Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0362, written 2 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Oct 2023 |
|---|---|
| Reference | 2023-0362 |
| Deceased | Jack Zarrop |
| Coroner | Anton Van Dellen |
| Coroner area | West London |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Home Office 2. National Police Chiefs’ Council 3. NHS England 1 CORONER I am Dr Anton van Dellen, HM Assistant Coroner, for the coroner area of West London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 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: Failure to remove the bedsheet and close the hatch allowing Jack to create a Suicide. We, the jury, find the: 1. ligature point Failure to refer to Liaison and Diversion services in Central and North-West 2. London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. history, both medical and custodial were the main contributing factors to the death of J. Zarrop. The difficulties accessing relevant and important information relevant to J. Zarrop’s The medical cause of death was 1a Aspyhxia 1b Hanging 4 CIRCUMSTANCES OF THE DEATH 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 1 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. 5 CORONER’S CONCERNS During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 3 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Jack Zarrop’s daughter 2. . 3. Ministry of Justice 4. His Majesty’s Prison and Probation Service 5. The Commissioner of Police of the Metropolis 6. Practice Plus Group 7. West London NHS Trust 8. Barnet, Enfield and Haringey Mental Health NHS Trust 9. 10. Forward Trust 11. Central and North West London NHS Foundation Trust 12. Serco I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 2nd October 2023 9 4
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Dr Anton van Dellen
HM Assistant Coroner
West London Coroner’s Service
25 Bagley’s Lane
Fulham
London
SW6 2QA
Dear Dr van Dellen,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
11 December 2023
Re: Regulation 28 Report to Prevent Future Deaths – Jack Peter Zarrop who
died on 20 March 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2nd
October 2023 concerning the death of Jack Peter Zarrop on 20 March 2021. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Jack’s family and loved ones. NHS England is keen
to assure the family and the coroner that the concerns raised about Jack’s care have
been listened to and reflected upon.
Matter of concern
The training of agency staff in the Assessment, Care in Custody and Teamwork
(ACCT) process and recognising the appropriate threshold to open an 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.
NHS England notes your concern relating to training of agency staff and the ACCT
process, and the absence of training for agency staff amongst individual providers.
NHS England is the responsible organisation for the commissioning of healthcare into
prisons, which is devolved to regional teams. Commissioning healthcare in prisons is
done on a principle of equivalence, which has been defined by the Royal College of
General Practitioners (RCGP) and has been adopted by the National Prison
Partnership Board1. The definition broadly states the aim is to ensure people detained
in prisons in England, are offered provision of and access to appropriate services and
treatment, considered to be at least consistent in range and quality, with that available
in the wider community.
ACCT is the care planning process for prisoners identified as being at risk of suicide
or self-harm, and training is provided by His Majesty’s Prisons and Probation Service
(HMPPS). The ACCT process requires that certain actions are taken to ensure the risk
of suicide and self-harm is reduced. The ACCT process is multi-disciplinary, involving
1 PowerPoint Presentation (publishing.service.gov.uk)
staff from all departments with knowledge of the individual, and consideration of all
interventions that may help to address their needs.
HMPPS is responsible for and oversees the delivery of effective training that is carried
out at establishment level. This includes the roll-out of suicide and self-harm training,
ACCT Case Manager, and ACCT Assessor training.
In response to the concerns noted, NHS England's National Director of Health &
Justice, Armed Forces and Sexual Assault Services Commissioning, has written to
Health & Justice regional teams sharing these concerns, asking commissioners to
work with prison healthcare provider organisations and HMPPS locally, to ensure all
staff, including agency and bank staff, have timely access to all joint training, including
ACCT, that is necessary for them to undertake their role effectively within the prison
environment. .
In addition, the findings in your report will be taken to the NHS England Health and
Justice Delivery Oversight Group (HJDOG) in December 2023. The HJDOG is the
senior leadership forum, which holds responsibility for the oversight of delivery and
continuous improvement in Health and Justice commissioned services, through both
the national and regional teams, with a focus on improving health outcomes and
reducing variation across England. Regional teams will be asked to give assurance at
the HJDOG meeting planned for June 2024, that the proposed action has been
delivered and agency and bank staff have timely access to ACCT training.
