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Reports by a medical practitioner

Legal and policy framework

  1. Rule 35 is a key safeguard for those in detention. It requires a medical practitioner (GP) to report to the centre manager where:
  • it is likely that a detained person’s health would be injuriously affected by continued detention (Rule 35(1));
  • the medical practitioner suspects that a detained person has suicidal intentions (Rule 35(2)); or
  • there is a concern that a detained person may have been a victim of torture (Rule 35(3)).

On receiving such a report, the manager must inform the Home Office “without delay”. It is then mandatory for the Home Office to review the detained person’s detention and consider whether the detained person should be released.

  1. The Adults at Risk policy sets out the process for determining whether an individual would be particularly vulnerable to harm in detention and, if so, whether they should nevertheless be detained for the purpose of immigration removal.2 It was and is necessary for the Home Office to ascertain the reasons why a person might be vulnerable to harm in detention, and to weigh those risk factors of harm to the detained person against immigration control considerations.3 These considerations included:
  • the length of detention;
  • public protection issues, including any criminal offending history and risk to the public if the individual was not detained; and
  • compliance issues, such as the risk of the person absconding, based upon their history of keeping to immigration bail conditions or immigration reporting requirements.
  1. There was a presumption that adults at risk would not be detained. Detention would be appropriate only where immigration control considerations outweighed the risk factors identified.4 In other words, unless it was strictly necessary to detain the person, the default position was that a vulnerable person would not be detained or would be removed from detention once they were classified as an adult at risk.
  2. The Adults at Risk DSO sets out a number of factors or experiences that indicate that an individual may be particularly vulnerable to harm in detention. These include, among others, having a mental health condition or impairment or having been a victim of torture.5
  3. The Adults at Risk policy provided for evidence in support of vulnerability to be categorised at three levels. These were then used to assess the likely risk of harm to a detained person:
  • A self-declaration by the detained person of being an adult at risk was regarded as level 1 evidence and was afforded limited weight.
  • Professional evidence (such as from a social worker, medical practitioner or non-governmental organisation) stating that the individual was at risk was afforded greater weight and considered level 2 evidence.
  • Professional evidence stating that the individual was at risk and that a period of detention would be likely to cause harm, such as an increase in the severity of symptoms or a condition that led to the individual being regarded as an adult at risk, was accorded significant weight and regarded as level 3 evidence.6
  1. The presumption set out in the Adults at Risk policy – that once an individual was regarded as being at risk, they should not be detained – was reiterated in the Adults at Risk DSO. However, immigration factors could then be balanced against that risk in making decisions as to whether to detain the individual.7

The application of this framework at Brook House

  1. In a 2019 report, the Home Affairs Select Committee set out that, according to Home Office statistics, the number of Rule 35 reports across the immigration detention estate ranged from 420 to 816 in each quarter between 2015 and 2018, resulting in between 13 per cent and 39 per cent of detained people being released.8 In 2019, the number of Rule 35 reports ranged from 503 to 657 in each quarter, in 2020 from 50 to 584, in 2021 from 150 to 337, and in the first two quarters of 2022 from 290 to 544, resulting in between 31 per cent and 55 per cent of detained people being released.9

Table 5: Reports made by a medical practitioner under Rule 35 from 2017 onwards

Note: R35(1): health concerns; R35(2): suicide risk; R35(3): torture allegation
Source: Immigration Enforcement Transparency Data Q1 2023, Home Office, 25 May 2023, DT_04: Reports made by a medical practitioner under Rule 35 by place of detention and level (1, 2 and 3)

