Of the 66 clients, 52 had evidence of a history of torture, 29 had evidence of a history of trafficking and 25 had evidence of a history of both torture and trafficking. Detention had already caused the mental state of 64 clients to deteriorate and had caused harm to all 66 clients.

63 had a diagnosis of at least one mental health condition and 49 people were recorded as having self-harmed, suicidal thoughts and/or attempted suicide. Uses of force included during transfer to segregation, removal from suicide netting and transfer to hospital appointments.

Medical Justice was appointed a Core Participant (CP) due to its extensive experience of the clinical safeguarding failures and understanding of the inadequate healthcare provision in IRCs.  One of our greatest concerns is the government’s plans to increase detention, despite the ongoing abuse, raises fears it is ignoring BHI findings.

Research published by Bail for Immigration Detainees, Medical Justice and Public Law Project shows that migrants fitted with GPS tags experience significant psychological and physical suffering, despite no clear explanation or evidence from the Home Office that tagging is necessary or cost effective.

Over 2,000 people on immigration bail are currently made to wear the GPS tags 24 hours a day, indefinitely, with cases often taking years to close. The latest figures show only 1.3% of people released from immigration detention absconded in the first six months of 2022.

GPS tagging collects more intrusive data than other electronic tagging, and the Home Office is able to access an individual’s ‘trail’ data in a wide range of circumstances. This includes if they make an immigration application involving the right to a family life under Article 8 of the ECHR.

With first-hand testimony from migrants who have been tagged and clinicians who work with them, Every move you make: the human impact of GPS tagging in immigration bail finds that:

• Wearers of GPS tags experience anxiety, stress, discomfort, and pain.
• Many wearers said they had no idea how to challenge the decision to tag them or indeed how their data was being used by the Home Office.
• People have been tagged despite the Home Office being aware of poor mental health or psychiatric conditions and their previous experience of trauma.
• Tagged individuals have reported increased feelings of social stigmatisation, isolation and avoidance of public spaces and activities.
• Tags affect every aspect of people’s daily life and routine, including the ability to exercise, sleep, work, have relationships and care for their children.
• The tags are used alongside strict requirements to report to the Home Office on a regular basis.
• There are a range of practical problems with the tags themselves, including devices failing or chargers not working.

A new report from HBF, and other NGOs Medical Justice, Anti Trafficking and Labour Exploitation Unit and Focus on Labour Exploitation, highlights the government’s failures to address this problem – and that it has deliberately put in place a system in which more trafficking victims will be locked up. The number held in immigration detention each year has tripled from 500 in 2017 to over 1600 last year. Even when identified as possible victims of trafficking, people are not being released and are detained while waiting for a final decision in their case, when the average time for making these decisions is a staggering 17 months.

The Home Office frequently claims that people ‘abuse’ the system by claiming to be trafficked to secure their release from detention. But over 90% of cases are confirmed to be genuine victims of trafficking. There is no evidence of a process being abused – rather, people who have already been exploited and mistreated are experiencing further abuse by an immigration system that is not fit for purpose.

This report makes practical recommendations for improving that system and calls for an urgent comprehensive review of the process for detaining confirmed or possible victims of trafficking.

Medical evidence emerges of the harm inflicted on those targeted by UK government for removal to Rwanda

Medical Justice today publishes “Who’s Paying The Price?: The Human Cost Of The Rwanda Scheme”, a comprehensive analysis of people targeted for removal to Rwanda which details medical evidence of the harm inflicted on them. The policy is damaging in general for anyone, acutely so for such vulnerable torture and trafficking survivors who are already paying a high human cost even before any flights have taken off to Rwanda.

The UK Government has entered a cruel and unconscionable agreement, which will forcibly remove people who have come to the UK seeking safety to Rwanda, with no return to the UK. It has been widely condemned by the UN High Commissioner for Refugees, parliamentary committees, as well as the medical community. It is being judicially reviewed in the High Court, with hearings starting on Monday 5th September 2022, the day the new Prime Minister will be announced. Both Rishi Sunak and Liz Truss have promised more Rwanda-style deals.

The first removal flight to Rwanda was halted. Yet the health and wellbeing of those targeted has already been severely impacted.

“Our clinicians have described the severe impact of the threat of removal to Rwanda on mental health: Experiences of intense fear, anxiety about the future, profound loss of hope, and traumatic reminders of past experiences of powerlessness deprive people of the sense of safety required for careful assessment and recovery. These experiences would be harmful in general, but are made even more acute by their being experienced within immigration detention and by a population with a high rate of vulnerability. 

