Healthcare

52. There are challenges to providing healthcare services in immigration detention (including the recruitment and retention of staff, a prevalence of mental ill health among those detained, and a lack of access to a full range of therapeutic interventions). However, inadequacies in healthcare provision risk deterioration in the health of detained people (particularly those who are vulnerable), as well as misinterpretation of their conduct, and may potentially expose them to incidents of abuse.
53. Detained people are entitled to the same range and quality of healthcare services as the general public receives in the community. Nonetheless, the Inquiry heard evidence indicating that doctors and nurses were, on occasions during the relevant period, dismissive of detained people and exhibited a lack of care or empathy. One detained person said that he:

“felt that the doctors and nurses were part of the system and they had the same lack of care and disrespect for the detainees as the guards”.¹

54. It was apparent, for example, that the issue of food and fluid refusal – for which, at any one time during the relevant period, between one and eight detained people were being monitored – was not afforded the attention it merited. Instead, it was sometimes dismissed as manipulative behaviour by detained people, a form of protest, or attention seeking. 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. One witness described this as “mental health symptoms … reinterpreted as behavioural symptoms”.² Rule 35 procedures (discussed above) were not routinely considered in cases of food and fluid refusal, even where this should have prompted concerns about mental health deterioration or risk of self-harm or suicide. As a result, vulnerable detained people were allowed to deteriorate and were exposed to a risk of harm in detention. I am therefore recommending an urgent update to the relevant guidance to immigration removal centres.

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 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 fluid, 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 fluid, 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.

55. The Inquiry was also concerned about the role of healthcare staff in incidents involving use of force, discussed more generally above. Healthcare staff have an important safeguarding role, which includes raising concerns about any use of force and identifying contraindications (clinical reasons not to use force on a particular detained person), both in advance and during an incident. The use of force on D1914, for example, who had a serious heart condition, lasted for approximately 18 minutes, was positively harmful and put him at further risk. There is a tension between the healthcare professional’s obligation to act in the best interests of the patient and their involvement in a use of force incident in custodial settings. Regardless, all healthcare staff should be vigilant in acting on concerns about their patients.
56. Healthcare staff are also responsible for monitoring the safety and wellbeing of a detained person during the course of a use of force incident. They have the power and duty to intervene or declare a medical emergency, and to issue an instruction to immediately stop restraint or other use of force. During the relevant period, there did not seem to be an understanding or recognition among Healthcare staff of this role. For example, Healthcare staff did not intervene when D2159 was held and handcuffed for five minutes in an incident involving a four- man team in full Personal Protective Equipment (PPE), even though he was in an obviously weakened physical state. This contributed to an unnecessary and disproportionate use of force on a vulnerable detained person. D1527 was the subject of an unplanned use of force as a result of an attempt to strangle himself, during which one officer restrained him including using a ‘chokehold’ (placing hands on the neck) and said, “I’m going to put you to fucking sleep.”³ The present Healthcare staff did not raise any concerns throughout the entirety of the use of force and restraint or afterwards, but should have challenged the actions of the other staff at the time in the strongest possible terms and should have reported the incident immediately to relevant managers.
57. Although the Inquiry understands that more bespoke training is planned for healthcare staff, it is unclear whether sufficient action has been taken to address the deficiencies relating to the role of healthcare staff in use of force incidents. Given that the risk of the inappropriate use of force on vulnerable detained people may well persist, I am recommending the issuing of guidance and the introduction of mandatory training for healthcare staff in immigration removal centres, to ensure that they fulfil their role appropriately.

Recommendation 19: Guidance and training for healthcare staff on the use of force The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with NHS England and any relevant medical regulators. The Home Office must ensure that mandatory training is introduced for healthcare staff, and those responsible for managing them, on their roles and responsibilities in relation to planned and unplanned use of force (liaising with NHS England and any other relevant parties). The training must be subject to an assessment.

