Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
Home Office received 3 coroners' reports about this hazard between 13 Feb 2019 and 25 Oct 2024.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies.”
Original on judiciary.uk ↗ Home Office responded, stating 1 specific action.Response (PDF) ↗
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
Stated timescale: end of April 2019
Web search (Tavily): No evidence found either way
IRC Co-Sponsorship ↗- 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“The Consultant [name redacted] psychiatrist did not read the ACDT documents. This puts detainees at risk.”
Original on judiciary.uk ↗ No published response from Home Office was found for this report.
- 5 years 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“Despite [the deceased] being witnessed as having made an attempt to take his life, and self- reporting a further attempt during his detention, no R35 report was made.”
Original on judiciary.uk ↗ Repeated from the earlier report:detentionreport
Home Office responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Home Office
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2019Amir Siman-Tov6 months after Branko Zdravkovic · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in the proper use of ACDT procedures to monitor suicidal detainees. The earlier report notes staff were discouraged from making Rule 35 reports and lacked information sharing, while the later report finds staff unaware of or not reading ACDT documents, leading to inconsistent monitoring.
Branko Zdravkovic · 13 Feb 2019
“they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies.”
Original on judiciary.uk ↗ Amir Siman-Tov · 28 Aug 2019
“The Consultant [name redacted] psychiatrist did not read the ACDT documents. This puts detainees at risk.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
2019 → 2024Frank Ospina5 years 8 months after Branko Zdravkovic · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern failures to make required Rule 35(2) reports for detainees with suicidal intentions. The earlier issue was training that discouraged reporting, while the later issue shows a gap between expectation and practice leading to missing reports.
Branko Zdravkovic · 13 Feb 2019
“they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies.”
Original on judiciary.uk ↗ Frank Ospina · 25 Oct 2024
“Despite [the deceased] being witnessed as having made an attempt to take his life, and self- reporting a further attempt during his detention, no R35 report was made.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
Stated action · timescale: end of April 2019
“The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information”
What happened next: No evidence found either way
The Home Office's promised action regarding information sharing in IRCs is not referenced in any of the provided sources.
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No evidence found does not mean the action did not happen.
No published response from Home Office was found for this report.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Home Office at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2019 | 0.69 | 0.10 | Closely related · 0.90 | different |
| 2019 → 2024 | 0.83 | 0.47 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.