Last week, a jury at the inquest into the death of American tourist Brian Dalrymple, who died after being detained at the Harmondsworth Immigration Removal Centre (pictured), delivered a verdict of ‘natural causes contributed to by neglect’. The jury’s verdict amounted to a finding that there were gross failures in the medical care Brian received which caused or contributed to his death.

The jury also gave a narrative verdict in which they set out their findings on the evidence. We hope there will be a Prevention of Future Deaths report from the coroner in due course which will identify lessons to be learned.

As with most deaths in detention, the inquest had to be ‘article 2 compliant’ – that is, the coroner had to investigate not only ‘how’ but also ‘in what circumstances’ the death occurred. He sat with a jury over a period of two weeks. The inquest heard evidence from detention centre and healthcare staff, immigration officials and medical experts. They detailed a catalogue of errors in Brian’s care, highlighting limited mental health training, shambolic medical record-keeping, inadequate systems and poor clinical and psychiatric care.

Brian suffered from schizophrenia, and severe hypertension. He arrived in the UK as a tourist on 14 June 2011 but was refused leave to enter because his behaviour was considered ‘odd’. UK Border Agency staff therefore detained him at Harmondsworth, pending removal back to the US. The chief immigration officer at Heathrow had significant concerns about Brian’s mental health and this led him to make repeated requests to the Home Office unit based at Harmondsworth for a psychiatric assessment. It appears his requests may not have been passed on to those responsible for Brian’s care at Harmondsworth. 

No psychiatric assessment was ever carried out despite the deterioration of his mental health, and his mental capacity was not considered in the detention centre when Brian refused to accept life-saving medication for his hypertension.

An expert cardiologist instructed by the coroner told the inquest that Brian’s blood pressure had been ‘ridiculous’ and in 30 years he had only seen a few that were that high. It was a ‘medical emergency’, requiring a degree of attention which was not represented by the medical notes. The inquest heard that had Brian been treated as he should have been, his death might well have been preventable.

The expert cardiologist’s evidence was that four to five days of hypertensive medication would likely have decreased Brian’s blood pressure to a normal standard. Despite being aware that Brian had a life-threatening condition, little or no attempt was made to treat this.  When his physical condition became critical no attempt was made to assess his mental capacity to refuse medication.

Just three and a half days before Brian died, he was transferred from Harmondsworth to another detention centre, Colnbrook. He was transferred without his medical records but Colnbrook staff immediately identified him as being mentally ill. By the time they had arranged a psychiatrist, however, Brian was dead. His blood pressure had caused an aortic rupture which was instantly fatal.

Evidence suggests that there was a failure to apply safe systems. The GP in Harmondsworth was a locum and had had no induction training. He was unaware he could access wing records which may identify concerns of operational staff regarding detainees, and was unaware of rule 35 of the Detention Centre Rules 2001, which is the key provision imposing a duty on medical practitioners to inform the Home Office of detainees who have medical reasons for being released. The inquest also heard that detention centre staff’s mental health awareness training was limited; leaving them (in the words of one) ‘underequipped’ to deal with vulnerable, mentally ill detainees.

The system of record-keeping was, as the jury recorded, ‘shambolic’. There was no computerised system for storing and accessing medical records; they were all handwritten. The system relied on to detect medical problems, whereby detainees in segregation were seen once a day by medical staff, sometimes for only 20 seconds, was said to be ‘not fit for purpose’ (it was apparently known as the ‘alive or dead’ round because that was all it could test).

An expert to the inquest said that the fact that no clinician had seen Brian at all in the critical nine days between his return from hospital and the period when medication could have saved him, amounted to a ‘lamentable’ failure.

The head of clinical practice at Primecare, which took over responsibility for healthcare from the Practice PLC once the latter’s contract was terminated, described the file-keeping as ‘chaotic’ and said there was an element of firefighting.

The case shines a light on the current state of immigration custody in the UK, highlighting a system that may be incapable of effectively fulfilling its duties under the European Convention of Human Rights. Brian was entirely dependent on the detaining authorities to meet his basic needs and as such the state owed him a duty under article 2 of the ECHR to take reasonable steps to protect his life from real and immediate risks.

The state also owed a duty to have safe systems in place. In the immigration context, the state has devolved these responsibilities to private contractors. Therefore the private companies running Harmondsworth IRC at the time of his detention, GEO UK Ltd, the Practice PLC and Nestor Primecare, all took on these obligations under the ECHR. In effect, they were private bodies carrying out public functions.  

While we were able to agree a financial settlement for Brian’s mother on the eve of the inquest, there has been no admission of responsibility from the private companies involved in his care in detention and, as yet, no apology. One must question, therefore, the extent to which these bodies will take on board the need to change.

There is a further worrying aspect to this case – perhaps connected with the fragmentation of the responsibilities between various providers – which is an apparent lack of a sense of individual officers and healthcare staff taking personal responsibility for detainee welfare. There was certainly no sign of a human rights or welfare culture in Harmondsworth while Brian Dalrymple was there.

The impact of the devolution of such public duties to private companies – whose primary duty is to shareholders and who lack a culture of public service – needs to be properly and urgently assessed. Of course, it is the Home Office which has created this system in the immigration context (although the Ministry of Justice is doing a similar thing in relation to prisons).

It must therefore be primarily for the Home Office to satisfy itself that it is devolving these crucial functions responsibly – that is to suitable bodies with effective systems for protecting the undoubtedly vulnerable people detained in our immigration removal centres.

Jocelyn Cockburn is a partner and Lucy Cadd a solicitor in the civil liberties team at Hodge Jones & Allen. The firm acted for Brian Dalrymple’s family