Complaints by detained people

3. Rule 38 of the Detention Centre Rules 2001 provides for detained people to make requests or complaints to the manager, the visiting committee (ie the Independent Monitoring Board or IMB) or the Secretary of State and requires those requests or complaints to be responded to in accordance with procedures approved by the Secretary of State.¹ This is expanded upon in Detention Services Order 03/2015: Handling of Complaints (the Complaints DSO), which includes mandatory instructions and guidance regarding the handling of complaints, as well as in G4S’s Requests and Complaints policy (the G4S policy).²
4. Within Brook House, detained people or others on their behalf could raise a complaint in writing or verbally.³ Forms were transferred electronically to a Home Office team known as the Detention Services Customer Service Unit, which was responsible for categorising and allocating them for investigation.⁴ Staff in receipt of verbal complaints were to encourage detained people to put the complaint in writing.⁵

Table 6: Allocation of complaints as required by Detention Services Order 03/2015: Handling of Complaints

Type of complaint	Investigated by	Time limit
Immigration removal centre (IRC) service delivery	IRC supplier (at Brook House, G4S Care and Justice Services (UK) Ltd)	Within 20 working days of allocation of the complaint
Minor misconduct	IRC supplier (at Brook House, G4S Care and Justice Services (UK) Ltd)	Within 20 working days of allocation of the complaint
Serious misconduct	PSU	Within 12 weeks of receipt within the Home Office (this includes the investigation)
Healthcare complaint (England)	Healthcare provider (at Brook House, G4S Health Services (UK) Ltd)	NHS England processes and timescales apply

Barriers to reporting

5. In a 2017 survey carried out by staff within Brook House, 42 per cent of detained people said that they did not know what to do if they were a victim or witness of violence.⁶ In the 2019 HM Inspectorate of Prisons (HMIP) report, 58 per cent of those surveyed said they did not know how to complain.⁷
6. This was supported by other evidence received by the Inquiry.

6.1 In its February 2018 report on D1527’s complaints, the PSU noted that many detained people discussed their complaint with an officer before submitting a formal complaint. The report stated, “It is not known why detainees do not formally complain and this may require further investigation with the detainees themselves.”⁸ Ms Julie Galvin (the investigating officer in this case) recommended that the Home Office Detention and Escorting Services (DES) consider discussing this with detained people.⁹ The Home Office recorded that this had been completed, but it is unclear whether any such discussion took place or, if it did, what the results were.¹⁰

6.2 The “reticence by detainees to using the formal complaint procedure” was also identified by the PSU in its February 2018 report into D668’s complaints. The report made two recommendations: first, that the Home Office use its direct contact with detained people to either address any concerns or organise an awareness-raising campaign; and second, that the ‘Immigration and Enforcement Complaints’ label on the complaints box be changed to make clear it is for complaints about Brook House and not immigration matters.¹¹

6.3 Ms Anna Pincus, current Director of Gatwick Detainees Welfare Group (GDWG), told the Inquiry that when detained people mentioned poor treatment, they would usually say that they did not want a complaint to be made. If there was a safeguarding concern, GDWG would inform the Safer Community team (the team of G4S staff within Brook House who were responsible for management of self-harm, Assessment Care in Detention and Teamwork and anti-bullying), ideally with the detained person’s consent.¹²

7. Some detained people did not understand their rights or what safeguards should be in place, or did not have confidence in making a complaint or reporting poor treatment by staff. D1713 said he did not know to whom he should report an incident of abusive and dehumanising language, or how to make a complaint. His cell mate suggested that there was no safe space in which to report a member of staff.¹³ D2158, D801 and D790 also indicated that they did not know how the complaints system worked.¹⁴ Although complaints forms were available in multiple languages, detained people may have found it more difficult to know how to complain.¹⁵
8. Additionally, many people suffered from health problems or disabilities that may have reduced their ability to follow the complaints process. For example, D313 said he was not aware of how to complain, and that he had a serious learning disability that would have prevented him from reading any materials explaining the process.¹⁶ Some might have felt more confident making a complaint through a legal representative, but many detained people did not have access to a lawyer, and legal advice surgeries were said to be insufficient.¹⁷
9. A good understanding of how the complaints process works can encourage detained people to use it. Once he was told (by a fellow detained person) that complaints made using the complaints form would go straight to the Home Office, D1747 followed this process.¹⁸ Under its contract with the Home Office and its own complaints policy, G4S was required to explain to detained people how to make a complaint, as well as to acknowledge, investigate and respond within a set time period to complaints allocated to it.¹⁹ Although some steps were taken by G4S to make detained people aware of the complaints process, it is clear that, for many detained people at Brook House, any explanations that were given were insufficient.²⁰
10. The Inquiry received evidence about why detained people felt unable to complain about poor treatment, either at the time or at all.

