Individual at Dungavel

The Death in Custody of a Detainee
Dungavel Immigration Removal Centre – 23 July 2004
Report by the Prisons and Probation Ombudsman for England
and Wales
August 2005
This is the report of an investigation into the circumstances of the death of a
Detainee at Dungavel Immigration Removal Centre in Lanarkshire on Friday
23 July 2004, he was a Vietnamese man who had arrived in the UK in March.
The man was arrested on 18 July in a London flat where he was living with his
girlfriend. The Immigration Service planned to remove him to Germany as he
first come to the attention of the authorities in that country. He spent just over
24 hours at Harmondsworth Removal Centre near Heathrow. However,
Harmondsworth had to be evacuated as a result of a major disturbance that
started on the evening of 19 July. Sixty detainees were moved to Dungavel.
The man arrived on the first coach on Wednesday 21 July. The next day, he
was served with Removal Directions by the Immigration Service and told he
was booked on a flight to Germany the following Tuesday. On Friday evening,
the man hung himself in his dormitory wash room area and was found by
another detainee at 9.50pm. Attempts by staff and paramedics to resuscitate
him failed.
I personally opened the investigation on 26 July. I returned to Dungavel the
following week with my Assistant Ombudsmen. She made a subsequent visit
to the Centre on 11 and 12 August.
I would like to extend our condolences to the family of the man and to his
partner.
I would like to thank the management and staff at Dungavel Immigration
Removal Centre for their assistance and co-operation during the course of
this investigation. I am also grateful to Strathclyde Police for providing copies
of their detailed witness statements.
Whilst I do not think that the man’s suicide could have been predicted by staff
at Dungavel I recommend that procedures are put in place to ensure medical
and unit staff are made aware of immigration decisions that may have a
significant impact on a person’s state of mind. Greater awareness of
important decisions would encourage closer observation of detainees by staff
during potentially critical periods.
I make a number of other recommendations and commend some examples of
good practice.
Stephen Shaw
Prisons and Probation Ombudsman August 2005
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Contents
Summary .................................................................
The investigation process ...........................................
Background .................................................................
The detainee
The man’s arrival in the UK and his asylum application
The time prior to his arrest
The man’s period in custody ......................................
Arrest on 18 July 2004 and Harmondsworth Removal
Centre
The man’s arrival at Dungavel Immigration Removal
Centre
Friday 23 July 2004
The discovery of his body in E2 dormitory
Issues considered during the investigation .....................
The influx of detainees arriving from Harmondsworth
Self Harm and Suicide Prevention at Dungavel
Communication issues at Dungavel
Events after the man’s death
Recommendations and Good Practice ............................
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Summary
1. The man, a Vietnamese national, died at Dungavel Removal Centre on
23 July 2004.
2. The man had entered Britain on 19 April 2004. Initially granted
temporary admission, he failed to comply with his reporting conditions
and was arrested and detained on 18 July.
3. The man was first held at Harmondsworth Removal Centre. He was
transferred to Dungavel following the major disturbance at
Harmondsworth that occurred on the night of 19 July following the
death of a detainee.
4. On arrival at Dungavel, on 21 July, he was not assessed as presenting
a special risk of suicide or self harm. The following day, he was
informed that Removal Directions had been served on him and he
would be flown to Germany the following week.
5. The report details the circumstances leading to the man being found
hanging on 23 July and the subsequent staff response, he left a letter
in Vietnamese that has been translated. On the face of it, the letter is
not a suicide note. However, the translator has suggested that the
form of the letter reflects Vietnamese custom to make a wish before
you die.
6. The report is critical of some aspects of family liaison between
Dungavel, the Immigration Service and the man’s bereaved relatives.
7. I suggest that having been arrested and detained, having experienced
the events at Harmondsworth, and having been transferred many
hundreds of miles to a Centre where nobody else spoke his first
language, the man would have been in a vulnerable state. However, I
suggest that the incident leading to his feeling potentially suicidal was
the serving of his Removal Directions.
8. The report makes six recommendations and indicates four areas of
good practice.
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Investigation Process
I opened the investigation on 26 July. When I arrived at Dungavel
Immigration Removal Centre I met with the Director and was given a full
briefing on the circumstances surrounding the man’s death regarding family
contact and actions instigated by the Centre. I was also updated in the
aftermath of his death. A notice to staff and a notice to detainees was issued
by Dungavel. These invited anyone who might have information relating to
the man’s death to make themselves known to the inquiry team. No one came
forward from these notices.
My colleague and I visited Dungavel again on 2 August. My colleague read
the man’s records and the police statements that had been taken. She made
one further visit on 11 and 12 August and spoke with staff on an informal
basis.
One of my family liaison officers contacted the man’s partner. They spoke on
the telephone and a letter was sent offering to meet with the man’s partner
and saying that an interpreter could be provided if necessary. At the time of
the draft report this meeting has not taken place. The final report may include
information that emerges from the meeting.
