NHS trust failed to properly care for suicidal teenager who was deemed high risk
A scandal-hit NHS trust failed to properly care for a suicidal teenager despite him being considered “high risk” and “grossly psychotic”, a court heard.
Jamie Osborne killed himself on the hospital wing of Lewes prison – run by Sussex Partnership NHS Foundation Trust – in February 2016.
The 19-year-old had already attempted suicide after being arrested and remanded in custody in 2015, but staff working for the mental healthcare trust failed to properly monitor and treat him, Brighton Magistrates’ Court was told.
He died three months later.
The trust faces an unlimited fine after admitting failing to provide care and treatment for patients in a safe manner in a prosecution brought by the Care Quality Commission (CQC) under health and social care laws.
The Worthing-based organisation – which has previously come under fire for several deaths linked to its care – was due to be sentenced on Thursday.
But after hearing the evidence, district judge Tessa Szagun adjourned the case until June 14.
The court heard Mr Osborne was moved to the hospital wing of the prison after trying to kill himself in his cell on the general wing in November 2015.
Mr Osborne was found dead on February 12, 2016.
Bena Brown, prosecuting on behalf of the health watchdog, told the court despite being observed as “grossly psychotic” and that he “remained a high risk of suicide”, there was “clear confusion by the staff” over his care.
She said: “They failed to provide healthcare and as a result Jamie died, and we say this was avoidable.”
Ms Brown told the court staff failed to properly assess him, he was not given medication he had previously been prescribed and a hospital transfer which was being arranged did not take place.
When he started having violent outbursts and fashioning weapons, sufficient action was not taken to address his behaviour, the court heard.
A statement read out on behalf of his mother said: “Knowing I will never speak to him again tears me apart.”
Simon Burrows, defending, said the trust is “deeply sorry”, adding: “He was their patient and he died in circumstances which may have been avoided.
“Systems were in place but they were not sufficiently implemented.”
He called on the court to also consider the Ministry of Justice’s (MoJ) responsibility for Mr Osborne’s care, adding: “Jamie was not just a patient, he was in fact primarily a prisoner.
“He was becoming increasingly frustrated at being incarcerated.”
A hospital transfer being arranged with the MoJ did not take place and trust staff could not visit patients until prison officers were available to unlock cell doors, the court heard.
Mr Burrows said: “When looking at culpability it is very important that this court recognises that the Ministry of Justice was an active participant in the drama which has been outlined here today.
“Of course, the secretary of state is not regulated by the CQC and the secretary of state cannot be the defendant in the proceedings.”
Dr Caroline Ardron, who was in charge of Mr Osborne’s care, won a High Court injunction preventing the trust from holding a gross misconduct hearing against her.
But in November the ruling was overturned when Mr Justice Richard Jacobs ruled there was a case to be heard.
In 2016, the trust – which the court heard has an estimated annual income of £1 million – came under fire over a review of nine killings carried out by patients as well as another who died in its care.
A review found the trust did not always learn from its mistakes and sometimes “severely underestimated” risks.
This included the case of Donald Lock, who was stabbed 39 times by patient Matthew Daley after the pair were involved in a car crash in 2015.
Daley was convicted of manslaughter by diminished responsibility and the trust apologised, saying it should have properly assessed him.
Last year, the trust also apologised for failings which led to the killing of Brighton University student Janet Muller, who escaped from its psychiatric hospital in Hove in 2015 and was found dead in the boot of a car after being burned alive.
Christopher Jeffrey-Shaw was jailed for her manslaughter and her family received an undisclosed financial settlement from the trust.
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