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Examination after admission

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Legal and policy framework

  1. Rule 34 of the Rules requires that there should be a medical examination of every detained person by a medical practitioner within 24 hours of their arrival in a detention centre. This must be a “physical and mental examination”.1 The Rules also state that a medical practitioner is someone “vocationally trained as a general practitioner” and registered with the General Medical Council.2
  2. There is a dual purpose to Rule 34.

8.1 It functions to identify the immediate health needs of a detained person upon arrival at an IRC.3 This is particularly significant given that the Home Office does not medically screen individuals to identify vulnerabilities before they are detained.4 Dr James Hard, the Inquiry’s medical expert, stated that Rule 34 is:

“inherently important for the early identification of ongoing health needs of an individual on arrival in a place of detention and is crucial for the planning of the detained person’s care whilst in Brook House or any other secure or detained setting”.5

8.2 The Rule 34 examination on arrival in detention is essentially the first opportunity to prevent a vulnerable detained person from being exposed to a risk of harm. It functions as an important safeguard to identify vulnerable people who should not be in detention. Dr Rachel Bingham, clinical advisor to Medical Justice (a charity that provides medico-legal reports and advice to detained people), described the functions of Rule 34 as being:

“to identify the need for a Rule 35 report, but also to undertake a physical and mental state examination to determine what, if any, treatment is required and capable of being provided within immigration detention. The absence of proper Rule 34 medical examinations leads to belated identification of physical health issues, and consequential delays to treatment. It also means an important piece of clinical evidence relevant to the consideration of decision-making concerning the exercise of detention powers is missing.”6

This reflects the important role of Healthcare in an IRC to provide both primary healthcare and also clinical safeguards that identify who is vulnerable to harm in detention.

  1. Where criteria are met, a Rule 35 report should be completed by the GP and raised with the Home Office “without delay”.7 The form might be completed at a Rule 34 examination, so that detention can be reviewed at a very early stage. This enables the Home Office to review an individual’s continued detention promptly and, unless there are exceptional circumstances, to remove them from detention.8 In this way, the two rules are designed to work together as a safeguard for vulnerable detained people at the start of detention.9 In my view, this is the only way to interpret the Rules correctly, given the policy background – as the Home Office appeared to accept.10 The aim of the policy is that those who may be vulnerable and at risk of harm should be consistently identified to ensure that their detention is reviewed by the Home Office and their release considered.

The application of this framework at Brook House

  1. It is, however, abundantly clear from the evidence received by the Inquiry that there were a number of deficiencies in the way in which Rule 34 was operating at Brook House in the relevant period (1 April 2017 to 31 August 2017), and indeed in the way in which it is currently operating.
  2. Although this is not reflected in Rule 34, health screening of a detained person on arrival operated in two parts at Brook House.

11.1 On immediate arrival, a nursing screen – sometimes referred to as an initial reception health screen – was to be carried out within two hours.11 This comprised a questionnaire designed to elicit information that would enable the immediate needs of the detained person to be met (such as obtaining medication) and to identify any vulnerabilities. The initial reception screenings were carried out 24 hours a day and the aim was for the screening to be completed within two hours of the detained person’s arrival.12 It was designed to elicit information from the detained person about their physical and mental health, background and any history of self-harm. Its purpose was to safeguard the detained person and to find out whether ongoing care was needed. This was described by Ms Sandra Calver, Head of Healthcare at Brook House during the relevant period and at the time of the Inquiry’s public hearings, as the first part of the two-part screening.13

11.2 The second part of the screening was undertaken by a GP within 24 hours of the detained person’s arrival.

  1. However, in practice, the nursing screen was sometimes the only appointment that occurred.14 It was effectively treated as the examination required under Rule 34. On its own, it could not fulfil the requirements of a mental and physical examination by a GP within 24 hours. It was also not a mental and physical examination, which was required. Instead, it involved the use of a proforma designed to elicit a basic history and medical information. Effectively, it was a tick box exercise.15 For example, D1538’s screening in June 2017 by a nurse did not elicit a history of torture, instead noting that his scars were from fights and accidents.16 D1538 was not provided with an interpreter during this assessment. D1538 was subsequently provided with a Rule 35(3) report on 24 July 2017 in Harmondsworth immigration removal centre which detailed his history of torture.17
  2. Detained people were entitled to refuse the appointment with a GP, and sometimes did so.18 However, the nature of the appointment was not routinely explained to them, ie that it was a safeguard to identify any health needs or vulnerabilities that may lead to a Rule 35 report, a review of their detention and consideration of their release.19 Refusals were therefore not likely to have been an informed choice.20 Dr Hard noted:

“I haven’t seen anything so far that explains what is advised of the detainee of the purpose of those subsequent appointments or the potential appointment with the GP the following day … I do think it’s the healthcare provider’s responsibility to explain the importance of attending that appointment.”21

This is a deficiency that could easily have been remedied.

