Part D: Issues at Brook House

17. In Part D in Volume II, I focus in detail on the core issues affecting Brook House. One key theme that runs throughout Part D is that rules and processes already existed to address the risks associated with immigration detention, and many of the issues that I identify relate to failures to follow those rules.

The contract to run Brook House (Chapter D.2)

18. G4S operated Brook House from 2009 to 2020 on behalf of the Home Office. In this part of the Report, I look at contract monitoring, the assessment of value and quality in the bid proposals, and the original procurement process.
19. In accordance with the Home Office’s process at the time, when assessing various bids for the contract it gave equal weighting to the operational ‘quality’ of each bid and to the cost element. Potential shortcomings, particularly in respect of staffing levels and the freedom of movement and welfare of detained people, were identified at an early stage. However, concerns raised about the quality of certain bids were not acted upon. I have concluded that these bids, which fell so far short of meeting an acceptable standard, should have been rejected or wholly revised, and that, in reality, cost-effectiveness was prioritised over the care and welfare of detained people.
20. The penalty structure of the contract emphasised security over care. There were no specific financial penalties for unsanctioned use of force, or for the abuse of detained people. The financial penalty for an escape was penalised at three times that of a death in detention from self-harm involving a failure in procedures. I consider this indicative of a lack of concern towards the wellbeing of detained people.
21. The contract largely relied on G4S to self-report any failures. The Home Office has accepted that it did not sufficiently resource its staff to enable more effective monitoring of the contract. Mr Philip Riley, Director of Detention and Escorting Services (DES) within the Home Office, told the Inquiry:

“if we had adequately resourced our management of the contract, then I don’t think that the abuse would have happened”.

(Mr Philip Riley, Director of Detention and Escorting Services within the Home Office, Philip Riley 4 April 2022 94/11-13)

I explored in particular the reporting of incidents of self-harm, which were significant, as a particular example of the inadequacy of the monitoring process. The evidence suggests that G4S and Home Office staff tasked with monitoring G4S’s arrangements for the prevention of self-harm did not take appropriate steps to check for failings, despite significant known levels of self- harm. Further, as a result of inadequate monitoring by the Home Office, G4S did not face financial sanctions in circumstances where robust monitoring would likely have revealed failures and, critically, opportunities to improve safety were also missed.

The physical design and environment (Chapter D.3)

22. The Home Office DES Area Manager for Gatwick IRCs, Mr Ian Castle, characterised Brook House as a place where:

“if you spend more than 24 hours … you’re going to develop mental health issues. It’s not a nice place to be.”

(Mr Ian Castle, Home Office DES Area Manager, Ian Castle 15 March 2022 38/16-18)

23. Brook House was described by many witnesses as unfit for purpose as an immigration removal centre. It had been built to the specification of a Category B prison, but without the appropriate facilities for holding detained people for more than a few days. In practice, most were held for much longer periods.
24. Poor, sometimes dirty, facilities and a lack of activities further contributed to the harshness of the environment. Detained people stayed in small, poorly ventilated cells, containing toilets that were sometimes unscreened and unclean. This led to humiliating experiences for many detained people. Constant noise – from the nearby airport and the loud internal environment – added to the already challenging living conditions. A humane and supportive regime was difficult to maintain, and the detrimental effects were particularly acute for those with mental ill health or other vulnerabilities.
25. Overcrowding was an issue. Following a request from the Home Office, the Extra Beds Programme was introduced. Brook House’s capacity was increased by 60 beds in 2017, which meant that some cells were converted from two-person to three-person capacity. Concerns about this change were raised by monitoring bodies and staff in advance. However, these warnings went unheeded.
26. Activities were limited by a lack of physical space and understaffing, and also as a result of being insufficiently valued by the Home Office and G4S. I am particularly concerned by the evidence the Inquiry received about the difficulties detained people experienced accessing the internet. Unnecessary restrictions were imposed on websites and, too often, computers were broken. This appears to have had the effect of impeding some detained people’s access to justice.

