Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Frank Steve Rios Ospina who died on 26 March 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 25 October 2024 concerning the death of Frank Steve Rios Ospina on 26 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Frank’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Frank’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report and I apologise for any anguish this delay may have caused Frank’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been a difficult time for them.

NHS England is the responsible organisation for the commissioning of healthcare in Immigration Removal Centres, which is devolved to regional teams. Commissioning healthcare is undertaken on the principle of equivalence, which has been defined by the Royal College of General Practitioners (RCGP), and broadly states that the aim is to ensure people detained in England are offered provision of and access to appropriate services and treatment, considered to be at least consistent in range and quality, with that available in the wider community.

I have considered the concerns raised in your Report regarding the use of Detention Services Order 09/2016, Rule 35. Please see my response below, which my colleagues from NHS England’s Health & Justice Specialised Commissioning Team have input into.

NHS England accepts that there is learning with regards to the appropriate use and adherence to the Home Office Adults at Risk policy and Rule 35 assessment process, which require the balanced consideration of vulnerability to ensure the appropriateness of decisions around suitability of detention. In this case these National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

17 January 2025

safeguarding processes fell short, resulting in key information about Frank’s attempts to take his life and current vulnerabilities being overlooked.

NHS England is working with the Home Office policy team to amend the Adults at Risk policy and Rule 35 assessment process. The aim of this work is to move the assessments towards a multidisciplinary approach, ensuring that completion of the assessment can be undertaken by a registered healthcare professional at the Immigration Removal Centre (IRC). Introducing this approach will ensure the management of safeguarding and vulnerability are not solely the responsibility of general practitioners. NHS England and the Home Office will, prior to full implementation during 2025, jointly develop a stakeholder engagement session to share the revised requirements with IRC providers and operators.

The NHS England Health and Justice Clinical Reference Group developed Detention Centre Rule 35 and Short-Term Holding Facility Rule 32 clinical guidance, which advocates this multidisciplinary approach. This guidance was disseminated to all IRC healthcare providers via an online event chaired by the NHS England Health & Justice National Clinical Lead in April 2024. The IRC Partnership Group provides the governance and oversight of the attainment of the NHS England and Home Office Detention joint priorities and assures the national system of the quality and consistency of healthcare provisions and reduction of health inequalities.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Frank, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mrs Brown,

Thank you for your Regulation 28 report, dated 25 October 2024, following the inquest into the death of Mr Frank Ospina. I am very 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 Frank Ospina’s detention last year. I am replying as Minister for Border Security and Asylum.

I can assure you that the Home Office takes the health and welfare of people in detention very seriously. Your report identified three matters of concern which have the potential to lead to future deaths, if left unaddressed, which have been carefully considered by officials. This response summarises the action being taken to address the three concerns as well as wider work being undertaken by the Home Office to prevent future deaths in immigration detention.

I am aware that officials from NHS England will write to you separately with regards to your concerns about the operation of Detention Centre Rule 35. I understand that Mitie Care and Custody will also be writing to you, and their response may touch on some of the issues which I address below.

Concern 1 – Rule 35 Detention Centre Rules 2001

With regards to your first concern relating to Rule 35 of the Detention Centre Rules 2001, you have raised two issues which together resulted in a Rule 35 (2) report not being raised in the case of Mr Ospina.

The first issue relates to a mismatch in the healthcare provider and Home Office expectations and practical application of the Rule 35 provisions. This is being addressed through the development of an interim update to the published guidance Detention Services Order (DSO) 09/2016. The interim guidance will make clear that healthcare staff must inform the doctor of a detained person if staff have concerns of suicidal intention.

This will strengthen the existing Assessment Care in Detention and Teamwork (ACDT) guidance which requires non-clinical staff working in an immigration removal centre (IRC) to report the opening of an ACDT plan to both healthcare teams and the local Safer Detention Co-ordinator. The interim version of DSO 09/2016 will also include guidance as to indicators of “suicidal intentions” for clinical and non-clinical staff, to ensure concerns are being raised appropriately. The draft updated interim DSO is currently with key partners, including NHS England for review and is expected to be published in March
2025.

In terms of the limitations on the production of a Rule 35 report, where only a General Practitioner can produce a Rule 35 report, the Home Office is currently conducting a review of the statutory Adults at Risk (AaR) policy and Rules 34 and 35 of the Detention Centre Rules 2001. The option to remove this restriction and extend the production of Rule 35 reports to other relevant healthcare professionals is being considered and will form part of an external engagement process. The review is expected to be completed in Spring
2025. Any changes would require new statutory instruments to be laid before Parliament.

