Appendix 4: continued
Healthcare (see Chapter D.8 in Volume II)
| Recommendation | Report | Reference in this Report | |
| 82 | All health care staff should be trained in the recognition and treatment of victims of torture. (para 5.44, p48) | Report on a Full Announced Inspection of Brook House Immigration Removal Centre, 15–19 March 2010, HM Chief Inspector of Prisons, July 2010 |
| 83 | Mechanisms need to be established for improving the working relationship with external stakeholders in order to make use of experiences, suggestions and actions that will promote the mental welfare of detainees. (recommendation 11, para 4.13) | Review of Mental Health Issues in Immigration Removal Centres, Dr David Lawlor, Dr Mannie Sher and Dr Milena Stateva, 9 February 2015 | |
| 84 | I note that DSO [Detention Services Order] 03/2013 on food and fluid refusal is currently the subject of internal review within the Home Office. I recommend that the review consider alternatives to treatment within a prison or IRC in light of my discussion of this issue. (recommendation 24, p194) | Review into the Welfare in Detention of Vulnerable Persons, Stephen Shaw, Cm 9186, January 2016 | The 2016 Shaw report |
| 85 | The Home Office and NHS England should conduct a clinical assessment of the level and nature of mental health concerns in the immigration detention estate. (recommendation 55, p180) | Review into the Welfare in Detention of Vulnerable Persons, Stephen Shaw, Cm 9186, January 2016 | The 2016 Shaw report |
| 86 | I recommend that talking therapies become an intrinsic part of healthcare provision in immigration detention. (recommendation 57, p181) | Review into the Welfare in Detention of Vulnerable Persons, Stephen Shaw, Cm 9186, January 2016 | The 2016 Shaw report |
| 87 | A health needs assessment should be carried out and a centre health and well-being strategy should be developed. (para 2.40, p36) | Report on an Unannounced Inspection of Brook House Immigration Removal Centre, 31 October– 11 November 2016, HM Chief Inspector of Prisons, March 2017 | The 2016 HMIP inspection report |
| 88 | Problems with recruitment and retention across the IRC workforce must be addressed in order to prevent staff shortages negatively affecting the health and wellbeing of detained individuals. (recommendation 3, p60) | Locked Up, Locked Out: Health and Human Rights in Immigration Detention, British Medical Association, September 2017 | |
| 89 | Doctors should never be involved in disciplinary or non- therapeutic activities within IRCs. (recommendation 5, p61) | Locked Up, Locked Out: Health and Human Rights in Immigration Detention, British Medical Association, September 2017 | |
| 90 | A best practice forum should be established across IRC healthcare providers. (recommendation 16, p56) | Assessment of Government Progress in Implementing the Report on the Welfare in Detention of Vulnerable Persons, Stephen Shaw, July 2018 | The 2018 Shaw follow-up report |
| 91 | Healthcare and G4S management should ensure that nurses involved in control and restraint understand their role and responsibilities. This should be as part of their induction and refreshed yearly. (recommendation 43, p38) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 92 | To G4S Health Services Ltd: … Staff recruitment and retention to be kept as a priority. (p5) | Annual Report of the Independent Monitoring Board at Brook House IRC for Reporting Year 2018, Brook House Independent Monitoring Board, June 2019 | |
| 93 | There should be regular training for all Home Office and healthcare staff on early indicators of mental health conditions and the circumstances in which capacity assessments should be triggered. This should be linked to safeguarding training … (para 9, p19) | Detention of People with Mental Disorders in Immigration Removal Centres (IRCs), Royal College of Psychiatrists, April 2021 | |
| 94 | Review the purpose and use of the Part C process, including clarifying and confirming the roles and responsibilities of Home Office staff and suppliers and the value of enabling Part Cs to be attached to electronic healthcare records. (para 4.6.i, p12) | Second Annual Inspection of ‘Adults at Risk in Immigration Detention’, July 2020– March 2021, Independent Chief Inspector of Borders and Immigration, October 2021 |
Staffing and culture (see Chapter D.9 in Volume II)
| Recommendation | Report | Reference in this Report | |
| 95 | I recommend that GSL [Global Solutions Ltd (predecessor to G4S at Brook House)] reviews its staff training in respect of handling and defusing confrontation. (recommendation 38, p385) | Report of the Inquiry into the Disturbance and Fire at Yarl’s Wood Removal Centre, Stephen Shaw, Prisons and Probation Ombudsman, November 2004 |
| 96 | I recommend that GSL reviews its management training to emphasise the need for managers to be visible, accessible and responsive. (p293) | Report of the Inquiry into the Disturbance and Fire at Yarl’s Wood Removal Centre, Stephen Shaw, Prisons and Probation Ombudsman, November 2004 | |
| 97 | I recommend that GSL reorganises its ITC [Initial Training Course] to ensure that race relations training informs the whole of the course. (recommendation 7, p107) | Inquiry into Allegations of Racism and Mistreatment of Detainees at Oakington Immigration Reception Centre and While Under Escort, Stephen Shaw, Prisons and Probation Ombudsman, July 2005 | The 2005 Shaw report |
