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6AS instruction; as revealed in evidence, the term is to cover many different issues; not all medical or matters requiring immediate action andlor consideration: The electronic nature of both instructions did not allow for a two-way communication: This therefore means that G4S is wholly reliant upon a) the information provided by UKVI on the forms and b) the extent to which service users are prepared to share information voluntararily upon induction into accommodation G4S does seek to obtain as much information as possible from service users: Unfortunately, Mr Mustafa did not reveal details of his past suicide threat or recent depressive episodes_ The matter of consent forms when service users are first assessed for accommodation is a matter for UKVI. G4S has however taken the following steps in order to seek improvements to the process and level of information exchange: G4S senior management form part of a UKVI led Senior Safeguarding working group which meet every month to review and discuss individual safeguarding cases with particular reference to ones where there are in information provided by UKVI
2) UKVI Chair of the above Working Group takes responsibility for investigating single case raised to identify gaps in the information provided by UKVI and ways in which this can be improved;
3) UHS, G4S's subcontractor; who receive SCFs direct from UKVI, in which safeguarding concerns are raised, alert G4S immediately of concerns about Service Users so that such cases can be raised with the Senior Safeguarding working group. Significant improvements have been made in relation to such cases, in particular, with the information conveyed by UKVI to G4SIUHS Response_to Matter_of Concern (2) As above; G4S were not aware of Mr Mustafa'$ prior suicide threat and are not responsible for managing the Safeguarding Hub. Given that this rests with UKVI; it is not something upon which it can respond further: G4S does however have systems in place to ensure that matters of safeguarding concerns uncovered during the course of delivering its services are notified to UKVI: UKVI has its own Safeguarding Hub as well as 2 X safeguarding leads in each of the G4S contract regions issues in relation to safeguarding are immediately raised with these respective leads as well as the Safeguarding Hub by our central contact centre which collates all information and feeds back advice and information to the relevant operational teams_ We also have robust incident management process and operational teams, including UHS, compile incident reports which include all relevant information about the incident in question. All incident reports are forwarded to UKVI by our central contact centre. Should these incidents relate to safeguarding concerns then the Safeguading Hub and leads are included in the communication. Securing Your World applied being gaps The every Any

GAS G4S' abilicy to take further action on the matters raised is limited given that its contract with UKVI ends on 3st August 20/9. It will thereafter have no involvement in the provision of asylum seeker accommodation services this response meets with your satisfaction_

Dear Mrs Hunt Inquest touching upon the death of Aram Ali Mustafa We write as requested, to respond to your report dated 19 June 2019. We would like to firstly set out our condolences to Mr Mustafa's friends and family. We note the two matters of concern set out in your report and deal with these in turn below.
1. Safeguarding Concerns Unfortunately, we were not made aware of the previous threats of suicide made by Mr Mustafa prior to his removal to Italy on 29 October 2018. At that time he was not resident with us. In January 2019, we were, as you note, provided with very limited information which simply confirmed Mr Mustafa was a "safeguarding" case. As was stated in evidence at the inquest, this can cover physical or mental health, along with a plethora of different (often non-health related) issues. As you noted in your questioning of witnesses we are limited by the information provided to us by other parties and the individual resident, who is free to provide as much, or as little, information as they choose. Following Mr Mustafa's tragic death, in conjunction with others involved in the provision of services to asylum applicants, we have reviewed our procedures and the way we interact. A Multi-Agency Review took place which we attended. This led to a number of recommendations which are in the process of being actioned, including:
i. UKVI is to review the details contained on the SCF form to ensure that all relevant information is provided;

