Ketheeswaren Kunarathnam
PFD Report
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Ref: 2022-0030
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· Deadline: 22 Mar 2022
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22 Mar 2022
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the inquest it became apparent that a certain number of prisoners in HMP Wormwood Scrubs were detained for deportation reasons after the conclusion of their prison sentence. There seemed to be a marked disparity between the information and advice available to a detained prisoner, compared with a free individual or one in a deportation centre. There was a paucity of available information and the letters sent out by the Home Office were written in legal English with no offer of translation or “plain English” assistance. Individuals in the community could access the internet, Law centres, citizens advice or any other sources of assistance that were not available to detained prisoners due to the restrictive regime, putting them at a disadvantage. Communication between the prison officers and home office officials and immigration staff was ineffective and frequently not evidenced at all. Pieces of paper were lost, phones were unanswered with no answer phone facility, email addresses were unavailable due to incompatible systems and there was no audit trail of attempted communications or the reason why these were unsuccessful. Many requests made by or on behalf of the prisoner were not dealt with in a timely manner or at all.
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Dear Ms Brown, MR KETHEESWAREN KUNARATHNAM REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 report, dated 26 January 2022, following the inquest into the death of Mr Ketheeswaren Kunarathnam. I am grateful to you for sharing your findings, and for the opportunity to reflect on the processes that were in place around the time of Mr Kunarathnam’s detention in 2018. I am sorry to learn of Mr Kunarathnam’s passing and would like to express my condolences to his friends and family. I can assure you that the Home Office takes the health and welfare of people detained under immigration powers very seriously. The concerns you have identified have been carefully considered by officials. This response summarises the action taken to address these concerns where they pertain to the Home Office. I also hope it will be useful to set out some wider reforms which impact on the detention of foreign national offenders (FNOs) as well as those actions taken following the death of Mr Kunarathnam in HMP Wormwood Scrubs. Concern 1 – Disparity between information and advice available depending on where the person was detained or within the community We make every effort to ensure that an FNO’s removal by deportation coincides, as far as possible, with their release from prison on completion of sentence. Where it is not possible, careful consideration is given on a case-by-case basis as to whether immigration detention is appropriate and justified. There is a presumption in favour of liberty for all individuals and decisions to detain are made in line with published guidance. A timely risk assessment is also carried out which reviews whether that person is suitable to be transferred into Immigration Removal Centres (IRCs) while detained. This transfer decision may also be further considered at subsequent points during detention. The Home Office and HM Prison and Probation Service (HMPPS) recognised that there were some disparities between those detained under immigration powers in IRCs and prisons. That is why a targeted project was initiated in 2019 to take forward work to bring parity where possible in the treatment of, and safeguards provided to, those detained under immigration powers. HMPPS are currently considering aspects of this work and a consultation on some elements is understood to be set to commence in Spring 2022.
In your report, you specifically highlighted an inability to access the internet, Law Centres, Citizens Advice or any other sources of assistance for those detained in a prison. We recognise that not all FNOs will be legally represented and therefore throughout the deportation process we will seek to explain and signpost appropriately whether through written documents or direct engagement. The deportation notice informs the FNO why deportation is being considered and invites the person to provide any reasons why they consider it should not be pursued. A statement of reasons accompanies this decision, clearly setting out examples of possible claims, including those protection and human rights based, which could be raised alongside possible sources of supportive evidence. These notices signpost Civil Legal Advice (and Scottish and Northern Ireland equivalents); an organisation which can provide information on legal aid if a person is unable to pay for a legal representative. A published list of legal aid providers is available from the Legal Services Commission. Removal paperwork reminds the person of the same. Additionally, in November 2021, HM Prisons and Probation Service (HMPPS) issued an instruction which allows all individuals held under immigration powers in a prison, access to 30 minutes of legally aided immigration legal advice. This provides a functional equivalent to the service currently available in IRCs.
