Manoel Santos
PFD Report
Partially Responded
Ref: 2023-0361
3 of 5 responded · Over 2 years old
Sent To
Response Status
Responses
3 of 5
56-Day Deadline
28 Nov 2023
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the Inquest, the evidence revealed matters giving rise to concern. A number of these have been addressed and do not require a PFD report.
I have also considered a report by HM Chief Inspector of Prisons, “The experience of immigration detainees in prisons,” dated September 2022. Some of the key concerns in that report mirror concerns I came to independently having heard the evidence in this Inquest. Published responses to the report suggest some concerns are being addressed, albeit it is not clear if they have been resolved.
In my opinion there is a risk that future deaths will occur unless action is taken. 1. Although the specific issues below were not left to the jury as “causative matters” in this Inquest, I am concerned about the potential impact of these issues in other cases. Timing of IS91 notification.
2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence. I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage. Signposting legal advice about immigration matters
3. Mr Santos signed a form on 24 October 2020 to receive support from a charity supporting immigration detainees. Bail forms were sent to them by the prison on 29 October 2020.
4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion. Communication between agencies
6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice to FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
Delays by SSHD and Probation and failure to obtain information.
8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information. The SSHD Internal report
10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which were recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been. Opening cell doors at night
13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night. This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers.
I have also considered a report by HM Chief Inspector of Prisons, “The experience of immigration detainees in prisons,” dated September 2022. Some of the key concerns in that report mirror concerns I came to independently having heard the evidence in this Inquest. Published responses to the report suggest some concerns are being addressed, albeit it is not clear if they have been resolved.
In my opinion there is a risk that future deaths will occur unless action is taken. 1. Although the specific issues below were not left to the jury as “causative matters” in this Inquest, I am concerned about the potential impact of these issues in other cases. Timing of IS91 notification.
2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence. I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage. Signposting legal advice about immigration matters
3. Mr Santos signed a form on 24 October 2020 to receive support from a charity supporting immigration detainees. Bail forms were sent to them by the prison on 29 October 2020.
4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion. Communication between agencies
6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice to FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
Delays by SSHD and Probation and failure to obtain information.
8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information. The SSHD Internal report
10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which were recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been. Opening cell doors at night
13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night. This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers.
Responses
The Home Office has implemented new commissioning and handling processes for PSU reports and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from investigations to prevent future oversights.
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Dear Ms Goldring,
MR MANOEL MESSIAS SANTOS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 report, dated 3 October 2023, following the inquest into the death of Mr Manoel Messias Santos (Mr Santos). 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 Santos’ detention in 2020 and any improvements that can be made in light of your report. I am sorry to learn of Mr Santos’ 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 Santos in HMP Belmarsh, on 2 November 2020.
Consideration as to whether FNOs can be notified at an earlier stage of their sentence that they are not going to be released.
Following conviction, where criminality is considered to meet the deportation criteria in a case involving a non-EEA Foreign National Offender (FNO), they are served, usually shortly after their conviction, with a deportation decision (Stage 1) and notified of why their deportation is deemed conducive to the public good. Within the Stage 1 letter, the FNO will also be notified of their liability to be detained under immigration powers. The individual is given an opportunity to submit information or evidence to support their claim about why they should not be deported or be allowed to remain in the UK. Following this, a Stage 2 deportation decision is made and depending on the nature of the representations, the individual is given an appeal right against the Stage 2 decision. The general expectation is to make the Stage 2 decision at an early stage, during an individual’s custodial sentence. This enables the FNO’s deportation within the Early Removal Scheme (ERS) window (depending on the length of the custodial sentence, the ERS window could be up to 12 months before the conditional release date), although this is not always possible; for e.g., due to delays caused by applications pursued by the FNO; asylum applications, referrals to the National Referral Mechanism, or pending prosecutions etc. Where a Stage 2 decision cannot be made during the individual’s custodial sentence, or it is not possible to
deport the individual by the end of their custodial detention, the caseworker will consider whether, at the end of their custodial sentence, the individual should be detained under immigration powers to facilitate their deportation. There is a presumption in favour of liberty for all individuals and decisions to detain are made in line with the published guidance. The published policy requires written reasons to be provided to the individual through the service of form IS 91R, before they are detained under immigration powers. However, under neither statute nor detention policy is there a specified timescale for the service of an IS 91R prior to the actual start of immigration detention. A person detained from the community will usually be served an IS 91R on the day of their initial detention. For those being transferred from custodial detention to immigration detention, the form IS 91R is completed and served closer to the actual date of immigration detention as the decision (to detain) is made on the basis of up-to-date information. Conversely, if the detention decision is made too early, it is likely to require a review each time there is a change in the circumstances, thus adding a disproportionate case working burden. The 30-day aspirational target for the service of a IS 91R was identified as the optimum term after consultation with operational teams across the Home Office and the Ministry of Justice. It seeks to strike the right balance between enabling a sufficiently up-to-date detention decision to be taken and providing the individual reasonable prior notice to enable them to seek legal advice and/or apply for bail as necessary.
