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Assessment and management of risks

  1. To ensure the safety and welfare of anyone detained at Brook House, staff should have assessed their needs and any potential risks to their wellbeing. Proper assessment and management of any risks, throughout their time in detention, were necessary in order to keep detained people safe.

Reception and induction

  1. Upon arrival at Brook House, all detained people should have received a reception and induction that familiarised them with their surroundings, answered any questions, and provided key information regarding the IRC, its regime and other factors relating to safety and decency.1 This was important in order to provide detained people with essential information about Brook House while continuing the process of assessing risks surrounding their detention, welfare needs, any vulnerability issues and their proficiency in English.2
  2. The reality was different: many detained people did not receive a proper reception or induction.3 The 2022 HMIP inspection report suggested that some of these issues persisted under Serco’s management of Brook House. Although detained people received a good one-to-one induction, HMIP had a key concern: “The identification and management of risks on arrival was not good enough.” It noted

“Not all detainees were offered a private interview on arrival and staff did not always spend enough time enquiring into detainees’ risks.”4

  1. The induction policy also required new admissions to be accommodated on B Wing (the wing designated as a First Night and Induction Unit) for at least 24 hours. This was to ensure that newly arrived detained people could receive a full induction and were not immediately mixed with those who had already been detained for a long time.5 This often did not happen because B Wing was being used to house other detained people.6 As noted in the 2018 Verita report:

“The failure to house detainees in an induction wing where they could be properly assessed and any concerns about them identified presented a risk to their welfare and wellbeing.”7

Cell sharing

  1. There also appears to have been an inadequate process for assessing risk when allocating detained people to cells.
  2. In accordance with Detention Services Order 12/2012: Room Sharing Risk Assessment, staff were required to carry out a room-sharing risk assessment for each detained person to identify those who posed a risk to others. They were also required to record any additional precautionary measures where cell sharing was unavoidable.8
  3. Proper risk assessment is crucial to avoid detained people being placed at unnecessary risk. However, the operation of this process appears to have been deficient. For example, D1876 was placed with a cell mate who subjected him to violence, although he indicated that he had told staff beforehand that there was a war between their countries of origin and that he did not want to share a cell with him, but “nobody listened”.9 D2033’s cell mate made him feel “very afraid” after he saw that his cell mate had “destroyed and broken everything in the room”, “was always shouting and screaming” and threatened him with what he thought was a plastic knife. This was after D2033 had “pleaded with the officers that I should be kept somewhere safe and transferred back to the first wing where I had a room by myself”.10 In both cases, the Inquiry did not receive any record of a room-sharing risk assessment being created or amended during the relevant period.11)
  4. There were also problems with allocation regardless of risk assessment. Some staff felt under pressure from the Home Office not to allocate detained people to single occupancy cells.12 Others said that they co-located potentially unsuitable detained people in cells together because Brook House was full.13
  5. There was an inadequate process for assessing risk when allocating detained people to cells and there were problems with allocation arising from capacity pressures. Risk assessment must be conducted properly and capacity issues should not be prioritised over the welfare of detained people. I am therefore recommending steps to assess and manage risks related to cell sharing.
Recommendation 5: Undertaking and complying with cell‑sharing risk assessment

The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least every 14 days) or following any relevant change in circumstances.
In the event that an immigration removal centre is unable to detain someone in accordance with the outcome of a risk assessment (due to capacity or for other reasons), the Home Office must ensure that the individual does not remain at that centre.

Staff response to bullying or intimidation among detained people

  1. Violence and bullying among detained people were undoubtedly part of life at Brook House during the relevant period.14 There were 32 reports of bullying, 28 recorded fights and 31 recorded assaults on detained people. In June 2017, around 10 per cent of detained people were recorded as being involved in physical violence, which dropped to around 4 per cent in July 2017 and 3 per cent in August 2017. For some detained people, it is likely that this had an impact on whether they felt safe at Brook House.
  2. G4S had procedures for addressing bullying among detained people.15 However, these were not always followed and the Inquiry saw evidence that instances of bullying and violence were not consistently, or promptly, investigated.16 Some detained people also told the Inquiry of a lack of intervention from staff when they or other detained people were being bullied or assaulted.17
  3. The ability of staff to prevent and respond to violence and bullying was affected by insufficient staffing levels, and their inability had a negative impact on life at Brook House for detained people.18