Our report shows extremely high rates of evidence of torture, trafficking and other vulnerabilities in this group, to whom the government plan to deny assessment or interview before they are forcibly removed. The policy knowingly places people in an extremely damaging situation and should be considered exceptionally harmful. 

As a doctor, what shocks me most is the total disregard for the need to assess the risks of subjecting individual people to this policy. “

Dr Rachel Bingham – Clinical Advisor for Medical Justice

“Medical Justice calls for the immediate and urgent release from indefinite immigration detention of all those targeted with removal for Rwanda, and for the policy to be abandoned.  To not do so, given the medical evidence, means the harm the government is inflicting is premeditated.”

Emma Ginn – Director, Medical Justice

51 people in immigration detention targeted for removal to Rwanda have contacted Medical Justice – detail on 36 of whom is provided in the “Who’s Paying The Price?” report, including Iranian (14), Iraqi (5), Sudanese (5), Syrian (4), Eritrean (3), Vietnamese (2), Egyptian (2), and one Albanian nationals. This report shines a light on the accelerated and unclear process they have been subjected to, plagued by procedural deficiencies, a lack of legal advice and a lack of translated documents. They include men, women, aged-disputed children or young people, people with mental health conditions, and people who have self-harmed and/or have suicidal ideation in detention. They have all come to the UK seeking safety, many also to join family here. There is no specific screening process, despite the government implicitly acknowledging that removal would not be safe or appropriate for all. Where vulnerabilities are belatedly identified, the Home Office justifies continued detention on the basis of potential removal to Rwanda.

Our evidence shows that the prospect of removal to Rwanda is in itself damaging; it is exacerbating detained people’s mental health conditions (including depression, anxiety and post-traumatic stress disorder (PTSD)), causing them to experience fear, confusion, uncertainty about their safety, and a loss of hope. For some, it has increased their risk of self-harm and suicide. For some, it has reduced resilience to the psychological effects of trauma and may interfere with their ability to engage with treatment.

The harms described were experienced by individuals irrespective of whatever situation they would have encountered in Rwanda, and indeed despite their removal not having gone ahead.

Out of 17 people Medical Justice doctors have conducted clinical assessments for, 14 had evidence of torture histories and 6 have indicators of trafficking. 15 had a diagnosis or symptoms of PTSD. One is likely to have a psychotic disorder and lack capacity to even instruct his solicitor. One requires urgent investigations to rule out recurrence of a previous brain tumour. 11 people had suicidal thoughts in detention, including one who attempted suicide twice. Some were clinically considered to be at high risk of suicide if threatened with removal Rwanda.

Following each assessments the Medical Justice clinician shared their concerns, including about the risks of continued detention, with the immigration removal centre healthcare team.

The Medical Justice “Harmed Not Heard” report evidences that the Home Office process to identify and release highly vulnerable people in immigration detention is totally and utterly flawed.

The report analyses Medical Justice clinical assessments carried out between July and December 2021 for 45 clients detained in various immigration removal centres (IRCs) across the UK. These clients’ histories included severe trauma, significant mental health issues, and being at risk of suicide. Our findings include:

• 100% of these clients were assessed as at clinical risk of harm caused by detention and 82% had already experienced deterioration in their mental state by the time they were seen by a Medical Justice clinician. Not a single one of them had a safeguarding report, as they should have done, from the IRC healthcare department to identify them to the Home Office as at risk of harm under a process known as Rule 35(1)
• 67% had no communication of any type by the IRC healthcare department to the Home Office explicitly addressing the risk to their health from detention, prior to their assessment by a Medical Justice clinician
• 87% had suicidal and/or self-harm thoughts recorded by a Medical Justice clinician at their assessment – all were deprived of a safeguarding report identifying their risk of suicide (Rule 35(2))
• 76% were assessed by our clinicians as having symptoms or a diagnosis of Post Traumatic Stress Disorder
• Only 51% saw a GP within the required 24 hours of admission to the IRC. Where identified as needing a Rule 35 safeguarding report, the average wait for an appointment was 29 days – one person’s appointment took 119 days
• Home Office case-workers only released 1 of our 45 vulnerable clients when given information about their vulnerability under safeguarding processes, many of whom included torture survivors

“My health was getting worse in detention. I felt like I couldn’t live anymore, I didn’t know what to do, it was really really terrible … they knew what was happening to me, that I needed help…. There is no help. Ask healthcare, they blame it on the Home Office, and the Home Office will in turn blame healthcare. It feels like you are buried alive.”
Dr D, torture survivor, detained for 4 months despite deterioration in mental health

“Our medical evidence is that extensive Home Office failures mean its safeguarding processes are so ineffective they are basically fictional. Medical Justice fears torture survivors and people who are mentally ill and suicidal could be sent to Rwanda, given the ongoing gross Home Office systemic failures in safeguards for detained people. The Memorandum of Understanding (MoU) with Rwanda indicates that slavery and human trafficking survivors will be sent to Rwanda by the UK.

