Monitor Brook House contract performance robustly
Recommendation
The Home Office must actively and robustly monitor the performance of the Brook House contract, including satisfying itself that any self-reported information is accurate. This may include engagement with monitoring bodies and appropriate stakeholders. Penalties must be attached to inadequate …
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The Home Office must actively and robustly monitor the performance of the Brook House contract, including satisfying itself that any self-reported information is accurate. This may include engagement with monitoring bodies and appropriate stakeholders. Penalties must be attached to inadequate self-reporting.
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Published evidence summary
- In March 2024, the Home Office stated that it had introduced new contracts requiring internal audit programmes and self-reporting by service providers, with two Home Office teams operating in each IRC: detention services compliance teams and Detention Engagement Teams (Government Response to the Brook House Inquiry, Home Office, March 2024).
- The March 2024 response stated that a Detention Services Operations Compliance and Assurance strategy had been published for 2024 onwards, with standardised monitoring schedules and quarterly executive oversight boards established with senior contractors (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independent verification of whether these monitoring arrangements are functioning effectively has been identified in published inspection or oversight reports to March 2026.
Home Office
(Primary)
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Require IRC contracts to uphold Rule 3 humane detention principles
Recommendation
The Home Office must ensure that each contract for the management of an immigration removal centre must expressly require compliance with the overriding purpose of Rule 3, which is to provide "the secure but humane accommodation of detained persons in …
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The Home Office must ensure that each contract for the management of an immigration removal centre must expressly require compliance with the overriding purpose of Rule 3, which is to provide "the secure but humane accommodation of detained persons in a relaxed regime with as much freedom of movement and association as possible, consistent with maintaining a safe and secure environment, and to encourage and assist detained persons to make the most productive use of their time, whilst respecting in particular their dignity and the right to individual expression". The provisions and operation of each contract must be consistent with and uphold the requirements of the Detention Centre Rules 2001, the Adults at Risk in Immigration Detention policy and the safeguards contained in detention services orders (including those concerning the use of force).
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Published evidence summary
- In March 2024, the Home Office stated that new contracts mandate adherence to Detention Services Orders including the Detention Centre Rules 2001 and that the overriding purpose of Rule 3 is reflected in contractual obligations (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No published independent assessment of whether new contracts are materially improving conditions in line with Rule 3 principles has been identified to March 2026.
Home Office
(Primary)
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Limit cell occupancy to maximum two people
Recommendation
The Home Office must ensure that a maximum of two detained people are accommodated in each cell at Brook House.
Published evidence summary
- In March 2024, the Home Office stated that all rooms across the removal estate meet standards under Rule 15(1) of the Detention Centre Rules 2001, that no room designed for two individuals at Brook House houses more than two, and that there are no plans to change this (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No published independent inspection of cell occupancy at Brook House has been identified since the government response.
Home Office
(Primary)
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Ensure reasonable internet and computer access for detainees
Recommendation
The Home Office and its contractors must ensure reasonable access to computers and the internet. Contractors must comply in full with Detention Services Order 04/2016: Detainee Access to the Internet, in particular: Computers and the internet provided for detained people's …
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The Home Office and its contractors must ensure reasonable access to computers and the internet. Contractors must comply in full with Detention Services Order 04/2016: Detainee Access to the Internet, in particular: Computers and the internet provided for detained people's use must be maintained and fixed, if broken, within a reasonable time period, in order to allow detained people to access the internet for a minimum of seven hours per day, seven days per week. Websites containing personal internet-based email accounts must not be blocked, since this is not a prohibited category of website. Websites facilitating the provision of legal advice and representation must not be blocked, as this is not a prohibited category of website.
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Published evidence summary
- In March 2024, the Home Office stated that service contracts mandate adherence to DSO 04/2016 (Detainee Access to the Internet) and that fines are available for non-compliance (Government Response to the Brook House Inquiry, Home Office, March 2024).
- DSO 04/2016 (Detainee Access to the Internet) was updated in 2024–2026, version 3.0 (Detention Services Order 04/2016 v3.0, Home Office, 2024–2026).
- No published independent assessment of internet access standards in practice has been identified to March 2026.
Home Office
(Primary)
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Require proper cell sharing risk assessments
Recommendation
The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least …
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The Home Office must ensure that adequate risk assessment for cell sharing is carried out by contractors in relation to every detained person. This must be done at the outset of detention and then repeated at reasonable intervals (at least every 14 days) or following any relevant change in circumstances. In the event that an immigration removal centre is unable to detain someone in accordance with the outcome of a risk assessment (due to capacity or for other reasons), the Home Office must ensure that the individual does not remain at that centre.
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Published evidence summary
- In March 2024, the Home Office stated that cell sharing risk assessments are covered under new contractual arrangements and that a new staffing model delivers a healthier ratio of custodial staff per detained individual (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independent assessment of whether cell sharing risk assessments are being carried out at the required frequency across the estate has been identified to March 2026.