The mixing of time served foreign national offenders with other detained people

  1. During the relevant period, approximately one-third of the detained people at Brook House were foreign nationals who had served a sentence in a UK prison having been convicted of a criminal offence (known as time served foreign national offenders (TSFNOs)) and were due to be deported as a result.19
  2. There were also individuals whose applications for asylum had been rejected or were still being considered. Others were thought to have entered or remained in the UK illegally, sometimes referred to as ‘overstayers’. The mixing of these groups was identified as a potential issue in the Panorama programme and in the 2018 Verita report.20 Some staff criticised the mixing of TSFNOs and others at Brook House, describing it as “very difficult” and “dangerous” as well as causing significant issues for staff and vulnerable detained people.21 Others were less concerned.22
  3. There was some evidence to suggest that TSFNOs were disproportionately involved in incidents of violence or threatening behaviour. However, this may have been because a few individuals were responsible for a large number of incidents.23 The Inquiry is also aware that TSFNOs detained in Tinsley House did not appear to present the same degree of problematic behaviour as those at Brook House. This suggests that behaviour was affected by the environment at Brook House rather than by the mixing of different groups.24 In my view, there is insufficient evidence to suggest that either the numbers of TSFNOs or the mixing of TSFNOs with others caused or contributed to conditions in which poor treatment was more likely to occur.25 There is no positive evidence of such a link, and the individual differences between detained people make it impossible to assess, in any event. If anything, as a group, TSFNOs might well have been more vulnerable than others at Brook House and might have had greater unmet needs.26


  1. CJS006042_004-007 p4, sections 1-2[]
  2. CJS006042_004; Detention Services Order 06/2013: Reception, Induction and Discharge Checklist and Supplementary Guidance (CJS000681), Home Office, July 2016, paras 11-15, 19-20 and 26 (updated August 2021, paras 28, 30-37, 41-42 and 48[]
  3. D643 22 February 2022 4/17-5/21; CJS0073709_158 para 10.35; VER000269_017-018; BHM000018_005 para 21 (D1713); DPG000040_002-003 paras 7-11 (D180); CJS0074154_003[]
  4. INQ000227_006 para 7; INQ000227_011 para 1.7[]
  5. CJS006042_004; CJS006042_010[]
  6. D1618 3 December 2021 12/24-13/8; Darren Tomsett 7 March 2022 6/8-7/17; CJS0073709_019 para 1.73; CJS0073709_158 para 10.35; INN000024_007 para 22[]
  7. CJS0073709_019 para 1.74[]
  8. See Detention Services Order 12/2012: Room Sharing Risk Assessment (CJS000710), Home Office, August 2012 (updated September 2016); CJS006042_022. See examples at CJS001148_013-014; HOM004135[]
  9. DPG000039_028 para 108[]
  10. DL0000149_005 para 19; DL0000149_006 paras 20-21; DL0000149_007 paras 25-26[]
  11. Although, for D1876, there is a record of such an assessment in 2018, when D1876 was placed in single occupancy (HOM032510[]
  12. CJS0073709_156 paras 10.29-10.30[]
  13. SER000447_009 paras 45-46[]
  14. CJS0073709_188[]
  15. CJS000015_001-004; CJS001127_001-007. Bullying was defined as “Conduct motivated by a desire to hurt, threaten or frighten someone. It can be physical, verbal, psychological, emotional or economical and often very subtle. It is usually repeated behaviour, unprovoked and intended to cause fear or harm to the victim” (CJS001127_001[]
  16. CJS0073709_198 paras 12.39-12.40; CJS000625_002; CJS000637_002[]
  17. DL0000228_041 para 146 (D643); INQ000055_005-006 paras 28-29 (D1618[]
  18. CJS0073709_189 para 12.12; CJS0073709_195 para 12.30; CJS0074154_007-008[]
  19. The average proportion of detained people at Brook House who were TSFNOs during the relevant period was 33–36 per cent (CJS000905; CJS000908; CJS000914; CJS000910; CJS000619; IMB000021; IMB000050; IMB000011; IMB000047; IMB000019). See also CJS0073709_060 para6.1 and CJS0073709_192, which show that the number of TSFNOs was higher in the period from December 2017 to May 2018[]
  20. CJS0073709_054 para 5.8[]
  21. VER000226_021; Callum Tulley 1 December 2021 14/21-16/10; Charles Francis 3 March 2022  20/2-22; Stephen Webb 8 March 2022 136/16-139/7; HOW000001_005; INN000007_048 para 193; IPA000001_012 para 92; CJS0074154_011[]
  22. SER000453_040 para 182; SER000436_013 para 62; INQ000166_032 para 94[]
  23. CJS0073709_063 para 6.10; CJS0073709_191-193 paras 12.21-12.22; VER0000226_009-010[]
  24. CJS0073709_063 para 6.10; VER000225_012[]
  25. This view is supported by both G4S (CJS0074153_034-035 para 101) and solicitors representing detained people (BHM000046_164-165 paras 400-402[]
  26. BHM000030_050-051 paras 115-118[]