Individual at Colnbrook

Investigation into the circumstances surrounding the
death of a man in September 2008
(the man had been released on temporary licence from
Colnbrook Immigration Removal Centre)
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the death of a man on 1 September 2008.
The man had been temporarily released on licence from Colnbrook Immigration
Removal Centre (IRC) on 22 July 2008 following an Appeals Tribunal hearing. He
had been detained at Colnbrook since June 2006, following release from HMP
Littlehey where he served a custodial sentence for sexual offences, pending removal
to his home land of Zimbabwe.
A post mortem was held at the request of HM Coroner for West London. It
concluded that the man’s death was due to natural causes, resulting from
tuberculosis. An inquest will not be held.
I extend my condolences to all those touched by the man’s death. He was just 32
years old.
This investigation was conducted under my discretionary powers to investigate
deaths following release from immigration detention. The last death to be
investigated by my office at a removal centre occurred in January 2006.
I would like to thank the Director of Colnbrook and his staff for their help and
assistance. I am especially grateful to a member of staff at the UK Boarder
Agency (UKBA), for her contribution. I would also like to thank a caseworker with
the UKBA.
I originally made four recommendations. Two related to the medical needs of
released detainees; and two to public protection. All have implications much wider
than the particular circumstances of the man.
My public protection recommendations have been accepted. However, I have learnt
more about access to National Health Service care, which is a matter for Department
of Health policy rather than the immigration services. It seems sensible to me that a
detainee with a notifiable disease which presents risks to the general public, should
have access to NHS treatment and so I recommend that the policy is reviewed.
In this final report the UKBA have now only partially accepted my recommendation in
regard of public protection, which has also been shared with the Public Protection
Unit of the National Offender Management Service. The other recommendation
remains accepted. Up to the circulation of this final report, the Department of Health
have not responded to my recommendation in relation to health care services.
However, I note the recent ruling by the Court of Appeal into asylum seekers access
to medical treatment, which ruled that they were not entitled to free health care on
the NHS.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
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CONTENTS
Summary 4
The Investigation Process 5
Colnbrook IRC 7
Key Findings 8
Issues 10
Recommendations 14
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SUMMARY
The man came to the United Kingdom from Zimbabwe in 2002 on a visitor’s visa. He
failed to leave the country when his visa expired. He was sentenced to 40 months
imprisonment in 2004 for serious offences at Crown Court. On passing sentence the
Judge told the man that he must sign the Sex Offenders Register indefinitely.
In November 2006, the man was detained by what is now the UK Border Agency on
his release from prison and escorted to Colnbrook Immigration Removal Centre
(IRC) to await removal to Zimbabwe. The present political situation in Zimbabwe has
resulted in a logjam, and therefore the man was detained at Colnbrook for nearly two
years. He made an unsuccessful attempt at challenging his deportation order.
In May 2008, the man reported to healthcare staff at Colnbrook that he was losing
weight. However, he refused medication and medical tests. In June, he agreed to
have a chest x-ray as he was still losing weight and having night sweats. Following
his chest x-ray, the man was admitted to hospital with a diagnosis of tuberculosis
and placed in isolation. (Tuberculosis is a common and often deadly infectious
disease caused by mycobacteria that affects the lungs.) Two days later, he was
transferred back to Colnbrook’s healthcare unit where he remained in isolation. Over
the next weeks medical tests were carried out to ascertain whether the tuberculosis
was infectious.
In mid July, the man was re-located to a normal wing following information from the
hospital that the tuberculosis was not infectious. Six days later, the man attended an
Appeals Tribunal and was released on temporary licence. In response to my draft
report, the UKBA have advised that the man was granted bail by the court and so no
release plans were possible. The National Asylum Seekers Service (NASS)
identified accommodation and the man moved into one of their supported housing
flats. As part of his release plan, the man was told to report twice a week to a
reporting centre near his address.
On 1 September, a neighbour noticed that the man’s door was open and the
television on. The neighbour had not seen the man for a few days and entered his
room. The man was in bed but not conscious. An ambulance was called and
paramedics confirmed the man’s death on their arrival.
Whilst in the community, the man was trying to register with a doctor but had not
signed the Sex Offenders Register as directed by the court.
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THE INVESTIGATION PROCESS
My office was notified of the man’s death by the former Director of Detention
Services, following information from HM Coroner on 9 September 2008. Under
my terms of reference, I have the discretion to investigate, to the extent
appropriate, deaths following release from detention that raise issues about the
care provided by UKBA. Terms of reference and notices of the investigation were
sent to Colnbrook the following day. A clinical review into the man’s healthcare
was not commissioned.
