Frank Ospina

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Independent investigation into
the death of Mr Frank Ospina,
a detainee at Colnbrook
Immigration Removal Centre,
on 26 March 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist in ensuring the standard of care received by those within
service remit is appropriate, our recommendations should be focused, evidenced and
viable. This is especially the case if there is evidence of systemic failure.
Mr Frank Ospina was found dead in the care suite at Colnbrook Immigration Removal
Centre on 26 March 2023. He had used his own scarf to strangle himself. He was 39 years
old. I offer my condolences to Mr Ospina’s family and friends.
At the time of his death, Mr Ospina was being monitored using suicide and self-harm
prevention procedures and should have been checked twice an hour. However, he had not
been checked for over an hour when he was found dead. A detention custody officer had
recorded that he had undertaken a check half an hour before when he had not done so. Mr
Ospina appeared to have been dead for at least two hours when he was found, which
casts doubt on whether previous checks were carried out correctly.
Mr Ospina’s mental health deteriorated from 22 March onwards when he self-harmed and
repeatedly said that he wanted to die. IRC staff should have alerted the Home Office so
that they could have reviewed whether Mr Ospina’s continued detention was appropriate,
in line with Home Office policy. This did not happen.
Following its last inspection of Colnbrook in 2022, HM Inspectorate of Prisons found that
there were insufficient safeguards against the detention of detainees with suicidal thoughts
and that reports to notify the Home Office of suicidal detainees were seldom prepared
when necessary. This process needs to improve if the Home Office is to prevent future
deaths by suicide at Colnbrook.
This version of my report, published on my website, has been amended to remove the
names of staff and detained persons involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 14
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Summary
Events
1. On 4 March 2023, Mr Frank Ospina was detained at Colnbrook Immigration
Removal Centre (IRC) pending his removal to Colombia.
2. When he arrived at the IRC, Mr Ospina said he would be at risk from gangs if he
returned to Colombia. Staff subsequently noted that he had declined the offer of
voluntary departure and had raised a possible asylum claim.
3. On 16 March, Mr Ospina told staff that he wanted to return to Colombia voluntarily.
He said his mother would bring his passport to the IRC, which she subsequently
did.
4. On 19 and 21 March, Mr Ospina saw healthcare staff and said he was stressed
about his immigration situation. They gave him advice on how to improve his mood
and advised him to contact the welfare team for an update on his case.
5. On 22 March, Mr Ospina jumped from the second floor internal balcony onto the
safety netting. Staff started suicide and self-harm prevention procedures (known as
ACDT). Mr Ospina said that he had been talking to underage girls online. He said
he wanted to confess and go to prison. He said he was a bad person and he
wanted to die. Staff placed Mr Ospina under constant supervision in the care suite.
A doctor prescribed antidepressant medication.
6. On 23 March, staff held an ACDT review. Mr Ospina said he felt better for talking to
staff the previous day and that he had no thoughts of suicide or self-harm. Staff
reduced his observations to one an hour and moved him from the care suite back
onto the main unit.
7. On 24 March, Mr Ospina self-harmed by whipping himself with the wire from a
television aerial and banging his head against the wall. Staff held a further ACDT
review and increased his observations to two an hour.
8. On 25 March, staff held another ACDT review and moved Mr Ospina back to the
care suite as his mental health continued to deteriorate. Later that day, police
interviewed Mr Ospina about his online contact with underage girls and he became
distressed. He was taken back to the care suite and remained on two observations
an hour.
9. CCTV shows that on 26 March, a detention custody officer (DCO) checked on Mr
Ospina at 7.22am, 7.42am and 7.52am. The DCO said that he saw Mr Ospina in
bed on each occasion. At around 8.00am, another DCO took over. He recorded that
he checked on Mr Ospina at 8.30am but CCTV shows that he did not. He told the
investigator that he had written it down as a reminder to do the check but had got
side-tracked with other tasks and not done it.
10. Shortly after 9.00am, the DCO went to Mr Ospina’s room to check on him. He
opened the door and looked in. Mr Ospina was not in his bed and did not respond
when the DCO called out to him. The DCO closed the door and called for
colleagues to attend as he thought he should not go into the room alone. After 13
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minutes, staff attended and went into the room where they found Mr Ospina lying on
the floor of the toilet area with a scarf tied around his neck. A manager instructed
staff to start CPR even though there were signs that Mr Ospina had been dead for
some time. When healthcare staff arrived, they also continued with CPR until
paramedics arrived and confirmed that Mr Ospina was dead.
