3 October 2023

Before HM Senior Assistant for West London, Dr Anton van Dellen, and a jury
West London Coroner’s Court
18 September – 29 September 2023

An inquest jury has concluded that the suicide of a 23-year-old man in HMP Wormwood Scrubs was contributed to by multiple significant failures by police, prison and prison healthcare staff responsible for his care, and that more should have been done to support and manage his risks of suicide. 

Jack Zarrop died on 20 March 2021 after having been found ligatured in his cell at HMP Wormwood Scrubs. Jack had been at Wormwood Scrubs for less than 48 hours when he died. 

Jack’s is one of a series of death at the London prison, where there have been 13 self-inflicted deaths since 2018. Jack was the youngest of those 13. 

Jack 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. 

Jack 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) Jack was taken by Serco transit officers to Uxbridge Magistrates’ Court, and a Suicide and Self-Harm (“SASH”) warning form was completed noting that Jack “would hang himself if he was remanded to prison”. 

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

During a nursing assessment on the morning 19 March 2021, Jack 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”. 

Jack 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 died by suicide, which was contributed to by:

  • the failure of Metropolitan Police custody officers and staff to refer Jack to Liaison and Diversion specialist mental health services while at Heathrow Police Station; 
  • the failure of prison officers and healthcare staff at Wormwood Scrubs to manage Jack 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 Jack’s history of vulnerability; and
  • the failure of prison officers to remove a ligature and to take steps to prevent Jack creating a fatal ligature point. 

The jury also commented that police, prison and healthcare staff had overemphasised Jack’s presentation as against clear evidence of previous suicide and self-harm risks and attempts, despite that information being available to them.

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

The PPO highlighted that Jack’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, as the department with responsibility for a Circular setting out requirements for the deployment and operation of healthcare professionals in custody suites, regarding concerns the coroner expressed in relation to the training of custody nurse practitioners in relation to mental health and recognition of suicide and self-harm,  and the manner in which they work alongside 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 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.”



For further information please contact Lucy McKay on [email protected] or 020 7263 1111.

Jack Zarrop’s family were represented by INQUEST Lawyers Group members Helen Stone and Toby Wilton of Hickman and Rose Solicitors, and Tom Stoate of Doughty Street Chambers. They were also supported by INQUEST caseworker, Caroline Finney

Other Interested persons represented included the Ministry of Justice, Practice Plus Group, the Metropolitan Police Service, Barnet, Enfield & Haringey NHS Foundation Trust, Central & North-West London NHS Foundation Trust, West London NHS Trust and the Forward Trust.