Detained people’s safety and experience (Chapter D.4)

27. Although people should only have been detained at Brook House if there was a realistic prospect of removal from the UK within a reasonable period of time, there was no fixed or maximum period for which someone could be detained at Brook House or any other IRC – and that is still the case. The Inquiry heard that indefinite detention caused uncertainty, frustration and anxiety for detained people, and had a negative impact on their health and wellbeing, a point that has been made by numerous observers repeatedly over many years.
28. Illicit drug use by detained people at Brook House was a significant problem during the relevant period, particularly with the new psychoactive substance known as ‘spice’. G4S and the Home Office were aware of the availability of drugs at Brook House. The Inquiry heard evidence alleging that staff members may have been bringing drugs into Brook House. G4S’s response to specific allegations against individual staff members was slow and inadequate. There was a sense of defeat from staff in how to address the spice problem and this was compounded by a lack of training on how to deal with those who were suffering the effects of spice.
29. Language barriers reduced the ability of detained people to interact with staff, access healthcare, make complaints and communicate with visitors. Insufficient steps were taken by G4S during the relevant period to reduce these barriers, including an over-reliance on informal translation. There were also deficiencies in the reception and induction given to detained people upon arrival at Brook House, and an inadequate process for assessing risk when allocating detained people to cells. The use of a policy of ‘no-notice removals’ during the relevant period appeared to have a detrimental impact on detained people, increasing levels of uncertainty, fear and use of force.
30. I am also concerned about the length of time detained people were locked in their cells overnight. This is an issue that has been raised previously on a number of occasions. Lengthy lock-ins have a detrimental impact on wellbeing and need to be kept to a minimum. I have concluded that one of the drivers for the restrictive regime was financial – higher staffing levels may be required to maintain safety when detained people are out of their cells. Regardless of the reason, detained people were and continue to be locked in their cells overnight for an excessive period of time.

Safeguards for vulnerable individuals (Chapter D.5)

31. I also looked in detail at failures in safeguards at Brook House for those individuals who may be vulnerable to suffering harm in detention. Those safeguards are intended to ensure that people are only detained when it is appropriate to do so and that they are not at serious risk of harm by continued detention. Failures to follow safeguarding rules and procedures clearly contribute to an environment in which harm may more easily occur. It was clear from the evidence the Inquiry saw that staff within Brook House, including medical professionals, were failing to apply the safeguards consistently.
32. I found serious failings in the application of Rule 34 and Rule 35 of the Detention Centre Rules 2001. These Rules require a physical and mental examination of a detained person by a medical practitioner within 24 hours of admission, and a medical report to be produced if a person’s health is likely to be affected by detention, they are suspected of being suicidal or they may have been a victim of torture. Many of these concerns have been raised previously by various oversight bodies and non-governmental organisations. Where Rule 35 reports were completed, the quality was generally poor. Dr James Hard, the Inquiry’s medical expert, considered that around 75 per cent of the Rule 35(3) reports he examined were inadequately completed. In particular, he noted that there was either no conclusion regarding the possibility of previous ill treatment being torture, or no conclusion on the impact of ongoing detention.
33. I have been particularly critical of the practice of using incorrect forms to notify the Home Office of vulnerable detained people. This was wholly inappropriate as it would not prompt a review of an individual’s suitability for ongoing detention, and I found no evidence of this practice acting as an effective safeguard.
34. I considered the Home Office’s Adults at Risk policy, which gives guidance on the care and management of detained people deemed to be particularly vulnerable or at risk in detention, and the Assessment Care in Detention and Teamwork process, which promotes a holistic approach to self- harm and suicide prevention. I found evidence of a disconnect between these policies and the Rule 35 process. There was no recognition that a holistic view needed to be taken in relation to self-harm and suicide risk, and that the various processes should be complementary. This undoubtedly exposed vulnerable people to a risk of harm and, in some cases, caused actual harm to be suffered.
35. I remain gravely concerned about the dysfunction in the operation of these layers of safeguards. Based on the evidence I have seen throughout this Inquiry, vulnerable people in detention are not being afforded the appropriate protections that these safeguards are designed to provide.

