Report published surrounding ‘troubled’ 19-year-old Lewes prisoner’s death

Jamie Osborne was found hanged in his cell by a nurse on February 12 2016 at 6.55am and the report into his death, carried out by the Prisons and Probation Ombudsman, was published today (March 4) detailing the findings of the inquest, which ended on March 3.

The report highlighted key areas for HMP Lewes to improve on with some already being recommended in a past inspection.

The ombudsman said in the report, “I am concerned that staff did not take account of Mr Osborne’s previous history, or information about his risk of suicide that accompanied him when he first arrived at Lewes.

“Second, when his risk was later identified, after he unsuccessfully tried to hang himself, the resulting self-harm prevention procedures were not managed fully in line with national policy.

“Third, despite his complex needs, it is disappointing that staff did not consider managing him using enhanced case management which would have brought a more co-ordinated approach to managing a troubled young man such as Mr Osborne.

“Finally, 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. As a result, the clinical reviewer concluded that Mr Osborne’s health care was not equivalent to that which Mr Osborne could have expected in the community.

“Had the process been better and successfully managed, the outcome for Mr Osborne might have been very different.”

According to the report, Mr Osborne initially served short sentences in 2014 and 2015 at HMP Lewes for burglary and theft offences, and once released he continued to re-offend and later returned to the prison.

The ombudsman summarised Mr Osborne’s time in prison and said, “Throughout his time at Lewes, Mr Osborne continued to make inappropriate sexual comments to female staff. He heard voices, became agitated and spoke to himself. He was often hostile and abusive to staff, threatening to assault them.

“He believed that staff were mistreating him by taking away his television and appeared not to be remorseful or understand the perspective of others.”

According to the report, on December 4 2015 Mr Osborne spoke to his brother who told an investigator that Mr Osborne had said he was lonely, no one cared about him and he wanted to transfer to Rochester prison, where his brother was, because he missed him.

On February 9 2016, two consultant psychiatrists independently assessed Mr Osborne. Both psychiatrists said the teenager required urgent treatment and wrote reports describing him as ‘grossly psychotic and that he remains at high risk of suicide’ and noting that ‘his psychotic disorder will deteriorate further without intervention, leading to a further exacerbation in risks’.”

Three days later Mr Osborne was found dead in his cell.

Sussex Partnership NHS Foundation Trust was fined £200,000 in February 2019 by Brighton Magistrates’ Court after admitting that it had failed to provide safe care and treatment for Mr Osborne.

Dr Paul Lelliott, deputy chief inspector of hospitals and lead for mental health for the Care Quality Commission, said, “In these circumstances, we had no choice but to prosecute the trust. I hope this case will serve as a warning to other providers to ensure they are taking all necessary steps to care appropriately for people who require close observation and careful management of the risks posed by the physical environment, managed by the prison, in which they are being cared for.

“I hope it also sends a clear message that people in prison have the same right to high quality mental healthcare as any other member of our society.”