| 98 | I recommend that GSL develops a training package for newly promoted managers which should cover amongst other things leadership, giving positive and negative feedback, and effective supervision of staff. (recommendation 15, p108) | Inquiry into Allegations of Racism and Mistreatment of Detainees at Oakington Immigration Reception Centre and While Under Escort, Stephen Shaw, Prisons and Probation Ombudsman, July 2005 | |
| 99 | Alongside the contractors, I recommend IND considers establishing a zero-tolerance campaign across the detention estate, with appropriate posters and literature, to remind staff of the expected standards of conduct. (recommendation 20, p108) | Inquiry into Allegations of Racism and Mistreatment of Detainees at Oakington Immigration Reception Centre and While Under Escort, Stephen Shaw, Prisons and Probation Ombudsman, July 2005 | The 2005 Shaw report |
| 100 | Detainee custody officers should be supported to develop positive relationships with detainees in their care, and all new and inexperienced staff should have mentors as part of a formal mentoring scheme. (para 10.6, p75) | Report on a Full Announced Inspection of Brook House Immigration Removal Centre, 15–19 March 2010, HM Chief Inspector of Prisons, July 2010 | |
| 101 | The Home Office should ensure that the behaviour management elements of the NOMS [National Offender Management Service] training are consistent with the initial training for DCOs. [Detention Custody Officers] (p60) | Report of the Independent Advisory Panel on Non-Compliance Management, Independent Advisory Panel on Non-Compliance Management, March 2014 | |
| 102 | Managers at Yarl’s Wood should put in place a programme of organisational development work involving all staff, to develop a clearer and better shared understanding of the centre’s mission, role and purpose, and the cultures and arrangements, including staffing arrangements, that will ensure the appropriate care of Yarl’s Wood’s residents. Such a programme should allow staff to share their insights and engage them in devising plans for how the centre will be managed in the best interests of residents and staff. (recommendation 5, p72) | Independent Investigation into Concerns about Yarl’s Wood Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), January 2016 | |
| 103 | Managers undertaking the current review of staffing should rectify the problems with management capacity. (recommendation 10, p111) | Independent Investigation into Concerns about Yarl’s Wood Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), January 2016 | |
| 104 | The new governance structure should redefine lines of responsibility for all managers and include … stronger appraisal and supervision arrangements so that the work of all staff members is rigorously supervised, particularly those in middle management positions (i.e. those currently in DOM [Detention Operations Manager], RSM [Residential Service Manager] and Team Leader positions) and that these staff members benefit from relevant ongoing training and continued professional development in childcare, behavioural management and supervision. (recommendation 4, p27) | Medway Improvement Board: Final Report of the Board’s Advice to Secretary of State for Justice, Dr Gary Holden, Bernard Allen, Sharon Gray and Emily Thomas, Medway Improvement Board, 30 March 2016 | |
| 105 | Mental health awareness training should be mandatory for all new IRC staff as part of their induction and all staff should have mandatory annual update training. (p5) | Immigration Removal Centres in England: A Mental Health Needs Analysis, Dr Graham Durcan, Jessica Stubbs and Dr Jed Boardman, Centre for Mental Health, January 2017 | |
| 106 | We recommend that public sector employers should identify employees at higher risk of stress or trauma and produce a national framework which coordinates support for these employees and establishes clear accountability for their mental health. (para 20, p10) | Thriving at Work: The Stevenson / Farmer Review of Mental Health and Employers, Dennis Stevenson and Paul Farmer, October 2017 | |
| 107 | Advanced mental health training for staff who interact with vulnerable detainees. (p5; repeated in 2018 and 2019) | Annual Report of the Independent Monitoring Board at Brook House IRC for Reporting Year 2017, Brook House Independent Monitoring Board, May 2018 | The 2017 IMB report |
| 108 | Require increase in staffing levels in future contracts to ensure greater presence of operational staff and managers on detainee wings. (p5) | Annual Report of the Independent Monitoring Board at Brook House IRC for Reporting Year 2017, Brook House Independent Monitoring Board, May 2018 | The 2017 IMB report |
| 109 | Staff recruitment and retention to be kept as a priority. (p5) | Annual Report of the Independent Monitoring Board at Brook House IRC for Reporting Year 2017, Brook House Independent Monitoring Board, May 2018 | The 2017 IMB report |
| 110 | I recommend that IRC staff who have regular contact with detainees should receive mandatory safer detention training on an annual basis. (recommendation 36, p98) | Assessment of Government Progress in Implementing the Report on the Welfare in Detention of Vulnerable Persons, Stephen Shaw, July 2018 | The 2018 Shaw follow-up report |
