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.

Segregation is one of the most severe and dangerous sanctions that can be imposed on detainees – its devastating impact on mental and physical health is widely recognised. Yet, there has been surprisingly little scrutiny of its use in Immigration Removal Centres (IRCs). Drawing on case studies from Medical Justice’s work in IRCs, this report sheds light on the solitary and secretive world of segregation.

Our research demonstrates that despite repeated damning critique from HM Inspectorates of Prisons (HMIP) and Independent Monitoring Boards (IMB), the over use and misuse of segregation continues in IRCs across the UK

Our research also found relatively widespread use of segregation which contravened the Detention Centre Rules:

• The unlawful use of segregation as a form of punishment for detainees who are held without the benefit of automatic judicial oversight and without access to adjudication processes;
• The use of segregation to manage detainees with mental health disorders that cannot be satisfactorily managed in detention. Behaviour rooted in on-going and untreated mental health issues is often mistaken as confrontational behaviour and managed through the use of segregation;
• The use of segregation to manage detainees at risk of self-harm, despite segregation being an entirely unsuited environment for vulnerable detainees in crisis;
• And the indiscriminate use of segregation as a means of aiding in removal processes in the absence of individual risk assessments. Some detainees are inappropriately segregated for months and even years, with one detainee being segregated more or less continuously for 22 months. One detainee was only removed to psychiatric hospital following 80 days in segregation whilst another was segregated more than 8 times during her 800 days in detention.

This report directly raises the conflict in healthcare departments in IRCs between a duty of care towards detainees and the Home Office’s desire to enforce removal. It notes examples of poor quality primary care, references inadequate clinical information systems in detention and that detainees often complain of a culture of disbelief. Additional inadequacies in healthcare include poor emergency care and cancelled hospital appointments. Deficiencies in the care of people with a mental illness, also applied to those lacking capacity and the absence of independent advocacy in detention.

Use of force was also raised in the report concerning the regular use of handcuffs at external medical appointments and a lack of examination and recording of the physical effect of the use of force. The findings of the Institute of Relations are included which comprised patterns of alleged racist incidents and poor investigation of this type of misconduct.

The report also noted detainees faced difficulties in making complaints, with criticism of the system by independent bodies such as HMIP and the IMB. The healthcare complaints system had also been criticised by the CQC.

In 2011 Medical Justice established a project to provide support and assistance to detainees making complaints against the Home Office and its contractors. This report is based on our experience of these 31 complaints made by 28 clients in detention. The complaints ranged from serious misconduct, particularly injuries sustained during attempts to transfer the detained person or remove them from the UK, as well as inadequate health care, frequent cancellation of hospital appointments, use of handcuffs and the presence of guards in medical consultations. Other complaints included verbal abuse, including racial and sexual language.

The findings were that the complaints system in detention had significant practical flaws: complaints forms were difficult to access, detention staff lacked training about complaints procedures and there was a lack of information about the complaints process provided to detainees. The conduct of investigations were inadequate: time scales for replies to complainants were not met, investigations were frequently inadequate and partial, biased towards the Home Office’s contractor, even when there was evidence to the contrary. Almost half the complaints required escalation to the Ombudsmen. The report identified difficulties caused by the use of subcontracting and the complexity of identifying the correct avenue for a complaint, and a lack of oversight and co-ordination by the Home Office.

The report also drew attention to the fact that similar findings about the inadequacy of the complaints system had been made by the Complaints Audit Committee which had responsibility for annual reports and systemic consideration until it was disbanded by the Home Office. The Committee’s last report in 2008 had assessed 83% of complaints investigations as inadequate. Concerns about the complaints system had also been raised by the IMB and HMIP.

The report also documented the reluctance of detainees to make complaints and the fear that complaining would adversely affect their treatment in detention or their immigration case. Practical difficulties with the system also included the use of information provided in a complaint to undermine an immigration case, difficulties with accessing evidence to support the complaint and inadequate CCTV recording of use of force.

Overall Medical Justice considered that the lack of a robust complaints system could allow some abuses to continue unchallenged, with a failure for the Home Office to learn from mistakes or improve.

A Medical Justice client spoke of his experience of the complaints system

“I was beaten by the guards during deportation attempts in June 2010 to an extent that one of them bit my leg. After this assault, my arm was in plaster for 11 weeks because I had resisted removal attempts. I had been detained for nearly 10 months and the experience during that time is unexplainable to anyone who has never been detained.

I made complaints to all the complaints units after my assault, but all of them were dismissed as I had suspected, because there isn’t any ‘fair and independent’ complaints unit. Moreover it is still the same company responsible for my grief at the time, whom I had to complain to.

