On 9 January 2019, the Priory Group pleaded guilty to breaches of health and safety law, in relation to the death of 14 year old Amy El-Keria. The INQUEST charity called this "a historic moment in terms of accountability following deaths of children in private mental health settings."[1]

This tragic case involved a child who was being cared for as an inpatient at Ticehurst Hospital in East Sussex. This was (and is) a private hospital run by the Priory Group, though care in this instance was being funded by the NHS.

The circumstances leading up to Amy's death had previously been investigated through the coroner's process, with a jury inquest being held at Horsham Coroner's Court in 2016. The jury concluded that neglect on the part of The Priory Group's staff had contributed to Amy's death. Contributory factors were felt to include, amongst others:

  • staffing levels;
  • inadequate systems for identifying and managing ligature risk;
  • missed opportunities for removing a scarf which was used as a ligature; and
  • failure to pass on key information about Amy's increased suicide risk on the day of her death and to increase observations by staff as a result

After the inquest, an investigation was mounted by the Health and Safety Executive. This resulted in the Priory Group's prosecution for criminal offences.

More recently, an inquest into the death of a 16 year old boy, Will Jordan, has also drawn attention to alleged shortcomings in care (this time at the Priory Hospital North London). The coroner heard evidence that staff had failed to carry out planned observations in the hours leading up to the death. The court was also told that staff had then changed the medical records to make it appear that observations had taken place.

These types of cases demonstrate the hugely important role that the coroners' courts can play in bringing to light failings in mental healthcare. The role of the coroner is not to allocate blame or legal liability for a death, but in certain circumstances they (and/or a jury) can decide that a death was contributed to by neglect. 

In addition, where a coroner considers that there is a risk of other deaths occurring and that action should be taken to prevent or reduce the risk, they must make a 'Prevention of Future Deaths' report to whoever they believe has the power to take the necessary action. The responses to these reports, indicating what the hospital/local authority etc. intend to do to address the risks, are a matter of public record. 

Cases of neglect will hopefully be rare, but where these occur it is essential that our legal system is able to respond appropriately. Inquests will sometimes be the only opportunity that families have to ask questions of those involved in their loved one's care. Evidence which is gathered for an inquest may prompt other agencies, such as the Health and Safety Executive or the police, to investigate further. 

If you are seeking guidance about the inquest process, and what this involves, information can be found on our website at https://www.russell-cooke.co.uk/what-is-an-inquest or you can contact a member of our team.

[1] For more information, please see https://www.inquest.org.uk/amy-el-keria-priory-guilty