Manoel Santos

Director General of Operations 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London 
SW1H 9AJ 

16 February 2024 

Ms Jenny Goldring 
HM Assistant Coroner 
Southwark Coroners Court  
1 Tennis Street  
London  
SE1 1YD 

Dear Ms Goldring  

Thank you for your Regulation 28 report of 3 October 2023, addressed to the Governor of HMP 
Belmarsh, the Lord Chancellor and Secretary of State for Justice, and the Director General Chief 
Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding on behalf of 
HMPPS as Director General of Operations. 

I understand that Mr Santos’s family were not involved in the inquest, however I would still like to 
express my condolences, every death in custody is a tragedy and the safety of those in our care 
is my absolute priority. 

You have raised some concerns regarding the management and support of Foreign National 
prisoners, specifically the signposting and facilitating of access to legal advice and 
communication between the Home Office, HMPPS and Healthcare. I understand that the Home 
Office and Practice Plus Group (the healthcare provider at HMP Belmarsh) will be providing a 
separate response. Further to this, you have raised concern with Operational Support Grades’ 
(OSG) understanding of the night state policy at HMP Belmarsh.  

In October 2021 guidance was provided to all establishments setting out the requirement that 
immigration detainees be informed about and provided with access to 30 minutes of legally aided 
legal advice. The operational implementation and support group have ensured that all prisons 
holding immigration detainees have implemented these instructions. As set out in the report,  
HMP Belmarsh published this information in the form of a poster on all houseblocks including the 
first night centre. This information also now forms part of the induction to custody process that all 
prisoners receive when they first come into custody. 

To implement a change programme that supports Foreign National Offenders (FNO) nationally, a 
specific coordination hub has been developed by the Probation Service. Seconded probation 
practitioners have been allocated to the Home Office to support the work in increasing 
efficiencies in the interface. Further to the probation specific strand on the joint HMPPS/FNO 
removal centre taskforce, the seconded members of staff support front line practice and respond 
to any escalations or obstacles that are brought to their attention.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Home Office uses a specific form called ‘Request for Risk Information’ to request an OASys 
assessment. These are now centrally administered by the FNO coordination hub to ensure that 
there is a central referral point for the Home Office. The request is then sent directly to the 
relevant practitioner to action, or the team if the matter is not yet allocated. We have also 
introduced an escalation process that highlights responses that have not been received within 20 
days.    

Separately, a new learning team has also been created and resourced by HMPPS to enable 
learning from probation-involved inquests to be disseminated across the probation service, and 
included as part of the Offender Management in Custody (OMiC) model of working.   

We remain committed to ensuring that staff and prisoner safety is a key priority across the prison 
estate. The prison have re-issued a notice to staff clearly stating the procedures to follow in the 
event that a cell door needs to be unlocked during the night state. Both officers and OSGs have 
been reminded that, subject to a dynamic risk assessment being completed, the preservation of 
life takes precedence over any normal circumstance. This has been highlighted further during full 
staff briefings.  

I hope the measures outlined above provide you with reassurance that learning and appropriate 
action has been taken following Mr Santos’s death. 

Thank you again for bringing your concerns to my attention. I trust that this response provides 
assurance that action is being taken to address.  

Yours sincerely, 

Director General of Operations

Michael Tomlinson KC MP 
Minister of State for Countering 
Illegal Migration  

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

Jenny Goldring 
Assistant Coroner – London Inner South Jurisdiction 
Southwark Coroner’s court 
1 Tennis St,  
London SE1 1YD 

Dear Ms Goldring,  

MR MANOEL MESSIAS SANTOS 
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Thank you for your Regulation 28 report, dated 3 October 2023, following the inquest into 
the death of Mr Manoel Messias Santos (Mr Santos). I am grateful to you for sharing your 
findings, and for the opportunity to reflect on the processes that were in place around the 
time of Mr Santos’ detention in 2020 and any improvements that can be made in light of 
your report. I am sorry to learn of Mr Santos’ passing and would like to express my 
condolences to his friends and family.   

I can assure you that the Home Office takes the health and welfare of people detained 
under immigration powers very seriously. The concerns you have identified have been 
carefully considered by officials. This response summarises the action taken to address 
these concerns where they pertain to the Home Office. I also hope it will be useful to set 
out some wider reforms which impact on the detention of foreign national offenders 
(FNOs) as well as those actions taken following the death of Mr Santos in HMP Belmarsh, 
on 2 November 2020.  

