Food and fluid refusal

31. Guidance regarding dealing with an adult refusing food and/or fluid was set out in Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid (the Food and Fluid DSO). As a result, where a detained person refused food and/or fluids for over 24 hours, they were required to be offered a routine medical appointment to ensure that the refusal was not caused by undiagnosed mental ill health or any physical illness, they understood the consequences and risks of their actions, and they were offered appropriate care. An ACDT document was to be opened after 24 hours of fluid refusal and after 48 hours of food refusal.¹
32. The Inquiry received records in relation to approximately 60 detained people refusing food and fluid during the relevant period for varying periods of time. Shift handover notes indicated that, at any one time, between one and eight detained people were being monitored for food and fluid refusal.
33. Ms Calver explained that, on days one and two, the checks carried out by Healthcare staff on a detained person refusing food and fluid involved a full set of physical observations, including blood sugars, blood pressure and weight. If necessary, a referral would be made to a GP, although this referral generally focused solely on physical abnormalities in observations.²
34. There may be many different reasons why a detained person refuses food and fluid. Dr James Hard, the Inquiry’s medical expert, told the Inquiry that it can be a sign of distress, that there can be psychological causes and that, depending upon the cause identified, different responses may be required.³
35. Ms Calver confirmed that detained people would be asked the reasons why they were refusing food and fluids, but an examination of their mental state would not be carried out unless there was continued refusal.⁴ This was, however, a cursory enquiry. She also said that consideration was not always given to food and fluid refusal as a form of self-harm, or to it being a manifestation of mental ill health.⁵ This demonstrated a tendency not to investigate adequately or explore any clinical or underlying reasons for food and fluid refusal in any depth.⁶
36. It was apparent from the evidence that the issue of food and fluid refusal was not afforded the attention it merited. Instead, it was sometimes dismissed as manipulative behaviour by detained people, some form of protest or attention-seeking behaviour.

36.1 Dr Oozeerally said that, when he asked detained people why they were refusing food or fluids, he often received a response along the lines of “I’m frustrated with the Home Office. I’m frustrated with my solicitor.”⁷ He also suggested that the most common reason for food refusal was protest.⁸ He said that, in his experience at that time, there were a lot of people refusing food and fluid together: “it was groups and co-ordinated”.⁹

36.2 This assumption is also demonstrated by Mr Ring’s attitude towards a detained person who had not eaten. Mr Ring called him a “penis” and Detention Custody Officer (DCO) Callum Tulley was effectively instructed to “cross him off” the list that recorded which detained people had eaten their meal.¹⁰ Mr Ring’s explanation was that he knew the detained person was eating food from the shop.¹¹ Whether or not this was correct, in circumstances where there was no reliable method to monitor each individual, it was inappropriate to bypass the system to identify and monitor detained people who were refusing food in this manner.

36.3 Ms Calver commented that “a lot of them were refusing [food and fluid] literally to prevent their flights”, ie their removal from the UK.¹²

37. I consider these examples to be further clear evidence of a culture among GPs and Healthcare staff at Brook House of characterising behaviour as wilfully disobedient and obstructive, instead of countenancing the idea that behaviour may be a manifestation of mental anguish or ill health. These are themes that were an inherent feature of the experience of detained people in Brook House. For example, DCO Daniel Small gave evidence that he construed self-harm as not being about mental health but about avoiding deportation.¹³ Dr Rachel Bingham, clinical advisor to Medical Justice (a charity that provides medico-legal reports and advice to detained people), described this as “mental health symptoms … reinterpreted as behavioural symptoms”.¹⁴
38. In cases of food and fluid refusal, there was inadequate consideration of the detained person’s mental capacity. The Inquiry heard evidence that assessments were not routinely carried out to ensure that they had the capacity to make the decision to refuse food and fluid.¹⁵ Instead, the ACDT process was used in response. An ACDT document could be opened by any member of staff who had a concern, for example, that a detained person had told someone that they wanted to die, or as a result of an incident of self- harm. The individual would then be reviewed and observed depending upon the level of risk. However, the ACDT process is not a clinical response and does not include therapeutic interventions or the provision of treatment for the underlying causes of the risk.¹⁶
39. Food and fluid refusal was not generally considered by Healthcare staff at Brook House to be a genuine form of self-harm, or considered in conjunction with any deterioration in mental health. Generally, it was felt to be a form of protest about detained people’s immigration cases. While this may sometimes have been the case, this could not always be reliably concluded without carrying out mental state, mental health or mental capacity assessments, and without more detailed exploration of the reasons for food and fluid refusal. The Inquiry received evidence of a number of examples of this.

39.1 Dr Bingham told the Inquiry that the Home Office’s statutory guidance Adults at Risk in Immigration Detention (Adults at Risk policy) should have been considered in relation to D13’s case in particular.¹⁷ D13 intermittently stopped eating for various periods throughout his detention at Brook House. There was a delay in identifying several episodes of food refusal and triggering the food and fluid refusal monitoring process, with physical observations belatedly imposed only several days after D13 had stopped eating. D13 was a patient of the mental health team throughout and subject to an ACDT for an overlapping period on account of his suicidal ideation. There was no substantive assessment of the motivation for his food refusal or the potential interplay with an exacerbating effect on his mental vulnerabilities and risk to himself, and no consideration of producing a report under Rule 35(1) or Rule 35(2).¹⁸

39.2 D1527 refused food, fluids or both for a prolonged period in Brook House – a total of 34 days within a 40-day period: on 19 April, for 6 days between 22 and 27 April, for 10 days between 30 April and 9 May, and for 17 days between 11 May and 27 May. He was accepted by the Home Office to be an ‘adult at risk’ who suffered from underlying mental health and self-harm issues, and was unwell and deteriorating.¹⁹The underlying reasons were not investigated and there was no apparent consideration of the Adults at Risk policy or Rule 35.²⁰ No capacity assessment was carried out, although this should have occurred routinely.²¹ Instead, D1527 was managed solely through the ACDT process, which does not provide any therapeutic interventions. It is hard to escape the conclusion that this too was a feature of the mischaracterisation of this behaviour as deliberately manipulative.

