Individual at Oakington

Investigation into the circumstances surrounding the death of a former
immigration detainee at Addenbrooke’s Hospital on 14 March 2005.
A report by the Prisons and Probation Ombudsman for England and
Wales
August 2005
A man died in Addenbrooke’s Hospital, Cambridge on 14 March 2005 of an
AIDS related illness. He had presented to the Asylum Screening Unit in
Liverpool on 22 February. He was taken directly into detention and held for
two nights at Manchester Short Term Holding Facility (STHF). From there he
was transferred to Oakington immigration reception centre, where he spent
just one night, before being taken to hospital the next morning.
During the course of my investigation, one of my Deputy Ombudsmen and an
Assistant Ombudsman visited the STHF at Manchester. They were generally
impressed with the cleanliness and brightness of the unit and with the staff,
who appeared engaged and caring. They noted, however, that the unit was
claustrophobic (having no windows) and that the health care facilities were
extremely poor. The nurse’s assessment room was no more than a cupboard
– in fact it doubled as a storage area for detainees’ property. They were also
told by one of the regular nurses that insufficient hours were allocated to the
unit for the amount of work they had to do. Many of my recommendations in
this case, therefore, relate to health care screening facilities and
environmental issues.
Not unexpectedly, those staff who came into contact with the man who died
have been concerned for their own health and that of their families. Clearly,
there are many reasons for getting health care provision right and for getting it
right at the very start of the process. This is in the best interests of the
detainees themselves, of the staff and other detainees with whom they come
into contact and ultimately for the population at large. The Immigration
Service must take action urgently to set its house in order.
I am grateful to Securicor staff at Manchester for their hospitality and
openness during the investigation. I am grateful too for the assistance I
received from the Immigration and Nationality Directorate.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN August 2005
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Contents
Summary 3
1. Background 5
The man 5
The Immigration Removal Estate 5
Manchester Short Term Holding Facility 6
Oakington 7
2. Investigation 7
3. The man’s period in detention 7
4. Post Mortem report 13
5. Healthcare provision at Manchester 13
6. Examination of the issues 15
7. Conclusions 19
Recommendations 20
Annex A - Clinical review into the care afforded to the man 21
2
Summary
This is my report on the death, from natural causes, of a Cameroon national.
He died of AIDS related illnesses following a three-week stay at
Addenbrooke’s Hospital in Cambridge. He had been referred there by
Oakington Immigration Reception Centre on 26 February, having been
received by them the previous night from Manchester Short Term Holding
Facility.
In the first section, I describe what little was known about the man. He was 33
and from a large family, with four children himself. He claimed asylum on 22
February 2005, saying that he had been tortured whilst in prison in the
Cameroon.
I also describe the two facilities in which the man was held. As its name
suggests, Manchester Short Term Holding Facility is used for holding
detainees in the short term before they are removed or transferred elsewhere.
The unit is small and claustrophobic but bright and clean. Staff are caring and
engaged. Oakington deals, amongst other things, with fast track asylum
cases. It has 24 hour medical cover but no in-patient healthcare provision.
Section 2 sets out details of the investigation, including a review of the
available papers, a visit to the STHF and an interview with the nurse
responsible there for the man’s care.
Section 3 describes how the man presented at Reliance House Asylum
Screening Unit in Liverpool. He was seen by a number of staff, some of
whom recorded that he had stomach and chest problems. His health did not
give undue cause for concern, however. The man was transferred later the
same day to the STHF.
He was seen the following day by a nurse who made a detailed note of his
symptoms and referred to the on-call doctor for advice. He was given
paracetamol and throat lozenges.
The man was not transferred later that day as planned, and the same nurse
saw him the next day. Again, he referred to the doctor, who instructed the
man be given amoxil. The man was considered to be fit for travel and left the
STHF at 7:40pm on 25 February, arriving at Oakington at 1am. He was seen
by a nurse on arrival and referred to the doctor the next morning. The doctor
immediately referred him to hospital and he was admitted later that day. He
died on 14 March. I record that there was significant concern amongst GSL
staff who had come into contact with him.
The next section gives details of the post mortem. This found that the man
died of natural causes owing to AIDS related illnesses.
I then look more closely in section 5 at healthcare at Manchester. I note that
nurses are contracted to attend for just three hours per day and that this is
considered to be inadequate. Healthcare staff looked out for the possibility of
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TB but detainees were not routinely screened for it. I refer to the unhelpful
conditions at the facility and the lack of a joined up approach to healthcare
across the detention estate. Finally, I record the nurse’s comments on
occupational health provision for GSL staff.
In my assessment of the issues in section 6, I note some ambiguity on
immigration screening forms in relation to healthcare and consider the fact
that there is no healthcare provision at Reliance House, even though
detainees might spend several hours there. I am critical of both healthcare
provision (in terms of hours allocated) and facilities at Manchester STHF, and
the fact that an unwell detainee who is not moved as expected can easily be
overlooked by healthcare staff. I note concerns about the apparent poor
ventilation of the facility and lack of opportunities for exercise in the fresh air,
despite the possibility that detainees might be held there for seven days. I
criticise the timing of the man’s journey to Oakington. I also note that he was
placed in normal accommodation, albeit in a single room. Finally, I consider
the concerns of all those staff who came into contact with the man who died,
in relation to their own health and that of their families. I make
recommendation about all of these matters.
At annex A is the clinical review of this case carried out by my Deputy
Ombudsman, Ms Emma Bradley, a trained healthcare professional. Her
review contains further recommendations.
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1. Background
The man
The man who died was a 33 year old Cameroonian national. He had formerly
worked off-shore for a petrol company. He was one of 12 children and was
himself married with four children, all aged under 8 years. The only family of
which the Immigration Service had details were still in the Cameroon.