Consideration as to how to ensure more effective communication/ information exchange between the SSHD and the prison and Healthcare.
The Home Office is committed to a collaborative relationship with HMPPS, prisons and other stakeholders in the management of persons subject to deportation action both during their custodial sentence and if detained in a prison estate following its 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.
Prisons refer all custodial sentenced FNOs to FNORC using an electronic referral form. The ERS estimated date (ERSED) is calculated at the same time as other key dates such as the conditional release date (CRD) and is included on the referral form. As part of a weekly update FNORC is notified of any changes to the ERS or CRD dates. The prison sends the form to FNORC’s Intake and Triage team, who prepare the necessary paperwork and allocate the case to a caseworker to process the case towards deportation or removal if appropriate, ideally in time for the FNO’s ERSED. The same form is used by FNORC to confirm to the prison the individual’s immigration status and likely removability (whether the Home Office intends and is able to deport or otherwise remove the prisoner during their ERS period). The form is also used by FNORC to inform the prison of the caseworker’s contact details. Once the prison governor has made a decision as to early removal under ERS, the prison will issue either an ‘ERS authorisation form’ or an ‘ERS refusal form’ to the individual and copy it to FNORC. If FNORC confirm they intend to pursue deportation an ERS is authorised by the prison governor. FNORC can then proceed towards deportation and ideally set removal directions for the ERSED or as soon as possible thereafter. Shortly after the initial referral, FNORC’s Intake and Triage team make a request, using the Request for Risk Information (RRI) form, for a copy of the OASys report or an updated risk assessment and an assessment of the suitability of the proposed bail address. The form is also used to obtain the contact details of the relevant Offender Manager (OM). FNORC caseworkers routinely use this form to seek ongoing updates from the OM, in relation to risk assessments and the suitability of release addresses. The FNO Coordination Hub, set up in early 2022, with embedded HMPPS staff, assist FNORC caseworkers with all queries relating to HMPPS. Furthermore, a bi-lateral working group, comprising of senior operational representatives from both HMPPS and FNORC,
meet every month to collaborate on operational issues and feed into the HMPPS/FNORC task force. 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 the individual 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 (IPTs). Due to third party confidentiality implications, healthcare teams at a prison or an IRC require the FNO’s consent before their medical records are disclosed to the Home Office. Therefore, in order to make informed detention decisions, caseworkers seek the individual’s consent at the earliest possible stage of the process. Once consent is given, the caseworker will directly contact the healthcare team within a prison or an IRC to obtain updated medical information relating to the individual. At a local level, the Home Office’s IPTs work very closely with prison colleagues, with established lines of communication and regular meetings between the two parties. IPT officers recognise it is paramount to consider the individual circumstances of an FNO and their vulnerabilities when serving immigration notices. This routinely takes place in prisons across the country where FNOs are serving their sentences. IPT Officers will make the relevant Offender Manager Unit and wing offices aware when serving immigration notices to ensure the FNO can access support as necessary. 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 appropriately documented. IPT officers 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 IPT Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. 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.
Consideration to be given as to why the Internal report dated February 2021 was not disseminated/placed on the Home Office file and to ensure this does not occur again
The Home Office is fully committed to ensuring that all immigration cases, including those relating to FNOs, are handled with care and in accordance with the published policies. Teams are expected to work collaboratively, both internally and with partner organisations in order to share best practice, to use continuous improvement to enhance existing capabilities and to develop and test new approaches. Feedback loops are put in place to ensure lessons are learnt promptly and operational delivery maximised.
The Professional Standards Unit (PSU) report in this case was commissioned on 6 November 2020, by the Deputy Director responsible for the team that had the conduct of Mr Santos’ case. On completion, the report was sent to the Commissioning manager. Whilst the report was contemporaneously shared with the senior managers, and an action plan drawn up to address the recommendations, in the absence of a central repository for
such reports, there was no mechanism in place to track the report or the action plan. The documents were neither placed on the Home Office file nor recorded on our central databases. Consequently, once the Commissioning manager left FNORC, the corporate knowledge about the PSU report and the action plan was lost with their departure.
We recognise and regret that this was a significant oversight and have taken immediate steps to address this issue. Following consultation with the PSU we have implemented new commissioning and handling processes to ensure that work commissioned by us from the PSU receives appropriate Director’s attention. Within FNORC a new team, the Strategic Improvement Operations team, has been set up to log, review and track recommendations from all internal and external investigations/ audits on our central records. The team is responsible for maintaining a central record of all the recommendations, assigning ownership, monitoring progress and coordinating actions with the central Immigration Enforcement Assurance and Risk team to ensure all FNORC risks are managed through a consistent assurance process and recommendations are implemented in a timely manner. We are confident that the changes that have been implemented within PSU and FNORC, will significantly improve the handling of PSU reports and eliminate the risk of similar oversights being repeated.
This Department is committed to learning lessons to prevent future deaths of persons detained under immigration powers and once again I am grateful to you for your report and for sharing your findings.