Consideration as to whether FNOs can be notified at an earlier stage of their 
sentence that they are not going to be released.  

Following conviction, where criminality is considered to meet the deportation criteria in a 
case involving a non-EEA Foreign National Offender (FNO), they are served, usually 
shortly after their conviction, with a deportation decision (Stage 1) and notified of why their 
deportation is deemed conducive to the public good. Within the Stage 1 letter, the FNO will 
also be notified of their liability to be detained under immigration powers. The individual is 
given an opportunity to submit information or evidence to support their claim about why 
they should not be deported or be allowed to remain in the UK. Following this, a Stage 2 
deportation decision is made and depending on the nature of the representations, the 
individual is given an appeal right against the Stage 2 decision. The general expectation is 
to make the Stage 2 decision at an early stage, during an individual’s custodial sentence. 
This enables the FNO’s deportation within the Early Removal Scheme (ERS) window 
(depending on the length of the custodial sentence, the ERS window could be up to 12 
months before the conditional release date), although this is not always possible; for e.g., 
due to delays caused by applications pursued by the FNO; asylum applications, referrals 
to the National Referral Mechanism,  or pending prosecutions etc. Where a Stage 2 
decision cannot be made during the individual’s custodial sentence, or it is not possible to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 deport the individual by the end of their custodial detention, the caseworker will consider 
whether, at the end of their custodial sentence, the individual should be detained under 
immigration powers to facilitate their deportation. There is a presumption in favour of 
liberty for all individuals and decisions to detain are made in line with the published 
guidance. The published policy requires written reasons to be provided to the individual 
through the service of form IS 91R, before they are detained under immigration powers. 
However, under neither statute nor detention policy is there a specified timescale for the 
service of an IS 91R prior to the actual start of immigration detention. A person detained 
from the community will usually be served an IS 91R on the day of their initial detention. 
For those being transferred from custodial detention to immigration detention, the form IS 
91R is completed and served closer to the actual date of immigration detention as the 
decision (to detain) is made on the basis of up-to-date information. Conversely, if the 
detention decision is made too early, it is likely to require a review each time there is a 
change in the circumstances, thus adding a disproportionate case working burden. The 
30-day aspirational target for the service of a IS 91R was identified as the optimum term 
after consultation with operational teams across the Home Office and the Ministry of 
Justice. It seeks to strike the right balance between enabling a sufficiently up-to-date 
detention decision to be taken and providing the individual reasonable prior notice to 
enable them to seek legal advice and/or apply for bail as necessary. 

Consideration as to how to ensure more effective communication/ information 
exchange between the SSHD and the prison and Healthcare.  

The Home Office is committed to a collaborative relationship with HMPPS, prisons and 
other stakeholders in the management of persons subject to deportation action both during 
their custodial sentence and if detained in a prison estate following its completion. Regular 
bilateral meetings between the Home Office and stakeholders at various levels support 
this closer working relationship and allow for opportunities for joint working to be effectively 
highlighted.   

Prisons refer all custodial sentenced FNOs to FNORC using an electronic referral form. 
The ERS estimated date (ERSED) is calculated at the same time as other key dates such 
as the conditional release date (CRD) and is included on the referral form. As part of a 
weekly update FNORC is notified of any changes to the ERS or CRD dates. 
The prison sends the form to FNORC’s Intake and Triage team, who prepare the 
necessary paperwork and allocate the case to a caseworker to process the case towards 
deportation or removal if appropriate, ideally in time for the FNO’s ERSED. The same form 
is used by FNORC to confirm to the prison the individual’s immigration status and likely 
removability (whether the Home Office intends and is able to deport or otherwise remove 
the prisoner during their ERS period). The form is also used by FNORC to inform the 
prison of the caseworker’s contact details. 
Once the prison governor has made a decision as to early removal under ERS, the prison 
will issue either an ‘ERS authorisation form’ or an ‘ERS refusal form’ to the individual and 
copy it to FNORC. If FNORC confirm they intend to pursue deportation an ERS is 
authorised by the prison governor. FNORC can then proceed towards deportation and 
ideally set removal directions for the ERSED or as soon as possible thereafter. 
Shortly after the initial referral, FNORC’s Intake and Triage team make a request, using 
the Request for Risk Information (RRI) form, for a copy of the OASys report or an updated 
risk assessment and an assessment of the suitability of the proposed bail address. The 
form is also used to obtain the contact details of the relevant Offender Manager (OM). 
FNORC caseworkers routinely use this form to seek ongoing updates from the OM, in 
relation to risk assessments and the suitability of release addresses.  
The FNO Coordination Hub, set up in early 2022, with embedded HMPPS staff, assist 
FNORC caseworkers with all queries relating to HMPPS. Furthermore, a bi-lateral working 
group, comprising of senior operational representatives from both HMPPS and FNORC, 

