Individual at Yarls Wood

Circumstances surrounding the death of a detainee in Yarl’s Wood
Removal Centre on 15 September 2005
Report by the Prisons and Probation Ombudsman for England and Wales
January 2006
A man brought his family to England from Angola during October 2001. He
claimed asylum immediately, but it was almost three years before a decision
was made. By that time, the man, his wife and two sons had settled in Leeds,
becoming fully engaged with the local community.
The man’s asylum application was refused in June 2004, and a subsequent
appeal (the outcome of which was announced in November 2004) was
unsuccessful. The man said he was not informed of the result of his appeal.
Ten months later, on 13 September 2005, he was visited by two Immigration
Officers. The next day, he and his 13 year old son awoke to find an
immigration officer and a police officer in their bedroom. They were told to
dress and pack and that they would be removed from the country the next
day.
The man was found hanging in a stairwell at Yarl’s Wood Immigration
Removal Centre at around 1:00 am the next morning (15 September 2005).
His son was still asleep in their shared room and had to be woken to be told
about his father’s death. The man left a note saying that he did not want his
son to go to Angola and that he hoped he would continue his studies in
England.
Whatever the rights and wrongs of immigration control, this is an immensely
sad and moving story. My heartfelt sympathies go out to the man’s son.
There are few worse things than to lose your father at such a young age and
in such shocking circumstances.
Staff of the Immigration Service, the escort contractor (G4S) and of the Yarl’s
Wood contractor (GSL), have all been shaken by the man’s death. It has
prompted much soul-searching as they have tried to identify whether they
missed an opportunity to save the man’s life. Each has concluded that they
did not. I agree. I doubt, however, that this will give them much comfort. I
am grateful to them all for their help and co-operation. My colleague who
conducted this investigation, Miss Ali McMurray, met with unfailing willingness
from all concerned.
This final version of my report reflects comments made at draft stage both by
the Home Office and, in particular, by the solicitors representing the man’s
son.
Stephen Shaw
Prisons and Probation Ombudsman January 2006
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Contents
Summary 4
1. Background 9
The man in question 9
The Immigration Removal Estate 11
Yarl’s Wood Immigration Removal Centre 11
2. Investigation 11
3. The man’s arrest 13
4. The journey to Yarl’s Wood 20
5. At Yarl’s Wood 20
6. The man’s death 25
7. After the death 30
8. Post mortem report 32
9. The man’s family 32
10. Examination of the issues 33
11. Conclusions 41
Recommendations 41
Annexes:-
Annex 1 - Chronological history
Annex 2 - Notification of asylum decision – 30 June 2004
Annex 3 - Notice of decision to remove – 6 July 2004
Annex 4 - Appeal determination – 23 November 2004
Annex 5 - Letter and encs. from a vicar – 19 August 2005
Annex 6 - Letter from Immigration Service to the man’s solicitors – 14
September 2005
Annex 7 - Letter from Immigration Service to the vicar – 14 September
2005
Annex 8 - Note of a conversation with Court Services
Annex 8a - Letter to the investigation from the vicar
Annex 9 - Note of a conversation with an Immigration Service official
Annex 10 - Removal visit briefing
Annex 11 - Detention visit report
Annex 12 - Notes of conversations with/e-mails from Immigration Officers
Annex 13 - Escort forms/statements
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Annex 14 - Immigration Service detention forms
Annex 15 - Yarl’s Wood reception reports
Annex 16 - Yarl’s Wood history sheet
Annex 17 - 1st Night in Custody form
Annex 18 - E-mail about 1st Night in Custody form
Annex 19 - Cancellation of a movement form
Annex 20 - Request for interview with Immigration Officer
Annex 21 - Chronological history of setting of removal directions
Annex 22 - Control room log
Annex 23 - Incident report
Annex 24 - Incident statements by staff
Annex 25 - The man’s “Declarations”
Annex 26 - Notice to staff and detainees
Annex 27 - The son’s statement to the police
Annex 28 - Notes of interviews with staff
Annex 29 - IMB report
Annex 30 - Health care forms
Annex 31 - Post mortem
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Summary
This is the report of my investigation into the death by hanging of a man in a
stairwell at Yarl’s Wood Immigration Removal Centre on 15 September 2005.
The report starts by providing some information about the man, a 35 year old
Angolan man with a wife and two sons. It describes his account of being held
in prison without trial in Angola as a result of his political activities, and of the
night when the authorities came and murdered his parents and sister. He
escaped and arrived in England with his family in October 2001. He claimed
asylum immediately, but his case was not determined for almost three years.
An appeal was unsuccessful, but the man said he never received notification
of the result. The man had lived in Leeds since his arrival in 2001 and had
established close links with the local church community. I quote at length
from a ‘Declaration’ written by the man in April 2005, in which he complains
that he has not heard about his appeal despite chasing the matter up, and
that he had “no life for live” (sic). He mentions killing himself.
The report then provides some background information about Yarl’s Wood
Immigration Removal Centre. It describes how it was purpose-built to hold
900 detainees, but was partly destroyed during a disturbance in February
2002. It has been run since its opening by the company now known as GSL
(formerly Group 4). At the time of the man’s death, it held just over half its
operational capacity. The rooms are clean, if somewhat spartan, and there is
a range of facilities on offer.
The next section, ‘Investigation’, describes the form my investigation took.
The Investigator, Miss Ali McMurray, viewed video footage of the man’s death
and the subsequent efforts to revive him. She interviewed a number of staff
at Yarl’s Wood and reviewed papers relating to the man’s custody as well as
statements by staff. She spoke to immigration staff, read reports relating to
the man’s arrest, and reviewed the man’s immigration case file. She also
liaised with a solicitor engaged by the man’s son to ensure his (the son’s)
needs were met by my investigation.
A section entitled ‘The man’s arrest’ describes how a vicar, also a family
friend, wrote to the Immigration Service in August 2005 to inform them that
the man’s wife had been arrested on her return to Angola the previous
October. Miss McMurray learned that the information was considered by an
Executive Officer who judged that a document referring to the arrest was not
authentic.
I go on to describe a so-called ‘pastoral visit’ conducted by two Immigration
Officers on 13 September. The purpose of the visit was to enable them to
prepare for the man’s arrest the next day. They had found the man to be
relaxed and hospitable, but he said he had not received the result of his
appeal. An Immigration Officer undertook to check on this. Miss McMurray
learned that he did so on his return to the office, and was satisfied that a
notice had been sent out to the correct address.
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A total of eight police and immigration officers went to the man’s house just
after 6:00 am the next morning. (Miss McMurray was told that this size of
team was about normal for this type of arrest. It was necessary to be
prepared for all eventualities.) They broke the lock on the door and found the
man and his son in bed. They allowed them to dress and pack and then took
them to the Leeds/Bradford Reporting Centre at Waterside Court. The man
had asked and been allowed to take his morning medication (for depression),
but was not allowed to take his evening medication. The man was apparently
calm and compliant throughout.
I then describe how Miss McMurray contacted The Court Service to find out if
a copy of the appeal decision had been sent to the man. Staff inferred from
their records that one had, but they could not say for certain.
I also set out details of a letter from the vicar. In this, he describes his
acquaintance with the man, the progress of the man’s asylum application, and
the actions he took following the man’s arrest. He said that, when he spoke to
the man that evening, the man complained that the Immigration Service had
not listened to him and that he had been injured when he had been pushed. I
describe the actions Miss McMurray took to investigate this last point.
‘The journey to Yarl’s Wood’ describes an uneventful journey under escort to
the removal centre. The only event of note was that escort staff confiscated
from the man a coiled washing line. They said he gave them no cause for
concern during the journey.
‘At Yarl’s Wood’ sets out the reception process. The man was interviewed by
two officers, who found him compliant and chatty. They shared a joke with
him and explained that he could not keep his medication with him. They had
also told him he could not have the washing line. He accepted both decisions
without question. The immigration forms that accompanied the man did not
indicate any risk of self-harm and the officers did not detect anything to give
cause for concern.
The man was then seen with his son by a nurse. She too found him pleasant
and easy to understand. He did not express any concerns to her about his
situation although he did mention that he was depressed. She told Miss
McMurray that it was not her custom to ask a direct question about self-harm,
and that it was a difficult subject to broach with the man’s son present. The
screening form she used did not refer specifically to mental health and self-
harm issues. The nurse said it was apparent from the man’s medication that
he had not been consistent about taking it. She also had concerns that some
of it contra-indicated. The nurse explained to the man that he would need to
collect his evening medication from healthcare at 6:30 pm. In the event, he
did not do so.
The officer who escorted the man and his son to the family unit said there was
nothing remarkable about them. The son had been quiet and kept his head
down, but the man had been responsive. He had subsequently found the
man on the phone and noted that he had a long list of numbers.
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During the afternoon, the man put in a request to see an immigration officer
about his case. This had been faxed to the Immigration Service.
Another officer had come across the man and his son on several occasions.
She had helped the man phone his solicitor and had subsequently, at the
man’s request, arranged for the vicar in Leeds to phone him. She said that, at
about 9:00 pm, the man had asked if he could collect his medication. She
had contacted healthcare, but was told he could not collect it as he had
missed his allotted time. The officer described the man and his son as really
nice people, who were polite and courteous. They had not mentioned to her
their impending return and gave her no cause for concern.
Miss McMurray asked the nurse about her decision not to allow the man to
collect his medication. She said she had concerns that it contra-indicated and
wanted him to see a doctor before any medication was given to him.
‘The man’s death’ describes CCTV footage of the man emerging from his
room, going to the stairwell and hanging himself from a banister. It then
describes the actions of a number of staff in trying to resuscitate him. CPR
was administered immediately and continuously until paramedics arrived.
Additional equipment had to be brought from the healthcare centre. The man
was taken to hospital but pronounced dead on arrival at 2:05 am.
I then quote from notes found in the man’s room after his death. In these, the
man assumes responsibility for his family’s situation and says he cannot
return to Angola. He says he does not want his son to go to Angola either,
but hopes he will continue his studies in England.
‘After the death’ describes actions taken after the man’s death. The chaplain,
a member of the Independent Monitoring Board (IMB) and the contract
monitor all arrived very quickly. A hot debrief was carried out and staff were
supported by the centre’s own Care Team.
The son was left to sleep but woken up at 4:50 am to be told the news. He
was then cared for in healthcare until Social Services found foster carers for
him.
‘Post mortem report’ sets out the principal findings from the post mortem.
These were that the man died from hanging.
‘The man’s family’ describes action taken by the Immigration Service in trying
to notify the man’s wife of her husband’s death. It also describes the son’s
engagement, via his solicitor, with this investigation. I report that the areas his
solicitor particularly asked to be investigated related to Immigration Service
handling of the man’s asylum application and the availability of publicly funded
immigration solicitors, the man’s arrest and transportation to Yarl’s Wood, and
his care there. I note that my investigation covers all these issues but I
consider that Government policy on legal advice for asylum applicants is not a
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matter properly within my remit. I record the solicitor’s concerns on the matter
and draw this to the attention of the relevant authorities.