1. The investigation into the man’s death was opened on 10 September when one
of my investigators made contact with the office of Her Majesty’s Coroner for
West London. My investigator spoke to a Coroner’s Officer who told her that a
post mortem examination of the man had been carried out and that the cause of
death was tuberculosis. The Coroner’s Officer told my investigator that HM
Coroner was satisfied that the man had died of natural causes and an inquest
would not be held.
2. My investigator made enquires with the Coroner’s Officer to establish if any next
of kin had been identified. The Coroner’s Officer did not have any details of the
man’s next of kin. His funeral and personal belongings were being looked after
by a member of the chaplaincy team at Colnbrook.
3. On 22 September, my investigator and her colleague visited Colnbrook. They
reviewed the man’s immigration files and medical notes. My investigator
requested copies of documents from the man’s files to be sent to her. Later the
two investigators spoke to the Healthcare Manager.
4. My investigator received information from the member of the chaplaincy team
that next of kin living in this country had been traced on 3 October. They had
attended a service at a funeral directors shortly before the man’s body was flown
back to Zimbabwe. Telephone contact numbers were passed on to one of my
Family Liaison Officers. My Family Liaison Officer has tried many times to
contact these family members using the telephone numbers, but as yet without
success.
5. On 2 October, my investigator and her colleague visited the UK Border Agency
offices in Croydon and met the man’s caseworker.
6. The report was published in draft and, following feedback received from UKBA, it
is issued in draft for a second time.
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COLNBROOK IMMIGRATION REMOVAL CENTRE
7. Colnbrook Immigration Removal Centre (IRC) is located near London’s Heathrow
Airport and opened in 2004. It holds up to 383 detainees on behalf of the UK
Border Agency, plus a further 20 people on behalf of HM Revenue and Customs.
It is one of the busiest removal centres in the UK. Custodial services are
provided by a private contractor, Serco.
8. In June 2007, an unannounced inspection of Colnbrook was undertaken by Her
Majesty’s Inspector of Prisons, Dame Anne Owers. The inspection report said
that:
“Colnbrook mainly houses detainees who have exhausted the immigration
process and are awaiting removal from the UK. The detainee population
normally held in Colnbrook is likely to be perceived by the UK Border
Agency as posing an unacceptable risk to a less secure establishment and
may be in need of psychiatric or 24-hour medical services, and detainees
subject to multi-agency public protection arrangements (MAPPA).
Approximately 80% of the population of Colnbrook are former prisoners.
Colnbrook has four long-term residential units each housing 66 male
detainees, the short term holding facility houses 80 male/female detainees
for a short period.”
“Health services had improved since the last inspection. While many
surveyed respondents had negative perceptions of health services, most
detainees interviewed were content with the service. There were no
waiting lists for the dentist or doctor. However, there was a significant
shortfall in mental health provision despite the high numbers of detainees
with mental health problems. The centre was at the edge of its ability to
cope with mentally unwell detainees, some of whom had been transferred
to Colnbrook against the wishes of its health professionals. Medicines
management had improved, as had clinical governance. Inpatient beds
were included, inappropriately, on the certified normal accommodation,
and were also used for constant observation of some … detainees who
had no other need to be in healthcare. We were also concerned that most
detainees attending outside medical appointments were handcuffed.”
9. The Annual Report for 2007 of the Independent Monitoring Board (IMB) for
Colnbrook commented on the healthcare services (which are also provided by
Serco) as follows:
“Overall the Healthcare team at [Colnbrook] are doing a good job in
difficult circumstances, but there are increasing signs of strain. This is
evidenced by around 14% of concerns raised with the IMB in 2007 being
related to healthcare matters.”
10. Colnbrook has suffered one death since it opened. The investigation by my office
raised no issues that apply to the death of the man.
6
KEY FINDINGS
11. In September 2004, the man was sentenced to 40 months imprisonment at
Crown Court for sexual offences. As part of the sentence, the man was required
to sign the Sex Offenders Register indefinitely. The man was first received into
HMP Winchester and later transferred to HMP Littlehey.
12. On 26 November 2006, the man was detained by officers of what is now the UK
Border Agency following his release from Littlehey. He was escorted to
Colnbrook Immigration Removal Centre (IRC) to wait for deportation to
Zimbabwe. His first reception health screen document noted that he was healthy,
with no medical or mental health problems, although he was concerned about his
deportation.
13. The man made an unsuccessful attempt to challenge his deportation and
remained at Colnbrook. On 26 June 2007, he transferred to Dover IRC, returning
to Colnbrook on 17 October. His case was reviewed on a monthly basis by
UKBA (from April 2008, by his caseworker).
14. On 26 January 2008, the man’s medical records note that he had begun to refuse
to eat. There are no details about his refusal to take food other than that he was
seen in healthcare and the situation was discussed with him. The situation
seems to have been resolved as there are no further entries until 29 May when
he was seen by a triage nurse. The man was complaining of weight loss. He
told the nurse he was stressed about his situation, and he was referred to the
doctor.