  1. At Brook House in quarters 2 and 3 of 2017 (which cover the relevant period from 1 April 2017 to 31 August 2017), only five Rule 35(1) reports were completed and no Rule 35(2) reports were completed. Only one detained person was released as a result. In the whole of 2017, only eight Rule 35(1) reports were completed.10 No Rule 35(2) reports were completed in 2017, or indeed in 2018, 2019, 2020 or 2021.11
  2. The vast majority of reports completed in the relevant period were Rule 35(3) reports relating to a concern that a detained person might have been a victim of torture. Based on his review of Rule 35(3) reports, Dr Hard considered that around 75 per cent of those reports were completed inadequately.12 In particular, he noted that there was either no conclusion regarding the possibility of previous ill treatment (namely torture) or no conclusion on the impact of ongoing detention.13 Many of the reports also failed to identify mental health consequences of torture or mental health symptoms experienced by the individual.14 On occasion, such as in relation to D1524 and D2287, the GP sought to explain a conclusion that there was no concern regarding prolonged detention by reference to the absence of “acute mental health issues” or “psychotic features or acute deterioration”.15 However, the Inquiry heard that psychotic symptoms are not core diagnostic features of post-traumatic stress disorder (PTSD), depression or anxiety, which were the most prevalent conditions among detained people. The absence of psychotic symptoms therefore could not be taken to be an indicator that harm was less likely.16
  3. Dr Bingham agreed that, where Rule 35 reports were written, the quality was often inadequate. Often, important issues were left out that should have been covered:

“For example, mental health symptoms. Sometimes comments are made that are really easily misinterpreted, like ‘no severe mental health issues’ when there clearly are significant mental health issues, or recently we have seen the term ‘stable in detention’ very frequently, which I think just means no issues so acute as to require hospitalisation. It doesn’t mean no mental health issues that are likely to deteriorate.”17

  1. It is difficult to understand the reasons why mental health conditions and symptoms were not considered, given that the Rule 35 report directs such consideration. Dr Bingham told the Inquiry:

“The reasons, I think, for missing this safeguard, it’s not, therefore, that there’s a lack of clarity in the form that needs to be filled in, but it’s that it’s not done. So to answer that question, I think we need to look at a bigger picture of systemic failures to implement these safeguards and to fully understand their importance.”18

  1. The Inquiry received a number of examples of inadequate reports, two of the most significant of which involved D1914 and D687.

37.1 On 17 July 2017, Dr Oozeerally completed a Rule 35(1) report for D1914 which stated that he had “no mental health issues”.19 This was despite the fact that D1914 had recently attempted suicide. It should have recorded mental ill health leading to self-harm. Given that significant omission, I agree with Dr Hard that the report was both inaccurate and inadequate.20

37.2 On 15 April 2017, Dr Oozeerally completed a Rule 35(3) report for D687 but there were a number of flaws in his conduct and in the subsequent report:

  • D687 had shown Dr Oozeerally fresh scars from self-harming two days earlier, but the report makes no mention of any recent self-harm.21
  • Dr Oozeerally did not provide an opinion on the impact of ongoing detention as he should have done, and there is nothing in the clinical record to indicate whether Dr Oozeerally considered opening an ACDT document at that time.22
  • The Home Office concluded that D687 met the threshold to be classified as an adult at risk but decided to maintain his detention at that time.23
  • D687 indicated that the Rule 35 report did not properly reflect his interaction with Dr Oozeerally on 15 April 2017.24
  • On 5 May 2017, it was noted that D687’s condition had deteriorated and an ACDT document was opened as a result of a reported intention to take an overdose. No subsequent Rule 35(2) report was provided to the Home Office to notify it of D687’s apparent suicidal ideation. Additionally, there was no Rule 35(1) report notifying the Home Office of the apparent worsening impact on D687 of his ongoing detention.25
  • D687 missed an appointment on 10 May 2017 but this was not followed up as it should have been.26
  • On 13 May 2017, during a planned transfer to The Verne immigration removal centre, while still at Brook House, D687 placed a ligature around his neck. This was subsequently removed during a use of force. Having been successfully transferred to The Verne, an ACDT document was opened in relation to D687. The ACDT document and Rule 35(2) report should have been completed at Brook House following the attempted use of the ligature.27

37.3 By the time D687 was involved in the self-harm incident on 13 May 2017, he had been presenting with deteriorating mental health symptoms for almost three months.28 D687 described multiple incidents in which he expressed suicidal ideation, having given up on life, having lost hope and feeling worthless, which all contributed to his self-harming in that incident.29 Dr Oozeerally’s failures – particularly his failure to report D687’s mental health deterioration to the Home Office – meant that D687’s mental state and the incident of self-harm were not factored in to the Home Office’s decision regarding his transfer to The Verne. Nor was the Home Office given the opportunity to consider this information in a review of his detention. He remained in detention, where he deteriorated, and was then subject to the use of force.

