Frank Ospina

Minister for Border Security & 
Asylum 
2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

Mrs Lydia Brown 
HM Senior Coroner for West London 
Coroners’ Court 
25 Bagleys Lane 
London 
SW6 2QA 

By Email: 

Your case reference: 

MR FRANK OSPINA 
 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

16 December 2024 

Dear Mrs Brown, 

Thank you for your Regulation 28 report, dated 25 October 2024, following the inquest into 
the death of Mr Frank Ospina. I am very 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 Frank 
Ospina’s detention last year. I am replying as Minister for Border Security and Asylum. 

I can assure you that the Home Office takes the health and welfare of people in detention 
very seriously. Your report identified three matters of concern which have the potential to 
lead to future deaths, if left unaddressed, which have been carefully considered by 
officials. This response summarises the action being taken to address the three concerns 
as well as wider work being undertaken by the Home Office to prevent future deaths in 
immigration detention.  

I am aware that officials from NHS England will write to you separately with regards to your 
concerns about the operation of Detention Centre Rule 35. I understand that Mitie Care 
and Custody will also be writing to you, and their response may touch on some of the 
issues which I address below. 

Concern 1 – Rule 35 Detention Centre Rules 2001 

With regards to your first concern relating to Rule 35 of the Detention Centre Rules 2001, 
you have raised two issues which together resulted in a Rule 35 (2) report not being raised 
in the case of Mr Ospina.  

The first issue relates to a mismatch in the healthcare provider and Home Office 
expectations and practical application of the Rule 35 provisions. This is being addressed 
through the development of an interim update to the published guidance Detention 
Services Order (DSO) 09/2016. The interim guidance will make clear that healthcare staff 
must inform the doctor of a detained person if staff have concerns of suicidal intention. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This will strengthen the existing Assessment Care in Detention and Teamwork (ACDT) 
guidance which requires non-clinical staff working in an immigration removal centre (IRC) 
to report the opening of an ACDT plan to both healthcare teams and the local Safer 
Detention Co-ordinator. The interim version of DSO 09/2016 will also include guidance as 
to indicators of “suicidal intentions” for clinical and non-clinical staff, to ensure concerns 
are being raised appropriately. The draft updated interim DSO is currently with key 
partners, including NHS England for review and is expected to be published in March 
2025.  

In terms of the limitations on the production of a Rule 35 report, where only a General 
Practitioner can produce a Rule 35 report, the Home Office is currently conducting a 
review of the statutory Adults at Risk (AaR) policy and Rules 34 and 35 of the Detention 
Centre Rules 2001. The option to remove this restriction and extend the production of Rule 
35 reports to other relevant healthcare professionals is being considered and will form part 
of an external engagement process. The review is expected to be completed in Spring 
2025. Any changes would require new statutory instruments to be laid before Parliament.   

Concern 2 – Closed Visits 

I am aware that a closed visit was imposed for Mr Ospina and his mother, which the 
inquest found to be inappropriate and unnecessary. Work has been undertaken in relation 
to your concern that under current practices, closed visits could potentially take place 
without the knowledge or consent of the Duty Manager, or without the necessary 
documentation being completed.  

In line with published Home Office guidance DSO 04/2012 ‘Visitors and visiting procedures 
for detained individuals’, ‘closed visits’ (those which take place behind glass, with no 
physical contact between the detained individual and the visitor) should only take place in 
certain circumstances, such as suspicion of drug smuggling, or risk to visitors or children. 
Any decision to impose a closed visit should be taken on a case-by-case basis, following a 
documented risk assessment by the IRC supplier. In response to this concern, officials 
have undertaken a review of closed visits across the estate covering the past 4 months 
and have issued communications to staff to ensure understanding of when a closed visit 
can be used and responsibilities around doing so.  

Officials have also considered longer term assurance and revised the draft DSO on visits 
to introduce annual self-audits and quarterly assurance reviews of both closed and banned 
visits. Learning from the recent review of closed visits is currently being considered and 
will be incorporated into the DSO. The updated DSO is expected to be published before 
March 2025. 

Concern 3 – Accessibility for visitors  

In relation to your concern regarding the accessibility of the visit procedures for family and 
friends visiting loved ones in an IRC, I am aware that you had particular concern with 
regards to language barriers, which caused difficulty for Mr Ospina’s mother in arranging a 
visit.  