In the response of the complaints I had made, I was made to believe that the guards were within their realm of their duty and it was my fault that they had to beat me up. This made me fear the worst, as I had been made to believe that I had proved to be the trouble maker, and they were going to treat me like wise.

The Home Office says there is independence in their complaints investigations against itself and its contractors. But to me it proved to protect its employees and its contractors. I feared making any complaints, or voicing anything against the guards and other detention staff because it was for my benefit to lie low and not seen as a trouble maker, this was for my good, (or so we/I was made to believe).

The detention guards’ treatment towards me and other detainees, made it clear that we had no say. You are shown that you are worthless, you are not a human being anymore. I was made feel like they can stamp on me or spit at me, and had no option than to submit to anything they subjected me to. Making a complaint feels pointless as you won’t get any form of justice. You are just isolating yourself, putting yourself at risk of bad treatment. You have the fear of deportation coming sooner as you show yourself to be a trouble maker.

The Home Office were only forced to respond to my complaints seriously when I was lucky enough to get a good solicitor. Eventually the Home Office apologised for detaining me unlawfully and paid compensation. After I was released I was granted refugee status. Most detainees in my position never got any justice.”

This report identified mental illness as the most significant issue for immigration detainees. Detained people had high levels of such illnesses with safeguards designed to prevent their detention proving to be ineffective. Detention caused exacerbation of mental disorders, sometimes to a degree requiring compulsory hospital treatment. The report noted particular harm caused to people with trauma-related mental illness such as PTSD and that the current arrangements were not in keeping with modern clinical practice which required the use of the least restrictive treatment options. There were inadequacies in healthcare offered to people with a mental illness, compounded by insufficient training, unsatisfactory record systems and poor access to specialist referrals. The effect of the detention of those with an illness was also recognised as impacting on other detained people exposed to behaviour caused by such illness.

Medical Justice identified problems with a lack of diagnosis of mental disorders with clinicians based in detention having potentially split loyalties and in receipt of documents from the Home Office characterising symptoms of illness as ‘manipulative.’ Treatment options were limited and there was an over reliance on psychoactive medication. Overall, diagnosis and treatment in detention were assessed as substandard.

Rule 35 did not operate as a safeguard as the assessments were often not initiated and once completed did not obtain the individual’s release as clinical judgment was overruled by Home Office caseworkers.

Recommendations include:

• Ending the detention of people with a mental illness of a severity that required any treatment as well as people requiring compulsory hospital admission
• Limitation of immigration detention to a period of no longer than 6 months
• Ending the detention of people vulnerable due to a history of torture or other abuse
• Ensuring that detention healthcare meets NHS standards for diagnosis and treatment of mental conditions
• All IRC and immigration enforcement staff to have mental health awareness and mental health training
• All IRCs to have policies for identifying and dealing with challenging behaviour related to mental illness, using the same least restrictive and participation principles that govern the application of the Mental Health Act 1983
• Segregation of detainees, as in prisons and as recommended by HMIP, should be conditional on a medical assessment of mental health, and involve regular multidisciplinary reviews, and never used as a substitute for proper treatment of mental illness, supported by detailed policy guidance and audits
• Regular audit and multidisciplinary reviews on the use of force on mentally ill detainees undertaken by the Home Office, NHS England and IRCs
• NHS‐equivalent mental health healthcare standards for detention that are resourced
• Proper assessments under rule 34 including access to previous clinical records
• Proper reports under rule 35, with proper respect for professional opinions
• There is a professional responsibility to generate rule 35 reports when appropriate, and clinicians should not be satisfied if they are rejected

There should be protocols to ensure there is proper liaison between healthcare services in detention centres and outside healthcare services, in particular when detainees are released.

This report presents an analysis of the immigration detention of pregnant women. The results show that the current policy of detaining pregnant women is ineffective, unworkable and damaging.

Case examples showing some of the adverse outcomes suffered by the women in the sample ;

* Maria was restrained and forcibly removed to her home country by four escorts. A few months after her return, she suffered a stillbirth.

* Aliya developed acute psychosis after she was prescribed anti-malarial medication in anticipation of her forced removal.

* Anna who had complained for three weeks about abdominal pains was sent to A & E where she miscarried where she miscarried with two guards in attendance. She subsequently attempted suicide and was admitted into a psychiatric ward.

The Home Office does not know how many pregnant women are detained. Without knowing or recording how many are detained, it is difficult to see how the Home Office is able to implement its own policy of detaining pregnant women in only very exceptional circumstances.

The primary purpose of detention is removal, yet this research and a previous Medical Justice audit show that only around 5% of pregnant women were successfully removed. This is because in the majority of cases, there is no medically safe way to return them.