  1. These were not isolated incidents. In preparing his two written reports for the Inquiry, Dr Hard reviewed in detail all the available contemporaneous documents in relation to five individuals – D1914, D687, D1527, D720 and D1538 – who were detained at Brook House during the relevant period. In these five case studies, he considered the effectiveness of the assessment of vulnerability, the suitability of healthcare provision, the clinical management of self-harm and of food and fluid refusal, and the extent to which mental ill health played a part in the treatment to which they were subjected. Dr Hard noted the apparent disconnect between the information known by Healthcare staff and their ability to ensure that a review by a GP was timely and that it prompted the provision of Rule 35(1) and Rule 35(2) reports where appropriate. This was particularly the case where there was an apparent deterioration in a detained person’s mental health or there had been an episode of self-harm or attempted suicide.30
  2. I agree with Dr Hard that the cases of D1914, D687 and D1527 illustrate various deficiencies within the system that are of serious concern.31

39.1 First, it appears that there was no system in place for the automatic review of a detained person’s health and welfare where there was self-harm, a suicide attempt or an apparent deterioration in their mental health.32

39.2 Second, it appears that, when the GP was asked to review detained people where there was self-harm, a suicide attempt or an apparent deterioration in their mental health, there was no systematic approach to using Rule 35(1) or Rule 35(2) reports in order to notify the Home Office of these changes in presentation to enable their detention to be reviewed.33

39.3 Third, there does not appear to have been any mechanism by which the detained person’s circumstances were systematically reviewed by the GP in order to consider whether or not their condition had changed over time and whether detention was having an impact.34 A failure to carry out Rule 34 examinations properly at the start of detention – and the lack of completed Rule 35 reports as a result – also led to an absence of any measure against which to assess whether there had been a deterioration.

  1. GPs and other Healthcare staff did not flag to the Home Office a lack of time as a reason for the failure. In any event, this would have been an insufficient excuse. Instead, as Dr Bingham noted, it is likely that there was and remains a failure to recognise the importance of the safeguards, the risks of detention and the responsibilities of Healthcare staff.35
  2. In my view, this was caused, in part, by the complete absence of a consistent mechanism for the routine follow-up of detained people who were considered to be victims of torture or adults at risk. The failure to complete Rule 35 reports in appropriate circumstances resulted in the deterioration in the mental health of detained people and an increased risk of self-harm and suicide. It therefore left them more vulnerable to harm.36 Deterioration was not detected or monitored adequately. More importantly, the person remained in detention and there was the potential for the risk to materialise, causing harm.37 The Home Office was not informed as it should have been and therefore did not review detention or consider release, as it ought to have done. These were serious systemic failures, indicating a wholesale breakdown in the system of safeguards designed to protect vulnerable detained people.38
  3. PPG has changed some arrangements.

42.1 It has increased the number of Rule 35 appointments available per week from 10 to 17. Despite this, there remained a backlog at the time of the Inquiry’s hearings.39 Without further changes to the arrangements, in my view the risk of a backlog occurring remains.