Home Office
(Primary)
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Review and reduce cell lock-in periods
Recommendation
The Home Office, in consultation with the contractor responsible for operating each immigration removal centre, must review the current lock-in regime and determine whether the period of time during which detained people are locked in their cells could be reduced. …
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The Home Office, in consultation with the contractor responsible for operating each immigration removal centre, must review the current lock-in regime and determine whether the period of time during which detained people are locked in their cells could be reduced. The Inquiry does not consider cost alone to be a sufficient justification for extensive lock-in periods.
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Published evidence summary
- In March 2024, the Home Office committed to implementing a maximum 9-hour overnight lock-in period, noting this was already being driven forward at Brook House (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In November 2024, the Home Office published a new Detention Services Order on the Management and Security of Night State, setting a maximum 9-hour overnight lock-in period across the immigration removal centre estate, with version 2.0 superseding the December 2018 original (Detention Services Order: Management and Security of Night State, Home Office, November 2024).
Home Office
(Primary)
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Introduce 28-day maximum time limit on detention
Recommendation
The government must introduce in legislation a maximum 28-day time limit on any individual's detention within an immigration removal centre.
Published evidence summary
- In March 2024, the government rejected this recommendation, stating that "a time limit would significantly impair the ability to remove those who have breached immigration laws and refused to leave voluntarily" (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No subsequent change of position has been identified in published government documents to March 2026.
Mandatory comprehensive Rule 34 and Rule 35 training
Recommendation
The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out urgently across the immigration detention estate. Staff must be subject …
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The Home Office (in collaboration with NHS England as required) must ensure that comprehensive training on Rule 34 and Rule 35 of the Detention Centre Rules 2001 is rolled out urgently across the immigration detention estate. Staff must be subject to refresher training, at least annually. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them, as well as GPs and relevant Home Office staff. Consideration must be given as to whether such training should be subject to an assessment.
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Published evidence summary
- In March 2024, the Home Office committed to reviewing Adults at Risk policy and Detention Centre Rules 34 and 35, and stated that NHS England was developing interim clinical guidance for GPs undertaking Rule 35 assessments (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In January 2025, the Home Office updated DSO 08/2016 (Management of Adults at Risk) including mandatory Vulnerable Adult Care Plans and caseworker responsibilities for Level 2 and 3 cases (Detention Services Order 08/2016, Home Office, January 2025).
- In July 2025, the Home Office published an interim DSO on Rule 35, adding guidance on suicidal intent and Home Office oversight of Rule 35 reports, pending completion of the full Adults at Risk and Rule 34–35 review (Detention Services Order 09/2016 interim version, Home Office, July 2025).
- The July 2025 interim DSO noted the Adults at Risk and Rule 34–35 review was expected to conclude by end of June 2025; no published final DSO had been identified at the time of this assessment.
Home Office
(Primary)
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Ensure effective operation and auditing of all Rule 35 limbs
Recommendation
The Home Office must, across the immigration detention estate, assure itself that all three limbs of Rule 35 of the Detention Centre Rules 2001 (reports by a medical practitioner where: (i) it is likely that a detained person's health would …
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The Home Office must, across the immigration detention estate, assure itself that all three limbs of Rule 35 of the Detention Centre Rules 2001 (reports by a medical practitioner where: (i) it is likely that a detained person's health would be injuriously affected by continued detention (Rule 35(1)); (ii) it is suspected that a detained person has suicidal intentions (Rule 35(2)); or (iii) there is a concern that a detained person may have been a victim of torture (Rule 35(3))) are being followed, are operating effectively and are adequately resourced, in recognition of the key safeguarding role that the Rule plays. The Home Office must also regularly audit the use of Rule 35 in order to identify trends, any training needs and required improvements.
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Published evidence summary
- In March 2024, the Home Office stated that a detention gatekeeper system reviews suitability for detention and that a review of the Adults at Risk policy and Rules 34 and 35 was underway (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In May 2024, the Home Office published an updated Adults at Risk in Immigration Detention policy (Adults at Risk in Immigration Detention policy, Home Office, 21 May 2024).
- In July 2025, the Home Office published an interim DSO on Rule 35 with strengthened guidance on all three limbs, including suicidal intent, pending the completion of the full review (Detention Services Order 09/2016 interim version, Home Office, July 2025).
- No independent audit of Rule 35 operation across all three limbs has been identified in published reports to March 2026.
Home Office
(Primary)
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Clarify authorisation for Rule 40 and Rule 42 segregation
Recommendation
The Home Office must amend, as a matter of urgency, Detention Services Order 02/2017: Removal from Association (Detention Centre Rule 40) and Temporary Confinement (Detention Centre Rule 42) and, if necessary, the Detention Services Operating Standards Manual for Immigration Service …
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The Home Office must amend, as a matter of urgency, Detention Services Order 02/2017: Removal from Association (Detention Centre Rule 40) and Temporary Confinement (Detention Centre Rule 42) and, if necessary, the Detention Services Operating Standards Manual for Immigration Service Removal Centres, to clarify who can authorise use of Rule 40 and Rule 42 of the Detention Centre Rules 2001, in both urgent and non-urgent circumstances, including providing a definition of the term 'manager' in Rule 40(2) and Rule 42(2). In anticipation of the update to Detention Services Order 02/2017, the Home Office must issue an immediate instruction to communicate this clarification to staff and contractors operating immigration detention centres.
