The Home Office contract performance management

20. Under its contract, G4S was required to monitor compliance with the performance measures and to report any failures to the Home Office. Compliance was monitored by the Home Office during the relevant period in various ways, including:

• quarterly, monthly and weekly meetings;
• weekly and monthly self-declaration;
• reviewing data such as raw staffing level data;
• talking to staff and walking around Brook House; and
• reviewing various forms and other paperwork.¹

Reliance on self-reporting by the contractor

21. Self-reporting by G4S was therefore an important feature of the contract. During regular meetings, G4S presented an account recording failures to comply with the performance measures in Schedule G and raised possible grounds of mitigation. Any issues or failings would be discussed at weekly meetings, and performance points would be agreed at monthly contract review meetings.²
22. To illustrate how the reporting system worked in practice, a number of witnesses were asked about the penalty points attached to the ‘self-harm resulting in injury’ performance measure.

22.1 This required reporting of:

“Any known incident of deliberate self-harm resulting in physical injury requiring any form of healthcare intervention and involves any failure to follow laid down procedures for the safety of Detainees set out in Schedule D”.³

22.2 Data gathered by G4S and the Home Office at the time showed that, during the relevant period, there were 60 acts of self-harm by detained people, of which four required treatment off site.⁴ None gave rise to a performance measure report or penalty.

22.3 There was an apparent lack of clarity over the circumstances in which a self-harm event would need to be reported as a possible contractual failure. For example, on 4 July 2017, D865 was found in his cell unconscious, having placed a ligature around his neck. Detention Custody Manager (DCM) Christopher Donnelly accepted that he failed to check for a ligature, which he should have done immediately, until around two minutes after entering the cell.⁵ The witnesses were divided as to whether, had this failure been reported, it would have amounted to a performance failure by G4S giving rise to penalty points. The view of Home Office Contract Monitor Mr Paul Gasson seemed to be that a reportable failure would be one where contractually required training updates had not been met, or where an Assessment Care in Detention and Teamwork (ACDT) plan had not been opened but should have been.⁶ Mr Daniel Haughton, G4S Support Services Manager during the relevant period, felt that an individual error was likely to amount to a failure to follow procedures, potentially giving rise to a penalty that was not reported because it was not declared by Mr Donnelly.⁷ Mr Ben Saunders, Centre Director for Brook House and Tinsley House (Gatwick IRCs) during the relevant period, told the Inquiry that all known self-harm events were reported to the Home Office at Safer Community meetings. Mr Saunders said that he signed off monthly G4S reports to the Home Office, adding: “I don’t know particularly how much scrutiny they paid to incidents. Not a huge amount, I would suggest.”⁸

22.4 There was no real suggestion of an interrogation of the levels of self-harm, or its causes, by Mr Gasson as the contract monitor, or by anyone else at the Home Office. Mr Ian Castle, Home Office Detention and Escorting Services (DES) Area Manager for Gatwick IRCs during the relevant period, managed the Compliance Team. He was unable to say whether the level of self-harm (60 acts over the relevant period) “was good or bad”, as he had nothing with which to compare it.⁹ Mr Gasson gave the impression that monitoring of self-harm was done within the quite rigid definitions of the contract, but in any event confirmed that his team would not go back and check for failures that might have led to the event.¹⁰

23. The G4S and Home Office staff tasked with monitoring G4S’s compliance with the prevention of self-harm did not take appropriate steps to check for failings, despite significant known levels of self-harm. If this was due to a lack of clarity in the wording of the contract, clarity should have been sought. Mr Castle told the Inquiry that he relied on G4S to accurately report any self-harm event that met the criteria. He did not “personally” ensure that performance reports were accurate and could not say with any certainty what, if anything, his monitoring team did to check the information.¹¹ He accepted that, in purely financial terms, G4S was disincentivised from reporting its own failures.¹² In his view, self-reporting was the only method available under the contract to ensure compliance: “we did rely on honesty and integrity from G4S”.¹³ Ms Michelle Smith, Home Office Service Delivery Manager for Gatwick IRCs during the relevant period, agreed that, where a contract requires self- reporting, “it’s a matter of trust”.¹⁴
24. The Home Office suggested that the lack of any penalties under the self-harm KPI, despite significant self-harm incidents, was explained by the fact that a penalty was incurred only if procedures were not followed.¹⁵ The Home Office said that this demonstrated that “the KPI … set too high a test for failure”.¹⁶ However, in my view, as there was no adequate process by the Home Office to check whether procedures had been followed correctly, it was not possible to tell whether the lack of penalty points was due to the threshold or to a lack of monitoring.¹⁷
25. Penalties also attached to staffing levels, which were similarly reported by G4S and subject to Home Office monitoring.