However, one man claiming to be the dead man’s brother apparently
appeared at the Coroner’s office after the man’s death, asking to see the body
and take photographs. He was allowed to do so. My office has dealt only
with a woman who told the Coroner she was acting on behalf of the family.
The man presented himself at the Asylum Screening Unit at Reliance House
on 23 February, having apparently arrived in the country, via Heathrow, the
day before. He said his entry to the country had been facilitated by an agent,
whom he met through his brother. (I understand, however, that during the
course of this inquiry, someone from the Cameroon claiming to represent the
wife of the man who died, told the Coroner’s officer that he had by this time
been in this country for 10 months.) The man said the agent had left him at
the bus station in Liverpool the night before. He had no money with him and
just one small bag and had apparently waited outside the building on the
street all night. He was French speaking and spoke no English. The man
gave as his reason for coming to the UK, “I’m running from the government, I
fear for my life.”
During a medical interview at Oakington, the man told the nurse that he had
been held in prison in the Cameroon and subjected to torture. He said he had
been given two injections in his arm and told that these would cause him to
die slowly. The man said he was held in inhuman and insanitary conditions,
beaten constantly, including on the soles of his feet, and immersed in water in
chains every night for long periods.
The Immigration Removal estate
The Immigration Act 1971 makes provision for the detention of 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.
IND’s Operational Enforcement Manual says:
“There is a presumption in favour of temporary admission or temporary
release. There must be strong grounds for believing that a person will
not comply with conditions of temporary admission or temporary
release for detention to be justified. All reasonable alternatives to
detention must be considered before detention is authorised. Once
detention has been authorised, it must be kept under close review to
ensure that it continues to be justified.”
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Those suffering from mental illness or who have been subject to torture are
“normally considered suitable for detention in only very exceptional
circumstances, whether in dedicated IS detention accommodation or
elsewhere”.
There are nine removal centres in England, and one in Scotland. There is no
centre in England further north than Lindholme Removal Centre in South
Yorkshire. However, there are almost 30 holding rooms (see below)
nationwide.
Manchester STHF
The STHF is located airside (so in a restricted area) at Manchester Airport, in
Terminal 2. At the time of the man’s stay, it was managed under contract by
Global Solutions Limited (GSL). (Group 4 Securicor (G4S) took over the
contract on 1 May.)
The facility holds people detained by the Immigration Service on arrival in the
country until they are released, removed or transferred to a longer term
immigration removal centre. It also accommodates those due to return to their
country of origin on the next available flight and other removals following
detention elsewhere. Finally, it is used as a holding area for those in transit
between different immigration facilities.
The unit is self-contained and can hold 16 detainees for up to five days
pending transfer or release, or seven days to effect removal from the country.
It takes both men and women, but not children. The unit comprises a single
corridor. There are four bedrooms, each capable of sleeping four. There is a
communal television area (where smoking is allowed), a kitchen/dining room,
two single showers and toilets. The healthcare screening/treatment room is
also on this corridor.
My investigators visited the STFH. They were impressed by the brightness of
the facility (the walls are painted an attractive yellow) and by its cleanliness.
Floors were spotless and all rooms were tidy. However, the facility has no
windows and is stuffy. This is especially pronounced in the communal TV
room, where smoking is allowed. The atmosphere was quite unpleasant.
The staff were engaged and appeared to enjoy positive, easy relationships
with the detainees. Only a television, some board games and a small amount
of reading material (donated by the staff themselves) was available by way of
occupation or entertainment.
The room in which healthcare staff worked was little more than a cupboard. In
fact, the room was also used as a storage room for detainee property, further
reducing the small amount of working space available. There was no sink.
The nurse told my investigators that, when he need to carry out tests, he had
to walk samples down the length of the corridor in order to have access to a
sink (which was for communal use). There was no phone either.
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Oakington
Situated in Cambridgeshire, the centre has a certified accommodation
capacity of 440 and an operational capacity of 360. It consists of five discrete
residential units (including a fenced-off female block), with accommodation on
two floors in each block. A family accommodation block is located outside the
secure compound.
The centre was originally intended as a reception centre holding detainees for
a maximum of 10 days, while initial fast-track decisions were made on their
cases.
Oakington has 24-hour healthcare cover (due to the fact it can receive
detainees at any time of day or night), but has no in-patient facility.
2. Investigation
The investigation into the man’s death was conducted by one of my Assistant
Ombudsmen, Miss Ali McMurray. In addition, my Deputy Ombudsman who
leads on the fatal incidents team, Ms Emma Bradley, took a close interest in
the case as part of a wider review of healthcare issues in the immigration
detention estate. She also conducted a formal clinical review of the man’s
care.
During the course of the investigation, Miss McMurray reviewed paperwork
generated by both the Immigration Service and GSL in relation to the man
who died and spoke to the centre manager at Oakington. She also obtained
further information from screening officers at Reliance House and spoke to the
Coroner’s officer. She and Ms Bradley visited the Manchester STHF and
interviewed the nurse responsible for the man’s care there. Finally, Miss
McMurray spoke and wrote to a woman who claimed to be the family’s
representative in this country, inviting her to engage in the investigative
process and submit any questions she or the family might have. (She did not
respond to the letter.)
3. The man’s period in detention
The man who died presented himself to the asylum screening unit (ASU) at
Reliance House on the morning of 23 February. He told staff he had spent
the previous night outside the building.
An Immigration Service file minute noted that the man was a walk-in applicant,
speaking French and from the Cameroon. He had a birth certificate, but no
other documents and claimed to have arrived in the country at Heathrow the
previous day. The man reported that he had chest and stomach problems,
had never claimed asylum, never been finger-printed and never applied for a
visa before.