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Dungavel Immigration Removal Centre
Dungavel is the only removal centre in Scotland. At the time of my
investigation, it held a mixture of single adults and families. Its maximum
occupancy is 148 people. Dungavel's role is to hold those detained by the
Immigration Service as overstayers, illegal entrants or failed asylum seekers
prior to their removal from the country. It also holds a proportion of detainees
whose cases have not yet been determined, but who are considered to be at
risk of absconding or whose identities are being established.
Dungavel is operated by Premier Detention Services Ltd.
The main accommodation is a former country estate mansion house that had
been used by the Scottish Prison Service as a prison before its change of use
and refurbishment as a detention centre. There is also a separate single
storey family unit and education block and a single storey gymnasium and
leisure complex.
The last published inspection of Dungavel was in October 2002. HM Chief
Inspector of Prisons came to the view that staff were dealing positively and
conscientiously with detainees, but that they were unable to compensate for
the profound feelings of insecurity and anxiety that detention at Dungavel
involved. Only 15 per cent of the detainees surveyed at that time told the
inspection team that they felt safe. The reasons for this were attributed to
three factors. Detainees said being detained in a prison-like environment was
difficult and some detainees reported being intimidated by others. The second
factor was the length and stress of the journeys many had experienced to get
to Dungavel, often in escort vans. The third factor that led to detainees feeling
insecure was weakness in communication and case management by the
Immigration Service, and the difficulty of accessing competent legal
representation for their cases.
The inspection report said that Dungavel provided a generous provision of
both constructive and leisure activities compared with other centres.
Detainees felt the centre was fair, decent and that they were well treated by
staff.
A more recent inspection was carried out towards the end of 2004 after the
man’s death, but the report into that inspection has not yet been published.
The most relevant recommendations from the inspection in 2002 relate to
immigration casework. The first was that interpreters or ‘Language Line’
should always be used for interviews where detainees are being informed of
important decisions or of their rights. The second was that on-site immigration
staff should be able to communicate up-to-date case information directly to
detainees. The man was given his Removal Directions by an immigration
officer without the assistance of an interpreter. The man spoke only broken
English. I repeat this recommendation to the Immigration Service and
Dungavel.
There had been no deaths of any detainees at Dungavel prior to the death of
the man.
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The Detainee
The man was born in Vietnam and he was one of five children. The man said
that his father was dead and that his mother remarried ten years ago and
moved to another city. He said that he last saw his mother two years before
his arrival in the UK. The man’s sister says that both his parents are alive and
that he may have painted a different picture in order to stay in the UK. The
man had attended school in Vietnam for a short period of time.
The detainee’s arrival in the UK and his asylum
application
The man was found by officials at Dover shortly after 8am on 19 April 2004,
concealed in a road train vehicle that had arrived from Calais. The vehicle had
been selected at random for searching. The man was found in the rear trailer
with two other men and a woman. The man was detained at Dover.
At about 2pm that afternoon, a search via Eurodac identified the man as
having already been apprehended in Berlin in 2003. Under the Dublin
Regulation, the EU Member State in which a person first claims asylum is the
Member State responsible for considering the application, even if the person
subsequently travels to another Member State and makes a new asylum
claim there. Because the man had already applied for asylum in Germany, the
Secretary of State would not give substantive consideration to his asylum
claim, but sought to remove him to Germany instead.
The man was interviewed by an immigration officer at 3pm and said that he
had entered the UK because he wanted to seek freedom and added that he
wanted asylum. The man said that he had no medical conditions, criminal
convictions and had never previously been detained or arrested in the UK or
another country. Officials knew this to be untrue, but did not question the man
about this at the time.
Form IS151 ‘Notice to a person liable to removal’ was completed on 19 April.
It indicated that the man was considered to be an illegal entrant as defined in
section 33(1) of the Immigration Act 1971. It informed the man that he was
liable to be detained prior to his removal from the UK. Form IS91 was also
completed, giving authority for the man to be detained. The form states that
the man speaks Vietnamese and does not highlight any risk factors such as
suicide or self harm risk, psychiatric illness, or violent tendencies. The
reasons given for his detention on Form IS91R were that there was
insufficient reliable information to decide whether to grant him temporary
admission or release, and that he had not produced satisfactory evidence of
his identity, nationality or lawful basis to be in the UK. The part of the form that
ensures the man has had the reasons explained to him was unsigned.
A later interview at 7.45pm was more in-depth. During this interview, the man
said that he was a 24 year old single man who had last worked about four
months ago. He told the interviewer that his father had died ten years ago and
that his mother had remarried and moved elsewhere. The man said that he
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was a Buddhist. The interviewer said that, in order to qualify for asylum, the
man must demonstrate that he had a well founded fear of persecution in his
country of nationality, on account of his race, religion, nationality or
membership of a particular social group or political opinion. The man stated
that he did not qualify for any of the above but that he was in the UK for a
better life.