42.2 Dr Sarah Bromley, National Medical Director for Health and Justice at PPG, told the Inquiry that temporary measures had been put in place to address concerns about the Rule 35 safeguards. For example, when an ACDT document is opened, a Rule 35(1) appointment is booked for that day or the following day. All patients are also reviewed by the mental health team when an ACDT document is opened. Nevertheless, it is unclear whether Doctor PA Ltd, which provides GP services at Brook House, or the individual GPs have been instructed to undertake Rule 35(2) assessments for all patients on constant supervision.40

42.3 Mr Luke Wells, Service Line Director for Health in Justice at PPG, told the Inquiry that other steps were being taken to improve the situation, including the design of a new pathway and the allocation of separate times for Rule 35(1), Rule 35(2) and Rule 35(3) appointments.41

42.4 The Serco Vulnerable People Strategy does not address Rule 35 and refers to the use of Part C forms by detention custody staff to inform the Home Office of vulnerabilities.42 As discussed below, Part C of the IS91 form primarily relates to the risk detained people pose to others. It does not relate to the risk of harm to detained people posed by detention and was not designed to notify the Home Office of vulnerabilities. It is therefore likely that detention custody staff do not understand the role of Rule 35. It is important that they understand Rule 35 and their role in the process. Without an adequate understanding of this role, detention custody staff will not be referring detained people to the Healthcare department or to GPs as they should for consideration of vulnerabilities under Rule 35. Instead, they will inappropriately be completing only Part C forms.43

  1. In its report for the reporting year 2021, the Independent Monitoring Board at Brook House noted:

“Brook House is not a safe or appropriate environment for the few men who have arrived in 2021 with severe mental health issues or have significantly deteriorated while in detention. The Board is concerned that the Home Office Detention Gatekeeper is not adequately preventing the detention of men whose mental health needs make such detention inappropriate or inadvisable (section 4.4).”44

The Home Office Detention Gatekeeper is an official who makes decisions about whether to detain an individual.45

  1. During the relevant period in Brook House, there was no adequate oversight of the operation of Rule 35. The Inquiry heard evidence of four particular failures.46

44.1 There was no quality assurance of Rule 35 reports by either G4S Health Services or the Home Office.47 There was no system or mechanism for feedback or review by the Home Office on the quality of the Rule 35 reports it had received. Mr Riley, who gave evidence on behalf of the Home Office, told the Inquiry that there was a dedicated team that reviewed Rule 35 reports and returned them if a decision could not be made about whether to release or maintain detention because the reports were incomplete.48 In my view, this remains insufficient as a system of oversight regarding the quality of Rule 35 reports.

44.2 There was no attempt by the Home Office to analyse whether Rule 35 was adequately achieving its stated aims and, if not, what needed to be changed. Mr Philip Schoenenberger, Head of the Home Office Detainee Escorting and Population Management Unit during the relevant period, gave evidence, for instance, that he was unaware of the practice of completing Part C forms (discussed below) instead of Rule 35 reports.49

44.3 There was no system to identify training needs or the reasons for inadequate reports.50 Mr Riley told the Inquiry that there was a planned roll-out of training on Rule 35 that had been trialled recently in one IRC.51 The Inquiry was not provided with any further details of the training.

44.4 There was no specific system in place, either as part of the operation of Rule 35(1) and Rule 35(2) or in addition to Rule 35, for the re-evaluation of detained people who had been identified as possible victims of torture, in order to ascertain whether ongoing detention was having a negative impact on them.52 D13 was identified as a victim of torture and a Rule 35(3) report was completed.53 He subsequently deteriorated in detention, leading to periods of food and fluid refusal, referral to the mental health team and a long period of management subject to an ACDT process due to suicidal ideation. No Rule 35(1) or Rule 35(2) report was completed in relation to him. There was no other follow-up or re-evaluation of him. The Home Office was not informed of his deterioration and so his detention was not reviewed or his release considered.54

  1. There is no oversight mechanism in the Home Office for the quality of Rule 35 reports being completed by GPs in Brook House.55 There is also no oversight, by the Home Office or by any other organisation, of the reasons why so many Rule 35 reports do not lead to the release of the detained person.56
  2. The Inquiry heard evidence that the Home Office Detention Gatekeeper is not an effective safeguard against the detention of vulnerable individuals at risk of harm in detention. This is because the Detention Gatekeeper lacks independence and does not have access to independent sources of information on individuals. Independent pre-detention screening should be coupled with effective clinical screening on arrival in detention – in other words, the proper operation of Rule 34.57

