‘Fit to fly and fit for detention’ letters and healthcare sanction of use of force

62. The Inquiry heard evidence of a practice by the Home Office of asking Brook House GPs to write letters regarding the fitness to fly and fitness for detention of individuals.¹ Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers set out the relevant process.² Dr Hard – and Dr Bingham – expressed reservations and concerns about the way in which GPs responded to such requests, with reference to D1914 in particular.³
63. There appeared to be no adequate physical or mental examination carried out immediately prior to the writing of such a letter by a GP.³ There was evidence that GPs would review a detained person’s medical records prior to writing such a letter.⁴ In my view, this process alone was unlikely to be sufficient in every case, and an examination might well have been necessary.⁵
64. On review of a detained person’s medical records, GPs would have been aware of relevant history such as physical or mental health conditions and past experience of trauma (such as torture). The Inquiry received evidence that, on occasion, limited details about an individual’s medical history were referred to in ‘fit to fly and fit for detention’ letters. However, significant concerns or contraindications were not routinely raised in relation to a use of force or whether they were fit to fly and fit for detention. On other occasions, no such details were referred to at all when assessing whether a detained person was fit to fly and fit for detention.⁶ In my view, this demonstrates that, generally, insufficient regard was had to the relevant medical history of detained people in the writing of such letters.
65. On occasion, this practice extended to pre-emptive positive approval for a planned use of force on a detained person by the GP.

65.1 For example, Dr Oozeerally wrote to the Home Office on 27 May 2017, at its request, regarding D1914. His letter stated:

“The above detainee is fit to fly and fit for detention. He will need a medical escort due to the nature of his medical condition. I am happy for reasonable force to be used (C and R) in order to facilitate the removal.”⁷

As is plain from the face of the letter, Dr Oozeerally approved or sanctioned the use of force against D1914 for the sole purpose of removing him from the country.

65.2 In oral evidence, Dr Oozeerally attempted to justify his sanction of the use of force against D1914 as being “unfortunate” wording.⁸ He did not accept that it was necessary to raise D1914’s heart condition as a concern or contraindication, or indeed any other concerns or contraindications, in relation to a planned use of force on D1914.⁹ This lack of insight by Dr Oozeerally, even by the time he gave his evidence to the Inquiry, was itself of serious concern.

65.3 The DCOs involved in the planned use of force on D1914 relied upon the sanction of the use of force by Dr Oozeerally, referred to by them as the “disclaimer”, effectively to abdicate any responsibility for D1914’s health and welfare during the use of force on him.¹⁰

65.4 The failures in the safeguards that should have operated to protect D1914 led to him being put in harm’s way.¹¹ Those systemic failures in the safeguards are linked with the treatment of detained people – for example, by exposing them to inappropriate and excessive use of force.¹²

66. This sanctioning of force is completely inappropriate and of serious concern.¹³ The decision to use force is a custodial one. It is important for GPs and healthcare staff not to involve themselves in custodial management decisions, but to maintain their independence in order to fulfil their important safeguarding role of raising concerns about, and contraindications to, the use of force on a detained person where concerns or contraindications are present.¹⁴)
67. GPs at Brook House did not appear to have an adequate understanding of the implications of this practice for the confidentiality of a patient’s medical information and the requirement to obtain a patient’s consent for disclosure of such information to the Home Office for this particular purpose.¹⁵
68. In my view, when writing letters about a detained person being fit to fly and fit for detention, GPs must be cognisant of the inherent potential for a conflict of interest and an inconsistency with the primary duty of the doctor to their patient in these circumstances. It is critical that appropriate clinical assessment of the individual is undertaken prior to writing any letter, and that medical concerns or contraindications are set out clearly in the letter in a way that is compatible with the provision of or refusal to provide patient consent to share medical information with the Home Office for such a purpose. I am therefore recommending that updated guidance and training be provided to doctors working within the immigration detention estate about their duties and responsibilities in this context.

Recommendation 20: Updating guidance regarding ‘fit to fly and fit for detention’ letters The Home Office must review and update Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers, to ensure that guidance given to GPs working in the immigration detention estate in relation to their duties and responsibilities in writing ‘fit to fly and fit for detention’ letters is clear. It must liaise with NHS England and any relevant medical regulators as necessary. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for GPs working in the immigration detention estate and those responsible for managing them. The training must be subject to an assessment. The Home Office must monitor compliance with this updated guidance at least annually.

1. DL0000218; CJS001048 027; CJS003768; CJS003264; CJS003608[↩]
2. Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers, Home Office, April 2016 (reissued May 2016[↩]
3. Dr James Hard 28 March 2022 87/9-88/16; Dr Rachel Bingham 14 March 2022 46/2-22[↩][↩]
4. Dr Husein Oozeerally 11 March 2022 97/18-98/4[↩]
5. Civil Aviation Authority (CAA) or British Medical Association (BMA) guidance on certification of fitness to fly was unlikely to have been sufficient to safeguard vulnerable detained people in these particular circumstances, given the context of the risk that a detained person may be forcibly removed from the country (see the CAA’s Guidance for Health Professionals and the BMA’s Guidance on Medico- Legal Aspects of Providing Certificates[↩]
6. CJS002771[↩]
7.  CJS001160[↩]
8. Dr Husein Oozeerally 11 March 2022 132/11-20, 135/12-20[↩]
9. Dr Husein Oozeerally 11 March 2022 136/9-138/15[↩]
10. Dr James Hard 28 March 2022 96/23-98/22[↩]
11. Dr James Hard 28 March 2022 97/18-98/23[↩]
12. Dr James Hard 28 March 2022 98/23-100/13[↩]
13. Dr James Hard 28 March 2022 89/15-24; Dr Rachel Bingham 14 March 2022 46/23-48/17; Sandra Calver 1 March 2022 247/11-21[↩]
14. LockedUp,LockedOut:Health andHumanRights inImmigrationDetention, British Medical Association, 2017, p5 (‘Dual loyalties in immigration detention’[↩]
15. Dr Rachel Bingham 14 March 2022 47/10-48/4. See LockedUp,LockedOut:Health andHumanRights inImmigrationDetention, British Medical Association, 2017, p6 (‘Capacity and consent’[↩]