He went on to say he had left Vietnam in early 2004 with 12 others, using a
small boat. They arrived some three days later in China and stayed overnight
in a house before getting into a lorry which drove for five days to a train
station. The man said he did not know which country he was in at this stage,
but that he got onto a train and travelled for two more days. After this the man
claimed that he had been in various lorries that had driven for two to three
days at a time before dropping him off and another lorry picking him up. The
man claimed that he had been in the last lorry, the one that had arrived in
Dover for one day, without any food, water or toilet facilities. The man denied
ever having had his fingerprints taken before and said that he was telling the
whole truth to the interviewer. The interviewer then asked the man to explain
why the police in Berlin had his fingerprints on file dated October 2003. At this
point the man became very quiet and could not explain how this happened.
The interview ended shortly before 10pm.
A further screening interview was conducted just after 2am on 20 April 2004.
This interviewer noted that the man was very vague in his account of what
happened. The man said he had left Vietnam about five or six months
previously and that he arrived by boat into China, where he stayed for two or
three days. The man then said he travelled for various periods, but that he
never knew which country he was in until he arrived in the UK. He said all the
swapping of transport had been done in secluded places. The man said that
he had been picked up in Germany as he was walking down the street, but he
did not know at the time which country he was in and that he did not claim
asylum when there. The man told the interviewer he wanted to claim asylum
in the UK because the English were nicer and more helpful. The man said his
aunt had paid for him to get to the UK. He had no problems in Vietnam, but
wanted a better life and a better job. The interviewer noted that the man was
uncooperative with the interview and that he contradicted himself on
occasions.
The man’s file was sent to the Immigration Service's Third Country Unit on 20
April. The unit is responsible for returning asylum seekers to their original
country of claim. Chasing phone calls on 22 and 23 April indicated that the
unit were unable to take any new cases and had no bed spaces until 25 April
at the earliest.
Because of the lack of available beds a decision was made to grant the man
temporary release. This was for one week, commencing 23 April. The man
was told that he must stay at the Cliff Court Hotel in Dover and report to
Folkestone Police Station on 30 April. He was issued with Form IS96
'Notification of Temporary Admission to a person who is liable to be detained.'
On 29 April, the Dover Induction Centre received a message via the Migrant
Helpline that the man had absconded from his hotel and given no forwarding
address.
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The time prior to his arrest
On 9 June the Immigration Service was informed that the man was living at in
London. The source of the information is thought to have been the man’s
solicitors at that time.
The man’s UK asylum claim was refused on 22 June 2004 by the Third
Country Unit. He had already first claimed asylum in Germany. Under the
Third Country procedures (Dublin Regulation), the man had to return to the
country where asylum was first claimed for his case to be decided. Germany
had agreed to accept the man back.
A Third Country Unit Starring Pro-Forma was completed and forwarded to
Communications House (an Immigration Service building in London) in order
that they could locate the man and remove him to Germany. The Starring Pro-
Forma indicated that the man’s asylum had been refused on 22 June 2004
and that there was no appeal procedure.
The man was granted temporary admission on 22 June 2004 using form IS96.
He was told to reside at where to reside and to report to an Immigration
Officer at Communications House on 22 July 2004 and then every month
thereafter. Another form dated 21 June, form ICD1161 from the Integrated
Casework Directorate, also appeared to give the man temporary admission
and told him to report to Communications House on 5 July. It is unclear
whether the man was served with both of these forms. (The latter form was
sent by the ICD Change Of Address Team in response to a letter sent in by
his solicitor advising the Home Office of his address. This letter sought to
regularise his temporary admission.)
The man continued to live at the agreed address with his partner, who was
granted British Citizenship on 29 June 1998.
The detainee’s arrest on 18 July and
Harmondsworth Removal Centre
On 7 July the information provided by the Third Country Unit was researched
and assessed by the Communications House Joint Intelligence Unit. It was
noted that there was no information on police or Home Office indexes to
suggest that there were any mental health or other special conditions
associated with the man.
In the early hours of 18 July, a Communications House arrest team went to
the home of the man’s partner. The man was still asleep in the main bedroom
with her. He arrived at Islington Police Station at 6:20am. Communications
House Enforcement Unit decided the man was to be detained and not granted
temporary release. The reasons given for his detention at this time was that
his removal from the UK was imminent, he was likely to abscond if given
temporary release, and he had previously failed to comply with the conditions
of his temporary release.
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The first assessment in the police station stated the man was single with no
family or dependants in the UK. The man said he had no medical conditions.
The Third Country Unit was faxed on 18 July and informed that the man had
been arrested and detained. The custody record in the police station showed
that the man said he had no history of self harm, had no illnesses or medical
conditions and was not taking any medication. The form was not signed by
the man.
At 10:45pm, the escort contractor (Wakenhut) arrived at Islington Police
Station and transferred the man to Harmondsworth Detention Centre near
Heathrow. Harmondsworth is run by UK Detention Services and UKDS staff
made an initial profile of the man on his arrival. This was completed at 1am.
The man must have been very tired by this time. He had been in detention
since 6am on 18 July. The profile stated his religion to be ‘none’ (he was
Buddhist), that he spoke no English and indicated there were no warnings on
his IS91 paperwork. (This list of ‘warning’ subjects includes self harm or
suicide risk.) A medical induction was carried out at 2.30am. This did not
raise any medical concerns about the man. It is not clear if this profile was
created with the assistance of an interpreter. A note at the end indicates that
the person completing it thought the man spoke Chinese.
