Jake O'Brien's mum said her son's death was preventable
Jake O'Brien
Jake O'Brien(Image: MEN/UGC)
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A mum has said her son was "failed" after he died weeks after being transferred from HMP Liverpool. Jake O'Brien, 22, died in hospital on November 12, 2024, three days after he was found hanging in Forest Bank prison in Salford.
Jake was transferred to Forest Bank from HMP Liverpool 18 days before his death. A watchdog has now published a report into his death after an inquest found "serious failings" into his care. The inquest heard Jake's mental health concerns were "overlooked" despite him being "severely mentally unwell" when he was transferred. Jake was in the process of being assessed for a transfer to a psychiatric hospital at the time of his death.
As the MEN reports, the report by the Prisons and Probation Ombudsman describes Jake who was from Altrincham in Trafford, as "a very challenging prisoner to manage safely" who was "clearly mentally unwell". But it says there were 'critical failures' in his care at Liverpool and Forest Bank.
The ombudsman, Adrian Usher, said there was "inconsistent documentation, poor case coordination, and missed opportunities to reassess his risk after serious incidents".
He said: "Communication between prison, healthcare, and external agencies was inadequate, with key information not shared. While there is evidence of staff making concerted efforts to support Mr O’Brien, overall this is a critical report making a number of recommendations to both Liverpool and Forest Bank."
Forest Bank Prison in Salford
Forest Bank Prison in Salford(Image: ABNM Photography)
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Jake's mum Sarah O'Brien, 41 and from Altrincham, said her son was "failed" and revealed she's launched a charity, Jake's Voice, in his memory to help and support other families and youngsters.
Speaking to the MEN after the report's publication, she said: "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?"
Mr Usher said there was a "limited handover between the two prisons and no managerial oversight" when he was transferred to Forest Bank. In late October, the secure hospital informed Forest Bank that Jake needed 'close monitoring, a psychiatric review and updated assessments".
But Mr Usher said in the report: "A nurse confirmed Mr O’Brien would be appointed a mental health nurse who would coordinate his care. This did not happen."
HMP Liverpool
HMP Liverpool(Image: Liverpool Echo)
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After he was involved in a number of incidents, a nurse assessed him as being fit for segregation, but didn't complete a required assessment.
The report highlighted "critical failures" in ensuring Jake's safety "along with accurate and up to date assessments of his risks". He added: "At Forest Bank, segregation procedures were not always followed despite Mr O’Brien’s deteriorating mental health."
He said he found after an investigation that Jake's mental healthcare at Forest Bank "fell short of the required standard". He said: "The clinical reviewers identified multiple communication failures between prison, healthcare staff and external agencies, where key information was not recorded or shared, potentially affecting the accurate assessment of Mr O’Brien’s risk."
Jake was on remand after his arrest for car crime offences. He died at Salford Royal Hospital. 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.
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'. A narrative verdict was recorded, stating it was unclear whether he intended to take his own life.
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 cooperated fully with the Prisons & Probation Ombudsman in its investigation and have implemented the recommendations in the report. 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.”
The charity foundation Jake's Voice can be accessed here.