Inappropriate use of other mechanisms

  1. The system of safeguards provided by Rule 34 and Rule 35 and the Adults at Risk policy failed those detained people who were vulnerable to suffering harm in detention. Instead of fulfilling their obligations under the Rules, Healthcare staff resorted to the inappropriate use of alternatives that were not designed for – and not capable of – adequately fulfilling the purposes of ensuring the safety and wellbeing of detained people and of notifying the Home Office of their vulnerabilities to ensure that their detention was reviewed.

Part C forms

  1. By the time of the relevant period, an inappropriate practice had developed of Part C forms being completed, primarily by GPs, to inform the Home Office of vulnerabilities or risk, instead of Rule 35 reports being used. Part C forms were not designed to notify the Home Office of a vulnerability or risk factor that would place someone at risk of suffering harm in detention and therefore would classify them as an adult at risk.58 An appropriate use might be, for example, to notify the Home Office of an altercation between detained people.59
  2. It was entirely inappropriate to use Part C forms instead of Rule 35 reports to inform the Home Office of concerns about a detained person, thereby bypassing the system of safeguards designed for this purpose. This was particularly the case in circumstances where the form did not achieve the purpose for which it was being used: namely, a review by the Home Office of a vulnerable person’s detention and consideration of their release. The fundamental difference between Part C and Rule 35 is that only Rule 35 requires the Home Office to review a detained person’s detention and consider whether they should be released. Rule 35 thus operates as a safeguard for individuals who are vulnerable to harm caused by detention. The important feature of a safeguard is that it requires a response.60 In the circumstances, the system of safeguards in place to protect vulnerable people from harm in detention became less robust and all the more likely to expose them to harm. Ms Calver was aware – or ought to have been aware – of the development of such an inappropriate practice among the GPs and should have reported it to her line manager. There is no evidence that she did so or that she raised any concerns at the time. Indeed, there is evidence that she, too, occasionally took part in this practice.61
  3. Dr Oozeerally said that the reason for using Part C forms instead of Rule 35 reports was that it was a more dynamic way of informing the Home Office of concerns. Part C forms would get a quicker response and, in his experience, the receipt of a Part C form would lead the Home Office to review detention and, indeed, release detained people, even though there is no statutory requirement for the Home Office to do so.62 These assertions were not backed up by any evidence or by any reference to identified individuals. Dr Oozeerally was unapologetic about his failure to fulfil his obligations under Rule 35, and he was intransigent in his view that Part C forms were an effective method of securing a Home Office review of detention, despite evidence to the contrary.63 He did not demonstrate insight into his actions and omissions. Upon publication of this Report, a copy will be provided to the General Medical Council.
  4. In contrast, Dr Bingham told the Inquiry that, in the experience of Medical Justice, Part C forms did not lead to a review of detention, as a Rule 35 report would and should have done.64 This was reflected in evidence received by the Inquiry.

51.1 D801 was detained in Brook House from 1 March 2017 to 3 April 2017 (for 35 days).127 During this time, four Part C forms were completed by GPs and by Ms Calver in relation to his mental health and self-harm or suicide attempts (on 1 March, 13 March, 19 March and 31 March 2017). These did not result in a review of his detention by the Home Office or in his release.65 D801 was instead managed using an ACDT document.66 A Rule 35(1) report was completed in relation to D801 only on the day of his release from detention, when the Home Office had already made the decision to release him as a result of correspondence from his legal representatives.67

51.2 During D1914’s detention in Brook House, nine Part C forms were completed between 11 April and 13 July 2017.68 Despite this, none led to a review of his detention or his release. Notably, the Part C form completed on 13 July expressed Dr Chaudhary’s concern that D1914’s condition was deteriorating, but Dr Chaudhary did not complete a Rule 35(1) report at that time.69 D1914 was released in August 2017 as a result of the Rule 35(1) report completed by Dr Oozeerally on 17 July 2017.70

