Following the death of 19-year old Mr Jamie Osborne on 12 February 2016, who was on remand at HMP Lewes, the Care Quality Commission (CQC) prosecuted Sussex Partnership NHS Foundation Trust (Sussex Partnership) in circumstances which the CQC reported as ‘avoidable’.

Sussex Partnership were responsible for managing the healthcare unit at HMP Lewes. It was found that staff were aware that Mr Osborne was a suicide risk and that the tap in his cell presented as a potential ligature point. Standards fell short of managing the risk however resulting in the unfortunate death of Mr Osborne.

Brighton Magistrates’ Court fined Sussex Partnership £200,000 after pleading guilty to an offence under Regulation 12(1) of Care Quality Commission (Registration) Regulations 2009 for failing to provide safe care and treatment that was equivalent to that in the community, and putting Mr Osborne at risk of avoidable harm. Furthermore, Sussex Partnership was ordered to pay the CQC’s costs of £25,000 and £170 for a victim surcharge.

Paul Lelliott, deputy chief inspector of hospitals and lead for mental health at the CQC, 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 that 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 that 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.”

The prosecution follows the warning by the CQC chief executive Ian Trenholm last year that “You will see the number of prosecutions increasing”. Previously Southern Healthcare FT was the first NHS Trust to be fined for failing to provide safe care in 2017 after a patient fell from a roof.

Whilst this is a case focussing on prison healthcare systems, all NHS and private providers should take notice of the circumstances in which the regulator may seek to prosecute. Early advice is crucial where there is a possibility of failings in systems resulting in harm to service users.

RLB are an experienced specialist healthcare team who can provide prompt, practical and cost effective advice.