10.1 Fear of repercussions from staff: In HMIP’s 2019 report, 35 per cent of those surveyed said that they had been too afraid to make a complaint about their treatment in Brook House.²¹ This issue had already been identified in a 2014 report by Medical Justice (a charity that provides medico-legal reports and advice to detained people).²² Both D313 and D1713 said that they were scared that officers might target them if they complained.²³ D2158 said he was scared of something being done to him if he complained.²⁴ Although she could not recall the detail of the conversations, Ms Pincus told the Inquiry that, about once a month, a detained person would tell her that detention staff had explicitly told them either not to make a complaint or to withdraw a complaint.²⁵

10.2 Fear of repercussions for their immigration case: Immigration removal centres (IRCs) differ from prisons in that the Home Office, rather than a third party, makes decisions about whether or not to remove an individual and determines the fact and length of detention.²⁶ The complaints form explicitly stated: “The submission of a complaint will not affect consideration of your immigration status.”²⁷ The Complaints DSO also made clear that detained people “must not be penalised for making a complaint” and that complaints would not interfere with a detained person’s immigration case.²⁸ However, it is unlikely that this was sufficient to dispel fears that it would do just that. Dr Hindpal Singh Bhui, Inspection Team Leader at HMIP, told the Inquiry that it was also his major concern that detained people might not make complaints for this reason.²⁹ Ms Pincus noted separately that “detained people had strong concerns that making a complaint could jeopardise their immigration case”.³⁰ This barrier may have been compounded by the PSU being part of the Home Office and by the labelling of the complaints box as ‘Immigration and Enforcement Complaints’.³¹ D668 told the PSU that his friend had made a complaint about “being beaten up at the airport … The last thing he heard from them (Home Office), they came to pick him up at 16:00 hrs and take him back to his country.”³²

10.3 Lack of confidence: Most critically, there was also a view among detained people that nothing would change as a result of a complaint or that nobody would listen. Some 10 per cent of detained people who responded to an internal Brook House survey in 2017 said that the reason they had not complained was that centre staff did not care. A further 22 per cent said that staff could not or would not do anything.³³ This was echoed by some detained people:

• D1713 said that he did not think anyone would listen or anything would change if he did report incidents.³⁴
• D668 told the PSU that he had filed a complaint once and received no feedback, so he stopped doing it.³²
• D1851 said that he thought it was a waste of time to complain in writing, as staff had not listened when he kept complaining verbally.³⁵

10.4 Ms Pincus confirmed that most people to whom GDWG spoke viewed complaining as pointless and had no confidence that their complaint would be dealt with fairly.³⁰

11. At least one member of staff was unaware of the barriers faced by detained people and relied on the lack of immediate complaints about their conduct to support their position that they had not behaved inappropriately.³⁶
12. It is evident that many detained people did not complain, or at least did not do so at the time, including those who featured in the Panorama programme. There are numerous reasons why some detained people felt unable to complain about their treatment at the time or at all, and there was a lack of understanding by at least one member of staff of the barriers to complaining. It was the Home Office’s and G4S’s responsibility to create an environment and relationships that enabled disclosure of any concerns, in order to provide opportunities for both parties to learn about what was happening. The 2022 HMIP inspection report noted that although most detained people they spoke to were confident about making complaints, a substantial number did not know how to make complaints or were not confident enough to complain.³⁷ Further action is required to ensure that processes for detained people to make complaints and for handling those complaints are improved. I am therefore recommending that both the Home Office and contractors take further action, as previously suggested by the PSU in February 2018.

Recommendation 28: Action to address barriers to making complaints The Home Office and its contractors operating immigration removal centres must take steps to identify and address the barriers to making complaints that are faced by detained people, including a fear of repercussions. This must include training for staff on their role in enabling detained people to overcome these barriers.