A fast-track form recorded that he was fit and well and had no special needs.
He was described as “Country without leave”.
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A Detention Review form said:
“The subject is an illegal immigrant, who admits to have entered the
United Kingdom at Heathrow airport and has claimed that with the aid
of an alleged agent who provided a forged passport, allowing subject to
enter the United Kingdom without leave of an Immigration Officer [sic].
The subject has therefore committed an offence under 24(1)(a) and in
breach of 3(1)(a) of the 1971 I.A.
Subject does not have any close family in the United Kingdom. Subject
is in good health. Subject has been accepted for the Oakington fast
track process.”
A section for 24-hour review bears a stamp mark stating, “Meets Oakington
criteria. Further detention authorised”. It is signed by a Chief Immigration
Officer and dated 24 February.
The man was apparently screened in the presence of an interpreter. The
Screening Interview notes said under “Are you in good general health?” “No.
Chest and stomach problems.” A further section asking if the applicant had
any medical problems was marked “no”.
Another form relating to mitigating circumstances notes that the man was
single, with no dependants and with no close ties in the United Kingdom. It is
ticked to show he was in good health. “N/A” has been written under, “There
are no known or compelling compassionate circumstances.”
The screening officer provided a statement to the Immigration Service shortly
after the man’s death. This read:
“I first noticed applicant … when I first entered the front entrance of
Reliance House. He was standing outside the doors of Reliance
House, just wearing a T-shirt and trousers and was shivering. When
ASU opened, I was asked to call the first ticket up to my screen to see
what the applicant had come for and if it was to claim asylum, to get his
file created and to take his basic details. It was the applicant who I had
seen outside and he was still shivering and was also coughing loudly. I
asked applicant why he had come to ASU and he said to claim asylum.
He was still coughing and I asked applicant if he was OK and if he had
any medical problems. Applicant said that he had “chest and stomach
problems” and that he had spent the night outside the building. I
offered to get the applicant a glass of water and went and handed it to
him. Applicant had several glasses of water and was continuing to
cough away. I recorded in my notes … about what applicant had said
about his medical condition and where he had spent the night.”
Another screening officer submitted a statement that said:
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“I level one screened [the] Cameroon applicant … on 23/2/2005, as it is
over 3 weeks since that screening and having conducted numerous
interviews since I found it difficult to recall. Having now looked at the
applicant’s photograph and screening interview I can remember the
applicant complaining he had chest and stomach problems, I recorded
this down but thought no more of it as the applicant had also stated he
slept outside that night and I thought his symptoms were a result of
this.”
The screening officer told Miss McMurray that she remembered that the man
said he did not feel well and about him coughing and spluttering, but said this
was based more on her colleague’s comments than on what she actually saw.
On a scale of 1 – 10 for poorliness, she placed him at 5. She did not think he
was “really, really sick”. She described him as a bit slow – she thought at first
he was deliberately trying to confuse her, but subsequently realised this was
not the case.
My investigator spoke to a manager at the Asylum Screening Unit. He said
that there was no healthcare provision at Reliance House. Some staff were
trained first aiders, but if anybody presented with symptoms beyond what first
aiders could cope with, staff were instructed to refer to a Chief Immigration
Officer (CIO) or Higher Executive Officer (HEO). They would then decide
whether to call an ambulance.
The manager said that the decision to detain was made by the Immigration
Officer, and endorsed by either an HM Inspector of Immigration (HMI) (men or
women) or a CIO (men). Unless the prospective detainee’s condition was so
serious as to warrant calling an ambulance, the health of the applicant would
not impact on the decision to detain. If there were medical concerns,
however, the HMI or the CIO would contact the detention centre to which the
person had been allocated to alert them to these. This might sometimes
result in the centre declining to take them, due to inadequate healthcare
facilities.
The man who died was put down for the 2pm bus, but in the event did not
leave Reliance House until 6:35pm. He apparently spent most of his time
there sleeping. The escort record shows that he had no special needs. He
coughed occasionally during the journey, and arrived at Manchester STHF at
7:45pm. There seems to have been a considerable amount of movement at
the facility whilst the man was there.
The Manchester STHF reception report noted that the man spoke no English
and had no special needs. He was not medically examined. He was
allocated to a room with three other detainees and took an evening meal at
about 8:15pm.
The following day, the man took breakfast at 7:45am. He was examined at
10:45am by a nurse. He recorded:
“Asked to see by DC staff.
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No English spoken. Can’t read.
Apyrexial at 36.5°c (repeated and apyrexial)
Resps 32/min
Pulse = 100 BPM
Severe productive cough with thin mucopurulent sputum/clearing to
white and 1 X slight blood streaking noted.
No to asthma disclosed. C/o burning anterior chest pain – bilaterally
History ? 2 months coughing – sputum – blood stained. No medical
help sought. Often vomits during coughing episodes. No headache.
Will d/w G.P. and commence paracetamol and cough lozenge.
C/o torture in prison in CMR. Describes various injections and ?
plunging into water. Displayed lesions to thigh and penis 2 wart like.
Very reluctant to display and became very distressed.
Nil else disclosed.
D/w doctor. Continue with paracetamol and strepsil. Refer to
Oakington H.C.”
The nurse also recorded that the man vomited part digested food as a result
of coughing. He also noted, “Unable to assess further.”
The nurse checked on the man again at 12:30pm and noted that he was
settled with less coughing. He had had his lunch and returned to bed. Later
that day he accepted an evening meal.
The man was due to transfer to Oakington the following day, but the transfer
was cancelled. No reason is recorded.
