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
The Home Office has introduced new contracts requiring internal audit programmes and self-reporting by service providers, supported by Detention Services Compliance Teams and Detention Engagement Teams within each Immigration Removal Centre (Govt response, March 2024). Quarterly Executive Oversight Boards have also been established to address unresolved issues between senior Home Office officials and service provider executives (Govt response, March 2024). While a Written Parliamentary Question in January 2025 stated the recommendation was completed as of October 2024, HM Inspectorate of Prisons reported in September 2025 that although oversight mechanisms were functioning, more work was needed, and the Inquiry Chair described the government's overall response as "inadequate" in September 2024.
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
The Home Office stated that new contracts for immigration removal centres mandate adherence to Detention Services Orders, including the Detention Centre Rules 2001, and its Detention Services Operations Compliance and Assurance strategy for 2024 onwards is being improved (Government Response, March 2024). The government reported this recommendation as completed and closed as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025). However, an HM Inspectorate of Prisons review in August 2025 found mixed progress on humane accommodation, noting rolling refurbishment and an upgraded library, but also inadequately ventilated cells with sealed windows.
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
The Home Office stated in March 2024 that all rooms across the immigration removal estate meet standards under Rule 15(1) of the Detention Centre Rules 2001, and that no room designed for two individuals at Brook House houses more than two, with no plans for change. A Written Parliamentary Question in January 2025 confirmed this recommendation was "Completed and closed as of October 2024." However, HM Inspectorate of Prisons reported in September 2025 "Mixed Findings," noting that while units were undergoing refurbishment, cells remained inadequately ventilated with sealed windows. The Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
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
The Home Office stated in March 2024 that service contracts mandate adherence to Detention Services Orders (DSOs) regarding the mandatory provision of and regulated access to IT equipment and internet services, with fines available for non-compliance. A Written Parliamentary Question in January 2025 confirmed this recommendation was "Completed and closed as of October 2024." HM Inspectorate of Prisons reported in September 2025 "Mixed Findings," noting an upgraded library described as a "relaxed and welcoming space," which may contribute to detainee access to resources. However, the Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
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
The Home Office stated in March 2024 that a new staffing model was delivering a healthier ratio of custodial staff per detained individual, and that cell sharing risk assessments were covered under new contractual arrangements. A Written Parliamentary Question in January 2025 indicated this recommendation was "due for closure by end of January 2025," and the government tracker marks it as "Completed." The Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
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
The Home Office stated in March 2024 that a maximum 9-hour overnight lock-in period had been implemented, and noted a drive to improve the range of activities available to detainees. A Written Parliamentary Question in January 2025 confirmed this recommendation was "Completed and closed as of October 2024." HM Inspectorate of Prisons reported in September 2025 "Mixed Findings," noting an upgraded library described as a "relaxed and welcoming space," which may contribute to improved activities. However, the Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 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
The government rejected the recommendation to introduce a 28-day maximum time limit on immigration detention, stating it would impair the ability to remove individuals who have breached immigration laws (Government Response, March 2024). This rejection was confirmed in a Parliamentary Written Question in January 2025 (Angela Eagle, Written PQ 23170, January 2025) and upheld by the High Court in July 2025, which found no legal obligation for the government to comply with inquiry recommendations (R (D1914) v SSHD [2025] EWHC 1853 (Admin)). As of August 2025, HM Inspectorate of Prisons reported that 67% of detainees were held for over two months, with the longest detention exceeding 550 days, indicating no change in practice (HM Inspectorate of Prisons report, September 2025).
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
The Home Office accepted this recommendation in principle, stating it is reviewing the Adults at Risk policy and Detention Centre Rules 34 and 35, with NHS England developing interim clinical guidance and full training to follow (Government Response, March 2024). A Parliamentary Written Question in January 2025 indicated the recommendation was "on track for closure by summer 2025" (Angela Eagle, Written PQ 23170, January 2025). However, an HM Inspectorate of Prisons review in August 2025 found that Rule 35 appointments were taking up to three weeks and there was a routine failure to submit reports for suicidal detainees, suggesting insufficient progress on effective implementation (HM Inspectorate of Prisons report, September 2025).
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
The Home Office stated it is reviewing the Adults at Risk policy and Rules 34 and 35, noting that the detention gatekeeper system and existing Adults at Risk policy are in place (Government Response, March 2024). A Parliamentary Written Question in January 2025 indicated the recommendation was "on track for closure by summer 2025" (Angela Eagle, Written PQ 23170, January 2025). However, a High Court ruling in December 2025 found that the Home Secretary failed to comply with Article 3 ECHR systems duty regarding Rule 35 safeguarding at Brook House between July 2023 and March 2024, with only a small number of Rule 35 reports filed despite numerous care plans (AH and IS v SSHD [2025] EWHC 3269 (Admin)). HM Inspectorate of Prisons also reported in September 2025 that Rule 35 appointments were taking up to three weeks and there was a routine failure to submit reports for suicidal detainees (HM Inspectorate of Prisons report, September 2025).
