**Early Years** 

Jake was born in Manchester on 22nd June 2002. From the moment of his birth, he was enveloped in love and affection. During his first year of life, Jake contracted encephalitis, necessitating life support and an induced coma. His mother, Sarah, was informed that he had only a ten percent chance of survival and that, should he endure, he would likely suffer profound brain damage. Remarkably, Jake did survive; however, the subsequent management of his acquired brain injury was inadequate, resulting in significant developmental delays. Consequently, he was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and learning disabilitieJake’s vulnerabilities rendered him susceptible to exploitation, leading to his initial encounter with the criminal justice system at the age of twelve, where he became embroiled in criminal activities and county lines gangs.

 **Teenage Years**

 By the age of fourteen, Jake had gone missing several times and was actively involved in county lines operations. He was first incarcerated at the age of fifteen. Despite Sarah's relentless efforts to solicit assistance for Jake, she encountered numerous obstacles. Upon his release, Jake was barred from his local area, severing ties with his family, which only exacerbated his engagement in exploitative gang activities. In 2020, Jake was involved in a high-speed incident in a stolen vehicle, resulting in a collision with a tree at 100 mph. Following the incident, his companion fled the scene, leaving Jake critically injured. Upon arrival at the hospital, he was reported to be in a coma due to a cerebral haemorrhage, resulting in yet another serious brain injury. Once revived, Jake absconded from the hospital, fearing reprisals.

**Adult Life**

 Jake was incarcerated for automotive offences immediately following his eighteenth birthday, entering HMP Forest Bank. During this period, he faced the tragic news of his biological father's suicide, a victim of schizophrenia, yet he was denied the opportunity to attend the funeral. Jake was released on 18th March 2022, exhibiting behavioural regression consistent with his acute brain injury, presenting as if he were aging backwards. Once again distanced from his familial support, he was placed in a hostel, where he resided for merely twelve weeks before being recalled to custody. As of November 2023, Jake was remanded again on alleged car offences. In August 2024, he ingested a substance thought to be ketamine from another inmate, resulting in an episode of psychosis. While the prison attributed this to drug use, Sarah recognised it as an indication of his underlying mental health condition, reminiscent of his father's illness. From late August to 9th November 2024, Jake experienced severe psychological distress, characterised by delusions and hallucinations, leading to a significant weight loss of twelve kilograms. Sarah urgently sought assistance, but the prison's response was to prescribe weight loss supplements and antipsychotics. While at HMP Liverpool, Jake awaited transfer to a mental health facility, cycling between segregation and healthcare. Tragically, he exhibited self-harming behaviour, including swallowing batteries. An inquest revealed that Jake should have been placed under medical supervision, but this did not occur. On 22nd October, when Sarah arrived for a visit, she was informed of Jake’s transfer to Forest Bank, a poorly managed private prison without the necessary healthcare provisions. Confusion around his care resulted in what sarah discribed as neglect, and accounts from the inquest indicated he was left in isolation, exhibiting bizarre behaviour and psychosis.

 **Sarah's Role**

 Sarah, who had been Jake’s staunchest advocate and legal representative, dedicated months to contacting prison officials to obtain essential support for her son. Despite her efforts, she was disparagingly labelled a drain on resources, rather than acknowledged as a concerned mother. On 7th November 2024, Sarah received a notification that her advocacy had borne fruit; Jake would finally be transferred to a mental health facility. However, during his stay at Forest Bank, he remained non-compliant with his medication. Sarah communicated her gratitude to the staff and requested they inform Jake of her love, yet this message was ignored, leaving him unaware of her support. On 9th November 2024, Jake was discovered malnourished and ligatured in his cell within the segregation unit, spending his final days in isolation, grappling with profound psychosis. The coroner’s court, while establishing that Jake was found ligatured, could not conclude with certainty that he had intended to take his life, citing a lack of capacity to do so. It was noted that the discontinuity in his mental health care contributed, on a balance of probabilities, to his tragic death.