In ‘Examination of the issues’, I identify and consider a number of matters
arising from my investigation. I am critical of the delays in progressing the
man’s asylum application and suggest that The Court Service should develop
a system of sending out notification of appeal decisions that would enable
delivery to be confirmed. I am also critical of the speed with which the man’s
removal was to be effected, and the number of people who carried out the
arrest on 14 September. I consider specifically the vicar’s report that the man
said the Immigration Service would not listen to him and that he was injured
during his arrest. I find the first allegation probably to be true but find no
evidence to support the suggestion that he was pushed and injured.
Although risk indicator forms were properly completed by Immigration Service
staff, I recommend that they should be required to mark all risk boxes either
‘yes’ or ‘no’ to show they have considered each point. I consider whether any
risk indicators were missed in relation to the man’s wish to take his evening
medication in the morning and in his wanting to take with him a washing line.
I conclude that they were not.
I also examine the healthcare screening process. I recommend that all adults
should be screened on their own, and suggest that it might be better to ask a
direct question about suicide ideation. I also recommend that staff use a form
that refers specifically to mental health and self-harm, and that they be
reminded to be especially careful when assessing those who are newly
arrested and due for immediate removal. I question whether proper
consideration was given to the man’s request to collect his evening
medication and suggest both that all decisions should be made on a clinical
basis and that they should be properly recorded.
I note that one member of staff responded to First Response when she should
not have done so. While not intending to undermine her contribution in trying
to save the man, I recommend that GSL reminds its staff to observe
established protocols at all times. The agency nurse did not carry keys. This
slowed progress as the two nurses responded to the alert. I recommend that
all healthcare staff working in the centre should be key trained and issued with
keys. I also recommend that GSL considers placing emergency medical
equipment on each unit and looks at the benefits and costs of having more
defibrillators and oxygen bottles round the centre. I record my concern that
only healthcare staff may ask for paramedics to be called. I suggest that this
should be automatic for a Code 1 alert.
I review the lack of contingency planning specific to the needs of children
following the death of a parent whilst in detention. I recommend that this
should be rectified. Finally, I am very critical of confusion over who should
notify the next of kin and suggest that this should always be done by someone
at the removal centre itself.
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In ‘Conclusion’, I write that all staff acted professionally and that the man’s
death could not reasonably have been predicted or prevented. I commend
staff for their efforts to revive him.
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1. Background
The man in question
The man was a 35 year old Angolan national. He was married and had two
sons, who are currently 8 and 14 years old. Before coming to the United
Kingdom, he had lived in the Bie province of Angola all his life and described
himself as a successful self-employed farmer. He had also helped his father
with his farm. The man said in a statement for the Immigration Service that
he had had plenty of land and lived a very comfortable lifestyle.
He told Immigration Service officials that his father had founded a political
party, the Associcao dos Jovens Democraticos (AJD), of which he, the man,
became first secretary. The party’s objective was to “demonstrate about
government policy, the lack of food and medicine, the corruption and so on
and campaign for democracy in Bie” (statement to Immigration Service dated
31 October 2001). He said he and his father were harassed by the Angolan
Government and that, on 31 December 2000, he and his father had been
arrested and detained without charge for almost six months. The man said
they were subjected to inhumane treatment while in prison.
Following their release in June 2001, the man said the party carried on its
work clandestinely, but on 28 August they held a demonstration. During the
early hours of 29 August, the army came to their farm. The man said he
escaped through an underground tunnel, but that his father was killed and his
mother and sister were raped and killed. He man said he subsequently hid
out in the jungle until a friend arranged his escape. He apparently met up with
his family en route and arrived in the United Kingdom with them on 17
October 2001. He claimed asylum the same day.
The man and his family settled in Leeds, where they worshipped at Christ
Church, Armley, an Anglican Church, and were supported by the church
community.
The man’s asylum application was refused in June 2004, on the grounds that
he had not “established a well-founded fear of persecution and … did not
qualify for asylum.” It seems the caseworker judged that the man’s account
simply did not add up. The man’s solicitors lodged an appeal on 15 July.
Before the appeal was heard, however, the man’s wife and younger son
returned to Angola in October 2004 to look after a relative who had been
orphaned.
The appeal was heard on 8 October 2004. The Adjudicator noted that the
man said his solicitor was no longer prepared to represent him because there
was no funding. The man had no private funds and “agrees to rep self”. The
Adjudicator also recorded that the man was satisfied with the Portuguese
interpreter. The determination was promulgated on 23 November. The
adjudicator concluded that, so far as the man’s claim under the Refugee
Convention was concerned, the man was “not credible in his account taken as
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a whole and has failed to show, to the low standard of proof which is upon
him, that there is a real risk of ill-treatment or torture on his return to Angola.”
He therefore dismissed this part of his appeal. As far as his appeal under the
Human Rights Convention was concerned, the adjudicator noted:
“I have already concluded that the Appellant is not credible in his
account and the authorities before me indicate and confirm my view of
the objective evidence produced to the Court by the Home Office and
the Appellant that the humanitarian situation at present in Angola is not
such that it crosses the high threshold required to engage Article 3 and,
therefore, Articles 2 and 3 are not engaged by this claim.”
The decision was apparently sent to the man’s address, although he was to
say that he did not receive it.
After his death, a note was found with the man’s property headed
“Declaration”. It had apparently been written on 15 April 2005. In it, the man
recorded that he had heard nothing about his appeal despite having phoned
and written to The Court Service, Immigration Appellate Authority. He said
they had not answered his letter. He went on (I have used his words exactly
as they were written):
“I don’t have any representative, because I don’t have the money for
pay the solicitor.
This situation is very distressful for me, because I don’t have life for
live, I can’t work, I can’t do nothing in my life is not too easy for my live
in this manner, have to take tablet during the day and nights for sleep, I
feel sick and so frustrate in my life.
The reason that I’m writing this document, I want to die or kill self.
Because I don’t have choice, is too sad for me. I can’t return to my
country, because is not safety for my son [name] and me.
If I return to my country we can be tortured the point being died for the
authority of government Angolan.
So that this not happen to me and my son in my country, I prefer to kill
myself hire in England and I would like to be embedded hire in
England.”
The man appears to have reported regularly to the Immigration Service, as he
was required to do, but heard nothing more from them until he received a
letter dated 19 August 2005 advising that his NASS support could be
withdrawn. On 13 September, he was visited by two Immigration Officers.
He and his son were then taken into Immigration Service custody on the
morning of 14 September, in readiness for his removal from the country the
next day.
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The Immigration Removal Estate
The Immigration Act 1971 makes provision for the detention of failed asylum
seekers and illegal immigrants who are awaiting imminent removal, deemed
to be easily removable, considered to be likely to abscond if released into the
country, or whose identities are in question.
There are nine removal centres in England, and one in Scotland. Most are
run by private contractors on behalf of the Immigration Service.
Yarl’s Wood Immigration Removal Centre
Yarl’s Wood is situated just outside the town of Bedford. It was a purpose-
built immigration removal centre, designed to hold 900 detainees. It has been
run since its opening in November 2001 by the company now called GSL. It
originally held men, single women and families.
In February 2002, one half of the building was destroyed by fire following a
major disturbance. The other half of the centre re-opened during September
2003, taking just single women. It now takes families too and has an
operational capacity of 405. At the time of the man’s death, the roll was 232.
Operational capacity in the family (‘Crane’) unit is 123, but the number on the
unit at the time of the man’s death was considerably less than this.
The accommodation consists of four units in a large, two-storey H block and is
built around six internal courtyards. Family units are double rooms with en
suite facilities. They are spartan but clean and reasonably spacious. Each
unit has a multi-faith room, library, association areas and laundry facilities.
Detainees are not locked in their rooms at night, though they are expected to
observe a quiet period between 11 pm and 7 am.
All detainees are given an induction, although a shortened version is given to
those expected only to stay overnight.
2. Investigation
Miss Ali McMurray, an Assistant Ombudsman, investigated the man’s death
on my behalf. Ms Lucy Phelan was the Family Liaison Officer.
Miss McMurray visited Yarl’s Wood the day after the man’s death. She spoke
to the deputy centre manager, who was in charge of the centre during the
centre manager’s absence on annual leave, and visited the unit where the
man died. She also spoke to the contract monitor and the member of the
Independent Monitoring Board (IMB) who had attended immediately following
discovery of the man’s death. Miss McMurray collected a bundle of
documents relating to the man’s stay at the centre as well as a number of
policy documents. She also arranged to be sent a video recording of CCTV
coverage of the man’s death and the attempts by staff to resuscitate him,
which she reviewed in due course.
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Miss McMurray arranged for notices to both staff and detainees to be put up
around the centre, inviting them to contact her if they wished to provide any
information to the investigation. She visited the centre on a further four
occasions to interview members of staff who had been involved on the night
or who had come into contact with the man and his son during the day. She
was not able to interview the officer who first discovered the man’s death, due
to his absence on sick leave.
Miss McMurray also obtained the Immigration Service caseworking file for the
man. This provided details of his asylum application and its consideration by
the Immigration Service, his appeal and the determination of the adjudicator.
She spoke to and corresponded with The Court Service Immigration Appellate
Authority about notification to the man that his appeal had failed, and to an
Executive Officer who considered a letter from a Leeds vicar, also a friend
and supporter of the man and his family, suggesting that the man’s wife had
been arrested on her return to Angola and could not be traced. She also
invited the vicar to contribute in whatever way he chose to the investigation.
Miss McMurray obtained copies of reports from staff involved in arresting the
man and interviewed some of those involved either in the pastoral visit or the
subsequent arrest. She also reviewed statements by officers who escorted
the man and his son from Leeds to Yarl’s Wood, and reviewed extracts from
CCTV coverage of the journey.
Finally, Miss McMurray obtained a copy of the post mortem report.
Miss McMurray liaised with a solicitor who had been retained by the man’s
son to represent him in relation to his father’s death. She furnished him with
copies of a range of documents relating to the man’s asylum application, his
arrest by the Immigration Service, transport to Bedfordshire and his stay at
Yarl’s Wood. She also disclosed to him (and to IND and GSL) a working draft
of this report.
Miss McMurray considered whether it would be appropriate to interview the
son, given that he was a witness to all that happened on the day of the man’s
death. She decided on balance, that, given his youth (he was just 13 years
old), it would not be appropriate. His solicitor concurred. However, Miss
McMurray spoke to the senior investigating police officer, and received from
him some notes taken of an interview with the man’s son.
It is normally my practice to commission a separate clinical review as part of
my investigation into a death in custody, and the son’s solicitor suggested that
this would be appropriate in this instance also. (The purpose of
commissioning a clinical review is to look into issues outside my area of
expertise where clinical knowledge and judgment is required – such as
diagnoses, appropriateness of medication, likely effects of medication etc.) I
was conscious that the man was in detention for only a matter of hours, and
that his health gave no cause for concern. But I have sought independent
clinical advice on what I have judged to be the single clinical issue arising –
that the man did not take his medication during the evening before his death.