My officials have taken action to explore options to translate the visitor information for 
IRCs and Residential Short-Term Holding Facilities on Gov.uk and the development of 
web pages to enable translation is underway. Officials have commissioned the translation 
of the current visitor information into the top 20 languages of those in detention. Allowing 
time to translate the relevant information and the development of relevant web pages, we 
expect this work to be complete by the end of January 2025. 

 
 
 
 
 
 
 
 
 
 
 
 Learning from this undertaking will be shared with our suppliers, and we will be endorsing 
the translation of visitor information pages on their respective websites. 

Continuous learning and improvement 

There is wider improvement work, both complete and ongoing, to ensure we continue to 
learn from the death of Mr Ospina. The Home Office has already strengthened the 
vulnerability identification and reporting mechanism (IS91 RA) through communications, 
training and the development of guidance, enabling material changes in health, risk and 
vulnerability to be consistently communicated to Home Office teams responsible for 
making decisions on ongoing detention. Work is also underway to review the 
documentation used for the risk assessment process, (IS91 RA forms A – C) with the 
intention to develop guidance on the process and use of the forms in the published 
Detention General Instructions.  

An internal thematic review into the operation of ACDT was completed in April 2024 and 
progress against recommendations was reviewed in November 2024. The published 
ACDT guidance, which is currently under review, will be revised to embed learning from 
the thematic assurance review and the inquest. The revised DSO will include guidance on 
the responsibilities, quality, and recording of observations, as well as further clarification 
on the management of personal items for those who are at risk of self-harm or suicide. 
Guidance on both issues has already been shared with staff by way of safeguarding 
bulletin. The revised ACDT guidance is expected to be published in late Spring 2025 after 
internal and external review.  

I am aware that during the process of the inquest, a potential issue was raised with the 
functionality of call bells in the care suite at Colnbrook IRC. Immediate action was taken to 
implement an additional, alternative means of communication between a detained 
individual and officers, in the form of wearable wrist call bells and these were in place from 
7 October 2024 and will remain in place until repairs are completed on the call bells in the 
care suite. We have confirmed with the contracted service providers the timeframe for the 
repairs would be approximately two days, though as yet, we do not have a confirmed date 
on when the work will begin. In November 2024, officials undertook an assurance review 
into the accommodation certification process and record keeping across the detention 
estate and further learning has been identified. The published guidance on 
accommodation standards (DSO 06/2018) will be updated to reflect this learning, with 
expected publication in June 2025 following both internal and external engagement. 

The Home Office is committed to continuous improvement in relation to the safeguarding 
and wellbeing of detained individuals and committed to embedding changes from the 
identification of learning from internal audits, ‘near-miss’ incidents and deaths in detention. 
I would like to assure you that in addition to first and second-line assurance carried out by 
Home Office officials, we welcome the scrutiny and independent oversight from a number 
of inspection and monitoring bodies, advisory panels and committees.  

Independent scrutiny is a vital part of assurance that our detention facilities are safe, 
secure, and humane. IRCs are subject to robust statutory oversight by Independent 
Monitoring Boards (IMB) and inspection (including by His Majesty’s Chief Inspector of 
Prisons, the Independent Chief Inspector of Borders and Immigration and others), 
ensuring that detained individuals are treated with proper standards of care and decency. 
We carefully consider the resulting findings and recommendations and involve all relevant 
parties in those considerations.  

 
 
 
 
 
 
 
 
 
 Preventing deaths in the immigration removal estate in particular remains a high priority. 
The Home Office is a co-sponsor to the Ministerial Board to Deaths in Custody, which 
originates from the recommendations of Robert Fulton’s Review of the Forum for  

Preventing Deaths in Custody (2008). Following a Home Office commissioned review into 
immigration detention by the Independent Advisory Panel on Deaths in Custody (IAPDC), 
a ‘Prevention of future deaths in immigration detention strategy’ is underway. This work 
includes research into the impact of cultural differences and trauma on suicide prevention 
strategies, learning from near miss incidents in detention and work with the Samaritans. 
Progress against recommendations made by the IAPDC are reported through the 
governance structures of the MBDC. 

I hope that the information provided addresses your concerns satisfactorily. 