  1. Dr Bingham also told the Inquiry that there were cases where Part C forms were not completed, even though there were concerns.71
  2. On 1 April 2022, the Inquiry was provided with a letter from Mr Riley and Ms Kate Davies CBE, Director of Health and Justice, Armed Forces and Sexual Assault Referral Centres for NHS England. This directed staff working in IRCs to fulfil their obligations under Rule 35 and to cease the inappropriate use of Part C forms.72 The letter arrived one working day before Mr Riley was due to give evidence to the Inquiry. In my view, this is indicative of the superficial and cursory approach of the Home Office to addressing serious deficiencies in a dysfunctional system for which it is responsible.

Assessment Care in Detention and Teamwork

  1. The ACDT process, which was drawn from the corresponding process in prisons, is primarily a tool for managing those at risk of self-harm and suicide in detention, through constant supervision.73 The ACDT DSO states:

“Any individual identified as at risk of suicide or self-harm must be managed using the ACDT procedures. ACDT is a detained individual centred, flexible care-planning system which, when used effectively, can reduce the distress of those in detention and mitigate the risk of self-harm or suicide.”74

  1. The process involves a series of actions to be carried out and documented in order to care for the detained person and manage and minimise their risk to themselves.

55.1. An ACDT document could be opened by any member of staff in an IRC where there was a concern that a detained person was at risk. Initially, an ‘Immediate Action Plan’ was created, setting out where the detained person was to be located and what level of support they required, including what level of observation was to be carried out and documented by staff members (either intermittently or constantly, depending on the level of risk).

55.2 An assessment interview would take place within 24 hours of the concern being raised. This interview addressed both the detained person’s history and their current mental state and intentions.

55.3 The interview also triggered engagement by staff with the detained person, including setting a level at which they would be observed. These observations ranged from daily contact or intermittent observations at regular intervals (such as hourly) to constant observations for those at high risk of suicide. Constant observations involved a member of staff observing the detained person, often while they were confined to their cell, on a constant basis – in other words, they watched them all the time.75

55.4 There was then a process of periodic case reviews by the case manager and detention custody staff.

55.5 There was a requirement to record these steps in the ACDT document, which was used to review the levels of risk and observations and to decide on any actions.

  1. A total of 248 ACDT documents were open during the relevant period, with 195 new ACDT documents opened in that time.76 In the relevant period, there was an average of 456 individuals per month detained in Brook House.77
  2. D1914’s case is illustrative of the disconnect between the ACDT process and Rule 35 for a vulnerable individual, as well as of other deficiencies in the safeguards.

57.1 D1914 had a serious cardiac condition, having undergone a double coronary artery bypass graft. He had cardiac symptoms in Brook House and abnormal blood results, was hospitalised on four occasions during his four months there and required a further cardiac procedure that was planned for August 2017. He also experienced mental ill health and had a history of episodes of serious self-harm and a suicide attempt while at Brook House. There were multiple indicators to flag up his risk in detention.78

57.2 D1914 was not identified at the outset as being vulnerable to harm in detention and his case was not notified to the Home Office as it should have been.79 This is particularly the case under Rule 35(1), as actual harm is not required to trigger completion of a report, only the likelihood of harm. Given his history, D1914 fulfilled those criteria at the outset of his detention – and all the more so when he demonstrably started to deteriorate, both physically and mentally.80

57.3 D1914 was made subject to an ACDT process between 11 and 17 April 2017 “after suggesting he would die if returned to Romania”.81 Throughout April and May 2017, he became more agitated and frustrated by his detention and by his inability to access the treatment he required. His mental and physical condition deteriorated as a result of the stress he suffered in detention.82 His mental ill health was mischaracterised as refractory or wilfully disobedient behaviour.83

57.4 D1914 was subject to a planned use of force for the sole reason that he could be removed from the UK on 27 May 2017 (as discussed in Chapter C.6 in Volume I).

