The Home Office locked Frank up in an environment known to cause severe harm co, then its notoriously dysfunctional and failing safeguarding ran their fatal course.
On 11th October 2024 an inquest jury found that Frank, a 39 year old Colombian man, killed himself in a locked cell at Colnbrook Immigration Removal Centre (IRC) on 26th March 2023 after three incidents of self-harm or attempted suicide. The jury found that multiple failings contributed to Frank’s death.
The Home Office cannot keep saying that it takes every detained person’s safety seriously – it is patently not true
Medical Justice clinicians and caseworkers assist over 600 people in detention each year and encounter alarmingly high suicide risk levels and deterioration in health on a daily basis – we provide evidence of these ongoing systemic and lethal failures to the Home Office, yet IRCs remain as dangerous as ever. HM Inspector of Prisons reported in July 2024 on the worst conditions it has seen in detention, including a ligature point not removed despite being used in three suicide attempts.
Immigration detention is known to cause severe harm – the evidence is undisputed. Yet, chillingly, the Home Office has purposefully weakened its already failing clinical safeguards at the same time as planning to expand detention. Clearly, increasing detention whilst weakening safeguards means severely harming more people. This harm is not accidental.
“That would have been the last opportunity I had to embrace my son but I couldn’t” – Frank’s Mother
Frank had disclosed no health issues when he was detained on 4th March 2023 for working without permission while spending time near his mother in the UK before taking up a place on a master’s course in Spain.
He became suicidal in detention and jumped from the second floor internal balcony, landing on safety netting. He was found banging his head against a wall after self-harming with a television cable which he insisted to staff he had been using to whip rather than strangle himself.
Frank’s mother, who left the coroner’s court in tears, described in a statement her struggle to book a visit with her son at Colnbrook and was eventually allowed a “closed visit” behind a glass screen which the inquest found “contributed to the deterioration of his mental health and incurred further stress”. She said “I was horrified, as I did not recognise my son. He was staring at me as if I was not there. … I felt helpless … That would have been the last opportunity I had to embrace my son but I couldn’t.” Frank’s brother-in-law, Julian Llano, told the BBC: “He kept insisting that he felt very bad, mentally, that he needed to get out of there. He didn’t ask for help – he begged for help, not only to us, but also to the people there.”
Unacceptably inadequate suicide watch observations failed to recognise Frank was not in his bed and was in fact dead
On 19th March a triage nurse assessed Frank and advised him to eat healthily, do some exercise and keep busy.
On the day he died, Frank was on a suicide prevention plan that required him to be checked on by a Detention Custody Officer (DCO) twice each hour after being deemed a “ticking time bomb”. CCTV shows that on 26th March, a DCO checked on Frank at 7.22am, 7.42am and 7.52am and said that he saw Frank in bed on each occasion. At around 8.00am, another DCO took over and falsely recorded that he had checked on Frank at 8.30am – CCTV shows that he did not.
Shortly after 9.00am, the DCO went to Frank’s cell. He opened the door and looked in. Frank was not in his bed. The DCO closed the door and called for other staff. After 13 minutes, staff attended and went into the room, finding Frank lying on the floor of the toilet area. Staff started CPR even though there were signs that Frank had been dead for some time as he appeared stiff and cold. No one called a medical emergency code. When healthcare staff arrived, they also continued with CPR until paramedics arrived and confirmed that Frank was dead.
Rigor mortis and staining on Frank’s body suggests he had been dead for at least 2 hours. The Prison & Probation Ombudsman noted that this casts doubt on the DCO’s account that he saw Frank in bed at 7.22am, 7.42am and 7.52am.
The inquest jury found Frank died by suicide, having been left in possession of an item which could be used for suicide, despite three instances of self-harm or suicide attempts in the previous days.
Two days later, an “attempted mass suicide” took place at Harmondsworth IRC, adjacent to Colnbrook IRC.