All persons detained under immigration powers, irrespective of their location, are notified that they can apply to the courts, at any time, for bail. The application forms for immigration bail for all detained individuals in prison have now been translated into the 18 most common languages to ensure individuals can be effectively signposted. Use of an interpretation service is sometimes available for deportation matters depending on the language proficiency of the FNO.
We have considered the concerns you have raised as to the effectiveness of in person engagement with immigration officials in Mr Kunarathnam’s case. The Home Office understands that in person contact with individuals subject to deportation action is hugely important. A dedicated team of immigration officers embedded in the prison estate carry out that engagement and endeavour to induct an FNO soon after they arrive at a prison. This induction seeks to explain the deportation process, obtain basic person details and any vulnerabilities or medical conditions. The induction process is periodically reviewed, and the interactions are now recorded and accessible to other Home Office officials on internal databases. FNOs can also request to speak with an immigration officer on an individual basis via a wing application that is lodged with the prison’s wing office which is then passed to the embedded Immigration Prison Teams.
Concern 2 - Communication between officials from the Home Office and HM Prison and Probation Service (HMPPS)
The Home Office is committed to a collaborative relationship with HMPPS in the management of persons subject to deportation action both during their custodial sentence and if detained in a prison following completion. Regular bilateral meetings between the Home Office and stakeholders at various levels support this closer working relationship and allow for opportunities for joint working to be effectively highlighted.
At a local level, the Home Office’s Immigration Prison Team (IPT) embedded at HMP Wormwood Scrubs now works very closely with prison colleagues, with established lines of communication and regular meetings between the two parties around vulnerable persons. Since 2018, IPT have also been working with individual prisons across the country to ensure the attendance of Home Office officials at all Assessment Care in Custody and Teamwork (ACCT) reviews so that updates on case progression can be provided and information effectively exchanged.
You concluded that an individualised assessment of Mr Kunarathnam’s needs did not take place when relaying immigration matters. I would like to assure you that officials recognise it is paramount to consider the individual circumstances of a FNO and their vulnerabilities when serving immigration notices. This routinely takes place in prisons across the country where FNOs are serving their sentences. Immigration Officers will make the relevant Offender Manager Unit and Wing Offices aware when serving immigration notices to ensure the FNO can access support if required. This will also be recorded on Home Office databases for other officials to view. A further line of assurance is provided by monthly meetings with senior immigration officers to discuss vulnerable cases and take forward actions in our hub prisons.
Communications are also more appropriately documented. Immigration officers embedded in prisons now ensure all conversations are recorded and where appropriate signed by the FNO. Digitalisation improvements have allowed for engagements with FNOs to be raised on internal databases along with any vulnerability concerns promptly after interactions, while Immigration Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. At HMP Wormwood Scrubs, immigration officers now have access to the HMPPS database where relevant information is also accessible. To further strengthen collaborative working an FNO Information Hub has been launched which will pave the way for a digital platform and sharing forum for both Home Office and HMPPS users which aims to provide signposting resources to prepare FNOs for their release or removal. We will continue to review where further technological improvements can be made to ensure the timely and secure exchange of information between itself and prison officials.
We recognise the benefit of improving a mutual understanding of relevant processes to both departments in our aim to work more cohesively. Therefore, awareness sessions have been provided at our hub prisons providing an overview of the deportation process, the service of immigration notices and the work of our immigration officers.
More broadly reforms to immigration detention have increased the scrutiny of such decisions. Once a person is detained, regular reviews are undertaken. The decision and the rationale for ongoing detention or alternatively notification for release, is also routinely shared with the person. Vulnerabilities are monitored in accordance with the Adults at Risk Policy (AAR) and reviewed at routine intervals. Case Progression Panels act as an internal assurance mechanism to ensure the appropriate progression of all persons detained under immigration powers. Since these were introduced in 2017, several improvements have been made to strengthen the review of case progression, vulnerability and public protection considerations. More recently this has also included the mandatory attendance of an independent panel member. Where barriers to removal are identified these will be considered by the panel in their discussions and recommendations.
