Hospital rated ‘inadequate’ after death prompts inspection

Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May.

The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020.

Mr Caseby had been detained under the Mental Health Act but managed to escape Woodbourne and died after being struck by a train.

Earlier this year, an inquest concluded his death was contributed to by neglect on behalf of the hospital. 

In April, Birmingham and Solihull coroner Louise Hunt flagged urgent concerns about record keeping, risk assessments and security of courtyard fences with Priory Group and the Department of Health and Social Care.

However, results of the CQC’s May inspection published today suggest that managers are yet to “fully respond” to concerns raised by the coroner in her report.

Ratings for safety and leadership were downgraded to “inadequate”, alongside the hospital’s overall rating, and the CQC also sent the hospital an urgent letter threatening future enforcement action.

Measures put in place to mitigate risks following Mr Caseby’s death had not been fully embedded, inspectors said.

Craig Howarth, CQC’s head of mental health inspections, said it was “concerning” that staff could not directly observe patients in all outside areas of the acute adult wards without physically escorting them.

Inspectors also identified inappropriate admissions to the community-facing Acer Ward where some patients had been admitted directly without fitting the “low-risk” admission criteria.

However, the CQC said risk assessments for patients, and of six outside garden and courtyard areas, had been updated since the May inspection.

Ratings suspended

The regulator received additional concerns about care at Woodbourne unrelated to Mr Caseby’s case which sparked a follow-up visit in August. Ratings have since been suspended while further investigations are carried out. 

In June, it emerged that the hospital was facing a possible criminal investigation over Mr Caseby’s care.

The 23-year-old was placed in an available bed at Woodbourne as an NHS-funded patient by Birmingham Women’s and Children’s Foundation Trust, his inquest heard. A trust spokesman said it has not suspended admissions to the hospital. HSJ has also contacted Birmingham and Solihull Integrated Care System, which commissions some services at Woodbourne, for comment.

A Priory Group spokesman said it acted “swiftly and responsively” to all concerns raised – despite the CQC saying they had not in patients observations and admissions criteria – and had implemented new patient safety processes such as daily staff meetings.

He said environmental changes had been made to the garden area of Beech Ward, from which Mr Caseby escaped, with a fence height of 3.2m and anti-climb roller bars attached.

The spokesman added: “We will continue to ensure that Woodbourne provides the highest level of care, and a positive environment for everyone we support.

“Priory undergoes regular scrutiny of its services by external agencies including the NHS, and the overwhelming majority of Priory sites are rated ‘good’ or better by UK independent regulators.”