A coroner has issued a prevention of future deaths report over the care of a vulnerable young man at Forest Bank prison. Jake O'Brien, 22, died in hospital on November 12, 2024, three days after he was found hanged in his cell on the segregation unit at the Salford prison.
A jury at an inquest into his death found there were 'serious failings' in his care. The inquest heard Jake's mental health concerns were 'overlooked' despite him being 'severely mentally unwell' when he was moved to Forest Bank from HMP Liverpool 18 days earlier.
Serious failings identified
At the time of his death Mr O'Brien, of Altrincham, Trafford, who was on remand for car crime offences, was in the process of being assessed for a transfer to a psychiatric hospital. The jury, in its conclusions, criticised a number of 'serious' and 'significant' concerns in his care.
They included a 'delay' in performing CPR on Mr O'Brien, who had ADHD, a history of self-harm and a 'strong probability' of having autism, and 'poor communication' between mental health experts. Jurors said they found no one carried out a formal capacity assessment of him.
Coroner's concerns
Now coroner Michael Pemberton has warned more deaths could occur unless urgent action is taken. Issuing a prevention of future deaths report, the coroner raised several concerns, including about a lack of ongoing first aid and basic life support training for prison officers and the fact that guidance relating to clinical holds and consistency of healthcare for prisoners is 20 years old and makes no reference to mental health conditions or neurodiversity issues.
Mr Pemberton wrote: "The lack of ownership/oversight of Jake’s mental health through a named nurse/clinician was a serious concern. We identified that there was a delay in CPR commencing. This appeared to be due to inadequate refresher training resulting in a lack of confidence, which was of significant concern.
"We identified that there was a lack of appreciation of Jake's ongoing accumulation of risk factors and incidents in relation to self-harm and behaviour deterioration. There was a lack of systematic risk assessment and thorough action planning. We concluded that the frequency of observations should have been increased.
"The complex crossover of differing roles and responsibilities and lack of professional curiosity from medical, nursing and custodial stay are likely to have contributed to confusion and solo working. This led to a serious failing in Jake’s care."
Family's response and actions taken
Speaking to the Manchester Evening News in July, Mr O'Brien's mum Sarah O'Brien, 41, said her son was 'failed'. She added: "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. 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?"
In response to the coroner's concerns, HM Prisons and Probation Service said the 'outdated' policy on holds was now being revised to 'place greater emphasis on the identification and management of mental health conditions and neurodiverse needs'.
Sodexo, which runs Forest Bank, said staff whose first aid training had expired were to be 're-accredited as a priority'. The firm said it would also introduce annual refresher training.
Greater Manchester Mental Health said following Mr O'Brien's death new guidance on completing the segregation form had now been shared with healthcare staff across the prison system. The trust said it had also set up weekly meetings for mental health care teams to allow them to 'discuss cases and escalate any concerns'.
It added: "Learning from Jake's death has been shared with staff through these meetings and in individual supervision sessions."