Restrictions on detained people (Chapter D.6)

36. Rule 40 (removal from association) and Rule 42 (temporary confinement) of the Detention Centre Rules 2001 contain powers that restrict the rights of detained people, segregating them to some degree from each other. These are important and necessary powers that should be used exceptionally for the shortest possible time and be subject to strict governance.
37. Safeguarding considerations are vital when it comes to segregation. A decision to segregate a person in a detention setting should not be taken lightly. Segregation has been associated with worsening symptoms of mental ill health, and in the case of already vulnerable individuals can exacerbate pre- existing conditions such as post-traumatic stress disorder (PTSD). Suicidal thoughts and the risks of acting on them can also increase.
38. I saw evidence that suggests that Rules 40 and 42 were routinely misunderstood, misinterpreted and misapplied by both G4S and the Home Office. Those working at Brook House, including senior members of staff, did not have a clear understanding of the circumstances in which the Rules could be used and who could authorise their use. Indeed, I heard evidence that this confusion and potential misunderstanding persists under Serco. By failing to adhere to the strict rules around these powers, far too many individuals may have been segregated without the proper level of authority or scrutiny. Evidence suggesting that ‘urgent’ provisions were being used to enable immediate segregation when there was time to seek the proper authorisation is of serious concern.
39. In addition to concerns about the authorisation of Rules 40 and 42, I found evidence of Rule 40 being used inappropriately as a punishment and for administrative convenience prior to a planned removal or transfer; and evidence of Rules 40 and 42 being used inappropriately to manage detained people with mental ill health. The Inquiry also received evidence that accommodating those subject to Rule 40 on E Wing, which was also used to house the most vulnerable detained people, had a harmful impact on those vulnerable individuals. In its 2021 report, the Independent Monitoring Board at Brook House (Brook House IMB) identified that there were continuing problems with the use of Rule 40 under Serco’s management of Brook House.
40. Overall, I have found the entire safeguarding system in a number of areas to be dysfunctional. This is not because the safeguards themselves are poor, but rather the adherence to and implementation of these safeguards is disregarded. This has resulted in a failure to protect those detained, as the safeguards intend them to be, and has left vulnerable people at risk of harm. A more consistent and robust application of existing safeguards is essential.

Use of force (Chapter D.7)

41. Force must only be used on detained people as a last resort, and should not be used unnecessarily, inappropriately or excessively. I found too often that this was not the case. When force is used unnecessarily, inappropriately or excessively, it has the potential to cause harm, and therefore it has been a critical focus of this Inquiry.
42. Several concerning themes arose from the evidence I reviewed, including force being used in order to provoke and punish detained people, use of force when it was not a last resort, a failure to employ de-escalation techniques and inappropriate use of Personal Protective Equipment (PPE). I was particularly troubled by the use of unauthorised techniques, including the continued practice of handcuffing detained people with their hands behind their backs when seated – which is no longer authorised following the death of a detained person in 2010 after being restrained by G4S officers.
43. The Inquiry also heard alarming evidence from those against whom force was used. The practice of using force on detained people who were mentally or physically unwell was common and sometimes used as a way to manage symptoms of illness. Force was also used inappropriately against naked or near-naked detained people, which resulted in the degrading treatment of individuals.
44. Monitoring and oversight of the use of force by senior managers was inadequate, which led to dangerous situations for detained people and staff. The reports officers submitted about incidents of use of force were sometimes inaccurate or lacked detail, and on some occasions were never completed at all. There were failures to wear or activate body worn cameras, despite such footage being crucially important in enabling the identification of serious issues arising from use of force incidents and in providing an opportunity to learn from them. Debriefs following incidents were generally of poor quality. Ineffective, cursory and/or delayed reviews of incidents meant opportunities to identify and address poor practice were missed.
45. There is no specific detention services order for the use of force inside IRCs. Instead, use of force within immigration detention is governed by a prison service order. This does not therefore take account of the specific needs, circumstances and vulnerabilities of detained people in immigration detention. A new detention services order that sets out comprehensive and mandatory guidance about the appropriate use of force in IRCs is urgently required.

