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Detained people’s safety and experience

  1. As reflected in the Detention Centre Rules 2001, as well as the G4S contract, people detained at Brook House were entitled to be treated humanely and with care, and to reside in an environment that ensured their safety and security. However, the evidence received by the Inquiry revealed several issues that had a detrimental impact on their quality of life.
  2. There was a significant drug problem during the relevant period at Brook House, particularly with a new psychoactive substance known as ‘spice’. For example, on 15 June 2017, there were four medical responses to spice attacks, three of which took place simultaneously. While Brook House was not unique in experiencing this problem, the Inquiry’s cultural expert considered the extent of its drug problem to be “shocking”.1 The frequent use of drugs and the consequences suggest that there was a failure by both the Home Office and G4S to take sufficient or adequate steps to control the availability and use of drugs, both prior to and during the relevant period. This failure likely contributed to an environment that felt unsafe.
  3. A large proportion of people detained at Brook House did not have a good understanding of English, creating additional difficulties and being a “key contributing factor to the anxiety and frustration of the detained population”.2 Language barriers also reduced the ability of detained people to interact with staff, access healthcare, make complaints and communicate with visitors. Insufficient steps were taken during the relevant period to reduce these barriers, which contributed to conditions where poor treatment was more likely to occur. Detention Services Order 02/2022: Interpretation Services and Use of Translation Services (the Interpretation and Translation DSO, introduced in June 2022) now makes clear that in-person or telephone interpretation services should be used for all essential interactions where accuracy is of significant importance.
  4. Despite the requirements of Detention Services Order 12/2012: Room Sharing Risk Assessment, there also appears to have been an inadequate process for assessing risk when allocating detained people to cells. For example, one detained person was placed with a cell mate who subjected him to “terrifying” violence, despite him informing staff beforehand that there was a war between their countries of origin.3 There were also problems with allocation regardless of risk assessment. Assessments must be properly conducted to avoid unnecessary risk, and capacity issues should not be prioritised over the welfare of detained people. I am therefore recommending steps to assess and manage risks related to cell sharing.
Recommendation 5: Undertaking and complying with cell‑sharing risk assessment

The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least every 14 days) or following any relevant change in circumstances.

In the event that an immigration removal centre is unable to detain someone in accordance with the outcome of a risk assessment (due to capacity or for other reasons), the Home Office must ensure that the individual does not remain at that centre.
  1. Violence and bullying among detained people was undoubtedly part of life at Brook House during the relevant period. Although G4S had procedures for addressing bullying among detained people, these were not always followed. Some detained people also told the Inquiry about a lack of intervention from staff, albeit that the ability of staff to prevent and respond to violence and bullying was affected by insufficient staffing levels.
  2. Before and during the relevant period, detained people at Brook House were locked in their cells from 21:00 to 08:00 every day and during two daily 30-minute roll calls. The harshness of this regime was flagged during the procurement process prior to the opening of Brook House. Concerns about the length and time of the lock-in period have also been raised repeatedly by HM Inspectorate of Prisons (HMIP), which queried “why detainees needed to be locked in their rooms at all” and described detained people being locked in their cells overnight as “inappropriate”.4 It has recommended – four times – that Brook House reduce the length of the lock-in period and institute a later lock-in. The Home Office and its contractors have failed repeatedly to engage adequately with the issues at the heart of those recommendations. HMIP noted: “it is, fundamentally, a staffing issue”.5
  3. In Detention Services Order 04/2018: Management and Security of Night State (the Night State DSO), it is suggested that a night state, or lock-in:

“creates a clearly defined day/night routine and offers detainees the opportunity to rest in a quiet and private space in contrast with the constructive activities available during the day time”.6

This explanation is likely to be an attempt retrospectively to justify a situation that was understood to be unjustifiable at the outset. In reality, I consider that one of the drivers for this highly restrictive regime was financial. In my view, the lock-in regime up to and during the relevant period conflicted with Rule 3 of the Detention Centre Rules 2001, which requires as much freedom of movement and association as possible.

  1. The individuals concerned are subject to the administrative process of immigration detention; they are not prisoners. Any time during which they are locked in their cells must be justified by the strongest reasoning. I am therefore recommending that this practice be reviewed, to allow greater free movement.
Recommendation 6: Review of the lock‑in regime

The Home Office, in consultation with the contractor responsible for operating each immigration removal centre, must review the current lock- in regime and determine whether the period of time during which detained people are locked in their cells could be reduced.

The Inquiry does not consider cost alone to be a sufficient justification for extensive lock-in periods.
  1. ‘No-notice removals’ is a term that is usually used to describe a three- month window given to detained people when – after an initial short period (of 72 hours, to include two working days) during which there was no risk of removal – they could be removed from the UK with no further notice. As one Home Office staff member described:

“the first thing the person knew when they were leaving was when the room door was opened and three officers in full personal protection kit stepped in and they were taking them down to reception. That was just a very grisly, unnecessary set of circumstances and failed communications.”7

  1. The use of this approach during the relevant period appears to have had a detrimental impact on detained people, increasing levels of uncertainty and fear as well as undermining trust in staff. The Inquiry was told that no-notice removals were a “significant contributing factor to the number of uses of force we have observed”.8
  2. There was and is no fixed or maximum period of time for which someone may be detained at Brook House or at any other immigration removal centre; it is also unclear, when an individual is detained, for how long detention will last. This is sometimes referred to as ‘indefinite detention’. Despite being designed to detain people on a short-term basis, the average stay at Brook House in July 2017 was 44 days; five people had been there for one to two years. The Inquiry received clear evidence that indefinite detention caused uncertainty, frustration and anxiety for detained people, with a negative impact on their health and wellbeing that left some detained people in “ever-spiralling circles”.9 As one member of G4S staff put it:

“if you lock people in what is effectively a prison for an indefinite amount of time then ultimately, however good the care is, they are going to suffer, particularly in respect of their mental health”.10

  1. A time limit on immigration detention has previously been recommended by various organisations. In my view, this would constitute a significant improvement to the treatment and wellbeing of those detained in immigration removal centres. Home Office guidance states that removal can be said to be imminent where, among other things, “removal is likely to take place in the next four weeks”.11 I consider that 28 days would be a reasonable time limit on detention.
Recommendation 7: A time limit on detention

The government must introduce in legislation a maximum 28-day time limit on any individual’s detention within an immigration removal centre.


  1. Professor Mary Bosworth 29 March 2022 9/13-20[]
  2. Professor Mary Bosworth 29 March 2022 17/5-6. See also HMIP000613_82; HMIP000613_072; HMIP000613_074[]
  3. DPG000039_028 para 108[]
  4. HMIP000311_016 para S23; HMIP000613_016 para S8. See also HMIP000674_005; HMIP000674_020 S46, para 1.46[]
  5. Dr Hindpal Singh Bhui 24 March 2022 176/2-11[]
  6. Detention Services Order 04/2018: Management and Security of Night State, Home Office, December 2018, para 3. See also DL0000082_007-009[]
  7. VER000264_016[]
  8. Lee Hanford 15 March 2022 87/7-8. See also CJS0074041_035 para 176 and Jonathan Collier 30 March 2022 61/1-62/3[]
  9. Stephen Skitt 17 March 2022 48/8-17[]
  10. MIL000003_022 para 107[]
  11. Home Office Enforcement Instructions and Guidance, Chapter, Application of the factors in 55.3.1 to criminal casework cases[]