Concern 2 – Closed Visits

I am aware that a closed visit was imposed for Mr Ospina and his mother, which the inquest found to be inappropriate and unnecessary. Work has been undertaken in relation to your concern that under current practices, closed visits could potentially take place without the knowledge or consent of the Duty Manager, or without the necessary documentation being completed.

In line with published Home Office guidance DSO 04/2012 ‘Visitors and visiting procedures for detained individuals’, ‘closed visits’ (those which take place behind glass, with no physical contact between the detained individual and the visitor) should only take place in certain circumstances, such as suspicion of drug smuggling, or risk to visitors or children. Any decision to impose a closed visit should be taken on a case-by-case basis, following a documented risk assessment by the IRC supplier. In response to this concern, officials have undertaken a review of closed visits across the estate covering the past 4 months and have issued communications to staff to ensure understanding of when a closed visit can be used and responsibilities around doing so.

Officials have also considered longer term assurance and revised the draft DSO on visits to introduce annual self-audits and quarterly assurance reviews of both closed and banned visits. Learning from the recent review of closed visits is currently being considered and will be incorporated into the DSO. The updated DSO is expected to be published before March 2025.

Concern 3 – Accessibility for visitors

In relation to your concern regarding the accessibility of the visit procedures for family and friends visiting loved ones in an IRC, I am aware that you had particular concern with regards to language barriers, which caused difficulty for Mr Ospina’s mother in arranging a visit.

My officials have taken action to explore options to translate the visitor information for IRCs and Residential Short-Term Holding Facilities on Gov.uk and the development of web pages to enable translation is underway. Officials have commissioned the translation of the current visitor information into the top 20 languages of those in detention. Allowing time to translate the relevant information and the development of relevant web pages, we expect this work to be complete by the end of January 2025.

Learning from this undertaking will be shared with our suppliers, and we will be endorsing the translation of visitor information pages on their respective websites.

Continuous learning and improvement

There is wider improvement work, both complete and ongoing, to ensure we continue to learn from the death of Mr Ospina. The Home Office has already strengthened the vulnerability identification and reporting mechanism (IS91 RA) through communications, training and the development of guidance, enabling material changes in health, risk and vulnerability to be consistently communicated to Home Office teams responsible for making decisions on ongoing detention. Work is also underway to review the documentation used for the risk assessment process, (IS91 RA forms A – C) with the intention to develop guidance on the process and use of the forms in the published Detention General Instructions.

An internal thematic review into the operation of ACDT was completed in April 2024 and progress against recommendations was reviewed in November 2024. The published ACDT guidance, which is currently under review, will be revised to embed learning from the thematic assurance review and the inquest. The revised DSO will include guidance on the responsibilities, quality, and recording of observations, as well as further clarification on the management of personal items for those who are at risk of self-harm or suicide. Guidance on both issues has already been shared with staff by way of safeguarding bulletin. The revised ACDT guidance is expected to be published in late Spring 2025 after internal and external review.

I am aware that during the process of the inquest, a potential issue was raised with the functionality of call bells in the care suite at Colnbrook IRC. Immediate action was taken to implement an additional, alternative means of communication between a detained individual and officers, in the form of wearable wrist call bells and these were in place from 7 October 2024 and will remain in place until repairs are completed on the call bells in the care suite. We have confirmed with the contracted service providers the timeframe for the repairs would be approximately two days, though as yet, we do not have a confirmed date on when the work will begin. In November 2024, officials undertook an assurance review into the accommodation certification process and record keeping across the detention estate and further learning has been identified. The published guidance on accommodation standards (DSO 06/2018) will be updated to reflect this learning, with expected publication in June 2025 following both internal and external engagement.

The Home Office is committed to continuous improvement in relation to the safeguarding and wellbeing of detained individuals and committed to embedding changes from the identification of learning from internal audits, ‘near-miss’ incidents and deaths in detention. I would like to assure you that in addition to first and second-line assurance carried out by Home Office officials, we welcome the scrutiny and independent oversight from a number of inspection and monitoring bodies, advisory panels and committees.