The impact on vulnerable asylum seekers could be devastating. Medical evidence of the harm inflicted would be beyond our reach so we would not be able to collate it in reports like “Harmed Not Heard” which are used to hold the government to account. These vulnerable asylum seekers could be ‘out of sight, out of mind’ in Rwanda with little chance of being heard.”
Medical Justice spokesperson

Evidence heard at public inquiry demonstrates extent of the Home Office’s safeguarding failures

The clinical expert appointed by the Brook House IRC Public Inquiry into mistreatment of detained people, Dr Jake Hard, concluded in March 2022 that there was “a complete systems failure” of safeguards to identify and release vulnerable people in detention. The Head of Healthcare, and the lead GP (still both working at Brook House IRC) gave evidence of systemic deficiencies and that they are continuing. Our report shows these deficiencies are not confined to Brook House and apply across the detention estate.

Victims of slavery and human trafficking, and possibly other vulnerable people, set to be sent to Rwanda

On 14^th April 2022 the Home Office announced its MoU outlining how asylum seekers will be sent to Rwanda. It commits to undertaking an “initial screening” of asylum seekers before sending them. The evidence from ‘Harmed Not Heard’, and from all our work since Medical Justice was founded in 2005, demonstrates that the Home Office is incapable of effective screening for vulnerabilities. This seems to be anticipated in the MoU which states the UK will take back and “resettle a portion of Rwanda’s most vulnerable refugees” in the UK. The MoU indicates that victims of modern slavery and human trafficking will be sent to Rwanda.

Vulnerable asylum seekers set to be held in quasi-detention in a tiny Yorkshire hamlet within weeks

Also announced on 14^th April is an ‘Accommodation Centre’ at RAF Linton-on-Ouse which the Home Office plans to open in a matter of weeks, where it will place 1,500 asylum seeking men. Linton-on-Ouse is village, with 500 residents, according to one of them.

The Home Office has said that Napier Barracks, where a few hundred asylum seeking men are placed, is the ‘pilot’ for ‘Accommodation Centres’. The All-Party Parliamentary Group (APPG) on Immigration Detention considers Napier Barracks to be ‘quasi-detention’ and that asylum seekers placed there “have been subjected to appalling treatment and conditions”.

The APPG found that the Home Office had failed to apply it’s own “suitability criteria” which is meant to screen out highly vulnerable asylum seekers. The “suitability criteria” that the Home Office refers to for Linton-on-Ouse may be the same as at Napier, and as dysfunctional. The Home Office Factsheet for Linton-on-Ouse says “There will be robust processes in place to assess and manage vulnerabilities”, so it’s not clear to what extent, if at all, vulnerable asylum seekers are screened out.

Contact : Emma Ginn on 07786 517379 / emma.ginn@medicaljustice.or.uk

Read Full Report here

Home Office failings led to unsafe release of extremely vulnerable, unwell people without adequate support

New research published today by Medical Justice shows that Home Office failings have led to the unsafe release of extremely vulnerable and unwell people into the community, without adequate support.

One woman whose delay in treatment “could potentially have life or limb threatening consequences”, struggled to re-arrange an orthopaedic oncology appointment that she missed because she had been detained. One released Medical Justice client described how he ended up a number of times in Accident & Emergency, having been unable to secure a recommended cardiology appointment.

Some released from immigration detention had pre-existing vulnerabilities and medical conditions exacerbated by their time in detention, whilst other had attempted suicide, self-harmed or suicidal thoughts in detention.