40. Such cases, where there was prolonged refusal of food and/or fluids combined with a history of mental ill health and/or self-harm, should have prompted consideration of the safeguards designed to protect vulnerable individuals provided under Rule 35 or the Adults at Risk policy as a matter of routine. This in turn would have triggered consideration of whether that person should continue to be detained.²² Instead, Rules 35(1) and (2) were not always or usually considered in cases of food and fluid refusal, even where this should have prompted concerns about a detained person’s mental health deterioration or risk of self-harm or suicide.
41. Dr Hard was critical of how the Rule 35 procedures worked in practice. They did not always ensure that the Home Office was notified of a change in the detained person’s circumstances (as demonstrated by refusing food and fluid) in order for their detention to be reviewed and for there to be consideration of their release.²³ For example, records from 13 April 2017 demonstrated a deterioration in D1527’s mental health following the completion of a Rule 35(3) report – used where a detained person may have been a victim of torture – and the subsequent response from the Home Office stating that detention was being maintained.²⁴ This case highlights that there was no appropriate and dynamic approach to the use of the Rule 35 system.²⁵ As Dr Hard noted, D1527’s prolonged food and fluid refusal, after the completion of the Rule 35(3) report and the Home Office decision to maintain his detention, should have prompted consideration of the Adults at Risk policy and a Rule 35(1) report, even if that “needed to have been on a repeated basis”.²⁶ He should also have undergone a mental capacity assessment.
42. As a result of failures to connect food and fluid refusal with consideration of whether the detained person was an adult at risk and with the Rule 35 process, vulnerable detained people were allowed to remain at risk of deterioration and exposed to a risk of harm in detention. In addition, the Home Office was not informed and so did not have the opportunity to review their detention and consider their release, as should have occurred. I am therefore recommending that the Food and Fluid DSO be updated urgently.

Recommendation 18: Urgent guidance in relation to food and fluid refusal The Home Office must, as a matter of urgency, update Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid, to ensure that it deals with: ● food and fluid refusal being clearly and directly linked to consideration of the Rule 35 process and whether a detained person is defined as an ‘adult at risk’; ● the consideration by the healthcare provider at each immigration removal centre, upon an incidence of food and fluid refusal occurring, of assessments of mental capacity, of mental state, and under Rule 35, and the conduct of these where indicated, as well as ensuring compliance with the Adults at Risk in Immigration Detention policy and making sure that decisions made in relation to these are recorded; ● the notification to the Home Office of the numbers of detained people refusing food and fluids, and the reasons for such refusal, on a monthly basis (in the same way that incidents of self-harm are notified); and ● the monitoring by the Home Office of the compliance by healthcare providers with Detention Services Order 03/2017 and the numbers of detained people refusing food and fluids, and the reasons for such refusal, in order to identify any patterns of concern and take appropriate action. The Home Office must ensure that mandatory training about the application of the updated detention services order takes place on a regular (at least annual) basis for all detention staff and healthcare staff, as well as those responsible for managing them. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them. The training must be subject to an assessment. In anticipation of the update to Detention Services Order 03/2017, the Home Office must issue an immediate instruction to communicate this clarification to those operating immigration detention centres.

1. Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid (CJS000724), Home Office, October 2017 (updated most recently September 2022), paras 17 and 18[↩]
2. Sandra Calver 1 March 2022 240/20-241/9[↩]
3. Dr James Hard 28 March 2022 167/21-168/3[↩]
4. Sandra Calver 1 March 2022 241/10-19[↩]
5. Sandra Calver 1 March 2022 241/20-22 and 242/4-22[↩]
6. Dr Rachel Bingham 14 March 2022 18/23-19/25; Dr James Hard 28 March 2022 167/5-20[↩]
7. Dr Husein Oozeerally 11 March 2022 158/9-19[↩]
8. DRO000001_011 para 99[↩]
9. Dr Husein Oozeerally 11 March 2022 157/25-158/11[↩]
10. TRN0000079_007[↩]
11. Nathan Ring 25 February 2022 112/7-14[↩]
12. Sandra Calver 1 March 2022 241/24-242/3[↩]
13. Daniel Small 28 February 2022 117/8-18[↩]
14. Dr Rachel Bingham 14 March 2022 20/3-22[↩]
15. Dr Rachel Bingham 14 March 2022 20/20-21/8[↩]
16. Dr Rachel Bingham 14 March 2022 21/9-22/7[↩]
17. Dr Rachel Bingham 14 March 2022 20/1-21/8[↩]
18. Dr Rachel Bingham 14 March 2022 22/8-23/14[↩]
19. HOM000644[↩]
20. INQ000075_053 para 5.78; INQ000075_80-81 para 5.147[↩]
21. Dr Rachel Bingham 14 March 2022 20/20-21/8[↩]
22. Dr James Hard 28 March 2022 167/5-168/20; Dr Rachel Bingham 14 March 2022 20/1-19; INQ000112_050[↩]
23. Dr James Hard 28 March 2022 168/21-170/7[↩]
24. CJS001002_034-051; CJS001123; HOM000644[↩]
25. Dr James Hard 28 March 2022 168/14-170/7; INQ000112_073 para 4.7.5[↩]
26. Dr James Hard 28 March 2022 168/21-25[↩]