He did not get up for breakfast on 25 February, but did accept lunch. The
nurse saw him again at 3:20pm. The medical record says:
“Temp 38.7°c, perspiring, feels hot.
Resps 32 min. P = 100 BPM. B.P = 110/70
Sputum tenacious – clear with purulent elements. No blood seen.
Copious amounts. Wheezy cough. Appetite poor. Not drinking much
according to DCO staff.
Paracetamol 1g given. Oral fluids encouraged.
Will d/w G.P. Supervisor informed.
For amoxil 250mg T.D.S and if deteriorates G.P to see. Can continue
transfer arrangements.
Commenced amoxil 250mg T.D.S as instructed.
Approx 600 mils H O taken orally.
2
Paracetamol given.
Review temp in 1 hour.
Supervisor aware.”
Later, the nurse noted that he had discussed the man with healthcare at
Oakington, who were aware of his condition. He saw the man again at
5:10pm. At this time, his temperature was 36.6°c, respiration 26/minute,
pressure was 96 BPM. The nurse noted that the man was now up and
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watching television. He was rested and “improved somewhat on earlier
today”.
Ms Bradley and Miss McMurray spoke to the nurse about the man who died
and about healthcare provision generally. Of the man who died, the nurse
said that he had been placed in a four-man room and had mixed openly with
other detainees in the facility - for example, when he had his evening meal.
The nurse noted that a couple of paracetamol had perked the man up
considerably, and at this time he was up and about.
He said he did not initially suspect TB – the man had an unusual BCG scar
high on the top of his shoulder. His attention had been drawn, however, by
the man’s reported weight loss. He said the man’s sputum was clear but not
frothy. He had been concerned and therefore consulted a doctor (the doctor
provides 24 cover for the facility), as he felt the man needed to be seen by a
GP. The doctor did not feel there was a need, however. He thought that TB
was likely and sought to contain the symptoms with paracetamol and
lozenges. He had not wanted the man to be given antibiotics. The nurse said
he had not been at all sure about this, but the paracetamol did seem to help.
He noted that he would not have expected TB to be improved by paracetamol,
but that the man had gone from pyrexial to apyrexial on just 1g of
paracetamol.
The nurse had not expected to see the man during his rounds the next day
and no-one had pointed him out – he noted he was still there from the
occupancy board. He said that the man was de-hydrated and responded well
to cold water. He had consulted the doctor once again, who considered the
man fit for transfer. The nurse thought the man needed somewhere with
better facilities. He had spoken to the nurse at Oakington and explained the
background to the case, as he wanted to ensure the man was assessed on
arrival. He felt the man had had a rough time because of his alleged torture
and abuse in his country of origin and “the unbelievable distress and suffering
this must have caused him”. He expressly told the Oakington nurse that the
man should not be placed in the general population on arrival. The nurse
noted that the man had been transferred at night, not arriving at Oakington
until after midnight. He said he understood the man had had a bit of a rough
time and queried why these moves had to take place at night.
The man who died had dinner at 5:30pm and was collected for transfer to
Oakington at 7:40pm. They arrived at Oakington at 1am the following
morning. There is nothing on the escort record to indicate that the man was
offered or took any food or drink or that they stopped for any comfort breaks.
The GSL reception report noted that the man was coughing and vomiting
upon arrival. He was seen by a nurse at 1:10am. She noted that he
complained of coughing, had been seen by medical staff at Manchester and
prescribed amoxil. She noted that no chest X-ray had been taken and that he
was apyrexial on arrival at Oakington. His temperature was 36.2°c. He was
given bronchial pastilles to ease the coughing. She noted that he was to see
the doctor that day for review.
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The man was allocated to a single room in one of the normal male
accommodation blocks.
At 9:20am the following morning, he was seen by the doctor with a French
speaking nurse present. The doctor noted that the man had been coughing
all day long for two months and that the sputum was blood stained. He also
suffered night sweats, had lost weight, had no appetite, was vomiting and
feeling weak. He had not had any problems before with breathing. The
doctor referred the man to Addenbrooke’s Hospital, noting that “TB is a
possibility and he may be HIV +”. The nurse also noted that the man might
have scabies which they had had not had an opportunity to treat.
A nurse recorded on an Allegation of Torture form the details the man had
given about his treatment in prison in the Cameroon. She noted that he had
multiple lesions over his body. She wrote down the same details on his
medical record. She also recorded that the man had become upset when
asked about possible HIV status and requested a test and that he complained
that, since the injections he was given in the Cameroon, he could no longer
read or write although there was no problem with his vision.
The man was taken to hospital at 11:55am on 26 February. A note written at
10:30pm the same evening said that he was still having tests and there was
no diagnosis as yet. He was subsequently moved to the intensive care unit.
The man was initially guarded by staff from Oakington, but granted temporary
release on 27 February. At this time, the bed watch was removed.
There is no paperwork to suggest any further contact with the man or the
hospital until, at 10:40am on 14 March, a doctor from Addenbrookes
contacted the Chief Immigration Officer at Oakington to ask for next of kin
details and any details relating to the man’s alleged torture. The doctor
advised that the man was in a very bad way and might die shortly. The Chief
Immigration Officer spoke to healthcare staff at the centre half an hour later,
having obtained the port file. During that meeting, the healthcare manager
phoned the hospital and learned that the man had died at 11am.
During my separate inquiry into the BBC programme Detention Undercover:
The Real Story, a number of staff spoke about their concerns over the man’s
death. Miss McMurray was told that those who had been deployed to escort
him to hospital or carry out the bed watch were especially concerned,
because of their prolonged contact with him. It was pointed out that it was not
just a question of their own health, but that of their families. They needed to
be able to make informed decisions about whether it was safe for them to
come into contact with others.