25.1 G4S was required to:

“ensure that staffing in the Removal Centre allows at all times for an ordered, controlled, disciplined and safe environment for Detainees, Staff and Visitors and meets the obligations and complies with the provisions of the Contract at all times”.¹⁸

25.2 The contract between G4S and the Home Office also included a ‘minimum’ or ‘required’ level of staff within the IRC based on the number of detained people at Brook House.¹⁹

25.3 Failures to achieve contractual minimum staffing levels at Brook House could result in penalties (performance points) for G4S, as set out in Schedule G.²⁰ The number of performance points would increase with the severity of the shortfall and where a failure was repeated multiple times in one month.²¹

25.4 During the relevant period, the total Detention Custody Officer (DCO) staffing achieved by G4S often fell short of the minimum requirement. For example, staffing levels gave rise to penalty points on 13 occasions between June and August 2017, almost always at weekends. On four occasions, staffing was 90 per cent of the minimum level or below.²² Fines for understaffing during the relevant period amounted to £2,205.75.²³

25.5 There were also other related contractual obligations that did not appear to have been met by G4S from time to time. For example, although this varied, three or four DCMs should have been present during the daytime and two at night.²⁴ However, Mr Stephen Loughton, a DCM during the relevant period (now Assistant Director), told the Inquiry that “Every couple of months” he had been the only DCM looking after four wings.²⁵ The Inquiry was told that there was an “unmanageable workload” for DCOs working on residential wings, involving such tasks as:

“admitting detainees to the wing, filling out ACDT observations, making property appointments, handing out essentials like toilet roll and soap, checking detainees’ cards as they tried to access the wing, allocating detainees to rooms, resolving detainee disputes, responding to incidents of violence or self-harm on the wing, escorting detainees to the kitchen to work and collecting the food trolley from the kitchen”.²⁶

25.6 Although the staffing requirements of Brook House fluctuated throughout the day and depended on the needs of the population, monitoring was simply based on the number of DCO hours on site over a 24-hour period. Ms Smith said that this method for calculating compliance was inappropriate, as “it doesn’t really give you any control over where people are at any given time”.²⁷

The adequacy of Home Office performance management

26. There were insufficient Home Office staff to properly monitor the contract during the relevant period. The National Audit Office concluded that, until 2018, the Home Office did not have sufficient staff to verify or validate G4S’s reported level of performance.²⁸ This was accepted by Mr Gasson.²⁹ Mr Riley said that the Home Office staff at Brook House were too focused on “serving of papers and doing the returns-focused work. We should have … taken more responsibility for monitoring the overall experience of detainees.”³⁰ Ms Smith agreed that “the team … had limited time to focus on the compliance activity” as a result of engagement work with detained people.³¹ She acknowledged that there was insufficient time to carry out dip sampling of G4S self-audits:

“there was a KPI within the business plan in detention that required the onsite team to carry out seven hours’ contract monitoring per week, that was the expectation, and an acceptance that, in the main, that didn’t really stretch further than being able to have – attend meetings”.³²