    
 
  
 
 meet every month to collaborate on operational issues and feed into the HMPPS/FNORC 
task force.     
The Home Office understands that ‘in person’ contact with individuals subject to 
deportation action is hugely important. A dedicated team of immigration officers embedded 
in the prison estate carry out that engagement and endeavour to induct the individual soon 
after they arrive at a prison. This induction seeks to explain the deportation process, obtain 
basic person details and any vulnerabilities or medical conditions. The induction process is 
periodically reviewed, and the interactions are now recorded and accessible to other Home 
Office officials on internal databases. FNOs can also request to speak with an immigration 
officer on an individual basis via a wing application that is lodged with the prison’s wing 
office which is then passed to the embedded Immigration Prison Teams (IPTs). 
Due to third party confidentiality implications, healthcare teams at a prison or an IRC 
require the FNO’s consent before their medical records are disclosed to the Home Office. 
Therefore, in order to make informed detention decisions, caseworkers seek the 
individual’s consent at the earliest possible stage of the process. Once consent is given, 
the caseworker will directly contact the healthcare team within a prison or an IRC to obtain 
updated medical information relating to the individual. 
At a local level, the Home Office’s  IPTs work very closely with prison colleagues, with 
established lines of communication and regular meetings between the two parties. IPT 
officers recognise it is paramount to consider the individual circumstances of an FNO and 
their vulnerabilities when serving immigration notices. This routinely takes place in prisons 
across the country where FNOs are serving their sentences. IPT Officers will make the 
relevant Offender Manager Unit and wing offices aware when serving immigration notices 
to ensure the FNO can access support as necessary. This will also be recorded on Home 
Office databases for other officials to view. A further line of assurance is provided by 
monthly meetings with senior immigration officers to discuss vulnerable cases and take 
forward actions in our hub prisons. 
Communications are also appropriately documented. IPT officers ensure all conversations 
are recorded and where appropriate signed by the FNO. Digitalisation improvements have 
allowed for engagements with FNOs to be raised on internal databases along with any 
vulnerability concerns promptly after interactions, while IPT Officers have access to a 
Ministry of Justice system, to ensure immigration contact and records are widely shared. 
We will continue to review where further technological improvements can be made to 
ensure the timely and secure exchange of information between itself and prison officials. 

We recognise the benefit of improving a mutual understanding of relevant processes to 
both departments in our aim to work more cohesively. Therefore, awareness sessions 
have been provided at our hub prisons providing an overview of the deportation process, 
the service of immigration notices and the work of our immigration officers.   

Consideration to be given as to why the Internal report dated February 2021 was not 
disseminated/placed on the Home Office file and to ensure this does not occur 
again 

The Home Office is fully committed to ensuring that all immigration cases, including those 
relating to FNOs, are handled with care and in accordance with the published policies. 
Teams are expected to work collaboratively, both internally and with partner organisations 
in order to share best practice, to use continuous improvement to enhance existing 
capabilities and to develop and test new approaches. Feedback loops are put in place to 
ensure lessons are learnt promptly and operational delivery maximised. 

The Professional Standards Unit (PSU) report in this case was commissioned on 6 
November 2020,  by the Deputy Director responsible for the team that had the conduct of 
Mr Santos’ case. On completion, the report was sent to the Commissioning manager. 
Whilst the report was contemporaneously shared with the senior managers, and an action 
plan drawn up to address the recommendations, in the absence of a central repository for 

 
 
 
 
 such reports, there was no mechanism in place to track the report or the action plan.  The 
documents were neither placed on the Home Office file nor recorded on our central 
databases. Consequently, once the Commissioning manager left FNORC, the corporate 
knowledge about the PSU report and the action plan was lost with their departure.  