| 111 | The SMT should be more present in the centre and should consider how they can better engage with staff. (recommendation 1, p77) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 112 | The SMT must ensure that DCMs [Detention Custody Managers] are given adequate training to fulfil the tasks and responsibilities of their role. (recommendation 2, p86) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 113 | G4S managers should undertake a comprehensive review of matters affecting staff retention at Brook House including remuneration, shift patterns and working hours and G4S needs to develop plans to address the matters arising from such a review. (recommendation 7, p38) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 114 | The SMT should ensure that staff dealing regularly with detainees with mental health problems or with drugs or other substance misuse issues receive specialist training. (recommendation 15, p37) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 115 | The safeguarding team should survey staff at Brook House regularly to ascertain their experience of and perspective on violence and bullying and its causes. (recommendation 48, p36) | Independent Investigation Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
Complaints and whistleblowing (see Chapter D.10 in Volume II)
| Recommendation | Report | Reference in this Report | |
| 116 | I recommend that the whistleblowing policy be ‘talked up’ during initial training and further endorsed during subsequent training. (recommendation 13, p107) | Inquiry into Allegations of Racism and Mistreatment of Detainees at Oakington Immigration Reception Centre and While Under Escort, Stephen Shaw, Prisons and Probation Ombudsman, July 2005 | The 2005 Shaw report |
| 117 | Managers should undertake a review of present local policies and arrangements for whistleblowing and reporting matters of concern. They should devise policies and arrangements that are easily understood by staff, command the confidence of staff and encourage and support them to report colleagues whose behaviours are inappropriate or below standard. (recommendation 8, p28) | Independent Investigation into Concerns about Yarl’s Wood Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), January 2016 |
| 118 | Policy for whistle-blowing and acting on information received from whistle-blowers needs to be redeveloped in both YJB [Youth Justice Board] and within the STC [Secure Training Centre] and it must ensure that whistle-blowers feel supported and listened to. (recommendation 10, p43) | Medway Improvement Board: Final Report of the Board’s Advice to Secretary of State for Justice, Dr Gary Holden, Bernard Allen, Sharon Gray and Emily Thomas, Medway Improvement Board, 30 March 2016 | |
| 119 | All whistle-blowing communication must be made available to the Governing Board on a monthly basis. (recommendation 11, p43) | Medway Improvement Board: Final Report of the Board’s Advice to Secretary of State for Justice, Dr Gary Holden, Bernard Allen, Sharon Gray and Emily Thomas, Medway Improvement Board, 30 March 2016 | |
| 120 | The SMT and G4S managers should review the policy and arrangements for raising concerns and their own handling of such matters to ensure that they encourage and support staff to report wrongdoing or misconduct or inappropriate behaviour by colleagues and managers. (recommendation 51, p227) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 121 | The SMT should ensure that a single log is kept of all allegations or instances of misconduct by staff and the actions taken in respect of them. (recommendation 52, p228) | Independent Investigation into Concerns about Brook House Immigration Removal Centre, Ms Kate Lampard and Mr Ed Marsden (Verita), October 2018 | The 2018 Verita report |
| 122 | The Home Office must take immediate steps to ensure that all IRCs have robust and effective whistleblowing procedures in place which IRC staff and detainees can use with complete confidence, knowing that they will be fully protected. IRC managers should ensure that both staff and detainees are regularly made aware of the whistleblowing procedures, providing clear written and verbal explanations of what the policy is for, with user friendly whistleblowing toolkits and publicity made available across the IRC. Staff and detainees should also be given explicit reassurance that they would be supported if they raised concerns about any wrongdoing or misconduct they witnessed. Failure to do so may result in further abuses across the immigration detention estate. (para 256, p82) | Immigration Detention: Fourteenth Report of Session 2017-19, House of Commons Home Affairs Committee, HC 913, 21 March 2019 | The Home Affairs Select Committee 2019 report |
| 123 | Managers should investigate and address the reasons for detainees’ low confidence in the complaints system (para S48, p54) | Report on an Unannounced Inspection of Brook House Immigration Removal Centre, 20 May-7 June 2019, HM Chief Inspector of Prisons, September 2019 | The 2019 HMIP inspection report |
| 124 | The Home Secretary should comission an urgent review of BICS [Borders, Immigration and Citizenship System] complaints procedure. Options could include establishing an Independent Case Examiner as a mechanism for immigration and nationality applicants to have their complaints reviewed independently of the department. (recommendation 20, p147) | Windrush Lessons Learned Review, Wendy Williams, March 2020 |
