Mr Caseby, 61, a communications consultant from Blackheath, London, told Birmingham Coroners’ Court: “We cannot understand how a young man like Matthew slipped through the fingers of his warm and loving family.”

As a photograph of Matthew was shown to the inquest jury, Mr Caseby turned to them and said: “He was a sensitive, gentle and intelligent soul – if you look at the photo of our beautiful son you can see a real and vivid person at the centre of this inquest, so take a good look at it while I describe him.”

Mr Caseby said his son – the youngest of three and a talented footballer who once had trials with Charlton Athletic – never drank, smoked or took drugs, “not even paracetamol”, because he was a fitness fanatic.

He had been living at home while he tried to build up his business as a personal trainer, and had started having counselling at the end of 2018 when he also “voiced a desire for clearer boundaries between family members and a need to have his privacy respected”.

In spring 2020, during lockdown, he told his family he wanted to see a counsellor because he had been feeling anxious. During the summer his parents moved to their holiday home in Suffolk to give him more privacy, and on August 27 he called his mother Jo on her birthday when there was “nothing in the call that raised any concerns”, his father said.

On September 3, a member of the public called the police after seeing Matthew running on railway lines in the village of Islip, near Oxford and he was detained and later sectioned under the Mental Health Act. 

He was sent to the Priory Woodbourne – part of the wider Priory Group – as an NHS patient under the care of Birmingham Women’s and Children’s NHS Foundation Trust, as he was registered with a GP in Birmingham and it was the nearest facility in that area that had a bed.

‘He’s never coming back’

On September 7, two days after being admitted, he jumped over a fence while he was unattended in a courtyard, even though his family were told he “could not be left alone”. The hospital alerted his parents and the police.

Mr Caseby said he spoke to Tracie Parker, a night supervisor at the Priory, who told him: “Oh, people abscond all the time for drink, drugs or to meet friends. It’s a common occurrence. They usually come back after they’ve done what they need to do.”

Mr Caseby told her: “You’re wrong about Matthew. He’s never coming back.”

He drove to Birmingham and mounted a search for his son, handing out “missing” posters to members of the public and to three police patrols “within a mile of the Priory”, none of whom had been alerted about a missing patient.

At 9 am on September 8, 2020, Mr Caseby had a meeting at the Priory with consultant psychiatrist Arshad Mahmood, who “sat down with me and assured me [Matthew] was a low suicide risk”.

As he later discovered, Matthew was already dead. He had been hit by a Cardiff to Birmingham express train at 8.46 am. His father, who had earlier gone to his son’s old university halls of residence thinking he might have sought refuge there, was just 200 yards away at the time, though his view of the railway line was obscured and he did not see it happen.

The hearing continues.