Yours sincerely,
MR MANOEL MESSIAS SANTOS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 report, dated 3 October 2023, following the inquest into the death of Mr Manoel Messias Santos (Mr Santos). 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 Santos’ detention in 2020 and any improvements that can be made in light of your report. I am sorry to learn of Mr Santos’ 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 Santos in HMP Belmarsh, on 2 November 2020.
Consideration as to whether FNOs can be notified at an earlier stage of their sentence that they are not going to be released.
Following conviction, where criminality is considered to meet the deportation criteria in a case involving a non-EEA Foreign National Offender (FNO), they are served, usually shortly after their conviction, with a deportation decision (Stage 1) and notified of why their deportation is deemed conducive to the public good. Within the Stage 1 letter, the FNO will also be notified of their liability to be detained under immigration powers. The individual is given an opportunity to submit information or evidence to support their claim about why they should not be deported or be allowed to remain in the UK. Following this, a Stage 2 deportation decision is made and depending on the nature of the representations, the individual is given an appeal right against the Stage 2 decision. The general expectation is to make the Stage 2 decision at an early stage, during an individual’s custodial sentence. This enables the FNO’s deportation within the Early Removal Scheme (ERS) window (depending on the length of the custodial sentence, the ERS window could be up to 12 months before the conditional release date), although this is not always possible; for e.g., due to delays caused by applications pursued by the FNO; asylum applications, referrals to the National Referral Mechanism, or pending prosecutions etc. Where a Stage 2 decision cannot be made during the individual’s custodial sentence, or it is not possible to
deport the individual by the end of their custodial detention, the caseworker will consider whether, at the end of their custodial sentence, the individual should be detained under immigration powers to facilitate their deportation. There is a presumption in favour of liberty for all individuals and decisions to detain are made in line with the published guidance. The published policy requires written reasons to be provided to the individual through the service of form IS 91R, before they are detained under immigration powers. However, under neither statute nor detention policy is there a specified timescale for the service of an IS 91R prior to the actual start of immigration detention. A person detained from the community will usually be served an IS 91R on the day of their initial detention. For those being transferred from custodial detention to immigration detention, the form IS 91R is completed and served closer to the actual date of immigration detention as the decision (to detain) is made on the basis of up-to-date information. Conversely, if the detention decision is made too early, it is likely to require a review each time there is a change in the circumstances, thus adding a disproportionate case working burden. The 30-day aspirational target for the service of a IS 91R was identified as the optimum term after consultation with operational teams across the Home Office and the Ministry of Justice. It seeks to strike the right balance between enabling a sufficiently up-to-date detention decision to be taken and providing the individual reasonable prior notice to enable them to seek legal advice and/or apply for bail as necessary.
Consideration as to how to ensure more effective communication/ information exchange between the SSHD and the prison and Healthcare.
The Home Office is committed to a collaborative relationship with HMPPS, prisons and other stakeholders in the management of persons subject to deportation action both during their custodial sentence and if detained in a prison estate following its 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.
Prisons refer all custodial sentenced FNOs to FNORC using an electronic referral form. The ERS estimated date (ERSED) is calculated at the same time as other key dates such as the conditional release date (CRD) and is included on the referral form. As part of a weekly update FNORC is notified of any changes to the ERS or CRD dates. The prison sends the form to FNORC’s Intake and Triage team, who prepare the necessary paperwork and allocate the case to a caseworker to process the case towards deportation or removal if appropriate, ideally in time for the FNO’s ERSED. The same form is used by FNORC to confirm to the prison the individual’s immigration status and likely removability (whether the Home Office intends and is able to deport or otherwise remove the prisoner during their ERS period). The form is also used by FNORC to inform the prison of the caseworker’s contact details. Once the prison governor has made a decision as to early removal under ERS, the prison will issue either an ‘ERS authorisation form’ or an ‘ERS refusal form’ to the individual and copy it to FNORC. If FNORC confirm they intend to pursue deportation an ERS is authorised by the prison governor. FNORC can then proceed towards deportation and ideally set removal directions for the ERSED or as soon as possible thereafter. Shortly after the initial referral, FNORC’s Intake and Triage team make a request, using the Request for Risk Information (RRI) form, for a copy of the OASys report or an updated risk assessment and an assessment of the suitability of the proposed bail address. The form is also used to obtain the contact details of the relevant Offender Manager (OM). FNORC caseworkers routinely use this form to seek ongoing updates from the OM, in relation to risk assessments and the suitability of release addresses. The FNO Coordination Hub, set up in early 2022, with embedded HMPPS staff, assist FNORC caseworkers with all queries relating to HMPPS. Furthermore, a bi-lateral working group, comprising of senior operational representatives from both HMPPS and FNORC,
meet every month to collaborate on operational issues and feed into the HMPPS/FNORC task force. 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 the individual 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 (IPTs). Due to third party confidentiality implications, healthcare teams at a prison or an IRC require the FNO’s consent before their medical records are disclosed to the Home Office. Therefore, in order to make informed detention decisions, caseworkers seek the individual’s consent at the earliest possible stage of the process. Once consent is given, the caseworker will directly contact the healthcare team within a prison or an IRC to obtain updated medical information relating to the individual. At a local level, the Home Office’s IPTs work very closely with prison colleagues, with established lines of communication and regular meetings between the two parties. IPT officers recognise it is paramount to consider the individual circumstances of an FNO and their vulnerabilities when serving immigration notices. This routinely takes place in prisons across the country where FNOs are serving their sentences. IPT Officers will make the relevant Offender Manager Unit and wing offices aware when serving immigration notices to ensure the FNO can access support as necessary. 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 appropriately documented. IPT officers 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 IPT Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. 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.