My investigator took this up with the centre manager. He told her that a note
was put out to staff immediately following the man’s death. This was based
on information from the hospital and advised that the man had not died of any
communicable diseases (although the post mortem results were not available
at this time, extensive tests for communicable diseases had been carried out
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on the man whilst he was still alive) and had not been isolated at the hospital.
A further note was issued once the post mortem results were known
emphasising that staff had nothing about which to be concerned. The centre
manager said the notes were supplemented by briefing.
More generally, the centre manager explained that staff were given guidance
about a wide range of communicable diseases. They were advised to treat all
detainees as though they had HIV – this enabled them to protect themselves
while avoiding breaching patient confidentiality. Staff were also supported in
obtaining occupational health care from their own GPs. In addition, the centre
has access to an occupational health adviser (OCCHIA) and to ICAS, a body
that provides counselling support. The centre also has good links with the
Communicable Diseases Directorate in Cambridge. People from the
directorate visited the centre from time to time and ran seminars on
communicable diseases and gave regular advice.
4. Post Mortem report
The post mortem was carried out the day after the man died, but no report
was submitted until 4 May. The pathologist noted that the man’s condition
had “rapidly deteriorated, requiring inotropic support and ventilation. Despite
this he developed respiratory, renal and cardiac failure of unknown cause.”
His conclusion was:
“There was no external or internal evidence of trauma and no
convincing evidence to confirm the history of torture. The cause of
death was severe intrapulmonary haemorrhage due to extensive
involvement of the lung by Kaposi’s sarcoma, due to HHV-8 infection
consequent on immunodeficiency due to HIV infection, which also
predisposed to the mycrobacterial infection present. In my opinion,
death was due to natural causes.”
Cause of death was:
I a. Intrapulmonary haemorrhage
b. Kaposi’s sarcoma
c. Immune deficiency due to retroviral disease (HIV infection)
II. Mycrobacterium avium infection.
The inquest has already taken place. Only the pathologist was called to give
evidence. The Coroner apparently enquired at length into the man’s claim
that he had been tortured, but found no evidence to support it. He determined
that death was due to natural causes and that no Immigration Service, GSL or
healthcare staff were in any way responsible for the man’s death.
5. Healthcare provision at Manchester
My Investigators learned that seven day healthcare cover is provided at
Manchester STHF by Saxonbrook. Saxonbrook is a GP clinic based in
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Crawley, which also provides healthcare services to Tinsley House. It is run
by two GPs. One of three nurses attends each day for a three-hour shift.
However, the nurse to whom my investigators spoke said it was frequently not
possible to do what needed to be done during this time. It could take up to six
hours to do the work properly.
A local GP provides 24 hour healthcare cover for the holding facility. The
nurses refer to him as necessary, though they can – and did – send detainees
to hospital via paramedics. (The nurse told the investigators that the man who
died did not warrant paramedic transfer at the time.)
The nurse said that detainees were not routinely screened for TB, but each
one was asked about TB, all BCG scars were noted and any possible
symptoms recorded. The GP and TB specialist nurse could then be informed
if necessary. Facilities militated against a comprehensive screening
assessment, however.
The nurse suggested that, ideally, all detainees should receive a
comprehensive ‘service’, similar to the well man or well woman clinics. They
should undergo a thorough health interview and assessment, during which
both TB and HIV could be properly explored and appropriate treatment
offered. Other issues, such as weight loss could be explored at the same
time, as could mental health problems. These were not dealt with at all well –
there was only a very limited reference to psychological mental health issues
(although two of the nurses who attended at the facility were mental health
trained nurses). However, referrals were made to local services – e.g. sexual
health clinics, antenatal services etc as appropriate and contact was often
made with the previous healthcare provider e.g. GP, hospital etc.
The nurse noted that the environment at the holding facility was not conducive
to medical care. The ventilation was poor, it was smoky and the air was
heavy. However, detainees were closely supervised and monitored by
detention staff, who spent much time in their company throughout the day,
recording what they ate, ensuring they ordered meals, reporting any concerns
etc. The supervisor could liaise with the GP and the nursing staff reviewed
them daily.
Detainees were not allowed medication in possession, although they could
retain Ventolin inhalers or GTN spray for example. Some minor medication,
such as E45 cream, could also be retained, so long as it was in plastic
containers. Much depended on which supervisor was on duty, however.
Medication was held by the supervisor for the detainee, who had to request it
when he wanted it. A note was made when any medication was handed out.
If staff had any concerns about a detainee after the nurse had left, they could
either call the paramedics if it was an emergency or they could refer to the
doctor who provided 24-hour cover. He would then decide how to deal with
the matter.
14
The nurse told my investigators that there was a requirement to see everyone
within 24 hours. He noted, however, that some detainees were in and out
before they could be seen.
The nurse referred to the difficulties caused by the many ‘islands’ of
healthcare services. Much of what he knew about what went on elsewhere he
had picked up through gossip. He was not specifically given information
about what the various removal centres had to offer or how they operated.
The investigators learned that, although medical records were sent with
detainees who left Manchester STHF, records did not routinely travel from
other centres with the detainees. Some went astray completely. The nurse
also suggested that a single, standardised medical record would be beneficial,
as they varied a lot.
No bespoke rooms were available if a detainee needed to be isolated for any
reason. Instead, one of the four four-man occupancy rooms was set aside for
the purpose (i.e. with its occupancy reduced to one).