Since 2018 there has been a significant focus on upskilling officials engaged in detention through the introduction of mandatory training which focuses on maintaining best practice and keeps vulnerability at the forefront of detention decisions. Front-line immigration officers in prisons also attend Self Harm Awareness Sessions run by HMPPS to improve their knowledge of dealing with individuals in prison who may be more susceptible to self-harm. Additionally, the immigration team who operate within HMP Wormwood Scrubs have also received Assessment Care in Custody and Teamwork training to supplement the wider vulnerability knowledge, as have other Immigration Prison Teams. Although you have found this unfortunately did not occur in Mr Kunarathnam’s case, immigration officers will frequently respond to requests from vulnerable persons, and where relevant identify a claim for asylum including taking the necessary steps to lodge the claim and progress it in good time by arranging interviews. The Assessment Care in Custody and Teamwork documents would also be updated if relevant to the individual.
This Department is committed to learning lessons to prevent future deaths of persons detained under immigration powers and will to explore any further improvements and is monitoring compliance. I hope that the information provided addresses your concerns satisfactorily.
In your report, you specifically highlighted an inability to access the internet, Law Centres, Citizens Advice or any other sources of assistance for those detained in a prison. We recognise that not all FNOs will be legally represented and therefore throughout the deportation process we will seek to explain and signpost appropriately whether through written documents or direct engagement. The deportation notice informs the FNO why deportation is being considered and invites the person to provide any reasons why they consider it should not be pursued. A statement of reasons accompanies this decision, clearly setting out examples of possible claims, including those protection and human rights based, which could be raised alongside possible sources of supportive evidence. These notices signpost Civil Legal Advice (and Scottish and Northern Ireland equivalents); an organisation which can provide information on legal aid if a person is unable to pay for a legal representative. A published list of legal aid providers is available from the Legal Services Commission. Removal paperwork reminds the person of the same. Additionally, in November 2021, HM Prisons and Probation Service (HMPPS) issued an instruction which allows all individuals held under immigration powers in a prison, access to 30 minutes of legally aided immigration legal advice. This provides a functional equivalent to the service currently available in IRCs.
All persons detained under immigration powers, irrespective of their location, are notified that they can apply to the courts, at any time, for bail. The application forms for immigration bail for all detained individuals in prison have now been translated into the 18 most common languages to ensure individuals can be effectively signposted. Use of an interpretation service is sometimes available for deportation matters depending on the language proficiency of the FNO.
We have considered the concerns you have raised as to the effectiveness of in person engagement with immigration officials in Mr Kunarathnam’s case. The Home Office understands that in person contact with individuals subject to deportation action is hugely important. A dedicated team of immigration officers embedded in the prison estate carry out that engagement and endeavour to induct an FNO soon after they arrive at a prison. This induction seeks to explain the deportation process, obtain basic person details and any vulnerabilities or medical conditions. The induction process is periodically reviewed, and the interactions are now recorded and accessible to other Home Office officials on internal databases. FNOs can also request to speak with an immigration officer on an individual basis via a wing application that is lodged with the prison’s wing office which is then passed to the embedded Immigration Prison Teams.
Concern 2 - Communication between officials from the Home Office and HM Prison and Probation Service (HMPPS)
The Home Office is committed to a collaborative relationship with HMPPS in the management of persons subject to deportation action both during their custodial sentence and if detained in a prison following completion. Regular bilateral meetings between the Home Office and stakeholders at various levels support this closer working relationship and allow for opportunities for joint working to be effectively highlighted.
At a local level, the Home Office’s Immigration Prison Team (IPT) embedded at HMP Wormwood Scrubs now works very closely with prison colleagues, with established lines of communication and regular meetings between the two parties around vulnerable persons. Since 2018, IPT have also been working with individual prisons across the country to ensure the attendance of Home Office officials at all Assessment Care in Custody and Teamwork (ACCT) reviews so that updates on case progression can be provided and information effectively exchanged.
