Jake O’Brien HMP Forest Bank Death: Serious Care Failings Found, Liverpool 2026

Key Points

• Over £39,000 worth of illegal cigarettes and hand-rolling tobacco have been confiscated from businesses in Oldham.
• This raid was conducted jointly by Oldham Trading Standards and Greater Manchester Police.
• It was a part of Operation Machinize, an initiative that is coordinated by the National Crime Agency.
• Operation Machinize aims to combat money laundering and criminal exploitation of high street businesses with significant cash flows.
• According to Oldham Trading Standards, the problem with illegal tobacco affects communities, funds organized crime, and unfairly treats local businesses that are following regulations.
• The residents are asked to contact police about the sale of abnormally cheap cigarettes because they might be counterfeit or smuggled.
• This information can be provided anonymously via Crimestoppers (telephone 0800 555 111) or keep-it-out.co.uk.
• No business organizations, persons, quantity of goods, or enforcement action were specified in the given news reports.

Liverpool (Liverpool standard) October 17, 2026 — A coroner has warned that more deaths could occur in prisons unless urgent action is taken following the death of Jake O’Brien, a vulnerable 22-year-old prisoner who died days after being moved from HMP Liverpool to HMP Forest Bank.

As reported by the Manchester Evening News, Mr O’Brien was found suspended by a ligature in his cell on the segregation unit at HMP Forest Bank on 9 November 2024. He died at Salford Royal Hospital on 12 November 2024 from irreversible hypoxic ischaemic brain injury and pneumonia.

The inquest, held before a jury at Manchester West Coroner’s Court between 20 April and 6 May 2026, heard that Mr O’Brien had been transferred from HMP Liverpool to Forest Bank 18 days earlier. At the time, he was on remand for car crime offences and was being assessed for transfer to a psychiatric hospital.

What did the jury find about Jake O’Brien’s care?

The jury identified several “serious” and “significant” concerns in his care. These included a delay in starting CPR, poor communication between mental health experts, and the absence of a formal capacity assessment.

As reported by the Manchester Evening News, jurors found that Mr O’Brien’s mental health concerns were overlooked despite him being “severely mentally unwell” when he arrived at Forest Bank. He had ADHD, a history of self-harm and a “strong probability” of having autism.

The jury also found that Mr O’Brien should have been placed on medical hold because of an ongoing Section 48 assessment. It concluded that a lack of continuity of care may have contributed to a decline in his mental health and subsequent death.

What did coroner Michael Pemberton warn?

Area Coroner Michael Pemberton, of Manchester West, issued a Prevention of Future Deaths report under Regulation 28. He stated that, unless the concerns were addressed, there was a “significant risk of future deaths”.

In the report, dated 18 May 2026 and published by the Courts and Tribunals Judiciary on 13 October 2026, Mr Pemberton wrote that the lack of ownership and oversight of Mr O’Brien’s mental health through a named nurse or clinician was a serious concern.

“We identified that there was a delay in CPR commencing,” Mr Pemberton wrote. “This appeared to be due to inadequate refresher training resulting in a lack of confidence, which was of significant concern.”

He added that there had been a lack of appreciation of Mr O’Brien’s accumulating risk factors and incidents relating to self-harm and behavioural deterioration. The coroner said there was also a lack of systematic risk assessment and thorough action planning, and concluded that the frequency of observations should have been increased.

What training concerns were raised?

Mr Pemberton said no ongoing training had been provided to prison officers since their initial training in basic life support or first aid. He said this meant officers who discovered a ligature situation were unable to provide immediate basic life support because of a lack of confidence and unfamiliarity with what to do.

The coroner noted that every second can matter in promoting the chances of an optimal recovery in such circumstances. He also raised questions about whether the Health and Safety Executive’s workplace standard of one trained first aider per 50 prisoners is sufficient for the “extraordinary” working environment of a prison.