Following the case of Chen, the Home Office is now unable to use force on pregnant women, save to prevent harm to the woman herself. Given that the use of force, which the Home Office had deemed essential, is now unlawful, pregnant women should no longer be detained as there is now an even smaller prospect of removal.

Experts agree that travel to malarious areas should be avoided because pregnant women have an increased risk of developing severe malaria and a higher risk of fatality compared to non-pregnant women. Home Office policy outlines that women should be offered malaria prophylaxis prior to their removal. In all the cases where anti-malarials were offered, Yarl’s Wood healthcare team failed to follow the relevant medical guidance.

Asylum seeking women have poorer maternity outcomes than the general population. Many women in the sample were victims of rape, torture and trafficking. However, there appeared to be no appreciation by Yarl’s Wood healthcare staff that even without complications, this is a group of vulnerable women who need to be managed as complex cases.

With limited prospects of removal, it is our recommendation that the government should stop detaining them. Detention is not serving any purpose: the costs are great and the damage to women’s health can be dramatic. This recommendation is in line with Asylum Aid’s Charter of Rights of Women Seeking Asylum that is supported by 337 organisations, including the Royal College of Midwives.

Victims of torture are routinely being held in immigration detention centres in breach of the government’s own rules. This report investigates Rule 35 of the Detention Centre Rules 2001: the primary safeguard to facilitate the release of torture survivors and vulnerable people from detention.

This report exposes start to end process failure. Of the 50 cases analysed, only one person was released through the Rule 35 process. Torture survivors were failed so badly that two of them were removed and tortured again in their home country before they made it back to the UK to claim asylum again. Apart from these two, no others were removed which begs the question why they were detained for the purpose of removing them in the first place.

“Surviving torture and surviving detention is equally very hard experience. I won’t forget neither as they are like wounds in my heart. I couldn’t talk to anyone about it.”
– Tortured in his home country; detained in the UK

The report is based on 50 people who were held in detention some time between May 2010, when the coalition government took office, and May 2011. All cases included in the sample involved torture and had a medico-legal report (MLR) or medical letter produced for them by Medical Justice independent doctors, which revealed injuries that accorded well with their accounts of torture.

They fled to this country in pursuit of sanctuary. Instead, they were detained for administrative purposes and the safeguarding mechanism that should identify and release them, failed to do so in all but one example.

The primary data sources relied upon in this investigation include immigration case files, healthcare notes, questionnaires completed by (ex) detainees and MLRs. The 50 people reported having endured various methods of torture. For example, beatings with various objects including: gun butts; bats or batons; sticks; cable wires; or metal objects as well as whippings. 16 out of the 50 suffered rape or instrumental rape. Everyone in the sample suffered from ongoing physical and/or mental effects owing to their torture and all have medical evidence supporting their accounts.

The Second Torture also traced the failure by the Home Office to address criticisms of the Rule 35 process by HMIP and stakeholders as well as concerns about the department’s conduct of audits and of refusals and delays in publishing the outcomes. Medical Justice’s analysis was that the procedures surrounding Rule 35(3) were not fit for purpose, there was inadequate training, with ill-considered responses from the Home Office and a lack of overall accountability.

Detained peoples’ experiences, assessed by standardised questionnaires, were reflected as overwhelmingly negative when considering the Home Office’s treatment of their torture claim, detention healthcare’s response to their health concerns arising from the torture and their overall assessment of the quality of healthcare. The report also identified common themes of emotional mistreatment by detention staff, increased psychological symptoms, self-harm and suicidal ideation.

Detailed assessment of medical records showed the Rule 34 process was flawed, with a high level of individuals where no assessment took place. When an assessment was conducted this was generally brief and inaccuracies were noted. There were significant discrepancies between the diagnoses of trauma-related mental illness made in the context of subsequent medico-legal assessments and information obtained at a Rule 34 appointment. There was also a lack of access to medical records from the community with adverse consequences for care.

Overall, Rule 35 was assessed as ineffective, with requests for assessments having to be prompted by external organisations. The standard Rule 35 forms were often incomplete, lacking in clinical information and failed to address the effect of continuing detention. Home Office responses to such reports only led to the release of one individual from the sample. The systemic failures in the responses to Rule 35(3) reports were summarised as failing to provide adequate reasons for continued detention and an inability to properly consider medical evidence. Wider systemic issues referenced in the report included a lack of knowledge and training, as well as attitudinal problems of both Home Office and healthcare staff involved in the Rule 35 process. This was compounded by poor quality healthcare in detention and a lack of accountability for flaws in the process. The report made brief reference to a high proportion of the files considered involving a complaint of assault in detention.