Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0308, written 5 Aug 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Aug 2015 |
|---|---|
| Reference | 2015-0308 |
| Deceased | Rubel Ahmed |
| Coroner | Stuart Fisher |
| Coroner area | Lincolnshire (Central) |
| Category | State Custody 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.
HM CORONER Central Lincolnshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Home Office 2. The Ministry of Justice CORONER ! am Stuart P G Fisher, Senior Coroner, for the coroner area of Central Lincolnshire, Lindum House, 10 Queen Street, Spilsby, Lincolnshire, PE23 5JE. 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. http:/www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 17 September, 2014 | commenced an investigation into the death of Rubel Ahmed, aged 26 years at the time of his death. The investigation concluded at the end of the Inquest on 18'" May 2015. The Jury returned an open conclusion with a Narrative Conclusion. The medical cause of death was: 1a. Hanging CIRCUMSTANCES OF THE DEATH Mr Ahmed came to the United Kingdom from Bangladesh in 2009. His Visa expired in 2011. Mr Ahmed was detained under immigration legislation on 21° July 2014 and was taken to Morton Hall Immigration Removal Centre pending deportation. It was intended that Mr Ahmed would be sent back to Bangladesh on 8" September 2014. On 5" September Mr Ahmed made a claim for asylum. He spoke with family members on the telephone on 5'" September 2014. Later that evening Mr Ahmed was found by staff hanging in his room. Despite attempts to resuscitate Mr Ahmed he was pronounced deceased shortly after midnight on 6" September, 2014. 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. — i. |THE LOCKING OF SOME DETAINEES IN THEIR ROOMS OVERNIGHT: In 2013, H.M Inspectorate of Prisons inspected IRC Morton Hall and recommended that detainees should not be locked into cells (rooms) and should not be restricted to units in 1 the early evening. Despite this recommendation, those in the Windsor Unit, in which Mr Ahmed resided, were locked into their rooms daily from 8:30pm to 8:00am on the following morning. This situation prevailed at the time of Mr Anmeds death. Whilst it was clear that significant efforts had been made to comply with the above HMIP recommendation, detainees in the Windsor Unit were still being locked into their rooms overnight at the time of the Inquest. My concern relates to whether the above HMIP recommendation has now been fully complied with and if not when compliance will be achieved. | consider that the practice of locking detainees in their rooms in the evenings and/or overnight should be discontinued as soon as is practically possible at Morton Hall I.R.C. DETENTION AWARENESS TRAINING: lam concerned that the detention awareness training given to the staff at Morton Hall |.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices. Further, little or no provision had been made to provide regular refresher training. | consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided. STAFF AWARNESS OF CHANGES IN DETAINEES CIRCUMSTANCES INCLUDING REMOVAL DIRECTIONS: It was disclosed at the Inquest that staff members, who dealt with Mr Ahmed on the evening of 5'" September, 2014 were not aware that he had been served with removal directions. Had staff been aware of this information it may have resulted in Mr Ahmed being monitored more comprehensively than was the case. My concerns relate to there being a need to implement a robust system to ensure that all relevant detention staff at Morton Hall IRC are aware of significant changes in detainees circumstances, including the service of removal directions upon them. PERSONAL OFFICER DETAIL: Despite the fact that Mr Ahmed had been allocated a Personal Officer it was abundantly clear that the officer had spent very little time with him, owing to other work pressures. It was also evident that there was no adequate system at Morton Hall for ensuring that staff have protected time to carry out this important work to enable detainees to discuss sensitive or distressing issues with an officer who was familiar to them. | consider that this situation needs to be reviewed to ensure that personal officers at Morton Hall IRC assigned to detainees are given protected time to carry out these duties. USE OF ELECTRICAL ITEMS IN ROOMS: Evidence at the Inquest established that Mr Ahmed utilised the electrical lead on his kettle to form a ligature with which he hanged himself. The electrical lead was noted to be two feet six inches in length. The lead could have been very much shorter and thus have avoided the risk of it being utilised as a ligature. This issue needs to be reviewed throughout Morton Hall IRC. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR your organisation 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 1 October, 2015. |, 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. 2 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons a) The Home Office b) The Ministry of Justice c) Solicitors representing Mr Anmeds Family — Bhatt Murphy | 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. aes itl Boo oo ren H.M Senior Coroner, Central Lincolnshire
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.
