to him having constant observation out there so there was no chance he could be left on his own.’
She said staff told the investigation they had ‘raised concerns about the fence, the environment of the courtyard, and they felt their concerns hadn’t been listened to in that respect’.
Prof Shaw said it ‘wasn’t until after’ a further incident of absconding on November 19 2020, more than two months after Mr Caseby’s death, ‘that there was any change in the physical security of that courtyard’.
She said this included increasing the height of the fence.
Prof Shaw said there had been previous incidents of absconding ‘both from the courtyard itself but also the adjacent garden area’ but there had not been a ‘conversation with staff as to what the lessons should be and how things should change’.
She said there had been no policy on observation in the courtyard.
She said the development of such a policy would have ‘generated conversation’ about security issues, including the height of the fence, staffing of the area, whether CCTV should cover the whole courtyard, and whether two-way radios should be used in the courtyard.
Prof Shaw said she identified two ‘root causes’ of the incident, with the first being that there was ‘no clarity on the status of the courtyard and on the required observation procedures within it’.
The second was that there was ‘no systematic strategic approach to learning lessons from the previous events in the courtyard area’.
Mr Caseby had been detained under the Mental Health Act by Thames Valley Police on September 3 after reports of a man running on to the railway tracks in a village north of Oxford.
The University of Birmingham graduate’s father, Richard, 61, previously told the inquest that health authorities had a basic legal duty to keep his son safe and secure.
The graduate’s father Richard, 61, told the court how the family were only fully told about the detention after his son vanished.
His father said the hospital authorities had a ‘basic legal duty… to keep our son safe and secure’.
He told the jury: ‘They did not. They did not. There have been catastrophic consequences for Matthew, for me, for my wife and our two daughters.’
His son was detained on September 3, after a member of the public reported concerns. Mr Caseby was taken to a psychiatric hospital and sectioned the next day.
He told doctors he had been hearing voices and receiving messages and was moved to the Priory in Birmingham on the Saturday.
His father said he and his wife Jo, 60, rang the Priory ‘about seven times’ that weekend, seeking and offering information on their son, but ‘none of this [information] was recorded by the hospital’.
They next heard from the hospital on the Monday after Mr Caseby had scaled a fence, having been left unattended. The family hurriedly printed ‘missing’ posters and headed to Birmingham from London.
While searching near the hospital, Mr Caseby’s father flagged down three police cars and discovered none of the crews was looking for his son or was aware he was missing.
Mr Caseby was only upgraded to a ‘high-risk missing person’ after a shift change at 7am – but by then 14 hours had been lost, his father said.
Before that Richard Caseby said he had spoken to a Priory worker who told him ‘people abscond all the time to get drink or drugs or see friends… they usually come back’. He said that comment remained ‘burned on my mind’.
His son was hit by a train at 8.46am.
His father was 200 yards away, exploring a hunch that his son may have sought refuge near his old hall of residence.
He found out what had happened after a 9am meeting with the Priory’s medical director who ‘assured me to my face that Matthew was a low suicide risk’.
The inquest, being heard by a jury, continues.