15. Two days later, the man saw the doctor who examined him and noted that he had
lost nine kilograms in weight since his reception into Colnbrook. The man told
the doctor he had little appetite and did not like the food at the centre. He also
said he had occasional night sweats and a slight cough. It was recorded in the
medical notes that the man refused blood tests and medication (despite the
doctor explaining the reason for the tests). Apparently. they were against his
religion. The man did agree to provide samples of faeces and urine, and to have
his weight monitored. The doctor told the man he would see him in a week’s
time.
16. On 10 June, the man saw the doctor for a review, and as a result he was referred
for a chest x-ray. On 23 June, the man was seen by a triage nurse. The nurse
noted that the man was complaining about getting his proper vegetarian diet. He
also told the nurse he had refused the blood tests, and that he was not ill and just
did not eat well. His medical notes show that he had lost another four kilograms
in weight in the last four weeks.
17. The following day, the man was escorted to hospital for a chest x-ray and
returned to Colnbrook. His medical notes show the x-ray indicated an abnormal
result. At 2.00pm, the man was taken to a hospital chest clinic where a
diagnosis of pulmonary tuberculosis was made. He remained at the hospital in
isolation, whilst further tests were carried to identify the specific strain of
tuberculosis. (It is common practice to isolate patients who have tuberculosis
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18. On 26 June, the hospital made contact with healthcare staff. The man was ready
to be discharged back to Colnbrook. He would need to remain isolated from
other detainees, and three sputum samples would need to be collected from him
on alternate days.
19. At about 6.30pm, the man arrived back into Colnbrook and was taken to an
isolation room in the healthcare unit. The man was now taking anti-biotic
medication for his illness.
20. From 27 June to 7 July, the man remained in isolation in the healthcare unit. He
was taking his medication regularly, as well as Fortisips (a food supplement
drink), and was seen daily by the doctor. The man told staff he was feeling better
and had some appetite. On 8 July, the man was escorted to hospital for an
appointment at the Respiratory Clinic and then returned to Colnbrook healthcare
unit. He was again located in an isolation room. The man continued to be cared
for by healthcare staff, although he became frustrated by his isolation.
21. On 16 July, the hospital made contact with healthcare staff to say the man could
now come out of isolation and no further sputum samples were required as the
latest specimens were clear. The man was transferred back to his wing within
the centre.
22. Six days later, the man was released on temporary licence by an Appeals
Tribunal Hearing to an address in south east London. Since my draft report was
published the UKBA have advised that the man was granted bail by the court and
so no release arrangements were made. It may be that his health was a
contributing factor in his release although my investigator could not identify the
specific reasons. The man had possession of his medication when he was
released.
23. The man’s release address was accommodation used by the National Asylum
Support Service (NASS). He was placed under the care of a hospital for
outpatient appointments to oversee his tuberculosis. Information from the
Coroner’s Officer indicates that the man was trying to register with a doctor in the
community for his medication.
24. A condition of his licence was that he should report to a UK Border Agency
Reporting Centre twice weekly. There is no evidence that on release the man
reported to his local police station to sign the sex offenders register, as directed
by his sentencing Judge in 2004.
25. On 1 September, a neighbour of the man’s became concerned as he had not
been seen for several days. The neighbour noticed that his television was on
and the door to the man’s flat was open. The neighbour gained access to the
man’s room and found him in his bed. An ambulance was called and paramedics
confirmed that the man had died.
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26. The man’s body was flown back to Zimbabwe after some relatives were traced by
the member of the chaplaincy team at Colnbrook.
9
ISSUES
Clinical Care
27. The man’s death had taken place whilst he was living in the community on
licence from Colnbrook. The care of the man’s tuberculosis was overseen by a
local hospital. From records held by the Coroner’s office, the man had not
registered with a doctor on his release from Colnbrook.
28. The man’s medical records from Colnbrook noted all the interventions made by
healthcare staff following his reception into the centre until he was discharged
from the healthcare unit following his diagnosis of tuberculosis. The notes detail
the actions by healthcare staff in relation to the man’s symptoms.
Medical care in Colnbrook
29. On arrival at Colnbrook, the man was seen by medical staff and details of his
medical history were noted. His first reception health screen document was
correctly completed, recording his blood pressure, temperature and pulse rate. It
concluded that he was well, he was not prescribed any medication, and had no
thoughts of self-harm.
30. Following sputum tests carried out over a two-week period in July, the hospital
informed healthcare staff that the man could now be taken out of isolation and he
returned to normal location in Colnbrook.
31. It would appear from this investigation that Colnbrook healthcare has good links
with Hillingdon Hospital. As Colnbrook holds many Foreign National Detainees
(FNDs), tuberculosis is an illness which healthcare staff have some experience of
treating. As soon as a detainee shows symptoms related to suspected
tuberculosis (weight loss, night sweats, cough), they are referred for a chest x-ray
and if needed to the Chest/Respiratory Clinic at the hospital.
