Recurring concern

Unreliable Rule 35 reporting for vulnerable detainees

Pin Get email alerts Request correction

First reported 13 Feb 2019•Latest report 25 Oct 2024

Definition

What this concern includes

Includes failures in the dedicated Rule 35(2) reporting process for detainees, including recognising when the statutory reporting threshold is met, completing and submitting reports, understanding the relationship between Rule 35 and ACDT or other monitoring procedures, and ensuring reports reach the responsible authority promptly.

Not included

  • Excludes general suicide-risk assessment, observation or ACDT failures when no Rule 35 reporting deficiency is identified.
  • Excludes generic detention healthcare staffing, training, communication or record-keeping deficiencies unless they directly impair the Rule 35(2) reporting process.
  • Excludes non-detainee safeguarding or statutory reporting processes, including ordinary clinical safeguarding referrals.
  • Excludes failures limited to the Home Office's subsequent review or detention decision after a Rule 35(2) report was reliably submitted.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2019–2024

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office2
Mitie1
NHS England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West London

    AI-generated summary

    Frank Steve Rios OSPINA · 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

    Frank Steve Rios OSPINA died by suicide in detention, with the cause of death recorded as ligature compression of the neck and coronary heart disease. The report raised concerns about the failure to make a Rule 35(2) report after apparent suicide attempts, inconsistent understanding of the reporting process, the conduct and oversight of a closed family visit, and difficulties faced by his non-English-speaking mother in arranging visits and telephone calls.

    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

    Restriction of Rule 35(2) report generation to general practitioners

    Wider context from the report

    “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2) The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention. Rule 35 (2) states 2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State. ‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay. Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made. The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days. There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task. ”

    Source location

    Frank Steve Rios OSPINA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 make Rule 35(2) reports when detainees are suspected of suicidal intentions

    Wider context from the report

    “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2) The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention. Rule 35 (2) states 2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State. ‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay. Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made. The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days. There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task. ”

    Source location

    Frank Steve Rios OSPINA · Prevention of Future Deaths report
    Page 2 · 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

    Amend the Adults at Risk policy and Rule 35 assessment process to support multidisciplinary assessments by registered IRC healthcare professionals.

    Verbatim wording from the response

    “NHS England is working with the Home Office policy team to amend the Adults at Risk policy and Rule 35 assessment process. The aim of this work is to move the assessments towards a multidisciplinary approach, ensuring that completion of the assessment can be undertaken by a registered healthcare professional at the Immigration Removal Centre (IRC). Introducing this approach will ensure the management of safeguarding and vulnerability are not solely the responsibility of general practitioners. NHS England and the Home Office will, prior to full implementation during 2025, jointly develop a stakeholder engagement session to share the revised requirements with IRC providers and operators.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 15 July 2025

    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

    Jointly develop a stakeholder engagement session to share revised assessment requirements with IRC providers and operators before full implementation.

    Verbatim wording from the response

    “NHS England is working with the Home Office policy team to amend the Adults at Risk policy and Rule 35 assessment process. The aim of this work is to move the assessments towards a multidisciplinary approach, ensuring that completion of the assessment can be undertaken by a registered healthcare professional at the Immigration Removal Centre (IRC). Introducing this approach will ensure the management of safeguarding and vulnerability are not solely the responsibility of general practitioners. NHS England and the Home Office will, prior to full implementation during 2025, jointly develop a stakeholder engagement session to share the revised requirements with IRC providers and operators.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 15 July 2025

    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

    Develop and disseminate clinical guidance advocating a multidisciplinary approach to Detention Centre Rule 35 and Short-Term Holding Facility Rule 32 assessments.

    Verbatim wording from the response

    “The NHS England Health and Justice Clinical Reference Group developed Detention Centre Rule 35 and Short-Term Holding Facility Rule 32 clinical guidance, which advocates this multidisciplinary approach. This guidance was disseminated to all IRC healthcare providers via an online event chaired by the NHS England Health & Justice National Clinical Lead in April 2024. The IRC Partnership Group provides the governance and oversight of the attainment of the NHS England and Home Office Detention joint priorities and assures the national system of the quality and consistency of healthcare provisions and reduction of health inequalities.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 15 July 2025

    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

    Review the Adults at Risk policy and Rules 34 and 35, including whether eligible healthcare professionals should produce Rule 35 reports.

    Verbatim wording from the response

    “In terms of the limitations on the production of a Rule 35 report, where only a General Practitioner can produce a Rule 35 report, the Home Office is currently conducting a review of the statutory Adults at Risk (AaR) policy and Rules 34 and 35 of the Detention Centre Rules 2001. The option to remove this restriction and extend the production of Rule 35 reports to other relevant healthcare professionals is being considered and will form part of an external engagement process. The review is expected to be completed in Spring 2025. Any changes would require new statutory instruments to be laid before Parliament.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 15 July 2025

    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

    Develop and publish interim DSO 09/2016 guidance requiring healthcare staff to report suicidal-intention concerns and clarifying relevant indicators.

    Verbatim wording from the response

    “The first issue relates to a mismatch in the healthcare provider and Home Office expectations and practical application of the Rule 35 provisions. This is being addressed through the development of an interim update to the published guidance Detention Services Order (DSO) 09/2016. The interim guidance will make clear that healthcare staff must inform the doctor of a detained person if staff have concerns of suicidal intention.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 15 July 2025

    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

    NHS England will respond separately regarding concerns about the operation of Detention Centre Rule 35.

    Verbatim wording from the response

    “I am aware that officials from NHS England will write to you separately with regards to your concerns about the operation of Detention Centre Rule 35. I understand that Mittie Care and Custody will also be writing to you, and their response may touch on some of the issues which I address below.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 15 July 2025

    Open published response

  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

    Failure to make statutory Rule 35 reports for detainees with suicidal tendencies

    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

    Conduct an internal review of Rule 35(2) reporting effectiveness and use its findings to inform wider policy work.

    Verbatim wording from the response

    “The Home Office keeps the effectiveness of its procedures under review. As part of this continuous improvement the Home Office conducted an internal review to analyse the use”

    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

    Finalise and introduce new Removal Centre Rules, including updated Rule 35 reporting arrangements.

    Verbatim wording from the response

    “The findings of the initial review have been used to inform our separate work to finalise new Removal Centre Rules to replace the current Detention Centre Rules. We are aiming to introduce the new Rules, which will include updates to the reporting system in Rule 35, by July 2019.”

    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

    Seek healthcare-provider assurances on correct Rule 35 processes and consult the assurance forum about broader implementation.

    Verbatim wording from the response

    “NHS England commission health services in prisons and other places of detention including IRCs. This is undertaken through six NHS England Health and Justice Teams. Healthcare in IRCs in Scotland is commissioned by the supplier running those centres. The Home Office’s Director of Detention and Escorting Services will write to NHS England (as the commissioning body for IRC healthcare services in England) and to the healthcare providers at Dungavel IRC by the end of April 2019 to seek assurances that all parties are following the correct process. The Home Office IRC Assurance Group forum will be consulted to consider how this can be more broadly implemented.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 3 · 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

    Home Office training does not direct doctors to substitute ACDT monitoring for Rule 35(2) reporting; the apparent issue was local misunderstanding.

    Verbatim wording from the response

    “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 2 · 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

    Only an IRC doctor may submit a Rule 35(2) report, and the decision rests solely with that doctor's clinical judgment.

    Verbatim wording from the response

    “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.”

    Source location

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

    Open published response
Back to top

Data last updated 7 September 2026