The man was put into a houseblock A. His room mate was a male from
Afghanistan. The room mate had first been detained on 15 June 2004. On
the evening of 19 July, a male detainee at Harmondsworth was found hanging
in a shower room. (I have conducted a separate inquiry into that death.) This
sad event seemed to trigger a disturbance which spread throughout the whole
of Harmondsworth. It continued until the next morning and led to the
evacuation of all detainees from the centre. After the riot, the man’s room
mate was taken to Dover. He was served with his Removal Directions and
subsequently self harmed and was placed on a suicide watch. The room mate
was not aware of the man’s death and I decided not to interview him in case
knowledge of this fact might upset his fragile state of mind still further. The
two men had only shared a room for just over one day.
The man was on the houseblock that was least involved in the disturbance.
The report into the disturbance at Harmondsworth by the Head of Security
Group in the Prison Service, said: “It is likely that the participation of detainees
on A wing was limited to their damaging CCTV cameras on the wing.
Indications are that they remained passive throughout the incident, even after
staff withdrew from the wing.” The report goes on to say “The centre was only
finally clear of detainees at 1300 hours on 20 July. About half had been
transferred to prison accommodation, the rest to other establishments in the
secure immigration estate.”
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The detainee’s arrival at Dungavel Immigration
Removal Centre
On 21 July 2005, two coaches arrived from Harmondsworth Removal Centre.
The first bus, with 25 detainees on it, arrived around 11.15am. A further bus
with 35 more people arrived between 3.30pm and 4.30pm. The man arrived
on the first bus. A reception officer remembered being part of the team that
looked after the arriving detainees and remembered the man. He said that the
man spoke very little English, but that nothing stood out in his mind about any
of the arriving detainees apart from one man who had mental health
problems. He said this person was not the man. The Officer’s job that
afternoon was to process the new detainees. This involved searching them
and recording their property in reception. He remembered that all the
detainees looked tired because they had been travelling all day. In total 60
new detainees arrived that day. Most of the new detainees were put onto the
family unit (which had no families on it at that time). The man was given a bed
in the main part of the centre, which had six beds in it.
The medical admission process at Dungavel is that each detainee is seen by
a registered nurse after they have been through the reception area. The nurse
assesses them for any current or previous health issues and the new arrivals
are screened for previous mental health or self harm problems. Each detainee
is then seen by a doctor within 24 hours.
A Nurse recalled being one of the medical team who screened arriving
detainees that Wednesday. Her role was to see each detainee individually
and complete a Medical Admission Form and conduct a nurse assessment.
The Nurse saw the man. She remembered that she needed to get the
assistance of a Cultural Advisor who could speak Cantonese, because the
man spoke very little English. The Nurse noted nothing untoward about the
man. She checked his blood pressure and noted he had a TB vaccination.
She said he was pleasant, had good eye contact with her and positive body
language. The cultural advisor then came into the room and the Nurse was
able to complete the rest of the medical assessment on the man. The cultural
advisor said that he and the man were able to converse easily together using
Cantonese. The cultural advisor does not speak Vietnamese. He remembers
interpreting the questions asked by the Nurse. He thought that the man gave
his family name differently to those already identified. The Nurse completed
the relevant parts of the Detainee Medical Record and notes the time she did
this to be 12.40pm. She recorded that the man was married and that his wife
was in London. She indicated that the man’s emotional state at that time was
appropriate and that he had no history of self harm and no current thoughts of
self harm or suicide.
On the cultural advisor’s way back to the dining room with the man, they
spoke generally about Scotland and Dungavel. The man asked for the
telephone number of Dungavel and the cultural advisor explained that he
would be able to receive calls as soon as he was allocated a dormitory and
that he would receive a free five minute call to anywhere in the world. The
man completed a form detailing property that was missing following his
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transfer from Harmondsworth. This list comprised a mobile phone, footwear
and paperwork.
The medical officer saw the man and made further entries in his medical
record. She noted the man had no history of any illnesses or allergies and that
he was not taking any medication. She described his mood, appearance,
attitude, speech and behaviour as normal and that he had no thoughts of self
harm or hopelessness. She concluded that no special watch or medication
was required.
The man settled onto a dormitory around 7pm and was given a telephone call
the following morning.
On Thursday afternoon, the man approached a second Officer. The officer
remembers that the man showed him his ID card and then asked him the
visiting times of the centre. The man said he was expecting visits. The Officer
said he was unsure whether the man said the visits would be from his
girlfriend or his sister. He said the man spoke in broken English.