Dr Rachel Bingham, Clinical Advisor at Medical Justice said :“These unsafe practices lead to greater unmet health needs, and to more serious health consequences, requiring more and longer treatments once people are able to access care. In the year reported on, over seventeen thousand people were released, despite the stated purpose of their detention being to remove them, indicating the senselessness of exposing people to these negative health consequences”

Ms A said : “I was getting prepped for major surgery when I was detained for 6 months. The healthcare at the Immigration Removal Centre was appalling. They failed to manage my condition and in the end had no choice but to release me. Although my health had deteriorated rapidly and the surgery was more urgent than ever, I was discharged without so much as a referral or medication. It was as if the centre was more concerned about washing their hands of me so they would not be held liable than they were about my aftercare. It was an awful experience and the whole time I was afraid for my health, and very, very anxious and emotionally distressed. I felt like nobody cared if I lived or died. It is unacceptable and inhuman in a first world country to treat people like this and it has to stop. Thankfully for me, my GP was very supportive and referred me back to the surgical team – I eventually had the surgery 7 months later.”

Thousands of people are released from detention into the community every year. Between 1 October 2020 and 30 September 2021, 81% of the 21,362 people detained were released back into the community.[1] 2,239 were considered to be ‘Adults at Risk’ whilst in detention by the Home Office,[2] however Medical Justice believes there to be far more vulnerable people in detention due to the systematic failures of the Adults at Risk policy to identify vulnerable people. With thousands released into the community every year, the impact of releasing those individuals in a medically unsafe release cannot be overstated.

The report Detained and Discarded: Vulnerable people released from immigration detention in medically unsafe way found that release from detention is often unplanned, chaotic and medically unsafe.

Medical Justice sees repeated cases of vulnerable people released into the community without adequate care plans, with little or no information and support about entitlement and how to access a GP, and rarely with referrals to community support services such as local mental health teams. This has included people who had very recently attempted suicide in detention.

One client said: “When I was told I was being released, no clinician or nurse gave me advice, my medication or any help with healthcare outside.”

Mohamed,[3] who was prescribed medication due to severe stomach pain and vomiting, was not provided with an adequate supply of his prescribed medication upon release and was not given his full medical records. As he did not have information or support about seeing a doctor in the community, he explained: “I experienced a long wait to see a doctor, meanwhile I was suffering during that time and I had no attention from anyone”.

Many experienced several of these issues at the same time, with a domino effect of one barrier leading to another. Additional difficulties were experienced with navigating the healthcare system in the community, as a result of their unstable immigration status and language barriers.

Abbas,[4] who suffers from physical health issues, including with his heart, and from depression and PTSD, struggled to see a cardiologist upon release. Despite having been recommended to see a cardiologist whilst in detention and by an A&E doctor in London after being released, it took over a year and a half for him to see a cardiologist. Abbas described multiple barriers he faced. For example, after being dispersed to outside of London, he explained: “Because of the language barrier and I had difficulty to go to London, I couldn’t go to the appointment.”

The report raises concerns about the Home Office’s application of its own policies on the safe release of vulnerable detainees as the unsafe release of people from detention persists.

Information obtained through Freedom of Information (FOI) requests suggests that the experiences of Medical Justice clients may be illustrative of a wider problem in the immigration detainee population. Shockingly, the Home Office revealed that only three people recorded as ‘Adult at risk’ had onward care plans arranged upon their release across three IRCs between January 2019 and June 2021.

The Home Office has further confirmed, in response to another FOI request, that it does not have any guidance or template letters for Home Office staff in IRCs to “advise individuals with health problems or those at risk of self-harm and/or suicide” at the point of release how to access health services in the community.

Immigration detention causes severe harm to those held there and can cause rapid deterioration over time. This is particularly true for those who have a history of mental health issues or a history of trauma. The Home Office failed to deliver on their responsibilities in accordance with their duty of care towards vulnerable individuals leaving detention and continues to toy with the lives of vulnerable people by releasing them in such an unsafe and dangerous way.

Related media article ;

British Medical Journal, 4th March 2022 : “Release of vulnerable people from immigration detention is often medically unsafe and chaotic, says charity”

[1] For statistics for September 2020 to September 2021, see Home Office National Statistics. 2021. Immigration Statistics, year ending September 2021. [Last accessed on 18 January 2022] Available at: https://www.gov.uk/government/statistics/immigration-statistics-year-ending-september-2021/how-many-people-are-detained-or-returned and Home Office Detention Summary Tables. 2021. Immigration Statistics, year ending September 2021. [last accessed on 18 January 2022] Available here. Does not include those who were returned or those classed as ‘other’ which includes people who have returned to criminal detention, those released unconditionally, those sectioned under the Mental Health Act, deaths and absconds. It also does not include those held in Pre Departure Accommodation (PDA). See Home Office Detention Summary Tables. Immigration Statistics, year ending September 2021.