Findings
11. A DCO falsely recorded that he had checked on Mr Ospina at 8.30am when he had
not done so. Mr Ospina should have been checked twice an hour but was not
checked for over an hour, between 7.52am and 9.03am. He had rigor mortis when
found, which suggests that he had been dead for at least two hours. This casts
doubt on the other DCO’s account that he saw him in bed at 7.22am, 7.42am and
7.52am.
12. The DCO who found Mr Ospina had not worked in the care suite before. He was
unaware that Mr Ospina should have been unlocked at 8.30am. He was also
unaware that additional staff were not needed to enter detainees’ rooms.
13. The purpose of Rule 35 procedures, as set out in published Home Office detention
policies, is to ensure that particularly vulnerable individuals, including those with
suicidal intentions, are brought to the attention of those with direct responsibility for
authorising, maintaining and reviewing detention. No Rule 35 report was raised in
relation to Mr Ospina after he self-harmed and expressed suicidal thoughts,
meaning that no one reviewed his continued detention as we would have expected.
14. During its last inspection of Colnbrook in February and March 2022, HM
Inspectorate of Prisons found that there were insufficient safeguards against the
detention of detainees with suicidal thoughts. They found that Rule 35 reports were
seldom prepared when necessary. The most recent annual inspection of Adults at
Risk in Immigration Detention by the Independent Chief Inspector of Borders and
Immigration also found that the Rule 35 process was not working effectively.
15. The clinical reviewer found that the care Mr Ospina received for his mental health
was of a good standard and was equivalent to that which he could have expected to
receive in the community.
Recommendations
• The Centre Manager should ensure that staff understand their responsibilities when
carrying out ACDT observations, including that they:
• obtain a clear visual sighting of the detainee using a torch if necessary; and
• accurately record the time of the check once they have completed it.
• The Centre Manager should ensure that ACDT reviews are multidisciplinary with
input from healthcare and any other relevant staff, including DET.
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• The Home Office should amend DSO 09/2016 so that it:
• it is clear what suicidal intentions means; and
• requires nurses and other healthcare professionals to report to a doctor any
detainee who is showing suicidal intentions.
• The Home Office should review the training provided to IRC staff on Rule 35
reports, particularly for those at risk of suicide.
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The Investigation Process
16. The Home Office notified us of Mr Ospina’s death on 26 March 2023.
17. The investigator issued notices to staff and prisoners at Colnbrook IRC informing
them of the investigation and asking anyone with relevant information to contact
her. One detainee responded but did not provide sufficient information to facilitate
an interview.
18. The investigator obtained copies of relevant extracts from Mr Ospina’s detention
and medical records.
19. NHS England commissioned an independent clinical reviewer to review Mr Ospina’s
clinical care at the IRC.
20. The investigator interviewed four members of staff at the IRC in August 2023.
21. We informed HM Coroner for West London of the investigation. The Coroner sent
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
22. The Ombudsman’s family liaison officer contacted Mr Ospina’s mother, with
assistance from the Colombian Embassy, to explain the investigation and to ask if
she had any matters she wanted us to consider. Mr Ospina’s mother wanted to
know:
• Why her son was not removed to Colombia immediately.
• Why her son had a scarf with him that he could use as a ligature when he had
previously tried to take his life.
• Why staff had not carried out proper checks on her son on the morning of 26
March.
We have addressed these issues in the report.
23. We shared our initial report with Mr Ospina’s mother, via the Colombian Embassy.
She did not raise any factual inaccuracies.
24. We shared our initial report with the Home Office. The Home Office requested
revised wording to one paragraph which has been amended within our report. The
action plan has been annexed to this report.
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Background Information
Colnbrook Immigration Removal Centre (IRC)
25. Colnbrook is an immigration removal centre situated next to Heathrow Airport in
West London. It holds up to 330 detainees. Mitie Care and Custody run the centre
under contract from the Home Office. Practice Plus Group provides physical and
mental health services. There is a six-bed care suite for detainees considered to be
in crisis and requiring time out from the normal regime. The care suite is upstairs
from the healthcare facility but is run by Mitie staff.
Rule 35 - Adults at risk in immigration detention
26. The purpose of Rule 35 of the Detention Centre Rules 2001 is “to ensure that
particularly vulnerable detainees are brought to the attention of those with direct
responsibility for authorising, maintaining and reviewing detention”. Detention
Services Order 09/2016 provides guidance to Home Office and IRC staff on the
operation of Rule 35.
27. Sub-paragraphs (1) to (3) of Rule 35 say that a medical practitioner must report
detainees to the Home Office where:
• the detainee’s health is likely to be injuriously affected by continued
detention.