“if we had done the Rule 35 … then we wouldn’t have had that outcome.” – Colnbrook IRC healthcare
An IRC doctor who treated Frank in an emergency appointment after his first suicide attempt failed to undertake a ‘Rule 35’ report alerting the Home Office of Frank’s suicidality and triggering a review of his continued detention. Frank later again told staff that he was having thoughts of suicide but again, no Rule 35 report was submitted. Asked at the inquest why not, the Practice Plus Group (PPG) head of healthcare at Colnbrook said: “It was not done. Healthcare missed that … We keep a waiting list for Rule 35 … At some point we had a waiting list of over 100 people… I can confidently say that if we had done the Rule 35 on the 22nd or 23rd [of March], then we wouldn’t have had that outcome.” He also added that the number of people waiting for a Rule 35 “has only increased.”
In a statement to Liberty Investigates PPG stated that there is no legal time limit for completing a Rule 35 and that urgent mental health issues are best dealt with via good clinical care instead. It confirmed that Frank was not even on the waiting list for a Rule 35 assessment.
Four ’Part C’ forms about Frank’s situation were submitted in the four days leading up to his death, but each time Home Office staff failed to forward them to his case worker and no assessment was made.
Medical Justice is not surprised by the failures and neither should the Home Office be as it has the data
Based on our evidence from assisting over 600 clients in detention each year, we have been warning the Home Office for the last 20 years that Rule 35 is not working, about dangerously long waiting lists for assessments, the specific lack of Rule 35(2) reports on suicide risk, and the inadequacies of suicide watch processes.
The Medical Justice “If he dies, he dies” research report found an alarming 74% of the 66 clients cases examined for the report had self-harmed, had suicidal thoughts and/or attempted suicide in detention yet very few Rule 35(2) reports documenting their suicidality were completed. Even after people attempted suicide, Rule 35(2) reports are rarely completed, and if they are, the assessment is often inadequate and incomplete, for example missing information such as a suicide attempt. Of the 46 detained people in this case-set who had suicidal thoughts, this was documented in their medical records for only 23. There should be a Rule 35(2) report for everyone on suicide watch. The Independent Monitoring Board’s report for Yarl’s Wood IRC published 17th October 2024 noted that just 1 of 181 detained people on suicide-watch had a Rule 35(2) report.
It’s not a matter of ‘if’, but ‘when’ the next person dies in detention – Medical Justice challenging the inexcusable inertia
A Home Office spokesperson said: “We offer our sincere condolences to Mr Ospina’s loved ones, and since his death in 2023 a number of actions have been taken to improve the safeguards for individuals in detention”. Yet disturbingly the Home Office has weakened its key Adults at Risk policy which sets out how Rule 35 reports are considered, removing the aim of reducing the number of vulnerable people in detention. Furthermore, it plans to re-open and expand two IRCs, adding capacity to detain an additional 1,000 people at any given time.
Following the Brook House [public] Inquiry (BHI) finding that the wholesale dysfunction of safeguards led to alarming levels of inhuman and degrading treatment in detention in 2017, the Home Office has mentioned a review of its Rule 35 policy but not provided any details about what this review will entail. Meanwhile, NHS England has produced Rule 35 Guidance – which Medical Justice has raised concerns about – as an interim measure before commissioning training from a Royal College on Rule 35, which has been paused while the Home Office review is awaited.
On 14th October 2024, supported by Medical Justice, the House of Lords debated Adults at Risk policy changes, which are contrary to BHI recommendations. We learned that the review is to be completed by “spring 2025”. Meanwhile, at least 312 people were on suicide watch in IRCs between April and June 2024.
Regarding ongoing Rule 35 failures and the increasing numbers of deaths in detention, Medical Justice will ;
- Continue with urgency our policy advocacy aimed at the Home Office and NHS England
- Support the securing of an adjournment debate about conditions at Harmondsworth and Colnbrook IRCs
- Support and hopefully join parliamentarians in meeting with Ministers about the deaths and safeguarding failures
- Send our independent clinicians to visit suicidal clients in detention and produce medico-legal reports
- Continue our specialised casework, providing emotional support for suicidal clients and advocating for them
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.