Consideration to be given as to why the Internal report dated February 2021 was not disseminated/placed on the Home Office file and to ensure this does not occur again
The Home Office is fully committed to ensuring that all immigration cases, including those relating to FNOs, are handled with care and in accordance with the published policies. Teams are expected to work collaboratively, both internally and with partner organisations in order to share best practice, to use continuous improvement to enhance existing capabilities and to develop and test new approaches. Feedback loops are put in place to ensure lessons are learnt promptly and operational delivery maximised.
The Professional Standards Unit (PSU) report in this case was commissioned on 6 November 2020, by the Deputy Director responsible for the team that had the conduct of Mr Santos’ case. On completion, the report was sent to the Commissioning manager. Whilst the report was contemporaneously shared with the senior managers, and an action plan drawn up to address the recommendations, in the absence of a central repository for
such reports, there was no mechanism in place to track the report or the action plan. The documents were neither placed on the Home Office file nor recorded on our central databases. Consequently, once the Commissioning manager left FNORC, the corporate knowledge about the PSU report and the action plan was lost with their departure.
We recognise and regret that this was a significant oversight and have taken immediate steps to address this issue. Following consultation with the PSU we have implemented new commissioning and handling processes to ensure that work commissioned by us from the PSU receives appropriate Director’s attention. Within FNORC a new team, the Strategic Improvement Operations team, has been set up to log, review and track recommendations from all internal and external investigations/ audits on our central records. The team is responsible for maintaining a central record of all the recommendations, assigning ownership, monitoring progress and coordinating actions with the central Immigration Enforcement Assurance and Risk team to ensure all FNORC risks are managed through a consistent assurance process and recommendations are implemented in a timely manner. We are confident that the changes that have been implemented within PSU and FNORC, will significantly improve the handling of PSU reports and eliminate the risk of similar oversights being repeated.
This Department is committed to learning lessons to prevent future deaths of persons detained under immigration powers and once again I am grateful to you for your report and for sharing your findings.
Yours sincerely,
Practice Plus Group confirmed that communication processes between prison and healthcare are well-established since they took over the contract, including weekly/fortnightly meetings with Governors and attendance at various prison forums. They also committed to sharing lessons learned across their services.
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Dear Madam
The Inquest touching upon the death of Mr Manoel Santos
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 3rd October 2023 and following the inquest touching upon the death of Mr Manoel Santos, who sadly passed away on 2nd November 2020 whilst residing at HMP Belmarsh.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Santos’ family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group (PPG). As you are aware, PPG were not the healthcare provider at the time of Mr Santos’ death but are the current healthcare provider at HMP Belmarsh as of 1 June 2023.
Matter of Concern
There are a number of concerns raised in your report which relate to the timing of the IS91 notification, the signposting for legal advice about immigration matters, delays by SSHD and probation, the disclosure of SSHD internal reports and the opening of cell doors at night. As these matters do not relate to healthcare and PPG we do not propose to respond. Another area of concern however is the communication between agencies to which you wrote the below concern.
Communication between agencies
1. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
2. I appreciate that any legal advice to FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration.
There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
We cannot respond directly to the above as this relates to other agencies but we note your further comment in relation to actions to be taken:
• Consideration as to how to ensure more effective communication/information exchange between the SSHD and the prison and Healthcare. (HMP Belmarsh, HMPPS, MOJ, SSHD, Practice Plus)
Please find our response to this below.
Response
As noted within the statement of , Head of Healthcare, Healthcare attends the Safety Intervention Meeting (SlM), which takes place on a weekly basis. This is something that has been instigated since PPG took over the healthcare contract in June 2023.
As part of SlM, prisoners who are on immigration hold are highlighted and any concerns regarding those prisoners are discussed. These prisoners are then discussed in the mental health MDT (Multi-Disciplinary Team) referrals meeting. This meeting used to take place once a week but has since been increased to twice a week since PPG took over the contract. During this meeting the team will discuss the patient and their needs and then make a decision on whether support is required and what support can be offered. We now send the outcomes of our referrals meetings to Custodial Managers and Senior Officers so they are aware of what services are going to be engaging with the patients.
Should any patient require support, there are applications on the house blocks that prisoners can access to self-refer to the mental health team or speak to a staff member and ask to be referred to the team. There is a mental health mailbox officers can also use to refer patients into. This means that there are a variety of ways in which patients can access support and that this is connected into any discussions patients have with officers as well as healthcare staff.