• the detainee is suspected of having suicidal intentions.
• the detainee may have been a victim of torture.
28. The Home Office weighs the health assessment against immigration and public
protection considerations to decide whether detention remains appropriate. DSO
09/2016 says that applications should be dealt with by the Home Office caseworker
within two working days.
HM Inspectorate of Prisons
29. The last inspection of Colnbrook took place between 28 February and 18 March
2022. Inspectors described the Centre as reasonably safe and decently run. Most
detainees spent around a month at the Centre, reported positive relationships with
staff, and said they felt safe there. Inspectors found that the suicide and self-harm
monitoring process (known as ACDT) generally worked well to support detainees in
crisis.
30. Health services were generally of a good standard and there was good support for
those who were most distressed, but it was disappointing that there was less
provision for those with lower-level mental health issues who needed support before
things reached crisis point.
31. Inspectors found that there were insufficient safeguards against the detention of
detainees with suicidal thoughts. Rule 35 reports were seldom prepared when
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necessary. Some distressed detainees who should have been released earlier due
to physical and mental health problems were not served well by inadequate
assessments in Rule 35 reports. Inspectors reported that in the previous six
months, a third of detainees had been released following a Rule 35 report, more
than at the previous inspection in 2018. However, very few reports related to health
concerns or suicide risk and those in the inspectors’ sample contained little detail.
The recommendation made in the 2018 inspection that Rule 35 reports should be
monitored to ensure they were submitted when necessary, had not been achieved.
32. Inspectors reported that uncertainty about their future was the most common cause
of frustration for detainees, so it was disappointing that the Home Office’s Detention
Engagement Team (DET), that was supposed to answer questions and provide
support, was functioning so poorly. Low staffing levels and a lack of ambition from
leaders meant that there was almost no face-to-face interaction, while the team’s
telephones often rung unanswered.
Independent Monitoring Board
33. Each immigration removal centre has an Independent Monitoring Board (IMB) of
unpaid volunteers from the local community who help to ensure that detainees are
treated fairly and decently. In its latest annual report for the year to 31 December
2022, the Board was concerned that while detainees received a reasonable
standard of healthcare provision, ongoing healthcare staff shortages could impact
on the services provided to detainees, particularly in relation to mental health
provision. The Board noted a significant increase in incidents of self-harm and the
number of detainees subject to suicide and self-harm monitoring. Detainees
reported their distress was usually due to frustration about their immigration status
or not being released when they expected to be.
Independent Chief Inspector of Borders and Immigration
34. The Independent Chief Inspector of Borders and Immigration carried out its third
annual inspection of ‘Adults at risk in immigration detention’ from June to
September 2022. It found that Rule 35, which is an important safeguard for
particularly vulnerable individuals being held in immigration detention, was not
working consistently or effectively.
35. Inspectors reported that there were disproportionately high volumes of Rule 35
reports concerned with torture in comparison with exceptionally low volumes of Rule
35 reports relating to health and suicidal intentions. They noted that while DSO
09/2016 said that “nurses and other healthcare professionals are aware that they
must report to an IRC doctor any detainee who claims to be a victim of torture or
gives an indication that this might have been the case”, there is no requirement for
nurses and other healthcare professionals to report equivalent concerns to the IRC
doctor where a detainee’s health is likely to be injuriously affected by continued
detention or where there are concerns of suicidal intentions.
Previous deaths at Colnbrook IRC
36. Mr Ospina was the first prisoner to die at Colnbrook since 2016. In 2016, there was
one homicide and one self-inflicted death. In the previous self-inflicted death, we
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made recommendations to Colnbrook about healthcare staff attending ACDT
reviews.
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Key Events
37. Mr Frank Ospina, a Colombian national, arrived in the UK on a visit visa on 9
February 2023. He was not permitted to work during his stay. On Friday 3 March,
Home Office Immigration Enforcement officers found him working at a restaurant.
They served him papers telling him that he was to be removed from the UK and
would be detained pending his removal to Colombia. On 4 March, Mr Ospina was
taken to Colnbrook Immigration Removal Centre (IRC).
38. When Mr Ospina arrived at the IRC, staff used a Spanish interpreting service and
noted no physical or mental health problems. During his induction, Mr Ospina said
he would be at risk from gangs if he returned to Colombia. Although Mr Ospina’s
first language was Spanish, staff did not always use interpreting services as they
said his level of English was sufficient to hold a conversation with him.