The nurse thought there had not been any screening of staff following the
man’s stay at the holding facility and his subsequent death. Staff routinely
received Hepatitis B jabs, but he noted that there were very poor systems for
dealing with staff health issues and that this was a cause for concern amongst
staff. There was an occupational health advisor, but generally speaking staff
were inadequately informed about health care issues. The nurse said he felt
there appeared to be a problem surrounding this case and the lack of
information concerning his diagnosis, which seemed to have caused some
staff concerns. (He added that he did not know until interviewed by my
investigators what the cause of death had been, and assumed that other staff
did not know either.)
6. Examination of the issues
The man who died was coughing when he presented to Reliance House in
Liverpool. Some staff noted this on Immigration Service documentation, but
others recorded that he was in good health and fit and well. I assume the
latter assessment was based on the fact that he was recorded as having no
medical problems. I am not entirely clear as to what distinction is intended in
the two questions on the Interview Screening form, “Are you in good general
health?” and “Do you have a current medical condition?” but consider they are
liable to create confusion and to mislead – especially where someone is
scanning the form very quickly.
I recommend that the Interview Screening form be revised to combine
the two healthcare questions in one.
I am also concerned that there is no healthcare provision at Reliance House.
Immigration Service detention centre standards stipulate that detainees must
be seen by a healthcare professional within two hours of arrival. Given that
many people are arriving from countries where highly infectious and life-
15
threatening diseases are prevalent, I consider this to be a sensible and
appropriate standard, since it means that serious health issues should be
identified before the person comes into contact with too many other people,
be they staff or other detainees. In the case of the man who died, however,
he arrived at the ASU first thing in the morning and remained there until
18:35pm. He was therefore on site, mixing with others for some 9½ hours,
without having been seen by a healthcare professional. I understand that staff
can call for medical intervention in emergency cases, but the man did not fall
into this category – one of the screening staff said she did not consider him
“really, really ill” and not unreasonably ascribed his coughing to having spent
a February night out of doors.
I recommend that a healthcare presence be maintained at all screening
and reception centres and that the two-hour requirement is rigorously
enforced.
In the event, the man was not even seen within two hours of arriving at
Manchester STHF. Healthcare provision there is for a nurse to attend just
three hours per day. While a GP provides 24-hour cover, this is not for the
purposes of screening all new arrivals and it is clear that, despite the man’s
coughing, he was not considered to be in imminent danger. Clearly, the two-
hour requirement is rarely capable of being met at Manchester.
I am also concerned by the nurse’s assertion that insufficient time is allowed
to provide appropriate medical screening and ongoing care. Even though the
medical provider is apparently now better at paying for additional time taken,
healthcare professionals should not be required regularly to work more hours
than they are contracted for – many will have other responsibilities which short
working hours are intended to accommodate.
I recommend that healthcare provision at all short-term holding facilities
be reviewed.
I understand that the healthcare facilities also leave much to be desired. It is
one thing having to work at speed and with people who present with a variety
of problems but who speak little or no English. It is quite another to expect
healthcare professionals to carry out their work in what amounts to little more
than a cupboard, with little space and no proper facilities.
I recommend that the Immigration Service urgently reviews the
healthcare facilities at Manchester and all other short term holding
facilities.
There is no standardised medical record or health screening form in use
across the immigration estate. This does not lend itself readily to good
communication between different healthcare professionals. It also leads to
inconsistencies in type and quality of assessment carried out.
16
I recommend that consideration is given to the introduction of a
standardised, transferable medical record and standard reception
screening assessment forms.
Despite the inadequacy of healthcare provision and facilities, my Deputy
Ombudsman, herself a healthcare professional, was impressed by the caring
and diligent attitude of the nurse. He clearly worked in very difficult
conditions, but had been thorough in his dealings with the man who died,
keeping detailed notes. He also acted properly in referring the case to the
GP.
It was only through the nurse’s vigilance that he became aware that the man
had not been transferred on 24 February as planned, as he saw his name on
the occupancy list. Nobody alerted him to the fact that the man remained on
site. He could easily have been overlooked. Given the number of movements
that are cancelled or postponed for various reasons, this is a matter of some
concern, especially since the same nurse may not attend on consecutive days
and the name of a particular detainee would not mean anything unless he or
she had been specifically referred by their colleague.
I recommend that Saxonbrook work with G4S to establish a system that
ensures that detainees whose health is a cause of concern are routinely
brought forward for a further appointment (to be determined by the
healthcare professional) unless the detainee is actually transferred in
the interim.
Generally speaking, my investigators were impressed with the brightness and
cleanliness of the STHF. However, they spent time in the communal area
talking to staff and noted that the atmosphere was close and smoky. In fact,
the atmosphere throughout the facility felt stale and lacking in air. As the
nurse noted, this is not conducive to patient care. Nor is it acceptable more
generally.
I recommend that the ventilation in the STHF be improved.
I also note that the facility has no windows. Detainees (and indeed staff) are
shut away from natural light for hours on end. The facility is small and there is
not much chance of detainees being able to stretch their legs. My
investigators learned that staff occasionally accompany detainees to the
airport shop, but this is not a routine activity. A television is provided, along
with a small amount of reading material (which is donated by the staff) and
some games, but there is little to occupy detainees. This is unacceptable,
given that they might be held at the facility for seven days. The lack of
possibility of exercise in the fresh air is of special concern in relation to
detainees who are ill.
I recommend that the Immigration Service explores with G4S the
possibility for providing an opportunity for daily exercise outside the
facility.
