Alfred Dosku

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Independent investigation into the
death of Mr Alfred Dosku,
a detained person at Brook House
Immigration Removal Centre,
on 17 November 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detained persons in immigration centres.
If my office is to best assist the Home Office in ensuring the standard of care received by
those within service remit is appropriate, our recommendations should be focused,
evidenced and viable. This is especially the case if there is evidence of systemic failure.
Mr Alfred Dosku died in hospital on 17 November 2023, eight days after he was found
hanging in his room at Brook House Immigration Removal Centre (IRC). He was 37 years
old. I offer my condolences to Mr Dosku’s family and friends.
Mr Dosku had been at Brook House for fewer than two weeks when he was found
hanging. He had no known history of self-harm and gave no indication to staff that he was
at risk of suicide or self-harm in the lead up to his death.
I make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and detained persons involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 8
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Summary
Events
1. On 1 November 2023, Mr Alfred Dosku was detained at Brook House Immigration
Removal Centre (IRC) pending removal to Albania. He reported no immediate
concerns.
2. On 5 November, a nurse saw Mr Dosku as he said he had a sharp burning pain in
his stomach. The nurse gave him medication for indigestion.
3. Later that evening, Mr Dosku’s fiancée visited him. During the visit Mr Dosku was
emotional and said he would rather take his own life than go back to Albania. Staff
were not aware of his comment.
4. On the evening of 9 November, Mr Dosku and his fiancée argued over the
telephone. Mr Dosku was crying and said that he wanted to kill himself.
5. At 10.13pm, a detention custody officer (DCO) let Mr Dosku’s roommate out of their
room for cleaning duties. The DCO saw Mr Dosku lying on his bed.
6. At 10.56pm, the DCO let Mr Dosku’s roommate back into the room and he found Mr
Dosku hanging behind the door. He alerted the DCO, who called out to two
detention operational managers (DOMs) who were close by. Staff cut the ligature
and started CPR. A DOM radioed a medical emergency code and staff called for an
ambulance.
7. At 11.06pm, ambulance paramedics arrived and continued CPR. Paramedics
regained a pulse and took Mr Dosku to hospital where he was placed in an induced
coma.
8. Mr Dosku did not regain consciousness and died in hospital on 17 November.
9. After Mr Dosku died, a detained person at Brook House told us that Mr Dosku had
said to him and others that he wanted to take his own life. They said that they told a
female member of healthcare staff but were unable to provide any further details.
Findings
10. Mr Dosku gave no indication to staff that he was at risk of suicide or self-harm
during his time at Brook House. There is nothing in any of the records to indicate
that other residents of Brook House reported that Mr Dosku had expressed
thoughts of suicide. We are satisfied that staff could not have foreseen his actions.
11. We make no recommendations.
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The Investigation Process
12. The Home Office notified us of Mr Dosku’s death on 17 November 2023.
13. The investigator issued notices to staff and detained persons at Brook House IRC
informing them of the investigation and asking anyone with relevant information to
contact him. Four detained persons contacted the investigator as a result.
14. The investigator visited Brook House on 23 November. He obtained copies of
relevant extracts from Mr Dosku’s detention and medical records, CCTV and body
worn video camera (BWVC) footage. He also obtained Serco custodial documents
and Ambulance Service records.
15. The investigator interviewed five members of staff and four detained persons in
person on 23 November, via telephone on 21 November and 1 December, and by
video call on 16, 23 and 26 February 2024.
16. NHS England commissioned an independent clinical reviewer to review Mr Dosku’s
clinical care at Brook House. The investigator and clinical reviewer conducted joint
interviews with three healthcare staff by video call on 15 February 2024.
17. We informed HM Coroner for West Sussex of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
18. The Ombudsman’s office contacted Mr Dosku’s fiancée to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Dosku’s fiancée
asked us how Mr Dosku had used the bedsheets to hang himself, how long he was
hanging before he was found, whether his roommate made a statement, and
whether Mr Dosku was on suicide and self-harm monitoring. She also asked if Mr
Dosku received adequate medical care. These questions are answered in this
report.
19. The Ombudsman’s office also tried to contact Mr Dosku’s brother but was
unsuccessful.
20. We shared our initial report with the Home Office. They pointed out a factual
inaccuracy which has been amended in this report.