We recognise and regret that this was a significant oversight and have taken immediate 
steps to address this issue. Following consultation with the PSU we have implemented 
new commissioning and handling processes to ensure that work commissioned by us from 
the PSU receives appropriate Director’s attention. Within FNORC a new team, the 
Strategic Improvement Operations team, has been set up to log, review and track 
recommendations from all internal and external investigations/ audits on our central 
records. The team is responsible for maintaining a central record of all the 
recommendations, assigning ownership, monitoring progress and coordinating actions with 
the central Immigration Enforcement Assurance and Risk team to ensure all FNORC risks 
are managed through a consistent assurance process and recommendations are 
implemented in a timely manner. We are confident that the changes that have been 
implemented within PSU and FNORC, will significantly improve the handling of PSU 
reports and eliminate the risk of similar oversights being repeated.         

This Department is committed to learning lessons to prevent future deaths of persons 
detained under immigration powers and once again I am grateful to you for your report and 
for sharing your findings.  

Yours sincerely,  

Yours sincerely, 

Michael Tomlinson KC MP 
Minister of State for Countering Illegal Migration

Practice Plus Group 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

practiceplusgroup.com 

Assistant Coroner Jenny Goldring  
London Inner South  

21 November 2023 

Dear Madam 

The Inquest touching upon the death of Mr Manoel Santos 

Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners 
(Investigations)  Regulations  2013  dated  3rd October  2023  and following  the  inquest touching 
upon the death of Mr Manoel Santos, who sadly passed away on 2nd November 2020 whilst 
residing at HMP Belmarsh.   

I  would  like  to  take  the  opportunity  on  behalf  of  Practice  Plus  Group  to  offer  my  sincere 
condolences to Mr Santos’ family and friends for their loss.  

This letter addresses the matters of concern insofar as they relate to Practice Plus Group (PPG). 
As you are aware, PPG were not the healthcare provider at the time of Mr Santos’ death but 
are the current healthcare provider at HMP Belmarsh as of 1 June 2023. 

Matter of Concern  

There  are  a  number  of concerns  raised  in  your report  which relate  to  the  timing  of  the  IS91 
notification, the signposting for legal advice about immigration matters, delays by SSHD and 
probation, the disclosure of SSHD internal reports and the opening of cell doors at night. As 
these matters do not relate to healthcare and PPG we do not propose to respond. 

Another area of concern however is the communication between agencies to which you wrote 
the below concern. 

Communication between agencies 

1.  Communication issues between the agencies dealing with immigration and sentence 

planning may lead to confusion and uncertainty for FNOs.  

2.  I appreciate that any legal advice to FNOs should be from a legal adviser. I am 

encouraged that the probation service (who employ community offender managers) is 
seeking to develop a cohort of probation officers specialising in FNOs and immigration. 

Practice Plus Group Health and Rehabilitation Services Limited. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There are now 201 SPOCs across 12 regions and a hub lead developing this model 
and leading engagement with the SSHD. There is no such model in the prison in 
respect of “prison offender managers” who also liaise with the SSHD about FNOs. 

We  cannot  respond  directly  to  the  above  as  this  relates  to  other  agencies  but  we  note  your 
further comment in relation to actions to be taken: 

•  Consideration as to how to ensure more effective communication/information exchange 
between  the  SSHD  and  the  prison  and  Healthcare.  (HMP  Belmarsh,  HMPPS,  MOJ, 
SSHD, Practice Plus) 

Please find our response to this below. 

Response 

As noted within the statement of 
, Head of Healthcare, Healthcare attends the 
Safety Intervention Meeting (SlM), which takes place on a weekly basis. This is something that 
has been instigated since PPG took over the healthcare contract in June 2023.  

As  part  of  SlM,  prisoners  who  are  on  immigration  hold  are  highlighted  and  any  concerns 
regarding  those  prisoners  are  discussed.  These  prisoners  are  then  discussed  in  the  mental 
health MDT (Multi-Disciplinary Team) referrals meeting. This meeting used to take place once 
a week but has since been increased to twice a week since PPG took over the contract. During 
this  meeting  the  team  will  discuss  the  patient  and  their  needs  and  then  make  a  decision  on 
whether support is required and what support can be offered. We now send the outcomes of 
our referrals meetings to Custodial Managers and Senior Officers so they are aware of what 
services are going to be engaging with the patients. 

Should any patient require support, there are applications on the house blocks that prisoners 
can access to self-refer to the mental health team or speak to a staff member and ask to be 
referred to the team. There is a mental health mailbox officers can also use to refer patients 
into. This means that there are a variety of ways in which patients can access support and that 
this is connected into any discussions patients have with officers as well as healthcare staff. 

