"GDPR Says Yes"

Regina was bed-bound following a hip operation, and was receiving double-handed domiciliary care 4 times per day. Her daughter was dissatisfied with the quality of care provided and asked for it to stop. There was no assessment of Regina's ongoing needs or her mental capacity, nor of her daughter's ability to understand and meet them.

Care home staff kept poor quality records of Wendy's condition. As a result her skin condition was not being managed properly, and she died as a result of pressur ulcers. The electronic care management system was not being used effectively, and the care home managers weren't able to monitor risks.

Zara was attacked and killed while walking home alone late at night. Her attacker was under the supervision of the Probation Service and had been recalled to prison when he attacked Zara. A great many concerns were raised, including: - Poor practice, record-keeping, decision-making and communication in the Probation Service, coupled with an "unwieldy" risk management system. - The Police rejecting the findings and recommendations of the Fast Time Review carried out by their own Directorate of Professional Standards. - Shortcomings in CCTV training at the local authority; the Coroner noted that this was partly a lack of two-way communication about the clarity and thoroughness of the training provided. - An equal lack of clarity among the wider public of the need to report sexualised or predatory behaviour.

Christopher was admitted to a private mental health facility commissioned by the NHS. The handover notes at admission were incomplete; the MH facility didn't seek further information from the NHS or from Christopher's famjily, and indeed didn't access his care notes until after his death. Coroner noted that electronic access to NHS records for NHS-commissioned private providers is not provided as standard.

Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance. The Coroner identified failures by Surrey County Council including: a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services. b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently. c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently. d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan. f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family. g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family. h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken. There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.

Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake’s condition and when to seek emergency medical assistance. The Coroner identified failures by Surrey County Council including: a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services. b.) Failing to obtain information about Jake’s cognitive ability and how it impacted on his ability to manage his diabetes independently. c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently. d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan. f.) Failing properly to plan for Jake’s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family. g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family. h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken. There was also a failure to talk to Jake's family about risks and mitigations or to gather information from them that should have informed their planning and risk assessment.

Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others. Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.

Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others. Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.

Susan was a resident in a care home who develo-ped pressure ulcers. She was under the care of District Nurses, who asked a GP and the tissue viability team for input, but they were shown out-of-date photographs and didn't appreciate the extent of her deterioration. As a result Susan wasn't precribed antibiotics when she should have been. She deteriorated rapidly and was admitted to hospital, where she died two months later. The DNs also failed to share information with the care team or Susan's family.

Multiple failures including: - Arranging a telephone appointment for someone known to be hard of hearing - Not following up when he didn't answer the phone for the appointment - No communication between the teams treating him

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home. Lack of system integration or clinical communication between the commissioning MH trust and The Priory Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.

System used to record welfare checks (Excel) was unfit for purpose, as were staff processes for completing and recording these checks.

"Raymond was admitted to hospital the day before with a history of recent falls attributable to orthostatic hypotension and was frail by virtue of his age. The falls risk assessment, prior to the fall on the ward, did not accurately take into account this history and as a consequence there was no assessment in respect of his additional care needs which more likely than not should have resulted in 1:1 care which probably would have avoided the severity of the injury by managing the fall when he needed to urinate or avoided him having to get out of bed in the first place."

Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody. (The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.) The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.

"During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user’s capacity there is not reliable and routine liaison between Adult Social Care and the care providers. I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person’s capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed. Mr Godderidge’s carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person’s capacity may be variable and fluctuating. I am concerned that this gives rise to a risk of future deaths if a person is considered on a ‘good day’ without understanding that their presentation fluctuates substantially over time."

Failure by ASC to take appropriate action when a safeguarding concern was raised (self-neglect). Failure to act on a referral for a needs assessment. Multiple general failures to communicate between teams within ASC.

(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment. (2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P. (3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact. (3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis.

Karmchand was admitted to hospital with acute intestinal obstruction. He was placed on the wrong referral pathway, resulting in severe delay to the surgery he needed. Observations were not carried out properly while he was awaiting surgery. Karmchand was unable to communicate the pain he was feeling to hospital staff. His family raised concerns, as did hospital staff who knew him, "but adequate notice does not appear to have been taken."

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

Morgan-Rose took her life while sectioned under the MHA. She was 18 with a diagnosis of Autism Spectrum Disorder; her transition from Children's to Adult1 Social Care had been badly managed, with a lack of information transfer between the two serevices and with no consideration of her own anxieties. MHU staff consistently failed to engage with Morgan-Rose, to the point where she felt they didn't have time for her. They failed to monitor her as they were required to, falsifying observation records and relying on the Oxevision automated observation system instead of face-to-face observations. When Oxevision triggered an alarm to say she had been unattended in the bathroom for three minutes, which should have resulted in an immediate welfare check, the system was reset by an unknown person and Morgan-Rose was left in the bathroom for 50 minutes. Staff had also failed to pick up on warning signals in her behaviour which should have led to heightened alertness. Basic record-keeping was extremely poor, as was the oversight and monitoring of records by senior staff.

Repeated failures by ASC to respond to multiple reports of safeguarding concerns and requests for Carer Act assessments

Miles was arrested while driving under the influence of drink and drugs. He had longstanding mental health needs and was experiencing a psychotic episode. The Police appear not to have realised this and didn't carry out any meaningful assessment of his mental health. They didn't pay adequate attention to information provided by his parents, Adult Social Care and the Mental Health Line. Miles was released from custody, and subsequently crashed his car into an HGV while still suffering a psychotic episode.

