An inquest jury has found that the suicide of a 23-year-old man in HMP Wormwood Scrubs was contributed by multiple failures by police, prison and healthcare staff responsible for his care. 

Jack Zarrop died on 20 March 2021 after having been found dead in his cell despite being in the prison for less than 48 hours. 

The 23-year-old was the youngest of 13 in a series of self-inflicted deaths since 2018.  

Mr Zarrop was described in the inquest as "intelligent and charismatic." He was a former care-leaver, and had a history of attempted suicide, alcohol and substance misuse, and mental ill-health. 

He was arrested and taken into police custody at Heathrow Polar Park on 17 March 2021, where he was kept overnight. 

The following day (18 March 2021) he was taken by Serco transit officers to Uxbridge Magistrates' Court, and a Suicide and Self-Harm ("SASH") warning form was completed noting that Mr Zarrop "would hang himself if he was remanded to prison". 

Despite this and other key information about Mr Zarrop's risks of suicide and self-harm being available to prison and healthcare reception staff, he was not deemed as being at risk of suicide or self-harm. 

During a nursing assessment on the morning of 19 March 2021, Mr Zarrop expressed a wish to see the prison mental health team but was never referred to them. 

Asked what mental health meant to him he replied: "A lot. I have a monologue in my head that tells me am not good enough and also instructs me to harm myself." 

Mr Zarrop reported a recent overdose attempt in the days before being remanded into custody, and that he had been due to see a mental health crisis team in the community but did not because he came to prison.  

The inquest jury concluded that Jack Zarrop died by suicide, which was contributed by:  

• Failure of Metropolitan Police custody officers and staff to refer Mr Zarrop to the mental health specialist team at Heathrow Airport. 
• Failure of prison officers and healthcare staff at Wormwood Scrubs to manage Mr Zarrop under prison suicide support procedures (known as ACCT), which would have triggered more thorough risk assessment of him. 
• The difficulties in accessing and sharing relevant and important risk information about Mr Zarrop's history of vulnerability. 
• Failure of prison officers to remove a ligature and to take steps to prevent Mr Zarrop creating a fatal ligature point. 

HMP Wormwood Scrubs where 13 self-inflicted deaths occured since 2018 (credit: Cesar Medina).

The jury noted that police, prison, and healthcare personnel had given too much weight to Mr Zarrop's outward appearance rather than considering the clear evidence of his previous suicide and self-harm history, even though they had access to that information.   

A highly critical independent review by the Prison and Probation Ombudsman (PPO), which included a specialist clinical review of the healthcare provided to Mr Zarrop, also found multiple failures in his care.    

The PPO highlighted that Mr Zarrop's was one of a number of self-inflicted deaths of prisons within a few days of arriving at Wormwood Scrubs, in which prison and healthcare staff had failed to identify that the prisoner had significant risk factors for suicide.    

The PPO called these deaths "extremely worrying" and urged the Governor and the Head of Healthcare to take urgent steps to address these shortcomings.    

Despite evidence of significant change in prison reception processes, the coroner, Dr Anton van Dellen, announced that he would be writing a Prevention of Future Deaths report to:  

• NHS England, as the commissioning body for healthcare provision in prisons, in relation to a concern that there is not a requirement that all healthcare staff, including agency nurses, employed in prisons are required to have ACCT training prior to working with prisoners. 
• The Home Office, responsible for guidelines on healthcare professionals in custody suites, is addressing the coroner's concerns about training for custody nurse practitioners regarding mental health, suicide, self-harm, and their work with doctors.   

Helen Stone of Hickman and Rose solicitors said: "The jury's conclusions lay bare how serial and fundamental failures by nearly all those responsible for keeping Jack safe in prison contributed to his death.   

"Vital screening processes, policies and procedures simply were not followed, with the police, the prison and healthcare staff all failing in their duty of care towards Jack. 

"Lessons must be learnt, and improvements made to reduce the risk to other vulnerable prisoners like Jack."  

Caroline Finney of INQUEST, a charity which deals with state related deaths, said: "Jack's was one of 13 self-inflicted deaths in Wormwood Scrubs since 2018, a number which reflects that the prison is not a safe or 'rehabilitative' environment. 

"Jack explicitly asked for support and he was failed.   

"Prison officers are responsible for ensuring that self-harm assessments are completed and yet they gave evidence that they are 'not trained in mental health' when asked about Jack's presentation. 

"The coroner's recommendations for compulsory ACCT training are recommendations which have been made to prisons across the country time and time again, often with a response that training has been implemented.    

"If young men like Jack are dying in preventable circumstances, then prison is not fit for purpose. At a minimum we need national oversight of the post death processes, ensuring that recommendations are acted upon and change actually happens." 

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