We heard during the Inquest that medical information is sometimes required by other agencies, specifically the Home Office in this case. Requests for medical information are reviewed on a case by case basis in order to ensure that client confidentiality and data protection laws are adhered to. Requests goes to the central admin mailbox and are usually completed by a particular staff member to ensure consistency. If that staff member is off then the requests are re-allocated. Requests are generally completed within the week and requests from the Home Office are normally prioritised.
In addition to Mr Santos’ immigration status, bullying was also a key theme that was investigated during the course of the Inquest. When a prisoner discloses allegations of bullying to a member of healthcare staff, the Custodial Managers should be notified on the houseblock, a Datix should be completed, the Safeguarding Lead should be notified and a referral to the Safer Custody Team should be completed. Since October 2023 a form has been implemented which is completed and sent to the Safer Custody Team rather than it simply being an email. This ensures that all relevant information is passed on. The patient in question would then be placed on our Safeguarding Assurance Framework Log which ensures that staff are aware of who was referred and when. Patients will also be referred to our Multi-professional Complex Care Clinic to be discussed as an IMDT. These meetings can include GPs, Psychiatrists, Psychologists, substance misuse professionals, senior clinical leads, and social care teams which are currently provided by Greenwich Council. Patients will be discussed in the Mental Health referrals
meeting and the team could put in welfare checks or he may be offered low level intervention with the psychological services.
Mr Santos was also subject to ACCT (Assessment, Care in Custody and Teamwork) procedures during his time at HMP Belmarsh. This is another area of collaborative working, particularly between the prison and Healthcare. ln the SIM meeting prisoners who are on ACCTs are discussed and any concerns raised regarding their mental health will be brought and discussed in the mental health referrals meeting. Each day a member of healthcare staff working in the houseblock treatment hatch for the day will attend the morning briefings held where they are informed of all patients located on the wing that are currently subject to ACCT protocols and any ACCT that requires a review that day. Attendance had previously been ad hoc but has since been made a routine practice to ensure consistency.
The total number of ACCTs on each houseblock and the number of reviews due/attended are reported to the clinical Lead at the daily Healthcare handover. Hotel 99, nurse in charge, should be informed if the staff at the medication hatch are not able to attend the review. lf an ACCT was closed without healthcare presence, then the officers should inform a member of the team. We have a well-established process and robust communication between the prison and healthcare.
As a healthcare provider working in prisons we are aware of the need to ensure close, efficient and collaborative working with other agencies, particularly with HMPPS as healthcare staff and officers interact and work together daily. In addition to the specific points addressed above relating to issues at this inquest, the Head of Healthcare and the Deputy Head of Healthcare at Belmarsh meet with the Healthcare Governors on a weekly basis. The Head of Healthcare also meets with the number 1 Governor on a fortnightly basis. This is something which has been implemented since PPG took over the contract.
These meetings provide an opportunity for any issues, either general or prisoner specific, to be raised and action points discussed. Healthcare attend the daily morning meetings, drug strategy meetings and SIM meetings. Local Deliver Board meetings are also attended which are specifically to discuss the delivery of services including healthcare at Belmarsh. The Head of Healthcare also attends the Senior Management Team meetings. All of these provide various forums and opportunities for close working and communication between agencies.
I hope that the above information provides you with reassurance that work between agencies is more efficient and collaborative since November 2020.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Belmarsh. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.
The Inquest touching upon the death of Mr Manoel Santos
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 3rd October 2023 and following the inquest touching upon the death of Mr Manoel Santos, who sadly passed away on 2nd November 2020 whilst residing at HMP Belmarsh.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Santos’ family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group (PPG). As you are aware, PPG were not the healthcare provider at the time of Mr Santos’ death but are the current healthcare provider at HMP Belmarsh as of 1 June 2023.
Matter of Concern
There are a number of concerns raised in your report which relate to the timing of the IS91 notification, the signposting for legal advice about immigration matters, delays by SSHD and probation, the disclosure of SSHD internal reports and the opening of cell doors at night. As these matters do not relate to healthcare and PPG we do not propose to respond. Another area of concern however is the communication between agencies to which you wrote the below concern.
Communication between agencies
1. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
2. I appreciate that any legal advice to FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration.
There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
We cannot respond directly to the above as this relates to other agencies but we note your further comment in relation to actions to be taken:
• Consideration as to how to ensure more effective communication/information exchange between the SSHD and the prison and Healthcare. (HMP Belmarsh, HMPPS, MOJ, SSHD, Practice Plus)
Please find our response to this below.
Response
As noted within the statement of , Head of Healthcare, Healthcare attends the Safety Intervention Meeting (SlM), which takes place on a weekly basis. This is something that has been instigated since PPG took over the healthcare contract in June 2023.
As part of SlM, prisoners who are on immigration hold are highlighted and any concerns regarding those prisoners are discussed. These prisoners are then discussed in the mental health MDT (Multi-Disciplinary Team) referrals meeting. This meeting used to take place once a week but has since been increased to twice a week since PPG took over the contract. During this meeting the team will discuss the patient and their needs and then make a decision on whether support is required and what support can be offered. We now send the outcomes of our referrals meetings to Custodial Managers and Senior Officers so they are aware of what services are going to be engaging with the patients.
