The death of 22-year-old Jake Anthony O’Brien at HMP Forest Bank has come under fresh scrutiny during an ongoing inquest, with particular attention on an email sent by healthcare staff at HMP Liverpool shortly before his transfer. O’Brien, who was on remand awaiting trial for car-related offences, was moved from HMP Liverpool to the Category B prison in Salford in late October 2024. Just three weeks later, he was found hanged in his cell on November 9 and died at Salford Royal Hospital on November 12, 2024.

O’Brien had a documented history of severe mental health difficulties, including ADHD, a strong likelihood of autism, terrifying hallucinations, psychosis, and behaviours consistent with a much younger mental age. His family repeatedly raised concerns with prison authorities about his vulnerability and the potential risks of moving him to a new facility. Despite this, an email from HMP Liverpool to Forest Bank reportedly stated there were “no medical concerns” regarding the transfer.

The inquest has heard evidence that O’Brien’s mental state was visibly deteriorating at the time of the move. Witnesses described his complex needs and competing behaviours as “plain as day,” raising questions about how the assessment of “no medical concerns” was reached. His mother, Sarah O’Brien, told the inquest she had an overwhelming feeling that the transfer to Forest Bank would end badly and that her son had been failed by those responsible for his care.

Once at Forest Bank, O’Brien stopped taking his prescribed antipsychotic medication. A mental health nurse later testified that she became aware of the non-compliance but passed the information to the secondary care team without stronger immediate escalation. She acknowledged deficiencies in her documentation of the situation. The inquest has examined whether proper protocols for monitoring high-risk prisoners and responding to medication refusal were followed.

The email from Liverpool has become a focal point in proceedings. Critics argue it significantly downplayed O’Brien’s known vulnerabilities, potentially contributing to inadequate support and monitoring upon his arrival at the new prison. Family representatives have suggested the transfer process prioritised operational needs over a thorough risk assessment of his fragile mental health.

O’Brien had previously contracted encephalitis as a baby, which doctors warned could lead to long-term neurological complications. He also had a history of self-harm and drug use, including ketamine, around the time his psychotic symptoms worsened. His mother described persistent efforts to alert mental health services, prison staff, and even her local MP about the dangers he faced in custody.

The inquest continues to explore the full timeline of O’Brien’s final weeks, including communication between the two prisons, medication management, and the response to his hallucinations and declining condition. An independent investigation by the Prisons and Probation Ombudsman is also underway, as is standard in deaths in custody.

Cases like this have prompted wider discussion about the challenges of providing adequate mental health care in the prison system, particularly for young remand prisoners with multiple diagnoses. Questions have been raised about resource pressures, staff training on recognising acute mental health crises, and the accuracy of information shared during inter-prison transfers.

Jake O’Brien’s family continues to seek answers through the inquest, hoping to establish whether preventable failures occurred. His mother has spoken emotionally about the pain of feeling her warnings were ignored despite her son’s clear vulnerability.

As the proceedings advance, the coroner is expected to examine whether the email stating “no medical concerns” represented a serious misjudgement or a failure in duty of care. The outcome may lead to recommendations for improved safeguards when transferring prisoners with significant mental health needs.

The death of Jake O’Brien highlights the serious responsibilities prisons hold when managing vulnerable individuals. With the inquest ongoing, attention remains on establishing a clear account of the events leading to his death and identifying any systemic or individual shortcomings that contributed to this tragic outcome.