ii. G4S now flag SCF forms where a safeguarding issue is raised without adequate detail being provided with UKVI. UHS also raise these issues with G4S; and
iii. Hospital visits are directly notified to Attwood Green Medical Centre. Staff training has been conducted. It was confirmed at the inquest that the staff present on the night of Mustafa's death were first aid trained. This is continually refreshed and further courses are being looked into. The out of hours guidance provided to security staff has been updated detailing when a resident should be directed to hospital. This has been briefed to staff. UHS has always undertaken welfare checks on residents whenever a concern is raised. These continue. Following Mr Mustafa's death additional information is being recorded in our staff handover book to ensure any issues raised are recorded and appropriate measures can be taken by site management. If a concern (such as mental health issues) about a resident is noted, an incident report is drafted and sent to G4S. This includes as much information as we have available and actions we have taken. This information can then be passed on to UKVI by G4S and ensures that these concerns can be notified to any future residence, or those with responsibilities for the resident. An email is also sent to the charity Migrant Help and Attwood Health Centre to enable the resident to obtain the appropriate level of support.
2. Safeguarding Hub The threats made by Mr Mustafa on 29 October 2018 were shortly prior to his removal from the country when he was not resident with us. UHS had no knowledge of this threat. We note this was not recorded with the Safeguarding Hub. The Safeguarding Hub is operated by UKVI and as such is outside of UHS' control. We understand UKVI is reviewing this system following the tragic death of Mr Mustafa.

Dear Ms Hunt Aram Ali Mustafa (Deceased) Thank you for your Regulation 28 Report of 19 June 2016 following the Inquest into the death of Aram Ali Mustafa on 8 February 2019. During the Inquest we understand that evidence revealed matters giving rise to concerns which could lead to future deaths_ You have required that the Home Office confirms details of what action has been taken or proposed to be taken, and set out the timetable for action: Otherwise the Home Office must explain why no action is proposed. First Concern The first concern you had was that once Mr Mustafa re-entered the UK the Service Commission Form recorded that he had urgent medical needs and was a safeguarding concern. However; no detail was provided: Neither G4S or Urban Housing Services requested any further details. You advised that a system needs to be put in place to ensure organisations provide sufficient details for providers to understand the nature of safeguarding concerns and health care matters_ GDPR concerns can be addressed a consent form at the time when the person is first seen. The Home Office have advised that when Mr Mustafa re-entered the UK he was seen by Immigration Enforcement: The Service Commission Form (SCF) is completed when the applicant has asked for accommodation: The Routing Teams complete the SCF which is sent to the provider; in this case it was G4S. Lee John-Charles Head of Division Sally Lister Deputy Director, Team Leader AG & General Private Law Lexcel UKAS Legal Practice Quality Mark Law Society Acta n clitad B,5a8169 Any by AboUt _ 0 1

So first responder; Immigration Enforcement; referred the case to NAAU Intake who then referred to NAAU Routing who arrange accommodation and transport if needed. The SCF was completed at this stage. The Home Office have confirmed that the first responders are being challenged for further detail when referring case into NAAU (National Asylum Allocation Unit) in relation to any indication of vulnerabilities This information is recorded on the CID database and on the SCF 4386 referral form prior to being forwarded to the Routing Team: CID is checked more thoroughly by the Intake Team to reduce the risk of information that wasn't forthcoming from the referring officers In addition, a spreadsheet has been introduced that records all the safeguarding action and will be jointly in use by all the Teams in accordance with the order of process, i.e Intake will make the initial input as per referral and followed by RIAV (Routing Initial Accommodation Validation) and Routing updating their subsequent action this will include onward referrals to the Service Providers, and the Safeguarding Hub. Additionally, a NAAU purpose matrix will be piloted, with a point base scoring system which will guide staff in terms of vulnerabilities that require escalation to the Hub. This is awaiting to be signed off by Senior Management The Matrix which is due to be introduced will help to decide o the level of vulnerability and hence if a Safeguarding Referral is required. Referrals can come into the Safeguarding Hub from any source however they deal with service users who have an asylum claim; they are only funded for this. G4S and others would have had access to Hub provided are regarding asylum applicants_ The Hub could not have done anything if & referral was made post removal. However; if a referral had been made prior to removal and included details of suicide risk, the Hub would have accepted referral: Specific safeguarding and vulnerable concerns are included in the referral form a list of possible concerns are listed and the referring officer is asked whether have any relevance to the customer. Checks are put in place to ensure this happens. Immigration Enforcement have acknowledged that more could have been done had the Immigration Officers identified the previous vulnerability notes on CID. It is been noted that the references to suicide were not easily identified in the special conditions (noted under DS: ACDT plan) and the appropriate CID (threat of self- harm) had not been raised at the point of Mr Mustafa's TCU removal If the vulnerabilities had been noted normal practice would have been to inform the Police of the juarding concerns on their system upon their initial contact; questioning custody as to whether Mr Mustafa had been medically deemed fit in light of the medical conditions, making safeguarding referral:. The case has been discussed with the Immigration Officers involved and will form part of NCCU's regular lessons learnt exercises In terms of work underway in Immigration Enforcement; they have been rolling out 2 day mandatory vulnerability training course to all staff, which includes how to identify vulnerability concerns and appropriate steps to take. have also now have a network of Vulnerability Champions across Immigration Enforcement the being being missing the they the they flag safegl and They