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Published evidence summary
- In March 2024, the Home Office stated that an interim DSO had been published clarifying Rule 40 and Rule 42 authorisation protocols and that a substantive revision was underway (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In November 2025, the Home Office published DSO 2/2017 version 5.0, described as containing "significant updates and clarifications to strengthen safeguards" on use of separation (Detention Services Order 02/2017 v5.0, Home Office, 28 November 2025).
- DSO 2/2017 v5.0 specifies that initial authorisation for 24 hours requires a Home Office Detention Services Manager (EO grade or above); extensions to 14 days require Grade 7 sign-off; the DSO explicitly states removal from association must be "necessary, as a last resort, and never as punishment"; daily multidisciplinary reviews are required; and seven annexes prescribe documentation (Detention Services Order 02/2017 v5.0, Home Office, November 2025).
Home Office
(Primary)
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Review E Wing suitability for vulnerable detainees
Recommendation
The Home Office and the current operator of Brook House must keep under review the appropriateness of the multi-purpose use of E Wing, particularly in relation to its suitability as a location to detain vulnerable people.
Published evidence summary
- In March 2024, the Home Office stated that the multi-purpose use of Eden Wing at Brook House was under consideration and that learning would be applied across the estate (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No subsequent published decision or outcome of the Eden Wing review has been identified to March 2026.
Home Office
(Primary)
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Annual training on Rule 40 and Rule 42 segregation powers
Recommendation
The Home Office and contractors operating immigration removal centres must provide regular training, at least annually, on the operation of Rule 40 and Rule 42 of the Detention Centre Rules 2001, which must include: that Rules 40 and 42 are …
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The Home Office and contractors operating immigration removal centres must provide regular training, at least annually, on the operation of Rule 40 and Rule 42 of the Detention Centre Rules 2001, which must include: that Rules 40 and 42 are the only powers under which detained people in immigration removal centres can be removed from association and/or located in temporary confinement; who is permitted to authorise use of those Rules and in what circumstances they may be authorised; that Rules 40 and 42 cannot be used as a punishment or solely for administrative convenience before a planned removal or transfer; and the need to assess any adverse effect that use of Rule 40 or Rule 42 could have on a detained person's physical or mental health, and to consider any steps that could be taken to mitigate those effects. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them. The training must be subject to an assessment.
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Published evidence summary
- In March 2024, the Home Office committed to including staff training requirements and compliance auditing as part of the substantive DSO revision on Rule 40/42 (Government Response to the Brook House Inquiry, Home Office, March 2024).
- DSO 2/2017 version 5.0, published in November 2025, includes training requirements for use of separation procedures and requires compliance auditing across the detention estate (Detention Services Order 02/2017 v5.0, Home Office, November 2025).
- No published audit confirming annual training is being delivered across the estate has been identified to March 2026.
Home Office
(Primary)
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Quarterly auditing of Rule 40 and Rule 42 use
Recommendation
The Home Office must regularly (and at least quarterly) audit the use of Rule 40 and Rule 42 across the immigration detention estate, in order to identify trends, any training needs and required improvements. In addition, HM Inspectorate of Prisons …
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The Home Office must regularly (and at least quarterly) audit the use of Rule 40 and Rule 42 across the immigration detention estate, in order to identify trends, any training needs and required improvements. In addition, HM Inspectorate of Prisons and the National Chair and Management Board of Independent Monitoring Boards must review processes to consider how they fulfil their oversight role in respect of Rule 40 and Rule 42, and report on the monitoring of the use of Rules 40 and 42 going forward.
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Published evidence summary
- In March 2024, the Home Office committed to compliance auditing across the detention estate as part of the DSO revision, noting this recommendation was also directed at HMIP and the IMB National Management Board (Government Response to the Brook House Inquiry, Home Office, March 2024).
- DSO 2/2017 v5.0, published November 2025, requires daily multidisciplinary team reviews and documentation of each removal from association via prescribed forms (Detention Services Order 02/2017 v5.0, Home Office, November 2025).
- No independent published audit confirming quarterly estate-wide auditing of Rule 40/42 use has been identified to March 2026.
Home Office
(Primary)
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Prohibit handcuffing behind back while seated
Recommendation
The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.
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The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.
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Published evidence summary
- In March 2024, the Home Office stated that it had communicated to all IRC and contracted service provider staff that handcuffing behind the back while seated is not permitted (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In December 2025, DSO 11/2025 (Use of Force for Adults in Detention) was published, explicitly prohibiting handcuffs behind the back while seated and citing the association with positional asphyxia, with a reference to the statutory basis in Section 44 of the Border Security, Asylum and Immigration Act 2025 (Detention Services Order 11/2025, Home Office, 19 December 2025).
