Chair of the Independent Monitoring Board

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First report 6 Jul 2020•Latest report 6 Jul 2020

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Chair of the Independent Monitoring Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  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. The report was sent to Chair of the Independent Monitoring Board; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Chair of the Independent Monitoring Board; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise when to refer cases to healthcare

    Wider context from the report

    “1. CNWL - All staff who would be expected to refer cases to healthcare need as much assistance as possible in order to discharge that responsibility effectively. It is recognised CNWL is the new healthcare provider and did not provide healthcare in 2012. It is also recognised that CNWL have improved the training on how to make a referral. However, there was knowledge on how to make a referral in 2012 and the jury have highlighted the failures that still occurred, leading to the death of Mr Fosu . My concern centres on improving the recognition of when to make a referral as opposed to knowing the mechanics of making a referral once a decision has been made to refer. By way of respectful analogy, medical practitioners referring cases to a coroner know how to make a referral but now have guidance in legislation as to when to refer. The Trust should give serious consideration to developing a guide to all staff on when to refer cases to healthcare. This should be achievable without being either over-prescriptive or over-restrictive. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026