Should any patient require support, there are applications on the house blocks that prisoners can access to self-refer to the mental health team or speak to a staff member and ask to be referred to the team. There is a mental health mailbox officers can also use to refer patients into. This means that there are a variety of ways in which patients can access support and that this is connected into any discussions patients have with officers as well as healthcare staff.
We heard during the Inquest that medical information is sometimes required by other agencies, specifically the Home Office in this case. Requests for medical information are reviewed on a case by case basis in order to ensure that client confidentiality and data protection laws are adhered to. Requests goes to the central admin mailbox and are usually completed by a particular staff member to ensure consistency. If that staff member is off then the requests are re-allocated. Requests are generally completed within the week and requests from the Home Office are normally prioritised.
In addition to Mr Santos’ immigration status, bullying was also a key theme that was investigated during the course of the Inquest. When a prisoner discloses allegations of bullying to a member of healthcare staff, the Custodial Managers should be notified on the houseblock, a Datix should be completed, the Safeguarding Lead should be notified and a referral to the Safer Custody Team should be completed. Since October 2023 a form has been implemented which is completed and sent to the Safer Custody Team rather than it simply being an email. This ensures that all relevant information is passed on. The patient in question would then be placed on our Safeguarding Assurance Framework Log which ensures that staff are aware of who was referred and when. Patients will also be referred to our Multi-professional Complex Care Clinic to be discussed as an IMDT. These meetings can include GPs, Psychiatrists, Psychologists, substance misuse professionals, senior clinical leads, and social care teams which are currently provided by Greenwich Council. Patients will be discussed in the Mental Health referrals
meeting and the team could put in welfare checks or he may be offered low level intervention with the psychological services.
Mr Santos was also subject to ACCT (Assessment, Care in Custody and Teamwork) procedures during his time at HMP Belmarsh. This is another area of collaborative working, particularly between the prison and Healthcare. ln the SIM meeting prisoners who are on ACCTs are discussed and any concerns raised regarding their mental health will be brought and discussed in the mental health referrals meeting. Each day a member of healthcare staff working in the houseblock treatment hatch for the day will attend the morning briefings held where they are informed of all patients located on the wing that are currently subject to ACCT protocols and any ACCT that requires a review that day. Attendance had previously been ad hoc but has since been made a routine practice to ensure consistency.
The total number of ACCTs on each houseblock and the number of reviews due/attended are reported to the clinical Lead at the daily Healthcare handover. Hotel 99, nurse in charge, should be informed if the staff at the medication hatch are not able to attend the review. lf an ACCT was closed without healthcare presence, then the officers should inform a member of the team. We have a well-established process and robust communication between the prison and healthcare.
As a healthcare provider working in prisons we are aware of the need to ensure close, efficient and collaborative working with other agencies, particularly with HMPPS as healthcare staff and officers interact and work together daily. In addition to the specific points addressed above relating to issues at this inquest, the Head of Healthcare and the Deputy Head of Healthcare at Belmarsh meet with the Healthcare Governors on a weekly basis. The Head of Healthcare also meets with the number 1 Governor on a fortnightly basis. This is something which has been implemented since PPG took over the contract.
These meetings provide an opportunity for any issues, either general or prisoner specific, to be raised and action points discussed. Healthcare attend the daily morning meetings, drug strategy meetings and SIM meetings. Local Deliver Board meetings are also attended which are specifically to discuss the delivery of services including healthcare at Belmarsh. The Head of Healthcare also attends the Senior Management Team meetings. All of these provide various forums and opportunities for close working and communication between agencies.
I hope that the above information provides you with reassurance that work between agencies is more efficient and collaborative since November 2020.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Belmarsh. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.
HMPPS has implemented guidance for legal advice access and specific measures at HMP Belmarsh, seconded staff to the Home Office to improve FNO case progression and inter-agency communication, and established a new FNO coordination hub and learning team. They have also re-issued night state policy procedures and conducted staff briefings.
AI summary
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Dear Ms Goldring
Thank you for your Regulation 28 report of 3 October 2023, addressed to the Governor of HMP Belmarsh, the Lord Chancellor and Secretary of State for Justice, and the Director General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding on behalf of HMPPS as Director General of Operations.
I understand that Mr Santos’s family were not involved in the inquest, however I would still like to express my condolences, every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised some concerns regarding the management and support of Foreign National prisoners, specifically the signposting and facilitating of access to legal advice and communication between the Home Office, HMPPS and Healthcare. I understand that the Home Office and Practice Plus Group (the healthcare provider at HMP Belmarsh) will be providing a separate response. Further to this, you have raised concern with Operational Support Grades’ (OSG) understanding of the night state policy at HMP Belmarsh.
In October 2021 guidance was provided to all establishments setting out the requirement that immigration detainees be informed about and provided with access to 30 minutes of legally aided legal advice. The operational implementation and support group have ensured that all prisons holding immigration detainees have implemented these instructions. As set out in the report, HMP Belmarsh published this information in the form of a poster on all houseblocks including the first night centre. This information also now forms part of the induction to custody process that all prisoners receive when they first come into custody.