He further criticised Prison Service Order 3050, which relates to clinical holds and consistency of healthcare for prisoners. The coroner said the order was 20 years old and made no reference to mental health conditions or neurodiversity issues, or to how those factors may affect the appropriateness of a prison transfer or a clinical decision to place a hold on transfer.

What was said about mental health assessments?

The coroner reported that mental health nurses from primary mental health care who were responsible for completing segregation algorithm forms had not received training on how to complete them, which definitions to apply, or when escalation to healthcare for a multi-disciplinary team meeting was necessary.

He said evidence indicated that whether a prisoner had self-harmed was interpreted as meaning only since arrival at the establishment. As a result, acts of self-harm at a previous prison were not included in the risk assessment matrix.

Mr Pemberton said this created confusion about when to refer to healthcare for advice and represented an apparent missed opportunity to escalate Mr O’Brien’s care to secondary mental health services, despite ongoing “bizarre behaviour” being witnessed.

What did Jake O’Brien’s mother say?

Speaking to the Manchester Evening News in July, Mr O’Brien’s mother, Sarah O’Brien, 41, said her son had been failed. She said:

“My precious son, Jake, died following a series of catastrophic failings by multiple agencies that had a duty to protect him.”

She added:

“His death was preventable. Jake should never have been transferred from HMP Liverpool to Forest Bank.”

Mrs O’Brien said her son had been severely unwell physically and mentally and should have received urgent medical care rather than isolation. She said she had spent more than 12 hours a day for nine weeks trying to save his life and had contacted everyone she could, including Greater Manchester Mayor Andy Burnham’s office.

How have prison and health bodies responded?

HM Prison and Probation Service said the outdated policy on clinical holds was being revised to place greater emphasis on identifying and managing mental health conditions and neurodiverse needs.

Sodexo, which operates HMP Forest Bank, said staff whose first-aid training had expired would be re-accredited as a priority. The company also said it would introduce annual refresher training.

Greater Manchester Mental Health NHS Foundation Trust said that, following Mr O’Brien’s death, new guidance on completing the segregation form had been shared with healthcare staff across the prison system. It said it had also established weekly meetings for mental health care teams to discuss cases and escalate concerns.

The trust added: “Learning from Jake’s death has been shared with staff through these meetings and in individual supervision sessions.”

Background of the development

Jake Anthony O’Brien was 22 years old and from Altrincham, Trafford. He died on 12 November 2024, three days after being found unresponsive in his cell at HMP Forest Bank, a category B prison in Salford operated by Sodexo.

The Prisons and Probation Ombudsman opened an investigation after his death, while the inquest began in April 2026. The jury’s conclusion recorded that Mr O’Brien died as a consequence of an act of self-ligature, but said it was unclear whether this was done with an intention to end his life or during a mental health crisis in which he was unable to comprehend the consequences of his actions.

The coroner’s Prevention of Future Deaths report was sent to the Ministry of Justice, Greater Manchester Mental Health Trust, Sodexo, the Health and Safety Executive and NHS England. Those organisations were required to respond within 56 days, setting out action taken or proposed, or explain why no action was proposed.

Prediction: What this means for prisoners and families

For prisoners with mental health needs, neurodivergent conditions or a history of self-harm, the case is likely to increase scrutiny of transfer decisions, segregation placements, observation levels and the recording of previous self-harm. The coroner’s findings specifically highlight the risk created when risk information is not carried across between establishments.

For families of prisoners, the development may strengthen calls for clearer named clinical responsibility, earlier escalation to secondary mental health care and more consistent communication between prison, healthcare and family contacts. Mrs O’Brien’s account, as reported by the Manchester Evening News, reflects the concern that families may identify deterioration but struggle to secure timely intervention.

For prison staff and operators, the report is likely to place greater operational focus on refresher training in basic life support and first aid, clearer segregation risk-assessment procedures, and updated national guidance that expressly considers mental health and neurodiversity. The responses from Sodexo, HM Prison and Probation Service and Greater Manchester Mental Health indicate that some changes have already been introduced, although the coroner’s warning makes clear that the wider risk remains unless those measures are applied consistently.