Branko Zdravkovic
PFD Report
All Responded
Ref: 2019-0047
All 1 response received
· Deadline: 12 Apr 2019
Coroner's Concerns (AI summary)
Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home Office, impeding Article 2 obligations.
View full coroner's concerns
_ The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies. There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT , In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35. Rule 35 imposes a requirement to speedily review whether someone should be released because f concerns recorded by the medical practitioner.Without To that information being provided the state cannot carry out its obligations under Article 2
Responses
Action Planned
The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures. (AI summary)
The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures. (AI summary)
View full response
Dear Mr Nicholls,
BRANKO ZDRAVKOVIC – REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 report, dated 13 February 2019, following the inquest into the death of Mr Branko Zdravkovic at The Verne Immigration Removal Centre (IRC).
Any death in detention is a tragic event, and I am very grateful to you for your report and for the opportunity to review and, where possible, strengthen our processes.
You have identified the following matters of concern, which you suggest have the potential to lead to future deaths, if left unaddressed:
• Training provided to doctors and healthcare staff directs doctors to use Assessment Care in Detention Teamwork (ACDT) procedures to monitor detainees with suicidal tendencies rather than Rule 35(2) of the Detention Centre Rules 2001, which triggers a prompt consideration by the Home Office of a detainee’s continuing suitability to remain in detention (Concern 1).
• There is no formal procedure for notifying the Home Office of detainees at risk of suicide or self harm when placed on ACDT monitoring procedures (Concern 2).
It may be helpful if I highlight our existing processes as well as set out the actions we have taken or intend to take to guard against future deaths.
The Home Office’s suppliers which operate IRCs on our behalf are required to operate within a strictly defined framework of legislation and guidance. This requirement is stipulated in our individual contracts and, with HMPPS, in our service level agreement. The inquest’s findings
demonstrate that the Home Office must continue to ensure that these systems are used appropriately and that they effectively support those at risk.
The Independent Advisory Panel on Deaths in Custody has been asked by the Home Office to review and report on issues pertaining to deaths and incidents of serious self-harm in immigration detention. This request has been made in support of three recommendations relating to deaths in detention made by Stephen Shaw in his second review of immigration detention, and will provide further insight into the availability and usefulness of the existing data on deaths in detention. To increase transparency on the reporting of deaths, the Home Office began publishing data on deaths in immigration removal centres in November 2018. This included data on the number of deaths in immigration detention in 2017 but did not include those who died while being detained solely under immigration powers in HM prisons, or after leaving detention.
The Home Office is making provisions to better identify and flag individuals in IRCs and foreign national offenders in prisons who are subject to ACDT/ ACCT1 monitoring, and those about whom a Rule 35 report has been submitted. This will ensure an early review of suitability for detention and the assessment of adult at risk factors, and will improve information sharing.
Concern 1 – Rule 35(2) reporting
ACDT monitoring procedures deliver a tailored support package to monitor individuals according to their assessed risk of self harm and suicide in detention. Scheduled and ad- hoc contact/interventions with the individual take place throughout each day to ensure contact is maintained, that welfare, mood and behaviour is kept under review, and that the necessary support is offered and increased/decreased as required.
Notwithstanding this, ACDT monitoring is not a substitute or alternative reporting or monitoring mechanism for those individuals of whom doctors have made a clinical assessment and have concerns in respect of their risk of suicide. Where these concerns are present, doctors are required to make a report under Rule 35(2).
ACDT monitoring and reporting under Rule 35(2) are reciprocal processes. The Home Office is committed to supporting medical practitioners in the submission of Rule 35(2) reports and ensuring that they are kept appraised of ACDT monitoring.
Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at The Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor. The Home Office keeps the effectiveness of its procedures under review. As part of this continuous improvement the Home Office conducted an internal review to analyse the use
1 Assessment Care in Custody Teamwork (ACCT); the self harm and suicide prevention monitoring system used by Her Majesty’s Prisons and Probation Services in prisons.
of Rule 35(2). Given the low levels of Rule 35(2) reports received, the analysis aimed to establish the effectiveness of the provisions of Rule 35(2) in identifying, safeguarding and managing those at risk of suicide and to inform wider work being undertaken to review and update the Detention Centre Rules.
The initial review covered the period 1 November 2017 to 1 November 2018, in which only six Rule 35 (2) reports were raised. This naturally limits the weight of the indicative outcomes. The review recognised that while ACDT plans are a useful tool in managing suicide risk and safeguarding individuals in detention, there is limited scope to raise concerns to the Home Office regarding continued detention and provide medical opinion of suicide risk without the Rule 35 (2) reporting mechanism.
