Abuses at the IRC likely amounted to mistreatment contrary to Article 3 of the European Convention on Human Rights
A report published today by the Brook House Inquiry presents the results of a comprehensive investigation into the mistreatment of detainees at Brook House immigration removal centre (IRC) following a BBC Panorama programme broadcast in 2017.
The report is in three volumes, totalling over 700 pages. You can access it from here on the Brook House Inquiry website or from here on GOV.UK. The investigation covers the period between 1 April 2017 and 31 August 2017 at the IRC located in the grounds of Gatwick Airport. At the time, the IRC was operated by the contractor G4S.
A helpful summary is available courtesy of the 8-page statement made by Kate Eves, the chair of the Brook House Inquiry, on the launch of the report. It is reproduced in full below.
Eves said the report reveals a "toxic" culture at the IRC, with credible evidence that detainees suffered mistreatment contrary to Article 3 of the European Convention on Human Rights (ECHR). Brook House was prison-like and entirely unsuitable for detaining people for anything other than a short period of time. Staff used force inappropriately, and used dehumanising, abusive, racist and derogatory language. Management was dysfunctional.
The charity Medical Justice said in summing up the findings of the report: "The [Brook House Inquiry] has exposed the inexcusable and unconscionable dehumanising abuse of vulnerable people held in immigration detention by the Home Office. The Inquiry has found the safeguarding system in detention to be 'dysfunctional', resulting in a failure to protect detained people as intended. Vulnerable people were exposed to the risk of mistreatment and were subjected to actual harm; there were 19 incidents of credible breaches of Article 3 of the ECHR, which prohibits torture, inhuman and degrading treatment within a 5 month period. … [P]eople were found to have been 'allowed to deteriorate' in their mental and physical health. Such failures were found to be interlinked with the inappropriate use of segregation and a quick resort to the use of force to manage incidents of self-harm and mental health crises. Healthcare failures put vulnerable people at risk of deteriorating in their health, and of instances of mistreatment."
As a result of her findings, Kate Eves makes a number of important recommendations on immigration detention in general, including the introduction of a 28-day time limit.
Eves noted in her launch statement: "I also heard evidence that the indefinite nature of immigration detention caused uncertainty and anxiety for detained people and had a detrimental effect on their wellbeing. There was no maximum period for which someone could be detained at Brook House or any other Immigration Removal Centre. This remains the case today. People should not be held indefinitely for immigration purposes in an environment designed to the specification of a prison. Immigration detainees are not prisoners. In light of what I have found, I am recommending that the government introduce a time limit, whereby those detained at Immigration Removal Centres, including Brook House, should only be kept there for a maximum of 28 days."
Eves also recommends that IRCs must not block internet access to websites facilitating the provision of legal advice and representation, which were blocked at Brook House.
A statement by the Home Secretary, Suella Braverman, in response to the Inquiry's report is available here. Braverman said: "The Government takes the welfare and safety of those we detain very seriously and has made significant improvements to immigration detention since the dates covered by the Inquiry. … We will carefully consider the findings of this Inquiry in its detailed report, including the recommendations in relation to the management of the immigration detention estate and the welfare of detained individuals."
A further Home Office statement here outlines the improvements made at Brook House in the wake of the "unacceptable" events in 2017. The Home Office says it remains committed to ensuring safety and security in all IRCs and to learn lessons from Brook House to ensure that such events never happen again.
David Neal, the Independent Chief Inspector of Borders and Immigration, wrote in an opinion piece for the Guardian, however: "[O]ver the last two years … I have issued my own reports, with findings similar to those published in the Brook House inquiry – and found that little has changed as a result. … The Home Office's responses to my reports have been characterised by defensiveness and excuses rather than a commitment to improvement and positive change."
Kate Eves full launch statement for today's report follows below:
Chair's launch statement
1. Good afternoon. I am today publishing my report into the mistreatment of detained people at Brook House in 2017. It comes at the end of more than three years of investigation, evidence gathering and consideration. The report provides a detailed account of what happened at Brook House and why. It contains 33 important recommendations which, when implemented, will not only ensure that what happened at Brook House does not happen in the future but will also provide a more humane, compassionate and professional environment for immigration detention.
2. This Inquiry was announced in November 2019, just over two years after a Panorama programme exposed shocking treatment of detained people at Brook House. I am conscious that the process of a public inquiry can involve recalling difficult experiences and may be retraumatising for those involved. I therefore wish to acknowledge all of those who provided witness statements to the Inquiry, and who gave evidence in person at the hearings. In particular, I would like to recognise the courage of those who came forward who were detained at Brook House.
3. I would urge readers of the report to consider it in conjunction with the footage of Brook House that the Inquiry has published on its YouTube site. The footage is often very distressing to watch but acts as a visceral reminder of the suffering that some people had to endure during that time.