Home Office
(Primary)
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New comprehensive use of force detention services order
Recommendation
The Home Office must introduce, as a matter of urgency, a new and comprehensive detention services order to address use of force in immigration removal centres. The detention services order must include the following issues: the permissible justifications for the …
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The Home Office must introduce, as a matter of urgency, a new and comprehensive detention services order to address use of force in immigration removal centres. The detention services order must include the following issues: the permissible justifications for the use of force within immigration removal centres, based on the key principle that force must not be used unnecessarily and must be used only as a last resort; the use of Personal Protective Equipment (PPE), including that it must be subject to a dynamic risk assessment before and during any use of force incident; the protection of dignity when force is used on a naked or near-naked detained person; the circumstances in which force can be used against a detained person with mental ill health; and monitoring, oversight and reporting of use of force by contractors and by the Home Office. The Home Office must ensure that training about the application of the new detention services order and use of force techniques takes place on a regular (at least annual) basis for all detention staff as well as healthcare staff. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them. The training must be subject to an assessment. In anticipation of a new detention services order on the use of force in immigration detention, the Home Office must issue an immediate instruction to its contractors managing immigration removal centres that force must be used only as a last resort, using approved techniques.
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Published evidence summary
- In March 2024, the Home Office stated that a new DSO on use of force was being developed in consultation with experts, alongside an overhaul of assurance processes and a new escalation system (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In December 2025, DSO 11/2025 (Use of Force for Adults in Detention) was published, covering: permissible justifications; a RAG rating system for all incidents assessed within 72–96 hours; mandatory body-worn cameras throughout all incidents; monthly oversight committees at all IRCs including IMB representatives; and annual 8-hour refresher training with exclusion from detainee-facing duties for non-completion (Detention Services Order 11/2025, Home Office, 19 December 2025).
- DSO 11/2025 was enacted under Section 44 of the Border Security, Asylum and Immigration Act 2025, providing a statutory footing for use of force standards in immigration detention (Border Security, Asylum and Immigration Act 2025, s.44).
Home Office
(Primary)
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Independent review of use of force on mentally ill detainees
Recommendation
The Home Office must urgently commission an independent review (with the power to make recommendations) of use of force on detained people with mental ill health within immigration removal centres. The review must consider: how, when and whether to use …
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The Home Office must urgently commission an independent review (with the power to make recommendations) of use of force on detained people with mental ill health within immigration removal centres. The review must consider: how, when and whether to use force on detained people with mental ill health (including the application of pain-inducing techniques); the likely effect of the use of force on a detained person's mental health; the use of individual risk assessments for detained people, which could be conducted by personal officers and healthcare professionals; and the increased use and prioritisation of de-escalation techniques for those who have mental ill health. The review must take place in consultation with relevant stakeholders, including detained people's representative groups and mental ill health experts. The recommendations of the review must be incorporated in the new detention services order regarding the use of force (see Recommendation 15), in respect of which additional, regular (at least annual) training must then be provided.
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Published evidence summary
- In March 2024, the Home Office accepted this recommendation in principle, stating it was working with HMPPS, NHS England and DHSC to develop new operational standards for use of force on detained people with mental ill health (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No published independent review, terms of reference, or interim report on this subject has been identified to March 2026.
Home Office
(Primary)
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Mandatory use of force debrief training and multi-level review process
Recommendation
The Home Office must ensure, as a matter of urgency, that training is delivered on how to conduct an effective use of force incident debrief, ensuring that issues of detained person and staff welfare, as well as training needs, are …
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The Home Office must ensure, as a matter of urgency, that training is delivered on how to conduct an effective use of force incident debrief, ensuring that issues of detained person and staff welfare, as well as training needs, are covered. The training must be mandatory for all immigration removal centre contractor employees who conduct such reviews and those who manage them. The Home Office must also require that use of force incidents be reviewed, at a minimum, at the following levels: Within 36 hours of each use of force incident, the Use of Force Coordinator must conduct a thorough incident review, ensuring that all documentation and footage are collated and preserved, and with a view to taking emergency action in instances of unlawful or inappropriate force. On a weekly basis, all use of force incidents must be reviewed (including all necessary paperwork and available video footage) at a formal meeting by the Use of Force Coordinator and a suitable manager in order to review each incident and to identify any issues or further action required. On a monthly basis, immigration removal centre contractor senior management must arrange meetings with other stakeholders (including detained people and representatives of non-governmental organisations) to review use of force trends. Periodically, the Home Office (or its Professional Standards Unit if the Home Office considers it more appropriate) must review use of force at Brook House and across the immigration detention estate, to identify trends and to direct the implementation of any changes and improvements that are required. This review process must be reflected in the new detention services order regarding the use of force – see Recommendation 15 – in respect of which additional, regular (at least annual) training must then be provided.
