A healthcare provider has been fined £300,000 over the tragic death of a 14-year-old girl in East Sussex.
Amy El-Keria was found hanged in her room at Priory Ticehurst House Hospital, where she had been a patient since August 2012.
Amy was taken to hospital but sadly died on November 13, 2012.
Mum Tania El-Keria said today was a 'historic day in my fight for justice for Amy'.
Amy had been a patient in the facility's high dependency unit.
Investigation found failures at Priory Healthcare
An investigation by the Health and Safety Executive (HSE) found Priory Healthcare Ltd had failed to identify or put in place control measures that would have better managed ligature risks, the HSE said.
Priory Healthcare Ltd of Hammersmith Road, London pleaded guilty to a breach under Section 3 (1) of the Health and Safety at Work etc. Act 1974.
The company was today fined £300,000 at Lewes Crown Court and ordered to pay costs of £65,801.38, the HSE confirmed.
The company successfully argued that direct causation to Amy’s death does not form part of the failures for which it has today been sentenced, according to the HSE.
When imposing the fine, the Mr Justice James Dingemans said he took into account the company's 'good' health and safety record, guilty plea and steps made to improve the service, the INQUEST organisation said.
An inquest jury in 2016 found that neglect and failures by Priory Healthcare Ltd contributed to Amy’s death, identifying failures across all aspects of the care and treatment provided to Amy during her three month admission, INQUEST said.
The HSE commenced a criminal investigation as a result of the evidence revealed by the inquest.
Ticehurst House is still run by Priory Healthcare Ltd.
Amy's mum: "Today is a historic day"
Following the sentencing, Amy's mum Tania El-Keria said: "Today is a historic day in my fight for justice for Amy.
"Amy loved life and I know she wanted to live."
She said that Amy's death at Ticehurst House Hospital will 'forever haunt' her.
Speaking after the hearing, HSE inspector Michelle Canning said: “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.”
HSE found the company’s main failings were as follows:
- Failure to carry out a suitable and sufficient risk assessment relating to the presence of ligature points and ligatures on upper court
- Failure to identify the control measures necessary to reduce ligature risks, so far as is reasonably practicable
- Failure to consider relevant industry and NHS guidance to inform its risk assessment process and determine the correct fixtures and fittings for units where patients were at high risk of self-harm and suicide
- Failure to ensure an adequate review was carried out of the systems and control measures relating to ligature risks at Ticehurst House following concerns raised by external bodies
- Failure to ensure all staff working on upper court were trained and their work practices appropriately monitored with respect to life support techniques.
Priory Healthcare offer 'sincere and profound apologies'
Trevor Torrington, the Priory Group chief executive, said: "We would like to repeat our sincere and profound apologies to Amy’s family.
"We note the findings of Mr Justice Dingemans. Overall, the court found that Priory Healthcare had co-operated with the HSE investigation and pleaded guilty at the first available opportunity.
"There was common ground between the experts that the care planning was of good quality, that the suicide of 14-year-olds is extremely rare and prediction is likely to be extremely difficult. Priory Healthcare accepts there were certain risk management procedures in 2012 in relation to environmental audits and BLS training which were not robust enough. However, the court found such shortcomings were not causative of Amy’s tragic death.
"Following the incident Priory Healthcare took significant steps to strengthen those areas at the hospital where the court found there were weaknesses including additional training and support for staff to enable them to manage patients at risk of self-harm more robustly including dealing with emergencies.
"The court remarked that Priory Healthcare had treated successfully very many young patients including some young people who have been taken from the brink of despair to a life with a future.
"The hospital is making substantial progress under an experienced senior management team. The latest CQC report, published in January this year, rated Ticehurst as 'Good' in all areas.
"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.
"We also intend to undertake a strategic review of our in-patient Child and Adolescent Mental Health Services (CAMHS) services to assess how best to respond to the individual needs of patients who are presenting with increasingly challenging conditions and self-harm risks."
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