Aram Mustafa

G4S Care and Justice Services (UK) Limited
Cariton House
7 | Carlton Road
Worksop
Nottingham
$81 7QF

www.g4s.com/uk

Telephone
01902 501584

Her Majesty's Senior Coroner

Louise Hunt

Birmingham and Solihull Coroner’s Court
50 Newton Street

Birmingham

B4 6NE

3 July 2019
Dear Coroner,
Inquest touching upon the death of Mr Aram Ali Mustafa
| write in response to your Regulation 28 Report to Prevent Future Deaths dated 19 June.
Your report raised the following Matters of Concern:

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

Response to Matters of Concern (1)

G4S Care and Justice Services (UK) Limited (‘G4S’) receive the initial transport instructions
directly from UKVI through an electronic portal. This is followed up with a Service
Commission Form (SCF) being sent by fax direct to Urban Housing Services. Whilst the
transport instruction notification and SCF both stated that there was a ‘safeguarding’ issue,
no further details were provided. The term ‘safeguarding’ does not have a defined meaning.
GAS therefore had no knowledge as to exactly what issue UKVI were referring to in the

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instruction; as revealed in evidence, the term is applied to cover many different issues, not all
being medical or matters requiring immediate action and/or consideration.

The electronic nature of both instructions did not allow for a two-way communication. This
therefore means that G4S is wholly reliant upon a) the information provided by UKVI on the
forms and b) the extent to which service users are prepared to share information voluntararily
upon induction into accommodation. G4S does seek to obtain as much information as possible
from service users. Unfortunately, Mr Mustafa did not reveal details of his past suicide threat
or recent depressive episodes.

The matter of consent forms when service users are first assessed for accommodation is a
matter for UKVI. G48 has however taken the following steps in order to seek improvements
to the process and level of information exchange:

1) G4S senior management form part of a UKVI led Senior Safeguarding working group which
meet every month to review and discuss individual safeguarding cases with particular reference
to ones where there are gaps in information provided by UKVI.

2) The UKVI Chair of the above Working Group takes responsibility for investigating every single
case raised to identify gaps in the information provided by UKVI and ways in which this can
be improved;

3) UHS, G4S’s subcontractor, who receive SCFs direct from UKVI, in which safeguarding
concerns are raised, alert G48 immediately of concerns about Service Users so that such cases
can be raised with the Senior Safeguarding working group. Significant improvements have
been made in relation to such cases, in particular, with the information conveyed by UKVI to
G4S/UHS.

Response to Matter of Concern (2)

As above, G4S were not aware of Mr Mustafa’s prior suicide threat and are not responsible
for managing the Safeguarding Hub. Given that this rests with UKVI, it is not something upon
which it can respond further. G4S does however have systems in place to ensure that matters
of safeguarding concerns uncovered during the course of delivering its services are notified
to UKVI. UKVI has its own Safeguarding Hub as well as 2 x safeguarding leads in each of the
GAS contract regions. Any issues in relation to safeguarding are immediately raised with these
respective leads as well as the Safeguarding Hub by our central contact centre which collates
all information and feeds back advice and information to the relevant operational teams. We
also have a robust incident management process and operational teams, including UHS,
compile incident reports which include all relevant information about the incident in question.
All incident reports are forwarded to UKVI by our central contact centre. Should these
incidents relate to safeguarding concerns then the Safeguading Hub and leads are included in
the communication.

GAS’ ability to take further action on the matters raised is limited given that its contract with
UKVI ends on 31% August 2019. It will thereafter have no involvement in the provision of
asylum seeker accommodation services.

| hope this response meets with your satisfaction.

Yours sincerely,

Head of Business Services
G4S Immigration and Borders

Government
Legal Department

Litigation Group T 020 7210 3000
Louise Hunt One Kemble Street.
Senior Coroner London
Birmingham and Solihull Coroners Court WC2B 4TS
50 Newton Street
Birmingham .
B4 6NE DX 123242 Kingsway 6 www.gov.uk/gid
Your ref:
Our ref: 21906976/LMO/HOI6
27 August 2019

Dear Ms Hunt
Aram Ali Mustafa (Deceased)

Thank you for your Regulation 28 Report of 19 June 2016 following the Inquest into the death of Aram Ali
Mustafa on 8 February 2019.

During the Inquest we understand that evidence revealed matters giving rise to concerns which could lead to
future deaths. You have required that the Home Office confirms details of what action has been taken or
proposed to be taken, and set out the timetable for action. Otherwise the Home Office must explain why no
action is proposed.

First Concern

The first concern you had was that once Mr Mustafa re-entered the UK the Service Commission Form recorded
that he had urgent medical needs and was a safeguarding concern. However, no detail was provided. Neither
G4S or Urban Housing Services requested any further details. You advised that 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. Any GDPR concerns can be addressed by a consent form at the time when
the person is first seen.

