An inquest report has warned that prisoners are “at risk of death” because of failures in the healthcare system, after a man killed himself at Wormwood Scrubs prison in west London 48 hours after arriving there. A jury at the inquest into the death of Jack Zarrop, 23, at the prison on 20 March 2021, found a number of failures contributed, both while he was in police custody and after he was taken to Wormwood Scrubs on remand. The senior assistant coroner for west London, Dr Anton van Dellen, said in his prevention of future deaths report: “In my opinion there is a risk that future deaths could occur unless action is taken.” The inquest scrutinised a process known as assessment, care in custody and teamwork (ACCT). This is the care planning process for prisoners identified as being at risk of suicide or self-harm. The court heard evidence that 65% of primary healthcare staff in prison were agency staff. In his report, Van Dellen said: “Training of agency staff in the ACCT process does not appear to be part of the commissioning process by NHS England … This places residents in prison at risk of death given the high level of usage of agency healthcare staff in prison.” The inquest conclusions come at a time when there has been an overall increase in the number of deaths in prison, including an increase in self-inflicted deaths. In the 12 months to March 2023, there were 322 deaths in prison custody, up from 287 in the previous 12 months. Of those, 82 were self-inflicted, an increase from 79, in the previous 12 months. There have been 13 self-inflicted deaths at Wormwood Scrubs since 2018. Zarrop was the youngest of those. Along with the multiple failures by prison and prison healthcare staff responsible for Zarrop’s care, the inquest jury also identified failings in police custody and concluded that more should have been done to support and manage his risks of suicide. Zarrop was arrested and taken into police custody at Heathrow Polar Park police station on 17 March 2021, where he was kept overnight. The next day he was taken to Uxbridge magistrates court, and a suicide and self-harm (Sash) warning form was completed, noting that Zarrop “would hang himself if he was remanded to prison”. Despite this and other key information about the risk to Zarrop of suicide and self-harm being available to prison and healthcare reception staff, he was not assessed as being at risk. 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 had not because he was taken to prison. Helen Stone, of Hickman and Rose solicitors, representing Zarrop’s family, 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.” Caroline Finney, of Inquest, a charity concerned with state-related deaths in England and Wales, 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.” The Metropolitan police and NHS England have been approached for comment. A Prison Service spokesperson said: “We want to see far fewer self-inflicted deaths and self-harm in custody which is why we have increased staff training on self-harm prevention, are working with the NHS to improve mental healthcare and fund the Samaritans. “In his most recent inspection, the Chief Inspector of Prisons found vulnerable prisoners at HMP Wormwood Scrubs are safe and treated with respect on arrival.”