An Immigration Officer arrived at Dungavel around 2pm on Thursday. During
her handover she was told that a fax had arrived from Communications House
with Removal Directions for the man. At around 4.30pm she met the man in
an interview room and served the Removal Directions (IS151). The man was
booked on a British Airways flight to Germany scheduled to leave Heathrow at
7.10am on 27 July. The Immigration Officer did not have an interpreter with
her but said that she was happy that the man understood what she was
saying. She said he replied “Germany, no” but that he was not angry or
agitated. She went on to explain to the man that he was being returned to
Germany because that was where he had first claimed asylum. The
immigration officer told the man that he might want to speak to his solicitor.
The man then left the room. A second Immigration Officer completed a form
advising Premier of the man’s planned removal on 27 July. This is normal
practice. A sentence on this form reads: “You may wish to monitor his/her
reaction to this news”. However, this is a standard letter and the intention was
not to draw particular attention to the man or any potential vulnerabilities he
may have had. It was faxed by the first immigration officer to the reception
office at Dungavel. There is no requirement for that office to alert the
Healthcare Department or unit staff of the removal directions.
Friday 23 July
The cultural advisor was back in Dungavel on Friday morning, escorting a
visitor from Japan. He recalled that, as he was walking with his visitor from the
main building to the family unit, he saw the man standing with an African
detainee. He said that, as he approached, the man turned towards him and
was concerned and upset. The cultural advisor asked the man what was
wrong. They spoke in Cantonese. The man showed him his Removal
Directions. The cultural advisor explained the contents to the man, but did not
tell him that he had no right of appeal. The cultural advisor did ask the man if
he had a solicitor and on hearing that the man had been unable to get one,
offered to try to get one for him later in the day, or the following Monday. The
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cultural advisor said that the man looked much happier, smiled and thanked
him for offering to help.
The Immigration Service's Third Country Unit faxed Germany on 23 July 2004
with the details of the man’s transfer from London Heathrow to Berlin due to
take place at 7:10am on 27 July 2004.
Several detainees described the man as often being on his own. They said he had
obvious difficulties communicating as no one else at the centre spoke Vietnamese
and he only spoke a very limited amount of English. One detainee said he knew
the man to say hello to, but that he could not communicate very easily with
anyone. He recalled seeing the man on Friday morning on the telephone and said
that he seemed upset. Another detainee said he saw the man about lunchtime and
that he had appeared okay.
Another detainee recalled seeing the man on Friday and said he had shown him
the papers from Immigration stating that he was to be sent back to Germany. He
said the man was upset and crying. He said the man was trying to tell him
something but that he could not understand him fully. The man apparently pointed
to his wedding ring finger and said ‘married in one month’. A Chinese detainee had
first met the man in Harmondsworth but said they did not understand each other’s
language.
The cultural advisor was in the visits area with his Japanese visitor when he
saw two solicitors. He approached one of the solicitors and asked him if he
would speak to the man as he wanted a solicitor urgently. This was duly
arranged and the cultural advisor went personally to get the man and
introduce him to the solicitor. The cultural advisor said that he did not offer to
do any translation work for the solicitor, as it was not part of his normal duties.
He said that, as he left the visits area, the man was buoyant, cheerful, smiling
and grateful for his assistance.
The man’s case was taken by another solicitor in the same firm as the
previously referred to solicitor (based in Glasgow). At 4.35pm on 23 July, the
man’s solicitor faxed the Duty Officer at Communications House and asked
that they suspend the removal directions. This solicitor stated in his fax that
"The Dublin Convention allows choice of a place of claim if a close relative
lives in the UK. The man has a wife in the UK... As she also wishes his claim
to be heard here we would ask you to suspend removal. See article 7 of
Dublin Convention.” These representations were not answered.
Between 6 and 7pm the man’s partner received a phone call from the man.
The phone call was apparently short and the man said that he was going to
get his meal. Another detainee had got to know the man a little since he
arrived at Dungavel. He said that the man’s English was not very good but
that they could communicate. The detainee said that the man was very
concerned about going back to Germany and that he said he was not going to
dinner that evening.
The detainee in the bed next to the man was from Cameroon. He said it was
difficult to communicate with him because the man could not speak French or
English. He thought he last saw the man at about 9pm walking up and down
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the corridor. This detainee told him to come to the party that was going on
downstairs but he refused. This detainee said that the man had been sad
since he received his removal letter.
The man was seen leaving the education area just before it closed at 9.30pm.
The discovery of the detainee hanging
At about 9.50pm on Friday 23 July, the second officer to have seen the man on his
arrival at Dunglaven was in the landing office on the top level of the main house. A
detainee came in looking flustered and said: “China gone, China sleeping”, and
gestured with his hands as if someone was hanging. The Officer was immediately
aware that something was very wrong and asked the detainee to show him where.
The detainee took him to the toilet area between E2 and E1 and pointed to the
cubicles. There are four cubicles, two toilets and two showers. The Officer could
see the man hanging from the top bar in the second left hand cubicle. There was a
dark leather belt around the man’s neck. The Officer used his personal radio to call
for a medical response. The Officer noticed that the man’s feet were still touching
the floor, so he got hold of the man’s waist to take some of the weight and then cut
the belt with his issued ligature knife. He lowered the man to the floor and told the
detainee to go into the hallway so that he could direct arriving staff. Due to the
position that the man was in, the Officer was unable to give mouth to mouth
resuscitation so he started to do chest compressions.
