Published on 29 May 2025
Victor Hugo Pereira Vargas. Photo: Family handout
Staff at hotel were ‘not appropriately trained’ and Home Office officials didn’t know who was providing crucial services
Reports Aaron Walawalkar and Harriet Clugston, for Liberty Investigates, and Holly Bancroft for the Independent.
Government officials were unaware that the staffing of an asylum hotel where a resident killed himself had been subcontracted to a company whose employees lacked compulsory safeguarding training, an inquest has heard.
Lawyers for the family of Victor Hugo Pereira Vargas, who was found dead in his hotel room in Hailsham, Sussex, on 13 October 2023, say the Home Office failed to put in place proactive systems to ensure frontline staff had been trained in safeguarding and suicide awareness, and that this remains a “real and obvious risk to life”.
But they were left disappointed after the coroner declined to issue a prevention of future deaths (PFD) report, which would have placed a legal duty on the Home Office to take action to avoid similar fatalities.
East Sussex assistant coroner Michael Spencer ruled the 63-year-old Colombian bled to death after wounding his throat following weeks of deterioration in his mental health, in which he told his son several times he was afraid of being moved to the Bibby Stockholm barge – described by critics as a “floating prison” – after fellow residents were allegedly removed to it.
While Victor’s door had been blocked from the inside, Spencer said he could not be sure he intended to kill himself as he did not leave a note nor express suicidal intent to others.
Instead of a formal suicide verdict, the coroner recorded in a narrative conclusion that Victor “died from self-inflicted injuries whilst suffering from extreme anxiety and distress”.
Other Spanish-speaking former residents of the hotel told the court they noticed Victor become increasingly erratic and paranoid during his time there, reporting he would regularly block his door and express concerns about microphones in his clothing. His former roommate was moved to another room after becoming alarmed by Victor’s behaviour.
But these signs were missed by inadequately trained staff who conducted welfare checks onsite – the thoroughness of which was questioned by the coroner. Staff also failed to help Victor file a police report about a robbery he suffered, and took two weeks to book him a GP mental health appointment once asked.
Clearsprings Ready Homes, the private firm that holds the Home Office asylum accommodation contract for the south of England, had subcontracted the running of Victor’s hotel to another company – Crown Lodge Accommodation Limited.
Crown Lodge then outsourced the staffing to a third company, Becker Hoffman Facilities Management Limited – without the knowledge of government officials responsible for overseeing Clearsprings’ contract.
Victor arrived in the UK and claimed asylum on 4 August 2023, explaining to family he had to flee Colombia after being attacked with a machete.
He later changed his mind and sought to voluntarily return home, telling the Home Office he was suffering from anxiety in his hotel – the Boship Lions Farm in Hailsham. The hotel is no longer hosting asylum seekers.
In a statement read to the court, Victor’s son Michael said he was unaware of his “sociable and easygoing” father having any mental health issues prior to arriving in Britain, but that he had relayed numerous complaints about the hotel to him, including the cold, the poor quality food and the feeling of isolation due to its distance from the nearest town.
Michael said: “I don’t understand what happened or why no one took care of him when he went there in the first place to find safety. He was already stressed about the situation, and he needed help.”
On 9 August, Michael received a voice note from his dad in which he “sounded really worried” after seeing news of the then Conservative government “putting people on a boat” – an apparent reference to the Bibby Stockholm.
On 12 August, he received another saying that people are “talking about it everyday”. Victor said: “What are they going to do with the people? Are they going to put them in jail? Because that was a maritime prison.”
The controversial vessel was used to house hundreds of asylum seekers between August 2023 and November 2024, during which time one young man died by suspected suicide, potentially deadly bacteria was discovered in the water, and fire safety concerns were raised.
Under the Asylum Accommodation and Support Contract (AASC), Clearsprings is required to ensure all staff who interact with asylum seekers are trained in areas including safeguarding and suicide awareness.