21. We sent a copy of our initial report to Mr Dosku’s brother and fiancée. They did not
notify us of any factual inaccuracies.
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Background Information
Brook House IRC
22. Brook House Immigration Removal Centre (IRC) is situated next to Gatwick Airport
in Crawley, West Sussex. Serco group run the centre under contract from the Home
Office. Practice Plus Group provides physical and mental health services. The
centre has five wings, including an induction wing (B Wing), and a smaller unit (E
Wing) used to manage detained persons with complex needs and those who are
separated from the rest of the population.
HM Inspectorate of Prisons
23. The most recent inspection of Brook House was in June 2022. Inspectors reported
that the identification and management of risks on arrival was not good enough. Not
all detained persons were offered a private interview on arrival and staff did not
always spend enough time enquiring into their risks. The standard of health
screening was variable.
24. Inspectors were concerned that the emergency protocols were not consistent and
not all staff used the centre’s method of summoning emergency assistance.
Independent Monitoring Board
25. Each IRC has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that detained persons are treated fairly and
decently. In its latest annual report for Gatwick IRC (Brook House and Tinsley
House) for the year to 31 December 2022, the IMB reported that Brook House
provided a generally safe environment for detained persons.
26. The Board observed mainly positive interactions between Serco and detainees, with
several instances of custody officers showing real concern for men and engaging
with them in a positive way.
27. The Board noted that reception at Brook House was generally stable and well-
managed, but they were concerned about the poor communication from the Home
Office about arrivals. They were also concerned with the use of interpretation,
where access to ‘Big Word’ (interpretation service) was frequently frustrated by long
waiting times. Although custody officers with language skills often stepped in to
help, this was not a solution as they were not specially trained or independent.
Previous deaths at Brook House
28. Mr Dosku was the first detained person to die at Brook House.
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Key Events
29. On 1 November 2023, Mr Alfred Dosku (an Albanian national) was arrested for
alleged domestic abuse (but was not charged with any offences). When police
identified that he had entered the UK illegally, they referred him to Immigration
Enforcement who detained him under immigration powers. He was taken to Brook
House Immigration Removal Centre (IRC) pending removal to Albania.
30. Mr Dosku arrived at Brook House very late at night and was not processed in
reception until the early hours of 2 November. The reception nurse recorded that Mr
Dosku understood basic English and that, because of the lateness, she used a
fellow detained person as an interpreter with Mr Dosku’s consent. The nurse
recorded that Mr Dosku was well-kempt and maintained good eye contact but was
tearful and said he did not want to return to Albania. Mr Dosku said that he had no
thoughts of suicide or self-harm.
31. New detained persons are usually placed on the induction wing (B Wing), where
staff can better observe them and identify any vulnerabilities. However, there were
no bed spaces on B Wing, so Mr Dosku was moved to a standard wing (C Wing).
32. On 2 November, Mr Dosku did not attend a scheduled GP appointment. (It is
standard practice for a GP to see new arrivals.)
33. The same day, there is an entry in Mr Dosku’s medical record from a member of the
psychosocial team to say that she had given Mr Dosku induction and harm
minimisation advice (in relation to illicit drug use). She made an identical entry on 3
November. When the investigator asked her about this, she said that she thought
she would have visited Mr Dosku only once and that the second entry must have
been an error. She said that her entry suggested that she did not see Mr Dosku and
that she put leaflets under his door.
34. On 3 November, a detention operations manager (DOM) helped Mr Dosku
complete an immigration request form. In the form, Mr Dosku asked for an update
on his case. He said his fiancée was three months pregnant and was stressed. Mr
Dosku said that he feared his fiancée would have a miscarriage due to the situation,
and that she had been going to the ‘emergency’ (believed to mean hospital)
because of how stressed she was.
35. On 4 November, a member of the Detention Engagement Team (DET) spoke to Mr
Dosku over the telephone (with the aid of an interpreter). Mr Dosku told the DET
staff member that he did not attend his GP appointment two days earlier as he
thought he had no need to see a doctor, but later said he sometimes experienced
stomach pain. Mr Dosku said that he had debts in Albania and was worried about
returning there.
