Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0410, written 18 Sep 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2014 |
|---|---|
| Reference | 2014-0410 |
| Deceased | Brian Dalrymple |
| Coroner | Jeremy Chipperfield |
| Coroner area | West London |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
West London Coroner's court
Re: Inquest Touching the Death of Brian Christopher Dalrymple
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Home Office (concerns 1,2,3,4 and 5 apply)
GEO Group, UK Ltd (concerns 1,2,3,4,and 5 apply)
Serco (concerns 4 and 5 apply)
Nestor Primecare (concerns 3 and 4 apply)
The Practice Pic (concerns 3 and 4 apply)
CORONER
| am Jeremy Chipperfield, assistant coroner, for the coroner area of West London
CORONER’S LEGAL POWERS
{ make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
The investigation into the death of Brian Christopher Dalrymple concluded at the end of
the inquest on 27-Jun-14. The jury's conclusion of the inquest was “natural causes
contributed to by neglect”; the medical cause was a ruptured dissection of the thoracic
aorta and hypertension. The jury produced a narrative conclusion, a copy of which is
attached herewith.
CIRCUMSTANCES OF THE DEATH
Having entered the UK from the USA on 14-Jun-11, Mr Dalrymple was refused entry by
the UKBA and detained at Harmondsworth Immigration Removal Centre pending
removal. On 27-Jul-11, he was removed to Colnbrook Immigration Removal Centre
where he died on 31-Jul-11.
The fatal rupture was caused by extreme hypertension- a condition for which he
declined treatment and monitoring for most of the period of his detention. He expressed
unusual views about his ability to control hypertension (by spiritual means) as well as
about other matters and exhibited unusual behaviour during his detention.
After his death it was discovered that Mr Dalrymple was schizophrenic and had been
prescribed medication for this condition in the USA.
The inquest considered issues related to his deteriorating psychiatric condition and
capacity in detention, amongst others.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. —
(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i)
behaviours (and reported experiences) which may indicate the existence of mental
health issues affecting particular detainees- particularly in relation to schizophrenia; and
(ii) the need to ensure that such potential indicators are brought to the attention of those
responsible for the particular detainee’s healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's
detention, indi s of his mental ill-health were not recognised as such. Witness
identified events and circumstances from the point of Mr Dalryple’s
presentation at port and throughout his period of detention that he said “should have
been picked up” and triggered a psychiatric assessment (for which there was an
“overwhelming need”). In Mr Dairymple's case such concerns were not properly
acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators.
The evidence was that officers were and remain unclear whether particular behaviours,
unusual in local society at large, should be regarded as significant amongst the
population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a
clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed
on the detention officers to raise concerns over a detainee’s mental heath.
(2)
Relevant and significant observations recorded by detention centre staff and others are
not actively brought to the attention of relevant healthcare staff.
in the present case, custody officers’ entries in wing history records were sufficient
(alone or in combination) to alert a reader to the possibility of mental health issues
affecting Mr Dalrymple whilst detained at Harmondsworth IRC; these indicators were
missed. In the terms of Witnes: the overall picture of developing
(relapsing) mental disorder was not available to any one set of people.
(3)
Medical practitioners may be employed at Harmondsworth IRC without knowledge
necessary to that role.
The locum GP who gave evidence at the inquest was unaware of Detention Centre
Rules 2001 or of the duties imposed on him by them- rule 35, for example. He was also
unaware that healthcare staff had access to wing history documents.
(4)
Routine medical visits to segregated detainees are inadequate properly to assess
detainees’ healthcare needs.
The evidence was that each detainee would be asked through the wicket “Any medical
problems?", and if the answer was negative, there would be no further interaction-
witness described the practice as “not fit for purpose”;
and
(5)
The absence of a comprehensive and accessible (computerised) clinical record relating
to each detainee at [RCs Harmondsworth and Colnbrook.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 13-Nov-14. |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
(mother of the deceased and representing the family of the deceased)
| have aiso sent a copy of this report to:-
HM Inspector of Prisons
National Offender Management Service and
Independent Advisory Panel on Deaths in Custody
MITIE
am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
18-Sep-14 Jeremy Chipperfield
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
& MORTUAR’ vom | GC® The GEO Group UK Ltd Mr. Jeremy Chipperfield RECEIVED The GEO Group UK Limited . os Second Floor au coroner Horizon Building oroners Co Honey Lane 25 Bagleys Lane Hurley Fulham SL6 6RJ Main Line: +44 1628 519 900 London Fax Line: +44 1628 519 920 SW6 2QA www, geogroup, co.uk one Your Ref: 26" September 2014 Dear Sir, Inquest touching into the death of Brian Christopher Dalrymple Thank you for your letter dated 18" September 2014 enclosing Regulation 28 Report and Record of Inquest. You will no doubt recall the written and oral evidence I gave in which I explained all of the actions taken to address the concerns you raise in your letter and indeed other concerns already raised by GEO. As the Contract for the management of Harmondsworth IRC passed to Mitie on 01" September 2014, there is of course no practicable steps GEO can take in relation to the working practices at Harmondsworth. However, the lessons learned from Inquests such as this are invaluable and I can assure you on behalf of GEO that we will be considering them very carefully in relation to the company’s other operations where appropriate, and in order to try and ensure that tragic deaths, such as this, can be avoided in future. I note that you have sent a copy of the report to Mitie. Please do not hesitate to contact me if I can assist further. Yours faithfully Chief Operating Officer 8 issn ely GS A D> counen. ee = prarer Registered Address: 100 New Bridge Street, Londen, EC4V 6JA. Companies House. Company registration number 2878845
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