Prince Fosu

Executive Office 
Tel: 020 3214 5760 

28  August  2020 

Mr Chinyere Inyama 
Senior Coroner  
Fulham Coroner’s Court  
25 Bagleys Lane 
London 
SW6 2QA  

Dear Mr Inyama, 

Re: Regulation 28: Report to prevent future deaths in relation to Prince 
Kwabena Fosu. 

I write to respond to the Regulation 28 report issued on 6th July 2020 following the 
inquest into the death of Mr Fosu in 2012. 

Whilst Central and North West London NHS Foundation Trust (CNWL) were not the 
provider of healthcare at the time of Mr Fosu’s death, we would very much like to 
extend our condolences to Mr Fosu’s family and friends. 

The specific concern that you have asked CNWL to address in its role as current 
provider of healthcare at the IRC regarded improving the recognition of when to 
make a referral as opposed to knowing the mechanics of making a referral once a 
decision has been made to refer. In your Regulation 28 report you stated: “All staff 
who would be expected to refer cases to healthcare need as much assistance as 
possible in order to discharge that responsibility effectively. It is recognised CNWL is 
the new healthcare provider and did not provide healthcare in 2012. It is also 
recognised that CNWL have improved the training on how to make a referral. 
However, there was knowledge on how to make a referral in 2012 and the jury have 
highlighted the failures that still occurred, leading to the death of Mr Fosu. My 
concern centres on improving the recognition of when to make a referral as opposed 
to knowing the mechanics of making a referral once a decision has been made to 
refer. By way of respectful analogy, medical practitioners referring cases to a coroner 
know how to make a referral but now have guidance in legislation as to when to 
refer. The Trust should give serious consideration to developing a guide to all staff 
on when to refer cases to healthcare. This should be achievable without being either 
over-prescriptive or over-restrictive.” 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700   
www.cnwl.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 The Trust has addressed these concerns in three ways: 

Firstly, mental health awareness training already taking place in the Immigration 
Removal Centre (IRC) and already available to Care and Custody staff as well as 
healthcare has been adapted to include specific information detailing when a referral 
should be made to the Mental Health Team. Included within the training package is 
an overview of what mental health is, the main groups of mental disorders and slides 
covering depression, bipolar, anxiety, panic attacks, Post-Traumatic Stress Disorder, 
Personality disorders, schizophrenia, treatment and referrals. For each of these 
conditions, there is a summary of how the conditions present, what staff should look 
out for and the action that they should take. The training recommends that if staff 
recognise any of these conditions they should refer the patient to the mental health 
team. In the previous 12 months, the Mental Health Team received in excess of 
2000 referrals to their services. It is anticipated that the addition of specific slides, 
relating to the circumstances of each condition, will increase the confidence of those 
in the Care and Custody and Primary Care teams in making appropriate referrals to 
the Mental Health Team. 

Secondly, the Offender Care directorate have reviewed the role of the deputy lead 
nurse for Offender Care as part of a wider piece of work improving mental health 
awareness in our Offender Care services. A new deputy lead nurse for Offender 
Care has been recruited to start in August 2020 and a significant part of their 
portfolio is to provide mental health education across services. They will be 
responsible for providing robust educational pathways within Offender Care and will 
develop a “train the trainer” programme to enable local sites to provide mental health 
awareness training routinely. Whilst this will primarily be focussed on supporting the 
Primary Care teams, these sessions will be open to custodial and detention centre 
staff.  

Thirdly the Offender Care directorate is drafting guidance on when a patient should 
be referred to the mental health team, including conditions and symptoms. This 
guidance will be added to the Offender Care Mental Health and Learning Disability 
Operating Policy. The Offender Care Mental Health and Learning Disability 
Operating Policy is applicable to all CNWL staff and sub-contractors in offender care 
settings and provides an overview of services and expectations of how these 
services will be delivered. The policy is also shared with commissioners, partner 
agencies, prisons and Immigration Removal Centre staff.  Including the guidance on 
when to refer to the mental health team within this document ensures it is available 
to all relevant parties. 

In addition to embedding this guidance into the Offender Care Mental Health and 
Learning Disability Operating Policy, we will also be circulating it as a standalone 
document to all CNWL staff and to all partner agencies in the IRC and across the 
prisons in which we provide healthcare by the end of November 2020. 

I hope that this provides you with sufficient assurance that the Trust has taken action 
in relation to the concern that you have raised.  The Trust continues to work to 
improve the service we provide both in the IRC Heathrow and in our wider Offender 

 
 
 
 
 
 
  
 
 Care Services.  If you have any questions or comments on the above please do not 
hesitate to contact me directly. 

