9 January 2019

Update: 5 Feb 2019 - the hearing scheduled for 6 February has now been vacated. The next hearing has provisionally been scheduled for mid-April. The nature and final date of the next hearing will depend on ongoing legal dialogues. 

The Priory Group have today pleaded guilty to health and safety charges following the death of 14 year old Amy El-Keria. This is understood to be the first prosecution of its kind and is a historic moment in terms of accountability following deaths of children in private mental health settings.

The hearing took place in Brighton Magistrates Court before District Judge Tessa Szagun. The judge has now committed the case to the Crown Court with a next hearing scheduled on 6 February. The Priory will now need to provide a detailed basis for their plea, including around whether their Health and Safety breaches are accepted as causative to Amy’s death.

Amy was a child with complex needs associated with multiple mental health diagnoses. She died whilst an NHS funded patient in a specialist children’s unit at Ticehurst House in East Sussex, a private psychiatric hospital run by the Priory Group.

Amy was found unresponsive with a ligature in her locked hospital room on 12 November 2012 and was pronounced dead the following day. An inquest jury in 2016 found that neglect by the Priory contributed to Amy’s death.  The inquest jury identified failures across all aspects of the care and treatment provided to Amy during her 3 month admission.

The HSE commenced a criminal investigation after the conclusion of the inquest. This resulting prosecution was brought against the Priory Group for offences relating to Amy’s death under Section 3 (1) of the Health and Safety Act.

Amy’s death is one of several concerning cases involving failures in mental health care by the Priory Group.  INQUEST remains concerned about transparency around deaths of children in both NHS and privately run mental health settings, as well as a lack of independent investigations into these deaths, despite higher standards in other detention settings. (See notes for more information.)

Responding to the plea, Amy’s mother Tania El-Keria said: "Amy was my dearly loved youngest daughter, a sister, niece and granddaughter with her whole life ahead of her. She had the warmest heart and a greatest sense of humour. She never liked to see people treated unfairly and would be the first to say, ‘that's not right’. 

Amy's mental health care should never have been in the hands of a company whose priority was placing profit over her safety.  For 14 years we kept her safe but within 3 months with the Priory she was dead.

Six long years it has taken for the Priory to be brought to Court. Every day I have to live with the heartbreak of my child’s death. Every day my family have to suffer her absence. The only thing that has kept me going is to achieve justice for Amy and to stop other families going through the torture we have endured. Today is a huge step forward achieving this. This guilty plea is a bitter but long awaited acknowledgement from the Priory of their criminal failure.”

Victoria McNally, Senior Caseworker at INQUEST who has supported the family since 2012, said: “This family have been failed by a system that placed Amy in the care of a private company, now exposed as operating criminally inadequate standards.  From the moment of Amy’s death the family have faced the hardest of battles for answers and action against those responsible. 

The government must now review whether the Priory is fit to receive such significant public expenditure for the provision of children’s specialist mental health care. The family call for an immediate meeting with the Minister to discuss their response to the gross failures now brought to light through Amy’s and other cases involving the Priory.”

ENDS

NOTES TO EDITORS
For further information, please contact Lucy McKay on 020 7263 1111 or [email protected]

INQUEST has been working with the family of Amy El-Keria since shortly after her death.  Amy’s family are represented by INQUEST Lawyers Group members Tony Murphy, Bhatt Murphy solicitors and Raj Desai of Matrix Chambers.

1. The prosecution has been brought by the Health and Safety Executive, the UK government agency responsible for the regulation and enforcement of workplace health, safety and welfare. Charges relate to section 3 (1) of the Health and Safety at Work Act 1974, which states “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.”
   
   
2. The inquest into Amy’s death concluded on 2nd June 2016 – see the media release for more information. The coroner wrote a Prevention of Future death report, which summarises the findings of the inquest.
   
   
3. Throughout Amy El-Keria’s case the Priory resisted scrutiny: refusing an independent investigation, arguing against an enhanced ‘Article 2’ inquest, opposing an inquest jury, claiming they weren't a public body in response to an FOI from INQUEST which sought details of possible other child deaths in their care. This conduct has exacerbated the trauma for Amy’s family, and frustrated the processes intended to keep others safe.
4. INQUEST has consistently highlighted the failures of oversight and scrutiny concerning the deaths of children in mental health settings. This was highlighted by BBC’s Panorama in 2016 with research by INQUEST.
   
   
5. Changes introduced since fail to address INQUEST’s central concerns:

• There is an absence of publicly available information about the number and circumstances of deaths of children and young people who have died while receiving in-patient mental health care from the Priory Group and other providers. This remains in contrast to all other state detention deaths. 
  
  
• There is no system of independent investigation into the deaths of children who die as mental health inpatients, equivalent to other detention settings. This is something which INQUEST have repeatedly called for. The mental health provider in which the death occurs remains responsible for deciding the investigation response. 

6. In the financial year 2017/18, the Department of Health reports that 44% of child and adolescent mental health services (CAMHS) expenditure was on services by the ‘Independent Sector’ of which the Priory is a significant recipient. Spend to Independent Sector providers in 2017/18 totalled £156.5 million. This information was published in answer to a parliamentary question by Luciana Berger.
   
   
7. Through INQUEST’s casework we are aware of the following cases involving the deaths of children and young people receiving Priory in-patient mental health care:

• Pippa ‘Pip’ McManus, 15 years old, died on 9 December 2015 while formally an inpatient of Priory Hospital Altrincham. See INQUEST media release.
• Evelina Alksne, 22 years old, died on 30 March 2015 while formally an inpatient of Priory Group’s Recovery First Hospital, Widnes.
• George Werb, 15 years old, died on 28 June 2014, in the care of Priory Hospital Southampton. See media coverage.
• Sara Green, 17 years old, died on 18 March 2014, in the care of Priory Hospital Cheadle Royal, Cheshire. See INQUEST media release.
• Francesca Wyatt, 21 years, died on 28 September 2013, in the care of Priory Hospital Roehampton. In March 2013 HM Senior Coroner for Inner West London, Dr Fiona Wilcox, issued a Regulation 28 report to prevent future deaths,  identifying her concerns about ongoing risks.
• Will Jordan, a 16 year old boy who died after he was found hanging in the Priory Hospital North London on 22 January 2018. In August an inquest highlighted serious failures in carrying out observations by Priory staff. See media coverage.