Inquest finds support given to suicidal teenager who died in prison ‘inadequate’
The support given to a suicidal teenager who died in prison was “inadequate” and he should have been in hospital instead, an inquest found.
Jamie Osborne took his own life on the hospital wing of Lewes Prison, East Sussex, in February 2016.
The 19-year-old had already attempted suicide after being arrested and remanded in custody in 2015.
In June last year the scandal-hit NHS mental health trust which ran the hospital wing was fined £200,000 for failing to care for Mr Osborne, despite him being considered high risk.
Staff at the Sussex Partnership NHS Foundation Trust failed to properly monitor and treat him, Brighton Magistrates’ Court previously heard, and he died three months later.
The Worthing-based organisation has come under fire in the past for several deaths linked to its care.
On Tuesday a jury at Hastings Coroner’s Court found Mr Osborne died by suicide, after being held in a prison “when he should have been in a hospital”.
According to a record of the inquest’s findings, the jury said he was “suffering from a psychotic illness and warranted urgent transfer to hospital”, mental health act procedures were not followed, and the support he was offered was “inadequate”.
The ruling added: “There was a delay in securing Jamie’s transfer to hospital as a result of disagreements on a suitable placement based on different views on the level of risk.”
The inquest ruling prompted the Prisons and Probation Ombudsman (PPO) on Wednesday to publish a series of recommendations to avoid a similar incident happening again.
The PPO’s report raised concerns that, although he was considered a “high risk of suicide by psychiatrists”, staff “did not take account of Mr Osborne’s previous history, or information about his risk of suicide”, and self-harm prevention procedures were not properly followed.
It also found the process for transferring prisoners under the Mental Health Act, which resulted in a delay in referring Mr Osborne for a place at a suitable secure hospital, was “mismanaged”.
A hospital transfer being arranged with the Ministry of Justice did not take place, and trust staff could not visit patients until prison officers were available to unlock cell doors, the court previously heard.
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 2018 the ruling was overturned when Mr Justice Jacobs ruled there was a case to be heard.
The trust said its own internal investigation into the death found “clear failings for which we are deeply sorry”.
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