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This advice was provided by my colleague, Ms Emma Bradley MSt (Cantab)
BSc RGN, who is a registered clinician in addition to her duties as Deputy
Ombudsman.
I have also carefully considered the actions and decisions taken by healthcare
staff – and make several observations about the screening that was carried
out to determine risk of self-harm. (I judge that these are matters on which I
myself, as a non-clinician, am equally qualified to comment.)
3. The man’s arrest
The man was designated All Appeal Rights Exhausted (ARE) on 10
December 2004, after he failed to exercise a final right of appeal to the
Tribunal following the failure of his asylum application and subsequent appeal.
He therefore became removable from the country at that point. However,
there appears to have been no further action on his case until 19 August
2005, when the man was warned that NASS support could be removed. On
23 August, a checklist was prepared for his removal.
Miss McMurray found out that the file was forwarded to Leeds RCT (the
caseworking arm of the North East Region) by the Presenting Officers Unit on
20 December 2004. A caseworker at Leeds sent the file to the work in
progress store. This was in line with their policy because Angolan nationals
were categorised as ‘amber’ cases at that time – that is, not readily removable
as they required Emergency Travel Documents to progress with removal.
The man and his son were subsequently identified as a removable family and
the file returned to Leeds RCT on 4 April 2005. As a result of pressure of
work and lack of caseworkers, the file was processed only when it came to
the top of the queue to be dealt with. The checksheet was completed on 23
August and the file was forwarded to the family team on 25 August. The
family team then started the planning on 8 September for the detention and
removal on 14 September.
On 26 August, the Immigration and Nationality Directorate (IND) received a
letter from Christ Church, Upper Armley, Leeds. This constituted a letter of
support from the vicar and included a copy of the Appeal Notice of Hearing. A
fax was attached, apparently from a cleric friend of the man’s in Luanda,
stating that the man’s wife had been arrested. There was also a copy of an
Amnesty International document, signed by the man, giving authority for
Amnesty International to use photographs to assist in locating the man and
their younger son.
An Executive Officer replied to the letter from the vicar on 14 September. She
advised that the Immigration Service did not engage in correspondence with
third parties about individual cases. However, she wrote separately to the
solicitors shown on the record as representing the man to inform them of
receipt of the documents and to advise that she did not judge the “Red Cross
document” (sic) to be authentic. Arrangements for the man’s removal would
therefore continue.
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Miss McMurray spoke to the Executive Officer. She said she had discussed
the vicar’s letter with her manager, as it was impossible to know what was
true and what was not. She said the document apparently from the pastor did
not look much and there was no way of telling from whence it came – but that
did not of itself mean it was not authentic. The Executive Officer said that,
having spoken to her manager, her judgement was that, given that the man’s
wife had volunteered to return to Angola she clearly felt safe to do so. This
suggested that it would be unlikely that she would be arrested. The Executive
Officer readily acknowledged that this judgement might have been wide of the
mark, but it was a judgement call made in circumstances where the
information was not verifiable.
On 13 September, two Immigration Officers conducted a ‘pastoral’ visit to the
man’s home on the outskirts of Leeds. Miss McMurray was told that the
purpose of such visits was to assess the mental and physical health of the
family to be removed and to ascertain that they know how far their
immigration case has got – that is, that they were now liable to removal. It
was also an opportunity to view the family as a unit. They would also check
who else lived at the location and whether there had been any additions to the
family. Generally speaking, the purpose was to check whether there were
any possible barriers to removal. (I have to say that in light of the avowed
purpose of the visits, I find the term ‘pastoral visit’ misleading and offensive.)
Miss McMurray was told that no appointment is made and the person is not
warned beforehand that the visit is to take place. Immigration Officers simply
turn up at the address, usually a couple of days before the date set for
removal. (The Executive Officer advised that, where it was considered such a
visit would cause the person or family to flee, no ‘pastoral visit’ was carried
out.)
A report of the ‘pastoral visit’ shows that it took place at approximately 8:40
am. The man apparently granted the officers entry and offered them a seat.
He confirmed that only he and his son lived at the address and that his son
was at school. The man stated that he was on medication for depression and
showed the officers what this was – mirtazapine, 30mg to be taken at night
and fluoxetine, 20mg to be taken in the morning. He also said that he had
instructed a new solicitor to look at his case at his own expense, as he did not
qualify for legal aid. He then apparently offered the officers a cup of coffee.
The man explained that he had represented himself at his appeal hearing as
he could not obtain legal aid, but claimed that he had not received the
determination and did not know what it was. One of the Immigration Officers
said he would look into this. (The Immigration Officer told Miss McMurray that
he had checked the file when he got back to the office and found a copy of the
determination, sent on 23 November 2004. The correct address was on it.)
The man also confirmed that he was still on benefits.
He then explained to the officers that his wife had returned to Angola the
previous year with his other son. He said he had subsequently contacted the
Red Cross, Amnesty International and the US Defense Department to seek
help with locating them, as he had not heard from them. As a result, he had
14
learned that they were both in Namibia. The officers left the address at 8:55
am.
The detention visit was carried out at 6:10 am on 14 September by three
Immigration Officers and four police officers. A Chief Immigration Officer
(CIO) (the Family Unit team leader) went to observe. A report of the visit says
it was highlighted during the briefing that the man suffered from depression
and was on medication.
The report says that the party found all the curtains at the property closed.
Officers attempted to gain entry by consent by repeatedly knocking at the
door. After about five minutes, however, there had still been no response and
a key provided by the housing consortium was tried. Either the wrong key
had been supplied or the locks had been changed, as the key did not work.
After discussion with the police and with the authority of the CIO, it was
decided to use the “Method of Entry” kit. One of the Immigration Officers
described this to Miss McMurray as a large heavy baton with a handle on
either end. She said that the locks flew off the door after it was struck.
The report says that one Immigration officer and two police officers then went
upstairs to the attic where the man and his son were in bed. The son was
awake, but his father had to be roused. When he was asked why he had not
heard the knocking, the man apparently indicated the tablets and said they
made him tired.
The report said that, once the man was dressed and in the lounge area with
his son, an Immigration Officer explained “in great detail” to the man that his
asylum claim was now at an end and that he would be taken into Leeds for
onward transfer to London. He and his son would be arrested under
paragraph 17(1) of Schedule 2 of the Immigration Act 1971. The man was
told that he and his son would have an opportunity to collect their belongings.
Miss McMurray spoke to the Executive Officer about why it was considered
necessary to detain and remove the man and his son without notice. The
Executive Officer said that this was standard policy. They tried to detain
people for as short a time as possible, and did not give notice of impending
detention and removal in case the person went into hiding. This policy
applied regardless of any previous history of compliance with Immigration
Service conditions. The only exceptions were for “operational reasons” or
where the Immigration Service knew that the person wanted to return.
The report says that, at this point, the man said he was not aware of the
decision in relation to his appeal as he had not received it. The Immigration
Officer showed him a copy and explained that the original had been posted to
the address at which they now were. The man said he wanted to make a
phonecall and was told he would be able to do so once they got into Leeds.
The man then said he needed his medication. On the grounds that he was
asleep when the Immigration officers arrived, a decision was taken to allow
this since he would not have had an earlier opportunity to take it. The man
15
said he wanted the other medication (intended to be taken at night) also, but
this was denied him. Miss McMurray asked if anything could be read into the
man’s wish to take both lots of medication, but the Immigration Officer was
certain there was nothing untoward about it. He thought the man might simply
have been confused as a result of being awoken in the way he was.
Father and son then collected their possessions before being escorted from
the premises.
Once in the Leeds/Bradford Reporting Centre at Waterside Court, the man
and his son were placed in a holding room. The man took a couple of glasses
of water when offered, but his son declined. The man said he wanted to
make a phonecall, but was told he could do so once the G4S (escort) officers
arrived. G4S officers took over custody of the man and his son at around
8:40 am. The report says that the man’s new solicitors were informed of the
man’s detention and removal directions.
The report adds that the man had been open and friendly during the pastoral
visit and remained calm and compliant during the detention process. It says
that, at no time, did he display any signs that he might be suicidal. Nor did he
do so in the holding room.
The Immigration Officers reiterated this to Miss McMurray when she spoke to
them. Another Immigration Officer said it had been an absolutely routine pick-
up. The man had packed and was compliant in all respects. The officer said
she had been involved in quite a number of family detentions and, even with
the benefit of hindsight, there was nothing out of the ordinary. She said the
man had not said a word on the way to the holding rooms but appeared to be
okay.
The male Immigration Officer described it as one of the better visits he had
done. The man remained quite calm throughout. He too had had a lot of
experience in family detention and was really shocked by the man’s death.
The female Immigration Officer told Miss McMurray that it was routine for
police to be present. Only a small number of Immigration Officers were PACE
trained and so able to carry out arrests. No-one on the Family Unit had had
the training. She noted that family pick-ups could be very emotional and lead
to public order/safety issues. In addition, it was not possible to predict what
might happen. Sometimes there were more or different people in the house
than expected. It was therefore normal for the police to be present. Four
police officers was normal also. The Immigration Officer said one police
officer might remain outside in case of trouble.
The male Immigration Officer said it was he who took the decision on the
numbers to carry out the arrest. He said he was influenced by the area in
which the pick up was to take place and by the possibility of public disorder.
The number of people engaged on this occasion was not unusual. He said
that, notwithstanding the pastoral visits, they still sometimes found more
people in the house than they expected. He added that the majority of the
16
personnel remained downstairs. In this instance, he and one police officer
had entered the man’s bedroom while the other police officer had waited
outside. The others were all downstairs.
Miss McMurray looked into the suggestion that the man had not received
notification of the Adjudicator’s decision. A member of staff at the Official
Correspondence Section at the Tribunals Support Centre advised that the
procedure adopted when sending out appeal decisions was that:
“the determination is posted by first class mail together with a notice of
promulgation endorsed by the Clerk to the Adjudicator. This indicates
the date of postage and the addresses of the recipients … In
accordance with the relevant Procedure Rules, the determination is
deemed to have been received two working days after the date of
postage. If a determination is returned to the AIT, records are updated
to indicate the date of receipt and the reason for return … I can confirm
that neither [the man] nor his solicitor’s copies of the determination
were returned to the AIT.”
The writer enclosed a copy of the notice of promulgation. The same address
as the one at which he was arrested was given for the man, while his
solicitor’s details accorded with information on the man’s immigration file. The
notice is annotated to show both letters were sent out by first class mail.
