Recurring concern

Unreliable reporting of detainee safety concerns to responsible oversight functions

First to latest report 13 Feb 2019 — 6 Jul 2020

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
3

What this concern includes

Includes failures of dedicated reporting or notification arrangements for detainee safety concerns between custody, healthcare, contract-monitoring and Home Office oversight functions, including missing parallel-reporting routes and absent formal notification procedures for safety-relevant detainee status or care concerns.

What is not included
  • Excludes generic inter-agency communication or information-sharing failures with no detainee-safety reporting or notification context.
  • Excludes clinical assessment, treatment, observation or safeguarding failures where the reporting or notification process is not itself deficient.
  • Excludes ordinary administrative notifications unrelated to detainee safety, health or protective oversight.
  • Excludes failures confined to a separately named process, such as ACCT case management or custody-to-healthcare medical-record transfer, when that process supplies the more specific supported boundary.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West London

    AI-generated summary

    Prince Kwabena Fosu · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Fosu was being held in a single cell at Harmondsworth IRC when he was found unresponsive on 30 October 2012. The inquest jury found that control points protecting vulnerable detainees were grossly ineffective and that there had been failures across agencies to recognise, monitor and respond to his deteriorating condition. The stated concerns included recognising when to refer detainees to healthcare and ensuring that concerns were reported simultaneously to healthcare managers and the Home Office contract monitor.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to report detainee concerns simultaneously to the Home Office contract monitor and healthcare managers at the IRC

    Wider context from the report

    “2. IMB- The current practise remains to refer concerns around detainees only to the Home Office contract monitor. I see no good reason not to, in addition and simultaneously, report concerns to the healthcare managers at the IRC. In recording this concern I have in mind the jury’s determinations and findings in the record of inquest which highlight ineffective joint working across all agencies. Simultaneous reporting of issues would lessen the prospect of a healthcare related issue slipping through the net and not being addressed. ”

    Source location

    Prince Kwabena Fosu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Dorset

    AI-generated summary

    Branko Zdravkovic · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Branko Zdravkovic, who was detained at the Immigration Removal Centre, The Verne, was found suspended by a ligature in a toilet cubicle and died on 9 April 2017. The inquest concluded that his death was suicide, with the medical cause recorded as ligature suspension. Concerns were raised that staff were instructed to use ACDT procedures instead of making Rule 35 reports, and that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT

    Wider context from the report

    “The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies. There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT. In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35. Rule 35 imposes a requirement to speedily review whether someone should be released because of concerns recorded by the medical practitioner. Without that information being provided the state cannot carry out its obligations under Article 2 ECHR. ”

    Source location

    Branko Zdravkovic · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop provisions to identify and flag detainees subject to ACDT monitoring or Rule 35 reporting.

    Verbatim wording from the response

    “The Home Office is making provisions to better identify and flag individuals in IRCs and foreign national offenders in prisons who are subject to ACDT/ACCT¹ monitoring, and those about whom a Rule 35 report has been submitted. This will ensure an early review of suitability for detention and the assessment of adult at risk factors, and will improve information sharing.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 2 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind IRC staff of ACDT information-sharing guidance and responsibilities through communications to all IRC parties.

    Verbatim wording from the response

    “There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 3 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use pilot learning to improve suicide and self-harm prevention guidance and procedures and clarify ACDT information-sharing responsibilities.

    Verbatim wording from the response

    “The Home Office will use the learning from the pilot to improve suicide and self-harm prevention guidance and procedures and to clarify the information sharing responsibilities in relation to those detainees assessed as being at risk of self harm and/or suicide.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 4 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing processes ensure Home Office officials and case workers are notified when ACDT monitoring begins for a detained individual.

    Verbatim wording from the response

    “There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 3 · response
    Published 24 May 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026