Amir Siman-Tov
PFD Report
Historic (No Identified Response)
Ref: 2019-0302
Coroner's Concerns (AI summary)
Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.
View full coroner's concerns
1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process. This puts detainees at risk.
2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process. This puts detainees at risk.
3. The Consultant Forensic psychiatrist did not read the ACDT documents. This puts detainees at risk.
4. The Centre Manager gave evidence that he recognised the importance of the
2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process. This puts detainees at risk.
3. The Consultant Forensic psychiatrist did not read the ACDT documents. This puts detainees at risk.
4. The Centre Manager gave evidence that he recognised the importance of the
Sent To
- CNWL NHS Trust
- Hillingdon Hospital NHS Trust ›Hillingdon Hospital
- Home Office
- Langley Health Centre
- Mitie
Response Status
Linked responses
0 of 5
56-Day Deadline
23 Oct 2019
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 28th February 2016 an investigation was opened into the death of Amir Siman-Tov. The investigation was concluded by way of Inquest over the period 13th May 2019 to 30th May 2019.
Circumstances of the Death
Mr Siman-Tov was detained on the 25th January 2016 under immigration regulations at The Beckett House Reporting Centre.
He had had previous involvement with police, custodial services and also the Home Office over a number of years and there were a number of documented suicide attempts.
He had had a diagnosis of paranoid schizophrenia, depression and epilepsy and was treated for all three.
At Beckett House Mr Siman-Tov asks to use the toilet. Sometime later a choking sound is heard coming from the toilet and officers enter to discover that he had attempted to strangle himself with an electrical wire that was in his pocket at the time of his arrest. The ligature was around his neck.
Following this, Mr Siman-Tov was moved to the Walworth Road Police Station.
At around 1750 on the 25th January 2016 at Walworth Police Station Mr Siman-Tov is subject to a forced search. His clothing is removed and he is placed in his cell in his underpants. He removes his underpants and attempts to make a ligature of them. His underpants are removed from his cell and he is then under constant supervision/watch whilst at the police station.
While at Walworth Police Station and partly because of (1) the attempt to strangle himself at Beckett House and (2) the attempt to strangle himself with his underpants at the police station he is deemed to require constant supervision.
On the 27th January 2016 Mr Siman-Tov was moved from the Walworth Road Police station to Colnbrook Immigration Removal Centre. Tascor, a private secure transport firm collected Mr Siman-Tov at 0055 from Walworth police Station and removed him to Colnbrook Immigration Removal Centre (IRC), Heathrow, arriving at 0230 hrs on the 28th January 2016.
On arrival Mr Siman-Tov was placed on an ACDT. An ACDT is an Assessment Care in Detention and Teamwork (ACDT) self harm reduction strategy. It provides a holistic approach to suicide prevention (with a move away from simple awareness to prevention), within the broader context of decency, safety, and the concept of a healthy centre, but also brings existing policy in line with similar changes implemented by the Ministry of Justice. In short it is a process designed to avoid at risk individuals taking their own lives. To be effective it needs participation in by all staff involved in caring for a detainee.
Mr Siman-Tov remained on an ACDT constant watch from his arrival at Colnbrook IRC to his death on the 17th February 2016. During his stay at Colnbrook IRC he repeatedly expressed suicidal thoughts and articulated that he would save his medication and take as an overdose.
At about 1042 on the 16th February 2016, Mr Siman-Tov was suspected of taking an overdose of medication. He was taken to the Hillingdon Hospital and assessed. After assessment he was discharged from the Hillingdon Hospital at 1710. The “discharge” note sent by Hillingdon Hospital staff contained no clinical information or advice.
He was returned to Colnbrook.
At 0419 the next morning he was found to have died. The medical cause of death is recorded as 1a Codeine Toxicity.
Mr Siman-Tov had a genetic variant which meant that his metabolism of codeine into morphine was faster than in people without the variant.
He had had previous involvement with police, custodial services and also the Home Office over a number of years and there were a number of documented suicide attempts.
He had had a diagnosis of paranoid schizophrenia, depression and epilepsy and was treated for all three.
At Beckett House Mr Siman-Tov asks to use the toilet. Sometime later a choking sound is heard coming from the toilet and officers enter to discover that he had attempted to strangle himself with an electrical wire that was in his pocket at the time of his arrest. The ligature was around his neck.
Following this, Mr Siman-Tov was moved to the Walworth Road Police Station.
At around 1750 on the 25th January 2016 at Walworth Police Station Mr Siman-Tov is subject to a forced search. His clothing is removed and he is placed in his cell in his underpants. He removes his underpants and attempts to make a ligature of them. His underpants are removed from his cell and he is then under constant supervision/watch whilst at the police station.
While at Walworth Police Station and partly because of (1) the attempt to strangle himself at Beckett House and (2) the attempt to strangle himself with his underpants at the police station he is deemed to require constant supervision.
On the 27th January 2016 Mr Siman-Tov was moved from the Walworth Road Police station to Colnbrook Immigration Removal Centre. Tascor, a private secure transport firm collected Mr Siman-Tov at 0055 from Walworth police Station and removed him to Colnbrook Immigration Removal Centre (IRC), Heathrow, arriving at 0230 hrs on the 28th January 2016.
On arrival Mr Siman-Tov was placed on an ACDT. An ACDT is an Assessment Care in Detention and Teamwork (ACDT) self harm reduction strategy. It provides a holistic approach to suicide prevention (with a move away from simple awareness to prevention), within the broader context of decency, safety, and the concept of a healthy centre, but also brings existing policy in line with similar changes implemented by the Ministry of Justice. In short it is a process designed to avoid at risk individuals taking their own lives. To be effective it needs participation in by all staff involved in caring for a detainee.
Mr Siman-Tov remained on an ACDT constant watch from his arrival at Colnbrook IRC to his death on the 17th February 2016. During his stay at Colnbrook IRC he repeatedly expressed suicidal thoughts and articulated that he would save his medication and take as an overdose.
At about 1042 on the 16th February 2016, Mr Siman-Tov was suspected of taking an overdose of medication. He was taken to the Hillingdon Hospital and assessed. After assessment he was discharged from the Hillingdon Hospital at 1710. The “discharge” note sent by Hillingdon Hospital staff contained no clinical information or advice.
He was returned to Colnbrook.
At 0419 the next morning he was found to have died. The medical cause of death is recorded as 1a Codeine Toxicity.
Mr Siman-Tov had a genetic variant which meant that his metabolism of codeine into morphine was faster than in people without the variant.
Copies Sent To
2. Mitie Care and Custody
3. Home Office
4. Central and North West London NHS Trust
5. Hillingdon Hospital NHS Trust
7. GP Langley Health Centre Common Road Langley SL3 8LE
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.