In light of what the man said in his Declaration of April 2005 about contacting
The Court Service about not having received the determination and hearing
nothing in response, Miss McMurray rang The Court Service Customer
Services Department. The member of staff to whom she spoke advised that it
would be an extremely protracted process to check whether the man had
called the Service as calls were not routinely logged on the computer and only
a proportion were recorded. However, he was able to confirm that they had
received a letter from the man on 16 December 2004 and that, as a result, the
file had been called up. The system did not show whether a copy of the letter
had been sent out, but the person to whom Miss McMurray spoke said he
assumed it had, given that the file had been requested.
Miss McMurray pursued this matter further with the Asylum and Immigration
Tribunal (AIT) and asked for the man’s file to be reviewed. She was advised
that the man’s solicitor’s details had been removed on 16 December 2004 as
requested by the man in his letter of 13 December, but that the writer was
“unable to confirm conclusively that a duplicate copy of the determination was
sent”. (The Immigration Service Executive Officer observed at draft report
stage that, “In my experience as a removals caseworker it is almost
impossible to obtain a copy of an appeal determination from The Court
Service, so it is highly likely that [the man] did not receive his determination.”)
The writer added that the man “indicated” (presumably in his letter to AIT) that
he had spoken to AIT Customer Service Centre staff on 13 December 2004
regarding the result of his appeal. She continued:
17
“The AIT database was updated to show the outcome of his appeal
when it was promulgated on 23 November. [The man] called after the
date of deemed service, and in these circumstances the standard
practice for Customer Service Centre staff is to inform the customer of
the Immigration Judge’s decision.”
In a letter to me received on 7 October 2005, the Leeds vicar told me that his
church ran an organisation that provided friendship and support to asylum
seekers and refugees. The man’s family became regular members of the
vicar’s congregation and also personal friends. The vicar said it was apparent
that the man had been “greatly affected” by his experiences in Angola and
became deeply depressed. He had represented himself at his appeal
because his solicitor did not turn up. The vicar thought the man foundered
badly whilst representing himself. He said the man was not notified of the
decision of the court.
The vicar said the man learned during November 2004 that his wife had been
arrested on her return to Angola. He informed the Immigration Service but got
no response. The man subsequently heard that his wife had been released
from prison and was now in Namibia.
The vicar said that, when he learned of the letter about withdrawal of NASS
support, he (the vicar) wrote to the Home Office and rang the ‘deportation
administrators’. He said the person to whom he spoke apologised profusely
and said the letter should not have been sent.
The vicar said the man phoned him following the pastoral visit, and they
agreed he should obtain legal representation. The following morning, the
vicar heard from neighbours that the man had been arrested. The vicar’s wife
then made a series of phonecalls to find out what was happening and to try to
secure the man’s release. Later that evening, the vicar and his wife both
phoned the man. The man said he was to be flown out the next day. He
seemed very down. The vicar said the man said he was not okay, that
Immigration would not listen to him when they came to the house, and that he
had been hurt when they pushed him.
Miss McMurray pursued some of these issues. There was no
correspondence from either the man or the vicar on the immigration files until
the vicar’s letter of 23 August 2005. A reply was sent to him on 14
September. Miss McMurray discovered that there is no system for recording
incoming mail in the Immigration Service. Any correspondence, whether
received in Leeds or Croydon, would simply be forwarded for the
caseworker’s attention. There is therefore no way of knowing what happened
to any letters sent by the man or the vicar.
Miss McMurray also investigated the suggestion that the Immigration Service
would not listen and that the man was injured when they pushed him. The
Chief Immigration Officer (CIO), Family Unit in Leeds, advised that a copy of
the adjudication determination was given to the man on the day of his arrest.
She surmised, however, that, if the man had not previously seen the
18
judgment, he might have felt he should not be detained. She thought this
might have given rise to him feeling that he was not listened to.
The CIO added that the situation was fully explained to the man, but that he
sought to extend the conversation. She noted that it was “usually unwise to
engage in lengthy discussion about such things”. She said the police are not
allowed for legal reasons to engage in detailed discussion following arrest,
and that the Immigration Service give an explanation initially but that it is
important that they then proceed with packing and leaving the address as
quickly as possible. This was for health and safety reasons. The CIO added
that experience had shown that one could become embroiled in lengthy
discussions, “which detract from the job in hand and achieve nothing but
delay, with the subject not in an ideal situation to take on board what is being
said.” The police apparently refer to this as ‘disorientation’.
The CIO said that, during the detention visit, the man was keen to locate
some papers that he held so that they could be forwarded to a neighbour. It
took some time to locate these. He was adamant that they were in a bedside
table in a bedroom. The police went to look, but could not find them after
quite an extensive search. The CIO also searched through papers located on
a table in the lounge, but to no avail. She said the man was clearly not happy
that the papers were not where he thought they should be, and kept repeating
himself about their whereabouts. He was told a number of times that they
were not there, and eventually the man was allowed exceptionally to go back
upstairs to the bedroom (accompanied by police) to see for himself. They
were subsequently located in the wallet of papers that he already had with
him. These papers were passed, at his request, to a neighbour. The CIO
said it took some time to get details of the neighbours whom he wanted to
receive the papers as his first choice were not at home and he took some time
to identify an alternative.
With regard to the suggestion that the man was pushed and injured, the CIO
said the man was not restrained during the visit. He was escorted to the van
from his address (a matter of about 10 yards). In practice, this meant the
police putting a restraining hand on him in a recognised manner. This was for
his own health and safety and to prevent him absconding. The CIO refuted
the possibility that the man would have been pushed in any way. He
remained compliant throughout and the requests that he made with regard to
disposal of his papers (and pet fish) were adhered to. She said he was not
apparently suffering any injury when they arrived back at Waterside Court and
certainly did not make any complaint.
IS91 is the form that authorises detention. On the reverse it has a section
entitled risk factors, which is designed to alert those responsible for the
detainee’s care of any special monitoring or supervision required. Nothing is
marked next to “Suicide/Self Harm Risk, but “Other Medical Concerns” is
marked. In “Comments”, is written “1 Fluoxetine tablet administered at the
address. Mirtazapine x 1 at night, Fluoxetine x 1 in the morning: depression.”
19
The Immigration Service Operation Enforcement Manual says that, “Once it
has been identified that the person is one who should be detained,
consideration should be given as to what, if any level of risk that person may
present whilst in detention. IOs should undertake the checks detailed on form
IS91RA part A ‘Risk Factors’ (in advance, as far as possible, in a planned
operation/visit when it is anticipated detention will be required).” (I understand
that all those joining the Immigration Service are given a full session on
suicide awareness as part of their training.) The IS91RA completed for the
man has neither yes nor no indicated alongside any of the various risks, with
the exception of “Medical problems/concerns”, which has been marked “yes”.
Comments are “Suffers from depression” with details of the man’s medication,
including the information that he had taken one tablet that morning.
4. The journey to Yarl’s Wood
The Detainee Escort Record shows that the man and his son were collected
from Waterside Court at 10:30 am and delivered to Yarl’s Wood at 12:55 pm.
One of the escort officers reported that both detainees were in the holding
room when the escort arrived. He said he asked them if they were okay and
both of them said that they were. He searched them and gave them a drink.
The escort officer said the man and his son were calm and talkative
throughout the journey and that they encountered no problems.
The other escort officer recorded that both the man and his son seemed fine
when they arrived. She said the man asked whether some money had been
given to a neighbour. When the man’s bags were brought out for checking, a
washing line was found amongst his property. When asked, the man said he
had it for protection. The washing line was removed and bagged separately
with the paperwork. The man was content with this. The escort officer
advised staff at Yarl’s Wood about the line when they arrived at the centre.
She too reported that the man and his son were fine - calm and compliant -
that there were no problems, and that they chatted throughout the journey.
.
5. At Yarl’s Wood
As noted, the man and his son arrived at Yarl’s Wood in the early afternoon.
A reception officer recalled that they arrived on a van by themselves and that
there was no-one else in reception at the time – although it had been a busy
day.
The reception officer explained to Miss McMurray that information from the
Immigration Service forms is entered on to the computer system, producing a
reception report. A copy of this report is passed to the nurse while the original
is placed in the detainee’s file to accompany him/her throughout the centre.
Although the computer system highlights ‘special needs’ (including risk of self-
harm), this is not flagged on the reception report print out. The officer said
that, where the Immigration Service form had not been completed fully or
where he identified a risk where none was mentioned on the form, he would
record his observations on a First Night in Custody form. This was passed to
the nurse and then forwarded to the unit.
20
No risk indicators were shown on the Immigration Service forms
accompanying the man, but one form recorded that the man suffered from
depression and was on medication for this reason. It provided details of the
medication and a manuscript note has been added to show that the man had
taken one of the tablets that morning. The reception officers did not
independently identify any signs that either the man or his son might harm
themselves.
On the contrary, both reception officers who dealt with the man said that he
was pleasant and very polite. He had been quite chatty and smiling. The
officers had established a rapport with him and they had joked about the
Leeds United bag he had with him. The man had smiled. The officers said he
was completely compliant and calm and seemed very confident. He did not
mention his impending removal or his arrest earlier in the day. One of the
reception officers thought the man might have asked about the time of his
flight, but nothing more. The officers agreed that he did not appear to have
any worries – one described the man as one of the calmest detainees he had
dealt with in a long time.
The man had not wanted to take much property with him – just some
overnight things and a change of clothing for him and his son.
The officers had explained to the man that he would not be allowed to take his
medication with him, but that it would be given to the nurse. He did not have
a problem with this and did not ask to be allowed to retain it.
During the reception process, one of the escort officers produced a new
washing line, still coiled up and fastened with plastic. They said they had
taken it off the man and that he said he had it as a weapon for protection. He
also said he no longer wanted it. The washing line was therefore retained in
reception and subsequently discarded. The man was relaxed about this. One
reception officer said that, following the man’s death, he had wondered
whether he should have flagged up the incident with the washing line.
However, they had not allowed the man to keep the line and there were no
indicators of risk, so he concluded they had not been remiss. (I agree.)
The man and his son were then seen by a nurse. She thought that healthcare
staff generally spent about 10 minutes on average with each detainee. This
might be less where detainees were known to be leaving the next day, as
there would be no need to obtain GP details etc. In the case of the man in
question, however, she thought the screening had still taken about 10
minutes. She had seen the man and his son together, as they are not allowed
to see minors by themselves.
(Another nurse said a questionnaire had been produced in all the most
common languages encountered at the centre to enable healthcare staff to
assess detainees whose English was poor. Where communication difficulties
were insuperable, the practice is to take the vital observations and then refer
the case to the doctor, who might use Language Line. Detainees must see
21
the doctor within 24 hours. (The man had no difficulty communicating,
however.))
The reception nurse said it was not generally her practice to ask a detainee
directly if he was thinking about killing himself or about self-harming. She
tried to broach the subject in a more oblique way, by asking about the
detainee’s mental health for example. (Another nurse told Miss McMurray
that she took the same indirect approach, asking the detainee if they felt low,
rather than asking them outright if they felt suicidal. She said she did not want
to put the thought in their heads.) The reception nurse noted that it was
sometimes difficult to talk about suicide and self-harm with the detainee’s
child present. She added, however, that there was nothing about the man to
give her any cause for concern that he might harm himself.