Regarding the matter of concern around the use of Custodial Nurse Practitioners, this
is for the Police Chief Council to respond to. NHS England does not hold responsibility
for commissioning healthcare in police custody settings, therefore cannot comment.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors and other clinical and quality colleagues from across the regions. This
ensures key learnings and insights around events raised in Reports to Prevent Future
Deaths are shared across the NHS at both a national and regional level and helps us
to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important issues to my attention and please do not
hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Dr Anton van Dellen HM Assistant Coroner West London Coroner’s Court 25 Bagleys Lane Fulham London SW6 2QA By email only: FAO Dr Anton van Dellen Date: 29th November 2023 Dear Dr van Dellen, Regulation 28 Report – Mr Jack Peter Zarrop I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to the prevention of future deaths report sent via email to the NPCC dated 2nd October 2023. The notice sets out concerns that arose from the information received during the inquest into the death of Mr Zarrop which occurred in March 2021. I am very sorry to read of the circumstances of Jack’s death. My sympathies are with his family and friends, and I hope the following information will go some way to reassure you that the current Healthcare model for Police Custody is robust. I note you set out two main areas of concern; the use of Custodial Nurse Practitioners (CNPs) in Police Custody instead of doctors, as set out in the 2003 Home Office circular and the training of agency staff in the Assessment, Care in Custody and Teamwork (ACCT). I have reviewed the 2003 circular and would like to highlight that custodial healthcare has changed considerably since that point. The 2003 circular refers to the practice of using Police Surgeons in custody, this role is no longer in existence. Police Custody is a very regulated and scrutinised area of policing, it plays a pivotal role in the criminal justice process and cares for some of the most challenging and vulnerable people in society at what is often a very testing time. Our aim is to be effective, safe and to ensure that people are treated fairly, with as much dignity as possible. Having professional officers and staff who are well trained is essential. The NPCC Custody Portfolio works closely with NHS England, partners, and other stakeholders to deliver a service specification that is fit for purpose. Whilst the NPCC helps to set standards and provide guidance; all Chief Constables/Commissioners are operationally independent and procure their own medical provision for their custody suites via a 1st Floor, 10 Victoria Street, London SW1H 0NN | 0203 276 3796 | www.npcc.police.uk tendering process. Chief Constables tender for medical provision using a National Health Service (England) (NHSE) Specification which is authored and reviewed by NHS-England for the NPCC, College of Policing, and Home Office. This specification is reviewed and updated periodically to cater for advances in care and additional needs when identified. Whenever an update is required, the document is widely consulted on, with private medical providers, NPCC Independent Medical Advisor, as well as medical bodies such as the Faculty of Forensic Legal Medicine (FFLM), and The UK Association of Forensic Nurses and Paramedics. (UKAFNP). Chief Officers are able to use the National Healthcare Specification to determine the type of medical care they require. The Specification can be tailored by forces should they not require all elements, and they can tender for the services they need; but the document is clear with regard training and qualifications. I attach the latest version of the service specification (draft until ratified by NHSE Clinical Refrence Group – Nov 2023), which may be useful, and would like to highlight the following sections which I hope will provide you with reassurance: - 9.30 Governance Roles - 9.31 Clinical Governance - 9.60 Workforce Standards - 9.61 Qualifications and Registration - 9.70 Competency Assessment - 9.72 Clinical Staff Supervision I hope the information provided goes some way to reassure you the Healthcare Specification is clear regarding experience and qualifications for Health Care Professionals in Police Custody in England and Wales and that you are satisfied that as well as Doctors; Nurses and Paramedics working in custody are suitably qualified and trained to work alone within the environment, with appropriate clinical support and supervision. For any further information please contact my Staff Officer ( who will be happy to address any concerns and answer any questions. ) Yours sincerely, Chair, National Police Chiefs’ Council
Minister of State for Crime, Policing and Fire 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 7th December 2023 Dr Anton van Dellen HM Assistant Coroner Coroner’s Officer West London Coroner’s Court 25 Bagleys Lane Fulham London SW6 2QA Via Email Only To Dr Anton van Dellen Response to coroner’s report Thank you for sending a copy of your report, dated 2 October 2023, and made under Regulation 28 of the Coroners (Investigations) Regulations 2013, into the death of Mr Jack Peter Zarrop, in which you asked the Home Office, National Police Chiefs’ Council (NPCC) and NHS England to detail the actions taken in response to the matters of concern which you identified. This letter represents the Home Office response under Regulation 29. Please accept my sincere apologies for responding after the statutory deadline, which is because of an administrative error. I would firstly like to express my deepest sympathies to Mr Zarrop’s family and friends over his tragic death. I believe that the element of the matters of concern identified which was directed to the Home Office was the exclusion from the list of core competencies for Custodial Nurse Practitioners within Home Office Circular 020/2003 (Healthcare Professionals in Custody Suites: Guidance to Supplement Revisions to the Codes of Practice Under the Police and Criminal Evidence Act 1984) of the ability to identify the risk of suicide and self-harm in detainees. Home Office Circular 020/2003 is no longer extant: it was archived in 2013 and does not appear on the Gov.UK website. It is therefore not possible for the Home Office to make amendments to it, which is why, formally, we propose to take no action in response to your report. However, this in no way represents a lack of interest in the issues which you have identified. As the response to your report from the Chair of the NPCC sets out, the 2003 Circular has effectively been superseded by the publication of the National Healthcare Specification for police custody, which is written by NHS England on behalf of the NPCC, College of Policing and Home Office, and which Chief Constables may use when tendering for healthcare provision. That document is far more comprehensive than the 2003 Circular. The Home Office has a close interest in the content of the Specification, and in ensuring that highly qualified and capable medical personnel work in police custody. I understand that the NPCC response also represents the response to the remaining content of your first matter of concern. I understand too that NHS England is responding to your second matter of concern, relating to the training of prison healthcare staff in the ACCT process. I can assure you that the Home Office continues to work collaboratively with our partners to further improve policing’s response to people who are vulnerable, including those with mental ill health issues. This includes support for Liaison and Diversion schemes in police custody suites, which had been fully rolled out across England by March 2020. The Home Office is also committed to ensuring that custody is a safe and dignified environment for all detainees, visitors and staff which operates professionally, respectfully, and lawfully. Yours sincerely, Minister of State for Crime, Policing and Fire
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