Aram Ali Mustafa · Prevention of Future Deaths report

On 08/02/2019, I commenced an investigation into the death of Aram Ali Mustafa. The investigation concluded at the end of an inquest on 19th June 2019. The conclusion of the inquest was Suicide.

The deceased had entered the UK illegally on 09/04/18 and had been deported to Italy on 29/10/18. At the time he was deported he stated he would kill himself – however, he was deported successfully. He returned to the UK illegally on 30/01/19 claiming asylum and was placed in initial accommodation in room 227 at Stone Road hostel. On 02/02/19 concern was raised about his welfare by a local shop owner who stated he had expressed suicidal thoughts. Security staff at Stone Road arranged for him to attend City hospital where he was assessed by a mental health nurse. He denied any suicidal thoughts and was noted to have depressive and anxiety symptoms. The assessment concluded there was no clinical need for urgent treatment or hospital admission. He was referred back to the NHS practice that supports all asylum clients for further treatment. He had failed to attend an appointment at the practice on 01/02/19 but he had a further appointment booked for 04/02/19. On 04/02/19 he attended a charity located at Stone Road at 09.45 to complete paperwork for his immigration application however he left before his appointment started. He attended the medical practice at 14.44 and complained to the receptionist that he had problems with dental implants. He was taken to see a dentist at the health centre who could not help. He then stated to an interpreter that he was feeling depressed and suicidal. As a result he was booked to see the GP but he was not present in the reception area when the GP called him for his appointment. He returned to the reception desk at 16.00 which was closing time where the GP and receptionist saw him. He was again complaining about his dental implants. They booked him a further appointment for 13.00 the following day to see the GP and a CPN. There were no concerns about his safety at this time. He returned to room 227 at 16.28. CCTV confirmed his roommate tried to gain access to the room at 17.20 and 17.39 but failed. At 23.00 his roommate used a key to enter the room and found him hanging by a scarf from the fixed wardrobe. Security staff attended and paramedics arrived at 23.09 but he was declared deceased 23.10. He left a note indicating his intentions..

Following a post mortem the medical cause of death was determined to be:
HANGING

1. When he had first illegally entered the UK Mr Mustafa was deported to Italy on 29/10/18. Just before he was deported he confirmed he would kill himself if he was deported. He was provided with 1:1 constant watch and was successfully deported. When he re-entered the UK on 30/01/19 he was seen by a member of the immigration compliance and enforcement team who completed paperwork for the national asylum accommodation unit who in turn completed a service commission form requesting initial accommodation. The service commission form recorded that he had urgent medical needs and was a safeguarding concern however no detail was provided. Neither G4S nor Urban housing services requested any further details. A system needs to be put in place to ensure organisations provide sufficient details for providers to understand the nature of safeguarding concerns and health care matters. If there are GDPR concerns these could easily be addressed by a consent form at the time the person is first seen.

2. The events on 29/10/18 when he made a threat to kill himself were not logged with the safeguarding hub as he was about to be deported. There needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in the system