Previous reporting by the human rights journalism unit Liberty Investigates has revealed the Home Office’s lists of subcontractors used by its three key asylum accommodation providers – which the firms are contractually obligated to keep updated – are five years out of date.
Steven Lakey, Clearsprings’ managing director, told the court the company came to rely on subcontractors as an emergency measure to cope with an unforeseen rapid increase in small boat arrivals shortly before the coronavirus pandemic.
The court heard that the Home Office and Clearsprings relied on assurances from Crown Lodge that staff were trained, while Crown Lodge in turn relied on similar assurances from Becker Hoffman – but did not seek further verification such as copies of certificates.
During the inquest proceedings, lawyers representing each party were frequently confused about who had a contractual duty for safeguarding when questioned by the coroner.
Becker Hoffman’s onsite staff – responsible for checking on resident’s welfare once a week – were “not appropriately trained,” the coroner concluded.
One staff member, who conducted the final two welfare checks prior to Victor’s death, had received no formal training whatsoever.
This staff member variously recorded that Victor had “no issues” and was “in good condition,” which contrasted with testimonies from several fellow residents alarmed by his increasing paranoia.
Assistant Coroner Michael Spencer expressed doubt as to whether staff really carried out all their checks as described and if they involved a detailed face-to-face conversation.
One welfare check was recorded to have taken place “face-to-face” with Victor on 25 September, despite Victor having left the hotel for an airport in a desperate, unsuccessful attempt to leave Britain by his own means.
After returning to the hotel, Victor told staff he had been robbed of his wallet by a group of fellow Colombians. The court heard suggestions that staff helped Victor report the crime to the police, but the coroner concluded this was not true as the police had no record of the incident.
The court was also told hotel staff were advised to book a mental health GP appointment for Victor on 11 September, after he told them he had not slept for three days, but did not do so until two weeks later – despite incorrectly logging they had booked it right away.
When Victor eventually received a text from the GP to arrange an appointment, he responded in Spanish saying he had no mental health issues.
He was however seen regarding a physical health complaint by a GP contracted for weekly hotel visits, though she told the court she could not recall being informed of any mental health issues and that Victor appeared “well in himself”.
The coroner said that “it is possible these factors cumulatively contributed to [Victor’s] decline and death”, in addition to his experience of trauma in his home country, his sense of isolation at the hotel, and desperation to leave the UK.
Had there been better welfare checks and assistance accessing a GP, it is possible Victor may have engaged and been given treatment, the coroner said, although this could not be certain.
“This deficit creates a real and obvious risk to the life of residents [...] underscored by the high incidence of mental illness and suicidality amongst the asylum seeker cohort”.
Following the conclusion of the inquest, lawyers for Victor’s family called on the coroner to issue a prevention of future deaths (PFD) report.
In written submissions lawyers said the Home Office had failed to set out what – if any – proactive systems are now in place to ensure all its face-to-face staff are compliant with training requirements.
“This deficit creates a real and obvious risk to the life of residents […] underscored by the high incidence of mental illness and suicidality amongst the asylum seeker cohort,” solicitors wrote.
Home Office lawyers said the department had made changes since the death, including having the safeguarding team conduct unannounced audits of accommodation providers.
The department also pointed out the statutory role of the Independent Chief Inspector of Borders in conducting periodic inspections of asylum accommodation.
The family’s lawyers said these safeguards were “plainly insufficient” due to their ad hoc nature.
After deciding not to issue a report last month, the coroner said: “I am [unable] to conclude on balance that the circumstances currently give a risk of future deaths […] That is not to say that there are no concerns, but to the extent that there are in my view they will need to be addressed through other channels.”
A Home Office spokesperson said: “This was a tragic incident and our thoughts are with Mr Vargas’ family and friends.” The department’s accommodation providers “maintain high standards and follow established standard procedures to manage [resident’s] safety, security and wellbeing”, they added.
Clearsprings Ready Homes declined to comment while a spokesperson for Crown Lodge said the firm was “deeply saddened” by the incident and would not comment further “out of respect for the individual and their loved ones”.
A version of this report was published with the Independent.