The Home Office have advised that when Mr Mustafa re-entered the UK he was. seen by Immigration
Enforcement. The Service Commission Form (SCF) is completed when the applicant has asked for
accommodation. The Routing Teams complete the SCF which is sent to the provider; in this case it was G4S.

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So the first responder, Immigration Enforcement, referred the case to NAAU intake who then referred to NAAU
Routing who arrange accommodation and transport if needed. The SCF was completed at this stage.

The Home Office have confirmed that the first responders are being challenged for further detail when referring
a case into NAAU (National Asylum Allocation Unit) in relation to any indication of vulnerabilities. This
information is being recorded on the CID database and on the SCF 4386 referral form prior to being forwarded
to the Routing Team. CID is being checked more thoroughly by the Intake Team to reduce the risk of missing
information that wasn’t forthcoming from the referring officers.

In addition, a spreadsheet has been introduced that records all the safeguarding action and will be jointly in use
by all the Teams in accordance with the order of process, i.e. intake will make the initial input as per referral
and followed by RIAV (Routing Initial Accommodation Validation) and Routing updating their subsequent action
~ this will include onward referrals to the Service Providers, and the Safeguarding Hub.

Additionally, a NAAU purpose matrix will be piloted, with a point base scoring system which will guide staff in
terms of vulnerabilities that require escalation to the Hub. This is awaiting to be signed off by Senior
Management. The Matrix which is due to be introduced will help to decide on the level of vulnerability and
hence if a Safeguarding Referral is required.

Referrals can come into the Safeguarding Hub from any source however they deal with service users who have
an asylum claim; they are only funded for this. G4S and others would have had access to the Hub provided
they are regarding asylum applicants. The Hub could not have done anything if a referral was made post
removal. However, if a referral had been made prior to removal and included details of suicide risk, the Hub
would have accepted the referral.

Specific safeguarding and vulnerable concerns are included in the referral form — a list of possible concerns are
listed and the referring officer is asked whether they have any relevance to the customer. Checks are put in
place to ensure this happens.

Immigration Enforcement have acknowledged that more could have been done had the Immigration Officers
identified the previous vulnerability notes on CID. It is been noted that the references to suicide were not easily
identified in the special conditions (noted under DS: ACDT plan) and the appropriate CID flag (threat of self-
harm) had not been raised at the point of Mr Mustafa’s TCU removal.

If the vulnerabilities had been noted normal practice would have been to inform the Police of the safeguarding
concerns on their system upon their initial contact, questioning custody as to whether Mr Mustafa had been
medically deemed fit in light of the medical conditions, and making a safeguarding referral. The case has been
discussed with the Immigration Officers involved and will form a part of NCCU’s regular lessons learnt

exercises.

In terms of work underway in Immigration Enforcement, they have been rolling out a 2 day mandatory
vulnerability training course to all staff, which includes how to identify vulnerability concerns and appropriate
steps to take. They have also now have a network of Vulnerability Champions across Immigration Enforcement

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who can support and advise colleagues when cases of concern arise. Best practice and lessons learnt are also
captured by the Immigration Enforcement Vulnerability Team and shared across Immigration Enforcement, to

continually improve their safeguarding response.

We set out below the factors provided by the Home Office to take into account while sharing information with
external contractors in line with GDPR.

“When deciding whether to enter into an arrangement to share personal data (either as a provider, a recipient
or both) you need to identify the objective that it is meant to achieve. You should consider the potential benefits
and risks, either to individuals or society, of sharing the data. You should also assess the likely results of not
sharing the data. You should ask yourself:

° What is the sharing meant to achieve? You should have a clear objective, or set of objectives. Being
clear about this will allow you to work out what data you need to share and who with. It is good practice
to document this.

° What information needs to be shared? You shouldn't share all the personal data you hold about
someone if only certain data items are needed to achieve your objectives. For example, you might
need to share somebody's current name and address but not other information you hold about them.

* Who requires access to the shared personal data? You should employ ‘need to know’ principles,
meaning that other organisations should only have access to your data if they need it, and that only
relevant staff within those organisations should have access to the data. This should also address any
necessary restrictions on onward sharing of data with third parties.

* When should it be shared? Again, it is good practice to document this, for example setting out
whether the sharing should be an on-going, routine process or whether it should only take place in
response to particular events.

¢ How should it be shared? This involves addressing the security surrounding the transmission or
accessing of the data and establishing common rules for its security.

« How can we check the sharing is achieving its objectives? You will need to judge whether it is still
appropriate and confirm that the safeguards still match the risks.

¢ What risk does the data sharing pose? For example, is any individual likely to be damaged by it? Is
any individual likely to object? Might it undermine individuals’ trust in the organisations that keep
records about them?

* Could the objective be achieved without sharing the data or by anonymising it? It is not appropriate to
use personal data to plan service provision, for example, where this could be done with information that
does not amount to personal data.