Independent scrutiny is a vital part of assurance that our detention facilities are safe, secure, and humane. IRCs are subject to robust statutory oversight by Independent Monitoring Boards (IMB) and inspection (including by His Majesty’s Chief Inspector of Prisons, the Independent Chief Inspector of Borders and Immigration and others), ensuring that detained individuals are treated with proper standards of care and decency. We carefully consider the resulting findings and recommendations and involve all relevant parties in those considerations.

Preventing deaths in the immigration removal estate in particular remains a high priority. The Home Office is a co-sponsor to the Ministerial Board to Deaths in Custody, which originates from the recommendations of Robert Fulton’s Review of the Forum for

Preventing Deaths in Custody (2008). Following a Home Office commissioned review into immigration detention by the Independent Advisory Panel on Deaths in Custody (IAPDC), a ‘Prevention of future deaths in immigration detention strategy’ is underway. This work includes research into the impact of cultural differences and trauma on suicide prevention strategies, learning from near miss incidents in detention and work with the Samaritans. Progress against recommendations made by the IAPDC are reported through the governance structures of the MBDC.

I hope that the information provided addresses your concerns satisfactorily.

Dear Sir / Madam, INQUEST TOUCHING THE DEATH OF MR FRANK OSPINA – REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Further to the letter provided to His Majesty’s Senior Coroner Lydia Brown (“the Coroner”) on behalf of Mitie Care and Custody Limited (“C&C” / “the Company”) dated 11 October 2024, we have been provided with a copy of the Coroner’s Regulation 28 Report to Prevent Future Deaths dated 25 October 2024 (“the PFD Report”). Within the PFD Report, the Coroner has identified two concerns in relation to C&C, set out here for ease of reference:
1. “Visits. The inquest was advised that Frank Ospina's mother visited him in the Heathrow Immigration Removal Centre (“HIRC”) on one occasion, and that was conducted as a "closed" visit. Her son was accompanied by 2 Officers and their meeting held behind a glass screen where no physical contact was possible. The Officers were overhearing the family conversation and making notes. MITIE who are responsible for the day to day running of the IRC were unaware that a "closed" visit had occurred and apologised for this, confirming it was inappropriate and Frank Ospina and his mother should have been allowed to meet in the usual communal area where they could have embraced and had a private conversation. This was the last time Frank Ospina was seen alive by his mother and the visit greatly distressed her;

Mitie Care & Custody Limited The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK , Managing Director T:

Mitie.com/all-services/care-custody Mitie Care and Custody Limited is registered in England under company number 6976230 at The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK
2. Frank's mother does not speak English and found it very difficult to arrange a visit. In fact rather than successfully navigate the system, she just turned up and was permitted to see her son as set out above. Telephone calls were not facilitated with an interpreter. The website where visits should be booked is entirely and only in English. This is a facility that by definition detains foreign nationals and predictably some of the family members do not speak English. A quick check of the local authority website (Hammersmith and Fulham) revealed a full immediate translation facility into over 100 languages, and so this is readily available technology. The Home Office and MITIE should consider the communications currently available to relatives trying to visit their loved ones and whether these can be improved by reasonable adjustments”. Since the conclusion of the Inquest, the Company has taken the opportunity to reflect on what further changes can be made to the visitor and translation arrangements at HIRC in order to ensure its safe and effective operation. We provide the following updates which should be read alongside our letter dated 11 October 2024 from , Centre Director for HIRC. Within this response to the PFD Report, we will refer to each of the Coroner’s concerns in turn. Visits The Company would like to reiterate the apology provided during the Inquest to Mr Ospina’s family within this response. The closed visit which took place on 22 March 2023 between Mr Ospina and his mother was inappropriate. As confirmed by and during the Inquest, in March 2023 there was a clear policy in place in relation to closed visits, in accordance with the requirements of Detention Services Order 04/12, ‘Visitors and Visiting Procedures’ (“DSO 04/12”). A number of administrative steps and safeguards were required before a closed visit could be authorised. In light of Mr Ospina’s case the Company has reviewed its policies and procedures in relation to closed visits within HIRC to ensure that such a situation cannot arise again. A Notice to Staff was issued to all C&C staff at HIRC in relation to closed visits on 28 November 2024 (see Appendix 1). The Notice to Staff confirmed that placing a resident on closed visits can only be approved by the Head of Security, or the Duty Director in their absence. The Head of Security and/or Duty Director will then inform the Home Office Compliance and Detention Engagement Team of the closed visit, in accordance with the requirements of DSO 04/12. The

