Jack Peter Zarrop · Prevention of Future Deaths report

An investigation was commenced into the death of Jack Peter Zarrop, aged 23. The investigation concluded on 29 September 2023. The conclusion of the jury in the inquest was:

Suicide.
We, the jury, find the:
1.     Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point
2.     Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment
3.     The difficulties accessing relevant and important information relevant to J. Zarrop’s history, both medical and custodial
were the main contributing factors to the death of J. Zarrop.

The medical cause of death was

1a Asphyxia
1b Hanging

Jack had a history of difficulties with his mental health and a history of alcohol abuse. He had made multiple previous suicide attempts, including a very serious previous suicide attempt of hanging. He had previously been arrested in December 2020 and assessed by Liaison & Diversion services whilst in Police custody. After he was remanded in custody, he was placed on an ACCT twice in prison. After his release from prison on 14th February 2021, he was referred to the community Mental Health Crisis service by his GP and also had another very recent suicide attempt in the form of an overdose of anti-depressants about a week before he was again arrested on 17th March 2021. In Police custody, he was seen by a Custodial Nurse Practitioner (CNP) who had very limited training in Mental Health and the recognition of the risk of suicide. The CNP was working alone and not alongside a doctor. The CNP assessed Jack’s risk as low. The CNP also did not refer him to Liaison & Diversion services, which the jury found that probably contributed to Jack’s death. A Forensic Medical Examiner in Police custody subsequently assessed Jack’s risk as high. Jack was again remanded in custody. Despite Jack’s significant risk history as well as other significant risk factors, such as being young, withdrawing from alcohol and early days in custody, no ACCT was opened by prison or healthcare staff, who were overly reassured by Jack’s presentation. An agency healthcare member of staff had no training in the ACCT process. The jury found that the failure to open an ACCT by prison and healthcare staff probably contributed to Jack’s death and that, on the balance of probability, the risk of suicide was not adequately identified for Jack. These findings by the jury were based on the over-emphasis by prison and healthcare staff on Jack’s presentation against clear and evidenced previous suicide and self-harm risks and attempts, which were available to relevant police, prison and healthcare staff. The Court heard evidence that 65% of primary care healthcare staff in prison are agency staff. The Home Office circular from 2003 relating to the use of Custodial Nurse Practitioners refers working alongside doctors and being specifically trained for their role. However, the Circular makes no mention of assessing the risk of suicide or self-harm in its Annex which lists competencies.

1.    The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health. The deployment in Police custody of CNPs places detained persons at risk of death in the future. The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency.

2.    The training of agency staff in the ACCT process and recognising the appropriate threshold to open an ACCT. The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process. This places residents in prison at risk of death, given the high level of usage of agency healthcare staff in prison.