39. On 8 March, Home Office staff carried out the seven-day detention review. They
assessed that Mr Ospina was at high risk of absconding if released on bail and
recommended that he should continue to be held in detention until his removal to
Colombia. Staff recorded that Mr Ospina had declined the offer of voluntary
departure. Staff noted that Mr Ospina had raised a possible asylum claim when he
said at his induction that he was at risk from gangs if returned to Colombia. A Home
Office manager recorded that this should be explored further by staff in the
Detention Engagement Team (DET) at the IRC. The manager authorised continued
detention on 9 March.
40. On 15 March, Home Office staff carried out the 14-day detention review. The
actions from the previous review were still outstanding and staff were no clearer if
Mr Ospina intended to raise an asylum claim. Staff noted that the likely timescale
for Mr Ospina’s removal would be a further four to five weeks unless he raised an
asylum claim. On 16 March, a Home Office manager authorised Mr Ospina’s
continued detention while waiting for DET staff to establish whether Mr Ospina was
making an asylum claim. The next detention review date was scheduled for 31
March (28 days).
41. On 16 March, Mr Ospina told DET staff that he wanted to accept the offer to return
voluntarily to Colombia. Staff noted that he did not have his passport but he said his
mother could bring it to the centre.
42. On 19 March, Mr Ospina said he wanted to speak to healthcare staff as he was
feeling stressed. A triage nurse assessed him and advised him to eat healthily, do
some exercise and keep busy. The nurse also advised him to contact the IRC
welfare team for advice regarding his immigration situation.
43. On 21 March, Mr Ospina attended a walk-in clinic and told the nurse that he was
stressed and he had no solicitor. The nurse spoke to staff on the unit who advised
that he should contact the welfare team for advice.
44. On 22 March, at around 9.00am, Mr Ospina jumped from the second floor internal
balcony onto the safety netting. A Detention Custody Manager (DCM) completed a
Concern Form and Immediate Action Plan as part of the suicide and self-harm
prevention process (known as ACDT procedures). The DCM noted that Mr Ospina
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told staff that he wanted to die and that he was not a nice person. He said he was
feeling stressed and was not sleeping as he was afraid of going back to Colombia.
Mr Ospina told staff that he had been using a web cam to talk to underage girls. He
said he wanted to confess and to go to prison. The DCM placed Mr Ospina under
constant supervision and moved him to the care suite while waiting for his first
ACDT review. She referred Mr Ospina to the mental health team and noted that he
should have supervised shaves but did not remove any other items from him.
45. At 10.30am, staff held the initial ACDT assessment interview in the care suite. Mr
Ospina, and two DCMs attended. Staff used an interpreter. Staff noted that Mr
Ospina said he felt better now that he had told them about his online contact with
underage girls. He said he had self-harmed three days previously but had not told
anyone. Staff noted that the care suite was the only suitable location for him due to
his risk of jumping over the balcony. He remained in the care suite under constant
supervision.
46. At 10.30am on 22 March, Home Office staff updated Mr Ospina’s Home Office
record to say that he had told DET staff that he wanted to return to Colombia.
47. Mr Ospina’s mother visited the centre at around 2.00pm to drop off her son’s
passport but she did not see him.
48. At around 3.00pm, a doctor saw Mr Ospina and prescribed sertraline (an
antidepressant). Mr Ospina told the doctor he had previously been treated for
anxiety and depression in Colombia. Due to his risk of suicide and self-harm, the
medication was not given to him in his possession so he received it each day in the
presence of healthcare staff. The doctor wrote that he planned to review Mr Ospina
again in two to three weeks.
49. At around 4.00pm on 23 March, a DCM chaired Mr Ospina’s first ACDT review.
Staff used an interpreter. No one attended from healthcare (the Head of Healthcare
told us that healthcare staff were available to attend ACDT reviews only between
10.00am and 12.00pm). Nor did DET, but they provided input by email. The DCM
noted that Mr Ospina had spoken to his solicitor (who had been appointed after Mr
Ospina’s conversation with the welfare team) and was still waiting to see DET and
the mental health team. He said that he did not want to return to Colombia and
wanted an opportunity to remain in the UK. Mr Ospina said that his medication was
helping him and he had no thoughts of suicide or self-harm. Staff stopped constant
supervision and set observations at one an hour. They moved him from the care
suite back onto the main unit.
50. At around 1.45pm on 24 March, a DCM chaired a further ACDT review after Mr
Ospina self-harmed. He used the wire from a TV aerial to whip himself and was
also banging his head against the wall. Staff did not use an interpreter as they
noted that Mr Ospina spoke English. No one from healthcare or DET attended the
ACDT review, although a mental health nurse provided information in advance by
telephone. Mr Ospina said he had seen DET staff and they had said he would be
prosecuted if he did not sign immigration paperwork. He was also concerned that
staff had told the police that he had been engaging with underage girls online. Staff
told him that they had not informed the police. Staff noted that Mr Ospina was
compliant with his medication but still waiting to see the mental health team. He
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said he was not going to harm himself. Staff increased his observations to two an
hour.