A Detention Custody Manager was arriving through the gates for the nightshift
when she heard the call for a first response / medical response to the top male
dormitory. On arrival a second Detention Custody Manager, was behind her and
the Officer was on the floor administering CPR to the man. A Nurse arrived and he
and the second Detention Custody Manager checked for a pulse. The first
Detention Custody Manager radioed for the control room to call an ambulance. The
control room timed this request to be at 9.52pm. The ambulance was called via
999 at 9.54pm and Dungavel were told it would arrive in less than 15 minutes. The
Nurse went over the partition of the cubicle and began mouth to mouth
resuscitation. The second Detention Custody Manager took over from the Officer in
giving chest compressions. The staff decided to move the man slightly in order to
get more room to work in. Two further officers were also present by this time. One
Officer started a log of events. The first Detention Custody Manger then went to
gates and opened then in order to ensure that they were no delays in the
ambulance getting to the dormitory as quickly as possible.
An Officer was walking down a corridor towards the staff room when he heard
‘personal alarm activated’ come over his radio earpiece. He ran up the stairs
towards the top male dorm on the second floor. As he was going up the stairs, two
more officers joined him. They arrived on the male dorm but there was confusion
about what the incident was and where it was. One of those officers thought that
an officer was in trouble. They checked Rooms E3, E4, E2, E1, D1, D2 and the TV
room before noticing some detainees going into Room E2 and decided to follow
them. On going into the toilet area in room E2, the officer and the others saw the
man. The officer and nurse that first attended the man were already administering
CPR. The staff cleared the area of detainees and locked them into areas away
from room E2.
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The officer that first administered chest compressions went to the office for about
one minute in order to note down timings of what had happened. He then returned
and took over from the Nurse doing mouth to mouth. Two of the officers went to
the Healthcare centre and obtained the green medical bag and some oxygen. One
of the officers opened the green bag up for the Nurse. The Nurse took some
equipment out but then both this officer and one other went back to Healthcare to
get a suction machine. The Nurse used the suction machine and inserted a plastic
airway. The man’s chest was seen to raise successfully and CPR was continued.
The police were called at 10.06pm. The ambulance arrived at the main gates at
10.13pm. One of the officers was on hand to direct the paramedics straight up to
where the man was. They arrived at the dormitory at 10.18pm. Throughout the
resuscitation attempts, who first administered chest compressions noticed that the
man’s lips and fingers were blue. The paramedics took over resuscitation and
worked on the man for about 20 minutes.
The police arrived at the centre at 10.30pm and got to the scene at 10.37pm.
The ambulance team put the man onto a stretcher at 10.48pm and, following a
further period of resuscitation on the ground floor of the unit, into the ambulance.
The ambulance left Dungavel just after 11pm with another officer. This Officer said
that ambulance staff continued to try to resuscitate the man on the way to
Hairmyers Hospital. Once at the hospital she gave his details to reception. The
man was confirmed dead at the hospital.
The deceased left a letter in Vietnamese which has been translated. The letter
asks the authorities to help him to be a refugee in England. The man says who he
is, that his father was shot and his mother left town and sold her body. He goes on
to say that he came to England and on his way stopped in Germany. He says he
did not want to seek asylum in Germany. The man says that he wants to stay in
England and that he is in love and engaged to his partner. The man says they love
each other and cannot be separated. He says “I now leave this letter as I hope you
can help me stay in England as I cannot go back to Germany”. The interpreter
offers the opinion that, although on the face of it the letter does not appear to be a
suicide note, it is Vietnamese custom to make a wish before you die and that the
deceased is clearly making a wish in this letter.
15
Issues considered during the investigation
The events after the detainee’s death
The Centre Manager at Dungavel, arrived and met with the Day Shift Manager who
had come back in and the two Detention Managers to discuss how the news
should be broken to the other detainees. The police had told the Centre Manager
that the man had died. The centre staff spoke to all the detainees during the early
hours of the morning of 24 July and advised them of the man’s death and how it
had happened. The Contract Monitor had also arrived at Dungavel by this time.
The Handover Book for the accommodation within the main house did not include
any reference to the man’s death. This seemed unusual, but my investigator was
told that it had been decided instead that the Duty Manager on Saturday 24 July
would brief all staff prior to them starting their shifts. Staff were asked to ensure
they mingled with the detainees extensively that day and to offer reassurance and
support. Managers and staff had concerns about detainee unrest in light of the
death of a detainee and subsequent disturbance at Harmondsworth only a few
days earlier. In fact, there were no acts of indiscipline amongst the detainees and
the staff's action may well have prevented such events occurring. The Centre
Manager sent an e-mail to all staff in the early hours of 24 July informing them of
the man’s death and thanking staff for their professionalism and care. He also
highlighted the need for staff to be particularly vigilant in the coming days and
weeks about how detainees might be feeling, and to speak to senior managers
about any concerns they had. Both the pre-shift briefing and e-mail are examples
of good practice.