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Published evidence summary
- In March 2024, the Home Office committed to developing training on effective use of force debriefs and stated that use of force monthly meetings and formal review processes were referenced in the Service Improvement Plan (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In December 2025, DSO 11/2025 (Use of Force for Adults in Detention) mandated a RAG rating system for all use of force incidents (assessed within 72–96 hours at site level, escalated if rated Red or Amber), monthly oversight committees at each IRC with IMB representation, and annual 8-hour refresher training with mandatory attendance requirements (Detention Services Order 11/2025, Home Office, 19 December 2025).
Home Office
(Primary)
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Update DSO on food and fluid refusal management and reporting
Recommendation
The Home Office must, as a matter of urgency, update Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid, to ensure that it deals with: food and fluid refusal being clearly and directly linked to …
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The Home Office must, as a matter of urgency, update Detention Services Order 03/2017: Care and Management of Detained Individuals Refusing Food and/or Fluid, to ensure that it deals with: food and fluid refusal being clearly and directly linked to consideration of the Rule 35 process and whether a detained person is defined as an 'adult at risk'; the consideration by the healthcare provider at each immigration removal centre, upon an incidence of food and fluid refusal occurring, of assessments of mental capacity, of mental state, and under Rule 35, and the conduct of these where indicated, as well as ensuring compliance with Adults at Risk in Immigration Detention policy and making sure that decisions made in relation to these are recorded; the notification to the Home Office of the numbers of detained people refusing food and fluid, and the reasons for such refusal, on a monthly basis (in the same way that incidents of self-harm are notified); and the monitoring by the Home Office of the compliance by healthcare providers with Detention Services Order 03/2017 and the numbers of detained people refusing food and fluid, and the reasons for such refusal, in order to identify any patterns of concern and take appropriate action. The Home Office must ensure that mandatory training about the application of the updated detention services order takes place on a regular (at least annual) basis for all detention staff and healthcare staff, as well as those responsible for managing them. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them. The training must be subject to an assessment. In anticipation of the update to Detention Services Order 03/2017, the Home Office must issue an immediate instruction to communicate this clarification to those operating immigration detention centres.
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Published evidence summary
- In March 2024, the Home Office stated that an updated DSO on food and fluid refusal had been published, linking food and fluid refusal to consideration of the Rule 35 process and the Adults at Risk policy (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independent assessment of whether the updated DSO has changed clinical practice or reporting rates on food and fluid refusal has been identified in published reports to March 2026.
Home Office
(Primary)
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Healthcare staff guidance and training on use of force incidents
Recommendation
The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with NHS England and any relevant medical regulators. The Home Office …
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The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with NHS England and any relevant medical regulators. The Home Office must ensure that mandatory training is introduced for healthcare staff, and those responsible for managing them, on their roles and responsibilities in relation to planned and unplanned use of force (liaising with NHS England and any other relevant parties). The training must be subject to an assessment.
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Published evidence summary
- In March 2024, the government rejected this recommendation, stating that NHS England commissions healthcare services and that it is their responsibility, alongside the Care Quality Commission, to set clinical guidance for healthcare staff (Government Response to the Brook House Inquiry, Home Office, March 2024).
- Notwithstanding the March 2024 rejection, DSO 11/2025 (Use of Force for Adults in Detention), published in December 2025, requires a healthcare professional to be in attendance at all use of force incidents in immigration removal centres (Detention Services Order 11/2025, Home Office, December 2025).
- No published guidance from NHS England or the CQC specifically addressed to healthcare staff roles in IRC use of force incidents has been identified to March 2026.
Home Office
(Primary)
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Update guidance on fit to fly and fit for detention medical assessments
Recommendation
The Home Office must review and update Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers, to ensure that guidance given to GPs working in the immigration detention estate in …
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The Home Office must review and update Detention Services Order 01/2016: The Protection, Use and Sharing of Medical Information Relating to People Detained Under Immigration Powers, to ensure that guidance given to GPs working in the immigration detention estate in relation to their duties and responsibilities in writing 'fit to fly and fit for detention' letters is clear. It must liaise with NHS England and any relevant medical regulators as necessary. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for GPs working in the immigration detention estate and those responsible for managing them. The training must be subject to an assessment. The Home Office must monitor compliance with this updated guidance at least annually.
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Published evidence summary
- In March 2024, the Home Office accepted this recommendation in principle but stated that fit to fly assessments are a "medico-legal practice" outside the responsibility of NHS England, and committed to ensuring clinicians share fitness-to-fly concerns with the Home Office where appropriate (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No published updated guidance to GPs on fit to fly or fit for detention assessment duties has been identified in DSO updates or NHS England publications to March 2026.
