Branko Zdravkovic

Rt Hon Caroline Nokes MP  
Minister of State for Immigration 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

11 April 2018 

Mr S J Nicholls 
H.M. Assistant Coroner 
The Coroner’s Office for the District of Dorset 
Town Hall 
Bournemouth 
BH2 6DY 

Dear Mr Nicholls, 

BRANKO ZDRAVKOVIC – REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Thank you for your Regulation 28 report, dated 13 February 2019, following the inquest into 
the death of Mr Branko Zdravkovic at The Verne Immigration Removal Centre (IRC).  

Any death in detention is a tragic event, and I am very grateful to you for your report and for 
the opportunity to review and, where possible, strengthen our processes.  

You have identified the following matters of concern, which you suggest have the potential 
to lead to future deaths, if left unaddressed: 

•  Training provided to doctors and healthcare staff directs doctors to use Assessment Care 
in Detention Teamwork (ACDT) procedures to monitor detainees with suicidal tendencies 
rather  than  Rule  35(2)  of  the  Detention  Centre  Rules  2001,  which  triggers  a  prompt 
consideration  by  the  Home  Office  of  a  detainee’s  continuing  suitability  to  remain  in 
detention (Concern 1). 

•  There is no formal procedure for notifying the Home Office of detainees at risk of suicide 

or self harm when placed on ACDT monitoring procedures (Concern 2). 

It may be helpful if I highlight our existing processes as well as set out the actions we have 
taken or intend to take to guard against future deaths.   

The Home Office’s suppliers which operate IRCs on our behalf are required to operate within 
a strictly defined framework of legislation and guidance. This requirement is stipulated in our 
individual contracts and, with HMPPS, in our service level agreement. The inquest’s findings 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 demonstrate  that  the  Home  Office  must  continue  to  ensure  that  these  systems  are  used 
appropriately and that they effectively support those at risk. 

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. 

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. 

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. 

Concern 1 – Rule 35(2) reporting 

ACDT  monitoring  procedures  deliver  a  tailored  support  package  to  monitor  individuals 
according to their assessed risk of self harm and suicide in detention.  Scheduled and ad-
hoc  contact/interventions  with  the  individual  take  place  throughout  each  day  to  ensure 
contact is maintained, that welfare, mood and behaviour is kept under review, and that the 
necessary support is offered and increased/decreased as required.  

Notwithstanding  this,  ACDT  monitoring  is  not  a  substitute  or  alternative  reporting  or 
monitoring  mechanism  for  those  individuals  of  whom  doctors  have  made  a  clinical 
assessment and have concerns in respect of their risk of suicide.  Where these concerns 
are present, doctors are required to make a report under Rule 35(2). 

ACDT  monitoring  and  reporting  under  Rule  35(2)  are  reciprocal  processes.    The  Home 
Office  is  committed  to  supporting  medical  practitioners  in  the  submission  of  Rule  35(2) 
reports and ensuring that they are kept appraised of ACDT monitoring.   

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. 
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 

1 Assessment Care in Custody Teamwork (ACCT); the self harm and suicide prevention monitoring system used by Her 
Majesty’s Prisons and Probation Services in prisons. 

 
 
 
 
 
 
 
                                                
 of Rule 35(2).  Given the low levels of Rule 35(2) reports received, the analysis aimed to 
establish the effectiveness of the provisions of Rule 35(2) in identifying, safeguarding and 
managing those at risk of suicide and to inform wider work being undertaken to review and 
update the Detention Centre Rules.  

The initial review covered the period 1 November 2017 to 1 November 2018, in which only 
six  Rule  35  (2)  reports  were  raised.  This  naturally  limits  the  weight  of  the  indicative 
outcomes.  The  review  recognised  that  while  ACDT  plans  are  a  useful  tool  in  managing 
suicide  risk  and  safeguarding  individuals  in  detention,  there  is  limited  scope  to  raise 
concerns to the Home Office regarding continued detention and provide medical opinion of 
suicide risk without the Rule 35 (2) reporting mechanism. 

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.  

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 monitored.  

Concern 2 - ACDT Monitoring Procedures 

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. 

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.   

The Home Office has closely followed the work being undertaken by Her Majesty’s Prisons 
and Probation Service (HMPPS) to review its Assessment, Care in Custody and Teamwork 
(ACCT) procedures, upon which our ACDT procedures are modelled. 

The HMPPS review has identified key elements of the ACCT process where practices need 
to  be  strengthened.  These  include  the  identification  and  assessment  of  risk,  multi-
disciplinary working and information sharing and the provision of person-centred care (with 
a focus on outcomes for the individual).  

 
 
 
 
 
 
 
 
 
 On 13 September 2018, the consultation period for the new HMPPS procedures developed 
as a result of this review ended, and a pilot for the new process was agreed.  Morton Hall 
IRC is currently trialling the new process on behalf of the immigration removal estate.  

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.  

I would like to thank you for raising these important issues and hope that this response 
addresses your concerns. I am copying my reply to Rory Stewart MP, Minister of State for 
Prisons at the Ministry of Justice. 

Rt Hon Caroline Nokes MP 
Minister of State for Immigration