You concluded that an individualised assessment of Mr Kunarathnam’s needs did not take place when relaying immigration matters. I would like to assure you that officials recognise it is paramount to consider the individual circumstances of a FNO and their vulnerabilities when serving immigration notices. This routinely takes place in prisons across the country where FNOs are serving their sentences. Immigration Officers will make the relevant Offender Manager Unit and Wing Offices aware when serving immigration notices to ensure the FNO can access support if required. This will also be recorded on Home Office databases for other officials to view. A further line of assurance is provided by monthly meetings with senior immigration officers to discuss vulnerable cases and take forward actions in our hub prisons.
Communications are also more appropriately documented. Immigration officers embedded in prisons now ensure all conversations are recorded and where appropriate signed by the FNO. Digitalisation improvements have allowed for engagements with FNOs to be raised on internal databases along with any vulnerability concerns promptly after interactions, while Immigration Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. At HMP Wormwood Scrubs, immigration officers now have access to the HMPPS database where relevant information is also accessible. To further strengthen collaborative working an FNO Information Hub has been launched which will pave the way for a digital platform and sharing forum for both Home Office and HMPPS users which aims to provide signposting resources to prepare FNOs for their release or removal. We will continue to review where further technological improvements can be made to ensure the timely and secure exchange of information between itself and prison officials.
We recognise the benefit of improving a mutual understanding of relevant processes to both departments in our aim to work more cohesively. Therefore, awareness sessions have been provided at our hub prisons providing an overview of the deportation process, the service of immigration notices and the work of our immigration officers.
More broadly reforms to immigration detention have increased the scrutiny of such decisions. Once a person is detained, regular reviews are undertaken. The decision and the rationale for ongoing detention or alternatively notification for release, is also routinely shared with the person. Vulnerabilities are monitored in accordance with the Adults at Risk Policy (AAR) and reviewed at routine intervals. Case Progression Panels act as an internal assurance mechanism to ensure the appropriate progression of all persons detained under immigration powers. Since these were introduced in 2017, several improvements have been made to strengthen the review of case progression, vulnerability and public protection considerations. More recently this has also included the mandatory attendance of an independent panel member. Where barriers to removal are identified these will be considered by the panel in their discussions and recommendations.
Since 2018 there has been a significant focus on upskilling officials engaged in detention through the introduction of mandatory training which focuses on maintaining best practice and keeps vulnerability at the forefront of detention decisions. Front-line immigration officers in prisons also attend Self Harm Awareness Sessions run by HMPPS to improve their knowledge of dealing with individuals in prison who may be more susceptible to self-harm. Additionally, the immigration team who operate within HMP Wormwood Scrubs have also received Assessment Care in Custody and Teamwork training to supplement the wider vulnerability knowledge, as have other Immigration Prison Teams. Although you have found this unfortunately did not occur in Mr Kunarathnam’s case, immigration officers will frequently respond to requests from vulnerable persons, and where relevant identify a claim for asylum including taking the necessary steps to lodge the claim and progress it in good time by arranging interviews. The Assessment Care in Custody and Teamwork documents would also be updated if relevant to the individual.
This Department is committed to learning lessons to prevent future deaths of persons detained under immigration powers and will to explore any further improvements and is monitoring compliance. I hope that the information provided addresses your concerns satisfactorily.