Complaints to Gatwick Detainees Welfare Group

13. In addition to making complaints to G4S staff or the Home Office, detained people could also raise concerns about their treatment with staff or visitors from GDWG. As one of the few non-governmental organisations with a presence on the ground at Brook House, and the only one concerned with detained people’s general welfare, GDWG was particularly important to the experience of detained people at Brook House. Several detained people described the group in positive terms ³⁸ and emphasised the significance of its role at Brook House.³⁹
14. GDWG provided anonymised summaries of occasions when it was told about concerns. For example, five detained people told GDWG that they had been physically abused by staff during the relevant period, a further three made allegations against escort staff in Brook House, and others made allegations outside the relevant period.⁴⁰ If a complaint was raised by a detained person or by a GDWG visitor on their behalf, the GDWG Director decided whether to pass it on to G4S.⁴¹ Mr James Wilson (Director of GDWG during the relevant period) said that, beyond a threshold of immediate risk, the decision whether to report a concern was fact-specific.⁴² Ms Pincus noted that one difficulty with taking action was that, after they reported something, a detained person might be moved around the immigration detention estate, making it more difficult for GDWG to follow up.⁴³ She also said that there were “very, very many people complaining about very, very many things”, and that GDWG would have overwhelmed G4S and the Home Office if it had raised matters with them on every occasion.⁴⁴
15. More generally, GDWG told the Inquiry that, although it knew that some detained people had complaints about their treatment and were not treated well, it only realised the gravity of the situation upon watching the Panorama programme.⁴⁵ Mr Wilson said that GDWG staff and visitors could not see things themselves because they were not allowed onto the wings.⁴⁶ Ms Pincus felt that they did not appreciate the situation from talking to detained people because poor treatment was just “another … manifestation of an injustice that they felt, but it was one of many, and they were bringing them all to us”.⁴⁷ Mr Jamie Macpherson, a GDWG visitor, said he was aware of inadequate healthcare and use of segregation as a punishment, but not of the sort of abuse shown by the Panorama programme.⁴⁸

Issues identified regarding the role of G4S in the complaints process

16. Complaints about minor misconduct (such as staff being rude or unhelpful) and service delivery (such as access to IT services or issues about the physical environment) were allocated to G4S.

Problems arising from the handling of complaints by G4S

17. Most of the complaints submitted during or about the relevant period about service delivery or minor staff misconduct, which G4S was responsible for investigating, were found to be unsubstantiated. This included complaints about facilities, staff behaviour, bullying, access to property, the smell of the cells and staff rudeness during visits.⁴⁹ Complaints about alleged racism and aggressive behaviour by Detention Custody Officer (DCO) Darren Tomsett, discussed in Chapter D.9, were found to be unsubstantiated.⁵⁰ Three complaints that were upheld against staff were related to allegations of the verbal abuse of D119.⁵¹
18. Several complaints investigations were carried out by Detention Custody Managers (DCMs) or acting DCMs who themselves were or had been subject to multiple complaints about their conduct towards detained people (such as Mr Tomsett, who was made acting DCM in August 2017) or who I have found to have verbally or physically abused detained people (such as DCM Nathan Ring).⁵² This may be unavoidable when complaints investigations are undertaken internally, but it is problematic.
19. The majority of complaints were found to be unsubstantiated, which may suggest a tendency for an accused member of staff to be believed over a detained person.⁵³ This is an inherent risk when staff members investigate their own colleagues.
20. There was, more generally, an incentive for G4S to find complaints to be unsubstantiated. In any system in which an organisation is investigating complaints made against its own staff, there is the potential for managers not to find such complaints to be substantiated because it would reflect badly on them. This can happen non-deliberately and is the inevitable consequence of permitting G4S to investigate complaints itself. There was also a specific incentive for G4S managers to find complaints to be unsubstantiated: penalty points were incurred under the contract for substantiated complaints.⁵⁴
21. Although it is appropriate for certain types of complaints to be investigated by contractors who run IRCs, the issues highlighted above must be taken into account to ensure a proper process. This includes guarding against managers feeling incentivised to find complaints to be unsubstantiated, ensuring that investigations are carried out by senior managers who are not themselves the subject of multiple complaints, and avoiding any tendency for accused members of staff to be believed over detained people.