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The man who died was collected from Manchester STHF at 7:40pm. He then
had to endure a journey of over five hours to reach Oakington almost an hour
after midnight. Some movements have to be effected either very late at night
or during the very early hours because of the need to make flights etc. In this
case, however, the movement was routine and the sole driver determining
when the man was moved was when he could be fitted in. I do not
underestimate the logistical difficulties inherent in the escorting business
(there are 8 or 9,000 movements every month), but the timing in this case
(and indeed in many others) was simply not decent. It is hard to imagine what
must have been going through the mind of a man who spoke no English and
who was clearly suffering as he travelled in darkness for hours. It can have
done little to improve his state of health.
I recommend that the Immigration Service considers with G4S how to
ensure that, wherever possible, routine movements are completed no
later than 10pm.
I note that, on arrival at Oakington, the man was seen promptly by a nurse,
(appropriately) placed in a single room and noted for review by the doctor the
next morning. In fact, the doctor saw the man at 9:20am and immediately
referred him to the hospital. I have no criticisms of Oakington staff with regard
to the man’s care (though they might have maintained contact whilst he was in
hospital). I am concerned, however (as I know some staff at the centre are),
that the man was placed in a normal accommodation block, presumably
sharing washing and toilet facilities with others. If he had had TB, a single
room would have done little to prevent the spread of infection. I appreciate,
however, that there was no alternative, given that Oakington does not have an
in-patient facility. I also appreciate that, in the event, the man did not have
any communicable diseases. This might not have been the case, however.
I recommend in my report into the BBC programme Detention
Undercover: The Real Story that separate provision be made within
Oakington for those at risk of self-harm. I recommend that, at the same
time, the Immigration Service and GSL consider how they might
effectively isolate detainees considered likely to have infectious or
contagious diseases.
Finally, I am conscious of the concern amongst staff at both Manchester and
Oakington over the man’s stay and subsequent death. My investigation has
revealed that staff at Oakington were given appropriate and timely
reassurances and that provision of occupational health was reasonably
comprehensive. It seems, however, that staff at Manchester were overlooked.
I recommend that, following a death from natural causes, staff at all
places where the detainee has been held are given early information
about the cause of death and advised of any action they should take.
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7. Conclusions
I am satisfied from my own investigation into the man’s death that Immigration
Service, GSL and healthcare staff all acted entirely properly in the level of
care they provided for him. This view is endorsed by the Coroner’s finding at
the inquest.
Nevertheless, I have discovered some worrying facts about healthcare
provision around the margins of immigration detention. There is no-one on
site at Reliance House to deal with healthcare issues beyond normal first aid
needs, and no routine screening of potential immigrants and detainees is
carried out at that stage. Those who are not taken into detention will simply
be returned to the community at large, with no account having been taken of
their state of health.
At Manchester STHF, a healthcare provider has been engaged to screen
detainees and attend to their immediate medical needs. But the facilities
there are poor and the number of hours allocated to the task may be
inadequate.
I do not believe that either of these circumstances was in any way responsible
for the death that is the subject of this report. They do, nevertheless, raise
serious, wider concerns for the individual detainee, for staff and other
detainees with whom they come into contact, and for the community at large.
Healthcare provision across the whole range of Immigration Service activity is
in need of urgent review.
I recommend that the Immigration Service reviews healthcare provision
across the entire range of its activity.
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Recommendations
1. I recommend that the Interview Screening form be revised to combine
the two healthcare questions in one.
2. I recommend that a healthcare presence be maintained at all screening
and reception centres and that the two-hour requirement is rigorously
enforced.
3. I recommend that healthcare provision at all short-term holding facilities
be reviewed.
4. I recommend that the Immigration Service urgently reviews the
healthcare facilities at Manchester and all other short term holding
facilities.
5. I recommend that consideration is given to the introduction of a
standardised, transferable medical record and standard reception
screening assessment forms.
6. I recommend that Saxonbrook work with G4S to establish a system
that ensures that detainees whose health is a cause of concern are
routinely brought forward for a further appointment (to be determined
by the healthcare professional) unless the detainee is actually
transferred in the interim.
7. I recommend that the ventilation in the STHF be improved.
8. I recommend that the Immigration Service explores with G4S the
possibility for providing an opportunity for daily exercise outside the
facility.
9. I recommend that the Immigration Service considers with G4S how to
ensure that, wherever possible, routine movements are completed no
later than 10pm.
10. I recommend in my report into the BBC programme Detention
Undercover: The Real Story, that separate provision be made within
Oakington for those at risk of self-harm. I recommend that, at the same
time, the Immigration Service and GSL consider how they might
effectively isolate detainees considered likely to have infectious or
contagious diseases.
11. I recommend that, following a death from natural causes, staff at all
places where the detainee has been held are given early information
about the cause of death and advised of any action they should take.
12. I recommend that the Immigration Service reviews healthcare provision
across the entire range of its activity.
20
Annex A
CLINICAL REVIEW OF THE CARE
AFFORDED TO THE MAN WHO DIED
Emma Bradley MSt (Cantab) BSc RGN
Deputy Ombudsman
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Clinical review into the care afforded to the man who died
Summary
1. The man arrived in the UK on 22 February 2005. He was initially seen
by immigration officers in Liverpool on 23 February, and taken later that
day to the Short Term Holding Facility at Manchester Airport. He was
then seen by healthcare and a physical and mental health review was
undertaken.
2. The man was quickly identified as requiring an increased level of
healthcare and so arrangements were made to transfer him to
Oakington. Within nine hours of his arrival, the man had been referred
to Addenbrooke’s Hospital.
3. He was admitted to Addenbrooke’s on 26 February with a chest
problem of unknown origin. The man’s condition deteriorated and he
was transferred to Intensive Care. He died on 14 March 2005 from HIV
related complications.
4. The man was cared for in a timely and sensitive manner by all
healthcare professionals. This report makes three recommendations
for improving health services in the immigration estate.