Home Office
(Primary)
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Update mental vulnerability and mental capacity DSO guidance
Recommendation
The Home Office must review and update Detention Services Order 04/2020: Mental Vulnerability and Immigration Detention: Non-Clinical Guidance to set out comprehensive guidance for detention and healthcare staff where there are concerns that a detained person is suffering mental ill …
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The Home Office must review and update Detention Services Order 04/2020: Mental Vulnerability and Immigration Detention: Non-Clinical Guidance to set out comprehensive guidance for detention and healthcare staff where there are concerns that a detained person is suffering mental ill health or lacks mental capacity. This must include an appropriate system for: the routine handover or sharing of relevant information between detention custody staff and healthcare staff (for example, in Security Information Reports and Anti-Bullying Support Plans); the identification and follow-up of missed medical appointments; the assessment of mental capacity where indicated; and mental health assessment where indicated. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for detention and healthcare staff, as well as those responsible for managing them. The training must be subject to an assessment.
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Published evidence summary
- In March 2024, the Home Office stated it was scoping requirements with NHS England regarding policy on detained people with mental ill health as part of wider work on vulnerable adults (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In January 2025, DSO 08/2016 (Management of Adults at Risk) was updated to include mandatory Vulnerable Adult Care Plans for Level 3 cases, standardised VACPs across all facilities, and new caseworker responsibilities (Detention Services Order 08/2016, Home Office, January 2025).
- The July 2025 interim Rule 35 DSO includes updated guidance on detained persons who may lack mental capacity, though the full mental vulnerability DSO revision remained pending the completion of the Adults at Risk and Rule 34–35 review (Detention Services Order 09/2016 interim, Home Office, July 2025).
Home Office
(Primary)
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Update healthcare complaints handling guidance
Recommendation
The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of complaints specific to the provision of healthcare in an immigration …
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The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of complaints specific to the provision of healthcare in an immigration detention setting. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for staff dealing with healthcare complaints, as well as those responsible for managing them. The training must be subject to an assessment. Healthcare providers in immigration removal centres must ensure that all healthcare complaints are robustly investigated in accordance with the updated guidance. The methodology and outcomes must be clearly communicated, including to the detained person. They must also ensure that appropriate, regular (at least annual) training and guidance is provided to those holding responsibility for the investigation of healthcare complaints.
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Published evidence summary
- In March 2024, the Home Office stated that a comprehensive review of complaints processes, including medical complaints, was underway in consultation with residents, IMBs, and the Prisons and Probation Ombudsman (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In February 2025, DSO 03/2015 (Handling Complaints in IRCs) was updated to include healthcare complaint escalation pathways, translation request forms, and quarterly healthcare reporting to the Home Office (Detention Services Order 03/2015, Home Office, February 2025).
- No independent assessment of whether the updated complaints process has improved healthcare complaint outcomes in practice has been identified to March 2026.
Home Office
(Primary)
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Quarterly assessment of staffing levels against population needs
Recommendation
The Home Office and contractors operating immigration removal centres must ensure that there is ongoing assessment of staffing levels (at least on a quarterly basis), so that the level of staff present within each centre is appropriate for the size …
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The Home Office and contractors operating immigration removal centres must ensure that there is ongoing assessment of staffing levels (at least on a quarterly basis), so that the level of staff present within each centre is appropriate for the size and needs of the detained population. The Home Office must also ensure that the detained population does not increase at any immigration centre unless staffing is at an adequate level.
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Published evidence summary
- In March 2024, the Home Office stated that a new staffing model had been implemented delivering a staffing ratio "nearly double what it was in 2017" and that contract reviews address safe staffing requirements (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In November 2025, DSO 02/2018 (Detainee Custody Officer certification and training) was updated (Detention Services Order 02/2018 v2.0, Home Office, November 2025).
- No independently published quarterly staffing assessment methodology or compliance audit has been identified to March 2026.
Home Office
(Primary)
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Mandatory staff training on mental health and trauma-informed approaches
Recommendation
The Home Office, in conjunction with contractors, must ensure that all relevant immigration removal centre staff receive mandatory introductory and annual training on: mental health; race and diversity; a trauma-informed approach; their own resilience; drug awareness; and the purpose of …
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The Home Office, in conjunction with contractors, must ensure that all relevant immigration removal centre staff receive mandatory introductory and annual training on: mental health; race and diversity; a trauma-informed approach; their own resilience; drug awareness; and the purpose of immigration removal centres. This training must include the perspectives of, or be conducted in consultation with, detained people. The Home Office must also ensure, in conjunction with contractors, that new joiners must start on probation on completion of introductory training and be adequately supervised for a period of time as necessary to establish their competence to work independently.
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Published evidence summary
- In March 2024, the Home Office stated that the Initial Training Course for all new contracted service provider staff was undergoing a full review, covering Adults at Risk, mental health awareness, racial awareness, and safeguarding, with a mentorship phase introduced following completion and annual refresher training required (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independently published assessment of whether the revised ITC has been completed and rolled out across the estate has been identified to March 2026.
Home Office
(Primary)
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Ensure senior manager presence and accessibility to staff
Recommendation
Contractors operating immigration removal centres must ensure that senior managers are regularly present and visible within the immigration removal centre and are accessible to more junior detention staff.
