Jack Zarrop
2 Oct 2023 · Coroner Anton van Dellen · West London
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. use of Custodial Nurse Practitioners in police custody without doctors
“The use of Custodial Nurse [name redacted] (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”
2. lack of ACCT process training for agency staff
“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.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”
This report
“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”
Identical hazardConfidence 0.95 · high
This report
“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.”
Later report
“(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff.”
Responses
2023-0362-Response-from-National-Police-Chiefs-Council.pdf ↗· National Police Chief's Council
2023-0362-Response-from-NHSE.pdf ↗· Home Office
Stated action
“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”
2023-0362-Response-from-the-Home-Office.pdf ↗· Home Office