Branko Zdravkovic
13 Feb 2019 · Coroner Stephen Nicholls · Dorset
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
“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”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“The Consultant [name redacted] psychiatrist did not read the ACDT documents. This puts detainees at risk.”
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“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.”
Responses
2019-0047-Response-by-Home-Office.pdf ↗· Home Office
Stated action · 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”