4. Places of detention are the hidden spaces in our society. As I said in my Opening Statement, most of us will have no experience of being incarcerated or of working in such an environment. They are places where isolation from loved ones is a fact of life, where communication is restricted and where rights and freedoms are curtailed. Detention can take a toll on both physical and mental wellbeing. There is no higher role for the state than as a guardian of those who are detained and in its care. For people who do not have citizenship, their precarious status makes them inherently more vulnerable and factors such as language barriers or poor health can intersect to make them yet more susceptible to harm.
5. An essential part of this Inquiry has been to reach conclusions about the mistreatment of detained people at Brook House between April and August 2017 where there is credible evidence that it occurred. Specifically, my Terms of Reference define mistreatment as treatment "that is contrary to Article 3" of the European Convention on Human Rights, which states "No one shall be subjected to torture or inhuman or degrading treatment or punishment'.
6. I have identified 19 instances in which I consider there is credible evidence of acts or omissions that were capable of amounting to mistreatment which is contrary to Article 3. Those incidents are discussed in detail in my report but I will briefly set out the nature of them now:
a. the most serious incident involved the application of pressure to a detained man's neck while he was in extreme distress;
b. other incidents included the repeated use of an inherently dangerous restraint technique, which has previously been associated with the death of a detained man, Jimmy Mubenga, in 2010;
c. there were instances of men being forcibly moved when they were naked or near naked;
d. force was used inappropriately, sometimes on people who were harming themselves;
e. unnecessary pain was inflicted on men during use of force incidents;
f. humiliating remarks were made towards men who were self-harming or being treated for a medical emergency;
g. segregation was used inappropriately and there were occasions where threatening or derogatory language was used towards men who were extremely vulnerable;
h. in one incident there was a failure to adequately respond to a detained man who had been found with a ligature around his neck;
i. I also saw evidence of physical violence by staff against detained people.
7. That I found this number of incidents took place within such a limited timeframe of five months is of significant concern. In my view, these incidents were able to happen because of a combination of factors. Under the Home Office and its contractor, G4S, Brook House was not sufficiently decent, secure or caring for detained people or its staff at the time these events took place. An environment flourished in which unacceptable treatment became more likely.
8. The physical environment itself was entirely unsuitable for detaining people for anything other than a short period of time. Some men were held there for more than a year. The building was designed to the specification of a Category B prison; that is one with physical security suitable for managing offenders. The environment was harsh. Men primarily slept in shared cells with poor ventilation and unscreened toilets. There were issues with overcrowding. It was extremely difficult to deliver a decent and humane regime for the men who were detained there. The impact of the prison-like environment was particularly detrimental for those with mental ill health or other vulnerabilities. Indeed, one Home Office manager told the Inquiry that if someone spent more than 24 hours at Brook House "you're going to develop mental health issues. It's not a nice place to be".
9. I also heard evidence that the indefinite nature of immigration detention caused uncertainty and anxiety for detained people and had a detrimental effect on their wellbeing. There was no maximum period for which someone could be detained at Brook House or any other Immigration Removal Centre. This remains the case today. People should not be held indefinitely for immigration purposes in an environment designed to the specification of a prison. Immigration detainees are not prisoners. In light of what I have found, I am recommending that the government introduce a time limit, whereby those detained at Immigration Removal Centres, including Brook House, should only be kept there for a maximum of 28 days.
10. This Inquiry found that, too often, there was a failure to follow the safeguarding rules and procedures that are in place to protect the most vulnerable. For example, I found serious failings in the application of safeguarding rules relating to individuals whose health may be detrimentally impacted by detention, notably around Rules 34 and Rules 35 of the Detention Centre Rules. The rules on when detained people could be segregated were also misunderstood and implemented incorrectly. These failures left detained people exposed to the risk of harm and, in some cases, caused actual harm to be suffered. I am clear that this was not because the safeguards themselves are poor. Rather, there was too often a widespread disregard or a lack of understanding of how to implement them in the way that they were designed. Concerningly, I have also heard evidence that this confusion and flawed implementation may persist.
11. This Inquiry received detailed evidence about how healthcare was delivered in Brook House. There are high levels of mental ill health in the detained population and a significant proportion are likely to be acutely vulnerable, having been victims of torture or exposed to trauma. There can be a heightened risk of self-harm or suicidal ideation. While I do not underestimate the challenges of delivering healthcare in such an environment, I was concerned by the evidence I saw and heard.
12. I found that healthcare staff did not sufficiently understand their safeguarding responsibilities towards detained people, particularly in relation to the use of force, and were too quick to dismiss difficult or challenging behaviour as disobedience rather than as an indication of mental ill health. I saw evidence of a lack of empathy and, on occasion, a mocking approach to the men in their care.
