Home Office still hasn’t followed 2019 advice on preventing detainee deaths, docs suggest

Harmondsworth Immigration Removal Centre in Middlesex UK
Safety measures were recommended following two suicide attempts at Heathrow detention centre four years ago

Reports Aaron Walawalkar and Harriet Clugston for Liberty Investigates and Open Democracy.


The Home Office has still not implemented measures to prevent deaths at a Heathrow immigration removal centre recommended after two suicide attempts four years ago, documents suggest.

Liberty Investigates and openDemocracy have obtained minutes and slides from meetings discussing self-harm incidents at Heathrow’s two IRCs, Harmondsworth and Colnbrook, where 39-year-old Frank Ospina died in March. The documents appear to contain the first official reference to Ospina’s death having been self-inflicted, and shed light on what critics describe as the Home Office’s “complete failure” to identify and protect vulnerable people in detention.

This week we revealed detainees in Harmondsworth staged a protest described by security staff as an “attempted mass suicide” two days after Ospina’s death.

Our investigation also found Home Office staff and senior detention centre managers did not, despite being invited, turn up to a key safety meeting in the wake of Ospina’s death and the protest – over five years after inspectors first highlighted poor attendance at such meetings. A spokesperson for Mitie, the private firm that runs both of the IRCs, said attendees were in line with “normal meeting procedures”.

The revelations add to mounting pressure on the Home Office to halt plans to expand the detention estate and come days before the UK’s first public inquiry into alleged violent abuses in immigration detention publishes its report.

Frank Ospina was found dead in Colnbrook IRC on 26 March 2023. Image: Adrian Dennis/AFP via Getty Images / Instagram

Nasrin Warsame, a policy and research coordinator at Bail for Immigration Detainees, said: “Given the government’s plan to expand the detention estate and detain and deport all new small boat arrivals through the Illegal Migration Act, the growing cohort of people detained will likely be more vulnerable people, such as people escaping from war, persecution, and victims of trafficking.

“Our government should be working to ensure people who arrive receive safety, dignity and welcome, not actively facilitating the opposite.”

Minutes from a meeting on 27 April record a safer community manager’s wider concerns that “staff are failing to identify residents that are vulnerable which in turn means that the resident is not provided with the correct care while in detention.”

Safer community meetings within detention centres are meant to provide an opportunity for staff to discuss serious cases of violence and self-harm with a view to learning lessons and preventing future incidents.

Yet only four out of the 20 staff invited to the safer community meeting on 27 April showed up, an attendance log shows. All three Home Office representatives eligible to attend sent apologies, as did senior employees at Mitie including the “centre manager”, “deputy centre manager” and “head of regimes-safer community”.

Past inspection reports of Harmondsworth in 2017 and Colnbrook in 2018 have raised concerns over “poor” and “inconsistent” attendance of these meetings.

A "near miss recommendation log" from the April 2023 safer community meeting. Credit: FOI

A slideshow presented at the meeting also reveals how recommendations to prevent deaths made in 2019, 2020 and 2022 have still not been implemented.

A Mitie spokesperson said costs for carrying out the work recommended in 2019 were submitted to the Home Office, which is responsible for deciding when maintenance works take place.

They denied the 2022 recommendations were still outstanding, saying it had been decided at least one of the measures identified was unnecessary, but that their slides had not been updated to reflect this. They also insisted the 2020 advice had been implemented as much as necessary. They did not explain why slides from the firm’s internal presentation listed this action as outstanding. When asked, the Home Office did not comment on why the 2019 recommendations have not been implemented.

The meeting came after a total of 24 self-harm incidents in March, more than the previous three months combined (21).

Yet official figures show not a single medical report flagging detainees at risk of suicide, which could lead to their release by the Home Office under a legal mechanism called Rule 35, was issued at Colnbrook or Harmondsworth between January and March 2023.

Emma Ginn, director of Medical Justice, a non-profit that sends doctors into detention centres, said: “It is clear that lessons are not being learnt and vulnerable people in detention continue to be failed by the system that should identify and protect them.”

She added: “The evidence could not be clearer. We have been warning the Home Office about this complete failure of clinical safeguards in no uncertain terms since Medical Justice was founded in 2005.”

A slide from the April 2023 safer community meeting. Credit: FOI

The Home Office said it would not comment on the details of Ospina’s death while investigations take place and a coroner has not yet made a ruling on how he died. But a spokesperson for Mitie pointed to the location of his death within the IRC as proof his mental state was being monitored.

“[The care] suite is only used for those who are identified as vulnerable, demonstrating that Mr Ospina’s vulnerability had been assessed,” the spokesperson said.

An investigation by the BBC has unearthed claims from Ospina’s family that he had begged for help and was willing to leave the UK.

The engineering graduate is reported to have been visiting his mother in the UK before starting a master’s degree in Spain when he was detained on 3 March for taking on a short-term job washing dishes without the right to work.

His sister, Tatiana, and brother-in-law, Julian Llano, who live in Chile, told the broadcaster he had no existing mental health problems but that his condition rapidly deteriorated in detention.

“He was hard-working and very intelligent. They took him to the limit of sanity,” Tatiana said.

“He kept insisting that he felt very bad, mentally, that he needed to get out of there,” Julian says. “He didn’t ask for help – he begged for help, not only to us, but also to the people there.”

A Home Office spokesperson said: “Our thoughts and condolences are with the family and friends of Mr Ospina. The welfare of all those in our care is of the utmost importance. Any death in immigration detention is a tragic event, and will be subject to investigation by the police, the coroner and the independent Prisons and Probation Ombudsman.

  • In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.

This story was also published by openDemocracy and internal documents shared with the BBC.