who can support and advise colleagues when cases of concern arise_ Best practice and lessons learnt are also captured by the Immigration Enforcement Vulnerability Team and shared across Immigration Enforcement; to continually improve their safeguarding response We set out below the factors provided by the Home Office to take into account while sharing information with external contractors in line with GDPR: 'When deciding whether to enter into an arrangement to share personal data (either as a provider; a recipient or both) you need to identify objective that it is meant to achieve. You should consider the potential benefits and risks, either to individuals or society, of sharing the data. You should also assess the likely results of not sharing the data. You should ask yourself: What is the sharing meant to achieve? You should have a clear objective, or set of objectives. Being clear about this will allow you to work out what data you need to share and who with. It is good practice to document this: What information needs to be shared? You shouldn't share all the personal data you hold about someone if only certain data items are needed to achieve your objectives: For example, you might need to share somebody's current name and address but not other information you hold about them Who requires access to the shared personal data? You should employ 'need to know' principles, meaning that other organisations should only have access to your data if they need it and that only relevant staff within those organisations should have access to the data. This should also address any necessary restrictions 0n onward sharing of data with third parties: When should it be shared? Again, it is good practice to document this, for example setting out whether the sharing should be an on-going, routine process or whether it should only take place in response to particular events. How should it be shared? This involves addressing the security surrounding the transmission or accessing of the data and establishing common rules for its security: How can we check the sharing is achieving its objectives? You will need to judge whether it is still appropriate and confirm that the safeguards still match the risks: What risk does the data sharing pose? For example, is any individual likely to be damaged by it? Is any individual likely to object? Might it undermine individuals trust in the organisations that keep records about them? Could the objective be achieved without sharing the data or by anonymising it? It is not appropriate to use personal data to plan service provision, for example, where this could be done with information that does not amount to personal data. In summary, the Home Office state they need to provide only information that they can show is required, is relevant; is secure and is provided in the best interests of applicant: Second Concern The second concern was in relation to the events on 29 October 2018 when Mr Mustafa made a threat to kill himself which were not logged with the Safeguarding Hub as he was about to be deported. You advised that the the

there needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in the system The Safeguarding Hub comes under the umbrella of the Resettlement; Asylum Support and Integration Directorate a joint unit between the Home Office; the Department for International Development; and the Ministry of Housing, Communities and Local Government The Safeguarding Hub receive referrals where there is a service user that is vulnerable. The team assess the referral to identify the level of action or intervention required. The service user may have declared self-harm or may have attempted suicide hub will make referrals to GPs or local services, or sign post service user to services depending on vulnerability identified; these cases are followed up as necessary. When there is a high risk case a case conference is completed. This would include the service user's medical history, which includes details of the GP and any recommendations. The case conference is submitted to Grade 7 for their input and sign off These cases are followed up ensuring all recommendations are put in place: Thank you again for bringing this matter of concern to my clients attention. My client will ensure that learning from this tragic incident is shared widely across the Home Office. Please let us know if you have any queries or you wish us to clarify any of the Home Office's responses