Jake O'Brien, a 22-year-old man from Altrincham, Trafford, died in hospital on November 12, 2024, three days after being found hanging in Forest Bank prison in Salford. He had been transferred from HMP Liverpool just 18 days earlier. A report by the Prisons and Probation Ombudsman has now highlighted 'critical failures' in his care at both prisons.
Ombudsman finds 'critical failures' in care
The ombudsman, Adrian Usher, stated that there was 'inconsistent documentation, poor case coordination, and missed opportunities to reassess his risk after serious incidents.' He added: 'Communication between prison, healthcare, and external agencies was inadequate, with key information not shared. 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.'
The inquest at Bolton Coroners' Court heard that Jake's mental health concerns were 'overlooked' despite him being 'severely mentally unwell' at the time of transfer. He was in the process of being assessed for transfer to a psychiatric hospital when he died.
Mother's grief and campaign for change
Jake's mother, Sarah O'Brien, 41, said her son was 'failed' by multiple agencies. 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 revealed that during the inquest, evidence showed staff ignored their own training and policies, keeping him in a segregation unit where he 'wasted away.' She added: '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 response, Mrs O'Brien has launched a charity called Jake's Voice to support other families and young people affected by similar issues.
Failures in transfer and segregation procedures
The ombudsman's report 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, a nurse confirmed he would be appointed a mental health nurse to coordinate his care, but 'this did not happen.'
After several incidents, a nurse assessed Jake as fit for segregation but did not complete a required assessment. The report highlighted 'critical failures' in ensuring Jake's safety along with accurate and up-to-date risk assessments. At Forest Bank, segregation procedures were not always followed despite his deteriorating mental health.
Mental health background and inquest verdict
Jake was on remand for car crime offences. He had ADHD, a history of self-harm, and a 'strong probability' of having autism. At the time of his death, he was experiencing psychosis and delusions. The inquest jury recorded a narrative verdict, stating it was 'unclear' whether Jake intended to take his own life or acted during a mental health crisis when he could not comprehend the consequences.
Forest Bank prison, a Category B men's private prison run by Sodexo, has faced criticism over the number of fatalities there. A spokesperson for HMP Forest Bank 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.'
The Jake's Voice charity foundation can be accessed for support.