57.5 On 5 July 2017, it was noted that D1914 had self-harmed by making severe cuts to his arms and neck and that he had taken an overdose of his medication. This was regarded by both detention and Healthcare staff as a suicide attempt. A second ACDT document was opened but no corresponding Rule 35(2) report was created to notify the Home Office of a suspicion of suicidal intentions.84 Additionally, no Rule 35(1) report was created to notify the Home Office of D1914’s apparent deterioration, demonstrated by his act of self-harm on 5 July.85 In my view, on any occasion when there was a serious act of self-harm or an attempted suicide, a report under Rule 35(1) and Rule 35(2) should have been completed, including on 5 July.86

57.6 A Rule 35(1) report should also have been completed on 13 July 2017, given Dr Chaudhary’s concerns on that date about the risk of D1914’s condition worsening in detention. Instead, on 13 July, Dr Chaudhary completed only a Part C form in relation to D1914 in order to relay those concerns to the Home Office.69 A Rule 35(1) report on D1914 was completed by Dr Oozeerally on 17 July 2017.87 Only then was the Home Office required to review his detention and consider his release. In the intervening four days, he was at further risk of deterioration in his physical and mental health.

  1. The ACDT process is not a clinical response and does not include any therapeutic interventions. It is not a process through which any treatment is given, nor is there clinical input into the management of a detained person.88 As such, it was not a mechanism to address the underlying causes of a detained person’s risk of self-harm or suicide. Dr Bingham explained:

“ACDT is a prison-style response, not at all suited to clinical presentations in immigration detention. Because it doesn’t address the underlying psychological symptoms, because it doesn’t relieve distress and because it doesn’t provide any therapeutic input, it is not only an inadequate response to those things, it is just not a response to them.”89

  1. The opening of an ACDT document in relation to a risk of self-harm, including after an act of self-harm or a suicide attempt, did not trigger the consideration of Rule 35. Nor did it trigger the completion of a Rule 35 report to inform the Home Office of the risk that the detained person may suffer harm or was already suffering harm in detention. That risk or suffering of harm was demonstrated by the necessity to manage them using an ACDT process. That is a significant concern. As noted by Dr Hard:

“this almost speaks back to that issue of desensitisation and normalisation, that, my population is likely to do self-harm at this sort of level and we will just manage it with an ACDT rather than considering our founding principles of what’s embodied within therule 35.”90

  1. PPG told the Inquiry that, in the period between January and October 2022, there were 184 ACDTs, 104 episodes of constant watch (in relation to 94 detained people), 73 incidents of self-harm (in relation to 57 detained people), and 63 periods of food and fluid refusal (in relation to 59 detained people).91 Despite extremely low numbers of Rule 35(1) and Rule 35(2) reports, there were relatively high numbers of ACDTs, incidents of self-harm and incidents of detained people on constant watch under the management of Serco and PPG. The Inquiry did not receive any satisfactory explanation for this discrepancy. I remain deeply concerned by these figures. In my view, they are indicative of a continuation of the serious failure in the safeguards under Rule 34 and Rule 35 for those detained people vulnerable to harm in detention. The figures are also indicative of clear disconnects between the ACDT process and Rule 35, and between food and fluid refusal and Rule 35.
  2. The 2022 HMIP inspection report noted with concern that, in the six months prior to its inspection, there was only one Rule 35(2) report that referred to suicidal ideation, despite 60 detained people being subject to a constant watch because of concerns about self-harm during the same period.92 The report recorded a key concern:

“The Rule 35 report process was not being used to its fullest extent to protect detainees who had conditions that might have been worsened by detention. Nearly all reports related to potential victims of torture and very few were prepared for detainees with health problems or suicidal ideation.”93