51. Later that day, a mental health nurse carried out a triage assessment with Mr
Ospina. The nurse noted that Mr Ospina was having thoughts of suicide and self-
harm but did not have an active plan to end his life. He noted that Mr Ospina was
complying with his medication and being supported by the ACDT process.
Events of 25 March
52. At 11.25am on 25 March, a DCM chaired an ACDT review. A mental health nurse
attended and DET provided input by telephone. Staff did not use an interpreter as
they noted that Mr Ospina spoke English. Mr Ospina told staff that he wanted to die
as the Home Office was investigating what he had done, and he did not want to go
to prison for 30 years. The DCM noted that Mr Ospina’s demeanour had changed
since the day before. She noted that DET staff had seen him that morning and
asked him to sign biodata forms, which had possibly been a trigger. She noted that
the Home Office had asked Mr Ospina to decide whether he wanted to return to
Colombia or remain in the UK as he had been changing his mind. The mental
health nurse said she would refer him to the psychologist. She noted that there was
no enduring mental illness and that Mr Ospina appeared to be struggling with guilt
about his alleged offences and the potential repercussions. Staff decided to move
Mr Ospina to the care suite. The DCM noted that he should have supervised
shaves and limited items in his room, but no further details were given.
53. Detention Custody Officer (DCO) A was on duty in the care suite when Mr Ospina
arrived. DCO A told the investigator that, at that time, he had only worked at the
centre for seven months and this was the first time he had worked in the care suite.
DCO A said Mr Ospina had his belongings in two large bags. He said he was not
made aware of any items Mr Ospina could not take into the room, so he allowed
him to take the bags in and he did not check them. He was tasked with calming Mr
Ospina and checking on him twice an hour. He was the only member of staff but
there were no other residents in the care suite at the time so he said he spent most
of the time with Mr Ospina.
54. Around 3.00pm, staff informed the police that Mr Ospina told them he had been
talking to underage girls online.
55. DCO A said that Mr Ospina wanted to know what was going on with his immigration
status and he contacted his colleagues in the welfare team to see if they could help.
They advised him to bring Mr Ospina to them. DCO A said that the visit caused Mr
Ospina some distress, but he did not know the nature of what he was told. Home
Office records show that DET staff spoke to Mr Ospina and they noted he seemed
unsure if he wanted to return to Colombia or stay in the UK. He eventually said he
wanted to stay in the UK.
56. DCO A said that, shortly after arriving back at the care suite after seeing DET staff,
he was asked to bring Mr Ospina to legal visits. DCO A said he was unaware what
the visit was about but, on arrival, he realised that it was a visit from the police. The
police spoke to Mr Ospina in relation to his disclosure that he had been talking to
underage girls online. Mr Ospina had previously been told by staff that they had not
reported this information to the police so this led to him becoming more distressed.
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57. DCO A told the investigator that Mr Ospina was very unsettled when he returned
him to the care suite and he spent time talking to him and calming him down. He
wrote in Mr Ospina’s ACDT paperwork that he was distressed after the police visit.
He said he also verbally informed the duty manager and other colleagues at the
time. A DCM said that she was not made aware that Mr Ospina had been seen by
the police and that his demeanour had changed. Had she known, as ACDT case
manager, she said she would have considered a further review.
58. At around 9.00pm, DCO A handed over to his colleague, DCO B. DCO A told the
investigator that Mr Ospina had calmed down and was talkative with him but he
became distressed again when he realised that DCO A was handing over to
someone else.
59. DCO B told the investigator that Mr Ospina was agitated, pacing the room and
saying that he wanted to call the police. Staff allowed him to do so but they did not
know what Mr Ospina said to the police. The police told the investigator that Mr
Ospina had said he had been grooming children in the UK and he wanted them to
take him out of the Centre so he could show them the evidence. They told him they
were unable to do anything immediately and he said he would be deported if they
left it too late.
60. DCO B said that Mr Ospina did eventually settle down and he took him a hot drink
at around 11.00pm. DCO B continued to check on Mr Ospina at least twice an hour.
He told the investigator that he was concerned about the amount of personal
possessions Mr Ospina had in his room, but he did not feel it was his place to
remove any of them.