Clinical events
5. The man arrived in the UK on 22 February 2005 from Cameroon and
claimed asylum in Liverpool. He was taken into detention on 23
February and transferred from Liverpool to the Short Term Holding
Facility at Manchester Airport. On arrival, he was seen by a nurse.
6. The nurse obtained a medical history from the man, including his
mental state. He noted that the man was feeling tense or stressed.
The man went on to describe alleged torture whilst in prison in
Cameroon. He became very tearful during this discussion. The nurse
also obtained a baseline set of observations and noted the man had a
BCG scar on his right shoulder.
7. Later the same morning, the detention centre staff asked the nurse to
see the man again, due to a severe productive cough, that was causing
him to vomit and giving burning anterior chest pain. The nurse
examined the man and noted he was apyrexial. The nurse decided to
commence the man on paracetamol and cough lozenges.
8. The nurse contacted the duty medical officer, a local GP. The GP’s
practice provides 24-hour medical cover for the facility. He advised to
continue with the paracetamol and throat lozenges and refer the man to
the health centre at Oakington.
22
9. The nurse saw the man again before he went off duty. The man
appeared to have settled, had eaten some lunch and taken himself
back to bed.
10. On the afternoon of 25 February, the nurse reviewed the man again.
He had spiked at temperature of 38.7oc at this stage and was hot to
touch. The custody officers advised the nurse that the man was not
eating much and his fluid intake was limited. The nurse appropriately
gave the man 1 gram of paracetamol to reduce his temperature. He
again contacted the GP, who recommended the man commence anti-
biotic treatment. Amoxycillin 250 mgs three times daily was duly
started. Arrangements also continued to transfer him to Oakington.
11. The nurse then contacted Oakington and briefed them about the man’s
condition. The nurse saw the man at 5:10 pm and noted he was more
settled and his temperature had returned to normal.
12. The man transferred to Oakington Immigration Removal Centre,
arriving at 1:10 am on the morning of 26 February. On arrival at
Oakington, he was seen by the healthcare nurse before being located
in a single room. He was listed to see the medical officer later that
morning.
13. At 9:20 am on 26 February, a doctor saw the man with a French
speaking nurse for translation purposes. The man gave a two month
history of coughing, with blood stained sputum. The doctor
immediately referred him to Addenbrooke’s Hospital, querying TB or
HIV.
14. The man was also seen by a nurse. He alleged that he had been kept
in inhumane and insanitary conditions, had been injected on two
occasions – being told they would cause him to die slowly - beaten
constantly and immersed in water every night. An Allegation of Torture
form was completed and the man consented to disclosure of this
information to the authorities.
15. The man was taken to Addenbrooke’s Hospital. At 6 pm, healthcare
staff were advised that he was being admitted to the Medical
Assessment Unit. He was due to be moved to ward D10 when a bed
became available. However, he was later moved to Intensive Care.
He remained in intensive care until his death on 14 March 2005 at 11
am.
16. A post mortem was carried out at Addenbrooke’s Hospital at the
request of the South and West Cambridgeshire Coroner. The cause of
death was given as:
Ia. Intrapulmonary haemorhage
b. Kaposi’s sarcoma
c. Immune deficiency due to retroviral disease
23
II Mycrobacterium
17. The pathologist noted that there was no convincing evidence to confirm
the history of torture and that the death was due to natural causes.
Findings and conclusions
18. The man was treated promptly and sensitively by all healthcare
professionals. He was provided with care commensurate with that in
the wider community. His clinical condition was not compromised by
being in detention.
19. The facilities available for health screening at the Short Term Holding
Facility in Manchester are little more than a store cupboard. Whilst it is
clean and brightly painted, the room is small, airless and has no
running water.
Arrangements should be made to provide an appropriately
equipped clinical room for use by healthcare professionals.
20. Detention Centre Standards require that all admissions are seen by
healthcare staff within two hours of admission and by a General
Practitioner within 24 hours. The arrangements at Manchester only
detail nurses on duty for three hours per day. Manchester receives and
discharges detainees 24 hours a day. There are arrangements in
place for 24 hour emergency medical cover, which custody officers can
readily access.
Consideration should be given to reviewing the healthcare staffing
arrangements to provide greater on site cover.
21. There is no standardised medical record or health screening form in
use across the immigration estate. The type and quality of
assessments is variable. The use of a standardised medical record
and health screening forms would ensure that comprehensive physical
and mental health assessments are undertaken. Furthermore, it would
prevent the duplication of work each time the detainee transfers. A
recent investigation at IRC Haslar identified as good practice their
reception screening document which is translated into 22 different
languages.
Consideration should be given to the introduction of a
standardised, transferable medical record and standard reception
screening assessment forms.
22. The nurse at Manchester STHF kept contemporaneous, concise
clinical records, giving a clear picture of the care and treatment
afforded to the man who died. The nurse contacted Oakington prior to
the man’s transfer to fully brief them of the situation. On his arrival at
24
Oakington a further health assessment was carried out and the findings
clearly and concisely documented.
The nurse at Manchester STHF, the reception nurse at Oakington
and the nurse who noted the man’s allegation of torture should be
commended for their standards of record keeping.
Recommendations
1. Arrangements should be made to provide an appropriately equipped
clinical room for use by healthcare professionals.
2. Consideration should be given to reviewing the healthcare staffing
arrangements to provide greater on site cover.
3. Consideration should be given to the introduction of a standardised
transferable medical record and standard reception screening
assessment forms.
4. The nurse at Manchester STHF, the reception nurse at Oakington and
the nurse who noted the man’s allegation of torture should be
commended for their standards of record keeping.
25