The Commission for Social Care Inspection (CQC) has launched only its second prosecution of an NHS Trust under the Health and Social Care Act, which gives the Magistrates Court the power to impose unlimited fines where unsafe systems in regulated activities lead to a risk of harm. 

The case concerned Jamie Osborne, a 19-year-old on remand at Lewes Prison. In February 2016, he hanged himself in his cell on the healthcare wing, operated by Sussex Partnership NHS Foundation Trust. It was the second time he had tried to do so, having been found hanging in his cell 3 months earlier, although then, fortunately, he was revived.

There were serious concerns over the standard of care he received in three particular areas. First, the suitability of his cell, which had ligature anchor points which had been identified many times before. Secondly, there was a failure to prescribe him antipsychotic medication. Finally, there was tardiness in arranging his transfer under s.48 of the Mental Health Act from prison to Hospital.

The Trust pleaded guilty, but in mitigation raised the serious problems associated with treating people with mental health problems in a prison. Jamie was primarily a prisoner- clinicians could only access him if two prison officers opened his cell- this led to examinations through the small window in the door when those officers were unavailable. The cells were entirely under the control of the Prison Authorities- so the ligature dangers could only be ameliorated by observations and risk assessments. Transfer was also problematic because there simply are not enough Hospital beds available in conditions of adequate security.

The sentencing decision was adjourned until June.

Simon Burrows advised and represented the NHS Trust, instructed by the Trust’s in-house solicitor. He has very considerable expertise in all areas of mental health and relevant regulatory law, and has acted in inquests & civil cases concerning the deaths of patients (detained and in the community) as well as deaths caused by patients. 

Further coverage of the matter can be read via the links below: 


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