Yours sincerely, 

Claire Murdoch 
Chief Executive

National Chair  
Independent Monitoring Boards 
Post Point 2, Third Floor 
10 South Colonnade 
Canary Wharf 
London 
E14 4PH   

Email: 

27th August 2020 

Chinyere Inyama 
Senior Coroner – West London Coroners Court 

(Via email to: 

 & 

Dear Sir, 

Re: Inquest touching the death of Prince Kwabena Fosu – Prevention of Future Deaths report 

I write in response to your report pursuant to reg.28 of the Coroners (Investigations) 
Regulations 2013 following the inquest touching upon the death of Prince Kwabena Fosu. 

During the inquest, you heard evidence from two former members of the Harmondsworth 
Independent Monitoring Board and from 
 explained the developments at 
the Independent Monitoring Boards. In her evidence, Mrs 
the Harmondsworth IMB and IMBs more generally since Mr Fosu’s death in 2012. Following the 
conclusion of the inquest you made a report pursuant to reg.28. You identified two matters of 
concern, one of which was directed to the IMB. I write in respect of that concern. 

, a member of the Management Board of 

As explained at the inquest, the IMB welcomes the opportunity to learn from the circumstances 
of Mr Fosu’s death. As an organisation which monitors the conditions in which detainees are 
held in Immigration Removal Centres, the IMB recognises that where there are opportunities to 
improve its own processes, these should be acted upon. In your report, you state: 

“The current practise remains to refer concerns around detainees only to the Home 
Office contract monitor. I see no good reason not to, in addition and simultaneously, 
report concerns to the healthcare managers at the IRC. In recording this concern, I have 
in mind the jury’s determinations and findings in the record of inquest which highlight 
ineffective joint working across all agencies. Simultaneous reporting of issues would 
lessen the prospect of a healthcare related issue slipping through the net and not being 
addressed.” 

Before addressing the steps taken since receipt of your report, it may be of assistance to set out 
’s statement 
some background. In doing so, I do not repeat the evidence contained in Mrs 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 or those parts of her oral evidence which concerned matters not directly relevant to the above 
concern. 

Background 

 explained that as at February 2020 there was no formal instruction 

In her evidence, Mrs 
to IMB members as to whom they should raise concerns about a detainee, other than to the 
Contract Manager and in some instances the Secretary of State directly. This reflects the 
Detention Centre Rules 2001 (which is the relevant legislative framework) which provide inter 
alia that: 

a.  The IMB “shall direct the attention of the manager to any matter which calls for his 
attention, and shall report to the Secretary of State any matter which they consider 
expedient to report” (r.61(3)); 

b.  The IMB “shall inform the Secretary of State immediately of any abuse which comes to 

their knowledge”; (r.61(4)); 

c.  The IMB “shall being to the attention of the Secretary of State any aspect of the process 
of consideration of the immigration status of any detainee that causes them concern 
insofar as it affects that detainee’s continued detention” (r.61(5)); and 

d.  The IMB is required to make an annual report to the Secretary of State (r.64(1)). 

Notwithstanding that framework, Mrs 
’s evidence was that IMB members are encouraged 
to identify who within an IRC is the most appropriate person to whom a concern may be raised. 
IMB members are taught to engage constructively with the most appropriate people. Further, 
as Mrs 
in serious and complex cases like that of Mr Fosu, but that she had personal experience of 
raising concerns directly with members of healthcare staff. 

 explained, in her experience the Contract Manager would be the ‘first port of call’ 

Whilst we recognise that there is no evidence that IMB members directly raised Mr Fosu’s case 
with healthcare staff, it is noteworthy that it was an IMB member who raised concerns with the 
Centre Manager (including that she felt Mr Fosu looked vulnerable and asked whether he had 
had a mental health assessment) and as a result Mr Fosu’s case was discussed at the multi-
disciplinary meeting the following morning. 

Reply 

As an immediate response to the inquest, 20 IMB members from IMBs across all six Immigration 
Removal Centres attended a workshop at a Study Day on 7th March 2020, entitled “Monitoring 
Separation and Adults and Risk”, which worked through the appropriate responses for raising 
concerns. The case study concerned a fictionalised detainee, but whose experiences were based 
very closely on those of Mr Fosu. I enclose a copy of the slides used during this session. You may 
wish to note in particular: 

•  Delegates were told that the case study was based on a real case.  