Yours sincerely, 

Minister for Border Security & Asylum

FAO: HM Senior Coroner Lydia Brown 
West London Coroner’s Court 
25 Bagleys Lane 
London 
SW6 2QA 

Sent by email only to: 

Dear Sir / Madam, 

10 January 2025

INQUEST  TOUCHING  THE  DEATH  OF  MR  FRANK  OSPINA  –  REGULATION  28  REPORT  TO 
PREVENT FUTURE DEATHS 

Further to the letter provided to His Majesty’s Senior Coroner Lydia Brown (“the Coroner”) on 

behalf of Mitie Care and Custody Limited (“C&C” / “the Company”) dated 11 October 2024, we 

have been provided with a copy of the Coroner’s Regulation 28 Report to Prevent Future Deaths 

dated 25 October 2024 (“the PFD Report”). 

Within the PFD Report, the Coroner has identified two concerns in relation to C&C, set out here 

for ease of reference: 

1. 

“Visits. The inquest was advised that Frank Ospina's mother visited him in the Heathrow 

Immigration Removal Centre (“HIRC”) on one occasion, and that was conducted as a "closed" 

visit. Her son was accompanied by 2 Officers and their meeting held behind a glass screen 

where  no  physical  contact  was  possible.  The  Officers  were  overhearing  the  family 

conversation and making notes. 

MITIE who are responsible for the day to day running of the IRC were unaware that a "closed" 

visit had occurred and apologised for this, confirming it was inappropriate and Frank Ospina 

and his mother should have been allowed to meet in the usual communal area where they 

could have embraced and had a private conversation. This was the last time Frank Ospina 

was seen alive by his mother and the visit greatly distressed her; 

Mitie Care & Custody Limited 
The Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

, Managing Director 

T: 

Mitie.com/all-services/care-custody 

Mitie Care and Custody Limited is registered in 
England under company number 6976230 at The 
Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. 

Frank's mother does not speak English and found it very difficult to arrange a visit. In 

fact rather than successfully navigate the system, she just turned up and was permitted to 

see her son as set out above. Telephone calls were not facilitated with an interpreter. The 

website where visits should be booked is entirely and only in English. This is a facility that by 

definition detains foreign nationals and predictably some of the family members do not speak 

English. A quick check of the local authority website (Hammersmith and Fulham) revealed a 

full  immediate  translation  facility  into  over  100  languages,  and  so  this  is  readily  available 

technology.  The  Home  Office  and  MITIE  should  consider  the  communications  currently 

available to relatives trying to visit their loved ones and whether these can be improved by 

reasonable adjustments”. 

Since the conclusion of the Inquest, the Company has taken the opportunity to reflect on what 

further changes can be made to the visitor and translation arrangements at HIRC in order to 

ensure its safe and effective operation. We provide the following updates which should be read 

alongside our letter dated 11 October 2024 from 

, Centre Director for HIRC.  

Within this response to the PFD Report, we will refer to each of the Coroner’s concerns in turn. 

Visits 

The Company would like to reiterate the apology provided during the Inquest to Mr Ospina’s 

family within this response. The closed visit which took place on 22 March 2023 between Mr 

Ospina and his mother was inappropriate. 

As confirmed by 

 and 

 during the Inquest, in March 2023 there 

was a clear policy in place in relation to closed visits, in accordance with the requirements of 

Detention Services Order 04/12, ‘Visitors and Visiting Procedures’ (“DSO 04/12”). A number of 

administrative steps and safeguards were required before a closed visit could be authorised. In 

light of Mr Ospina’s case the Company has reviewed its policies and procedures in relation to 

closed visits within HIRC to ensure that such a situation cannot arise again. 

A Notice to Staff was issued to all C&C staff at HIRC in relation to closed visits on 28 November 

2024 (see Appendix 1). The Notice to Staff confirmed that placing a resident on closed visits can 

only be approved by the Head of Security, or the Duty Director in their absence. The Head of 

Security  and/or  Duty  Director  will  then  inform  the  Home  Office  Compliance  and  Detention 

Engagement Team of the closed visit, in accordance with the requirements of DSO 04/12. The 

Mitie Care & Custody Limited 
The Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

, Managing Director 

T: 

Mitie.com/all-services/care-custody 

Mitie Care and Custody Limited is registered in 
England under company number 6976230 at The 
Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

 
 
 
 
 
 
 
 Notice to Staff also reminds officers that if they have any queries as to whether or not a resident 

has been placed on closed visits, they must check this with the Security team.  