  1. When GP appointments were ostensibly provided under Rule 34, they were often not provided within 24 hours of a detained person’s arrival.22 This was in breach of Rule 34.
  2. Those GP appointments that did take place within the first 24 hours of a detained person’s arrival were scheduled to last for five minutes during the relevant period.23 This is not sufficient time to complete an adequate mental and physical examination in compliance with Rule 34.24 It is also insufficient time to complete a Rule 35 report, if required.25 Dr Husein Oozeerally, lead GP at Brook House during the relevant period and at the time of the Inquiry’s public hearings, accepted that it was not possible to perform the sort of physical and mental health examination required at this initial GP appointment. His evidence was: “It’s almost like a triage.”26 There was also only provision for one Rule 35 assessment to be carried out per day.27 In contrast, there were 641 new admissions to Brook House in April 2017, 702 in May, 531 in June, 593 in July and 603 in August.28
  3. Even when the nursing screening identified vulnerabilities, such as when an individual disclosed that they were a victim of torture, it did not always lead to a Rule 35 assessment or report, when it should have done so in every such case.29 Ms Calver told the Inquiry:

“It is now a mandatory question, asking about torture, and if it prompts ‘Yes’, there is a prompt that comes up to say make the appointment.”30

Often mental health was not properly assessed or recorded.31 This left detained people at risk of harm in detention, as their vulnerabilities were not notified to the Home Office for their detention to be reviewed.

  1. A practice also arose whereby Rule 35 reports were not written – or, indeed, considered – at the Rule 34 GP assessment.32 Instead, a second assessment appointment under Rule 35 was booked if something was flagged initially through screening or in that initial appointment. There was sometimes a considerable delay before the Rule 35 assessment.

17.1 During D1538’s Rule 34 appointment, for example, Dr Saeed Chaudhary recorded nothing about D1538’s history of torture despite scars on his body consistent with torture and a history recorded in the nurse’s screening of having run away from his family at the age of eight. Dr Chaudhary decided that D1538’s other complaints were to be discussed in a separate appointment.33 Those complaints related to physical symptoms such as headaches and backache as a result of previous assaults amounting to torture.

17.2 The Rule 34 process did not adequately identify D1914’s physical health issues either. He suffered from a serious heart condition and had a complex clinical history. He was taken to A&E by ambulance while he was at Brook House on multiple occasions after he complained of chest pains and palpitations and also following a blood test result indicating a possible blood clot. He did not receive a Rule 35(1) report until almost four months into his detention. Those medical vulnerabilities should have been identified far earlier.34 Consequently, in 2017, the safeguard was not operating effectively at the start of detention. The Inquiry heard evidence from a number of witnesses that this remained the case at the time of the Inquiry’s hearings.35

  1. Disconnecting Rule 34 and Rule 35 in this way was inappropriate. As Ms Theresa Schleicher, Casework Manager for Medical Justice, told the Inquiry:

“The whole purpose of the two rules taken together is to identify people immediately and route them out of detention. So if, instead, a period is a – a waiting period is allowed, that means people may deteriorate in the meantime.”36

The identification of any one of the criteria set out in Rule 35 in a Rule 34 appointment should have triggered automatically the immediate creation of a Rule 35 report. The detained person should not have been placed on a waiting list for a later Rule 35 appointment.37

  1. In my view, the Rules, operating together, require a proactive approach to the identification of vulnerabilities and require any such vulnerabilities to be acted upon without delay.
  2. The Inquiry also received evidence that a practice seemed to have developed that a detained person would have to ask for a Rule 35 report to trigger an assessment.38 Such a practice is entirely inappropriate. It was not for detained people to have to advocate for or request a report. The responsibility and obligation rested with the Healthcare staff and GPs to ensure that these reports were completed when necessary. Some detained people may not have been aware of the system, and so they would not have known to request a report. They would, therefore, have fallen through the cracks. This also led to a perception that detained people who asked for a report were “demanding” or somehow abusing the system.39
  3. These were significant deficiencies in the operation of Rule 34 (in conjunction with Rule 35) to properly protect vulnerable detained people at Brook House.40 Not having a functional way of identifying whether someone is at risk of harm in detention at the first opportunity is a serious concern. This is likely to have caused detained people to suffer actual harm – for example, through a deterioration in their mental or physical health. (See, for example, the cases of D1914 in Chapter D.8 and Chapter C.6 (in Volume I) and D1527 in Chapter C.4 (in Volume I)). The situation left vulnerable detained people in particular at risk of mistreatment, such as the inappropriate use of segregation and the rapid resort to use of force to manage incidents of self- harm and mental health crisis.41 It also meant that vulnerable people were detained when detention was not appropriate for them.42
  4. PPG, the contractor providing healthcare at Brook House, told the Inquiry of various improvements made to the provision of healthcare services since it took over the contract in September 2021.43 These are considered in more detail in Chapter D.8. At the time of the Inquiry’s public hearings, in significant respects the arrangements remained substantially the same as in the relevant period. For example, Rule 34 GP appointments were scheduled to last 10 minutes; this remained inadequate, as it provided insufficient opportunity to perform the requisite physical and mental examination.44 The 2022 HM Inspectorate of Prisons (HMIP) inspection report found that nursing staff and healthcare assistants completed a healthcare screening of detained people when they first arrived at the centre, but that the screening was not carried out consistently well. HMIP considered this to be a key concern.45
  5. A key contributing factor to the failure of the safeguards is likely to have been the unacceptable lack of training on Rule 34 and Rule 35 (and on the Adults at Risk policy) in Brook House, which appears still to be the case.46