The nurse said that the man had been quite chatty, had maintained
appropriate eye contact and had interacted well. The son was a bit quieter.
She said that the screening was a mix of direct questions and engaging the
detainee in conversation. The man had not said anything about his
impending return to Angola. He had, however, told her about his depression
(which she noted on his screening form). The nurse said he had with him
three types of anti-depressant medication. One was dated January and
others March/April, so it seemed likely he had not been consistent about
taking it. She was rather surprised that he had the three types, as they did
not work well together. Apart from the anti-depressant medication, the man
had quite an assortment of other medication for run of the mill complaints
such as constipation etc. They were the sort of items one might find in a
bathroom cabinet.
The nurse said it was normal practice to take medication away from detainees
until they had seen the doctor (which happened within 24 hours). She had
therefore taken the man’s medication and explained that the doctor would
review it with him the next morning. (She knew he was due to leave the next
day, but said she usually tried to avoid referring to the detainee’s removal in
case they were not already aware of it.) She also explained to the man that
he would need to go to healthcare at 6:30 pm for his evening medication. (In
the event, he did not attend.) The medical record shows that he was to see
the doctor and receive a full screening the next day.
The screening form filled in for the man has sections for health problems and
allergies, blood pressure, height, pulse, weight and medication. There is no
reference to suicidal ideation or mental health.
An officer escorted the man and his son to Crane unit. The walk took about
4/5 minutes. The officer said the man’s son had been really quiet the whole
time and the officer had tried to engage him in conversation by asking if he
played football. The officer said the man did not say much - he certainly did
not mention his impending return to Angola - but was smiling and pleasant,
and more attentive than his son. He seemed not to have any worries. They
were both very polite. The officer had explained to the man that, once they
got to the unit, they would be able to wander round freely – they would not be
22
locked up. He also explained a little about the facilities they would find there –
the library etc. He said that the man and his son did not talk amongst
themselves at all.
The officer took them to their room and showed them what there was and
explained about things such as the hygiene pack. He told them that, if they
needed anything at all, they should ask at the unit office which was open 24
hours a day.
When he looked for them shortly afterwards to give them their ID cards, the
officer found them in the phone room. The man was at the phone, though the
officer was not sure whether he was actually talking or just dialling. The
officer noticed that the man had a piece of paper with lots of numbers on it.
The man’s son stood a little apart and was sullen and quiet. The officer
recalled that, every time he saw him, the boy was staring down at the floor.
A First Night in Custody form completed by an officer on Crane Unit noted
that:
“Both lads appear polite. They have concerns about leaving but are
making necessary arrangements by talking to solicitors and contacting
Immigration.”
Miss McMurray was told that this entry was based on what the officer
overheard of a telephone conversation the man had with his solicitor when the
man used a phone in the unit office. The officer heard the man say that he
did not want to leave the United Kingdom. However, when asked, the officer
said the man was no more anxious than any other detainee who had just
arrived at the centre.
Another officer who was on Information Officer duties on the day of the man’s
arrival, said she came across them several times. She had gone upstairs on
patrol and found them at the phone. The man wanted to contact his solicitor,
but could not work out how to use the phone. The officer showed them what
to do and got them connected with their solicitor. Subsequently, the man’s
son had gone to the information office asking for a toothbrush. She went back
to their room with him to check what was there, as detainees are provided
with a basic hygiene kit on arrival. She found they had only been given one,
so gave them another. Later on, both the man and his son went to the office
as they had run out of phone credit and wanted to phone a religious friend to
let him know where they were. Another officer had phoned the number for
them and asked the vicar to phone the man back. Finally, the officer saw both
father and son at dinner time when she was marking detainees off on the
board.
The officer described them as really nice people who were polite and
courteous. She particularly noticed what a good relationship father and son
seemed to have. They were both nicely spoken and had no problem
understanding or making themselves understood. The officer said she did not
have any conversation with them as such, and neither had said anything to
23
her about their impending removal or any other concerns. The officer said
she did not see any signs of distress or unease. She said they did not seem
to engage with other detainees – but that that in itself was not unusual. They
had only just arrived at the centre. People usually took a little time to find their
way round and find out who was there to speak to.
At 3:30 pm, the centre was notified that the man’s removal had been
cancelled. This information was not apparently relayed to him. (In the event,
the removal order was re-instated. Annex 21 sets out the history of the
removal process.)
At 3:35 pm, the man submitted a “Request for Interview with Immigration
Officer” form. On this he stated:
“I have been to court last year and had no reply (Oct). Could you
please tell me what’s going on.”
This was faxed to the Immigration Service.
The officer in charge of Crane unit office said she had seen the man’s son
playing outside at one point. In addition, the man had come to the office
because he wanted to go to healthcare for his medication. She could not say
what time this was, but it was quite late. She had phoned healthcare to see if
he could be squeezed in and had asked the man to come back in half an
hour. Healthcare said he was too late (different units are allocated different
times for attending), so the man did not get his medication. The officer added,
however, that he had not come back to the office as asked and that she had
not therefore been able to explain the position to him. She said she had
found him “really pleasant”, though he had not been chatty. His English was
not good, but he was understandable.
The man’s medical record says:
“Contacted at approximately 21:00 by manager [name] to inform that
detainee escorted to Healthcare. Reason? (Myself /colleague at
detainee reception advised by DCO “Charlie 1” that [deleted] stated he
had been informed by member of nursing staff to present for
medication. Advised Charlie 1 that he had been instructed by member
of staff to present between 18:30 – 19:00 hrs (designated medication
time).”
Miss McMurray pursued this point with healthcare staff. She was told that, at
about 9:00 pm, a message was relayed to the night nurses (who were both in
reception) by Control. The nurses were told that somebody (no name was
given) from Crane wanted to come up to healthcare for his medication. One
of the nurses said she was unaware that anybody was expected and would
contact Crane on her return to healthcare. She did this at about 10:00 pm
(having been busy in reception in the interim) and found out who the detainee
in question was. She declined to give any medication, as the tablets he had
were contra-indicated and it was not clear which he was taking at that time.
24
There was also some concern about the dates on the bottles. She therefore
advised him to attend his doctor’s appointment the next day.
The man’s son told the police that his father had told him not to worry and that
they would be treated okay at the detention centre. His father had said that, if
they returned to Angola, the army might kill him. He told his son that, if
anything happened, he wanted his son to be brave and stay in England. The
boy said his father “tried everything to stay in the country” the day before he
died and had been in touch with solicitors. Finally, however, he had said
there was no hope and they were being deported. He told the boy to be
strong and do his studies. He did not tell him that he intended to take his own
life.
The man’s son told the police that he had gone to bed at 10:30 pm, and that,
before he did so, his father told him to be strong and not blame him.
6. The man’s death
Much of Yarl’s Wood is covered by closed circuit television and CCTV
cameras at the centre filmed the man killing himself. The tape shows the man
emerging from his room at 12:42 am with something wrapped loosely round
his neck. He walked straight to the stairwell (no more than a few yards from
his room) and went though the door. He appeared briefly to check that there
was no-one in the corridor before closing the door. The man then walked
straight to the banister, unwrapped a length of cloth from round his neck,
leaving one end attached, and climbed over. He braced himself with one foot
against the landing and the other on the staircase while he tied the other end
of the sheet to the upright of the banister. The man then lowered himself
down as far as he could before dropping. At that point, he disappeared from
sight of the camera. The ligature would not have been apparent on a cursory
glance at the screen.
Twelve minutes later, the tape showed a male officer coming in through the
downstairs door underneath the stairs. The officer saw the man hanging and
immediately went to support the body, before cutting him down. He then went
to the door before returning to the body.
This officer was off work for an extended period following the man’s death. I
understand that he was extremely upset. Given that his initial reaction was
caught on film and that other staff who arrived within seconds have been able
to provide detailed accounts of what happened next, Miss McMurray judged
that she could conclude her investigation without interviewing him.
A female officer said she had been over to Bunting unit to collect some
paperwork and was on her way back to the office. She heard her colleague
call her name in a panicky sort of way. She looked round but could not see
him. She guessed where the shout had come from, however, and went to the
stairwell. She said another female officer had just come over for her break
and followed her, a couple of seconds behind.
25
The female officer said that, on entering the stairwell, she saw the man on the
floor and the male officer bending over him. She assumed from his position
that the man had fallen down the stairs as he was in a heap in the corner.
The male officer told her that his radio batteries were dead, so she used her
radio while he checked the man’s vital signs. She said she called a Code 1
which was a healthcare code for the most serious type of incident. It meant
that someone was unconscious and/or was not breathing.
The female officer explained that staff generally took the radio of the person
from whom they were taking over. That person would tell them if they had
changed the batteries within the last hour or whatever. She said that the
radios gave out a couple of beeps when the battery went dead. It was still
possible to hear what was going on, but you could no longer send messages.
The female officer then checked the man’s vital signs herself. She saw the
SASH (suicide prevention) knife and a piece of sheet on the floor. She then
saw the ligature. As soon as she realised the man had hanged himself as
opposed to having fallen down the stairs, she and the male officer moved him
into a better position for CPR to be administered (she had not wanted to move
him immediately for fear of causing further damage). The male officer had
already removed the ligature from around the man’s neck. He gave mouth to
mouth whilst the female officer administered chest compressions.
The second female officer said she and the first female officer had just left the
office to go for a cigarette and were explaining to a new colleague where they
were going. They were therefore in the doorway. The male officer had called
out the female’s officer’s first name and she had gone in the direction from
which he had shouted. The second female officer followed a couple of
seconds behind.
She said that, when she arrived, the man was on the floor with the male
officer standing beside him. He said his battery was dead, so her female
colleague called First Response on her radio. The second female officer said
she tapped her on the shoulder to tell her to call a Code 1 also. This would
indicate to healthcare staff to bring everything (1 was the most serious, 2
meant bleeding and 3 was for fainting or similar).
The second female officer said she and the male officer got on the floor near
the man’s head. She said his arms were above his head because of the way
he had been cut down. The first female officer was on his right hand side.
The second female officer said she felt for a pulse, but could not feel anything.
She asked her female colleague to double check in case she had been feeling
in the wrong place. Her colleague could not find a pulse either.
They then moved the man’s body to give them more room to carry out CPR.
At that point, a third female officer arrived and took over from the male officer
on mouth to mouth. The first female officer was giving chest compressions.
The third female officer asked the male officer to step aside which he did.
The second female officer confirmed that the male officer had already
26
removed the ligature from around the man’s neck and that the SASH knife
was lying by his side.
The third female officer to arrive was First Response for Avocet and Crane
units. She said she heard over the radio that First Response was required in
Crane. It was a Code 1, which meant that the person was unconscious or not
breathing. She said she thought she probably had to go through about six
doors to reach the Crane stairwell. The distance was about 100 feet. She
thought it had probably taken no more than a couple of minutes for her to get
there.
