The death of 22-year-old Jake O’Brien while in custody at HMP Forest Bank has raised serious questions about prison procedures, particularly an email sent by staff at HMP Liverpool that described him as having “no medical concerns” shortly before his transfer. O’Brien, who was on remand awaiting trial for car theft charges, died on November 12, 2024, at Salford Royal Hospital after being found unresponsive in his cell at the Category B prison in Salford.

O’Brien suffered from severe ADHD, suspected autism, and significant mental health difficulties, including terrifying hallucinations and episodes of psychosis. His family had repeatedly warned prison authorities about his vulnerability and expressed fears that he would not cope well in custody. Despite these concerns, records show that healthcare staff at HMP Liverpool sent an email to Forest Bank stating there were “no medical concerns” regarding the transfer. This assessment has come under heavy criticism during the ongoing inquest into his death.

The inquest has heard evidence that O’Brien’s mental state deteriorated sharply after arriving at Forest Bank. He stopped taking his prescribed antipsychotic medication, a critical detail that a mental health nurse later admitted she was aware of but did not escalate with sufficient urgency. His mother described him as functioning at the mental age of a much younger child due to his conditions and a history of encephalitis as an infant. She told the inquest she had an overwhelming sense that something tragic would happen once he was moved to the new facility.

Testimony revealed that O’Brien experienced vivid hallucinations and delusions while locked in his cell. Despite clear signs of serious psychological distress, the transfer proceeded based on the email from Liverpool describing his condition as stable from a healthcare perspective. Family representatives have argued that this assessment was dangerously inaccurate and contributed to an environment where his needs were not properly managed.

A prison nurse, Lauren Debenham, told the inquest she discovered O’Brien had stopped taking his antipsychotic medication but handed the information to the secondary care team without further immediate escalation. She acknowledged shortcomings in documentation. The coroner questioned whether proper protocols for monitoring medication compliance and responding to rapid mental health decline were followed.

O’Brien was discovered in his cell on November 9, 2024, and transferred to hospital, where he died three days later. His death was consistent with hanging, and no suspicious circumstances were identified at the time. An independent investigation by the Prisons and Probation Ombudsman is also underway.

The case has highlighted broader concerns about the transfer of vulnerable prisoners between facilities and the adequacy of mental health support in the UK prison system. Questions remain about whether staff at both prisons adequately assessed O’Brien’s risk of self-harm and whether communication between healthcare teams met required standards.

Jake O’Brien’s family continues to seek answers through the inquest process. His mother has spoken emotionally about feeling unheard despite her repeated attempts to advocate for her son. The proceedings are examining whether missed opportunities to intervene — particularly around medication refusal and the accuracy of transfer information — played a role in the tragic outcome.

As the inquest continues, attention is focused on the email from HMP Liverpool and whether it accurately reflected O’Brien’s fragile mental state at the time. Critics argue the “no medical concerns” description minimized his documented vulnerabilities and contributed to a fatal lack of appropriate care upon arrival at Forest Bank.

The death of Jake O’Brien has sparked calls for a review of how prisons handle inmates with complex mental health needs, especially young adults on remand. It also raises questions about accountability when internal assessments appear to downplay serious risks in order to facilitate transfers.

The full circumstances surrounding his final weeks remain under examination, with the coroner and investigators working to determine whether systemic failures or individual negligence contributed to this preventable tragedy.