[2] Data extracted from statistics provided in Home Office response to FOIA 68200 received 22 February 2022. The number of Adults at Risk in PDA and those identified under column ‘other’ is not included. See Annex 1 for Home Office responses to Freedom of Information Access Requests.

[3] Mohamed’s name has been changed to protect his identity.

[4] Abbas’ name has been changed to protect his identity.

Since March 2020, our clients held in prisons under immigration powers have suffered profound harm as a result of indefinite solitary confinement.

Prisons have been put under a severe lockdown regime with people being locked in their cells for over 22 hours a day. Some have spent 24 hours a day in their cells, for days or weeks at a time.

Our joint report ​”Every day is like torture”: Solitary confinement & Immigration detention, published with Bail for Immigration Detainees, documents the disturbing suffering and harm people have endured. Our clients have experienced the onset of new mental health conditions and the distressing deterioration of pre-existing conditions and histories of trauma, such as survivors of torture.

The government suggest that the use of solitary confinement is a public health response to COVID-19. However, this cannot be justified; prolonged solitary confinement is a practice that has been prohibited internationally by the UN in their ‘Mandela Rules’.

This practice is another iteration of the government’s cruel treatment of immigration detainees, where there is a total disregard of individual rights and safety. It must end urgently.

Related media articles ;

The Independent, 11th July 2021 : “‘It’s psychological torture’: Immigration detainees tell of being locked up for up to 24 hours a day during pandemic”

The British Medical Journal, 18th June 2021

Consecutive government policies claiming to protect vulnerable people from the harmful impact of detention have failed to achieve their stated purpose and many continue to suffer avoidable harm in immigration detention. This report tells the story of some of those whom the policies failed.

The Home Office commissioned Stephen Shaw, a former Prison and Probation Ombudsman, to review the use of immigration detention in 2016. Following the highly critical Shaw review, which found that detention was being used too frequently, that too many people were ending up in detention and that safeguards were inadequate, we were hopeful that there may be significant reform addressing the systemic issues.

However, the government’s response – the so called Adults at Risk policy – has not achieved this aim and is not fit for purpose. What follows in this report is an outline of how the system fails individuals caught up in it, how people known to be at increased risk of harm in detention continue to be detained in what is widely accepted to be a harmful environment. Also the safeguards fail to identify the predictable deterioration of vulnerable detainees until serious harm has been inflicted; harm which may take years to recover from, if at all. This continues whilst ministers and civil servants loudly repeat their commitment to not detaining vulnerable people and despite all the evidence available of the harm detention inflicts.

The kinds of stories featured here should never happen. All of the people featured in this report are clients of Medical Justice.

“Putting Adults at Risk” reports that the Adults At Risk (AAR) policy was having the opposite effect to its stated aim of increasing protections for the vulnerable and called on the Home Office to review the policy. “The AAR policy leads to more vulnerable people being detained for longer and does not provide the safeguards needed to avoid future Article 3 breaches.”

The report set out concerns that the policy failed to identify vulnerable people as it lacked provision for active screening and did not effectively link with Rule 35 processes. Other concerns included the increased evidential burden on individuals to prove their vulnerability, in circumstances where the most vulnerable would struggle to do so. The key concern was that evidence of harm required by the policy was hard to obtain prior to detention, and although this might be available after detention once the individual had deteriorated, the policy was not then operating to prevent harm being caused in the first place.

The research considered a sample of Rule 35 reports and found that 97% identified the individual as an adult at risk and in 95% the decision was taken to maintain detention. Only 2% of cases were assessed as at level 3 despite reports referencing significant mental health symptoms and in 14% detention was maintained despite the doctor specifying that the detainee was deteriorating. Immigration factors used to justify continued detention seemed much less than would have been required under the previous policy requiring ‘exceptional circumstances’ and there was evidence of prolonged detention of people who had been identified as vulnerable under the policy.

There were also concerns of a lack of follow up of people identified as at risk, with the policy again operating only when there was evidence that harm had occurred, and the research referencing examples where harm had resulted but had initially been missed.

