Jake O’Brien, from Altrincham, died on November 12, 2024 after being found in his cell at Forest Bank prison
Jake Anthony O’Brien, 22, who died at Salford Royal Hospital on November 12, 2024(Image: MEN/UGC)
A 22-year-old who was ‘in crisis’ and ‘severely mentally unwell’ was transferred to a new prison despite grave concerns for his health – and was found dead in his cell just three weeks later, an inquest has heard.
Mental health concerns for Jake Anthony O’Brien, from Altrincham, were ‘overlooked’, before he was found dead in his prison cell at Forest Bank in 2024, an inquest has heard.
The inquest into his death heard today, April 21, that HMP Liverpool sent an email to Forest Bank claiming they had ‘no concerns from a healthcare perspective regarding this transfer’.
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It was ‘plain as day’ that Jake needed help and given ‘what we know now that there is reason to question his transfer at the time,’ the inquest into Jake’s death, which is currently on going at Bolton Coroner’s Court, heard.
Jake, who had the mental age of a ten year old, had ‘complex and competing needs and behaviours’ and ‘skewed perspectives of life and relationships’, the inquest heard from social services, which added at the time that ‘a psychiatrist unit would be a safer place’ for him.
The jury heard how concerns for Jake’s safety and mental wellbeing were raised multiple times by various people and organisations, including Owain Williams, a senior litigator at Draycott Browne Solicitor.
Mr Williams said in a statement heard at the inquest that after Jake’s sentencing was pushed back when he was sent to hospital for hurting himself he advised that ‘an assessment should be made to see if it was more appropriate for a hospital order for Jake’.
He added that Jake was becoming increasingly unwell and concerns were raised that his mental health needs weren’t being met.
This included a ‘vital’ assessment due to take by Consultant Forensic Psychiatrist Dr Plunkett, which wasn’t carried out due to Dr Plunkett being an hour late to the appointment. He added that two other appointments had also been missed in the past.
Mr Williams added that he told various authorities involved that if they didn’t explain what had been going on with Jake’s care then he would summon them to court to explain.
In an email sent at the time, Mr Williams said he was ‘becoming increasingly concerned that Jake is not receiving the care that he needs’, adding that it is ‘plain as day’ that Jake needed help.
Mr Williams added that he was suspicious of the timing of Jake’s transfer – which came shortly after he emailed a judge raising his concerns for Jake’s safety.
James Winrow, Head of Safety at HMP Liverpool, explained to the jury how Jake was transferred to Forest Bank under a court transfer, meaning he was moved to a prison closer to Manchester where he was due to be attending court.
Jake was ‘in crisis’ before being sent to Forest Bank(Image: MEN/UGC)
This was questioned at the time by Jake’s solicitor who noted that Jake had had three previous court dates where he hadn’t been moved to a closer prison in the past. The inquest also heard how Forest Bank doesn’t have the same 24/7 healthcare access that HMP Liverpool does.
The jury heard how an email was sent to Forest Bank from HMP Liverpool around the time of Jake’s transfer stating that they had ‘no concerns from a healthcare perspective regarding this transfer’. However, it was noted that confidential information regarding Jake’s mental health may have been directly communicated between the two mental health teams at the prisons.
Jake wasn’t put on a medical hold, which would have stopped a transfer to another prison, and the jury heard how Forest Bank hadn’t been told that he was mid-referral with an ongoing deferred formal assessment for referral to Edenfield, a medium secure service that provides care and treatment for people with enduring mental health needs.
The jury heard how it ‘appears that was overlooked for his transfer’, and that the mental health team might have been overlooked before his transfer.
It was noted that Forest Bank were given background information on Jake’s self-harming, paranoia and other behaviour at HMP Liverpool which were not necessarily medical in nature.
The jury also heard how, at the point of his transfer, HMP Liverpool hadn’t received the outcome of the initial referral assessment – meaning it was still possible to them that he could have been transferred to Edenfield and would have come under the requirements of a clinical hold to not be transferred between prisons.
It was also noted that Jake’s court date was not imminent. Mr Winrow, who was not Head of Safety at the prison at the time, added that Jake was ‘always found to be pleasant’ and that there’s ‘no such thing as a high maintenance prisoner’.
He agreed when questioned that with what we know now that there is reason to question his transfer at the time.
The jury also heard from prison officers working with Jake at HMP Liverpool before his transfer who say the 22-year-old was ‘severely mentally unwell’ and ‘in crisis.’
Supervising Officer Adam Lavin, who worked with Jake in Care and Separation Unit told the jury about how he ‘really liked Jake’. He added that ‘when he first came down Jake he was severely mentally unwell’ but he saw ‘him get so much better’ under their care.
He added that Jake would deliberately do things to get sent to CSU, where he saw a mental health team every day, a doctor three times a week as well as having other welfare checks, because he was scared of the hospital wing at the prison.
Mr Lavin told the jury how he had a mutually beneficial relationship Jake’s mum which helped them understand his mental health issued. He added that he became ‘settled’ in the CSU in terms of his regime and how the team ‘coaxed’ him to do things that would be good for his health such as getting fresh air.
He added that they were given no notice of Jake being sent to Forest Bank.
The inquest continues