When she arrived, a female officer was holding the door open. She was
extremely pale and the newly arrived officer feared the worst. The male
officer was checking on the man’s breathing whilst the first female officer to
have arrived was administering chest compressions. The First Response
officer said she just took over. The male officer told her he could not detect a
pulse or any breathing, so she checked for herself. She also checked that the
man’s mouth was clear, and noticed that his jaw was quite tight. She did not
get her mask out but just started giving mouth to mouth straightaway.
Someone subsequently offered her a mask but she continued as she was.
The officer said the signs were not good – the man’s eyes were staring and
bloodshot, as well as his jaw tightening.
The officer, a first aid trainer, explained that the correct procedure was to give
fifteen chest compressions and then two breaths. She said the first female
officer to have arrived had the procedure exactly right. The First Response
officer extended the man’s airway and gave some good breaths.
A fourth female officer was working on Dove unit. She was not First
Response for Crane, but was aware that they were short-staffed and that
there had been an incident with an aggressive detainee the evening before.
She therefore responded to the First Response call because she thought an
officer might be in trouble.
When she arrived at the lower stairwell, she saw the man on the floor. Two
female officers were administering CPR. The Dove unit officer had looked up
and seen a green and white length of sheet hanging from the banister. It was
only then that she realised what had happened. She offered to take over with
the CPR but both officers declined. She therefore went to hold the door back.
Other officers upstairs were making sure that no-one came down. She said it
felt like a lifetime whilst they waited for healthcare assistance, but in reality it
was probably a few minutes.
A nurse said she had been working in reception with an agency colleague
when she heard a Code 1 call on the radio. This indicated a medical
emergency and that the victim/patient was unconscious and possibly not
breathing. No further details were given out, so she did not know the precise
nature of the emergency until she arrived at the Crane stairwell.
27
The nurse thought it took a minimum of three minutes to get from reception to
the scene. She did not know how long it took, but it seemed a long time. She
explained that there were between 10 and 12 doors and that she had to
unlock and lock each one (the other nurse did not carry keys so they had to
stay together). Some of the doors were difficult to open and different keys
were required for different doors. In addition, she was initially carrying the
emergency bag, and this had to be put down and picked up at each door.
She had taken the emergency bag from reception. This contained general
medical equipment such as bandages, an airway, a BP cuff etc.
As they arrived at the gates, they had been met by the duty manager who told
them that someone had hanged himself. When they got there, they found a
man on the floor between the bottom step and the door. The nurse could not
recall whether staff were trying to resuscitate the man when she arrived. She
had been told subsequently that the first man to discover the apparent death
had attempted resuscitation. The man was flat out on his back and there was
enough room to enable them to work effectively.
The first female officer to arrive said that, as soon as she was relieved from
administering chest compressions, she went to check that the man’s son was
unharmed. He was still asleep. She had subsequently checked on him once
more.
The nurse had checked the man’s vital signs and found no sign of life. She
administered chest compressions and asked the duty manager for an
ambulance. She noted that, wherever CPR was necessary, it would be
appropriate to call an ambulance. She then commenced CPR. There had
been no ambu-bag with the emergency bag (the ambu-bag was normally
attached to the outside of the emergency bag, as it was too cumbersome to
go inside. It could become detached when the bag was picked up in a hurry.)
She also needed a defibrillator. (Neither oxygen nor a defibrillator was kept in
Detainee Reception, so it had not been possible to bring these items with
her.) She had physically administered mouth to nose (mouth to mouth was
not possible) while they waited for staff to bring it.
The agency nurse could not go for the defibrillator as she had no keys. The
First Response officer went, therefore, as she knew what she was looking for.
The fourth female officer to have arrived took her place in administering CPR.
The First Response took the male officer with her just to get him away and for
help with opening and closing doors quickly. She thought they had taken
about five minutes. The officer explained that there were no healthcare staff
in healthcare to bring the equipment. This was why someone had to go and
fetch it (the Crane stairwell was in the middle between Detainee Reception
and healthcare – the two nurses had not therefore been able to collect what
they needed on the way.) The male officer had picked up a second
emergency bag just in case it was needed.
The First Response officer then took over mouth to mouth from hr colleague,
as she looked as though she was not coping well emotionally. They did not
28
disrupt the procedure. She said the agency nurse had asked a couple of
times if they wanted any help but both had declined. They were anxious to
avoid a gap in the CPR.
The agency nurse said she and the nurse had tried to put in an airway, but
were unsuccessful as the man was biting his tongue. They then found that
they needed the oxygen, so the agency nurse went with an officer to fetch it
from the healthcare centre. Progress was slowed by the number of doors and
the need for the two of them to lock and unlock each time, rather than one
person unlocking and the other following behind to lock. She thought they
might have taken 4/5/6 minutes to bring the oxygen back to the stairwell. The
agency nurse said she was very frustrated at all the rushing backwards and
forwards to get equipment.
The nurse said that officers applied the ambu-bag as soon as it arrived. She
was not sure who did what when – staff were constantly changing over, due to
the tiring nature of resuscitation – but she and the agency nurse had carried
out the chest compressions whilst two members of GSL staff had operated
the ambu-bag. The nurse was happy with their technique.
She thought that it took about 20-25 minutes for the paramedics to arrive.
This was broadly in line with the time it had taken on other occasions. She
noted both the distance they had to come and the delays inherent in passing
through gates etc. She had continued to help with the resuscitation attempt
after the arrival of the paramedics.
The man’s medical record says:
“Paramedics applied ECG monitor to [the man]; monitor: ASYSTOLE;
attempted cannulation by paramedics in L arm and neck:
UNSUCCESSFUL. Intubated by emergency personnel; adrenaline
administered by above personnel on two occasions, via endotracheal
tube.”
The man was taken to hospital, but pronounced dead on arrival at 2:05 am.
Two notes were found in the man’s room (one of them was in the bin). One
note was in two parts. The first part said:
“[Son’s name]
I am really sorry. I don’t you come to Angola to suffer.
To: This centre crew
Is not fault for anybody just my decision.
Sorry
[His first name]
29
14.09.05”
The second part was headed “Declaration” and said:
“[The man’s first name], 35 years old from Angola. I am writing this
declaration to UK Immigration.
I am the person the responsible to put through my family in this
situation.
I put a lot of pressure in my wife when she live with me to agree for
everything that I’ve said here in the UK.
Also I tried to kill, because she don’t agree with me in all situation and
immigration and everything.
I kill my self, because I don’t have life for live any more.
My son [name] stay here in UK to continue his studying. When he
grow up, he [illegible] your decision.
I really sorry because I can’t return to Angola.
[The man’s first name]
14.09.05”
The note found in the bin was also headed “Declaration” and was virtually
identical to the other note.
7. After the death
After the ambulance had left, staff were assembled in the library. Some
members of staff in other parts of the centre were Care Team members and
were made available to help those involved straightaway. Two or three other
members of the Care Team were also brought in, and additional staff were
called in to replace those who had been most closely involved in the attempt
to resuscitate the man.
The centre chaplain and an IMB member both arrived at the centre at 1:50
am. The contract monitor arrived just after 2:00 am. Staff were given a hot
debrief at 2:00 am.
The chaplain told Miss McMurray he asked how staff knew the man’s son was
asleep and they told him they had looked in and had seen him breathing. As
time went by, however, his anxiety about the boy increased. He was
concerned that there might have been some form of collusion between father
and son and that the boy might in fact be unconscious. He thought staff
should be taking account of the family aspect of the case and the possibility
that a family suicide had been intended. He raised these concerns with a
30
senior manager who, while agreeing that this was an issue, was reluctant to
take any action until a senior police officer gave the go-ahead.
During all this time, the man’s son was apparently still ‘asleep’, but no-one
was willing to make a decision to wake him. There was uncertainty about how
to proceed. One manager thought the boy should be told as soon as
possible, in case he awoke and found his father’s bed empty. Another wanted
to wait to give him the news until they had moved on operationally.
The chaplain said that, even after the police arrived, there did not appear to
be any urgency to establish the boy’s well-being or how the news should be
disclosed to him. He said he had spoken to the police about his concern
about the boy’s health, but they wanted to wait for their Detective Chief
Inspector to arrive – hence there was a further hiatus while they waited for
him. There was also uncertainty over who should tell the man’s son. No-one
was willing or thought they had the authority to do it. In the event, the
chaplain said he would tell the boy.
The chaplain and a Detective Sergeant had gone to wake the boy at about
4:50 am. They found him asleep in his clothes (the chaplain surmised that
this was perhaps because he knew he was leaving early the next morning).
He said the boy was immediately awake and alert. His intuition was that the
boy already knew something had happened to his father.
He said he did not tell the boy on the spot what had happened. He simply
asked him to go with him to the healthcare centre so that he could speak to
him. The chaplain noted the number of doors that had to be unlocked and re-
locked. He said officer presence was kept to a minimum, but speculated even
so on what the man’s son must have been thinking.
The boy was cared for in healthcare for the remainder of the day before Social
Services arranged local foster care for him.
The chaplain contacted the Leeds vicar to inform him of the man’s death. The
chaplain said that when he explained who he was, the vicar’s first question
was to ask if he was phoning about the Angolan man. His second was
whether the man had hung himself. The vicar and another family friend
attended the centre later during the day.
The man’s sonhas now been placed in foster care in Leeds.
The chaplain said that the duty manager had been absolutely clear that he
wanted everyone to be told at the same time about the man’s death.
Operational instructions covered the simultaneous debriefing/briefing of staff
going off shift and coming on respectively, but they had to decide how best to
communicate the news to the other detainees. There was clearly a need to
do this in a controlled way so that they did not cause tension. They therefore
agreed that all detainees throughout the centre should be given a letter setting
out what had happened.
31
GSL brought in ICAS to provide counselling for staff. The first six on scene
were told that they must go to see the counsellor, even if it was only to say
they did not want counselling. One officer said she went to let the counsellor
know she did not require counselling and spent some considerable time there.
Another member of staff said she had not realised she had any symptoms of
stress until she spoke to the counsellor. A notice was issued to all staff to
inform them of the man’s death and offering the opportunity to speak either to
the chaplain or the counsellor. Nearly all the staff interviewed said they felt
very well supported after the man’s death. Immigration Service staff had,
naturally, also been very shocked by the death. They too reported that they
were well supported afterwards. This is to be commended.
8. Post mortem report
A post mortem was carried out on 15 September. It found nothing unusual
and concluded that the cause of death was hanging. A toxicology report
noted “a negative screen” apart from minimal amounts of Mirtazapine.
9. The man’s family
The man’s wife returned to Angola in 2004. The man said he had lost contact
with her and did not know where she and his other son were. Shortly after the
man’s death, someone who said they were a friend of the family phoned the
centre to say that the man’s wife was in Portugal. He gave a mobile phone
number for her.
