In November 2021, Nottingham Coroner’s Court found that ‘serious and inexplicable omissions in care’ at the Priory Hospital in Arnold, Nottinghamshire, contributed to the death of a father of three – Gary Mavin.
In her conclusion, the coroner stated that “Gary’s case [was] one of the worst examples of care provided to a vulnerable, mentally ill patient” and that the care he received was “seriously flawed”.
Since November, there have been subsequent reports concerning the state of care at the Priory Group’s Clinics and Hospitals across the country and, recently, a wider exposé on the Group was published by The Times.
The Times’ recent exposé on the Priory Group’s Hospitals
The articles focused on the deaths of various patients and the legal action that three grieving families are taking against the Priory Group, the UK’s largest private mental healthcare provider, concerning the failings in care which they feel have contributed to their loved ones’ deaths
One of the articles focused on the death of Gary Mavin and included an interview with Lea Mavin, who was separated from Gary at the time of his death but remained legally married and close with him.
Within the article, The Times reported that Care Quality Commission (CQC) inspectors found human waste, blood and dried food on the floors and walls at the Priory Hospital Arnold in March 2021 and the Hospital was placed into special measures.
Then, in December, following the Coroner’s Court’s findings into the death of Gary Mavin, the Hospital was placed into special measures for the second time in nine months as it “did not always provide safe care”.
The Times expose also revealed the following:
- That the NHS sent a letter to the Priory Group last year stating that it would take action against the Group unless there were “rapid improvements” to its services.
- The CQC investigation found that there were at least 30 patient deaths at the Group’s Clinics and Hospitals over the past decade where the care provided had been criticised.
- Several months after the death of Gary Mavin, the CQC reported that the Priory Hospital Arnold had failed to take any action to reduce ligature risks.
Lea Mavin told The Times:
“It feels like utter contempt and disrespect for not only Gary, but for all of the family, that six months later they still hadn’t bothered to rectify these ligature risks, even though their inaction had already resulted in a death.”
As noted previously, as part of The Times’ expose, it also reported on the deaths of other patients who attended different Priory Group Hospitals and tragically took their own lives. To access The Times’ article in full, please click here.
November 2021 inquest into the death of Gary Mavin
The inquest into the death of Gary Mavin was initially due to conclude on Monday 19 July 2021 after a three-day hearing. However, the inquest was adjourned by HM Assistant Coroner, Laurinda Bower, to obtain an independent report from a psychiatric expert about the care Gary received prior to his death.
Gary was voluntarily admitted to Priory Hospital Arnold on 31 August 2020 after displaying paranoid thoughts and poor mental health for a number of weeks and attempting to end his own life.
On admission to the Priory, Gary was placed on anti-depressants that were discontinued only one week later due to side effects, without any alternative being considered or provided to him.
Following an incident on 13 September where staff were concerned about the behaviour Gary was exhibiting, they discovered a self-made ligature during a search of his room. He was temporarily detained under section 5(2) of the Mental Health Act for a maximum of 72 hours pending a formal Mental Health Act assessment. He was reviewed at a multidisciplinary team meeting the next day and the decision was made not to proceed with a formal assessment. The section 5(2) detention was left to lapse.
A week later, during the night of 20 September, Gary was discovered to be missing from his bedroom and after a search of the Hospital’s communal areas, he was found hanging in the en-suite bathroom attached to his room.
The hearing was an Article 2 inquest – an enhanced inquest, which is held in cases where the state or “its agents” (in this case, the Priory Hospital) may have “failed to protect the deceased against a human threat or other risk” or where there has been a death under some form of detention, such as the Mental Health Act. In her conclusion, Ms Bower found that neglect contributed to Gary’s death.
As The Times reports, when Gary was admitted to the Hospital he had been diagnosed with a recurrent depressive disorder but the Hospital’s Consultant Psychiatrist, Dr Daniel Moldavsky, misdiagnosed Gary when, according to an independent expert during the inquest, there was ample evidence of psychosis.
Instead, Dr Moldavsky believed that Gary was “malingering” and that he was faking symptoms in order to secure better housing. It has been confirmed by the General Medical Council (GMC) that:
“Dr Moldavsky has now removed his name from our register meaning he can no longer work as a doctor in the UK, therefore ensuring patients are protected from future risk”.
Lea Mavin commented after the findings of the inquest were announced:
“While it has been a long process, we’re satisfied with today’s conclusion. I feel like our concerns have finally been heard and listened to, particularly by the independent expert evidence, whose report was accepted in its entirety by the coroner.
“While we’re pleased that The Priory has provided evidence to show that it is making the changes needed to ensure that what happened to Gary doesn’t happen again, we feel that the provision of basic care should have been in place at the time that Gary needed it most and the fact that it wasn’t will stay with us forever.
“The last message I received from Gary was just before half-past ten in the evening on 20 September; he thanked me for my confidence in him and told me that he loved me. When I found out in the early hours of the next morning that he had passed away, I was absolutely heartbroken.
“Telling our sons about what had happened to their father was one of the hardest things I’ve ever had to do – I knew that it would destroy their whole world. We’re completely shattered by losing Gary and it’s very hard to put into words, but I’ve tried to stay strong for our children and they’ve tried to stay strong for me in return.
“Gary was such a kind person who was willing to help anyone with anything – if there was ever a problem, he would be there. He was also a fantastic, hands-on father for our three sons and even though we separated around 12 months prior to his death, he visited us on a regular basis, was the backbone of our family and such a big support for us all.
“That’s what makes all of this even harder to accept, that we were unable to help him through his struggles and that he’s no longer with us.”
Nelsons’ specialist Medical Negligence team has been assisting Lea Mavin since her husband’s death. Barrister Rachel Young, of Ropewalk Chambers, represented the family in Court during the inquest.