To implement a change programme that supports Foreign National Offenders (FNO) nationally, a specific coordination hub has been developed by the Probation Service. Seconded probation practitioners have been allocated to the Home Office to support the work in increasing efficiencies in the interface. Further to the probation specific strand on the joint HMPPS/FNO removal centre taskforce, the seconded members of staff support front line practice and respond to any escalations or obstacles that are brought to their attention.
The Home Office uses a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. We have also introduced an escalation process that highlights responses that have not been received within 20 days.
Separately, a new learning team has also been created and resourced by HMPPS to enable learning from probation-involved inquests to be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.
We remain committed to ensuring that staff and prisoner safety is a key priority across the prison estate. The prison have re-issued a notice to staff clearly stating the procedures to follow in the event that a cell door needs to be unlocked during the night state. Both officers and OSGs have been reminded that, subject to a dynamic risk assessment being completed, the preservation of life takes precedence over any normal circumstance. This has been highlighted further during full staff briefings.
I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Santos’s death.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address.
Thank you for your Regulation 28 report of 3 October 2023, addressed to the Governor of HMP Belmarsh, the Lord Chancellor and Secretary of State for Justice, and the Director General Chief Executive of His Majesty’s Prison and Probation Service (HMPPS). I am responding on behalf of HMPPS as Director General of Operations.
I understand that Mr Santos’s family were not involved in the inquest, however I would still like to express my condolences, every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised some concerns regarding the management and support of Foreign National prisoners, specifically the signposting and facilitating of access to legal advice and communication between the Home Office, HMPPS and Healthcare. I understand that the Home Office and Practice Plus Group (the healthcare provider at HMP Belmarsh) will be providing a separate response. Further to this, you have raised concern with Operational Support Grades’ (OSG) understanding of the night state policy at HMP Belmarsh.
In October 2021 guidance was provided to all establishments setting out the requirement that immigration detainees be informed about and provided with access to 30 minutes of legally aided legal advice. The operational implementation and support group have ensured that all prisons holding immigration detainees have implemented these instructions. As set out in the report, HMP Belmarsh published this information in the form of a poster on all houseblocks including the first night centre. This information also now forms part of the induction to custody process that all prisoners receive when they first come into custody.
To implement a change programme that supports Foreign National Offenders (FNO) nationally, a specific coordination hub has been developed by the Probation Service. Seconded probation practitioners have been allocated to the Home Office to support the work in increasing efficiencies in the interface. Further to the probation specific strand on the joint HMPPS/FNO removal centre taskforce, the seconded members of staff support front line practice and respond to any escalations or obstacles that are brought to their attention.
The Home Office uses a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. We have also introduced an escalation process that highlights responses that have not been received within 20 days.
Separately, a new learning team has also been created and resourced by HMPPS to enable learning from probation-involved inquests to be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.
We remain committed to ensuring that staff and prisoner safety is a key priority across the prison estate. The prison have re-issued a notice to staff clearly stating the procedures to follow in the event that a cell door needs to be unlocked during the night state. Both officers and OSGs have been reminded that, subject to a dynamic risk assessment being completed, the preservation of life takes precedence over any normal circumstance. This has been highlighted further during full staff briefings.
I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken following Mr Santos’s death.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address.
Action Should Be Taken
Action should be taken by The Secretary of State for the Home Department, HMP Belmarsh, His Majesty’s Prison and Probation Service, the Ministry of Justice and Practice Plus Group:
1. Consideration as to whether FNOs can be notified at an earlier stage of their sentence that they are not going to be released. (SSHD)
2. Consideration as to how to ensure there is effective signposting and facilitating of access to legal advice for FNOs. (HMP Belmarsh, HMPPS, MOJ)
3. Consideration as to how to ensure more effective communication/information exchange between the SSHD and the prison and Healthcare. (HMP Belmarsh, HMPPS, MOJ, SSHD, Practice Plus)
4. Consideration to be given as to why the Internal report dated February 2021 was not disseminated/placed on the Home Office file and to ensure this does not occur again. (SSHD)
5. Consideration as to how to ensure OSGs are aware that the policy on opening cell doors at night applies to them as well as prison officers. (HMP Belmarsh, HMPPS, MOJ)
1. Consideration as to whether FNOs can be notified at an earlier stage of their sentence that they are not going to be released. (SSHD)
2. Consideration as to how to ensure there is effective signposting and facilitating of access to legal advice for FNOs. (HMP Belmarsh, HMPPS, MOJ)
3. Consideration as to how to ensure more effective communication/information exchange between the SSHD and the prison and Healthcare. (HMP Belmarsh, HMPPS, MOJ, SSHD, Practice Plus)
4. Consideration to be given as to why the Internal report dated February 2021 was not disseminated/placed on the Home Office file and to ensure this does not occur again. (SSHD)
5. Consideration as to how to ensure OSGs are aware that the policy on opening cell doors at night applies to them as well as prison officers. (HMP Belmarsh, HMPPS, MOJ)
Report Sections
Investigation and Inquest
1. The death of Manoel Messias Santos (“Mr Santos”) was reported to the coroner by HMP Belmarsh on the date of his death, 2 November 2020. .