In summary, the Home Office state they need to provide only information that they can show is required, is
relevant, is secure and is provided in the best interests of the applicant.”

Second Concern

The second concern was in relation to the events on 29 October 2018 when Mr Mustafa made a threat to kill
himself which were not logged with the Safeguarding Hub. as he was about to be deported. You advised that

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there needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in
the system.

The Safeguarding Hub comes under the umbrella of the Resettlement, Asylum Support and Integration
Directorate — a joint unit between the Home Office, the Department for International Development, and the
Ministry of Housing, Communities and Local Government. The Safeguarding Hub receive referrals where there
is a service user that is vulnerable. The team assess the referral to identify the level of action or intervention
required. The service user may have declared self-harm or may have attempted suicide. The hub will make
referrals to GPs or local services, or sign post the service user to services depending on vuinerability identified;
these cases are followed up as necessary. ;

When there is a high risk case a case conference is completed. This would include the service user's medical
history, which includes details of the GP and any recommendations. The case conference is submitted to a
Grade 7 for their input and sign off. These cases are followed up ensuring all recommendations are put in
place.

Thank you again for bringing this matter of concern to my client's attention. My client will ensure that learning
from this tragic incident is shared widely across the Home Office.

Please let us know if you have any queries or you wish us to clarify any of the Home Office’s responses.

Yours sincerely

Ly

For the Treasury Solicitor

mung

HM Senior Coroner Hunt

Birmingham and Solihull Coroner's Court

50 Newton Street

Birmingham

B4 6NE

By email: coroner@birmingham.gov.uk

5 July 2019

Dear Mrs Hunt

Inquest touching upon the death of Aram Ali Mustafa

We write as requested, to respond to your report dated 19 June 2019.

We would like to firstly set out our condolences to Mr Mustafa's friends and family. 

We note the two matters of concern set out in your report and deal with these in turn below. 

1. Safeguarding Concerns

Unfortunately, we were not made aware of the previous threats of suicide made by Mr Mustafa 
prior to his removal to Italy on 29 October 2018. At that time he was not resident with us.

In  January  2019,  we  were,  as  you  note,  provided  with  very  limited  information  which  simply 
confirmed  Mr  Mustafa  was  a  "safeguarding"  case.  As  was  stated  in  evidence  at  the  inquest, 
this  can  cover  physical  or  mental  health,  along  with  a  plethora  of  different  (often  non-health 
related) issues. As you noted in your questioning of witnesses we are limited by the information 
provided to us by other parties and the individual resident, who is free to provide as much, or 
as little, information as they choose.

Following Mr  Mustafa's  tragic  death,  in  conjunction  with  others  involved  in  the  provision  of 
services to asylum applicants, we have reviewed our procedures and the way we interact. 

A  Multi-Agency  Review 
recommendations which are in the process of being actioned, including:

took  place  which  we  attended.  This 

led 

to  a  number  of 

i.

UKVI  is  to  review  the  details  contained on  the  SCF  form  to  ensure  that  all  relevant 
information is provided;

 ii.

G4S now flag SCF forms where a safeguarding issue is raised without adequate detail
being provided with UKVI. UHS also raise these issues with G4S; and

iii.

Hospital visits are directly notified to Attwood Green Medical Centre.

Staff training has been conducted. It was confirmed at the inquest that the staff present on the 
night of Mustafa's death were first aid trained. This is continually refreshed and further courses 
are being looked into.

The  out  of  hours  guidance  provided  to  security  staff  has  been  updated  detailing  when  a 
resident should be directed to hospital. This has been briefed to staff. 

UHS has always undertaken welfare checks on residents whenever a concern is raised. These 
continue.  Following  Mr  Mustafa's  death  additional  information  is  being  recorded  in  our  staff 
handover  book  to  ensure  any  issues  raised  are  recorded  and  appropriate  measures  can  be 
taken by site management.

If  a  concern  (such  as  mental  health  issues)  about  a  resident  is  noted,  an  incident  report  is 
drafted and sent to G4S. This includes as much information as we have available and actions 
we  have  taken.  This  information  can  then  be  passed  on  to  UKVI  by  G4S  and  ensures  that 
these  concerns  can  be  notified  to  any  future  residence,  or  those  with  responsibilities  for  the 
resident. An email is also sent to the charity Migrant Help and Attwood Health Centre to enable 
the resident to obtain the appropriate level of support. 

2. Safeguarding Hub

The threats made by Mr Mustafa on 29 October 2018 were shortly prior to his removal from the 
country when he was not resident with us. UHS had no knowledge of this threat. We note this 
was not recorded with the Safeguarding Hub. The Safeguarding Hub is operated by UKVI and 
as such is outside of UHS' control. We understand UKVI is reviewing this system following the 
tragic death of Mr Mustafa.

Yours faithfully

Urban Housing Services