Ombudsman publishes report on the death of Mr Jamie Osborne at HMP Lewes

The Prisons and Probation Ombudsman (PPO) has today published a report on the self-inflicted death in HMP Lewes of a 19-year man who had been assessed as a high suicide risk and whose transfer to a psychiatric hospital was mismanaged and delayed.

An inquest into the death of Jamie Osborne finished today, four years after he was found hanging in his cell at the prison in east Sussex. Sue McAllister, the PPO, published a report prepared for the coroner in 2016 by the then-PPO, Nigel Newcomen. The report noted that Mr Osborne was a vulnerable and challenging young man who had been assessed as at high risk of suicide by psychiatrists. The PPO identified areas for improvement in his care at Lewes, some of which repeated findings from previous investigations into deaths at the prison.  The PPO was 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.

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. Despite his complex needs, it was disappointing that staff did not consider managing him using enhanced case management which would have brought a more co-ordinated approach. The report also found that 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.

Sue McAllister said: “This is a sad and disturbing case and I offer my condolences to Mr Osborne’s family. I hope the findings and recommendations for improved health care can help reduce the risk of such a case happening again.”

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Notes to editors

  1. An inquest into Mr Osborne’s death ended on 3 March 2020.
  2. The PPO report on the death of Mr Osborne can be found here –
  3. In 2019, the Sussex Partnership NHS Foundation Trust, which ran the hospital wing at Lewes, was fined £200,000 by Brighton Magistrates’ Court after it was prosecuted by the Care Quality Commission (CQC). CQC press release on the prosecution of Sussex Partnership NHS Foundation Trust, which ran the hospital wing of Lewes Prison, is here –
  4. The Prisons and Probation Ombudsman (PPO) is appointed by and reports directly to the Secretary of State for Justice. The Ombudsman’s office is wholly independent of the services in remit, which include those provided by Her Majesty’s Prison and Probation Service (HMPPS), the National Probation Service for England and Wales, the Community Rehabilitation Companies for England and Wales, Prisoner Escort and Custody Service, the Home Office (Immigration Enforcement), the Youth Custody Service, and those local authorities with secure children’s homes. It is also operationally independent of, but sponsored by, the Ministry of Justice (MoJ).
  5. The PPO investigates:  Complaints made by prisoners, young people in detention, offenders under probation supervision and immigration detainees; Deaths of prisoners, young people in detention, approved premises’ residents and immigration detainees due to any cause.
  6. Contact John Steele on 07880 787452 ‐ ‐ for more information. Please note that Sue McAllister is not available for broadcast interviews.
  7. This news release is available for download at