Mitie Care & Custody Limited The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK , Managing Director T: Mitie.com/all-services/care-custody Mitie Care and Custody Limited is registered in England under company number 6976230 at The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK Notice to Staff also reminds officers that if they have any queries as to whether or not a resident has been placed on closed visits, they must check this with the Security team. When a resident is placed under closed visits, this will be explained to them, utilising the Big Word translation service where required. Any risks to a resident’s wellbeing will be monitored and reported by staff and the suitability of closed visit status kept under review by the security team. Likewise, staff have been reminded to explain to visitors how a closed visit will take place and answer any questions they may have courteously, to provide them with reassurance and an optimal experience. If a resident is also under an Assessment Care in Detention and Teamwork status (“ACDT”), as was in the case of Mr Ospina, staff will now explain to the visitor why there will be additional staff present in order to maintain their ACDT observations. Staff can also use the Big Word translation service with visitors on their arrival and in the visitor’s centre. By way of further control measures: if a resident is placed on closed visits then this will be identified on the scrolling bar of their electronic Detainee Management System profile, to which all staff members have secure access to; a list of residents on closed visits is circulated weekly by the Company’s security team; which is in turn provided to the visitor’s centre reception team and each visits hall to ensure that all staff are aware of residents allocated to closed visits. The security team will circulate an updated list should that information change during the week, and they will also confirm if no residents are subject to closed visits, ensuring that staff have accurate and up to date information on who is subject to a closed visit at all times. Signs have also been placed on the door to the closed visit rooms, and in the reception of the visitor’s centre of HIRC as a reminder to staff that closed visit rooms are only to be used if a resident has an approved closed visits form on their file (see Appendix 2). We considered placing coded locks on the closed visit room doors, however this may create a fire evacuation risk for visitors and residents in the event of an emergency, and secondly, whilst closed visits are put in place to prevent security breaches, adding a lock to the door would make the room more formal and potentially intimidating for visitors and residents. For these reasons the closed visit rooms will remain unlocked. In order to further ensure that closed visits do not take place without the required authorisation, the Company will include audits of closed visits within its audit programme which ensures compliance with DSO 04/12, and managers will carry out spot checks to ensure compliance with these requirements and for quality assurance.

Mitie Care & Custody Limited The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK Managing Director T:

Mitie.com/all-services/care-custody Mitie Care and Custody Limited is registered in England under company number 6976230 at The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK Translation Services The Company has worked with the Home Office to identify what reasonable adjustments may be made to its systems in order to make the process of visiting HIRC more accessible. As confirmed at the Inquest by Frances Hardy, Director of Detention Services for the Home Office, whilst all efforts are made to accommodate visitors whose first language is not English, such as utilising a member of staff who also speaks the same language and the Big Word translation service, there is currently no known system which would act as an in-call two-way translation service between those inside and outside of HIRC. The preferred method of communicating information or submitting a visit request is therefore by email, as this can be translated where required, and details on how to contact HIRC (including details of the Safer Community Helpline) is set out clearly on the Company’s website. In terms of website translation services, C&C has now implemented a website translation and accessibility service called ‘Recite’ for use by visitors across each of its immigration removal centres, including HIRC. As such, there is now an accessibility button on the bottom right-hand side of each page of the Company’s website, which provides multiple options including the translation of all web content into 100 written languages and 65 ‘text to speech’ voices. Users are also able to utilise the ‘Recite’ function in order to customise the text to their preference, including colour, font style, spacing and layout. The Recite function is available across the entire mitie.com website. We have included a screenshot of the mitie.com IRC Visitors website below, with the ‘Recite’ function and its associated tools highlighted in purple boxes:

Mitie Care & Custody Limited The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK , Managing Director T:

Mitie.com/all-services/care-custody Mitie Care and Custody Limited is registered in England under company number 6976230 at The Shard, Level 12, 32 London Bridge Street, London, SE1 9SG, UK

Figure 1- Mitie Care and Custody Limited visitor website- https://www.mitie.com/visitors/ It is hoped that the above information, together with the improvements set out in our first letter dated 11 October 2024, is of assistance to the Coroner and demonstrates our commitment to providing safe and decent facilities for those in our care and their visitors. We take these matters seriously and we hope this response provides both the Coroner and Mr Ospina’s family with the reassurance that these matters have been given prompt and thorough consideration. If we can be of any further assistance, please do not hesitate to contact me on the details below.