Following an Article 2 inquest into the tragic death of Prince Fosu, a vulnerable foreign national detained in an immigration removal centre, a jury has found that Mr Fosu’s death was avoidable and was caused by a number of gross failures on the part of the Home Office and various agencies to provide appropriate care in immigration detention at Harmondsworth Immigration Removal Centre.
Background
Mr Fosu, a car parts dealer from Ghana, entered the UK in April 2012 on a valid business visa. However, on arrival, he was refused leave to enter. His subsequent in-country appeal was rejected in September 2012 and he was booked on a flight to leave the UK on 5 November 2012.
A month after his unsuccessful appeal, he was arrested after walking naked on the road. He continued to act bizarrely at the police station and kept undressing. However, following assessment, mental health professionals at the station determined that he did not need to be sanctioned and was fit for detention. When he urinated in his cell, he was labelled as a “dirty protestor” rather than being re-referred for medical assessment. After three days in police custody, Mr Fosu was transferred to Harmondsworth on the basis that he had overstayed his stay and was liable to immigration removal.
As part of reception screening at Harmondsworth, Mr Fosu was seen by nurse, who carried out a five-minute healthcare assessment, without having access to any of his medical records. At the inquest the nurse accepted that she had done a “completely inadequate assessment” and that she was “out of her depth”.
Mr Fosu was placed in a normal cell but he continued to act oddly, including talking to himself in the mirror. After Mr Fosu assaulted a member of staff and had to be restrained by at least three officers, he was labelled as disruptive and was placed in segregation without a mattress or bedding.
Welfare checks conducted every fifteen minutes documented Mr Fosu lying naked in his bare cell, hardly eating or drinking, and sleeping for only 45 minutes over the six days. Staff believed that he was a “dirty protestor” when he defecated in his cell and threw food. None of the custody staff asked him about his bizarre behaviour. No mental health assessment took place.
After six days in segregation, Mr Fosu had lost 18 pounds (8kgs), 15% of his body weight, and he suffered cardiovascular collapse and died while in segregation. During his detention, no one recognised that he was suffering from psychosis or that his health was deteriorating.
Findings and Conclusion of the Jury
The jury identified the medical cause of death as “a sudden death following hypothermia, dehydration and malnourishment in a man with psychotic illness”. However, in addressing the question of how Mr Fosu came by his death, the jury concluded that neglect contributed to the cause of death and that
there was a gross failure across all agencies to recognise the need for and provide appropriate care in a person who was unable to look after himself or change his circumstances.
Additionally,
the control points put in place to protect vulnerable detainees … were grossly ineffective.
The jury came to specific conclusions in respect of each of the agencies, starting with the staff at Corby police station, where Mr Fosu was held in custody following his arrest and before transfer to Harmondsworth, who were criticised for their mental health team missing opportunities to fully look into Mr Fosu’s medical background and history, resulting in an inadequate mental health assessment. Police staff in turn were criticised for failing to react to Mr Fosu’s changing behaviour while in custody and failing to re-refer him to medical staff for re-assessment.
In respect of Mr Fosu’s treatment at Harmondsworth, the Home Office’s individual staff were found to have carried out inadequate checks on Mr Fosu, a situation exacerbated by staffing issues, so that they failed to assess and monitor Mr Fosu and therefore failed to spot and respond to Mr Fosu’s deteriorating condition. The Home Office also failed “to effectively monitor the service provided by the contractor staff”.
GEO, the company with which the Home Office contracted for the management of Harmondsworth, was found to have inadequate and unsatisfactory training, knowledge and awareness amongst its officers and management around mental health and mental capacity issues. More generally, there was a failure by GEO staff and management to recognise and escalate Mr Fosu’s deteriorating behaviour as well as a failure to monitor, recognise and escalate Mr Fosu’s food and fluid refusal, resulting in dehydration and malnutrition. Additionally, the quality and monitoring of records by GEO staff was found to be inadequate, and the flexible GEO management structure at Harmondsworth led to an absence of continuity of care. The jury specifically highlighted the fact that
the removal of Mr Fosu’s bedding and mattress from his cell, in the absence of any written lawful authority to do so, was indicative of the casual approach to the welfare of Mr Fosu by GEO staff and was a contributing factor to hypothermia.