HMIP also noted that the recommendation from its previous report – that “Doctors should submit a rule 35 report to the Home Office on any detainee they suspect of having suicidal ideation” – had not been achieved.94

  1. Dr Bromley told the Inquiry that the Rule 35 process was still failing “at various points throughout the system” and that Rule 35(1) and Rule 35(2) in particular appeared to have been “a little lost along the way”.95 She sought to explain that ACDTs and acts of self-harm are not always indicative of suicidal ideation and therefore may not warrant the completion of a Rule 35(2) report in each case.96 This does not address the very low numbers of Rule 35(1) reports completed, which she sought to explain as a matter of clinical judgement. She also suggested that risks would be increased because those most vulnerable would be hidden among high numbers of reports if there were a:

“literal interpretation of the rules resulting in a requirement for aRule 35(1) assessment potentially for everyone, or for a Rule 35(2) for anyone placed on an ACDT … It is arguable that detention has the potential to be injuriously detrimental to anyone’s physical or mental health and therefore in theory everybody coming into a detention centre could be eligible for assessment under Rule 35(1).”97

I consider this explanation deficient and a further indication of an abdication of corporate responsibility.

  1. There was no recognition by the GPs or Healthcare staff at Brook House that a holistic view needed to be taken in relation to self-harm and suicide risk. Nor did they recognise that the various processes should be complementary, working together to protect and care for vulnerable people in detention. This undoubtedly exposed vulnerable people to a risk of harm and caused actual harm to be suffered in some cases, as well as leaving certain individuals susceptible to mistreatment. D1851 was one such example whose mental health deteriorated, who was subject to unjustified use of force and who was left susceptible to mistreatment (see Chapter C.8 in Volume I). In my view, this risk remains.
  2. In my view, the disconnect between the ACDT process and the other safeguards for vulnerable people is symptomatic of wider and deeply rooted problems. It is indicative of a system not fit for purpose.

‘Satisfactory management in detention’

  1. In 2016, Mr Stephen Shaw, a former Prisons and Probation Ombudsman, recommended removing the test of ‘satisfactory management in detention’. This had been the practice in place under the guidance prior to the Adults at Risk policy.98 Mr Shaw considered the term to be vague and lacking in clinical meaning. He stated:

“it is perfectly clear to me that people with serious mental illness continue to be held in detention and that their treatment and care does not and cannot equate to good psychiatric practice (whether or not it is ‘satisfactorily managed’). Such a situation is an affront to civilised values.”99

The practice resulted in a ‘wait and see’ approach, where a detained person could be left to deteriorate: that is, waiting for harm to be suffered to the point where the person could no longer be satisfactorily managed in detention.

  1. It is apparent from the evidence in relation to the lack of use of Rule 35(1) and Rule 35(2) reports that there remained a reliance on the ability of Healthcare to ‘satisfactorily manage’ the ill health of the detained person in detention, despite this not forming part of the Adults at Risk policy as a result of Mr Shaw’s recommendation that it be removed.100 For example, Dr Oozeerally told the Inquiry that the reason for the lack of Rule 35(1) reports was that Healthcare was able to manage people in the detention environment. As a result, he considered that the threshold for a Rule 35 report was not met.101
  2. This practice was wholly inappropriate and, to the extent that it is continuing, it should cease immediately. The placing of further informally adopted obstacles to the operation of the safeguards under Rule 35 resulted in failures to make proper use of those safeguards and to ensure that those who were vulnerable to harm in detention were notified to the Home Office to have their detention reviewed and release considered. This was likely to have caused actual harm to have been suffered by detained people when they were allowed to deteriorate in terms of their mental or physical health. Further, they were subjected to the inappropriate use of segregation and the quick resort to use of force to manage incidents of self-harm and mental health crises. In this way, the practice left vulnerable detained people exposed to the risk of incidents of mistreatment.102


  1. Legal and policy framework

    1. Rule 35 is a key safeguard for those in detention. It requires a medical practitioner (GP) to report to the centre manager where: