Challenges facing delivery of healthcare services

9. The management of healthcare and delivery of clinical care in Brook House presented a number of challenges for both staff and detained people.

Staffing levels

10. During the relevant period, there were long-standing difficulties in the recruitment and retention of staff members.

10.1 In the Healthcare department, many of the staff were agency staff. Ms Calver stated that the department had “never been fully staffed with permanent staff since 2012”. Despite several recruitment drives, there were vacant permanent positions and “19.5% of shifts were covered by agency staff” between April and August 2017.¹

10.2 Ms Havva Daines, an RGN who had worked at Brook House since 2010, said that staffing levels were insufficient “to provide adequate healthcare to the detainees”.² She stated:

“We did our best but some days, I don’t think it was enough … A lot of the time, there would only be one RMN on shift … This was not enough to treat all of the detainees who were suffering from mental health issues.”³

However, Ms Calver did not consider lack of resources to be an issue. She told the Inquiry: “we had a fully staffed team even if partially covered by agency staff”.⁴

10.3 The Inquiry received some evidence of delays and frustration related to Healthcare staff attending to incidents.⁵ For example, as discussed in Chapter D.5, detained people were sometimes not seen within the required two-hour time frame on admission to Brook House and their admission was therefore unduly delayed.⁶ Additionally, where an incident needed a medical emergency response, two members of Healthcare staff were required to respond, which had an impact upon the availability of staff to undertake initial reception health screening or triage clinics.⁷ This would have been likely to leave detained people waiting in Reception, which may have caused frustration and disruption.

Prevalence of mental ill health in the detained population

11. The prevalence of mental ill health, the presence of high risks of self- harm and suicide, a stressful environment, a significant number of victims of torture and other past trauma, and vulnerability to the loss of mental capacity are all factors that present challenges to the assessment of the medical needs of detained people and their care and medical treatment. From the evidence the Inquiry heard and received, it is clear that this was very much the case during the relevant period in Brook House, and is likely to still be the case.⁸
12. Conditions such as depression, anxiety, post-traumatic stress disorder (PTSD), psychosis and substance abuse are more common in IRCs than in the community. Research suggests that a high proportion of detained people display clinically significant levels of depression, PTSD and anxiety, as well as intense fear, sleep disturbances, profound hopelessness, self-harm and suicidality.⁹ There is also a heightened risk of self-harm and suicide among those in immigration detention, and self-harm is a risk factor for both mental ill health and suicide. Self-harm may be a symptom of complex PTSD, personality disorder or other mental ill health.¹⁰
13. Stressors associated with detention, including the sudden nature of being detained, uncertainty and anxiety about the future, separation from social support and other coping mechanisms, and the highly stressful environment of detention, may exacerbate mental ill health. Detention can also be very disruptive to pre-detention medical care.¹¹
14. In addition, many detained people report a history of torture or serious ill treatment. Specific experiences of detention, such as the banging of cell doors and jangling of keys, may trigger powerful and traumatising memories of past experiences of ill treatment. These effects not only often exacerbate pre-existing mental ill health but also may specifically elicit trauma-related symptoms such as nightmares and flashbacks.¹²
15. As discussed further below, detained people with mental ill health may be more vulnerable to losing mental capacity to make decisions about their medical care and treatment.

Lack of therapeutic interventions

16. The absence of access to a full range of psychiatric interventions available to victims of torture, those who had experienced trauma, PTSD sufferers and others experiencing mental ill health was a further challenge facing Healthcare staff in Brook House during the relevant period.
17. There was a lack of trauma-related psychological therapies and cognitive behavioural therapy during the relevant period.

17.1 Ms Calver agreed with Professor Cornelius Katona, Emeritus Professor of Psychiatry at the University of Kent and Medical and Research Director at the Helen Bamber Foundation (a human rights charity that assists victims of torture and trafficking), that detention was not an appropriate therapeutic setting to promote recovery from mental ill health, due to the nature of the environment and the lack of specialist mental health treatment resources. ¹³

17.2 Ms Karen Churcher (an RMN during the relevant period) told the Inquiry that, although there were group talking therapy sessions at Brook House, they did not explore trauma. In her view, Brook House was not an appropriate environment in which to give trauma therapy. There were emotional support groups but they did not provide treatment for PTSD. Some detained people, such as D643, did not like these groups and found that they exacerbated their PTSD symptoms. ¹⁴

17.3 Ms Williams said that she was not confident her staff could identify symptoms of trauma and PTSD, and that neither she nor her staff had received any training on PTSD or torture awareness.¹⁵

18. Despite the clear need for them among detained people, which should have been obvious to G4S Health Services and the Home Office, appropriate interventions and resources were not available during the relevant period. In my view, they should have been. This contributed to an environment that rendered those vulnerable detained people yet more vulnerable. In such circumstances, the operation of the systems to safeguard the welfare of those who may be subject to harm in detention (see Chapter D.5) was crucial.
19. Similar concerns remained at the time of the Inquiry’s hearings. The 2021 Independent Monitoring Board (IMB) report stated:

“However, irrespective of Serco’s efforts, 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).”¹⁶

20. PPG told the Inquiry that it had made various improvements to the provision of healthcare services since it took over the contract for Brook House in September 2021. These included increasing levels of Healthcare staff and the provision of mental healthcare through, for example, low and medium- intensity trauma-based psychological interventions led by a psychologist and assistant psychologists.¹⁷ As Dr Sarah Bromley (National Medical Director for Health and Justice at PPG) explained, the psychologist would support psychological interventions, initiate psychological therapy programmes and introduce training for Healthcare staff in trauma-informed practice. ¹⁸In addition, PPG stated that:

• Training sessions on self-harm and suicidal thought were provided as part of the Healthcare staff induction programme.
• Multi-Professional Complex Case Clinics were introduced which fed in to weekly ‘vulnerable persons’ meetings to ensure that the full clinical picture was taken into account when considering a detained person’s ongoing fitness for detention.¹⁹
• All detained people placed on constant supervision underwent a mental health assessment to ensure that mental health needs were identified and (wherever possible) met.²⁰
• Trauma-informed training was provided for the mental health team and bespoke mental health assessment training for secure environments, although its intention is for all Healthcare staff at Brook House to be given trauma-informed training.²¹

21. I remain concerned that the improvements made by PPG, while welcome, focus upon the management of mental ill health in detention and do not address significant concerns about the lack of priority given to the safeguards for vulnerable people in detention and the deficiencies that remain in that system (discussed further in Chapter D.5).
22. The 2022 HM Inspectorate of Prisons (HMIP) inspection report recorded the following as a priority concern:

“The centre did not meet the needs of the high number of detainees with mental health problems. The centre held many people with low level mental health needs who could not access psychological interventions as all the psychology posts were vacant. Several detainees with poor mental health had been located in the separation unit, which was not a suitable place for them.”²²

The Care Quality Commission issued a ‘requirement to improve’ notice following the 2022 HMIP inspection concerning insufficiencies in staffing levels, particularly in relation to mental health staff and the absence of psychology provision.²³

Drugs

23. As discussed in Chapter D.4, during the relevant period there was a significant problem in Brook House with a new psychoactive substance known as ‘spice’.²⁴
24. Healthcare staff were required to respond to a number of medical emergency calls in relation to detained people who were intoxicated with spice.²⁵ This sometimes had the effect of diverting resources away from the provision of medical care – for example, the nurses’ triage clinic would be closed.²⁶
25. For the most part, the responses to calls for emergency assistance and the care given on those occasions by Healthcare staff were appropriate.²⁷ However, on occasion, Healthcare staff made inappropriate, mocking and derogatory comments about, and in the presence of, intoxicated detained people.²⁸ The Head of Healthcare accepted that some comments by a nurse had been inappropriate and dehumanising. For example, one nurse who was caring for and conducting observations on a detained person who had been unconscious due to intoxication with spice made comments such as:

“Let’s open your eyes. Oh, like saucers. That’s what we like. You’ve had a good old time, haven’t you? Was that fun? You enjoyed a good time. I think you enjoyed your stash.”²⁹