Published evidence summary
- In March 2024, the Home Office stated that contractors are required to ensure senior managers are regularly present and visible within IRCs, addressing desensitisation and staff culture concerns (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independently published assessment of senior manager visibility in practice across the detention estate has been identified to March 2026.
Home Office
(Primary)
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Ensure Home Office staff presence and visibility in IRCs
Recommendation
The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Published evidence summary
- In March 2024, the Home Office stated that Detention Engagement Team expansion was underway with further recruitment to increase Home Office staff presence in each IRC (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No published report on the outcome of Detention Engagement Team recruitment or independent assessment of Home Office staff visibility across the estate has been identified to March 2026.
Home Office
(Primary)
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Action plan to address staff desensitisation and secondary trauma
Recommendation
Contractors operating immigration removal centres must develop and implement an action plan to ensure a safe and healthy staff culture in immigration removal centres. The action plan must address: the identification of and response to any sign of desensitisation among …
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Contractors operating immigration removal centres must develop and implement an action plan to ensure a safe and healthy staff culture in immigration removal centres. The action plan must address: the identification of and response to any sign of desensitisation among staff; training staff on coping mechanisms and secondary trauma awareness; and maintaining an appropriate balance between care and safety or security. The Home Office must regularly monitor each contractor's compliance with their action plans.
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Published evidence summary
- In March 2024, the Home Office stated that a code of conduct and mandatory staff engagement strategy had been introduced, and that the ITC review addresses staff wellbeing and secondary trauma awareness (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independently published staff culture action plan, implementation progress report, or outcome assessment has been identified to March 2026.
Home Office
(Primary)
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Address barriers to detainee complaints including fear of repercussions
Recommendation
The Home Office and its contractors operating immigration removal centres must take steps to identify and address the barriers to making complaints that are faced by detained people, including a fear of repercussions. This must include training for staff on …
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The Home Office and its contractors operating immigration removal centres must take steps to identify and address the barriers to making complaints that are faced by detained people, including a fear of repercussions. This must include training for staff on their role in enabling detained people to overcome these barriers.
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Published evidence summary
- In March 2024, the Home Office committed to a comprehensive review of complaints processes, including barriers faced by detainees, in consultation with residents, IMBs, and the Prisons and Probation Ombudsman (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In February 2025, DSO 03/2015 (Handling Complaints in IRCs) was updated (Detention Services Order 03/2015, Home Office, February 2025).
- In July 2025, DSO 03/2020 (Whistleblowing) version 3.0 was published, introducing a confidential hotline and monthly reporting requirements for contractors (Detention Services Order 03/2020 v3.0, Home Office, July 2025).
- No independent assessment of whether detainee-facing barriers to complaint have been reduced in practice has been identified to March 2026.
Home Office
(Primary)
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Improve Professional Standards Unit investigation procedures and training
Recommendation
The Home Office must update Detention Services Order 03/2015: Handling of Complaints to clarify that, in investigations carried out by the Professional Standards Unit into allegations of serious misconduct against contractor staff: Professional Standards Unit investigators must carry out interviews …
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The Home Office must update Detention Services Order 03/2015: Handling of Complaints to clarify that, in investigations carried out by the Professional Standards Unit into allegations of serious misconduct against contractor staff: Professional Standards Unit investigators must carry out interviews themselves and not rely on contractors to do so. All staff against whom allegations are made must be invited to interview. Where there are inconsistencies between any accounts given of events, any evidence relating to those accounts (including footage and documentation) obtained by an investigating officer must be shown to the complainant and to the subject of the complaint, prior to reaching a conclusion. The Professional Standards Unit must be given information about previous complaints made against alleged perpetrators, including unsubstantiated complaints. Previous disciplinary action against alleged perpetrators must be taken into account. Investigators must look for evidence that is both supportive and undermining of the complaint. Full reports must be sent to complainants (and their solicitors if applicable). Investigation reports and/or outcome letters must be sent directly from the PSU to complainants (and their solicitors if applicable). The Home Office Professional Standards Unit must ensure that training about the updated guidance takes place on a regular (at least annual) basis for staff dealing with investigations, as well as those responsible for managing them. The training must be subject to an assessment. The Professional Standards Unit must also review the training provided to investigators and ensure that investigators receive regular and adequate training, from a variety of perspectives, on issues including: the nature of immigration removal centres and issues that may arise; obstacles that detained people may face in making complaints; interviewing vulnerable witnesses; and use of force and assessing reasonableness of force.
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Published evidence summary
- In March 2024, the Home Office stated that the PSU had updated its training to reflect Brook House Inquiry findings, including training in interviewing vulnerable witnesses, and that an embedded use of force expert had been added to the PSU (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No independently published assessment of PSU investigation quality or outcomes since the March 2024 response has been identified to March 2026.
Home Office
(Primary)
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Enhance Professional Standards Unit independence and seniority
Recommendation
The Home Office must: take steps to enhance the independence of the Professional Standards Unit from the Home Office and the perception of this independence; and increase the seniority of the Head of the Professional Standards Unit so that they …
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The Home Office must: take steps to enhance the independence of the Professional Standards Unit from the Home Office and the perception of this independence; and increase the seniority of the Head of the Professional Standards Unit so that they are closer in status to the Heads of the relevant Home Office Immigration Enforcement teams.
