Jamie Osborne was 19 years old when he tragically took his own life at HMP Lewes on 12th February 2016.
At the time of his death Jamie was an extremely vulnerable young man who had been assessed as a high risk of suicide by psychiatrists. Just 3 months prior to his death, Jamie had made a serious attempt to take his own life requiring resuscitation and hospitalisation. He returned to HMP Lewes several days later and following mental health assessments, professionals concluded that he should be transferred to a secure mental health unit, but a suitable placement was not found. He therefore remained on the healthcare unit and suicide monitoring (known as ACCT monitoring) continued until his death.
Following Jamie’s death, HM Senior Coroner for East Sussex opened an inquest into his death and the Prison and Probation Ombudsman carried out an investigation. The investigation identified a number of areas for improvement in Jamie’s care at HMP Lewes, some of which repeat findings from previous investigations into deaths at the prison.
In summary, the PPO identified;
Concerns that staff did not take account of Jamie’s previous history, or information about his risk of suicide that accompanied him when he first arrived at HMP Lewes;
When his risk of suicide was later identified, following an unsuccessful attempt at hanging himself, the resulting self-harm prevention procedures were not managed fully in line with national policy;
Despite Jamie’s complex needs, staff did not consider managing him using enhanced case management which would have resulted in a more co-ordinated approach to managing someone as vulnerable as Jamie;
The process for transferring prisoners under the Mental Health Act, which resulted in a delay in referring Jamie for a place at a suitable secure hospital, was mismanaged. As a result, the clinical reviewer concluded that Jamie’s healthcare was not equivalent to that which he could have expected to receive in the community. Had the process been better and successfully managed, the outcome for Jamie might have been very different.
On 6th March 2019 at Brighton Magistrates Court, Sussex Partnership NHS Foundation Trust who provides primary care services at HMP Lewes pleaded guilty to criminal charges brought against them by the Care and Quality Commission (“CQC”) for failing to comply with the regulations under the Health and Social Care Act 2008, which state it must provide care and treatment in a safe way.
District Judge Tessa Szagun said the Trust faced an ‘unlimited fine’ and requested to see details of its accounts before she passed sentence, adjourning the case until 2 May.
Jamie’s mother said;
We as a family are glad that the Trust has chosen to admit their guilt in respect of the failings in my son’s care.
We were extremely upset to learn that to date there has been no accountability or transparency from the Doctor in charge.
Since Jamie’s death, I have been working with Jamie’s mother in connection with his inquest which has not yet taken place. It is 3 years since Jamie’s death and there are still many questions his family have surrounding his death that remain unanswered. The admission of guilt by the Trust is welcomed, and will hopefully go some way in avoiding any further delay and distress being caused to Jamie’s family in awaiting the inquest.
To speak to a specialist in legal representation at inquests, call Farleys Solicitors on 0845 287 0939 or email the team through our online contact form.