2. A forensic post-mortem was conducted on 5 November 2020. The medical cause of death of MS was 1a: Hanging
3. On 24 February 2021 an Inquest was opened into the death of Mr Santos and an Article 2 Inquest was heard between 11 September 2023 and 25 September 2023 with a jury. The jury concluded with a narrative conclusion incorporating a conclusion of suicide.
4. I considered Prevention of Future Death (“PFD”) evidence (written and oral) on 27 September 2023.
2. A forensic post-mortem was conducted on 5 November 2020. The medical cause of death of MS was 1a: Hanging
3. On 24 February 2021 an Inquest was opened into the death of Mr Santos and an Article 2 Inquest was heard between 11 September 2023 and 25 September 2023 with a jury. The jury concluded with a narrative conclusion incorporating a conclusion of suicide.
4. I considered Prevention of Future Death (“PFD”) evidence (written and oral) on 27 September 2023.
Circumstances of the Death
1. Mr Santos was a Brazilian national who lived in the United Kingdom since 1997. He applied for indefinite leave to remain in 2004 but this was rejected in the same year.
2. He had a history of severe mental health issues.
3. Mr Santos was remanded to HMP Highdown on 29 October 2019, being transferred to HMP Belmarsh on 26 November 2019. On 6 May 2020, Mr Santos was sentenced to two years’ imprisonment and was due to be released on 27 October 2020.
4. On 5 October 2020, the Immigration Service served an IS91 notice of a decision to detain on Mr Santos. This meant he would not be released from prison at the end of his sentence whilst his deportation was considered. A Stage 1 letter had been served on 28 December 2018 but a Stage 2 letter had not been served. There was also an outstanding appeal in the First-tier immigration Tribunal.
5. Mr Santos wrote a letter on a bail form outlining his concerns about returning to Brazil, referring to his sexuality and his health. This was sent by the prison to a charity assisting immigration detainees on 29 October 2020.
6. In the early hours of 2 November 2020, the night officer found Mr Santos hanging in his cell during a routine check. Staff tried to resuscitate him. Ambulance staff arrived. Mr Santos was declared dead at 3.30am.
In summary, the jury found as follows:
• That Mr Santos’ understanding of his immigration position at the conclusion of his custodial sentence made a material contribution to his death.
• There was a failure to notify Mr Santos of the incoming IS91 form and its significance.
• The central issue was communication between Mr Santos and the various agencies involved with him. By 16 October 2020 Mr Santos understood he would be detained at the end of his sentence but was confident his bail application would lead to resolution. However in the days prior to his death he told a fellow prisoner he believed he was to be placed in immigration detention and deported within days.
• Confusion amongst the agencies involved in communicating with Mr Santos is likely to have played a vital role in his change of understanding but it was difficult to pinpoint the role that information passed to Mr Santos played in changing his understanding of his position. There were no adequate notes of a meeting on 22 October 2020 with Mr Santos and his prison and community offender managers. However it was clear that his view of his circumstances changed and he decided to end his life and deliberately did not clearly communicate his intent to those around him.
2. He had a history of severe mental health issues.
3. Mr Santos was remanded to HMP Highdown on 29 October 2019, being transferred to HMP Belmarsh on 26 November 2019. On 6 May 2020, Mr Santos was sentenced to two years’ imprisonment and was due to be released on 27 October 2020.
4. On 5 October 2020, the Immigration Service served an IS91 notice of a decision to detain on Mr Santos. This meant he would not be released from prison at the end of his sentence whilst his deportation was considered. A Stage 1 letter had been served on 28 December 2018 but a Stage 2 letter had not been served. There was also an outstanding appeal in the First-tier immigration Tribunal.
5. Mr Santos wrote a letter on a bail form outlining his concerns about returning to Brazil, referring to his sexuality and his health. This was sent by the prison to a charity assisting immigration detainees on 29 October 2020.
6. In the early hours of 2 November 2020, the night officer found Mr Santos hanging in his cell during a routine check. Staff tried to resuscitate him. Ambulance staff arrived. Mr Santos was declared dead at 3.30am.
In summary, the jury found as follows:
• That Mr Santos’ understanding of his immigration position at the conclusion of his custodial sentence made a material contribution to his death.
• There was a failure to notify Mr Santos of the incoming IS91 form and its significance.
• The central issue was communication between Mr Santos and the various agencies involved with him. By 16 October 2020 Mr Santos understood he would be detained at the end of his sentence but was confident his bail application would lead to resolution. However in the days prior to his death he told a fellow prisoner he believed he was to be placed in immigration detention and deported within days.
• Confusion amongst the agencies involved in communicating with Mr Santos is likely to have played a vital role in his change of understanding but it was difficult to pinpoint the role that information passed to Mr Santos played in changing his understanding of his position. There were no adequate notes of a meeting on 22 October 2020 with Mr Santos and his prison and community offender managers. However it was clear that his view of his circumstances changed and he decided to end his life and deliberately did not clearly communicate his intent to those around him.
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