Healthcare (Chapter D.8)

46. Immigration detention is a highly challenging environment in which to deliver healthcare services. There are high levels of mental ill health among the detained population. A significant proportion are likely to be acutely vulnerable, having been victims of torture or having experienced trauma, and there are heightened risks of suicide and self-harm. All of these factors can make it difficult to assess and treat the medical needs of patients in detention.
47. The Inquiry received evidence from formerly detained people that doctors and nurses were dismissive and exhibited a lack of care or empathy. A view sometimes prevailed that a patient was exaggerating their symptoms, conditions or past history for the purposes of furthering their immigration case. The failure to recognise challenging behaviours as a manifestation of mental ill health rather than wilful disobedience is a theme that runs throughout this Report.
48. For example, the Inquiry received records in relation to approximately 60 detained people refusing food and fluid during the relevant period for varying lengths of time. There may be many different reasons why a detained person refuses food and fluid, such as distress or psychological causes. I found food and fluid refusal was not afforded the attention it merited; there was inadequate consideration of the detained person’s mental capacity, and food and fluid refusal was generally felt to be a form of protest about detained people’s immigration cases, rather than a sign of mental ill health. Crucially, it did not necessarily prompt consideration of a Rule 35 report by a GP, or monitoring under Adults at Risk procedures. Moreover, the Home Office was not informed and so did not have the opportunity to review the individual’s detention and consider their release.
49. I found instances of inappropriate mocking or derogatory remarks made by healthcare staff about, and in the presence of, detained people. The Inquiry also received evidence that healthcare staff failed to challenge inappropriate behaviour from custodial staff.
50. I am particularly concerned that healthcare staff did not understand their obligations towards detained individuals and failed to appreciate their key safeguarding role. This was particularly evident in the context of use of force. They must be focused on the welfare of the detained person and not inappropriately defer to detention staff, matters of convenience, or security considerations.

Staffing and culture (Chapter D.9)

51. I considered the staffing issues at Brook House, the culture among those working at Brook House, and the extent to which circumstances have changed under the current contract with Serco.
52. During the relevant period, the environment at Brook House was not sufficiently caring, secure or decent for detained people or staff. It is clear that inadequate staffing levels were a significant issue and affected the experience of detained people. Indeed, witnesses told the Inquiry that Brook House was dangerous because of understaffing. Senior G4S managers and the Home Office were aware of staffing issues, but I found little evidence of attempts to combat them and in turn meet the needs of the increasing numbers of detained people.
53. I found evidence that the Senior Management Team (SMT) within G4S was dysfunctional. Senior managers were not sufficiently visible to junior staff, who were left largely to manage on their own, and SMT inattention was compounded by unprofessional behaviour such as in-fighting. The gulf between senior managers and those ‘on the ground’ reduced the likelihood of custodial staff seeking SMT advice or sharing concerns. It also reduced the ability of SMT members to act upon troubling behavioural and cultural issues, of which they should have been aware.
54. When working in a very challenging environment, staff are likely to feel the need to rely on colleagues. For example, Detention Custody Manager (DCM) Stephen Loughton (now Assistant Director of Brook House) in his evidence to the Inquiry talked of staff feeling “let down” by DCO Callum Tulley. However, while this reliance on colleagues can create strong bonds, it can also operate as a powerful disincentive to reporting poor staff behaviour, and those in leadership roles must constantly be alert to this risk.
55. Evidence obtained by the Inquiry revealed the use of abusive, racist and derogatory language towards detained people by G4S staff. Disturbingly, this was explained by some as a way to ‘fit in’. It was common for staff to talk about detained people in an abusive manner. There were also multiple occasions where staff talked about past violence, verbal abuse and threats to detained people, or described future intentions to use violence. I was shocked at how desensitised many staff appeared to be towards the vulnerabilities of detained people. For example, the Inquiry saw footage of occasions where staff, talking about a detained person, used the phrase “if he dies, he dies” – evidence of a dehumanising response to detained people’s welfare by some staff.
56. There was little recognition among staff witnesses of the power imbalance that exists between detained people and those responsible for their care. Too often, inappropriate behaviour was dismissed as ‘banter’ and it was evident that some staff felt emboldened to behave without fear of consequence. I am particularly concerned by the lack of reflection by some of those who remain working at Brook House, a number of whom are now in more senior roles. It inevitably casts doubt on how far the cultural changes described by Serco can be said to have been embedded. There is more to do.