26. There were also occasions where Healthcare staff did not challenge or report inappropriate, derogatory and dehumanising language used by detention custody staff about and towards detained people.44 On 14 June 2017, Detention Custody Manager (DCM) Nathan Ring was heard to say, for example, “Does your face taste nice? Because you appear to be chewing it off” to a detained person who was intoxicated with spice in the presence of a nurse.³⁰
27. In regulated and trained professionals – whose primary duties are to put the interests of their patients first, to make their patients’ care and safety their main concern and to make sure that their dignity is preserved – this behaviour and lack of action is particularly shocking.³¹ It is indicative of the ingrained nature of a toxic culture in Brook House during the relevant period, to which the Inquiry returns later in this Report. It also reflects some of the issues with the adequacy of care provided during the relevant period, as set out below.

1. DWF000009_008 paras 42-44; DWF000020_010 para 54[↩]
2. DWF000001_005 para 46; DWF000001_009 para 97[↩]
3. DWF000001_005 para 46 ; DWF000001_005 para 51; DWF000001_009 para 97. See also DWF000014_010 para 35[↩]
4. DWF000009_008 paras 42-44. See also DWF000020_010 para 54; DWF000003_006 para 34; DWF000003_006 para 40; INQ000052_058 para 221[↩]
5. INQ000052_060 para 230[↩]
6. DWF000010_013 para 55; D1851 3 December 2021 64/12-65/7, 104/18-106/19[↩]
7. DWF000001_002 para 8; DWF000001_009 para 94; DWF000003_014 paras 97-99[↩]
8. BHM000033_010 paras 35-36; BHM000030_008-009 para 17; BHM000030_039-040 paras 81-83[↩]
9. BHM000033_010 para 35; BHM000033_017-018 para 58; INQ000060_083-085 paras 4.1-4.16;BHM000030_008-009 para 17; BHM000030_011 paras 20-21[↩]
10. BHM000033_022 para 65[↩]
11. BHM000033_010 para 35; INQ000060_307; INQ000060_321-322[↩]
12. BHM000033_010 para 36; BHM000033_013-016 paras 46-53; INQ000060_091-092; INQ000060_316; INQ000060_320-321; INQ000060_324; BHM000030_008-009 para 17[↩]
13. BHM000030_009 para 18; Sandra Calver 1 March 2022 189/10-190/10, 190/23-191/23[↩]
14. Karen Churcher 10 March 2022 40/19-41/3, 59/23-61/13; DL0000228_009 paras 39-40[↩]
15. Christine Williams 10 March 2022 103/11-21[↩]
16. Annual Report of the Independent Monitoring Board at Gatwick IRC: For Reporting Year 1 January–31 December 2021, IMB, June 2022, p9 section 4.4. See also SER000038 regarding Serco. The Home Office Detention Gatekeeper is a Home Office official who makes decisions about whether to detain an individual[↩]
17. PPG000172_004. See also PPG000169_003 paras 13-14[↩]
18. PPG000172_004 para 15[↩]
19. PPG000172_020 para 116[↩]
20. PPG000204_005 para 19[↩]
21. PPG000172_004 paras 15-16[↩]
22. HMIP000702_048 para 3[↩]
23. HMIP000702_035 para 3.25; HMIP000702_061-062 Appendix III[↩]
24. DWF000001_002 para 8; DWF000003_14 paras 97-99; Anton Bole 8 December 2021 128/15-131/4; HOM0331981_011 para 41; Darren Tomsett 7 March 2022 37/10-14[↩]
25. DWF000001_002 para 8; DWF000003_014 paras 97-99[↩]
26. DWF000001_005 para 51[↩]
27. TRN0000083_006; TRN0000083_009; TRN0000083_011[↩]
28. Sandra Calver 1 March 2022 146/9-147/13; INQ000075_154 para 6.1.1.7[↩]
29. Sandra Calver 1 March 2022 146/9-147/13 ; INQ000075_154 para 6.1.1.7[↩]
30. Sandra Calver 1 March 2022 145/24-146/8[↩]
31. Good Medical Practice, General Medical Council, updated 29 April 2014, paras 1, 2, 4; The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates, Nursing and Midwifery Council, updated 10 October 2018, para 1[↩]