Jake O’Brien

On 13 November 2024 I commenced an investigation into the death of Jake Anthony O’BRIEN aged 22. The investigation concluded at the end of the inquest before a jury between 20 April 2026 and 06 May 2026. The medical cause of death was recorded as: I(a) Hypoxic Ischaemic Brain Damage with Pneumonia I(b) Hanging

The conclusion of the jury at the inquest was: Jake Anthony O’Brien died as a consequence of an act of self-ligature [REDACTED] however, it is unclear whether this 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 findings of the jury were recorded as follows: Jake Anthony O’Brien died on 12 November 2024 at Salford Royal Hospital. On 9 November, Jake was found suspended by a ligature [REDACTED] in a cell at HMP Forest Bank. He died of irreversible hypoxic ischaemic brain injury and pneumonia.

During the previous weeks to months, Jake had acute psychotic episodes as well as self-neglect and other behaviour that was out of character. It is also evident that Jake had not been taking his medication for a few weeks as well as having a pending referral to an MSU (Edenfield). 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.

During our deliberations, we identified a few factors which, on the balance of probabilities, may have contributed to Jake’s death.

Jake should have been placed on medical hold due to the ongoing Section 48 assessment. The lack of continuity of care may have contributed to a decline in Jake’s mental health and subsequent death.

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 stay. 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 stay. This was  compounded by multiple digital systems and differing access between different  individuals and organisations involved in Jake’s care.

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. There was also concern about the provision of training relating to completing the segregation algorithm.

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 stay are likely to have  contributed to confusion and solo working. This led to a serious failing in Jake’s care.

In my opinion, unless action is taken to address the above concerns, there is a significant risk of future deaths and I believe each of you have the power to take such action.