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Deaths prompt Priory care concerns.

Coroners have issued five formal notices during the past five years highlighting care failures after patients’ deaths in the care of the Priory Group’s hospitals.

Among the recurring problems highlighted in the coroners’ “prevention of future death notices” are failures to adequately monitor patients at risk of self-harm, failures in training and inadequate record keeping.

At least eight patients have died in the hospital group’s care since 2012. A report by the Care Quality Commission (CQC) on the Priory hospital in Roehampton, southwest London, warned last year that there was a “high level of risk to patients’ safety” and there were “ligature risks throughout the hospital.”

In the most recent case highlighted by an inquest, Anthony McManus, 48, killed himself at Chadwick Lodge mental health unit, Milton Keynes, in December 2015, when the Priory Group operated it. He had been severely unwell for many years and had been at the unit since 2009.

A coroner’s suicide and narrative verdict concluded that a failure to carry out proper observation checks “may have caused, or contributed, to his death.” The inquest jury said it did not consider the required hourly checks on Mr McManus were “done accurately or even done at all in certain circumstances.”

The verdict also concluded there was a likely delay in starting resuscitation and an “excessive delay” in calling an ambulance.

There had been numerous warnings about similar failings. In November 2012, an information technology consultant, Neil Carter, 37, died under a train after going missing from Roehampton’s Priory Hospital. The coroner found there were “gross failures” in his care, including to perform “basic nursing observations.”

In another case, a company chairman, Stephen Bantoft, 49, was found hanged just three hours after arriving at the Priory Hospital in Roehampton in December 2015.

A teenage girl, Amy El-Keria, 14, died under the care of the Priory in September 2013 while at Ticehurst House, East Sussex, after being found with a scarf around her neck. Again, it was found that there were observation failures, as well as inadequate ligature management and inadequate training.

Another Roehampton patient, Francesca Whyatt, 21, also hanged herself in September 2013. “The ward is simply unsafe for the patients,” ruled the coroner.

The next year, another patient, Sara Green, 17, died after tying a ligature around her neck at Priory Hospital, Cheadle Royal. Again, the case highlighted weaknesses in monitoring and inadequate record keeping.

A leading town planner, Keith Hearn, 58, killed himself in June 2015 after observation failures at Priory Hospital, Roehampton. A coroner ruled his death was preventable.

The Priory Group said it was investing £500,000 in safety initiatives and was testing a new patient-monitoring system. The group added that it had a strong safety record and that in 2015-16 just 0.05% of reported incidents had resulted in permanent harm.

A spokesman said the group cared every year for thousands of severely ill people, many of who had long histories of self-harm. It said tragedies were “extremely rare”, but it investigated all serious incidents and worked hard to ensure its services were among the safest in the country.