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Healthcare complaints

  1. Complaints concerning healthcare provision and the conduct of healthcare staff, including GPs, were investigated under NHS complaints procedures in a separate process from that for detention custody staff.1 Detention Services Order 03/2015: Handling of Complaints (the Complaints DSO) provided the process for the investigation and response to complaints including healthcare complaints.2
  2. Healthcare complaints could be made in writing on a complaint form.3 The Inquiry received evidence of the complaints made during the relevant period. None of the complaints recorded appear to relate to verbal or informal complaints and the Inquiry did not receive any evidence to suggest that such complaints were investigated by the Healthcare department.4 In my view, they should have been.

79.1 Only two complaints were made directly to NHS England, or were referred by G4S Health Services.5 As Ms Williams explained, only “serious complaints” were referred to NHS England.6 Ms Williams was left to use her own judgement as to what amounted to a serious complaint.

79.2 Others were investigated by G4S Health Services. Written complaints would “be passed for assessment to the on site healthcare manager for the NHS commissioned service” by Home Office staff emptying the complaints box, although the Home Office would record the date and the name of the complainant.7

  1. During the relevant period, 53 written complaints relating to healthcare were received by the Healthcare department. It is likely that barriers to the making of complaints, discussed in relation to detention staff in Chapter D.10, also existed in relation to healthcare complaints. These included, for example, language and communication issues, a lack of understanding among detained people of their rights and a view that nothing would change or no one would listen.
  2. As Clinical Lead at Brook House, Ms Williams investigated and determined the outcome of 51 of the 53 healthcare complaints. She told the Inquiry that she was not given any training for this role or any particular written guidance to follow, but was shown by her manager what to do.8 Ms Williams explained that her investigations involved looking at any relevant documents and speaking to the member of staff concerned.9 She did not speak to the detained person who had made the complaint.10 This cursory investigation was also reflected in the responses to complaints. For the most part, the written responses provided to complainants – produced by reference to a template – were lacking in any detail. Responses did not engage with the underlying substance of the complaint on anything other than a superficial level. Most were without any analysis or conclusion as to whether medical care had been inadequate or the complaint was substantiated. Routinely, responses merely offered an apology that the detained person was unhappy with the medical treatment and advised them to attend the Healthcare department if required.11
  3. Most complaints (35 of 53 complaints, or 66 per cent) concerned medication: either a failure to obtain medication or delays in obtaining it, or the inadequacy of the medication prescribed.12 This has been a consistent theme within healthcare complaints over a period of time. For example, in his 2016 report, Mr Shaw noted that a high proportion of the written complaints he reviewed were about medication.13
  4. Of the remaining 18 complaints during the relevant period, 7 related to Rule 35 reports or the attitude of doctors or other healthcare staff being rude or dismissive.14 In my view, this is also an area in which it is apparent that the conflict of interest arising between GPs’ obligations towards the Home Office on the one hand and their role within the system of safeguards and duties to vulnerable detained people on the other is likely to have been problematic.
  5. Dr Bromley stated that there were 13 healthcare complaints in total in the five-month period between September 2021 and January 2022. The subject matter varied and there was no discernible pattern to the complaints.15 All complaints were internally investigated by a clinician within Brook House.16 Themes arising from a review of complaints were shared at PPG local quality assurance (QA) meetings and shared with the wider healthcare team locally as well as via PPG regional QA meetings. Learning from complaints is shared via learning bulletins cascaded to all staff. Dr Bromley also said that significant concerns arising from a complaint would be escalated by the regional governance manager and a Clinical Case Review that would utilise a multidisciplinary team to review the care provided. If failures were identified from this process, an Internal Learning Review would be commissioned and the incident reported to NHS England as a significant incident.17
  6. The Complaints DSO provides for complaints which have been formally investigated by the local IRC healthcare provider to be reported to the Home Office via a quarterly Healthcare Partnership Board meeting.18 It also allows the healthcare provider to send a table recording the previous quarter’s complaints to the Detention and Escorting Services Complaints team at the Home Office.19 The Inquiry is not aware of whether this is currently occurring or what, if any, action is generally taken by the Home Office as a result of such reporting.
  7. For detained people using healthcare services, complaints matter. They deserve an explanation when things go wrong and should be informed that steps have been taken to make it less likely to happen to anyone else. A robust and effective complaints procedure in healthcare is also important to promote accountability and help the healthcare provider and healthcare staff learn, as well as to improve the quality of care they provide. I am therefore recommending improvements to the handling and audit of healthcare complaints.
Recommendation 22: Improving the handling and audit of healthcare complaints

The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of complaints specific to the provision of healthcare in an immigration detention setting.
The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for staff dealing with healthcare complaints, as well as those responsible for managing them. The training must be subject to an assessment.
Healthcare providers in immigration removal centres must ensure that all healthcare complaints are robustly investigated in accordance with the updated guidance. The methodology and outcomes must be clearly communicated, including to the detained person. They must also ensure that appropriate, regular (at least annual) training and guidance is provided to those holding responsibility for the investigation of healthcare complaints.


  1. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), para 9[]
  2. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), paras 9-21[]
  3. DWF000020_020 para 110[]
  4. CJS001413[]
  5. NHS000053 rows 39 and 40[]
  6. Christine Williams 10 March 2022 89/6-11[]
  7. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023[]
  8. Christine Williams 10 March 2022 88/9-20[]
  9. Christine Williams 10 March 2022 88/13-89/5[]
  10. Christine Williams 10 March 2022 91/3-10[]
  11. CJS001610; CJS001389; CJS001396; CJS001417[]
  12. Christine Williams 10 March 2022 90/6-19; DWF000020_21; CJS001413[]
  13. INQ000060_167[]
  14. CJS001413; CJS001389; CJS001396; DL0000273_14-15 paras 36-37; DL0000228_063 para 212[]
  15. PPG000172_014 para 74[]
  16. PPG000172_011 para 58; PPG000172_012 para 65[]
  17. PPG000172_013 paras 68-69[]
  18. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), para 18[]
  19. Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023), para 27[]