Recurring concern

Unreliable reporting of detainee safety concerns to responsible oversight functions

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First reported 13 Feb 2019•Latest report 6 Jul 2020

Definition

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.

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: 2
Individual concerns: 2
Date range: 2019–2020
Stated actions: 3

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Central and North West London NHS Foundation Trust1

Chair of the Independent Monitoring Board1

Home Office1

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.

6 Jul2020
West London
Concerns raised1
1. Failure to report detainee concerns simultaneously to the Home Office contract monitor and healthcare managers at the IRC
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
13 Feb2019
Dorset
Concerns raised1
1. Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop provisions to identify and flag detainees subject to ACDT monitoring or Rule 35 reporting.
  Stated by Home OfficeStated in progress
2. Action
  Remind IRC staff of ACDT information-sharing guidance and responsibilities through communications to all IRC parties.
  Stated by Home OfficeStated planned
3. Action
  Use pilot learning to improve suicide and self-harm prevention guidance and procedures and clarify ACDT information-sharing responsibilities.
  Stated by Home OfficeStated planned
Respondent positions 1
1. Position
  Existing processes ensure Home Office officials and case workers are notified when ACDT monitoring begins for a detained individual.
  Stated by Home OfficeExisting arrangements considered sufficient
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 1