36. On 5 November, a nurse saw Mr Dosku (with another detained person who acted
as interpreter). Mr Dosku was clutching his abdomen and said he had a sharp
burning pain in his upper abdomen that would come and go. After examining Mr
Dosku, she diagnosed suspected indigestion. She gave him Gaviscon (a
medication used to treat heartburn and indigestion). Over the next four days,
healthcare staff administered Gaviscon to Mr Dosku on a further five occasions.
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37. Later that evening, Mr Dosku’s fiancée visited him. She told us that Mr Dosku was
emotional during the visit and said he would prefer to take his life rather than go
back to Albania. At the time, Mr Dosku’s fiancée was around ten weeks’ pregnant
with their child. A detained person told the investigator that Mr Dosku was upset
that day and did not speak with anyone. He said a DCO spoke to Mr Dosku for five
minutes, but Mr Dosku just said he was fine. Staff recorded no concerns about Mr
Dosku (and if Mr Dosku spoke to a DCO it was not logged in his records).
38. On 7 November, a solicitor met with Mr Dosku. The solicitor was in the process of
gaining instructions from Mr Dosku regarding seeking asylum.
Events of 9 November
39. On the evening of 9 November, between 6.30pm and 9.00pm, Mr Dosku and his
fiancée argued over the telephone (detained persons have access to their mobile
phones and so staff were unaware of the call). She told us that Mr Dosku was
crying and said that he wanted to kill himself. (Mr Dosku’s roommate told the
investigator that Mr Dosku had been arguing with his fiancée over the telephone for
two days.)
40. CCTV footage shows that at 10.13pm, a DCO unlocked Mr Dosku’s room to let his
roommate out to do his wing cleaner duties. She told the investigator that she saw
Mr Dosku lying on his bed. She said Mr Dosku did not show any signs of distress
and appeared to be watching television.
41. The DCO told the investigator that later, while he was cleaning, the roommate told
her that he could hear someone calling Mr Dosku’s mobile telephone, but Mr Dosku
was not answering.
42. At 10.56pm, the DCO let the roommate back into Mr Dosku’s room. The roommate
told the investigator that when he entered the room, he could not see Mr Dosku. He
said he called out to ask if Mr Dosku was in the toilet, but there was no response.
When he closed the door, he found Mr Dosku hanging behind the door.
43. The DCO told the investigator that she heard the roommate say, “Oh my god”, and
then he indicated to her to look behind the door. She then entered the room and
saw Mr Dosku hanging. Mr Dosku had a ligature made from a bedsheet around his
neck, which he had tied to a wooden television bracket that was above the top right
hand of the door.
44. The DCO quickly ran out of the room and shouted to alert DOM A (Oscar 1, the
senior officer in charge), who was in the wing office nearby. The DCO, DOM A and
DOM B (Oscar 2, the second most senior officer on duty) then ran into Mr Dosku’s
room. DOM A and the DCO cut the ligature around Mr Dosku’s neck.
45. At 10.57pm, DOM A radioed a code blue (a medical emergency code used when a
detainee is unconscious or having breathing difficulties which alerts healthcare staff
and tells the control room to call an ambulance). At 10.59pm, the control room
called an ambulance. (We have used BWVC timings - there is a discrepancy of
around a minute between CCTV and BWVC footage.)
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46. DOM A started chest compressions, while the DCO administered respiratory
breaths. More detention staff responded.
47. Shortly after, two nurses arrived at Mr Dosku’s room. One nurse applied an
Automated External Defibrillator. (AED - a portable device that can be used to treat
a person whose heart has suddenly stopped working.) The AED stated that no
shock was advised on three occasions and staff continued CPR.
48. At 11.06pm, an ambulance crew arrived at Mr Dosku’s room and continued CPR.
Paramedics regained a pulse and took Mr Dosku to hospital where he was placed
in an induced coma on a ventilator.
49. Detention staff at Brook House began suicide and self-harm monitoring procedures
(known as ACDT) for Mr Dosku. Detention staff remained with him in hospital.
50. On 13 November, the Home Office assessed that Mr Dosku was no longer well
enough to be detained and released him on bail. They closed Mr Dosku’s ACDT
plan, and detention staff left the hospital.