We heard during the Inquest that medical information is sometimes required by other agencies, 
specifically the Home Office in this case. Requests for medical information are reviewed on a 
case  by  case  basis  in  order to  ensure  that  client  confidentiality  and  data  protection  laws  are 
adhered  to.  Requests  goes  to  the  central  admin  mailbox  and  are  usually  completed  by  a 
particular staff member to ensure consistency. If that staff member is off then the requests are 
re-allocated. Requests are generally completed within the week and requests from the Home 
Office are normally prioritised. 

In addition to Mr Santos’ immigration status, bullying was also a key theme that was investigated 
during the course of the Inquest. When a prisoner discloses allegations of bullying to a member 
of healthcare staff, the Custodial Managers should be notified on the houseblock, a Datix should 
be  completed, the  Safeguarding  Lead  should be notified  and  a  referral to  the  Safer  Custody 
Team  should  be  completed.  Since  October  2023  a  form  has  been  implemented  which  is 
completed  and  sent  to  the  Safer  Custody  Team  rather  than  it  simply  being  an  email.  This 
ensures that all relevant information is passed on. The patient in question would then be placed 
on our Safeguarding Assurance Framework Log which ensures that staff are aware of who was 
referred and when. Patients will also be referred to our Multi-professional Complex Care Clinic 
to be discussed as an IMDT. These meetings can include GPs, Psychiatrists, Psychologists, 
substance misuse professionals, senior clinical leads, and social care teams which are currently 
provided  by  Greenwich  Council.  Patients  will  be  discussed  in  the  Mental  Health  referrals 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 meeting and the team could put in welfare checks or he may be offered low level intervention 
with the psychological services. 

Mr Santos was also subject to ACCT (Assessment, Care in Custody and Teamwork) procedures 
during  his  time  at  HMP  Belmarsh.  This  is  another  area  of  collaborative  working,  particularly 
between  the  prison  and  Healthcare.  ln  the  SIM  meeting  prisoners  who  are  on  ACCTs  are 
discussed and any concerns raised regarding their mental health will be brought and discussed 
in the mental health referrals meeting. Each day a member of healthcare staff working in the 
houseblock treatment hatch for the day will attend the morning briefings held where they are 
informed of all patients located on the wing that are currently subject to ACCT protocols and 
any ACCT that requires a review that day. Attendance had previously been ad hoc but has since 
been made a routine practice to ensure consistency.  

The total number of ACCTs on each houseblock and the number of reviews due/attended are 
reported to the clinical Lead at the daily Healthcare handover. Hotel 99, nurse in charge, should 
be informed if the staff at the medication hatch are not able to attend the review. lf an ACCT 
was closed without healthcare presence, then the officers should inform a member of the team. 
We  have  a  well-established  process  and  robust  communication  between  the  prison  and 
healthcare.  

As a healthcare provider working in prisons we are aware of the need to ensure close, efficient 
and collaborative working with other agencies, particularly with HMPPS as healthcare staff and 
officers  interact  and  work  together  daily.  In  addition  to  the  specific  points  addressed  above 
relating to issues at this inquest, the Head of Healthcare and the Deputy Head of Healthcare at 
Belmarsh meet with the Healthcare Governors on a weekly basis. The Head of Healthcare also 
meets with the number 1 Governor on a fortnightly basis. This is something which has been 
implemented since PPG took over the contract. 

These meetings provide an opportunity for any issues, either general or prisoner specific, to be 
raised and action points discussed. Healthcare attend the daily morning meetings, drug strategy 
meetings  and  SIM  meetings.  Local  Deliver  Board  meetings  are  also  attended  which  are 
specifically to discuss the delivery of services including healthcare at Belmarsh. The Head of 
Healthcare also attends the Senior Management Team meetings. All of these provide various 
forums and opportunities for close working and communication between agencies. 

I hope that the above information provides you with reassurance that work between agencies is 
more efficient and collaborative since November 2020. 

Practice Plus Group is committed to ensuring the high quality provision of healthcare services 
to all prisoners at HMP Belmarsh. We will also ensure that the lessons learnt as a result of this 
inquest are shared across all of Practice Plus Group’s services.  

I  do  hope  that  this  letter  provided  the  necessary  reassurance  sought  and  if  I  can  be  of  any 
further assistance you should not hesitate to contact me directly. 

Yours sincerely 

National Medical Director, Health in Justice, Practice Plus Group 

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