NHS Trust faces fine after failure to check room of suicide patient

NHS Trust faces ‘unlimited fine’ after admitting it failed to check room was safe before ‘suicide risk’ teenage, 19, hanged himself in hospital prison wing

  • Jamie Osborne, 19, hung himself in the hospital wing of HMP Lewes prison 
  • CQC brought a criminal prosecution against the Trust for its failures to comply 
  • The Trust entered a guilty plea via defence lawyer at Brighton Magistrates Court 

An NHS Trust could be hit with an unprecedented fine after it admitted it failed to check a room of an at-risk suicide patient who hung themselves. 

Jamie Osborne, 19, killed himself in the hospital wing of HMP Lewes prison, which is run by Sussex Partnership NHS Foundation Trust.

The Care Quality Commision (CQC), the health watchdog, brought a criminal prosecution against the Trust for failing to comply with the regulations of the Health and Social Care Act, which state it must provide care and treatment in a safe way.

The Trust entered a guilty plea via defence lawyer Simon Burrows at the hearing in Brighton Magistrates’ Court.

The Trust entered a guilty plea via defence lawyer Simon Burrows at the hearing in Brighton Magistrates’ Court (stock image)

The case is just one of numerous offences to hit the health Trust.

In 2016, it was criticised for 10 patient deaths, while last year it apologised for failings which led to the death of Brighton University student Janet Muller.

It was revealed Osborne moved to the healthcare unit within the prison after he attempted suicide on November 18, 2015, when he was on a general wing.

The attempt was so serious prison staff had to resuscitate him. 

Despite the fact he was a suicide risk, he did not receive medication and a planned transfer to hospital did not take place.

Three months later, on February 12 2016, Osborne was found dead in his room.  


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Outside court, Bena Brown, prosecuting for the CQC, said: ‘The healthcare provided to Mr Osborne should have been that which he could have received in the community. Our case is that it fell far below that standard.’

She said the Trust’s key failures included a failure to assess the area he was staying in.  

District Judge Tessa Szagun said the Trust faced an ‘unlimited fine’ and was requested to see details of its accounts before she passed sentence. The case was adjourned for sentencing until May 2.  

Dr Caroline Ardron, who was in charge of Osborne’s care, was accused in a separate investigation by the Trust for failing to keep proper records, and not giving him medication after she provisionally diagnosed him with schizophrenia.   

At the High Court lat year, she won an injunction against the Trust after a gross misconduct hearing, where she could have been dismissed.  

The injunction was lifted in November but the judge made clear he thought the Trust’s case against her was unlikely to succeed.   

In a judgement he said: ‘I have considerable doubt as to the strength of the Trust’s case that Dr Ardron was acting willfully in breach of her professional code of conduct.

‘It seems to me that to be far more probable… that a tribunal would find that any failures were inadvertent negligent (whether or not amounting to gross negligence) rather than in the nature of deliberate misconduct.’

Jamie Osborne, 19, hung himself in the hospital wing of HMP Lewes prison, which is run by Sussex Partnership NHS Foundation Trust (stock image)

In a statement, Sussex Partnership NHS Foundation Trust said: ‘Our thoughts today are with Jamie Osborne’s family and friends.

‘Jamie died on 12 February 2016 on the Healthcare Wing at Lewes Prison whilst under our care.

‘In 2016 our investigation into Jamie’s death found clear failings for which we are deeply sorry. We have today pleaded guilty to the CQC’s prosecution for not providing Jamie with the safe care and treatment he and his family were entitled to expect.

‘Whilst we recognise the inadequacy of an apology, we offer one to Jamie’s family and friends in acknowledgment that Jamie was not provided with the care he deserved while an inpatient at HMP Lewes.’

Osborne’s family attended the case in Brighton but were too upset to comment afterwards.

The CQC can bring criminal prosecutions against NHS Trusts and care home providers which it oversees. The last published case was against Southern Health NHS Foundation Trust in June 2017. 

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