When a resident is placed under closed visits, this will be explained to them, utilising the Big 

Word translation service where required. Any risks to a resident’s wellbeing will be monitored 

and reported by staff and the suitability of closed visit status kept under review by the security 

team. Likewise, staff have been reminded to explain to visitors how a closed visit will take place 

and answer any questions they may have courteously, to provide them with reassurance and an 

optimal experience. If a resident is also under an Assessment Care in Detention and Teamwork 

status (“ACDT”), as was in the case of Mr Ospina, staff will now explain to the visitor why there 

will be additional staff present in order to maintain their ACDT observations. Staff can also use 

the Big Word translation service with visitors on their arrival and in the visitor’s centre. 

By  way  of  further  control  measures:  if  a  resident  is  placed  on  closed  visits  then  this  will  be 

identified on the scrolling bar of their electronic Detainee Management System profile, to which 

all staff members have secure access to;  a list of residents on closed visits is circulated weekly 

by the Company’s security team; which is in turn provided to the visitor’s centre reception team 

and each visits hall to ensure that all staff are aware of residents allocated to closed visits. The 

security team will circulate an updated list should that information change during the week, and 

they will also confirm if no residents are subject to closed visits, ensuring that staff have accurate 

and up to date information on who is subject to a closed visit at all times. 

Signs have also been placed on the door to the closed visit rooms, and in the reception of the 

visitor’s centre of HIRC as a reminder to staff that closed visit rooms are only to be used if a 

resident  has  an  approved  closed  visits  form  on  their  file  (see  Appendix  2).    We  considered 

placing coded locks on the closed visit room doors, however this may create a fire evacuation 

risk for visitors and residents in the event of an emergency, and secondly, whilst closed visits are 

put in place to prevent security breaches, adding a lock to the door would make the room more 

formal and potentially intimidating for visitors and residents. For these reasons the closed visit 

rooms will remain unlocked. 

In order to further ensure that closed visits do not take place without the required authorisation, 

the  Company  will  include  audits  of  closed  visits  within  its  audit  programme  which  ensures 

compliance with DSO 04/12, and managers will carry out spot checks to ensure compliance with 

these requirements and for quality assurance. 

Mitie Care & Custody Limited 
The Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

, Managing Director 

T: 

Mitie.com/all-services/care-custody 

Mitie Care and Custody Limited is registered in 
England under company number 6976230 at The 
Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

 
 
 
 
 
 Translation Services 

The Company has worked with the Home Office to identify what reasonable adjustments may 

be  made  to  its  systems  in  order  to  make  the  process  of  visiting  HIRC  more  accessible.  As 

confirmed at the Inquest by Frances Hardy, Director of Detention Services for the Home Office, 

whilst all efforts are made to accommodate visitors whose first language is not English, such as 

utilising a member of staff who also speaks the same language and the Big Word translation 

service, there is currently no known system which would act as an in-call two-way translation 

service  between  those  inside  and  outside  of  HIRC.  The  preferred  method  of  communicating 

information or submitting a visit request is therefore by email, as this can be translated where 

required, and details on how to contact HIRC (including details of the Safer Community Helpline) 

is set out clearly on the Company’s website. 

In terms of website translation services, C&C has now implemented a website translation and 

accessibility  service  called  ‘Recite’  for  use  by  visitors  across  each  of  its  immigration  removal 

centres, including HIRC. As such, there is now an accessibility button on the bottom right-hand 

side  of  each  page  of  the  Company’s  website,  which  provides  multiple  options  including  the 

translation of all web content into 100 written languages and 65 ‘text to speech’ voices. Users 

are also able to utilise the ‘Recite’ function in order to customise the text to their preference, 

including colour, font style, spacing and layout. The Recite function is available across the entire 

mitie.com website. 