Early on Saturday 24 July the deceased’s partner telephoned and spoke to an
immigration officer at Dungavel. One of her sons also spoke to this immigration
officer and asked to speak with the man. He was told that the man was not
currently in the centre. The immigration officer contacted the duty Chief
Immigration Officer at Communications House, at 9.15am. They agreed that the
duty Chief Immigration Officer would take urgent steps to find the appropriate next
of kin for the man. Later that morning, a family friend rang and told the immigration
officer of their concerns about the welfare of the deceased man. The immigration
officer said that he was not able to divulge personal information and suggested that
they make contact via the deceased’s solicitor.
It is regrettable that the deceased’s partner had not been identified as the next of
kin by this stage, and that steps had not been taken to inform her of her partner’s
death. It is also unacceptable that his partner and her family were ringing in order
to try to find out what was happening, but without any information being relayed to
them. However, I understand the position that the immigration officer found himself
in that morning and his concern to not divulge sensitive information to people
whose identities he was uncertain of. Nevertheless, this must have been a time of
great distress and uncertainty for the deceased’s partner and her family.
It was not until 3.15pm in the afternoon of Saturday 24 July, some 15 hours after
the man had died, that two chief immigration officers made arrangements to visit
his partner’s address with two police officers and a Vietnamese interpreter. The
deceased’s partner was not at her home at that time and so they all returned at
16
7.25 that evening. Again, the deceased’s partner was not at home but some
children playing nearby said that she is normally home shortly after 9pm. The team
therefore arranged to return at 10pm that night. This time she was at home. She
said she was the girlfriend of a name previously stated by the deceased in
conversation with the cultural advisor and that he lived with her and her two sons
from a previous relationship. On hearing the news of her partner’s death, his
partner became very upset and blamed the Immigration Service for his death. She
asked to go to Scotland immediately to see the body. As it was very late, the
visiting staff told his partner that they would make enquiries and seek the
agreement of the Procurator Fiscal in the morning. His partner contacted her
sister-in-law by telephone and told her the news. Several minutes later deceased
man’s brother-in-law rang and he decided to come and stay with the partner. The
Immigration Service seemed unaware that the deceased had any family living in
the UK as he had told staff on interview that he had no family or dependants in the
UK.
The partner said they were planning to get married and that the deceased had
come to the UK in order to marry her. She said she wanted to arrange for the
deceased’s body to be taken to London so she could arrange a cremation.
The next day, discussions took place between Dungavel and the Immigration
service. Arrangements were made for travel and accommodation for the
partner and her children to visit Scotland in order to view the deceased’s
body. The police visited the partner to inform her of this and she told them that
the deceased’s sister was arriving from Europe and that she also wanted to
see his body.
A Buddhist religious ceremony (Freeing of the Spirit) was conducted in E2
dormitory on 25 July 2004.
The deceased’s partner and sister visited Wishaw General Hospital on 26
July. They were not offered the opportunity of visiting Dungavel or E2
dormitory although I was told that they could have visited had they asked to
do so. There was no policy in place at Dungavel about communication with
families at difficult times such as this.
The influx of detainees arriving from Harmondsworth
On Wednesday 21 July, the two coaches carrying detainees from
Harmondsworth arrived at Dungavel. These two coaches had the effect of
doubling the previous population of Dungavel up to 111 detainees.
One officer said he normally knew every detainee by name, but that with such
a large number of detainees arriving in one day he had only just started to
recognise some of the new faces by Friday 23 July. It is very unfortunate that
one of the side effects of the riot at Harmondsworth was that staff at Dungavel
were faced with 60 new detainees in one day. Processing such a large
number of men through reception and medical screening would have meant
that procedures were more hurried than would normally have been the case.
All of the detainees had already experienced a very long coach journey from
London to Dungavel, and some may well have been traumatised and shocked
by what they had witnessed at Harmondsworth. The deceased was on the
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unit at Harmondsworth that had not taken part in the disturbance. Whilst the
Nurse indicated that the deceased’s demeanour and behaviour were calm
and normal, no specific questions were asked in relation to the riot and how
the deceased felt about what had happened. Nevertheless, I do not think that
his reception and medical screening were at error in identifying that the
deceased did not present a special risk of suicide or self harm when he first
arrived at Dungavel.
Suicide and Self Harm Prevention at Dungavel
Although the deceased was not on any form of suicide or self harm watch, my
investigator looked at the policies and procedures in place at Dungavel.
The policy on Management of Detainees at Risk is comprehensive and sets
out clearly that any member of staff can and should open a monitoring form if
they have any concerns about a detainee. The form used by Premier
Detention Services at Dungavel for monitoring is modelled on the system that
the Prison Service in England and Wales use. The level of observations that
can be implemented stretch from constant observations at no more than an
arm's length away, through timed observations every 2 to 60 minutes down to
general staff observations at least twice per shift. The policy states regular
case reviews must be held, with input from the Healthcare team.