There was some delay before any attempt to contact the man’s wife was
made. Indeed, no-one seemed sure about whose responsibility it was to do
so. The Family Team leader was asked to do it, but did not consider it
appropriate for her to do so (I agree). Eventually, an Immigration Service
Assistant Director in Leeds took responsibility for contacting the man’s wife,
as “someone had to do it.” I understand that he left a message on the mobile
phone but, at the time of writing, nothing has been heard from her.
The man’s next of kin in this country is his son. (He says his father’s wife is
not his natural mother.) My normal practice would be to appoint a family
liaison officer to explain to the next of kin my role and to engage them as far
as they wish to be engaged in my investigation. The Investigator did not
consider it appropriate to contact the man’s son directly, however, and no-one
from this office has spoken to him (although the Investigator advised the boy’s
solicitor that she would be happy to meet the man’s son if he wanted to do
so).
The Investigator has dealt instead with the boy’s solicitor. The solicitor
suggested that the issues my investigation needed to deal with were:
• “The lack of availability of competent publicly funded immigration
solicitors to assist [the man] with his immigration case.
• The apparent failure to notify [the man] of his immigration appeal
decision.
32
• The failure to deal adequately or at all with queries from [the
man] and [the Leeds vicar] relating to [the man’s] immigration
appeal.
• The failure to deal adequately or at all with the fresh evidence
giving rise to a fresh claim for asylum for [the man] in relation to
his wife’s arrest and detention on her return to Angola.
• The ‘dawn raid’, albeit that this may be regarded by the police
and immigration as ‘routine’ this practice as you will appreciate
has been described by the Commission for Children in Scotland
as ‘terrorising’ families of asylum seekers.
• [The man’s] transportation from Leeds to Yarl’s Wood.
• The screening of [the man] for medical issues and risk of self
harm at Yarl’s Wood.
• The supervision of [the man] during his period of custody at
Yarl’s Wood.”
(The solicitor also asked Miss McMurray to investigate the non-return of two
SIM cards that had apparently been removed from the man’s mobile phones
at Yarl’s Wood. The cards could not be found, however, and there was no
evidence that staff had removed them – it was apparently not usual practice to
do so. Miss McMurray suggested the solicitor pursue the matter directly with
the centre manager.)
I have covered each of these points in my investigation, but I do not think that
Government policy on the question of publicly funded legal advisors for
asylum applicants falls within my remit. I am, however, happy to record the
solicitor’s concern on this matter. This report will of course be considered
widely within the Immigration Service and I draw the solicitor’s comments to
their attention.
10. Examination of the issues
Handling of the man’s asylum application
The man arrived in this country in October 2001. It was almost three years
before there was any progress on his asylum application. No reason for the
delay is apparent from the files. I assume it was due simply to the large
backlog of work in the Immigration Service. In the interim, the man and his
family had put down roots and settled in this country. The rejection of his
asylum application must have been an extremely heavy and traumatic blow.
Thereafter, the man and his son were allowed to remain in the country for
almost a year before the unexpected ‘pastoral’ visit from the Immigration
Service on 13 September 2005. Such treatment may not be unusual but it
does not reflect well upon the Immigration Service. Indeed, in its impact upon
children in particular, a long period of inaction followed by the robust exercise
of state power, is frankly cruel and lacking in humanity. While it is beyond my
remit specifically to address the point, I hope the Immigration Service is doing
all it can to reduce delays in the consideration of asylum claims.
33
The man alleged that he had not received the adjudicator’s determination of
his appeal despite having chased it up. The Immigration Officer who arrested
him said he checked on the file and saw that the letter had been sent on 23
November 2004. The indications from The Court Service are that the
documents were correctly sent out, although there is nothing to show
conclusively that a copy was sent at the man’s request in December 2004.
An Executive Officer in the Immigration Service has suggested that, in her
experience, it was unlikely that they would have been. However, policy is to
tell customers the result of their appeals if they phone, and the man’s details
had been properly updated on the system when he phoned on 13 December.
On balance, I conclude that the man was properly notified of the decision.
Whether he was able to understand it or its implications is, however, a
different matter.
The procedures followed by The Court Service in promulgating asylum appeal
decisions appear akin to those followed by other courts (although it is not
clear whether the clerk who signs the notice of promulgation physically posts
the documents himself). This system does not allow for letters that simply go
astray. Given the importance and implications of asylum decisions, it seems
to me that a more fool-proof method of proving service – such as the Royal
Mail’s “signed-for” service – should be sought.
I am also concerned that the decision itself is a lengthy document that may
not be very accessible to those whose command of English is limited. Where
an appellant is not legally represented and relies on the services of an
interpreter during the proceedings, consideration should perhaps be given to
providing a copy of the decision in the appellant’s own language.
I recommend that a copy of this report is forwarded to The Court Service
so that it can consider further both a more fool-proof method of proving
service of decisions and the feasibility of providing decision letters in
the appellant’s own language.
The arrest
I am also very concerned by the manner of the man’s removal, although again
the circumstances are by no means unique. The shock of waking from a
deep sleep to find two men in your bedroom and six other strangers in your
house must have been immense. The effect this shock might have had on a
13 year old boy or someone suffering from depression can only be guessed
at. I understand that it is ‘normal’ for eight people to carry out an arrest such
as that of this man. I accept that arrests have to take place very early in the
morning to ensure all personnel are at home. I also accept that, despite the
‘pastoral’ visit, it is possible that arresting officers might be unpleasantly
surprised on finding additional people at home or encountering hostility on the
day. And it goes without saying that Immigration Service must have adequate
protection as they carry out their lawful work. But if arrests are to be
conducted as humanely as possible (in circumstances that are always going
to be traumatic), the approach taken must be proportionate. Each situation
must be carefully risk assessed and the approach tailored appropriately.
34
Given the report of the pastoral visit, I am puzzled that it should have been felt
necessary to deploy a total of eight people to arrest the man and his 13 year
old son.
I recommend that the Immigration Service reviews how it conducts risk
assessments to ensure that its approach to each arrest is proportionate.
I have examined the Leeds vicar’s statement that the man told him that
Immigration staff would not listen and that he had been injured when he was
pushed. From the CIO’s account, I think it quite likely that, after a point, the
Immigration Service staff did cease to listen. Certainly, it is likely that the man
would consider they had not listened. However, I cannot be overly critical on
this point. The Immigration Service staff report that they explained the
situation fully to the man, but then moved swiftly on to avoid letting the
situation get out of hand. I do not see what choice they had.
As for the allegation that the man was injured when he was pushed, I have
found no evidence to support it.
I have also considered the speed with which the man and his son were to be
removed from the country. The Immigration Service has advised that this is
normal practice (though there is apparently no written policy on effecting
removals). A Chief Immigration Officer from the Leeds Family Team
explained:
“We would not give notice of the actual removal directions until the
family were placed in detention. Experience has shown that if families
were given notice prior to detention – then there is a high risk of them
absconding. The decision to detain a family to effect removal is not
lightly taken. If we can avoid detention then we will do so and we
would set removal directions and advise the family that they should
attend the airport for removal themselves. They would be given
adequate notice of RDs (would probably be a couple of weeks) in order
to allow them to make arrangements. This is clearly more cost
effective and preserves a level of dignity. Unfortunately, the very fact
that someone remains in the UK after they have exhausted all appeal
rights indicates that they are unwilling to comply with removal
themselves – hence the decision to detain. They would be advised of
the removal directions when they had been detained. We always seek
to keep detention to a minimum and hence notice of RDs can vary
depending when the RDs have been scheduled in relation to the flight.
For operational reasons we sometimes detain a few days before the
flight and this may explain why notice varies.”
I accept that the Immigration Service’s approach is driven by experience and
that it is likely that some people, given notice of their impending removal, will
disappear. However, I dislike the blanket approach and the assumption that
everyone would react in the same way. The man had consistently complied
with the reporting conditions imposed on him, even after (as far as the
Immigration Service was concerned) he knew he had exhausted all his rights.
35
They had no reason to suppose he would not comply with any instruction to
leave the country.
I recommend that the Immigration Service reviews its policy on the
execution of removal directions and issues appropriate guidance.
Risk indicators
I have considered whether there was any particular significance in the man
wanting to take his evening medication with his morning medication on 14
September. Immigration staff, who inevitably have scrutinised the whole
arrest very carefully to ascertain whether they might have missed anything,
assured Miss McMurray that there was nothing about the man’s manner when
asking for the medication to arouse any suspicions. They concluded simply
that he was confused having been awoken from a deep sleep.
I have also considered the significance of the man taking a washing line with
him. It is hard to see what purpose he might have intended it for. Should
either escort or reception staff have read anything sinister into this? I do not
believe so. In the first place, detainees not uncommonly bring with them
unusual items of property. In the second, there was nothing to suggest that
the man might harm himself. Lastly, he did not argue or seek to retain the
rope when it was taken from it. Staff said he was quite relaxed about letting it
go.
On balance, therefore I do not consider that any obvious risk indicators were
missed.
Neither the IS91 nor the IS91RA forms indicated that the man presented a
risk of suicide or self-harm (although both mentioned his depression). In light
of everything I have learned about the man’s demeanour and behaviour
during both the ‘pastoral visit’ and the arrest, I do not consider this was an
unreasonable assessment. However, I am concerned that not all the risk
indicators are marked one way or the other. There is nothing to show
therefore whether each of them has been considered. Whilst I understand
that anyone would be reluctant actually to state that there was “no risk”, I
consider best practice would be to enter an assessment alongside each factor
(this would show, not that there was or was not any risk, but that there was or
was not an indication of such risk).
I recommend that Immigration Officers be instructed to annotate each of
the factors on the risk assessment sections of the IS91 and IS91RA
forms.
Screening
The nurse who carried out the healthcare screening interview with the man
said she saw him and his son together, as it is unlawful for them to interview a
minor without a responsible adult present. She said that this could sometimes
inhibit the sorts of questions they could ask detainees, as it was not
36
appropriate to ask a parent in front of its child if he/she had self-harmed or
was thinking of suicide, or even about more general anxieties about leaving
the country. Healthcare staff might be the first people to whom new detainees
feel they can open up to. Everybody else is likely to be perceived as
somehow hostile to the detainee. It is therefore vital that the healthcare
interview is carried out in optimum conditions, where the detainee feels able
to confide in staff. In this case, I see no reason why the man and his son
could not be seen together and then the man by himself.
I recommend that all adult detainees are screened on their own by
healthcare staff.
I also note that it is not the practice of healthcare staff at Yarl’s Wood to
address the question of suicide ideation directly. It was suggested that this
was for fear of putting the thought into detainees’ minds. Received wisdom
on this matter is that asking the question will not make someone more likely to
self-harm if they were not previously considering suicide, and that it is most
effective to ask specific questions.
