PFD report

Branko Zdravkovic · Prevention of Future Deaths report

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Issued 13 Feb 2019•Dorset

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to make statutory Rule 35 reports for detainees with suicidal tendencies
    Part of recurring concern: Failure to reliably report self-harm and suicide risks to people able to helpPart of recurring concern: Unreliable Rule 35 reporting for vulnerable detainees
  2. Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT
    Part of recurring concern: Unreliable ACDT suicide and self-harm risk-management processesPart of recurring concern: Unreliable reporting of detainee safety concerns to responsible oversight functions
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

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

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.
  2. Action

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

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.
  3. Action

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

    Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

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

    Stated by Home OfficeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to reliably report self-harm and suicide risks to people able to help; Unreliable Rule 35 reporting for vulnerable detainees.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Unreliable ACDT suicide and self-harm risk-management processes; Unreliable reporting of detainee safety concerns to responsible oversight functions.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Establish Detention Engagement Teams in all immigration removal centres to link Home Office casework areas with detainees.

    Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
  2. 2

    Publish data on deaths in immigration removal centres to increase transparency.

    Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.
  3. 3

    Ask the Independent Advisory Panel on Deaths in Custody to review and report on deaths and serious self-harm in immigration detention.

    Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 24 May 2019.

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

Establish Detention Engagement Teams in all immigration removal centres to link Home Office casework areas with detainees.

Verbatim wording from the response

“Separately, we have established Detention Engagement Teams within all IRCs, to provide an onsite link between the Home Office’s various casework areas and the detained population. We are confident that this will, in the fullness of time, allow for improved assessments of vulnerabilities, including where detainees are subject to the ACDT process.”

Source location

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

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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

Publish data on deaths in immigration removal centres to increase transparency.

Verbatim wording from the response

“To increase transparency on the reporting of deaths, the Home Office began publishing data on deaths in immigration removal centres in November 2018. This included data on the number of deaths in immigration detention in 2017 but did not include those who died while being detained solely under immigration powers in HM prisons, or after leaving detention.”

Source location

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

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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

Ask the Independent Advisory Panel on Deaths in Custody to review and report on deaths and serious self-harm in immigration detention.

Verbatim wording from the response

“The Independent Advisory Panel on Deaths in Custody has been asked by the Home Office to review and report on issues pertaining to deaths and incidents of serious self-harm in immigration detention. This request has been made in support of three recommendations relating to deaths in detention made by Stephen Shaw in his second review of immigration detention, and will provide further insight into the availability and usefulness of the existing data on deaths in detention.”

Source location

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

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026