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Published evidence summary
- In March 2024, the government rejected this recommendation, stating: "The seniority of the Head of the PSU will not be changed," and expressing confidence in existing ACAS Code of Practice compliance mechanisms (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No subsequent change in the government's position has been identified in published documents to March 2026.
Home Office
(Primary)
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Update whistleblowing DSO with anonymous reporting mechanisms
Recommendation
The Home Office must update Detention Services Order 03/2020: Whistleblowing – The Public Interest Disclosure Act 1998 to require contractors that run immigration removal centres to: have a whistleblowing policy and procedure that is specific to the immigration detention environment; …
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The Home Office must update Detention Services Order 03/2020: Whistleblowing – The Public Interest Disclosure Act 1998 to require contractors that run immigration removal centres to: have a whistleblowing policy and procedure that is specific to the immigration detention environment; ensure that the whistleblowing mechanism is not limited to a hotline and allows for anonymous reporting of concerns; ensure that those who receive whistleblowing concerns have an understanding of immigration removal centres; take active steps to encourage staff to use whistleblowing processes, for reasons including those set out at paragraph 10 of Detention Services Order 03/2020; and ensure that whistleblowing concerns are investigated thoroughly by someone external to the immigration removal centre, and that the Home Office is informed of the nature of the concern and the investigation carried out. The Home Office must ensure that training about the updated guidance takes place on a regular (at least annual) basis for staff dealing with whistleblowing, as well as those responsible for managing them. The training must be subject to an assessment.
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Published evidence summary
- In March 2024, the Home Office committed to including whistleblowing process improvements in its comprehensive complaints and DSO review (Government Response to the Brook House Inquiry, Home Office, March 2024).
- In July 2025, DSO 03/2020 (Whistleblowing) was published as version 3.0, introducing a confidential whistleblowing hotline, a requirement for contractors to report to the Home Office Compliance Team and DS Counter Corruption and Investigations Unit within monthly returns, and updated PIDA guidance (Detention Services Order 03/2020 v3.0, Home Office, July 2025).
- The July 2025 DSO was further updated in November 2025 to reflect contact detail changes (Detention Services Order 03/2020, Home Office, November 2025).
Home Office
(Primary)
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Strengthen Independent Monitoring Board statutory footing and responsiveness
Recommendation
The government must: respond to and publish responses to all concerns raised by any Independent Monitoring Board regarding immigration removal centres; take steps without further delay to amend the Detention Centre Rules 2001, in so far as they govern Independent …
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The government must: respond to and publish responses to all concerns raised by any Independent Monitoring Board regarding immigration removal centres; take steps without further delay to amend the Detention Centre Rules 2001, in so far as they govern Independent Monitoring Boards, in order to accurately reflect their current role; and consider whether to put the National Chair and Management Board of the Independent Monitoring Boards on a statutory footing.
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Published evidence summary
- In March 2024, the Home Office stated that the Ministry of Justice had committed in the 2021 Prisons Strategy White Paper to pursue legislative reform to provide IMBs with a statutory framework, and that the government intended to legislate "as soon as Parliamentary time allows" (Government Response to the Brook House Inquiry, Home Office, March 2024).
- No legislation amending the statutory position of Independent Monitoring Boards in immigration removal centres has been identified in Acts passed between March 2024 and March 2026, including the Border Security, Asylum and Immigration Act 2025.
- No further published government update on the timeline for IMB legislation has been identified to March 2026.
Improve HMIP and IMB evidence gathering and reporting processes
Recommendation
HM Inspectorate of Prisons and Independent Monitoring Boards working within immigration removal centres must ensure that they have robust processes for: obtaining and reporting on an enhanced range of evidence and intelligence from detained people and those who represent or …
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HM Inspectorate of Prisons and Independent Monitoring Boards working within immigration removal centres must ensure that they have robust processes for: obtaining and reporting on an enhanced range of evidence and intelligence from detained people and those who represent or support them, staff and contractors, including that which is received outside of inspections or visits; and reporting on any concerns about the Home Office and contractors.
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Published evidence summary
- In March 2024, the Home Office stated that it was considering its reliance on external scrutiny organisations, and noted this recommendation was directed primarily at HMIP and IMBs themselves (Government Response to the Brook House Inquiry, Home Office, March 2024).
- DSO 11/2025 (Use of Force for Adults in Detention), published December 2025, requires monthly oversight committees at all IRCs with IMB representation, providing a structural mechanism for IMB involvement in ongoing monitoring (Detention Services Order 11/2025, Home Office, December 2025).
- No published HMIP inspection of Brook House or estate-wide review of IMB evidence-gathering practices has been identified in publicly available reports to March 2026.
HM Inspectorate of Prisons
(Primary)
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