We have included a screenshot of the mitie.com IRC Visitors website below, with the ‘Recite’ 

function and its associated tools highlighted in purple boxes:  

Mitie Care & Custody Limited 
The Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

 Managing Director 

T:

Mitie.com/all-services/care-custody 

Mitie Care and Custody Limited is registered in 
England under company number 6976230 at The 
Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

 
 
 
 
 
 
  
 Figure 1- Mitie Care and Custody Limited visitor website- https://www.mitie.com/visitors/  

It is hoped that the above information, together with the improvements set out in our first letter 

dated 11 October 2024, is of assistance to the Coroner and demonstrates our commitment to 

providing safe and decent facilities for those in our care and their visitors.  We take these matters 

seriously and we hope this response provides both the Coroner and Mr Ospina’s family with the 

reassurance that these matters have been given prompt and thorough consideration. If we can 

be of any further assistance, please do not hesitate to contact me on the details below. 

Yours faithfully, 

Managing Director for Immigration & Justice - Mitie Care & Custody Limited 

Enc.: 
Appendix 1 – Notice to Staff 
Appendix 2 – Closed Visits Door/Reception Signage Poster 

Mitie Care & Custody Limited 
The Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK  

, Managing Director 

T: 

Mitie.com/all-services/care-custody 

Mitie Care and Custody Limited is registered in 
England under company number 6976230 at The 
Shard, Level 12, 32 London Bridge Street, 
London, SE1 9SG, UK

Lydia Brown 
HM Senior Coroner 
West London Coroner Service  
25 Bagleys Lane  
Fulham 
London  
SW6 2QA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

17 January 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Frank Steve Rios Ospina 
who died on 26 March 2023 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  25 
October 2024 concerning the death of Frank Steve Rios Ospina on 26 March 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences to  Frank’s family  and  loved ones. NHS  England are 
keen to assure the family and the Coroner that the concerns raised about Frank’s care 
have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report and I apologise for 
any  anguish  this  delay  may  have  caused  Frank’s  family  or  friends.  I  realise  that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been a difficult time for them.  

NHS England is the responsible organisation for the commissioning of healthcare in 
Immigration Removal Centres, which is devolved to regional teams. Commissioning 
healthcare is undertaken on the principle of equivalence, which has been defined by 
the Royal College of General Practitioners (RCGP), and broadly states that the aim is 
to  ensure  people  detained  in  England  are  offered  provision  of  and  access  to 
appropriate services and treatment, considered to be at least consistent in range and 
quality, with that available in the wider community. 

I have considered the concerns raised in your Report regarding the use of Detention 
Services  Order  09/2016,  Rule  35.  Please  see  my  response  below,  which  my 
colleagues from NHS England’s Health & Justice Specialised Commissioning Team 
have input into.  

NHS England accepts that there is learning with regards to the appropriate use and 
adherence to the Home Office Adults at Risk policy and Rule 35 assessment process, 
the 
the  balanced  consideration  of  vulnerability 
which 
appropriateness  of  decisions  around  suitability  of  detention.  In  this  case  these 

to  ensure 

require 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 safeguarding processes fell short, resulting in key information about Frank’s attempts 
to take his life and current vulnerabilities being overlooked.  

NHS England is working with the Home Office policy team to amend the Adults at Risk 
policy  and  Rule  35  assessment  process.  The  aim  of  this  work  is  to  move  the 
assessments  towards  a  multidisciplinary  approach,  ensuring  that  completion  of  the 
assessment  can  be  undertaken  by  a  registered  healthcare  professional  at  the 
Immigration  Removal  Centre  (IRC).  Introducing  this  approach  will  ensure  the 
management  of  safeguarding  and  vulnerability  are  not  solely  the  responsibility  of 
general  practitioners.  NHS  England  and  the  Home  Office  will,  prior  to  full 
implementation  during  2025,  jointly  develop  a  stakeholder  engagement  session  to 
share the revised requirements with IRC providers and operators. 

The NHS England Health and Justice Clinical Reference Group developed Detention 
Centre  Rule  35  and  Short-Term  Holding  Facility  Rule  32  clinical  guidance,  which 
advocates this multidisciplinary approach. This guidance was disseminated to all IRC 
healthcare providers via an online event chaired by the NHS England Health & Justice 
National  Clinical  Lead  in  April  2024.  The  IRC  Partnership  Group  provides  the 
governance  and  oversight  of  the  attainment  of  the  NHS  England  and  Home  Office 
Detention  joint  priorities  and  assures  the  national  system  of  the  quality  and 
consistency of healthcare provisions and reduction of health inequalities.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Frank, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director