Monitoring

22. The Complaints DSO required G4S to appoint a manager with responsibility for ensuring that effective systems and processes were in place to manage and investigate complaints relating to service provision or the behaviour of G4S staff.⁵⁵ In turn, the G4S policy required a monthly complaints report to be compiled detailing the nature of the complaints, their outcomes, which areas actioned the investigations, their categories and the nationalities of the complainants. Its purpose was to inform senior management of all the complaints received during the previous month and to offer comparisons on a quarterly basis for trend analysis purposes.⁵⁶
23. During the relevant period, Ms Karen Goulder was the Complaints Administrator and maintained a Master Complaints Register or log.⁵⁷ The Inquiry has not seen evidence of monthly reports being produced or shared. Although Ms Goulder stated that a spreadsheet was sent to senior managers and directors on a monthly basis, the absence of any other evidence of this being produced or shared suggests that it is unlikely that this was correct.⁵⁸ One consequence of the lack of monthly reports is that the number of complaints made during the relevant period remains unclear.⁵⁹ It is therefore difficult to see whether or how G4S could have undertaken any analysis of trends.
24. In its 2019 report, HMIP recommended that managers investigate and address the reasons for the low confidence of detained people in the complaints system, noting:

“During the last six months, 95 complaints had been dealt with by G4S, only one of which (1%) had been substantiated. We saw evidence that some of the unsubstantiated complaints should have been upheld.”⁶⁰

This had not been achieved by the time of HMIP’s 2022 inspection report (by which time Brook House was run by Serco), in which it was noted that there were fewer complaints and a higher proportion of them had been upheld.⁶¹ Any complaints that were substantiated or involved staff members were sent to the Deputy Director to review, but no other quality assurance process for complaints was in place. The complaints were not discussed in detail at any meetings in order to identify patterns or emerging trends.⁶²

25. During the relevant period, Home Office staff were required to have undertaken “a monthly dip sample of responses in order to monitor the quality of initial responses”; this requirement continues today.⁶³ In addition, under the Complaints DSO (updated most recently in April 2023), the Home Office now requires an annual self-audit of complaint responses to be carried out by contractors and provided to the Home Office.⁶⁴This may be helpful but, in my view, the Home Office should have a more active role in the complaints process – in order to assure itself that it understands the quality of contractors’ investigations, as well as to identify patterns or trends of complaints, whether by dip sampling or other means. More recently, since October 2022, the Home Office has introduced an ‘Independent Examiner of Complaints’ service, which is responsible for dealing with appeals against responses to service delivery and minor misconduct complaints.⁶⁵ Its efficacy is as yet unclear given its recent introduction.
26. With express consent, all complaints and responses were required to be sent to the IMB.⁶⁶ The IMB’s role was limited to monitoring the nature and extent of complaints and the timeliness of responses, rather than reviewing the investigations or outcomes reached.⁶⁷