Events of 26 March
61. CCTV shows that DCO B carried out checks on Mr Ospina at 7.22am, 7.42am and
7.52am. CCTV shows that at 7.22am, DCO B looked into the room and cupped his
hands around his face as though he was trying to get a better view. He did not do
this for the subsequent checks, which consisted of a quick glance into the room.
There was no light in the room and the main lights on the unit were off. DCO B said
that he did not use a torch for any of the checks as he said he did not want to
disturb Mr Ospina. DCO B was confident that he saw Mr Ospina lying in his bed
during all the checks he conducted during the night and early morning of 26 March
and he had no concerns about him.
62. DCO B handed over to DCO A at around 8.00am. DCO A told the investigator that
he briefly looked into Mr Ospina’s room as he was on his way to the handover and
he noticed his bed was empty. He said he asked DCO B how Mr Ospina had been
and he told him that he was fine during the night and he had last checked on him
just before 8.00am. DCO A noted that he would have to do another check at
8.30am and he said he wrote this in the ACDT paperwork as a reminder to do it.
However, he said he was side-tracked doing other work and then went to prepare
Mr Ospina’s breakfast, so he missed the 8.30am check.
63. CCTV shows the main lights on the unit came on at 8.31am. DCO A went to Mr
Ospina’s room at 9.03am and opened the door but he did not go inside. DCO A told
the investigator he was concerned as Mr Ospina was not in his room and he noticed
that his bed was the same as when he had looked in earlier. He called out to him
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but he did not respond so he closed the door and went to call colleagues to help.
DCO A said that he thought it was unsafe to go further into the room without the
support of a colleague as this is what he had been trained to do when working in
the Care and Separation Unit (CSU) which is used for more volatile residents.
64. CCTV timings show that it was a further 13 minutes before DCO A’s colleague,
DCO C, arrived. At 9.16am, they both went into Mr Ospina’s room and found Mr
Ospina lying on the floor of the bathroom with a scarf tied around his neck. DCO A
said he was certain that Mr Ospina had been dead for some time as he appeared
stiff and cold with signs of rigor mortis. No one called a medical emergency code
but DCO A said he and DCO C called other members of staff to attend and phoned
the control room.
65. A Duty Shift Manager attended at 9.18am. She removed the ligature from Mr
Ospina’s neck and told staff to start CPR. Another member of staff went to call a
nurse from a nearby clinic who attended with the emergency bag at 9.22am and
continued CPR even though there were clear signs that Mr Ospina had been dead
for some time. Paramedics arrived and declared, at 9.47am, that Mr Ospina was
dead. Body worn camera footage records paramedics confirming that Mr Ospina
had signs of rigor mortis and staining on his body suggesting he had been dead for
some time.
Contact with Mr Ospina’s family
66. Mr Ospina did not provide a named next of kin when he arrived at Colnbrook and
this resulted in a delay in informing his family that he had died. The investigator was
told that although Mr Ospina’s mother had dropped his passport at the centre, she
had not visited her son and so her details were not recorded in his file. With
assistance from the Colombian Consulate, the Home Office’s family liaison officer
spoke to Mr Ospina’s mother on the telephone on 29 March, although Consulate
staff had already made her aware of her son’s death by that time. Mr Ospina’s
mother asked that staff at the Colombian Consulate act on her behalf.
67. The Home Office assisted in the arrangements and financial cost of repatriating Mr
Ospina to Colombia for his funeral.
Support for detainees and staff
68. An IRC manager debriefed the staff involved in the emergency response to ensure
they had the opportunity to discuss any issues arising, and to offer support. The
staff care team also offered support. However, DCO A said he did not feel
sufficiently supported. He said he was not offered the opportunity to go off duty and
was asked to attend an interview in the care suite while Mr Ospina’s body was
being removed.
69. The IRC posted notices informing other detainees of Mr Ospina’s death and offered
support. Staff reviewed all detainees assessed as at risk of suicide or self-harm in
case they had been adversely affected by Mr Ospina’s death.
70. In the days following Mr Ospina’s death, detainees staged a protest regarding their
perceived treatment at the IRC.
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Post-mortem report
71. The post-mortem and toxicology reports showed that Mr Ospina died due to
strangulation. The toxicology results showed a high level of his prescribed
antidepressant medication, sertraline, although the toxicologist was unable to
conclude if he had taken an excessive amount immediately before his death.
72. Although evidence indicates that Mr Ospina had been dead for some time by the
time he was found, the exact time of death has not been established. However, the
pathologist’s view is that body changes reported by paramedics, such as rigor
mortis and staining, would be unlikely to occur until at least two hours had passed
since the time of death.