Inspection and monitoring (see Chapter D.11 in Volume II)
| Recommendation | Report | Reference in this Report | |
| 125 | There should be a system of independent oversight of independent oversight for the operation of detention officers (DCOs) and immigration escorts. (p4) | Outsourcing Abuse: The Use and Misuse of State- Sanctioned Force During the Detention and Removal of Asylum Seekers, Birnberg Peirce & Partners, Medical Justice and the National Coalition of Anti- Deportation Campaign, July 2008 | |
| 126 | Independent Monitoring Boards should … work transparently and engage with visitors and groups. (p5) | Outsourcing Abuse: The Use and Misuse of State- Sanctioned Force During the Detention and Removal of Asylum Seekers, Birnberg Peirce & Partners, Medical Justice and the National Coalition of Anti- Deportation Campaign, July 2008 | |
| 127 | I recommend that the Home Office consider if the inspection arrangements for IRCs can ensure the involvement of the ICI [Independent Chief Inspector of Borders and Immigration]. (recommendation 43, p196) | Review into the Welfare in Detention of Vulnerable Persons, Stephen Shaw, Cm 9186, January 2016 | The 2016 Shaw report |
| 128 | The Home Office should review with the Ministry of Justice the resource allocated to each IM [Independent Monitoring Board] in the immigration detention estate. (recommendation 39, p126) Monitoring Board] in the immigration detention estate. (recommendation 39, p126) | Assessment of Government Progress in Implementing the Report on the Welfare in Detention of Vulnerable Persons, Stephen Shaw, July 2018 | The 2018 Shaw follow-up report |
| 129 | The Subcommittee recommends that the authorities of the United Kingdom review the statutes of the Independent Monitoring Boards and the lay observers to ensure their full independence and to prevent actual or potential conflicts of interest in their roles within the national preventive mechanism. (para 41) | Visit to the United Kingdom of Great Britain and Northern Ireland Undertaken from 9 to 18 September 2019: Recommendations and Observations Addressed to the State Party, Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 26 February 2020 | |
| 130 | The Subcommittee recommends that NPM [National Preventive Mechanism] of UK take steps to enhance its cooperation and channels of communication with CSOs [civil society organisations], for example through an annual forum or other avenues, and strive to maintain a proactive dialogue with the civil society. Regarding concerns expressed by the NPM, the Subcommittee recommends that the NPM involve NGOs [non-governmental organisations] in its work in a transparent manner and strictly from the perspective of prevention of torture. (para 77, p12) | Visit to the United Kingdom of Great Britain and Northern Ireland Undertaken from 9 to 18 September 2019: Recommendations and Observations Addressed to the National Preventive Mechanism, Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 26 February 2020 | |
| 131 | Despite the inherited complex nature of the NPM, the SPT [Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment] recommends that the NPM take proactive steps aiming at transforming itself into a more cohesive preventive body. (para 109, p16) | Visit to the United Kingdom of Great Britain and Northern Ireland Undertaken from 9 to 18 September 2019: Recommendations and Observations Addressed to the National Preventive Mechanism, Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 26 February 2020 | |
| 132 | The Home Secretary should introduce a Migrants’ Commissioner responsible for speaking up for migrants and those affected by the system directly or indirectly. The commissioner would have a responsibility to engage with migrants and communities, and be an advocate for individuals as a means of identifying any systemic concerns and working with the government and the Independent Chief Inspector of Borders and Immigration to address them. (recommendation 9, p142) | Windrush Lessons Learned Review, Wendy Williams, March 2020 | |
| 133 | The Home Office should establish a central repository for collating, sharing and overseeing responses and activity resulting from external and internal reports and recommendations, and adverse case decisions. This will make sure lessons and improvements are disseminated across the organisation and inform policy- making and operational practice. (recommendation 16, p145) | Windrush Lessons Learned Review, Wendy Williams, March 2020 | |
| 134 | It recommends that the authorities of the United Kingdom take such steps as may be necessary to ensure that the NPM [National Preventive Mechanism] is fully in compliance with OPCAT [Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment] requirements, notably the requirement for statutory recognition of the NPM. (para 8, p12) | Report to the United Kingdom Government on the Visit to the United Kingdom Carried Out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 13 to 23 May 2019, European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, 30 April 2020 | |
| 135 | Senior civil servants in the Home Office must promote a genuine learning culture that actively seeks to act on the evidence of system failures. (recommendation 28, p43) | Beyond Belief: How the Home Office Fails Survivors of Torture at the Asylum Interview, Freedom From Torture, 16 June 2020 |