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
The Home Office published an interim Detention Services Order (DSO) to clarify authorisation protocols for Rule 40 (removal from association) and Rule 42 (temporary confinement) (Govt response, March 2024). A substantive revision of the DSO is underway, which includes examining assurance mechanisms, staff training, and compliance auditing (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated this revision was on track for closure by summer 2025, but no further specific update on its completion has been identified since that date.
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
The Home Office stated in March 2024 that the multi-purpose use of Eden Wing at Brook House was under consideration, with learning to be applied across the immigration removal estate (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated that this recommendation was due for closure by the end of January 2025, suggesting completion. However, no specific details regarding the outcome of the review or any resulting changes to E Wing's suitability for vulnerable detainees have been publicly identified.
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
The Home Office stated in March 2024 that the substantive revision of the Detention Services Order (DSO) for Rule 40 and Rule 42 includes an examination of staff training requirements and compliance auditing (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated this work was on track for closure by summer 2025, but no specific evidence of the implementation of annual training on Rule 40 and Rule 42 segregation powers has been publicly identified since that date. HM Inspectorate of Prisons reported 'Good Progress' in September 2025 regarding reduced use of force incidents and improved detainee safety, which could be an indirect positive outcome of improved training.
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
The Home Office stated in March 2024 that the ongoing revision of the Detention Services Order (DSO) includes compliance auditing across the immigration detention estate (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated this work was on track for closure by summer 2025, but no specific evidence confirming the implementation of regular, at least quarterly, auditing of Rule 40 and Rule 42 use has been publicly identified since that date.
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
The Home Office communicated to all Immigration Removal Centre (IRC) and contracted service provider staff that the technique of handcuffing detained people with their hands behind their back while seated is not permitted (Govt response, March 2024). A Written Parliamentary Question in January 2025 confirmed that this recommendation was completed and closed as of October 2024.
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
The Home Office stated in March 2024 that a new comprehensive Detention Services Order (DSO) on use of force is being developed in consultation with experts, alongside an overhaul of assurance processes and a new escalation system (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated this work was on track for closure by summer 2025, but no specific evidence of the new comprehensive DSO's publication or implementation has been publicly identified since that date. HM Inspectorate of Prisons reported 'Good Progress' in September 2025 regarding strengthened staffing and implemented training on a "Monitor, Challenge and Support" process, which may contribute to improved use of force practices.
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
The Home Office stated in March 2024 that it is working with HMPPS, NHS England, and DHSC to develop new operational standards for the use of force on detained people with mental ill health (Govt response, March 2024). This represents an internal development of standards rather than the independent review requested by the recommendation. A Written Parliamentary Question in January 2025 indicated this work was on track for closure by summer 2025, but no specific evidence of an independent review being commissioned or its findings has been publicly identified since that date.
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
The Home Office stated in March 2024 that training and escalation systems for use of force incidents are referenced, and a Service Improvement Plan includes use of force monthly meetings and formal review processes (Govt response, March 2024). A Written Parliamentary Question in January 2025 indicated this work was on track for closure by summer 2025, but no specific evidence confirming the implementation of mandatory use of force debrief training or a multi-level review process has been publicly identified since that date.
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
The Home Office published an updated Detention Services Order (DSO) on food and fluid refusal, which links food and fluid refusal to the consideration of the Rule 35 process and the Adults at Risk policy (Govt response, March 2024). A Written Parliamentary Question in January 2025 confirmed that this recommendation was completed and closed as of October 2024.
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
The government explicitly rejected this recommendation, stating that NHS England and the Care Quality Commission are responsible for assuring healthcare quality within the detention estate (Government Response, March 2024). This rejection was confirmed in a Written Parliamentary Question in January 2025 (Angela Eagle, Written PQ 23170, 15 January 2025).
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
The government accepted this recommendation in principle, acknowledging NHS England's commissioning responsibility for healthcare services and clarifying that "fit to fly" letters are a medico-legal practice (Government Response, March 2024). As of January 2025, the government stated the recommendation was on track for closure by summer 2025 (Angela Eagle, Written PQ 23170, 15 January 2025), but no further update has been provided since that date passed. An HM Inspectorate of Prisons review in August 2025 noted improved healthcare provision but did not specifically address the update of guidance for "fit to fly and fit for detention" medical assessments.
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
The Home Office stated it was considering policy on detained people with mental ill health as part of wider work on vulnerable adults and scoping requirements with NHS England (Government Response, March 2024). While the government reported in January 2025 that this was on track for closure by summer 2025 (Angela Eagle, Written PQ 23170, 15 January 2025), a High Court ruling in December 2025 found a systemic disconnect between Adults at Risk policy, ACDT systems, and Rule 35 processes at Brook House (AH and IS v SSHD [2025] EWHC 3269 (Admin)). HM Inspectorate of Prisons also reported "Insufficient Progress" in August 2025, noting limited engagement with charities and issues with adults at risk.