Report Sections
Investigation and Inquest
On 23rd February 2018 I commenced an investigation into the death of Ketheeswaren KUNARATHNAM . The investigation concluded at the end of the inquest on 10th December 2021. The conclusion of the inquest was Medical cause of death 1a Hanging Conclusion Suicide There were shortcomings from all organisations. Healthcare did not carry out their daily checks, prison officers did not carry out their conversations, as set in the Assessment, Care in Custody and Teamwork document. Immigration Officers did not attend to Mr Kunarathnam's requests in good time, particularly in the weeks leading up to his death. The Immigrations Officers did not take into account Mr Kunarathnam's specific needs. He did not take bad news well and reacted badly to it. This wasn't always factored in when dealing with him and his particular worries surrounding his immigration. The Assessment, Care in Custody and Teamwork document was not always carried out effectively by all staff. For example, dates and times were missed while Mr Kunarathnam was in Wormwood Scrubs Prison. If conversations took place, they were not always recorded. Comments and discussions were not explicit, ad comments had no framework and remained unstructured. A lack of training and resources played a part. All agencies worked on different operating systems and records, the lack of communication, basic training and resources made it challenging for them to work as one cohesive unit. Significant staff workload contributed to the issues around affective communication and recordkeeping
Circumstances of the Death
After being tortured in Sri Lanka, Mr Kunarathnam was given indefinite leave to remain as a refugee in the United Kingdom. He was detained on the sixth September 2017 at Her Majesty's Prison Wormwood Scrubs in West London. Mr Kunarathnam was detained for 28 days. Following this he was kept in further detention by the Home Office due to a deportation order. After completing his 28 day sentence, there were alternative pathways at every stage, and the relevant agencies did not fully explore these. Mr Kunarathnam was not managed when he was on an assessment, care in custody and teamwork document by the multiple agencies responsible for his care, There was evidence of poor record keeping, communication and untimely responses. There was a failure to follow prison procedural systems. High staff workload appeared to play a crucial factor. The prison did monitor Mr Kunarathnam early in his stay and records state this. A pattern of food refusal is evident and not considered later in his detainment. At this point, the introduction of a food refusal log should have been appropriate, given the history
- a failure on a multi agency level. The prison staff didn't appropriately review his mental health. For example, according to the mental health team, multiple prison stays, under different names meant that Mr Kunarathnam's records were not easy to find. Records were lept but often not shared with others at the correct time. The core failure is communication for several reasons: one includes patient confidentiality. It meant that non-health professionals were not party to Mr Kunarathnam's entire and current medical state. The mental health team mentioned that Mr Kunarathnam was an 'impulsive ma who reacts badly to information he finds distressing'. His considered actions, often coupled with impulsive behaviour, sent mixed messages to the parties involved - including his mentions of suicide and food refusal. Mr Kunarathnam had made a bail application. A Home Office representative recognised that information on it could form the basis for an asylum application. Nothing in writing or on record suggests that anyone from the Home Office discussed this with Mr Kunarathnam. It is not entirely clear to the Jurors if Mr Kunarathnam had all the information he needed to make an asylum application. Regarding bail, his immigration status and rights of appeal, Mr Kunarathnam was kept informed by being invited to Assessment, Care in Custody and Teamwork reviews and paperwork delivered to his cell. It is unclear whether the Home Office carried out the required reviews and as such vague whether they would assess any risk. On the twenty third of February 2018 Mr Kunarathnam was found hanging in his cell at Her Majesty's Prison Wormwood Scrubs.
- a failure on a multi agency level. The prison staff didn't appropriately review his mental health. For example, according to the mental health team, multiple prison stays, under different names meant that Mr Kunarathnam's records were not easy to find. Records were lept but often not shared with others at the correct time. The core failure is communication for several reasons: one includes patient confidentiality. It meant that non-health professionals were not party to Mr Kunarathnam's entire and current medical state. The mental health team mentioned that Mr Kunarathnam was an 'impulsive ma who reacts badly to information he finds distressing'. His considered actions, often coupled with impulsive behaviour, sent mixed messages to the parties involved - including his mentions of suicide and food refusal. Mr Kunarathnam had made a bail application. A Home Office representative recognised that information on it could form the basis for an asylum application. Nothing in writing or on record suggests that anyone from the Home Office discussed this with Mr Kunarathnam. It is not entirely clear to the Jurors if Mr Kunarathnam had all the information he needed to make an asylum application. Regarding bail, his immigration status and rights of appeal, Mr Kunarathnam was kept informed by being invited to Assessment, Care in Custody and Teamwork reviews and paperwork delivered to his cell. It is unclear whether the Home Office carried out the required reviews and as such vague whether they would assess any risk. On the twenty third of February 2018 Mr Kunarathnam was found hanging in his cell at Her Majesty's Prison Wormwood Scrubs.
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