Migrants in detention ‘faced month long wait for mental health assessments’ when man took his life

Suicidal migrants were facing a month-long wait for GP assessments which could lead to their release from a Heathrow detention centre when a mentally distressed detainee died last year, an inquest has heard.

The lifeless body of Colombian man Frank Ospina, 39, was found at 9.15am on 26 March 2023 inside his cell in Colnbrook Immigration Removal Centre’s care suite, in Heathrow, where he was being kept on suicide watch following multiple self-harm attempts.

Jurors were told the engineering graduate disclosed no health issues when he was locked up for working without a visa on 4 March – but his mental state deteriorated in detention, leading to a first suicide attempt on 22 March, when he jumped over second floor railings.

On Friday (11 October) the jury found Mr Ospina died by suicide involving ligature compression to the neck following a catalogue of failings and “missed opportunities” from the Home Office, healthcare workers and Mitie, the private firm that runs Colnbrook. These included “unacceptably inadequate” monitoring by Philip Dimbleby, the detention officer assigned to check on him twice per hour during the night of his death, which led to his body lying undiscovered for at least two to three hours.

Mitie’s head of security also apologised to Mr Ospina’s mother over the centre’s “unusual” decision to only allow her to see her distressed son through a glass panel, acknowledging an embrace from family is “one of the easiest ways to bring [a suicidal detainee] out of crisis”.

Mr Ospina was described by his mother as an “excellent son” and a “loving and happy person” who adored and was adored by his family. He was spending time near her in the UK before taking up a place on a master’s course in Spain when he was detained, she said.

The inquest at West London Coroner’s Court heard that “a massive backlog” in cases meant healthcare workers at the facility “missed” an opportunity to assess Mr Ospina under the main mechanism by which vulnerable detainees can be released.

Under detention centre Rule 35, a medical professional must report to the Home Office on detainees who are “injuriously affected” by being locked up – which can be due to their suicide risk as well as past experiences of torture.

This should trigger the department to review their detention and make a decision on their release within three days.

Senior Coroner Lydia Brown questioned the centre’s head of healthcare Mark Adjorlolo – who is employed by Practice Plus Group, the private company contracted at the facility – about why no report was done following Mr Ospina’s first suicide attempt.

Adjorlolo said: “Healthcare missed that … We keep a waiting list for Rule 35, when a person requires one. Our waiting list at the time was about four weeks. At some point we had a waiting list of over 100 people.”

He added: “The number of applications we were getting was really high and the number has only increased.” Increased staffing levels and appointment numbers have reduced the waiting list which still stood at 70 people as of Thursday (10 October), he told the court.

He added: “We did not have enough time. I can confidently say that if we had done the Rule 35 on the 22nd or 23rd [of March], then we wouldn’t have had that outcome.”

In a statement Practice Plus Group told Liberty Investigates the waiting list at Heathrow is now one to two weeks. It pointed out there is no legal time limit for completing a Rule 35, which does not guarantee release after the Home Office reviews them, and that urgent mental health issues are best dealt with via good clinical care instead. Mr Ospina was not on the waiting list for an assessment at the time of his death, it confirmed, and his depression was being appropriately treated and monitored, it said.

Mr Adjorlolo told the court however that the company had warned NHS England and the Home Office several times that demand was too great and extra resources were needed. Staff were left trying to “buy some time” by placing detainees on a care plan while they awaited a Rule 35 appointment, he said.

Dr Irfan Syed, a GP who treated Mr Ospina after his 22 March suicide attempt, told the court he did not conduct a Rule 35 amid the “intense pressure” to comprehensively deal with detainees’ health in 15-minute appointments.

Giving their verdict, jurors found “the failure to submit a rule 35 report despite meeting the criteria deprived [Frank] of the opportunity of a detention review”. Mitie staffs’ failure to follow risk assessment procedures also led to a missed opportunity to remove possessions that posed a suicide risk.

The court also heard how an internal Home Office “failure” meant Mr Ospina was also not considered for release under a second safeguarding mechanism, whereby custody officers alert the department to “material changes” in detainees’ circumstances, such as a suicide attempt.

Frances Hardy, the Home Office’s deputy director of detention services, told jurors that four updates were sent about Mr Ospina’s suicide risk in the four days before his death – but each time Home Office staff failed to forward them to his case worker and no assessment was made.

An internal Home Office investigation was unable to establish the reason for this error, Hardy added.

Emma Ginn, director of charity Medical Justice, whose doctors support people in removal centres, said the Home Office had recently weakened its already “failing” clinical safeguards while planning an expansion to the detention estate – a move she described as “beyond comprehension”.

“The Home Office cannot keep saying that it takes every detained person’s safety seriously – it is patently not true,” she said. “Immigration detention is known to cause severe harm. It’s not a matter of ‘if’, but ‘when’ the next person dies.”

In April the Conservative government amended rules governing the imprisonment of migrants with vulnerabilities such as mental health problems, removing its goal of reducing the number detained. The Home Office stated at the time that since it planned to increase the number of migrants detained as a whole, “logically” the number of vulnerable people imprisoned would rise too.

The new Labour government has since announced plans to increase detention places by opening two new detention centres.

A statement read on behalf of Mr Ospina’s Spanish-speaking mother, who left the court in tears on the first morning of the inquest, described her struggle to book a visit with her son over the phone. Matthew Webb, Mitie head of security, confirmed translation services are not provided to help with bookings.

After then turning up unannounced the day of her son’s first suicide attempt, Mrs Ospina was eventually allowed a “closed visit”, which takes place behind a glass screen and is normally reserved for detainees deemed a risk to visitors or suspected of smuggling in contraband, said Webb, who admitted this was not “appropriate” in Frank’s case. Mrs Ospina, who is also Colombian but lives in the UK, said it had made her feel as though she were visiting a convict in prison.

Mrs Ospina said: “I was horrified, as I did not recognise my son. He was staring at me as if I was not there. Almost like he was looking right through me. I felt as though my son had lost his mind so to speak. I felt helpless.”

She added: “”That would have been the last opportunity I had to embrace my son but I couldn’t … I left more distraught than before I arrived.”

A Home Office spokesperson said: “We offer our sincere condolences to Mr Ospina’s loved ones, and we deeply regret any missed opportunities to respond to his mental health needs.

“Since Mr Ospina’s death, we have taken a number of actions to improve the safeguards for individuals in detention. This includes an increase in staffing numbers, training and guidance for staff.

“We will listen to the coroner’s recommendations on what more can be done and will take appropriate action, including reviewing the current process for communicating risk and vulnerability of detained individuals.”

A Mitie spokesperson said: “Our sympathies are with Mr Ospina’s family at this difficult time.

“The physical and mental wellbeing of those in our care is of the utmost importance to us. We accept that the decision to place Mr Ospina’s family in a closed room for their visit was wrong and not in accordance with our policies and procedures, and we have apologised for this.

“A number of measures have already been implemented and we will continue working with the Home Office and Practice Plus Group to address the matters raised by the Coroner.”

Practice Plus Group said: “We would like to express our deepest sympathies to the family of Mr Ospina. We take our role of providing healthcare to people detained in immigration removal centres extremely seriously. Our aim is to provide care that is equivalent to NHS provision in the community and we were pleased that the Prisons and Probation Ombudsman noted this had been achieved in this case, and that the mental health provision was good.

“We continually strive to improve the service we provide and to work closely with the Home Office and NHS England to meet the needs of this vulnerable population of patients with very complex needs.”

When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org  to find your nearest branch.

A version of this article was published with inews.