23.1 Nurses did not routinely receive such training, despite their crucial role in identifying the need for Rule 35 reports and in referring detained people to GPs to complete such reports.46 This contributed to a lack of understanding of Rule 35.47 The Inquiry understands that further training is planned by PPG.48

23.2 Such training as was available from the Home Office (primarily for GPs) was inadequate. The Home Office ceased to provide it in 2016. Such training as was available from G4S Health Services during the relevant period, and from PPG more recently, was also inadequate. There was an inappropriate focus in the training on Rule 35(3) and the identification of victims of torture, to the exclusion of Rule 35(1) (health would be injuriously affected by continued detention) and Rule 35(2) (there is a suspicion of suicidal intentions).49 There was also a lack of training on identifying symptoms of torture.50 The provision of such training is ultimately the responsibility of the Home Office.51

  1. The Home Office should have prioritised the delivery of a comprehensive mandatory programme of training for relevant staff in Brook House, to ensure that they understood how to apply properly the policy and their obligations under the Rules. The Inquiry received evidence of current practice that indicates that problems persist.52 In October 2022, Mr Philip Riley (Director of Detention and Escorting Services within the Home Office) stated that a Rule 35 training package for medical practitioners working in the immigration removal estate had been developed by the Home Office. The Home Office was consulting with PPG on how this could be delivered in conjunction with further training that PPG was developing to improve the standard of reporting on medical issues. It was clear from Mr Riley’s statement that this had not yet been delivered at Brook House.53 In its response to the Third Annual Inspection of ‘Adults at Risk in Immigration Detention’ by the Independent Chief Inspector of Borders and Immigration (ICIBI), the Home Office accepted a recommendation that within three months it would “ensure that planned training on Rule 35 for doctors draws on feedback from the Rule 35 team” and is “tailored to the identified needs of doctors, to enable the production of consistent and high quality Rule 35 assessments and reports”.54
  2. Based upon the evidence available to the Inquiry, it is not clear what training has been delivered, and I am therefore recommending that a comprehensive training programme be rolled out as a matter of urgency to ensure the immediate safety of detained people. This is of such significance that I am recommending that this apply across the immigration detention estate, not just to Brook House.
Recommendation 8: Mandatory training on Rule 34 and Rule 35 of the Detention Centre Rules 2001

The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out urgently across the immigration detention estate. Staff must be subject to refresher training, at least annually.
Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them, as well as GPs and relevant Home Office staff. Consideration must be given as to whether such training should be subject to an assessment.