Miles was arrested while driving under the influence of drink and drugs. He had longstanding mental health needs and was experiencing a psychotic episode. The Police appear not to have realised this and didn't carry out any meaningful assessment of his mental health. They didn't pay adequate attention to information provided by his parents, Adult Social Care and the Mental Health Line. Miles was released from custody, and subsequently crashed his car into an HGV while still suffering a psychotic episode.

(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evidence that significant changes are being put in place the efficacy of these changes has not yet been evidenced. (2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.

(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evidence that significant changes are being put in place the efficacy of these changes has not yet been evidenced. (2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.

The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not. In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.

The current SCR model does not appear to automatically flag drugs such as steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not. In addition, the SCR does not have a space recording for clinical indication for initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated.

Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment. There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.

Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment. There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.

On 29 September 2022, Kevin was discovered deceased in his cell, having died as a result of ligature asphyxiation. He had a long history of mental ill health, paranoia and self-harm behaviours. He was on an Assessment, Care in Custody and Teamwork (ACCT) plan. However: - Information about Kevin's needs was not being shared between staff at handover - The ACCT plan itself was unavailable to staff on the day of his death - a day known to be a trigger date for Kevin - as it had been removed for quality assurance - Staff were not trained in ACCT observations, and some were simply completing "signs of life" checks" - After Kevin's death, records were falsified to state that ACCT checks had been carried out

Trevor died in prison. His cause of death was Sudden Unexpected Death in Epilepsy (SUDEP). His epilepsy was known to prison healthcare staff but not to prison staff. There was no seizure care plan, no seizure diary, and no means of monitoring his condition. Response from prison healthcare provider: “As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

Trevor died in prison. His cause of death was Sudden Unexpected Death in Epilepsy (SUDEP). His epilepsy was known to prison healthcare staff but not to prison staff. There was no seizure care plan, no seizure diary, and no means of monitoring his condition. Response from prison healthcare provider: “As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

Rachel was known to the Intensive Home-Based Treatment Team (IHBTT) to be at high risk of suicide, but they failed to take all the necessary steps to protect her. Her family contacted IHBTT multiple times to raise concerns about her wellbeing, but these were not acted on, and nor were family members given any support and advice about how to care for Rachel.

Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children? The following specific issues were identified: The patient safety plans are not always read and understood by transport crew. Home visits between passenger and transport crew often do not occur when contractually required. The local authority are often not notified of personnel changes in the transport crew. The need for proper handovers at drop off and pick up is not understood. There is no requirement for transport crew to be qualified first aiders. The passenger assessment test requires further improvement. There is no comprehensive schedule for inspection of transport operators. There is no mandatory training or forums for operators to attend where information can be cascaded to them. Operators have to approach multiple organisations which leads to confusion and inconsistency.

Keith was diagnosed through MRI as suffering from degeneration of his lumbar spine which caused impingement of his lower sciatic nerve resulting in chronic pain. He called his GP on three successive days as his pain was increasing. The response from the surgery was chaotic and at times the behaviour of those taking telephone calls was unprofessional and inappropriate. The surgery failed to call him back as promised. On the evening of the third day his family called an ambulance, but Keith suffered a heart attack and died despite CPR.

The Court heard evidence despite a warning ‘flag’ being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during his admission.

Multiple concerns about the Trust's approach to risk assessment (including a failure to prescribe appropriate medication); the way they carried out observations; and failure to pay regard to information provided by Larry's partner, which was put on the record but ignored.

Tom sought help for depression, stating that he had suicidal thoughts. He was assessed by the MH team, but the assessment wasn't properly recorded; no discharge letter was sent to the GP, meaning that Tom didn't get the medication he needed. "It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care."

Two consecutive welfare checks were omitted by different officers; one completed the log to say he had carried out the check.

Missed observations; falsified observation records; lack of supervision of newly qualified staff

1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise. 2) A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist following the appointment on 2 February 2023, but not acted on. 3) The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 September 2023, identified numerous matters and learning points, including, but not limited to the following: – There had been a lack of “professional curiosity” in the assessment and planning of Mr Whitelaw’s care and treatment – “Discussions and assessments of risk should be clearly documented” – “Risk formulations should consider both current and historic/contextual risks and incorporate ratings of mood to ensure that these are not used in isolation and are linked with appropriate interventions” – There were “missed opportunities identified in relation to LW’s self-reported deterioration following his discharge from hospital which do not appear to have been fully explored.”

a.[REDACTED] evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and [REDACTED] of which treating clinicians were aware. On at least one of those occasions [REDACTED] spoke with Spenser Ward staff. I noted that Ms. Woodman had not [REDACTED] given consent for staff to contact [REDACTED] concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from [REDACTED]; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with [REDACTED] on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted [REDACTED} ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.

We, the jury, find the: 1. Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point 2. Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. The difficulties accessing relevant and important information relevant to J. Zarrop’s history, both medical and custodial were the main contributing factors to the death of J. Zarrop.

We, the jury, find the: 1. Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point 2. Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. The difficulties accessing relevant and important information relevant to J. Zarrop’s history, both medical and custodial were the main contributing factors to the death of J. Zarrop.