Recommendations

Medical Justice reminded the Home Office that the concerns set out in the research had been identified when the policy was proposed and suggested a new meaningful consultation process to develop an effective policy. The conclusion remained that the best solution was to end immigration detention but in the absence of such a commitment, proposed the following recommendations:

• Reinstating a category-based approach to identifying vulnerability where demonstrating that one belongs to a category at increased risk of harm in detention triggers protection from this risk – including an effective catch-all and effective screening for vulnerability.
• Replace the ‘torture’ and ‘victims of sexual or gender based violence’ categories with a more inclusive category modelled on the UNCHR detention guidelines, namely ‘victims of torture or other serious, physical, psychological, sexual or gender based violence or ill-treatment’.
• Abandon AAR evidence levels and ensure that all those identified as particularly vulnerable to harm in detention can be detained only if there are ‘very exceptional circumstances’. The policy should retain the commitment to self-declaration of vulnerability but this should trigger a duty of inquiry on the Home Office into the vulnerability.
• Update the Rule 35 process to ensure that it can effectively identify all vulnerable groups, lower the threshold for reporting health issues and improve the reporting of suicide and self-harm risk. Such assessments must happen within 24 hours and doctors must be properly trained. The policy and its protections should be extended to all immigration detainees, including those held in prisons to whom the policy does not currently apply.
• Ensure that there are robust independent monitoring mechanisms in place to ensure that the operation of policies achieve their stated aim and to avoid unintended consequences. To move towards a culture of transparency and openness around Home Office processes where independent oversight is welcomed, and external input recognised as a valuable opportunity to improve processes and safeguard the wellbeing of vulnerable people in immigration detention. This must include a commitment to future reviews of the impact of detention policy.

This report documents deaths in immigration detention from 2000 to 2015. It includes deaths that occurred a few days after the person was released from immigration detention.

Immigration removal Centres (IRCs) are notoriously difficult to get information from and gaining insight into ongoing practices can be almost impossible, with requests for access denied and requests for information delayed or refused on grounds of cost or commercial sensitivity.

One tragic exception to this is when a death occurs in detention. Investigations into deaths in detention provide a window into otherwise closed institutions and highlight the ultimate impact of a system that fails to properly protect vulnerable detainees. The Prison and Probation Ombudsman (PPO) is required to carry out a full investigation into all deaths in detention and must be granted access to all personnel and files pertaining to the matter. This is also usually followed up by a public inquest. So with every tragic death comes an opportunity for insight into unsafe systems and practices.

In 2016 Medical Justice decided to pull together all the findings of all the investigations into deaths in detention since 2000. We were able to identify 35 deaths in immigration detention centres, amongst detainees recently released from centres or in people held under immigration powers in prison.

One of the first hurdles in this research was the fact that there is no specific monitoring of these deaths so we couldn’t simply request a list of known deaths amongst people held under immigration powers but had to piece together an overview from formal sources, legal representatives and anecdotal accounts. We believe the list we arrived at is the most complete listing available but if you are aware of others who should be on this list please do let us know.

The PPO reports on these deaths make shocking reading, not merely for the tragic outcome or the systemic failings revealed but for the fact that the same failings are reported year on year in the same centres and cross centres without apparent improvement.

In about half their investigations into deaths the PPO directly criticises healthcare provisions in immigration detention. In 2 cases the inquest jury found that neglect contributed to the death and in others they found that death might well have been avoided if healthcare provision was improved.

The reports highlight 5 main areas of failings:

1. Failures in immigration processes leading to inappropriate detention of vulnerable detainees. In addition, inadequate safeguard within detention (such as Rule 35) fail to offer intended protection once in detention.
2. Failure of custody and escort services, such as systemic over-reliance on use of restraints. Investigation into deaths reveal people dying in handcuffs. Inappropriate use of segregation to manage detainees with mental health issues or at risk of self-harm.
3. Lack of coordination between institutions and providers. This has arguably worsened with the proliferation of providers through subcontracting.
4. Failures of healthcare: This includes failures in emergency responses, inadequate clinical record keeping, poor staff training, lack of attention to mental health issues and assessments, detention of people with serious physical illness.
5. Immigration detainees held in prisons: Lack of understanding of the immigration process, inadequate follow- up during key stress points such as serving removal directions, lack of access to legal advice and lack of safeguards such as Rule 35 puts those held under immigration powers in prisons at increased risk.

Death from natural causes and illness is a proper end to life. However, locking people up in detention centres without meaningful judicial oversight is unnecessary as were the deaths in detention. Each death in detention is a tragedy. No one should have to die whilst detained indefinitely, isolated from their community, many facing deportation to a country they have fled in fear. Some of the deaths resulted from catastrophic failures which could have been avoided.