Jake Anthony O’Brien, aged 22, died on 12 November 2024 after ligaturing in his cell at HMP Forrest Bank whilst on the Care and Separation Unit.
The jury concluded the medical cause of death of be Ischaemic brain injury caused by hanging.
The inquest took place between 20th April – 6th May and was heard before HM Area Coroner Michael James Pemberton, sitting with a Jury, at Manchester West Coroner’s Court.
Background
Jake was a remand prisoner at HMP Liverpool before being transferred to HMP Forest Bank on 22 October 2024. Jake had suffered a deterioration in his mental health for which he was being assessed by a Consultant Psychiatrist. The Jury found that this transfer should not have taken place, and that Jake ought to have been placed on a “medical hold”, pending the outcome of an ongoing Section 48 assessment, which was to assess his suitability for a placement at a medium secure unit as opposed to the prison environment. They concluded that a lack of continuity of care following the transfer likely contributed to the deterioration in his mental health.
Jake was placed in the Care and Separation Unit (CSU/Segregation) at HMP Forest Bank on 25 October 2024, where he remained until his transfer to hospital on 9 November 2024 after being discovered ligatured in his cell.
Evidence before the Jury established that in the weeks and months prior to his death, Jake had experienced acute psychotic episodes, self‑neglect and behavioural deterioration that was significantly out of character. It was also identified that he had not been taking prescribed medication for several weeks and had a pending referral for transfer to a medium secure unit under a Section 48 assessment.
The Jury identified a number of factors which, on the balance of probabilities, may have contributed to Jake’s death.
Of particular concern was the absence of clear ownership and oversight of Jake’s mental health care through a named nurse or clinician, resulting in poor communication within the multidisciplinary team and between healthcare and custodial staff. This was compounded by the existence of multiple digital systems and differing levels of access across organisations, which hindered effective information sharing.
The Jury further identified a lack of systematic risk assessment and thorough action planning, together with a failure to adequately appreciate the cumulative nature of Jake’s risk factors. They concluded that the frequency of observations should have been increased. The complex crossover of roles and responsibilities, combined with a lack of professional curiosity and silo working across medical, nursing and custodial staff, was found to have led to a serious failing in Jake’s care.
Concerns were also raised regarding delays in the commencement of CPR, which the Jury attributed to inadequate refresher training and a resulting lack of staff confidence. Additional concerns were identified in relation to training on the completion of the segregation safety algorithm.
In their conclusion, the Jury determined that Jake Anthony O’Brien died as a consequence of an act of self‑ligature. However, due to concerns regarding his mental health and capacity at the relevant time, it could not be determined whether Jake acted with a specific intention to end his life or during a period of mental health crisis in which he was unable to comprehend the consequences of his actions.
The Coroner will be issuing a Prevention of Future Deaths report as a result of evidence heard during this inquest. Of concern, evidence was heard that mental health nurses are not appropriately trained on segregation safety algorithms. This often leads to these important assessments being completed incorrectly and absent of key information relating to risk.
The Coroner also highlighted that PSO 3050 – Ensuring healthcare for prisoners requires urgent update. This policy is over 20 years old, out of date and fails to differentiate between mental health and neurodivergence.
Jake’s death is 1 of 5 deaths our inquest team are represented in connection with that have occurred between 2024 to date. The Prison and Probation Ombudsman has identified significant issues with the quality of mental health care at HMP Forrest Bank in the majority of these cases.
Jake’s family were represented by Kelly Darlington and David Corrigan of Farleys Solicitors. Huw Davies of Farrar’s Building Chambers was instructed Counsel for Jake’s mother.
