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Safeguards for vulnerable individuals

  1. There are a number of critical provisions that seek, collectively, to provide safeguards for those individuals who may be vulnerable to suffering harm in detention. These include Rule 34 and Rule 35 of the Detention Centre Rules 2001, and the statutory guidance Adults at Risk in Immigration Detention (Adults at Risk policy).
  2. Rule 34 – which requires a medical examination of every detained person by a GP within 24 hours of their arrival at an immigration removal centre – functions to identify the immediate health needs of a detained person. It is also an important safeguard to identify vulnerable people who should not be in detention. Where the criteria for a Rule 35 report are met (where the health of a detained person is likely to be injuriously affected by continued detention or any conditions of detention, where it is suspected that a detained person has suicidal intentions, or where there is a concern that a detained person may have been a victim of torture), this should be completed by the GP and raised with the Home Office “without delay”.1 Its completion might be at a Rule 34 examination, so that detention can be reviewed at a very early stage. This enables an individual’s continued detention to be reviewed promptly by the Home Office and, unless there are exceptional circumstances, for them to be removed from detention. In this way, the two rules are designed to work together as a safeguard for vulnerable detained people at the start of detention.
  3. This safeguard was not operating effectively at the outset of detention in 2017 and evidence indicated that this remained the case at the time of the Inquiry’s hearings. A nursing screen was sometimes the only appointment that occurred. Those GP appointments that did take place within the first 24 hours of arrival were scheduled to last for five minutes, which is insufficient time to complete an adequate mental and physical examination. Even when vulnerabilities (such as torture or mental health concerns) were identified, this did not always lead to a Rule 35 assessment or report. A practice also arose whereby Rule 35 reports were not written, or indeed considered, at the Rule 34 assessment; instead, a second later assessment was booked. In my view, Rules 34 and 35, operating together, require a proactive approach to the identification of vulnerabilities and acting upon any such vulnerabilities without delay. Disconnecting them was inappropriate. It is likely to have caused some detained people to have suffered actual harm – for example, through a deterioration in their mental or physical health. It left vulnerable detained people in particular exposed to a risk of incidents of mistreatment, such as the inappropriate use of segregation and the rapid resort to use of force to manage incidents of self-harm and mental health crisis. It also meant that vulnerable people, for whom detention was not appropriate, were being detained.
  4. A key contributing factor in the failure of the safeguards is likely to have been the unacceptable lack of training on Rules 34 and 35 (and on the Adults at Risk policy) in Brook House, which appears still to be the case. A comprehensive mandatory programme of training should have been prioritised for relevant staff in Brook House, to ensure that they understood their obligations under the Rules and how to properly apply the policy. In its response to the 2023 inspection report of the Independent Chief Inspector of Borders and Immigration (ICIBI), the Home Office accepted a recommendation about training for doctors. Based upon the evidence available, it is not clear what training has been delivered, and I am therefore recommending that a comprehensive training programme be rolled out as a matter of urgency, to ensure the immediate safety of detained people.
Recommendation 8: Mandatory training on Rule 34 and Rule 35 of the Detention Centre Rules 2001

The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out urgently across the immigration detention estate. Staff must be subject to refresher training, at least annually.

Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them, as well as GPs and relevant Home Office staff. Consideration must be given as to whether such training should be subject to an assessment.
  1. A presumption applied under the Adults at Risk policy that adults at risk would not be detained. Detention would only be appropriate where immigration control considerations outweighed the risk factors identified, such as having a mental health condition or impairment or having been a victim of torture. The vast majority of reports in the relevant period related to a concern that a detained person might have been a victim of torture (Rule 35(3)); the Inquiry’s medical expert considered that around 75 per cent of those reports he reviewed were inadequately completed. In the whole of 2017, only eight Rule 35(1) reports were completed (where it is likely that a detained person’s health would be injuriously affected by continued detention). No Rule 35(2) reports were completed in 2017, 2018, 2019, 2020 or 2021 (where it is suspected that a detained person has suicidal intentions). Healthcare staff resorted to the inappropriate use of alternatives (such as Part C forms and the Assessment Care in Detention and Teamwork (ACDT) process) not designed for – and not capable of – adequately fulfilling the purpose of ensuring the safety and wellbeing of detained people.
  2. The failure to complete Rule 35 reports in appropriate circumstances resulted in the deterioration in the mental health of detained people, increased their risk of self-harm and suicide, and therefore left them more vulnerable to harm. Deterioration was not detected or monitored adequately. More importantly, the person remained in detention with the risk potentially to materialise, causing harm. The Home Office was not informed and therefore did not review detention and consider release. These were serious systemic failures, indicating a wholesale breakdown in the system of safeguards designed to protect vulnerable detained people.
  3. The Inquiry has not received any evidence of any fundamental changes to the system of safeguards since 2017. There has been no amendment to Rules 34 and 35, nor any significant change in relation to their application in practice, and there have been no material changes to the Adults at Risk policy. Concerns in these areas were not raised for the first time in this Inquiry. Most recently, in January 2023, the ICIBI stated that “the Rule 35 process needs to be called out for what it is – ineffective”.2 In my view, there is clearly a deeply rooted, systemic problem in relation to the adequacy of the operation of the safeguards under Rule 35. I do not consider that immigration detention practices have significantly or sufficiently addressed these issues and am therefore recommending a review of the implementation of Rule 35 across the immigration detention estate.
Recommendation 9: Review of the operation of Rule 35 of the Detention Centre Rules 2001

The Home Office must, across the immigration detention estate, assure itself that all three limbs of Rule 35 of the Detention Centre Rules 2001 (reports by a medical practitioner where: (i) it is likely that a detained person’s health would be injuriously affected by continued detention (Rule 35(1)); (ii) it is suspected that a detained person has suicidal intentions (Rule 35(2)); or (iii) there is a concern that a detained person may have been a victim of torture (Rule 35(3))) are being followed, are operating effectively and are adequately resourced, in recognition of the key safeguarding role that the Rule plays.

The Home Office must also regularly audit the use of Rule 35 in order to identify trends, any training needs and required improvements.


  1. Detention Centre Rules 2001, Rule 35[]
  2. Inspection report published: Third annual inspection of ‘Adults at risk in immigration detention’, June–September 2022,; see Third Annual Inspection of ‘Adults at Risk in Immigration Detention’, Independent Chief Inspector of Borders and Immigration, January 2023[]