I recommend that GSL reviews with Veritas (the healthcare provider at
Yarl's Wood) the approach taken by healthcare staff to assessing
suicide ideation.
I also note that the screening form attached to the man’s medical record does
not refer specifically to suicide or self harm. It is important both that there is a
prompt to staff to assess detainees for risk of self-harm and also that there is
a record of that assessment.
I recommend that a screening form that requires healthcare staff
specifically to address issues of mental health, self-harm etc be used for
all new receptions.
Nursing staff said that the healthcare screening carried out in relation to those
whose stay would be 24 hours or less was often shorter than that for longer
term detainees. This is apparently because less information - for example,
GP name and address - needs to be obtained. It is important, however, that
screening for risk of self-harm is at least equally rigorous as for other
detainees. Imminent removal may be a trigger and this may be exacerbated
by the shock of being arrested in the early hours and not being given the
opportunity to prepare for departure.
I recommend that healthcare staff be reminded to take special care in
assessing newly arrested, short term stayers for risk of self-harm.
Issue of medication
According to the man’s medical record, he was not allowed to go to
healthcare to collect his medication because he had missed his allotted time.
This tallies an officer’s recollection of her conversation with the nurse. When
asked about this, however, the nurse said she made the decision on the
37
grounds that the medicines contra-indicated and there was some doubt about
what the man was actually taking. She therefore wanted him to see a doctor
first. If this was the case, it was a sensible decision. However, in light of the
written record and the officer’s recollection of the conversation, I am inclined
to believe that the fact the man had missed his allotted time was a factor. Any
request by a detainee to collect medication should be treated on its medical
merits and not purely on the basis that he should have collected it at the
proper time.
I recommend that nursing staff be reminded individually to consider any
requests by detainees for medication and, where there are medical
grounds, allow deviations from established routine.
I also recommend that the precise reasons for any decisions taken be
recorded in the medical record.
In this instance, Ms Emma Bradley MSt (Cantab) BSc RGN advised me that
the man not taking his evening medication would not have had any
repercussions for his mental health in the short timespan that obtained.
Radios
I note that the male officer who discovered the man’s death was not able to
transmit on his radio because the batteries were dead. In other
circumstances, this might have caused critical loss of time before help arrived
(in this case, he was able to call for assistance from staff who were a matter
of feet away). I understand that the radios bleep when the battery runs out.
I recommend that GSL reminds its staff to change the radio batteries as
soon as they hear the bleep.
Staff in attendance
I note that one of the staff who responded to the First Response call was not
designated to attend, but did so thinking a colleague might be in difficulty. I
understand the intention, but it is important that only those staff designated to
attend any given response call do so. Otherwise, there is a danger of
additional people getting in the way and leaving other parts of the
establishment under-staffed. (This is not intended to undermine the officer’s
contribution on the evening.) Given the potential for unrest after a death in
custody, this is to be avoided.
I recommend that GSL reminds staff that the correct protocol for
responding to incidents must be observed at all times.
Keys
The agency nurse told Miss McMurray that she did not carry keys on the night
and in fact had never been issued with any. This was because she came
from an agency, rather than being employed by either GSL or Veritas. She
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said that not carrying keys could make life very difficult – especially at night.
She noted that there could be particular problems if two detainees needed
medical attention at the same time.
On the night of the man’s death, the speed with which the nurses were able to
respond to the Code 1 was impeded by two factors. First, the number of
doors through which they had to pass, and second by the fact that the same
person had both to unlock and then lock each door, rather than racing ahead
and leaving her colleague to lock up behind her. The same situation arose
when the agency nurse went to fetch the oxygen. Given the length of time the
man had been hanging before he was discovered, I do not consider this delay
mattered on the night. In other circumstances, however, the delay could be
fatal.
I recommend that all healthcare staff working in the centre be key-
trained and issued with keys.
Accessibility of equipment
I was struck by the amount of to-ing and fro-ing there was to collect what
might have been life saving equipment. The agency nurse told Miss
McMurray that she found it very frustrating. I also note that the ambu-bag,
which is normally attached to the emergency bag, became detached.
Because the bag was brought from Detainee Reception, it was not easy to
retrieve.
I recommend that GSL considers placing emergency medical bags on
each unit.
I also recommend that they review the benefits and costs of providing
additional defibrillators and oxygen bottles around the centre.
Summoning paramedics
A Code 1 was called by staff. This meant that someone was unconscious and
possibly not breathing. Nevertheless, no ambulance was called until the
nurse had arrived and carried out an initial assessment. Inevitably, this was
some minutes after the man’s apparent death was first discovered. The delay
might in other circumstances have proved costly. I understand that only a
member of healthcare staff can request that an ambulance be called. While I
appreciate that detainees sometimes feign injury or illness, I do not consider
risks should be taken where someone is apparently unconscious.
I recommend that, wherever a Code 1 is called, paramedics be
summoned immediately.
Contingency plans for families
In describing to Miss McMurray the decisions and actions taken in relation to
the man’s son following his father’s death, the chaplain was critical that there
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was no guidance to follow and no specialist resource on whom to call. He
said managers and staff were unsure what to do and who should do it. This
meant both that the man’s son was potentially not as well served as he might
have been and that staff were put through additional stress. The chaplain
also pointed out that it was fortunate that the boy spoke English and that he
and the chaplain had religion in common (both belonged to the Anglican
Church). The chaplain said it might have been very different if the boy had
been a Muslim or a non-English Ethiopian child of 10. Finally, he said he was
very conscious that the man’s son had no advocate on hand to care for his
rights and needs. The Social Worker had not been able to attend at the
centre until late afternoon.
I recommend that all centres holding families review their contingency
plans to ensure they deal specifically with actions to be taken with
regard to family members following a death.
I also recommend that centres holding children arrange with Social
Services for a child-care specialist to be on-call in case of emergencies.
The chaplain was also critical that it was some time before the man’s son was
told about his own immigration status following his father’s death. For many
hours after he heard the news, he must have assumed he was to return to
Angola alone. An Immigration Service manager readily agreed to talk to the
boy, but no-one thought about this for some significant time.
I recommend that the Immigration Service’s Operating Standards for
Immigration Removal Centres be amended to ensure the family of the
deceased are promptly informed about what will happen to them. The
standard should also give clear guidance on who pays for the funeral.
Notifying next of kin
The delay in locating the man’s wife could not be helped – indeed it is by no
means certain that the information that she was in Portugal was in fact
correct. I am concerned, however, about the apparent confusion over whose
responsibility it was to inform her.
It is clearly not appropriate for Immigration Service staff involved in the
detainee’s case work or arrest to convey the news, as they are liable to be
subjected to considerable hostility (for being ‘responsible’ in the first place for
the detainee’s detention) and will not be able to tell the family what they need
to know.
The Detention Services Order on Deaths in Custody states that either the
senior immigration official at the centre or the on-call senior manager is
responsible for contacting the next of kin. (Since the on site senior
immigration official is now the contract monitor (a post currently graded at
HEO), I have said in a previous report that I do not consider this is
appropriate.) Given the clarity of this instruction, I am not sure why there was
so much confusion over who should contact the man’s wife.
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It is clear to me that notification must come from someone sufficiently senior
or appropriately trained/experienced at the removal centre, as the family will
almost certainly want to know details of the death and events leading to it and
will also want to make arrangements for visiting the centre.
I recommend that, regardless of the length of stay, the next of kin
should be informed of a death by a senior manager at the removal
centre or someone else at the centre suitably experienced in conveying
bad news.
11. Conclusions
The circumstances surrounding the death of this man are especially sad.
However, I am satisfied that everyone who came into contact with the man on
14 September acted professionally. I have found no indication that staff
overlooked any signs that he might kill himself. On the contrary, given what
Miss McMurray was told about his clearly close relationship with his son, little
can have been further from their thoughts.
The man did not want to return to his own country and had been picked up
from his home in hugely stressful circumstances that morning. But in this, he
was no different from many other detainees. If he had already made up his
mind to kill himself (a possibility suggested by the ‘Declaration’ he wrote in
April), it is perhaps unlikely that he would have given staff any clue.
Following discovery of the man’s body, a number of staff worked extremely
hard to try to revive him. They could not have known at that time how long he
had been hanging, but a number have reported that it was immediately very
clear that he was beyond saving. It is enormously to their credit that staff
persevered as they did until the paramedics arrived.
There are of course ethical questions of decency and respect about whether it
is right to try to resuscitate someone who is clearly dead, but that is not a
question for this report. I have the greatest respect for those who carry out
the physically and emotionally draining demands of CPR. All those staff
involved in trying to resuscitate this man are to be commended.
Recommendations
1. I recommend that a copy of this report is forwarded to The Court
Service so that it can consider further both a more fool-proof
method of proving service of decisions and the feasibility of
providing decision letters in the appellant’s own language.
2. I recommend that the Immigration Service reviews how it
conducts risk assessments to ensure that its approach to each
arrest is proportionate.
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3. I recommend that the Immigration Service reviews its policy on
the execution of removal directions and issues appropriate
guidance.
4. I recommend that Immigration Officers be instructed to annotate
each of the factors on the risk assessment sections of the IS91
and IS91RA forms.
5. I recommend that all adult detainees are screened on their own by
healthcare staff.
6. I recommend that GSL reviews with Veritas (the healthcare
provider at Yarl's Wood) the approach taken by healthcare staff to
assessing suicide ideation.
7. I recommend that a screening form that requires healthcare staff
specifically to address issues of mental health, self-harm etc be
used for all new receptions.
8. I recommend that healthcare staff be reminded to take special
care in assessing newly arrested, short term stayers for risk of
self-harm.
9. I recommend that nursing staff be reminded individually to
consider any requests by detainees for medication and, where
there are medical grounds, allow deviations from established
routine.
10. I also recommend that the precise reasons for any decisions
taken be recorded in the medical record.
11. I recommend that GSL reminds its staff to change the radio
batteries as soon as they hear the bleep.
12. I recommend that GSL reminds staff that the correct protocol for
responding to incidents must be observed at all times.
13. I recommend that all healthcare staff working in the centre be key-
trained and issued with keys.
14. I recommend that GSL considers placing emergency medical
bags on each unit.
15. I also recommend that they review the benefits and costs of
providing additional defibrillators and oxygen bottles around the
centre.
16. I recommend that, wherever a Code 1 is called, paramedics be
summoned immediately.
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17. I recommend that all centres holding families review their
contingency plans to ensure they deal specifically with actions to
be taken with regard to family members following a death.
18. I also recommend that centres holding children arrange with
Social Services for a child-care specialist to be on-call in case of
emergencies.
19. I recommend that the Immigration Service’s Operating Standards
for Immigration Removal Centres be amended to ensure the
family of the deceased are promptly informed about what will
happen to them. The standard should also give clear guidance on
who pays for the funeral.
20. I recommend that, regardless of the length of stay, the next of kin
should be informed of a death by a senior manager at the removal
centre or someone else at the centre suitably experienced in
conveying bad news.
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