The findings of the initial review have been used to inform our separate work to finalise new Removal Centre Rules to replace the current Detention Centre Rules. We are aiming to introduce the new Rules, which will include updates to the reporting system in Rule 35, by July 2019.
NHS England commission health services in prisons and other places of detention including IRCs. This is undertaken through six NHS England Health and Justice Teams. Healthcare in IRCs in Scotland is commissioned by the supplier running those centres. The Home Office’s Director of Detention and Escorting Services will write to NHS England (as the commissioning body for IRC healthcare services in England) and to the healthcare providers at Dungavel IRC by the end of April 2019 to seek assurances that all parties are following the correct process. The Home Office IRC Assurance Group forum will be consulted to consider how this can be monitored.
Concern 2 - ACDT Monitoring Procedures
There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.
Separately, we have established Detention Engagement Teams within all IRCs, to provide an onsite link between the Home Office’s various casework areas and the detained population. We are confident that this will, in the fullness of time, allow for improved assessments of vulnerabilities, including where detainees are subject to the ACDT process.
The Home Office has closely followed the work being undertaken by Her Majesty’s Prisons and Probation Service (HMPPS) to review its Assessment, Care in Custody and Teamwork (ACCT) procedures, upon which our ACDT procedures are modelled.
The HMPPS review has identified key elements of the ACCT process where practices need to be strengthened. These include the identification and assessment of risk, multi- disciplinary working and information sharing and the provision of person-centred care (with a focus on outcomes for the individual).
On 13 September 2018, the consultation period for the new HMPPS procedures developed as a result of this review ended, and a pilot for the new process was agreed. Morton Hall IRC is currently trialling the new process on behalf of the immigration removal estate.
The Home Office will use the learning from the pilot to improve suicide and self-harm prevention guidance and procedures and to clarify the information sharing responsibilities in relation to those detainees assessed as being at risk of self harm and/or suicide.
I would like to thank you for raising these important issues and hope that this response addresses your concerns. I am copying my reply to Rory Stewart MP, Minister of State for Prisons at the Ministry of Justice.
Rt Hon Caroline Nokes MP Minister of State for Immigration
BRANKO ZDRAVKOVIC – REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Thank you for your Regulation 28 report, dated 13 February 2019, following the inquest into the death of Mr Branko Zdravkovic at The Verne Immigration Removal Centre (IRC).
Any death in detention is a tragic event, and I am very grateful to you for your report and for the opportunity to review and, where possible, strengthen our processes.
You have identified the following matters of concern, which you suggest have the potential to lead to future deaths, if left unaddressed:
• Training provided to doctors and healthcare staff directs doctors to use Assessment Care in Detention Teamwork (ACDT) procedures to monitor detainees with suicidal tendencies rather than Rule 35(2) of the Detention Centre Rules 2001, which triggers a prompt consideration by the Home Office of a detainee’s continuing suitability to remain in detention (Concern 1).
• There is no formal procedure for notifying the Home Office of detainees at risk of suicide or self harm when placed on ACDT monitoring procedures (Concern 2).
It may be helpful if I highlight our existing processes as well as set out the actions we have taken or intend to take to guard against future deaths.
The Home Office’s suppliers which operate IRCs on our behalf are required to operate within a strictly defined framework of legislation and guidance. This requirement is stipulated in our individual contracts and, with HMPPS, in our service level agreement. The inquest’s findings
demonstrate that the Home Office must continue to ensure that these systems are used appropriately and that they effectively support those at risk.
The Independent Advisory Panel on Deaths in Custody has been asked by the Home Office to review and report on issues pertaining to deaths and incidents of serious self-harm in immigration detention. This request has been made in support of three recommendations relating to deaths in detention made by Stephen Shaw in his second review of immigration detention, and will provide further insight into the availability and usefulness of the existing data on deaths in detention. To increase transparency on the reporting of deaths, the Home Office began publishing data on deaths in immigration removal centres in November 2018. This included data on the number of deaths in immigration detention in 2017 but did not include those who died while being detained solely under immigration powers in HM prisons, or after leaving detention.
The Home Office is making provisions to better identify and flag individuals in IRCs and foreign national offenders in prisons who are subject to ACDT/ ACCT1 monitoring, and those about whom a Rule 35 report has been submitted. This will ensure an early review of suitability for detention and the assessment of adult at risk factors, and will improve information sharing.
Concern 1 – Rule 35(2) reporting
ACDT monitoring procedures deliver a tailored support package to monitor individuals according to their assessed risk of self harm and suicide in detention. Scheduled and ad- hoc contact/interventions with the individual take place throughout each day to ensure contact is maintained, that welfare, mood and behaviour is kept under review, and that the necessary support is offered and increased/decreased as required.