 
 
 
 
 
 
 
 
 •  Delegates were challenged on whether their monitoring had been taking place in ‘silos’. 
•  Delegates were encouraged to ask questions of Centre and Healthcare staff: they were 
told to look for and interrogate information contained in documents such as PERs or 
ACDTs. 

•  Rule 42 of the Detention Centre Rules 2001 (and its importance) was discussed. 
•  Delegates were asked how they could challenge or probe statements made by staff in 
the CSU. They were reminded of the types of information that they should consult and 
that they should not take statements made by staff at face value. 

Delegates were told that the workshop was intended to be a starting point for their thinking: 
they should return to their individual Boards and begin a conversation with their fellow 
members about the issues raised. This session has since been adapted for use within other more 
general training sessions. 

In addition to this specific training, an external review was commissioned to review IMB training 
more generally. Informed by that review, and reflecting on the issues that arose during Mr 
Fosu’s inquest, the Management Board identified a need for three additional areas where 
specific training for members in IRCs was required, viz.: 

a.  Mental health awareness; 
b.  Monitoring the separation of adults at risk; and 
c.  Raising concerns and preventing abuse. 

At a meeting of the Management Board in July 2020, the Board approved a requirement that all 
members of IMBs at IRCs should complete all three elements of the above training. Where 
relevant, members of IMBs at Short-Term Holding Facilities will also be required to complete 
the mental health awareness and raising concerns modules. In due course, this training is likely 
to be rolled out to all parts of the IMB, i.e. including IMBs within prisons. 

The training sessions, which we anticipate running on three occasions in September 2020, will 
be for two-hours. The training will consist of a presentation with a series of training segments 
and will be supported with multimedia such as video content (the ‘presentation element’). Each 
presentation may have a live introduction, and all will have a live Q&A / discussion after the 
presentation element. 

The first module of training specifically focusses on mental health awareness. Working with the 
Centre for Mental Health (www.centreformentalhealth.org.uk) a training programme has been 
agreed. Its aims and learning outcomes are: 

“On completion of the training, members will: 

•  Have an enhanced understanding of mental health problems and associated 

vulnerabilities 

•  Know how to recognise signs indicating poor mental wellbeing  

 
 
 
 
 
 
 
 •  Have an overview of what effective mental health provision and support for detainees 

should look like 

•  Understand key points on monitoring the impact of IRC/STHF provision on mental health 

and wellbeing of people in detention and how to escalate any concerns” 

The training will be delivered by Dr 
for nearly 40 years and was a psychiatric nurse. He has worked in a variety of settings, including 
CAMHS, community, acute inpatient, high secure. For the last fifteen years he has led the 
Centre for Mental Health work in Criminal Justice and has worked on projects covering: prisons, 
secure care services, policing, liaison & diversion, resettlement, probation, immigration removal 
and gangs, as well as internationally.  

 who has worked in the mental health field 

The second module specifically covers the monitoring in separation units, particularly in relation 
to adults at risk. This training will cover: 

Identifying factors which may indicate that a detainee in separation is at particular risk; 

• 
•  Analysing how to broaden and deepen the monitoring of adults at risk in separation; 
•  Exploring techniques for questioning challenging and escalating concerns; and 
• 
Identifying and taking forward actions for individual members and for boards’ 
monitoring in these areas. 

The third session focuses on how to raise concerns about potential abuse. This training will 
cover: 

•  The IMB’s role in responding to allegations of abuse made by detainees and how this 

• 

• 

relates to formal establishment processes; 
Identifying how to respond to allegations of abuse made by detainees against members 
of staff; 
Identifying how to respond to allegations of abuse made by detainees against other 
detainees; and 

•  Exploring the monitoring and follow-up activities that Boards should undertake in 

response to allegations or concerns about abuse. 

Though the COVID-19 pandemic has delayed matters a little, this training will commence in 
September 2020. We anticipate that all training of the current 91 IMB members in the 
immigration detention estate should be completed by the end of 2020 although there may be 
some sessions thereafter to ensure that everyone has participated. The Management Board also 
determined that these three elements of training will be required for all future IMB members in 
the immigration detention estate, both when they first become members and thereafter with 
refresher training on at least a three year cycle to coordinate with the current triennial 
appointment structure for members. 

 
 
 
 
 
 
 
 
 
 Conclusion 

The above are specific steps which the IMB have taken in response to Mr Fosu’s death and in 
light of the matters which emerged during the inquest. More specifically, I hope the above 
provides some reassurance that the IMB have taken steps in light of the concerns which you 
have identified. 

Yours faithfully, 

 – National Chair, Independent Monitoring Boards