James Brokenshire MP Immigration Minister 2 Marsham Street, London SW1iP 4DF Home Office www.gov.uk/home-office Stuart P G Fisher H.M. Senior Coroner Lindum House . 10 Queen Street 29 SEP 208 Spilsby Lincolnshire PE23 5JE Dear Stuart INQUEST INTO THE DEATH OF RUBEL AHMED — REGULATION 28 REPORT Thank you for your regulation 28 report to prevent future deaths of 5 August 2015 addressed to the Home Office and the Ministry of Justice, following the inquest into the death of Rubel Ahmed who died on 6 September 2014 at Morton Hall immigration removal centre (IRC). You identify the following five matters of concern: The locking of some detainees in their rooms overnight; Detention awareness training; Staff awareness of changes in detainees’ circumstances including removal directions; Personal officer detail; and Use of electrical items in rooms. Any death in detention is deeply regrettable, and | am grateful to you for your report. | am replying on behalf of both Departments, as the Home Office Minister for Immigration. We understand your concerns about the practice of locking some detainees in their rooms overnight and acknowledge that a similar recommendation was accepted in principle following an inspection of the centre by Her Majesty’s Chief Inspector of Prisons (HMCIP) in 2013. Windsor Unit, where Mr Ahmed was accommodated, was originally designed, fitted and approved for use as a custodial building in which prisoners were locked in their rooms overnight. In order to operate a new regime in which rooms in Windsor Unit remain unlocked overnight, major changes to the fire safety measures are required to ensure detainee and staff safety and compliance with Crown Premises Inspectorate Group requirements. There is ongoing work to praotahbliah _ establish the costs of these measures. However, since the HMCIP inspection there has been a significant change in the profile of the detainee population at Morton Hall, with a large increase in ex foreign national offenders, often with complex needs. As a result the availability of more secure accommodation, including Windsor Unit, is necessary to house any detainees whose risk assessment makes them unsuitable to be held in more open conditions. We agree that it is important that all staff working in an IRC have a broad understanding of the needs of detainees. There is a comprehensive Detention Awareness training package in place for all staff at Morton Hall IRC and work is underway to implement a programme of regular refresher training. There is a robust safer detention system in place across the detention estate to identify and manage detainees who are at risk of self-harm or suicide, which includes Assessment, Care in Detention and Teamwork (ACDT) and Vulnerable Adult Care Plans. The large majority of detainees who are monitored on an ACDT are assessed as vulnerable as a result of their concerns about being deported or because of a change in circumstances. This is kept under review. Staff at Morton Hall IRC are aware that the service of removal directions can be a significant event for a detainee and provide individual support if there are signs or indications that the detainee is at rick...Mr Ahmed had ressived his removal directions six days prior to his death and there were no indications that he was at risk of self harm or suicide, which would have resulted in extra care and support. At Morton Hall all staff operate on the basis that every contact matters: every interaction between a member of staff and a detainee contributes to they effective management and care, and positive engagement is not limited to a relationship with a single personal officer. Welfare services are provided by specialist staff from Children’s Links, and each detainee has a welfare booklet opened during induction which is regularly reviewed and updated during their stay at Morton Hall. Again, | must stress that in the case of Mr Ahmed there were no indications prior to his death that he was at risk of self-harm or suicide. The use of electrical items in rooms has also been reviewed by officials at the National Offender Management Service. The electric leads on the kettles at Morton Hall are standard issue for the type of kettle in use in custodial settings as are all other electrical items in rooms at Morton Hall such as TVs and DVD players. Shortening electrical leads would unfortunately not eliminate the risk of self-harm or suicide. Instead, when a detainee presents a risk of self-harm or suicide, he will continue to be managed and monitored on an ACDT document and any necessary steps to reduce risk (including limiting access to items that could be used in acts of self-harm) will be taken, as is the existing policy. | would like to thank you for raising these important issues and hope that this response addresses your concerns. A copy goes to Andrew Selous MP, Parliamentary Under Secretary of State for Prisons, Probation, Rehabilitation and Sentencing at the Ministry of Justice. () V Q Rt Hon James Brokenshire
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