A coroner has urged Sajid Javid, the Health Secretary, to impose stricter security requirements on private psychiatric hospitals after a patient absconded and was killed by a train.

Matthew Caseby, 23, was able to scale a 7ft-high fence at Priory Woodbourne hospital in Birmingham after being left unattended outdoors despite being a suicide risk, and 18 months after his death there remains no minimum standard for perimeter fences at acute mental health facilities.

After an inquest jury found that “neglect” contributed to his death, Louise Hunt, senior coroner for Birmingham and Solihull, has told the Department of Health it must impose national guidelines for fences and security in general in outdoor areas of mental health units.

Mrs Hunt said “action must be taken to prevent future deaths” as she published a series of recommendations following the findings of the inquest last week.

Mr Caseby, a personal trainer, had been sent to the private Priory Woodbourne hospital by the NHS following a psychotic episode in September 2020.

Despite having been seen running on a railway line and being sectioned under the Mental Health Act, he was allowed outdoors on his own, where he was easily able to scale the fence.

Mrs Hunt listed five areas of concern about Matthew’s care at the Priory, including poor record-keeping, problems with risk assessments, and a failure to learn from past incidents. 

It emerged during the inquest that another patient had scaled the fence in 2019 but “critical lessons” had not been learnt and nothing had been done to raise the height of it.