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
The Home Office initiated a comprehensive review of complaints processes, including medical complaints, with Detention Services Orders to be updated upon completion (Government Response, March 2024). The government reported this recommendation as completed and closed as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025). HM Inspectorate of Prisons (August 2025) noted "Reasonable Progress" on oversight mechanisms, with an active Home Office team increasing contact and communication with detainees.
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
The Home Office implemented a new staffing model, reportedly achieving a considerably healthier ratio of custodial staff per detained individual, nearly double what it was in 2017 (Government Response, March 2024). Contract reviews also address safe staffing policies. The government reported this recommendation as completed and closed as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025).
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
The Initial Training Course for all new contractor staff underwent a full review to cover mental health awareness, racial awareness, and safeguarding children, including a mentorship phase and annual refresher training (Government Response, March 2024). HM Inspectorate of Prisons (August 2025) reported "Good Progress," noting strengthened staff capability and implemented training on the "Monitor, Challenge and Support" process. The government reported this recommendation as completed and closed as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025).
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
The government stated that contractors are required to ensure senior managers are regularly present and visible within immigration removal centres, addressing this under staffing and culture (Government Response, March 2024). This recommendation was reported as completed and closed by the government as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025). No independent evidence directly confirms the consistent presence and accessibility of senior managers.
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
The Home Office initiated the expansion of its Detention Engagement Team and further recruitment to increase Home Office staff presence in Immigration Removal Centres (Government Response, March 2024). The government reported this recommendation as completed and closed as of October 2024 (Angela Eagle, Written PQ 23170, 15 January 2025). HM Inspectorate of Prisons (August 2025) reported "Good Progress" with reduced use of force incidents and detainees reporting feeling safer, which could be an indirect outcome of improved staff presence.
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
The government introduced a code of conduct and a mandatory staff engagement strategy, and the Initial Training Course review addresses staff wellbeing and secondary trauma awareness (Government Response, March 2024). HM Inspectorate of Prisons (August 2025) reported "Good Progress," noting improved body-worn camera usage, staff visibility, and effective de-escalation practices. The government stated this recommendation was due for closure by the end of January 2025 (Angela Eagle, Written PQ 23170, 15 January 2025).
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
The Home Office stated in March 2024 that a comprehensive review of complaints processes was underway, involving detainees, the Independent Monitoring Board (IMB), and the Prisons and Probation Ombudsman, with Detention Services Orders (DSOs) to be updated. A Written Parliamentary Question in January 2025 indicated the recommendation was "due for closure by end of January 2025," and the government tracker marks it as "Completed." However, the Brook House Inquiry Chair, Kate Eves, described the government's response as "inadequate" in September 2024, warning that abuse would recur. HM Inspectorate of Prisons reported in September 2025 that mental health provision was improving but remained inadequate for demand, and a higher percentage of detainees were assessed at higher risk.
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
The Home Office stated in March 2024 that its Professional Standards Unit (PSU) updated its training to reflect Brook House Inquiry findings, specifically including training in interviewing vulnerable witnesses, and embedded a use of force expert. A Written Parliamentary Question in January 2025 indicated the recommendation was "due for closure by end of January 2025," and the government tracker marks it as "Completed." However, the Brook House Inquiry Chair, Kate Eves, described the government's response as "inadequate" in September 2024, warning that abuse would recur.
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
The Home Office explicitly rejected this recommendation in its March 2024 response, stating that the seniority of the Head of the Professional Standards Unit would not be changed. The government expressed confidence in existing ACAS Code compliance and Prisons and Probation Ombudsman escalation routes. A Written Parliamentary Question in January 2025 confirmed that this recommendation was among the three rejected by the government.
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
The Home Office stated in March 2024 that a broader complaints and whistleblowing review was underway, which included a review of Detention Services Orders (DSOs) and efforts to improve the visibility of whistleblowing processes within Immigration Removal Centres. A Written Parliamentary Question in January 2025 indicated that this recommendation was "on track for closure by summer 2025." No further public update on its completion has been identified since that date. The Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
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
The Ministry of Justice committed in its 2021 Prisons Strategy White Paper to pursue legislative reform to provide Independent Monitoring Boards (IMBs) with a statutory framework, intending to legislate "as soon as Parliamentary time allows," as stated in the Home Office's March 2024 response. A Written Parliamentary Question in January 2025 indicated that this recommendation was "on track for closure by summer 2025." No specific legislative reform has been identified as enacted since that date. The Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
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
The Home Office stated in March 2024 that it was considering its reliance on external scrutiny organisations, noting that this recommendation was directed primarily at HM Inspectorate of Prisons (HMIP) and Independent Monitoring Boards (IMBs). A Written Parliamentary Question in January 2025 indicated that this recommendation was "on track for closure by summer 2025." No specific evidence of HMIP or IMB having implemented robust processes for enhanced evidence gathering and reporting has been identified since that date. The Brook House Inquiry Chair, Kate Eves, described the government's overall response as "inadequate" in September 2024.
HM Inspectorate of Prisons
(Primary)
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