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.
Personal trainer, Matthew Caseby, 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, the city's coroner's court heard.
The 23-year-old was hit by a train in Birmingham on September 8 2020.
Lack of Constant Observation
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.
"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."
Raised Concerns by Staff Were Unmet
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 2 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 inquest, being heard by a jury, continues.
This article contains information from PA Media
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