13. My report addresses the use of force against detained people. Force must only be used as a last resort and should not be unnecessary, inappropriate or excessive. Too often I found this was not the case at Brook House. I have seen concerning evidence of dangerous techniques being used - techniques that can lead to serious injury or death; of force being used to provoke or punish detained people; of force being used not as a last resort; of pain being inflicted inappropriately and of equipment such as riot shields and balaclavas being used in situations where this was inappropriate and intimidating. Force was also used on naked or near naked people, which was humiliating. Governance of the use of the force was inadequate.
14. I have concluded that the approach to using force in immigration detention, which is based on how it is used in prisons, does not take sufficient account of the specific needs, circumstances and vulnerabilities of detained people. I have therefore recommended that new comprehensive and mandatory rules for how force is used in Immigration Removal Centres is urgently needed.
15. The culture amongst G4S staff at Brook House was at times described to me by witnesses as "toxic". I have reached the same conclusion. I have rejected the narrative portrayed by both the Home Office and G4S in their evidence that the events at Brook House were primarily the result of a small minority of G4S staff. What I have heard in the course of this Inquiry does not support this. It is a narrative which seeks to distance both organisations from their responsibility for the prevailing culture at the time. There was significant understaffing at Brook House, an issue that both the Home Office and G4S were aware of. The G4S Senior Management Team was dysfunctional and they were not sufficiently visible to junior staff, who were largely left to manage highly complex situations on their own. These junior members of staff were ill-equipped and inadequately trained to do this.
16. The handling of complaints from detained people was flawed and whistleblowing procedures were inadequate. Junior, often inexperienced, staff were frequently dealing with medical emergencies and extremely challenging behaviour relating to the use of 'spice' a new psychoactive drug and not enough was done to prevent its use.
17. I saw evidence that it was common for staff to talk about detained people in an abusive manner, including the use of racist and derogatory language. There were multiple occasions where staff talked about past violence or future intentions to use violence against detained people. I was alarmed by how desensitised many staff appeared to be towards the vulnerabilities of the men being detained. Dehumanising language was not uncommon – including the repeated use of the mocking phrase "if he dies, he dies". Senior Managers missed opportunities to identify indicators of a troubling culture. An environment where mistreatment became more likely was able to develop.
18. There was little appreciation among staff witnesses of the inherent power imbalance between themselves and detained people. Unacceptable, often abusive behaviour was dismissed as 'banter'. I have been particularly troubled by the evidence of some of those staff who remain working at Brook House. Even amongst those who now hold senior positions, there was a lack of reflection. This casts doubt over how far the cultural changes that have been described to me have really taken root. I fear that there is still some way to go.
19. The primary responsibility for the welfare of detained people at Brook House lay with the Home Office and its contractor at the time G4S. I have been troubled to discover the extent to which the Home Office and G4S relied upon the monitoring provided by volunteers on the Brook House Independent Monitoring Board and on infrequent inspections conducted by HM Inspectorate of Prisons. Both oversight organisations provide important scrutiny, and I have found that their methodologies could be improved in the light of the events at Brook House. However, I am very clear that neither organisation could or should have been expected to act as a substitute for robust internal monitoring. It is crucial that the Home Office and its contractors recognise this.
20. My report presents 33 recommendations which need to be implemented to ensure that other detained people do not suffer in the same way as those at Brook House did. My recommendations provide practical steps for improving oversight of contracts by the Home Office, improving the environment, people's safety and their experience of detention. I have recommended formal clarifications to a range of important rules that have been shown by the Inquiry to have been regularly misused or misunderstood by staff. I have recommended a step change in staff training and management processes, in recognition of the complexity of immigration detention environments and the demands that they place on those who work within them. If implemented, these recommendations will enhance the Immigration Detention profession and improve the experience for those it serves.
21. When I was appointed to conduct this Inquiry, the use of immigration detention was falling, and a number of Immigration Removal Centres had been closed. The government has made clear its intention to expand the use of immigration detention. This Inquiry has not considered – and I do not comment on – current government policy. However, any expansion or other change should be considered in the context of learning lessons from past failures.
22. The failure to act on previous recommendations is a dark thread that runs throughout this report. With depressing regularity, I am making broadly similar findings and recommendations to those made in the long line of investigations that preceded this inquiry. I therefore conclude my remarks today by acknowledging the words of the former Home Secretary who, in announcing my appointment as chair, said she wanted "to establish the facts of what took place at Brook House and ensure lessons are learned to prevent these shocking events happening again." The Home Office and other recipients of my recommendations should publish their responses within six months. It is my sincere hope that more than mere lip service will be paid to this report. The events that occurred at Brook House cannot be repeated.