A young man with complex mental health needs died after a series of failures in his care across two prisons, the Prisons and Probation Ombudsman has found.
Jake O’Brien, 22, died in hospital on 12 November, three days after staff found him in his cell on the segregation unit at HMP Forest Bank. Adrian Usher, the Ombudsman, published his report into the death on 22 June.
Mr Usher concluded that HMP Liverpool could, and should, have kept Mr O’Brien while a place in a specialist hospital was found. He also found that mental health care at Forest Bank fell short of the required standard. It was only partly equivalent to the care Mr O’Brien would have received in the community.
Clinical reviewers identified repeated breakdowns in communication between the prison, healthcare staff and outside agencies. Key information went unrecorded or unshared. That may have affected how staff judged the risk he posed to himself and to others.
A history of vulnerability
Mr O’Brien went to HMP Birmingham on remand on 20 November 2023 for several alleged offences, including burglary, theft and affray. It was not his first time in prison.
He reported a history of self-harm, substance use, anxiety and ADHD (Attention Deficit Hyperactivity Disorder). He also had memory problems linked to an earlier head injury. Doctors had diagnosed learning difficulties and borderline autism.
He later moved to HMP Brinsford and then to HMP Liverpool. There he became involved in repeated fights and damaged prison property, which led to spells in segregation and disciplinary sanctions. In September 2024 staff found him under the influence of ketamine.
His mental health then declined. He behaved bizarrely, assaulted staff and other prisoners, self-harmed and set fires. Staff opened ACCT (Assessment, Care in Custody and Teamwork) monitoring, the process for prisoners at risk of suicide or self-harm. At times they placed him under constant supervision.
Brief periods of stability gave way to impulsive behaviour, paranoia and more substance misuse. He moved between segregation, residential wings and the healthcare unit. He rarely took the antipsychotic medication that a psychiatrist had prescribed for him.
Transfer to Forest Bank
In October 2024 a psychiatrist referred him for assessment for a move to a medium secure psychiatric hospital. The assessment took place on 16 October. On 22 October the hospital deferred the referral for another month of monitoring and told the psychiatrist verbally.
Mr O’Brien moved to HMP Forest Bank that same day. Despite his complex condition, the two prisons exchanged little information and no manager oversaw the handover.
A mental health nurse at Liverpool emailed details of his care to the Forest Bank mental health team. The email set out his vulnerabilities, his history of substance use, his ACCT monitoring and the outstanding hospital referral. It also noted that he had not taken his medication for four days.
Reception staff placed him on a standard residential unit. On 23 October the secure hospital told Forest Bank that he needed close monitoring, a psychiatric review and updated assessments. A nurse confirmed that a mental health nurse would coordinate his care. That never happened.
On 25 October he again refused medication, tried to harm himself, set fire to his cell and hid a blade. Staff moved him to segregation. A nurse judged him fit for segregation but did not properly complete the safety assessment or file it in his medical record. He stayed in segregation because of continuing aggression and refusal of medication. Nobody passed this on to the secure hospital.
On 31 October he assaulted his mother during a private visit. A nurse examined him, found no injuries and decided he needed no treatment. Nobody told the mental health team or the hospital. He also missed a psychiatric appointment that day because of clinic overbooking. The psychiatrist rebooked it and asked staff to alert the hospital if his condition worsened.
He missed further appointments on 4 and 5 November. The mental health team only learned of the assault on his mother on 6 November. A nurse then told the hospital, noting that he still had not had a psychiatric review or a detailed mental health assessment. That day he assaulted an officer.
At 9.03am on 9 November, staff found him in his cell and raised the alarm. Healthcare staff began resuscitation. Paramedics arrived at 9.20am and took him to hospital, where he died on 12 November.
HMP Forest Bank is a reception prison for men in the North West. At its last full inspection, in March 2025, inspectors rated safety and purposeful activity as not sufficiently good, and respect and preparation for release as reasonably good.
Anyone who is struggling can call Samaritans free, day or night, on 116 123, or visit samaritans.org.