32. From information held within the man’s medical notes it is evident that his
symptoms were treated appropriately and in a timely way once he reported them.
The man’s release into the community
33. There is no documentation to indicate that the man was seen by a member of
healthcare staff before his release. He was granted bail by the courts and so
Colnbrook did not make any pre-release arrangements. Consequently there are
no records of information passed to him in relation to his illness, his medication,
or registering with a doctor. The man’s medical record ends on the day he was
discharged from healthcare back to his wing on 16 July. No entries were made
following this date.
34. The man’s caseworker told my investigators that he was not made aware of the
man’s serious medical condition. When other concerns are raised by Colnbrook
staff about a detainee, such as serious self harm or discipline issues, a form is
forwarded to the caseworker to provide up to date information about the
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Release of detainees with a notifiable illness
35. I believe that the state has a duty of care to those it is releasing from immigration
detention. Detainees released on licence should be given help and information to
allow them to access medical care in the community and obtain their medication.
Since I published my draft report I have been advised by UKBA that detainees
are only entitled to minimum emergency treatment and not to the full range of
National Health Services.
36. I acknowledge that the man was placed in accommodation by NASS, and would
have received some support through them. Nevertheless, there were no
documents in his case file that detailed what support he was to be given. Whilst
recognising the importance of medical confidence, the caseworker was unaware
of the man’s condition, and so he too was not in a position to advise him. The
man could have been asked if details of his medical condition could be released
to the caseworker.
The Department of Health should review its policy regarding access by
detainees, particularly those with a notifiable disease, to medical care in the
community.
Public Protection Issues
37. When convicted of his offence in 2004, the man was told he must sign the Sex
Offenders Register indefinitely. On 22 July 2008, the man was released on
temporary licence by an Appeals Tribunal and moved into a local community. As
part of the conditions of his release licence, he had to attend a reporting centre
twice a week. (The man did in fact report twice weekly to the centre in line with
his licence conditions.) This was in addition to reporting to the police for
registering as a sex offender. Enquiries were made by my investigators with the
Metropolitan Police. It was found that the man had not signed on the Sex
Offenders Register after his release from Colnbrook.
38. My investigators raised this issue with the caseworker. He said that he had been
on leave when the paperwork for the man’s appeals tribunal hearing was
prepared. The document did not indicate that he should sign the Sex Offenders
Register on release, but did show that he had been convicted of a serious sexual
offence and had served a custodial sentence. On release, the man did not
register his address with the local police and the police were not informed of his
whereabouts in the community. Nor had Colnbrook raised this issue when he
was released from their charge.
39. The caseworker said that the relevant caseworker would not be informed that
‘their’ detainee had been released until the following day when the paperwork
from the appeals tribunal hearing was forwarded to them. I believe the issue of
the man signing the Sex Offenders Register should have been identified at that
11
The UK Border Agency should ensure that any detainee who is required to
sign the Sex Offenders Register is reminded to do so in the event of their
release.
The UK Border Agency should ensure that all caseworkers and managers
dealing with convicted detainees understand Multi Agency Public
Protection Arrangements, and check that detainees comply with the
conditions of their release.
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RECOMMENDATIONS
For the Head of Criminal Casework Directorate UK Border Agency and the
Director of Colnbrook IRC
1. The UK Border Agency should ensure that any detainee who is required to sign
the Sex Offenders Register is reminded to do so in the event of their release.
Accepted
2. The UK Border Agency should ensure that all caseworkers and managers dealing
with convicted detainees understand Multi Agency Public Protection
Arrangements, and check that detainees comply with the conditions of their
release.
Partially Accepted by UKBA – UKBA are working with the National Offender
Management Service (NOMS) to look at whether more can be done to ensure
detainees understand the conditions of their release and the consequences of
them not doing so.
The Public Protection Agency of NOMS have commented – “ Offender
managers supervise offenders on licence and are responsible for enforcing
licence conditions. They will be fully aware of MAPPA, as the probation service is
one of the responsible agencies. The key to managing offenders released from
immigration detention is making sure that the probation area responsible for the
offender’s supervision is made aware that the offender is back in the community
so that they can activate supervision.
3. The Department of Health should review its policy regarding access by
detainees, particularly those with a notifiable disease, to medical care in the
community.
A recent ruling by the Court of Appeal said that failed asylum seekers with
chronic illnesses were not entitled to free healthcare on the National Health
Service but, hospitals have the discretion to provide free treatment to such
individuals if they cannot afford to pay. The Health Secretary said that his
department accepted the lack of clarity in the official guidance for hospitals and
will ensure guidance is amended.
At the time of circulation of this draft report, no comment has been received from
the Department of Health.
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