D.1 Introduction

1. Part D examines in detail 10 key issues identified, on the basis of all the evidence heard and received by the Inquiry, as being the most significant issues affecting the operation of Brook House during the relevant period. The combination of these broader factors contributed to a negative experience for many detained people and, crucially, to conditions where mistreatment was more likely to occur.

1.1 The contract to run Brook House: Brook House, like most immigration removal centres (IRCs) in the UK, was and is managed by a private outsourcing firm on behalf of the Home Office, subject to contractual as well as other legal obligations. The Inquiry identified key issues in relation to the way in which the bidding process for the initial Brook House contract was undertaken, the terms of the contract that was implemented and the monitoring of the contract by the Home Office. In respect of the new contract for the operation of Brook House that is now in place between the Home Office and Serco, evidence of current practice suggests that there are ongoing issues in the Home Office’s approach to performance management.1.

1.2 The physical design and environment: Detention for immigration purposes is not equivalent to a prison sentence. The Inquiry identified a number of issues linked to the design of Brook House and the intention that people be held there only on a short-term basis. In addition, the Inquiry found issues with the operation and provision by G4S of computers and internet access for detained people at Brook House, as well as with a decision to add extra beds to the centre in early 2017.

1.3 Detained people’s safety and experience: Those detained at Brook House and elsewhere should be treated humanely and with care. The Inquiry identified a number of issues that adversely affected detained people’s safety and experience at Brook House, including drug use, language barriers, inadequate management of risk, a strict lock-in regime, no-notice removals and the impact of the indefinite nature of detention.

1.4 Safeguards for vulnerable individuals: There are critical safeguards to protect the physical and mental health of a detained person. The Inquiry identified significant issues in the operation of Rule 34 and Rule 35 of the Detention Centre Rules 2001 (the Rules) at Brook House, and in the way in which other mechanisms (such as Part C forms) were used inappropriately by Healthcare staff. In addition, the Inquiry identified a disconnect between the Assessment Care in Detention and Teamwork (ACDT) process and other safeguards for vulnerable people.

1.5 Restrictions on detained people: Detained people can be removed from association or segregated only in strictly defined circumstances set out within Rule 40 and Rule 42. However, the Inquiry found that these Rules were being misinterpreted and misapplied routinely by Brook House staff during the relevant period, and that a misunderstanding about who can authorise use of those Rules persists under Serco’s operation of the centre. The Inquiry also identified significant issues with the oversight and monitoring of the use of Rule 40 and Rule 42.

1.6 Use of force: Force may be used by detention staff on detained people only in particular circumstances, as set out in various rules and regulations, and it should be a measure of last resort. Where a use of force is unnecessary, inappropriate or excessive, it plainly has the potential to cause harm. The Inquiry identified serious problems with the way in which force was used at Brook House by G4S staff, as well as with the systems of reviewing and monitoring use of force incidents.

1.7 Healthcare: The delivery of healthcare services in IRCs can be challenging because of high levels of mental ill health. However, inadequacies in the provision of healthcare to detained people (particularly those who are vulnerable) risk a deterioration in their physical or mental health. This, in turn, can affect their behaviour. Too often, Brook House staff misinterpreted this as disruptive conduct. The Inquiry identified key issues with the provision of healthcare at Brook House, the approach to detained people refusing food or fluid, and the healthcare complaints system.

1.8 Staffing and culture: The Inquiry examined staffing and culture at Brook House and found that G4S and the Home Office did not provide a sufficiently caring, secure or decent environment for detained people or staff at Brook House. The Inquiry identified a number of key issues that negatively impacted on staff culture and morale: namely, inadequate staffing; retention and recruitment issues; inadequate development and support of staff; ineffective management and supervision by the G4S Senior Management Team; and a hands-off approach by Home Office staff on the ground. In addition, the Inquiry found that there was a toxic culture among staff, with racism, bullying, bravado and ‘macho’ attitudes present. There was also a considerable amount of abusive, racist and derogatory language used by staff towards or about detained people.

1.9 Complaints and whistleblowing: Detained people and staff should be able to raise concerns and have those issues resolved satisfactorily, with thorough investigations into alleged wrongdoing and action taken against any staff responsible for misconduct. However, the Inquiry found that many detained people felt unable to complain about poor treatment, and most staff were either unwilling or unable to raise concerns. When complaints or concerns were raised, there were a number of failures in the responses from G4S, the Home Office and the Home Office’s Professional Standards Unit. The Inquiry also identified inadequacies with the whistleblowing procedures in place during the relevant period.

1.10 Inspection and monitoring: The Inquiry examined the adequacy of inspection and monitoring during the relevant period. The Inquiry identified key issues relating to inspection and monitoring, including a problematic over-reliance on external organisations by senior management within G4S and the Home Office.

2. While numerous failings specific to each issue are identified within Part D, there are several common threads. In particular, rules and processes already exist to address the key risks associated with immigration detention, and in many instances the failures identified in this Report were the result of non-compliance with those existing rules and processes. Entire safeguarding mechanisms in a number of areas were shown to be dysfunctional, resulting in a failure to protect those detained as intended.
3. In many cases, the issues identified by the Inquiry had already been raised by oversight bodies and non-governmental organisations, or in previous investigations. The repeated failures to learn lessons and to act on recommendations made are inexcusable.
4. It is the Home Office that ultimately bears the crucial safeguarding responsibility for the welfare of detained people. The significance of that responsibility cannot be overstated and cannot be removed by subcontracting. The Inquiry identified a comprehensive range of failings by the Home Office, spanning all of the key issues set out in this Part of the Report.
5. G4S was responsible for ensuring that it complied with its contract with the Home Office, as well as with the relevant rules and guidance, such as the Detention Centre Rules 2001 and the detention services orders. It failed to do so. The Inquiry identified a comprehensive range of failings by G4S staff at Brook House, but also at a management and ultimately at a corporate level.
6. While this Inquiry was not an investigation into current practice within Brook House or into immigration detention more generally, it is concerning that the Inquiry identified evidence that suggests many of the issues present during the relevant period persist under Serco’s management of Brook House.