Mental healthcare group the Priory has been fined £300,000 over the death of teenager Amy El-Keria after it admitted breaching health and safety law.
The 14-year-old, who had a history of suicide attempts, was receiving treatment at the group’s Ticehurst House psychiatric hospital when she died in November 2012.
An inquest in 2016 heard neglect had contributed to her death and found she died accidentally of unintended consequences of a deliberate act.
A subsequent criminal investigation from the Health and Safety Executive (HSE) lead to the London-based company pleading guilty to a charge of being an employer failing to discharge its duty to ensure people were not exposed to health and safety risks.
Sentencing at Lewes Crown Court on Wednesday, Judge Mr Justice James Dingemans said: “It is obvious that any penalty I impose can never reflect the loss suffered by Amy’s family in this case.”
He said investigations carried out since Amy’s death meant there was a “better understanding of young person suicide, and that vital lessons have been learned.”
The judge said he “unable to be sure” if the offence caused the teenager’s death, but found the Priory had a “high” level of culpability in the case.
Safety breaches continued for many years and the company had failed to take action when required by the Care Quality Commission (CQC), the judge said.
He added: “There was, in my judgment, insufficient urgency demonstrated in dealing with these problems.”
Prosecutors had previously indicated that Priory could be facing a multimillion-pound fine, but Mr Justice Dingemans said he found no aggravating factors.
He said the sentence reflected the company’s guilty plea, lack of previous convictions, “good” health and safety record and the steps taken close and refurbish the unit where Amy lived.
Priory, which had a turnover of £133 million and profit of £2 million in 2017, was also ordered to pay the HSE’s costs of more than £65,000.
Speaking outside court, Amy’s mother Tania El-Keria said the “historic day” was “not about the money”, but revealing “what the Priory stand for, profit over safety”.
“Our Amy died in what we know to be a criminally unsafe hospital being run by the Priory,” she said.
Ms El-Keria accused the company of not showing “any level of remorse” and being “morally bankrupt”.
She said she would continue to fight against the company receiving “large sums of public money”.
An earlier court hearing was told that Amy had arrived at the hospital’s High Dependency Unit on August 23 2012.
On November 12, at 8.15pm, she was found in her bedroom with a ligature tied around her neck and taken to Conquest Hospital in Hastings, where she died the following day after life support was withdrawn.
Prosecutor Sarah Le Fevre said information relating to Amy’s care had not been properly handled.
A ligature audit of her room, carried out by an untrained member of staff, identified medium risks which were not followed up.
The hospital was also slow to tackle concerns over risks identified in a Care Quality Commission (CQC) inspection in November 2011.
Details of a conversation on suicide Amy had with a nurse in the early hours of November 12 were not passed on to her doctor.
In a statement, Priory CEO Trevor Torrington, offered the company’s “sincere and profound apologies” to Amy’s family.
The company accepted that in 2012 certain procedures and training were “not robust enough”, but highlighted the court found the shortcomings had not caused Amy’s death.
“We remain absolutely focused on patient safety and will continue to work closely with commissioners and regulators to learn lessons from incidents and inspections quickly and ensure all concerns are addressed in a timely and robust way,” he said.
The CQC’s January report on Ticehurst hospital rated it as “good” in all areas, Mr Torrington added.
The 2016 inquest jury’s findings were highly critical of the Priory, ruling staff failed to dial 999 quickly enough, failed to call a doctor promptly and were not trained in CPR.
Staffing levels were inadequate, Amy was not resuscitated properly by staff, and had to be removed from the hospital on a body board because the ambulance stretcher could not fit in the lift, it found.
The response of staff was so inadequate the jury agreed there was a possibility that Amy may have lived if she had received proper care.
INQUEST has worked with the family since Amy's death. Their caseworker Victoria McNally responded, highlighting the need for immediate intervention by the government and an urgent review of the Priory's fitness to deliver national CAMHS hospital services. pic.twitter.com/8Aju0u0Vzz
— INQUEST (@INQUEST_ORG) April 17, 2019
The charity Inquest, which has supported Amy’s family, said: “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.”
It added: “There is a lack of transparency surrounding deaths of children in both NHS and privately-run mental health settings, in addition to the lack of pre-inquest independent investigations into these deaths despite higher standards in other detention settings.”
The charity called on the Government to conduct an “urgent review” into the Priory’s delivery of national CAMHS hospital services.
Ms El-Keria is due to meet with mental health minister Jackie Doyle-Price in May.