There were nine detainees on the self harm at risk form at Dungavel at the
time of my investigation. My investigator looked in detail at three of these
forms. They were comprehensive in both their initial assessments of the
detainees and in relation to the case reviews. Case reviews were held every
three to four days and included a multi-disciplinary group of staff, including
Healthcare. Staff seemed aware of their responsibilities in relation to
detainees considered to be at risk.
I was also shown a letter used by the medical officer at Dungavel to alert
Immigration Officers to a detainee who may react badly to adverse news. The
letter asks the Immigration Officer to alert Healthcare, prior to giving the
named person Removal Directions or other adverse news, so that appropriate
support can be given to the detainee. This is good practice and seeks to
ensure that medical staff are made aware of immigration decisions that may
adversely affect someone’s mental or physical health when they are already
identified as being at risk. The deceased had not been brought to the attention
of medical staff as being a possible suicide or self harm risk. Medical staff
who had first met and screened the deceased on Wednesday 21 July had not
identified him as being at risk of self harm and he had arrived with no such
history. As a result, there was no letter asking Immigration Officers to alert
Healthcare to any unexpected or adverse news being given in respect of the
deceased.
Having been arrested and detained, having experienced the major
disturbance at Harmondsworth, and having been transferred hundreds of
miles from his partner in London to a Centre where nobody else spoke his first
language, I have no doubt that the deceased was in a vulnerable state.
However, the evidence suggests that the incident that led to the deceased
feeling distraught and potentially suicidal was the serving of his Removal
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Directions on Thursday afternoon. It was then he learnt that he was to be
sent to Germany early the following week.
The response to finding the detainee
Dungavel have a written instruction called a ‘Manager’s Rule’ on Cut Down
Procedures. Cut down knives are carried by residential staff and others in
case of emergency. This is good practice. The fact that the officer who found
the deceased had a cut down knife on his belt meant that there was no delay
in cutting him down and commencing treatment. Medical assistance was
called for immediately but some of the arriving staff seemed unsure of where
the emergency was. Staff should be reminded to ensure that emergency radio
messages include their precise location so that responding staff know where
an incident is occurring.
The staff involved in the attempt to resuscitate the deceased are to be
commended for their efforts. However, there may have been a short delay in
getting the right medical equipment to dormitory E2. The Nurse had to go
back to the medical room to get suction equipment. I do not think that this
brief delay would have made a difference for the deceased, but it may be
significant on a different occasion. The director may want to consider using
distinctly coloured equipment bags, such as blue for someone not breathing
and red for someone bleeding. This would help to ensure that any member of
staff could quickly bring the right equipment to the scene of an emergency.
Dungavel have a defibrillator machine and the majority of medical staff are
trained appropriately in its use. It is not clear why it was not taken to dormitory
E2, and whilst it is very unlikely to have made a difference in this case, the
healthcare manager may wish to remind medical staff to consider taking the
defibrillator machine to every emergency situation.
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Recommendations and Good Practice
Recommendation 1 – Immigration Service
Immigration Officers should be reminded to ensure that decisions and their
reasons are explained to asylum seekers in a language they understand,
using interpreters when necessary. Immigration forms should be completed in
full and signed appropriately by immigration staff and the individual
concerned.
Recommendation 2 – Immigration Service and Removal Centre
Contractors
Immigration staff based in Removal Centres and those responsible for the
management of such centres should consider drawing up a protocol that
ensures significant information given to detainees is communicated to medical
and unit staff that are involved in their day to day care. This should include the
serving of Removal Directions.
Recommendation 3 – Dungavel Centre Manager
Staff should be reminded that emergency radio messages should include their
precise location so that responding staff know where an incident is occurring.
Recommendation 4 – Dungavel Centre Manager
The Centre Manager should consider using distinctly coloured equipment
bags, such as blue for someone not breathing and red for someone bleeding.
This would help to ensure that any member of staff could bring the right
equipment to the scene of an emergency quickly.
I understand from the Dungavel Centre Manager that all relevant equipment is
stored in one emergency bag. During the night this emergency trolley is now
located outside the pharmacy and is therefore accessible by any staff in an
emergency.
Recommendation 5 – Dungavel Centre Manager
The Centre Manager may wish to ask the healthcare manager to remind
medical staff to consider taking the defibrillator machine to emergency
situations.
Recommendation 6 – Dungavel Centre Manager
A policy should be developed to cover family liaison in the event of a fatal or
potentially fatal incident. The policy should include details of who will break
news of a person’s death or serious self harm attempt to the next of kin and
how ongoing support, contact and information can be provided to them.
Good practice 1 - I was pleased to note that ligature scissors are carried by
all unit staff.
Good practice 2 - I believe the personal involvement of the cultural adviser
in this sad case has been an example of good practice
and wish to commend him.
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Good practice 3 - The fact that managers and staff told detainees in person
about the circumstances of the deceased’s death was
good practice.
Good practice 4 – A final example of good practice was the briefing of all
staff arriving for shift on the Saturday morning, and the e-
mail sent by the Centre Manager to all staff informing
them of the deceased’s death, offering his thanks and
asking that they be particularly vigilant in the aftermath.
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