51. Mr Dosku died in hospital on 17 November.
Information received after Mr Dosku’s death
52. A detained person told us that Mr Dosku had said in front of a group of other
Albanians that he wanted to take his own life. The detained person said they told a
female member of healthcare staff about this. The detained person was unable to
tell the investigator the name of the staff member, what they looked like, or when or
where they told the staff member. There was no information in Mr Dosku’s medical
record to indicate that healthcare staff had been approached, or that they had any
concerns about Mr Dosku’s mental state or risk to self.
Contact with Mr Dosku’s family
53. Initially, Home Office staff thought that hospital staff would liaise with Mr Dosku’s
family. When, on 10 November, it became clear that this was not happening, the
Home Office appointed a family liaison officer (FLO). That afternoon, the FLO
contacted Mr Dosku’s fiancée and told her that Mr Dosku was in hospital.
54. The FLO made further enquiries regarding Mr Dosku’s other next of kin. On 12
November, she contacted Mr Dosku’s brother and informed him of the situation.
The following day she contacted Mr Dosku’s cousin.
55. After Mr Dosku’s death, the FLO kept in contact with Mr Dosku’s family. Over the
following weeks, she continued to offer support and advice.
56. The Home Office assisted in the arrangements and financial cost of repatriating Mr
Dosku to Albania for his funeral.
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Support for prisoners and staff
57. After Mr Dosku’s death, IRC managers debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
58. The IRC posted notices informing other detained persons of Mr Dosku’s death and
offering support. Staff reviewed all detained persons assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr Dosku’s death.
59. Immediately after Mr Dosku was found, a DCO took his roommate aside and spoke
to him. He was later moved to a different unit. He said that he was offered mental
health support.
60. IRC staff also held meetings with Albanian residents, to support them and attempt
to address their questions and concerns.
Post-mortem report
61. The post-mortem report concluded that Mr Dosku died from hypoxic brain injury
(lack of oxygen to the brain) caused by hanging. The toxicology report showed no
illicit substances in Mr Dosku’s system at the time of his death.
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Findings
Assessment of Mr Dosku’s risk
62. Mr Dosku had been at Brook House for less than two weeks when he was found
hanging in his room. He gave no indication to staff when he arrived at Brook House
that he was at risk of suicide or self-harm. A detained person told us that Mr Dosku
later said in front of a group of Albanians that he wanted to take his own life and
they told a female member of healthcare staff. The detained person was unable to
provide any details about the staff member, or when or where this happened. We
have been unable to corroborate this account. There are no custody or medical
records that indicate IRC staff were made aware that Mr Dosku had expressed
thoughts of suicide.
63. Mr Dosku expressed thoughts of suicide to his fiancée during her visit and during
telephone calls. However, IRC staff were not aware of these conversations.
64. We are satisfied that Mr Dosku gave no indication to staff that he was at risk of
suicide and that they could not have foreseen his actions.
Emergency response
65. Detention Service Order (DSO) 09/2014 on Medical Emergency Response Codes
says that all IRCs should have local operating procedures in place based on a two-
code system for medical emergencies (code red for bleeding/burns and code blue
for collapse/breathing difficulties). This should ensure that healthcare staff attend
promptly with the correct equipment and that an ambulance is called immediately.
66. When the DCO found Mr Dosku hanging, she did not call a code blue as she should
have done. Instead, she called for help from the DOMs who were nearby. They
responded quickly, cut down Mr Dosku and started CPR. One of the DOMs then
radioed a code blue. This all happened in under a minute.
67. The DCO told us that she knew that a DOM was in the office close by and thought it
would be quicker to physically get support. She said if the DOM had not been close,
she would have radioed a code blue. While the correct procedure was not followed,
staff started CPR quickly and there was a minimal delay in calling the code blue.
We therefore make no recommendation.
68. There was a short delay in the control room calling for an ambulance when the code
blue was called. The control room seemed unsure that they were supposed to call
an ambulance immediately in response to a code blue and a DOM had to
specifically ask for an ambulance to be called twice. We bring this to the Director’s
attention.
Clinical care
69. The clinical reviewer concluded that the care Mr Dosku received at Brook House
was of a reasonable standard and at least equivalent to that which he could have
expected to receive in the community.
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70. She made one recommendation, which the Head of Healthcare will wish to address.
She also noted concerns about using other detained persons as interpreters for
clinical assessments.
Inquest
71. At the inquest, held on 21 July 2025, the jury concluded that Mr Dosku died by
suicide.
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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