1. Detention Centre Rules 2001, Rule 38. Healthcare complaints were usually handled separately and are discussed in Chapter D.8 (HOM0331998_005 para 18; see also CJS000727_007-009 paras 9-21) [↩]
2. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023); Requests and Complaints policy (CJS000700), G4S Gatwick IRCs, September 2008[↩]
3. A complaints form (DCF9) or any other written complaint was to be deposited in boxes at Brook House, marked ‘Immigration and Enforcement Complaints’ (HOM002748_046). Example form: CJS001616_003-005[↩]
4. CJS000727_004 para 1; HOM0331998_004[↩]
5. CJS000727_010 para 27[↩]
6. CJS0074154_005 Q11[↩]
7. HMIP000674_083[↩]
8. CJS001107_041 para 9.11[↩]
9. CJS001107_041 para 9.14[↩]
10. HOM0332029 row 90[↩]
11. HOM002748_046; HOM0332047_010 paras 34-35. It is unclear what, if any, changes were made by the Home Office in response (see HOM0332029 row 83) [↩]
12. DPG000002_031-032 para 83 (see also CJS000625) [↩]
13. BHM000018_009 para 34; BHM000018_012 para 40[↩]
14. BHM000029_010 para 38; BHM000034_022 para 60; DPG000022_012 para 44; BHM000039_008 para 43[↩]
15. HOM0331998_005 (see also BHM000031_077; DL0000226_039 para 158) [↩]
16. DL0000233_018 paras 83-84[↩]
17. DPG000002_033-034 para 88[↩]
18. HOM002521; HOM002520[↩]
19. CJS000421; HOM000798_124-126; CJS000700; CJS000292; HOM0331998_005-006 para 16; CJS000727_010-011. They were also required to encourage a detained person to make their complaint in writing, and to make arrangements to help people who might find it difficult to submit a complaint in the correct way (for example, because of language or literacy difficulties) [↩]
20. See, for example, DL0000151_004 para 21; CJS000994_011[↩]
21. HMIP000674_091[↩]
22. BHM000041_042-043 para 117 (see also INQ000057_015 para 43) [↩]
23. DL0000233 para 85; BHM000018_012 para 40[↩]
24. BHM000029_010 para 38[↩]
25. Anna Pincus 9 December 2021 61/6-63/20; DPG000002_033 para 87[↩]
26. HMIP000671_009. By contrast, in prisons, the Ministry of Justice is responsible for detention and complaints but a judge decides on fact and length of sentence[↩]
27. See, for example, CJS001616_003[↩]
28. CJS000727_006 para 6[↩]
29. Dr Hindpal Singh Bhui 24 March 2022 146/5-15[↩]
30. DPG000002_033 para 87[↩][↩]
31. HOM002748_046. This labelling is mandated by the Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), para 25[↩]
32. HOM002748_012[↩][↩]
33. CJS0074154_011[↩]
34. BHM000018_012 para 40[↩]
35. D1851 3 December 2021 76/7-11[↩]
36. See, for example, Sean Sayers 10 March 2022 164/11-165/22[↩]
37. Report on an Unannounced Inspection of Brook House Immigration Removal Centre 30 May–16 June 2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022, p66[↩]
38. D668 22 February 2022 68/14; DPG000023_010 para 37; DPG000040_010 para 43[↩]
39. Anton Bole 8 December 2021 160/1-10; Anton Bole 8 December 2021 160/1-10; SER000455_022 para 60; SER000453_057 para 253[↩]
40. GDW000010; DPG000002_023 para 58[↩]
41. Anna Pincus 9 December 2021 57/3-58/14[↩]
42. James Wilson 10 December 2021 71/19-25[↩]
43. Anna Pincus 9 December 2021 69/10-70/13[↩]
44. Anna Pincus 9 December 2021 78/10-20[↩]
45. DPG000002_027-031 paras 70-82; DPG000003_004 para 14[↩]
46. James Wilson 10 December 2021 68/17-24[↩]
47. Anna Pincus 9 December 2021 92/14-16[↩]
48. Jamie Macpherson 8 December 2022 222/23[↩]
49. See, for example, HOM002781; HOM002695; HOM002783; HOM002697; HOM005233; HOM005232; HOM005247; HOM005246[↩]
50. For example, HOM002784; HOM002714; HOM002767; HOM002190[↩]
51. HOM002709; CJS005888; HOM002789; HOM002701[↩]
52. INN000024_001 para 2; Mr Tomsett said that he dealt with complaints with an open mind, but had no formal training in investigations (Darren Tomsett 7 March 2022 66/25-67/12, 68/1-11, 78/2-8). See Chapters C.11 and C.4 in Volume I regarding Mr Ring’s conduct in relation to D1275 and D1527 respectively[↩]
53. See, for example, HOM002769; HOM002767[↩]
54. HOM000921_003[↩]
55. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017, para 35 (updated April 2023 – see para 52) [↩]
56. CJS000700[↩]
57. SER000460_010-012 paras 39-46; CJS001558[↩]
58. SER000460_013 para 50[↩]
59. For example, G4S/IMB combined reports record 76 complaints during the relevant period (CJS004580; CJS004579; CJS004586; CJS004581; CJS004585; IMB000021; IMB000050; IMB000011; IMB000047; IMB000019), but it is not clear if this means 76 different individuals or 76 different allegations, or whether the total number is of new complaints or a rolling total. Additionally, one G4S spreadsheet on complaints (CJS000651) suggests that 40 complaints were received during the relevant period, whereas another (CJS001558 rows 56-149) suggests that this number is 94[↩]
60. HMIP000674_035 para 2.19; HMIP000674_054 para S48. HMIP noted that, during 2018, 8 per cent of complaints were fully substantiated (HMIP000674_035 para 2.19) [↩]
61. Report on an Unannounced Inspection of Brook House Immigration Removal Centre 30 May–16 June 2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022, p53[↩]
62. Report on an Unannounced Inspection of Brook House Immigration Removal Centre 30 May–16 June2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022, para 3.11[↩]
63. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017, para 41 (updated April 2023 – see para 60). See also HOM0331998_004[↩]
64. Detention Services Order 03/2015: Handling of Complaints, Home Office, April 2023, para 64[↩]
65. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), para 56. See also the guidance about making a complaint to the Independent Examiner of Complaints[↩]
66. HOM0331998_009 para 32. See also CJS000727_015 para 45; CJS000727_016 para 47[↩]
67. VER000138_009-010; VER000138_012; VER000138_017; VER000138_019[↩]