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The Priory fined £300k over death of girl who hanged herself

Mental health care provider the Priory Group has been sentenced after a teenage patient died at one of its hospitals.

The Priory's flagship rehabilitation centre in Roehampton, London | Image credit: ©Tony Larkin/REX/Shutterstock
Fourteen-year-old Amy El-Keria was found hanged in her room at the group’s private psychiatric hospital Ticehurst House, East Sussex, in 2012.
An investigation by the Health and Safety Executive (HSE), which began after an inquest in 2016, found the Priory had failed to identify or implement control measures that would have better managed ligature risks.
The private healthcare provider was fined £300,000 yesterday at Lewes Crown Court and ordered to pay costs of £65,801 after it pleaded guilty to breaching s 3(1) of the Health and Safety at Work Act in January. 
The charity Inquest, which has provided support for Amy’s family, said the ruling is a “historic moment in terms of accountability following deaths of children in private mental health settings”. 
Amy was deemed at high risk of self-harm and suicide when she was admitted to Ticehurt’s specialist child and mental health high dependency unit on 24 August 2012.   
On 12 November Amy was found with a scarf tied around her neck in her bedroom. She was taken to Conquest Hospital in Hastings but died the next day. 
The 2016 inquest jury found the Priory had failed to meet Amy’s care needs or to manage the risks she faced properly. 
It concluded that staffing levels were inadequate, and that workers had not called an ambulance or administered cardiopulmonary resuscitation (CPR) quickly enough. 
Staff lacked knowledge of or training in basic policies on all key areas of day to day care and risk planning, it found. 
The HSE’s investigation revealed the Priory had not risk-assessed the presence of ligature points and ligatures, failed to determine the correct fixtures and fittings for units where patients were at high risk of self-harm and suicide, and failed to ensure its staff were trained and their work practices monitored with respect to life support techniques. 
When setting the level of fine, Mr Justice Dingemans said he considered the Priory’s “good” health and safety record, guilty plea and steps made to improve the service.
The London-based company had a turnover of almost £134m in 2017 and is therefore classed as a “very large” organisation under the safety and health sentencing guidelines.
After the hearing Victoria McNally, senior caseworker at Inquest, said: “The marketisation of our mental health system enables the Priory to put profit over the safety of children in its care. The lack of any independent system of investigation, allowing the Priory to investigate their own actions, has meant it took six and a half years for their criminally unsafe practices to be exposed. 
“If we are serious about child safety and welfare, such a blatant lack of oversight and scrutiny cannot continue. The grave concerns for safety raised by Amy's and other children’s deaths must lead to an immediate intervention by the government and an urgent review of the Priory's fitness to deliver national CAMHS [child and adolescent mental health services] hospital services. 
“The mental health minister has agreed to meet with Amy's family and Inquest. These concerns will be matters for urgent discussion during that meeting.”
HSE inspector Michelle Canning added: “This is a heart-breaking case. Our detailed investigation uncovered a number of failures. Our thoughts remain with Amy’s family and we are so very sorry for their loss.”


Keeley Downey is acting deputy editor of IOSH Magazine. She is a former editor of Biofuels International, Bioenergy Insight and Tank Cleaning Magazine

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