As for Primecare, the agency responsible for healthcare at Harmondsworth, the jury found that the initial healthcare assessment was inadequate and failed to highlight that Mr Fosu had any medical issues. Nurses carrying out mental health and healthcare visits were over-reliant on GP assessments and on custody staff to provide updates as to Mr Fosu’s healthcare status rather than engage directly with Mr Fosu. The standard and levels of GP care provided was in turn inadequately monitored by Primecare managers.
More generally, the record keeping by all Primecare staff was inadequate with confusion over access to records and an unsatisfactory approach to multidisciplinary record-keeping resulting in “a complete failure of any member of the healthcare team having a full picture of Mr Fosu’s situation”. The jury plainly stated that
the failure of Primecare staff to effectively see, assess and provide healthcare to Mr Fosu [was] inexplicable.
Jersey Practice, the GP surgery to which Primecare outsourced the provision of GP care, also came in for criticism. The jury found that there was confusion over whose responsibility it was to induct and ensure adequately trained and experienced GPs were hired to work at Harmondsworth. Those GPs contracted by Jersey Practice (including locum GPs through an agency) were found to have shown
insufficient professional curiosity throughout Mr Fosu’s dentention … [which] resulted in an absence of any kind of medical intervention which in turn contributed to Mr Fosu’s deterioration.
In addition, record-keeping was found to be inconsistent, and “where record-keeping did appear, there was a failure to record anything meaningful”.
The Independent Monitoring Board (IMB), a statutory body whose role is “to monitor the treatment received by those detained in custody to confirm it is fair, just and humane, by observing the compliance with relevant rules and standards of decency”, was also found wanting — its monitoring of Mr Fosu was “ineffective and inadequate”. The IMB member giving evidence to the inquest lamented that
Mr Fosu died in plain sight. We let him down big time.
Comment
The Prisons and Probation Ombudsman (“PPO”) recognised that managing Mr Fosu’s complex and difficult behaviour as a result of his psychosis would have presented staff with challenges. However the PPO commented that the care he received was inhumane and degrading and “fell considerably below acceptable standards”.
This tragic case highlights many of the problems resulting from fragmentation of service-provision for those in custody, with multiple agencies being involved and the use of sub-contractors both in relation to healthcare as well as in day-to-day management.
In Mr Fosu’s case, there were five levels of sub-contractors responsible for the provision of healthcare at Harmondsworth, a situation made worse by the fact that Primecare’s predecessor had been sacked a year before and healthcare services were described as being in chaos at the time.
This led to disjointed systems and practices, problems with communication, and difficulty maintaining and accessing comprehensive records. Detention staff told the inquest that they expected healthcare staff to identify problems with detainees, while a mental health nurse, who could not remember actually seeing Mr Fosu wrote in his records that Mr Fosu had no mental health issues. The four GPs who had seen him in segregation were not familiar with relevant detention centre rules and could not recall seeing him face-to-face. Remarkably, two had not made any notes in the GP records and the other two noted that he had declined to be seen but had not made any assessment as to whether he had capacity to make that decision.
The fragmentation was coupled with an apparent disregard for Mr Fosu’s welfare from those at the very top of the agencies, with GEO’s head of residence having told an investigation into the death that he thought that Mr Fosu was a “prat”.
Since Mr Fosu’s death in 2012, there have been a number of changes, including healthcare being commissioned by NHS England, an increase in the number of staff at immigration removal centres, introduction of an Adults at Risk policy, and increased monitoring and safeguarding of vulnerable people in detention.
However, there was a considerable delay between Mr Fosu’s death in 2012 and the conclusion of the inquest in 2020. This delay not only would have added to the grief suffered by his family but also makes it more difficult to hold individuals to account. The CPS initially charged GEO and Primecare but those charges were dropped controversially in 2018. Three of the GPs have been referred to the GMC and the PPO has recommended that the Home Office investigate the actions of staff responsible for monitoring Mr Fosu’s care.
Whilst the recognition and acceptance of failures in respect of Mr Fosu’s death are to be welcomed, with the Home Office conceding that it had failed him with tragic consequences, one hopes that his death will not be in vain and that such a case will never be seen again.
Suzanne Lambert is a barrister at 1 Crown Office Row.
Christopher Mellor and Emma-Louise Fenelon appeared on behalf of GP interested persons at this inquest. Neither was involved in the writing of this post.
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