Notwithstanding this, ACDT monitoring is not a substitute or alternative reporting or monitoring mechanism for those individuals of whom doctors have made a clinical assessment and have concerns in respect of their risk of suicide. Where these concerns are present, doctors are required to make a report under Rule 35(2).
ACDT monitoring and reporting under Rule 35(2) are reciprocal processes. The Home Office is committed to supporting medical practitioners in the submission of Rule 35(2) reports and ensuring that they are kept appraised of ACDT monitoring.
Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at The Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor. The Home Office keeps the effectiveness of its procedures under review. As part of this continuous improvement the Home Office conducted an internal review to analyse the use
1 Assessment Care in Custody Teamwork (ACCT); the self harm and suicide prevention monitoring system used by Her Majesty’s Prisons and Probation Services in prisons.
of Rule 35(2). Given the low levels of Rule 35(2) reports received, the analysis aimed to establish the effectiveness of the provisions of Rule 35(2) in identifying, safeguarding and managing those at risk of suicide and to inform wider work being undertaken to review and update the Detention Centre Rules.
The initial review covered the period 1 November 2017 to 1 November 2018, in which only six Rule 35 (2) reports were raised. This naturally limits the weight of the indicative outcomes. The review recognised that while ACDT plans are a useful tool in managing suicide risk and safeguarding individuals in detention, there is limited scope to raise concerns to the Home Office regarding continued detention and provide medical opinion of suicide risk without the Rule 35 (2) reporting mechanism.
The findings of the initial review have been used to inform our separate work to finalise new Removal Centre Rules to replace the current Detention Centre Rules. We are aiming to introduce the new Rules, which will include updates to the reporting system in Rule 35, by July 2019.
NHS England commission health services in prisons and other places of detention including IRCs. This is undertaken through six NHS England Health and Justice Teams. Healthcare in IRCs in Scotland is commissioned by the supplier running those centres. The Home Office’s Director of Detention and Escorting Services will write to NHS England (as the commissioning body for IRC healthcare services in England) and to the healthcare providers at Dungavel IRC by the end of April 2019 to seek assurances that all parties are following the correct process. The Home Office IRC Assurance Group forum will be consulted to consider how this can be monitored.
Concern 2 - ACDT Monitoring Procedures
There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.
Separately, we have established Detention Engagement Teams within all IRCs, to provide an onsite link between the Home Office’s various casework areas and the detained population. We are confident that this will, in the fullness of time, allow for improved assessments of vulnerabilities, including where detainees are subject to the ACDT process.
The Home Office has closely followed the work being undertaken by Her Majesty’s Prisons and Probation Service (HMPPS) to review its Assessment, Care in Custody and Teamwork (ACCT) procedures, upon which our ACDT procedures are modelled.
The HMPPS review has identified key elements of the ACCT process where practices need to be strengthened. These include the identification and assessment of risk, multi- disciplinary working and information sharing and the provision of person-centred care (with a focus on outcomes for the individual).
On 13 September 2018, the consultation period for the new HMPPS procedures developed as a result of this review ended, and a pilot for the new process was agreed. Morton Hall IRC is currently trialling the new process on behalf of the immigration removal estate.
The Home Office will use the learning from the pilot to improve suicide and self-harm prevention guidance and procedures and to clarify the information sharing responsibilities in relation to those detainees assessed as being at risk of self harm and/or suicide.
I would like to thank you for raising these important issues and hope that this response addresses your concerns. I am copying my reply to Rory Stewart MP, Minister of State for Prisons at the Ministry of Justice.
Rt Hon Caroline Nokes MP Minister of State for Immigration
Sent To
- Home Office
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56-Day Deadline
12 Apr 2019
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 13/04/17 ! commenced an investigation into the death of Branko Zdravkovic aged
43. The investigation concluded at the end of the inquest on 27/11/18. The conclusion of the inquest was Suicide, medical cause of death ligature suspension:
43. The investigation concluded at the end of the inquest on 27/11/18. The conclusion of the inquest was Suicide, medical cause of death ligature suspension:
Circumstances of the Death
Branko Zdravkovic was born in Slovenia. He lived in the UK since at least 2008. The Immigration Authorities had cause to detain him and seek his removal from the UK. He was taken to the Immigration Removal Centre, The Verne in Dorset arriving there on 21/03/17. Whilst at The Verne he was placed in the Segregation Unit on two separate occasions as a result of his behaviour under the influence of Spice. He was placed on an Assessment Care in Detention Treatment (ACDT) on two occasions_ He self-harmed and was threatening suicide, and was he was later reassessed his risk had reduced and he returned to his unit: He was under regular observations by the staff. He was found suspended by a ligature in a toilet cubicle despite CPR and the attendance of both Healthcare and an ambulance he was pronounced dead at 00.09 on the 09/04/17.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.