References

  1. Detention Centre Rules 2001, Rule 34(1[↩]
  2. Detention Centre Rules 2001, Rule 33(1[↩]
  3. Dr James Hard 28 March 2022 10/12-12/2; Dr Rachel Bingham 14 March 2022 27/5-28/2[↩]
  4. Dr James Hard 28 March 2022 20/15-21/10; Theresa Schleicher 14 March 2022 83/4-20[↩]
  5. INQ000112_056[↩]
  6. BHM000033_028 para 80; Dr James Hard 28 March 2022 12/3-24[↩]
  7. Detention Centre Rules 2001, Rule 35[↩]
  8. Dr James Hard 28 March 2022 6/20-8/24[↩]
  9. Dr James Hard 28 March 2022 12/25-13/15; Theresa Schleicher 14 March 2022 62/4-17[↩]
  10. HOM0332160; HOM0332165_0008 para 122[↩]
  11. Sandra Calver 1 March 2022 157/5-9, 158/16-22[↩]
  12. DWF000020_013 para 72[↩]
  13. Sandra Calver 1 March 2022 159/1-160/4[↩]
  14. BHM000032_015 para 49[↩]
  15. Dr James Hard 28 March 2022 13/25-15/6; BHM000033_028-030 para 80[↩]
  16. CJS007239[↩]
  17. CJS003632[↩]
  18. Sandra Calver 1 March 2022 214/8-12[↩]
  19. BHM000032_015 para 51[↩]
  20. Dr James Hard 28 March 2022 16/4-12[↩]
  21. Dr James Hard 28 March 2022 15/18-16/3[↩]
  22. Dr James Hard 28 March 2022 15/7-16/12; Sandra Calver 1 March 2022 210/24-212/7; BHM000032_015 para 49; DPG000002_038 para 103[↩]
  23. Sandra Calver 1 March 2022 207/4-11[↩]
  24. Sandra Calver 1 March 2022 208/16-209/15; Dr James Hard 28 March 2022 18/12-20/5; Theresa Schleicher 14 March 2022 62/18-63/12; DPG000002_038 paras 104 and 105[↩]
  25. Dr James Hard 28 March 2022 18/12-20/5; Sandra Calver 1 March 2022 207/4-209/6[↩]
  26. Dr Husein Oozeerally 11 March 2022 9/9-20[↩]
  27. Dr James Hard 28 March 2022 35/14-36/20[↩]
  28. IMB000021_001; IMB000050_002; IMB000011_002; IMB000047_002; IMB000019_002[↩]
  29. Dr James Hard 28 March 2022 21/15-22/6[↩]
  30. Sandra Calver 1 March 2022 214/23-215/10[↩]
  31. Dr James Hard 28 March 2022 21/15-22/6; Theresa Schleicher 14 March 2022 62/18-64/7; BHM000032_015-016 paras 49, 50 and 52[↩]
  32. Dr Husein Oozeerally 11 March 2022 13/9-17[↩]
  33. CJS007239_002[↩]
  34. Dr Rachel Bingham 14 March 2022 44/3-45/19; BHM000033_030 para 80c[↩]
  35. Dr James Hard 28 March 2022 16/13-17/20; Sandra Calver 1 March 2022 208/16-21; Dr Husein Oozeerally 11 March 2022 13/18-16/14; Dr Rachel Bingham 14 March 2022 26/25-28/8[↩]
  36. Theresa Schleicher 14 March 2022 63/13-21[↩]
  37. Theresa Schleicher 14 March 2022 63/5-12[↩]
  38. Theresa Schleicher 14 March 2022 65/11-25[↩]
  39. Dr James Hard 28 March 2022 22/7-19; Theresa Schleicher 14 March 2022 65/9-66/10; Dr Husein Oozeerally 11 March 2022 103/23-108/9[↩]
  40. Dr Rachel Bingham 14 March 2022 44/3-45/19; Dr James Hard 28 March 2022 84/8-85/82, 113/8- 114/12; HOM000644; INQ000075_053 para 5.78; INQ000075_80-81 para 5.147[↩]
  41. Dr James Hard 28 March 2022 177/14-179/9; Dr Rachel Bingham 14 March 2022 54/15-55/15[↩]
  42. Dr James Hard 28 March 2022 20/15-21/10; Theresa Schleicher 14 March 2022 60/6-61/142[↩]
  43. PPG000204_007 para 30[↩]
  44. Sandra Calver 1 March 208/16-209/15; Dr James Hard 28 March 18/12-20/5; Theresa Schleicher 14 March 2022 62/18-63/12[↩]
  45. Report on an Unannounced Inspection of Brook House Immigration Removal Centre 30 May–16 June2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022, para 3.38 and p49, para 7[↩]
  46. Sandra Calver 1 March 2022 151/14-152/5; Dr James Hard 28 March 2022 24/14-26/11[↩][↩]
  47. Sandra Calver 1 March 2022 229/1-230/25[↩]
  48. PPG000204_007 paras 29 and 30[↩]
  49. Dr James Hard 28 March 2022 27/18-29/6, 30/8-24[↩]
  50. Sandra Calver 1 March 2022 186/6-187/18[↩]
  51. Dr James Hard 28 March 2022 25/22-26/11[↩]
  52. PPG000207; Theresa Schleicher 14 March 2022 85/17-86/9; Sandra Calver 1 March 2022 234/23- 236/18; Dr Sarah Bromley 1 April 2022 195/18-201/22[↩]
  53. HOM0332184_004 para 15[↩]
  54. ThirdAnnualInspection of ‘Adults atRisk inImmigrationDetention’, Independent Chief Inspector of Borders and Immigration, January 2023; Home OfficeResponse to theThird ICIBIInspection ofAdults atRisk inImmigrationDetention, Home Office, 12 January 2023[↩]
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