58. The Inquiry also 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. There appeared to be no adequate physical or mental examination carried out immediately prior to the writing of such a letter by a GP. On some occasions, limited details about an individual’s medical history were referred to in ‘fit to fly and fit for detention’ letters but significant concerns or contraindications were not routinely raised; in other cases, no such details were referred to at all when making an assessment that a detained person was fit to fly and fit for detention. Sometimes this practice extended to pre-emptive positive approval by the GP for a planned use of force on a detained person. This sanctioning of force is completely inappropriate and of serious concern. It is important that GPs and healthcare staff do not involve themselves in custodial management decisions, to maintain their independence and their important safeguarding roles. 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.

59. There were also concerns that the processes to deal with detained people with mental ill health (who might be more vulnerable to losing their capacity to make decisions about their medical care and treatment) were ineffective. For example, despite bizarre and aggressive behaviour, D1275’s severe mental ill health was not identified or managed, and he received no mental health treatment. He missed 13 appointments for a mental health assessment between May 2017 and January 2018, but the Inquiry did not see any evidence that his non-attendance was followed up by Healthcare staff. There should have been a more proactive investigation into the reasons D1275 had missed so many appointments. His mental health continued to deteriorate and, after his release, D1275 was diagnosed with schizo-affective disorder and assessed as lacking capacity to make decisions about medical appointments.
60. The Inquiry also did not hear any evidence of a system in existence or guidance available to staff for the routine transfer of relevant information about mental health concerns from residential wings to Healthcare staff. Detention Services Order 04/2020: Mental Vulnerability and Immigration Detention: Non-Clinical Guidance does not adequately address concerns about the efficacy of the safeguards for vulnerable people concerning missed healthcare appointments. The provisions in relation to assessments of mental capacity, mental health and mental state are also inadequate (for example, the DSO does not contain any provision for independent advocacy). As there remain gaps, I am recommending an update to the guidance to ensure effective communication of medical information between staff in immigration removal centres.

Recommendation 21: Ensuring effective communication of medical information The Home Office must review and update Detention Services Order 04/2020: Mental Vulnerability and Immigration Detention: Non-Clinical Guidance to set out comprehensive guidance for detention and healthcare staff where there are concerns that a detained person is suffering mental ill health or lacks mental capacity. This must include an appropriate system for: ●  the routine handover or sharing of relevant information between detention custody staff and healthcare staff (for example, in Security Information Reports and Anti-Bullying Support Plans); ●  the identification and follow-up of missed medical appointments; ●  the assessment of mental capacity where indicated; and ●  mental health assessment where indicated. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for detention and healthcare staff, as well as those responsible for managing them. The training must be subject to an assessment.

61. The Inquiry received evidence of the complaints made about healthcare during the relevant period. None of the complaints recorded appear to relate to verbal or informal complaints, which were covered by Detention Services Order 03/2015: Handling of Complaints (the Complaints DSO), and the Inquiry did not receive any evidence to suggest that verbal or informal complaints were investigated by the Healthcare department. In my view, they should have been. Staff were also left to use their own judgement as to what amounted to a serious complaint.
62. During the relevant period, 53 written complaints relating to healthcare were received by the Healthcare department. It is likely that there were barriers to the making of complaints about healthcare similar to those discussed below in relation to detention staff. Only two complaints were made directly to NHS England or were referred to NHS England by G4S Health Services. The Clinical Lead at Brook House investigated and determined the outcome of the remaining 51, without any training or any particular written guidance. The investigations and resulting reports were cursory; 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.
63. A robust and effective complaints procedure in any healthcare setting is important to explain problems to patients, to promote accountability, to help the healthcare provider and healthcare staff learn, and 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. DL0000226_036 paras 144-145[↩]
2. Dr Rachel Bingham 14 March 2022 20/3-22[↩]
3. Day 2 AM 24 November 2021 00:53-01:23:53 (KENCOV1007 – V2017042500021)[↩]