Watchdog Report Condemns Prison Failures
Forest Bank prison has been condemned over 'critical failures' in the care of a vulnerable young man who was found dead in his cell on a segregation unit. Jake O'Brien, from Altrincham, Trafford, died in hospital on November 12, 2024, three days after being found hanging. He was 22. A watchdog report published following an inquest investigation found 'serious failings' in his care.
The inquest heard that Jake's mental health concerns were 'overlooked' despite him being 'severely mentally unwell' when he was transferred to Forest Bank from HMP Liverpool 18 days before his death. At the time, he was being assessed for a transfer to a psychiatric hospital.
Ombudsman Highlights 'Critical Failures'
The report by the Prisons and Probation Ombudsman describes Jake as 'a very challenging prisoner to manage safely' who was 'clearly mentally unwell'. It identifies 'critical failures' in his care at both Liverpool and Forest Bank. Ombudsman Adrian Usher stated: 'There was inconsistent documentation, poor case co-ordination, and missed opportunities to reassess his risk after serious incidents. Communication between prison, healthcare, and external agencies was inadequate, with key information not shared.'
Usher added: 'While there is evidence of staff making concerted efforts to support Mr O'Brien, overall this is a critical report making a number of recommendations to both Liverpool and Forest Bank.'
Mother's Heartbreaking Response
Jake's mother, Sarah O'Brien, 41, from Altrincham, said her son was 'failed' and has launched a charity, Jake's Voice, in his memory. Speaking after the report's publication, she said: 'My precious son, Jake, died following a series of catastrophic failings by multiple agencies that had a duty to protect him. His death was preventable. Jake should never have been transferred from HMP Liverpool to Forest Bank. He was severely unwell, both physically and mentally, and should have been receiving urgent medical care, not isolation.'
She continued: 'During the inquest, evidence showed that staff ignored their own training and policies, keeping him in a segregation unit where he wasted away. For nine weeks, I spent over 12 hours a day desperately trying to save my son's life. I contacted everyone I could, even Andy Burnham's office. I knew my son was in grave danger. He should still be here. In his memory. Every young person deserves dignity, compassion, and proper mental health care. How many more families must suffer before change happens?'
Specific Failures in Care
Usher noted a 'limited handover between the two prisons and no managerial oversight' when Jake was transferred to Forest Bank. In late October, the secure hospital informed Forest Bank that Jake needed 'close monitoring, a psychiatric review and updated assessments'. However, Usher said: 'A nurse confirmed Mr O'Brien would be appointed a mental health nurse who would co-ordinate his care. This did not happen.'
After Jake was involved in several incidents, a nurse assessed him as fit for segregation but did not complete a required assessment. The report highlighted 'critical failures' in ensuring Jake's safety and accurate, up-to-date risk assessments. Usher added: 'At Forest Bank, segregation procedures were not always followed despite Mr O'Brien's deteriorating mental health.'
Mental Health Care Fell Short
Usher found that Jake's mental healthcare at Forest Bank 'fell short of the required standard'. He said: 'The clinical reviewers identified multiple communication failures between prison, healthcare staff and external agencies, where key information was not recorded or shared, potentially affecting the accurate assessment of Mr O'Brien's risk.'
Jake was on remand after his arrest for car crime offences. He died at Salford Royal Hospital. The inquest at Bolton Coroners' Court heard that Jake, who had ADHD, a history of self-harm and a 'strong probability' of autism, was experiencing psychosis and delusions. The jury returned a narrative verdict, stating it was 'unclear' whether Jake intended to end his life or acted during a mental health crisis.
Prison's Response
The Category B men's private prison in Pendlebury, Salford, is run by France-based Sodexo and has faced long-standing criticism over fatalities. An HMP Forest Bank spokesperson said: 'We extend our deepest sympathies to Jake O'Brien's family and all those affected by his death. We are sorry for what they have endured and recognise how difficult and distressing this process will have been for them. We cooperated fully with the Prisons & Probation Ombudsman in its investigation and have implemented the recommendations in the report. We take this matter extremely seriously, our focus is on learning from what happened and continuing to work closely with our healthcare partners to help ensure the safety of those in our care.'