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Findings
Management of Mr Ospina’s risk of suicide and self-harm
73. Detention Services Order (DSO) 01/2022 provides instruction and guidance for
identifying and supporting individuals in detention who may be at risk of suicide or
self-harm. Any individual identified as at risk of suicide or self-harm must be
managed using the Assessment Care in Detention and Teamwork (ACDT)
procedures.
74. Mr Ospina was supported using ACDT procedures from 22 March, when he jumped
from the balcony, until his death on 26 March.
ACDT observations
75. On the day he was found dead, Mr Ospina should have been checked twice an
hour. The ACDT paperwork records that a check was made on Mr Ospina at
8.30am but CCTV shows that it did not happen. Mr Ospina had not been checked
for over an hour, between 7.52am and 9.03am, when he was found dead. DCO A
said he had recorded the 8.30am check to remind him to do it but had then got side-
tracked and not done it. This practice is unacceptable. In fact, Mr Ospina should
have been unlocked at 8.30am, but DCO A was unaware of this as he usually
worked in the CSU, where prisoners remained locked in their rooms. He said he
was unaware of the regime in the care suite.
76. Mr Ospina had rigor mortis when he was found, which suggests that he had been
dead for at least two hours. This casts serious doubt on DCO B’s account that he
had seen Mr Ospina lying in his bed when he checked on him at 7.22am, 7.42am
and 7.52am. The unit was dark, there was no light on in Mr Ospina’s room and
DCO B did not use a torch so we doubt that he could have seen Mr Ospina clearly.
77. We recommend:
The Centre Manager should ensure that staff understand their responsibilities
when carrying out ACDT observations, including that they:
• obtain a clear visual sighting of the detainee using a torch if necessary;
and
• accurately record the time of the check once they have completed it.
ACDT management
78. DSO 01/2022 says that healthcare staff should be invited to all case reviews and
that DET staff should be invited if considered relevant. Written contributions should
be provided if staff are unable to attend.
79. We found that healthcare staff attended only one review and provided verbal input
to another. They provided no input at all to the first case review, at which staff
decided to stop constant supervision and set observations at one an hour. DSO
01/2022 says that healthcare staff must attend the case review held after a detainee
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is placed under constant supervision. The Head of Healthcare told us that
healthcare staff were only available to attend ACDT reviews between 10.00am and
12.00pm. We note that the case review was held at 4.00pm. Nine other residents
were subject to ACDT procedures at the same time as Mr Ospina.
80. We consider that DET staff were relevant to Mr Ospina’s case and should have
been invited to all case reviews. They attended none and provided written input to
only one. The value of multidisciplinary reviews in the effective management of
suicide and self-harm risk is self-evident. Given the relatively low numbers of
residents managed under ACDT procedures at the time of Mr Ospina’s death and
yet the apparent difficulties in arranging reviews when relevant staff can attend, we
make the following recommendation:
The Centre Manager should ensure that ACDT reviews are multidisciplinary
with input from healthcare and any other relevant staff, including DET.
81. DSO 01/22 says, “Consider the location of any possessions which might be used to
self-harm and may need to be removed from the individual. Removal of items
should never be automatic and should be kept to a minimum as it can have a
negative impact on wellbeing. Decisions relating to the removal of items must be
fully defensible and must be recorded in the ACDT plan at the point the decision is
taken…”
82. Staff noted that Mr Ospina should have supervised shaves but there is no record
that they removed any other items from him. While we note that Mr Ospina used his
own scarf to strangle himself, it does not appear that there would have been
justification to remove this item, and similar items, from him. Up to being found
dead, he had not used any clothing as ligatures.
Rule 35 – review of detention for adults at risk
83. Despite Mr Ospina jumping from a balcony on 22 March and telling staff that he
wanted to die, a Rule 35 report was never completed for him. On 24 March, Mr
Ospina again told staff that he was having thoughts of suicide but again, no Rule 35
report was submitted. This meant that Mr Ospina’s detention was not reviewed by
Home Office staff to assess whether his continued detention was appropriate.
84. When the investigator asked the Head of Healthcare why a Rule 35 report had not
been submitted for Mr Ospina, he said that Mr Ospina had always denied suicidal
intent and they had no reason to doubt him. He also said that there were delays in
getting an appointment with a doctor and a backlog of Rule 35 reports awaiting a
decision from the Home Office.
