An inquest into the death of Jake O'Brien, from Trafford, has concluded. After jurors identified 'serious failings' in the care received by the 'vulnerable' 22-year-old, his mother spoke of her anger.
Jake O'Brien(Image: Family handout)
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A jury has found 'serious failings' in the care received by a vulnerable young man found dead in his cell at Forest Bank. Jake O'Brien's mother - speaking out following the conclusion of an inquest examining the circumstances surrounding her 22 year-old son's death - said he should have been in hospital, not prison.
His death, Sarah O'Brien said, was 'entirely preventable'. She told how staff at Forest Bank referred to her as a 'drain' when she made repeated telephone enquiries about Jake. She said the calls were '[her] desperate pleas for help', but that no one listened.
The Manchester Evening News has seen an email from a member of prison staff, included in the inquest evidence bundle, in which Ms O'Brien was described as 'becoming a drain on the phones with her constant demands'.
The 41-year-old said after the inquest concluded this week: "I knew this was going to happen. There were gaps in his healthcare and no one knew what was going on.
"He did not need to die. If people would have just listened, but they didn't. Everyone was presuming other people were doing things when they weren't.
"The coroner looked at me at the end of the inquest and said 'I am so sorry this has happened to you'." Ms O'Brien claimed Jake was kept in segregation at Forest Bank when he wasn't fit to be.
At the inquest, she said that when she heard Jake was moving to Forest Bank from HMP Liverpool she knew it was 'the start of the end of his life'. Ms O'Brien said: "I can't even tell you the feeling that I had. Nobody listened and he ended up dead."
The inquest heard mental health concerns were 'overlooked' and he was 'severely mentally unwell' when he was transferred. HMP Liverpool, however, sent an email to Forest Bank claiming they had 'no concerns from a healthcare perspective regarding this transfer'.
Jake was on remand at Forest Bank(Image: MEN/UGC)
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The jury, in its conclusions, criticised a number of 'serious' and 'significant' concerns in his care. They included a 'delay' in performing CPR on Jake. 'Poor communication' between mental health experts was cited. And jurors said they found no one carried out a formal capacity assessment of him.
Jake, from Altrincham in Trafford, was on remand after his arrest for car crime offences. He died at Salford Royal Hospital on November 12, 2024, three days after being found hanged in his cell at the prison in Pendlebury, Salford.
The inquest at Bolton Coroners' Court heard that while in prison Jake, who had ADHD, a history of self-harm and a 'strong probability' of having autism, was experiencing psychosis and delusions. He also had a history of schizophrenia in his family and had taken ketamine around the time of his psychosis, it was said.
Speaking to the Manchester Evening News, following the inquest, Ms O'Brien said Jake should have been on a 'medical hold' to a secure mental health unit at the time of his death - something she repeatedly asked for.
She said: "At the time of death he was suffering from severe psychosis and had been since early September. He had a history of schizophrenia on the paternal side of his family.
"Jake was described as a 'vulnerable young adult' who looked and acted much younger than his age. He had multiple acquired brain injuries. His death was preventable and reading internal emails of them calling me a 'drain' on the phone lines was heartbreaking.
HMP Forest Bank(Image: Men Media)
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"So many professionals could have helped him. He died cold and alone. He deserved so much more and I want to raise awareness and prevent further deaths. I just wish someone would have listened to my desperate pleas for help."
The jury said that during the weeks and months before his death, Jake had 'acute psychotic episodes'. He also hadn't been taking his medication. The inquest heard there was a 'pending referral' to a medium secure mental health unit in Prestwich because of those factors.
"Due to the above factors, there were concerns about his capacity meaning that on the balance of probabilities, it cannot be determined whether he could form a specific intent to end his life," jurors concluded.
Jurors said they had 'identified a few factors' which 'may have contributed to Jake's death', saying they, too, found he should have been placed on a medical hold.
There was also a criticism of a 'lack of continuity of care'. "The lack of continuity of care may have contributed to a decline in Jake's mental health and subsequent death," the jury added.
A single named professional wasn't assigned to him either. The jury, recording a narrative verdict, added: "The lack of ownership/oversight of Jake's mental health through a named nurse/clinician was a serious concern.
"This resulted in poor communication between members of the wider MDT as well as communication between medical and custodial staff. This also likely contributed to nobody carrying out a formal capacity assessment. However, we appreciate the difficulties caused by trying to maintain confidentiality between medical and custodial staff.
Jake pictured as a boy(Image: UGC/FAMILY/MEN)
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"This was compounded by multiple digital systems and differing access between different individuals and organisations involved in Jake's care."
A MDT is a Mental Health Multidisciplinary Team, a group of specialists who work together to create treatment plans for patients. The jury also said they found delays in trying to save Jake's life by Forest Bank staff, calling it a 'significant concern'.
They concluded: "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 staff are likely to have contributed to confusion and silo working.
"This led to a serious failing in Jake's care."
In conclusion, the jury said it was 'unclear' whether Jake what did was done 'with an intention to end his life or during a period of mental health crisis when he was unable to comprehend the consequences of his actions'.
The Category B men's private prison in the Pendlebury area of Salford is privately run by France-based facilities giant Sodexo, but has long faced criticism and concern over the number of fatalities there.
An HMP Forest Bank spokesperson 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 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."