27. Ms Smith also told the Inquiry that there was no contractual requirement on the Home Office team at Brook House to report on the overall welfare of detained people, and that she expected external monitoring bodies to perform this role.³³ It appears therefore that, during the relevant period, Home Office staff at Brook House paid only superficial attention to welfare standards, which should have been their fundamental concern.
28. In my view, as a result of inadequate performance management by the Home Office, its contractor, G4S, did not face financial sanctions in circumstances where robust monitoring would likely have revealed failures that merited them. Critically, opportunities to improve safety were also potentially missed. As Mr Riley conceded, “if we had adequately resourced our management of the contract, then I don’t think that the abuse would have happened”.³⁴
29. Following the Panorama programme, the Home Office concluded that the behaviour depicted did not constitute evidence of systemic failures or a material breach of the contract, and that it was not necessary to try to terminate G4S’s contract. The Home Office and G4S “analysed the Panorama programme and counted 84 separate incidents”, some of which related to different aspects of the same event.³⁵ Some related to the inappropriate use of force and language, which were not themselves contractual performance measures. Most of the uses of force by staff against detained people shown in the Panorama programme were already known to G4S and the Home Office. Of the 84 incidents, the majority had not been previously reported under the contractual performance and incident reporting, but the Home Office agreed that G4S did not have a responsibility to report most of these incidents, finding that only four required reporting according to the contract.³⁵
30. In its Closing Statement to the Inquiry, the Home Office acknowledged that “the treatment shown in the Panorama Broadcast was completely unacceptable”.78 Mr Riley also conceded that its contract “did not give the Home Office sufficient ‘leverage’” to hold G4S to account in delivering services in accordance with the contract or the requirements of the Rules and other guidelines.³⁶

1. HOM0332165 para 106; see also HOM0332004_006-007 paras 14-17; HOM0332152_003-006 paras 12-25; Michelle Smith 23 March 2022 114/21-133/6, 143/13-21[↩]
2. Daniel Haughton 16 March 2022 79/2-23; HOM0332004_005-006 paras 12-15[↩]
3. HOM000921_005[↩]
4. IMB000021; IMB000050; IMB000011; IMB000047; IMB000019[↩]
5. Christopher Donnelly 23 February 2022 116/3-4[↩]
6. Paul Gasson 15 March 2022 156/3-161/5[↩]
7. Daniel Haughton 16 March 2022 87/5-88/7[↩]
8. Ben Saunders 22 March 2022 159/18-24[↩]
9. Ian Castle 15 March 2022 22/23-23/2[↩]
10. Paul Gasson 15 March 2022 161/21-162/10[↩]
11. Ian Castle 15 March 2022 20/1-4[↩]
12. Ian Castle 15 March 2022 20/19-23, 21/13-20[↩]
13. Ian Castle 15 March 2022 21/5-12[↩]
14. Michelle Smith 23 March 2022 145/16-22[↩]
15. HOM0332165_035-036 para 110[↩]
16. HOM0332165_036 para 110[↩]
17. Paul Gasson 15 March 2022 161/12-162/10; Ian Castle 15 March 2022 16/25-20/7[↩]
18. HOM000798_180 clause 19.1[↩]
19. During the relevant period, G4S should have provided 668 hours of DCO time each weekday (655 hours at weekends) and at least two DCOs should have been on duty on each residential wing during the daytime (CJS0073709_010; CJS004586_014[↩]
20. HOM000921_007 para 2(iii)(o)(ii); CJS000524; CJS004452[↩]
21. HOM000921_006-007 (updated October 2009); CJS004452[↩]
22. Data from monthly performance reports (CJS004586; CJS004581; CJS004585[↩]
23. CJS0074522_006-007 para 28; 1,275 penalty points were incurred at £1.73 per point[↩]
24. VER000266 paras 138-145; SER000453 para 123[↩]
25. Stephen Loughton 1 March 2022 73/23-75/7[↩]
26. INQ000052 para 71[↩]
27. Michelle Smith 23 March 2022 115/13-17[↩]
28. DL0000175[↩]
29. Paul Gasson 15 March 2022 145/5-25[↩]
30. Philip Riley 4 April 2022 57/15-1[↩]
31. Michelle Smith 23 March 2022 111/20–112/6[↩]
32. Michelle Smith 23 March 2022 114/12-18. Along with attending compliance meetings, Home Office representatives would attend ‘detainee forum meetings’ as well as monthly Independent Monitoring Board (IMB) meetings, while other Home Office employees acted as IMB clerks and took minutes (INQ000057 para 37; Michelle Smith 23 March 2022 110/4-6[↩]
33. Michelle Smith 23 March 2022 129/22-24[↩]
34. Philip Riley 4 April 2022 94/11-13[↩]
35. DL000175_021 paras 2.7-2.9[↩][↩]
36. HOM0332165 para 2[↩]