Complaints and whistleblowing (Chapter D.10)

57. Many detained people felt unable to complain about their treatment or raise concerns. This applied to many of the incidents shown in the Panorama programme. Language and communication issues, a lack of understanding of their rights, a lack of confidence in the complaints system, and a belief that nothing would change or no one would listen, created barriers to detained people making complaints. Some feared repercussions from staff and/or for their immigration case. When detained people did make complaints, they were often poorly investigated.
58. Complaints about minor misconduct and about service delivery were dealt with by G4S. This included complaints about facilities, staff behaviour, bullying and access to property. Most were found to be unsubstantiated. Some complaints were investigated by DCMs who themselves had been subject to multiple complaints and I am concerned that there may have been a tendency to believe an accused staff member over a detained person. There was a financial incentive for G4S to find complaints against their own staff to be unsubstantiated – penalty points were incurred under the contract for substantiated complaints.
59. Complaints about serious misconduct were required to be allocated to the Home Office Professional Standards Unit (PSU) for investigation. However, there were some occasions where cases were wrongly allocated or there was a delay in taking meaningful action. Further, I identified a number of concerning themes arising from the PSU’s investigations, including the process under which some of the investigations were carried out, the decision-making of investigators when determining whether allegations were substantiated or not, and the communication of outcomes.
60. Staff at Brook House lacked trust in the whistleblowing process – when ‘Speak Out’ posters were defaced with graffiti saying “snitches” and “don’t be a rat”, they remained up for months. I found no common practice of reporting colleagues for inappropriate behaviour towards detained people. A culture of not ‘snitching’ was allowed to prevail, and several members of staff told the Inquiry that they did not report incidents for fear of being labelled a “grass” or being bullied. Although the extent of whistleblowing was not entirely clear, a large number of staff at Brook House witnessed inappropriate behaviour during the relevant period but did not use Speak Out or any other process to raise concerns about that behaviour. Senior management showed a lack of understanding about the willingness of staff to use the processes in place and the reasons why they might not do so. The whistleblowing policy and processes themselves were inadequate, ineffective and were not adequately tailored to Brook House or IRCs more generally. Disappointingly, when staff did raise concerns or grievances, there was often an inadequate response.

Inspection and monitoring (Chapter D.11)

61. Primary responsibility for the welfare of detained people at Brook House and compliance with rules and procedures lay with the Home Office and its contractors (during the relevant period G4S, and currently Serco). It was therefore alarming to discover, in the course of this Inquiry, the extent to which both the Home Office and G4S relied upon the monitoring provided by volunteers on the Brook House IMB, and on infrequent inspections conducted by HM Inspectorate of Prisons (HMIP). While both organisations have important and complementary roles in monitoring welfare standards, neither organisation can provide a level of scrutiny that can act as a substitute for critical internal monitoring, and it is crucial that the Home Office and its contractors recognise this.
62. It is not surprising that neither organisation identified the abuses shown on the Panorama programme. These are behaviours that would be kept hidden from monitors. Indicators of abuse can be insidious and I have found that both HMIP and the Brook House IMB need to do more to ensure that they are alert to the signs of mistreatment, that they carry out their roles with robust independence and that their methodologies are effective.
63. Every IRC has an IMB operating within it, to provide regular and independent oversight with a focus on the welfare of detained people, and IMB members visit at least once a week. The Inquiry saw evidence from Brook House IMB members raising concerns on behalf of detained people on many occasions. However, the Brook House IMB was insufficiently challenging of G4S and the Home Office, and the Inquiry saw examples of an inappropriately sympathetic approach to these bodies. More recent evidence has demonstrated a more robust and rights-based approach by the Brook House IMB, which must continue.
64. HMIP’s purpose is to report on the treatment of detained people and conditions in detention centres. Although HMIP received some information between inspections, this was sporadic and largely reliant upon an individual or organisation deciding to raise a matter.
65. The 2016 HMIP inspection report about Brook House was overly positive in places, including in the introduction and comments on the governance of use of force. Where it was critical it sometimes did not go far enough, while in some instances the inspection report did not adequately reflect some of the adverse evidence HMIP had obtained about Brook House. HMIP deserves credit for its swift and proactive response to the Panorama programme, and the enhanced methodology introduced in the aftermath is an improvement on the previous approach. As HMIP cannot enforce adherence to its recommendations, the onus is on the Home Office and its contractors to respond properly to recommendations, and to accept them wherever feasible.
66. It is vital that, in closed institutions, those responsible for management and oversight embrace challenge and feedback. A culture of robust scrutiny must prevail, but primary responsibility for ensuring the proper treatment of detained people lies with the Home Office and its contractors.