Urgent concerns have been raised about the care of a vulnerable young man who was imprisoned in HMP Forest Bank. Jake O'Brien died in hospital on November 12, 2024, three days after he was found hanged in his cell on the segregation unit of the category B prison.
A jury found serious failings in his care during an inquest into his death, with the court hearing how Mr O'Brien's mental health concerns were overlooked despite him being mentally unwell when he was transferred to Forest Bank from HMP Liverpool 18 days earlier. At the time of his death, the 22-year-old, from Altrincham, was on remand for car crime offences and was in the process of being assessed for a transfer to a psychiatric hospital.
Jury criticises serious failings
In its conclusion, the jury at the inquest criticised a number of serious and significant concerns in his care. This included a delay in performing CPR on Mr O'Brien and poor communication between mental health experts. Mr O'Brien was said to have had ADHD, a history of self-harm and a "strong probability" of having autism.
The jury also found no one carried out a formal capacity assessment on him, the MEN reports.
Coroner issues prevention of future deaths report
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."
Mother says son was failed
Speaking to the MEN 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?"
Responses from prison and health services
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 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."
When life is difficult, Samaritans are available day or night, 365 days a year. You can call them for free on 116 123 or visit samaritans.org.
