Tarek Chowdhury

An investigation was commenced into the death of Tarek Mahmood CHOWDHURY, born 13 May 1952, who died on December 2016 The investigation concluded at the end of the inquest before a jury on 25 March 2019. The conclusion of the inquest was that the Deceased, while detained at Heathrow Immigration Removal Centre (IRC) , was unlawfully killed by another detainee: As part of its conclusion, the jury expressed concerns about the sharing of information between prisons and IRCs and about the operation of the SystmOne healthcare technology which is used in prisons and IRCs_

On December 2016, while detained in Heathrow IRC, the Deceased was beaten to death by another detainee. assailant was subsequently convicted of manslaughter by reason of diminished responsibility resulting from a drug-induced psychosis_ The focus of the inquest was on the assailant; who had a long history of criminality, including offences of violence, and of mental health problems_ After serving a sentence of imprisonment; the assailant was kept in HMP Wormwood Scrubs pending removal from the UK. However; as a result of a shortage of prison beds for Foreign National Offenders awaiting deportation; he was transferred first The IRC (as it then was) and from there to Heathrow IRC, First;, the jury found (and witnesses from the Home Office admitted) that the assailant should never have been transferred to an IRC. Obviously, had he remained in prison, he would not have been at Heathrow IRC and the Deceased would not have been killed. The assailant was selected for transfer to The Verne IRC by the Home Office's DEPMU, because DEPMU lacked information about him from Mercury Intelligence_NOMIS being The Verne

OASYS , etc, which was not provided to it by HM Prison & Probation Service (HMPPS) in particular , the fact that he had attacked another prisoner with a table the very before he was selected for transfer from prison to an IRC. It became clear, moreover, that there is a general lack of information sharing between prisons and IRCs when a prisoner is transferred to an IRC. This hinders the ability of IRC staff to manage former prisoners. Prison staff are reluctant to share Mercury intelligence with IRCs The inquest heard that the Mercury system is likely to be rolled out to IRCs in the near future. However, other sources of information (such as NOMIS reports and OASYS) will still not be available_ Secondly; whenever an individual first arrives at an IRC, it is compulsory for a nurse to provide a clinical screening in relation to both physical and mental health. Where the new detainee has previously been in custody, this should be facilitated by reference to previous SystmOne records_ It became clear, however , that where a new detainee has come from a prison; nurses in IRCs are not able immediately to access previous SystmOne records; they say they cannot do so until a process of "merger" occurs overnight In this case, it meant that the nurse who screened the assailant when he arrived at Heathrow IRC was unaware of his mental health history (and the assailant lied about it). We heard evidence that a nurse can indeed immediate access by inputting the new detainee's prison number (available the Person Escort Report). However, if it were as simple as that; any nurse in an IRC could access the records of any prisoner at any time (ie, whether or not that prisoner was coming to an IRC); as long as slhe had the prison number: Plainly, this is not the case. There must;, therefore, be a moment at which the IRC nurse is authorised to look at a prisoner's records by using his prison number However, we were unable to establish the mechanism for that; and the suspicion is that it does not occur prior to the new detainee's arrival from prison and that is why the nurses at Heathrow IRC are saying that they do not have access during the initial screening process: There may also be a training issue here_

In my opinion action should be taken t0 prevent future deaths and believe you andlor your organisations have the power to take such action.