Three recent coroners’ Prevention of Future Deaths reports on St. Andrews Healthcare Ltd

By Dr Minh Alexander retired consultant psychiatrist 18 February 2026

This is a very brief note for anyone interested in the ever-deepening crisis affecting highly vulnerable patients and their families, who are forced to rely on one of the largest providers of private secure mental healthcare purchased by the NHS.

It is clear that St. Andrew’s Healthcare’s governance has been deplorable, and combined with ineffective regulation, this has allowed systemically abusive practices to flourish. It all now culminates in a substantial police investigation that has led to arrests for wilful neglect and ill-treatment, assault, rape, and manslaughter

Some of the incidents which have led to these arrests were captured on CCTV.

Many, many questions arise about why staff felt comfortable to abuse patients on camera.

Much of what went wrong is still hidden, and sadly I think much will remain secret and hidden.

But examining three coroners’ warning reports published in 2023 on St. Andrews Healthcare facilities shows some of the neglectful practices. These reports are only issued exceptionally when there are serious risks:

Jason Bayley died of constipation, a known side effect of his psychiatric medication. He is not the first St Andrew’s patient to have died in these circumstances. An alarm was raised years ago by the Healthwatch Chair with NHS England’s CEO after four St. Andrews patients died in similar circumstances and NHSE seemed reluctant to act robustly. St Andrews was, and still is, a powerful and well-connected institution, based in a county with reportedly the highest concentration of landed gentry. The fact that two of these previous deaths were not subject to inquest, that one was ruled a natural death and failure by the Care Quality Commission to investigate all raised eyebrows: Call for inquiry into deaths of four men at psychiatric hospital. The failure by St. Andrews to learn and the horrendous repetition in the death of Jason Bayley speaks volumes, but responsibility must surely be shared by the regulators.

Sasha Mishabi died with skin ulcers after a total failure to follow any sort of protocol for managing his high risk of pressure sores. No Datix incident report was submitted when ulcers developed, arguably a preventable failure of care in most cases. No serious incident investigation was undertaken when Sasha died. Staff claimed they “forgot” that there was a pressure sore policy:

“At inquest it was identified that [REDACTED] had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it).”

Steven Sanders It was thought from other patients’ reports and discovery of cocaine on the unit after his death that Steven may have smuggled an illicit drug onto the secure ward after leave, and that drug use may have been a factor in his death. Subsequent police investigation revealed several positive drug tests on the unit. There was also an unexplained death of another patient. The coroner was concerned about “endemic” illicit drug use and lack of mitigation by St Andrews Healthcare.

All three PFD reports relate to detained patients, making these failures all the more egregious, as the duty of care is even greater. Condolences to their families.

Declaration of interest:

I was a St. Andrews whistleblower.