85. The failure to complete Rule 35 reports is an issue that has been highlighted by HM
Inspectorate of Prisons following its inspections of Colnbrook in both 2018 and in
2022. During its 2018 inspection, inspectors found that Rule 35 reports were rarely
submitted for detainees who were suicidal. They recommended that Rule 35 reports
should be monitored to ensure that they were submitted when necessary. However,
the 2022 inspection found that this had not been achieved. Inspectors found that
there were insufficient safeguards against the detention of detainees with suicidal
thoughts and Rule 35 reports were seldom prepared when necessary. The Home
Office’s Service Improvement Plan issued in response to the recommendations said
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that a training pack had been developed for medical practitioners across the
immigration detention estate and delivery was expected to start in summer 2022. It
also said that the healthcare provider was aware of the concerns in this area and
was actively working with the Home Office to address them.
86. We note that following its latest annual review of Rule 35, the Independent Chief
Inspector of Borders and Immigration found that this important safeguard was not
working consistently or effectively. Inspectors reported that there were
disproportionately high volumes of Rule 35 reports concerned with torture in
comparison with exceptionally low volumes of Rule 35 reports relating to suicidal
intentions. While there is a requirement for nurses and healthcare professionals to
report to an IRC doctor any detainee who claims to be a victim of torture, there is no
requirement for them to do so for detainees with suicidal intentions.
87. Mr Ospina self-harmed while at Colnbrook and told staff he wanted to die. We
consider that staff should not have taken Mr Ospina’s subsequent denial that he
had suicidal intent at face value and instead considered whether he was at risk of
suicide based on his actions and known risk factors. We consider that Mr Ospina’s
behaviour indicated that he was particularly vulnerable, and his detention should
have been reviewed. We consider that there needs to be more clarity in policy
guidance about what suicidal intentions means and also that nurses and healthcare
professionals should be required to report detainees with suicidal intentions to an
IRC doctor.
88. We recommend:
The Home Office should amend DSO 09/2016 so that it:
• is clear about what suicidal intentions means;
• requires nurses and other healthcare professionals to report to a
doctor any detainee who is showing suicidal intentions.
The Home Office should review the training provided to IRC staff on Rule 35
reports, particularly for those at risk of suicide.
Clinical care
89. The clinical reviewer concluded that Mr Ospina’s physical and mental health care
was at least equivalent to that which he could have expected to receive in the
community. She considered that the mental health care provided was of a good
standard and provided within an appropriate time frame.
Centre Manager to note
Emergency response
90. DCO A was confused about the guidance on entering a detainee’s room as he had
only worked in the CSU where staff are told not to go into a room alone. He
therefore tried to contact colleagues to assist him as he was alone in the care suite
and had no experience working there. As a result, there was a delay of 13 minutes
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between DCO A becoming concerned about Mr Ospina and staff entering his room.
It made no difference in this case as Mr Ospina had been dead for some time, but a
delay could be crucial in a future medical emergency. We make the Centre
Manager aware of this issue.
91. When staff found Mr Ospina, there were clear signs that he had been dead for
some time as he was stiff and cold. The Duty Shift Manager told staff to start CPR
and, when healthcare staff arrived, they continued CPR. While we recognise the
challenging circumstances in which decisions such as this are made, there is clear
guidance from the Royal College of Nursing (RCN) that CPR should not be carried
out when it would be futile.
Staff training
92. The Centre Manager may wish to review the training and guidance provided to staff
working in the care suite to ensure that they are fully aware of the regime, carry out
their duties with confidence, and appropriately observe vulnerable detainees.
Support for staff
93. DCO A said he did not feel sufficiently supported. He said he was not offered the
opportunity to go off duty and was asked to attend an interview in the care suite
while Mr Ospina’s body was being removed. The Centre Manager will wish to
consider how staff are supported following a death.
Inquest
94. At the inquest, held from 30 September to 11 October 2024, the jury concluded that
Mr Ospina died by suicide. The jury found multiple failings that contributed to his
death and considered there were missed opportunities to provide more appropriate
and responsive care given the severity of his mental health crisis. These included:
• Failure to submit a Rule 35 report which deprived Mr Ospina of a review of his
detention.
• Mr Ospina being allowed only a closed visit which contributed to the
deterioration in his mental health.
• Mitie’s security staff did not communicate with staff directly responsible for Mr
Ospina’s care that they had reported his disclosure to police, which meant that
staff could not mitigate the impact of the police interview on Mr Ospina’s mental
health.
• Unacceptably inadequate observations on 25 and 26 March that failed to
recognise that Mr Ospina was not in his bed.
• Lack of risk assessment and review of items in his possession when Mr Ospina
was sent to the care suite.
• Insufficient urgent mental health care when Mr Ospina reported suicidal
thoughts.
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