2 March 2020

Before HM Coroner Chinyere Inyama
West London Coroner’s Court
3 February – 2 March 2020

The inquest into the death of Prince Kwabena Fosu has concluded today finding neglect contributed to his death, with serious failures by the Home Office and across all the agencies in immigration detention, as well as failures by police who sent him there. Prince died at Harmondsworth Immigration Removal Centre (IRC) on the morning of 30 October 2012, in a shocking example of wholesale system collapse.

The medical cause was sudden death following hypothermia, dehydration and malnourishment in a man with psychotic illness. Prince, a Ghanaian national, was 31 years old. He is survived by his wife, child and parents.

Prince was experiencing a psychotic episode which an independent psychiatrist told the inquest was so obvious it did not require psychiatric expertise. Six days of purported checks every 15 minutes showed no positive evidence that Prince had eaten, drunk or slept and that he was naked. Both detention and medical staff recorded this, and that Prince was often lying on the cold concrete floor, in unsanitary conditions, behaving ‘bizarrely’, not communicating with anyone and with no bedding or mattress. His bedding had been removed on the first day leaving him with nothing soft to sit or lie on and there was nothing else in his room save for it being smeared with his own faeces, urine and food debris.

Even so, four GPs, two nurses, two Home Office contract monitors, three members of the Independent Monitoring Board and countless Detention Custody Officers and managers who visited him failed to take any meaningful steps. Prince was not referred for a mental health assessment and his capacity to control his behaviour was not even considered. As one member of the Independent Monitoring Board (IMB - voluntary detention visitors) later told the jury, “Mr Fosu died in plain sight. We let him down big time”. Three of the doctors have been referred to the General Medical Council.

Prince entered the UK on a valid business visitor visa. He was then refused leave on entry but appealed. Shortly after that appeal concluded he was encountered running naked down the street in Kettering. Despite concerns of police officers, a mental health assessment in Corby police station concluded that he was, at least at that time, not sectionable and he was fit to be detained and transferred to immigration detention. However, the reception nurse at Harmondsworth said she had not seen the police medical documents. The jury also heard that she dismissed the concerns of the searching officer who felt that his mental state was such that he could not be searched. A short period later, Prince was found ranting into a mirror. He was then restrained and put into segregation where he remained until his death six days later.

Prince had lost 15% of his bodyweight in six days at Harmondsworth and was described as ‘emaciated’. The jury heard evidence and saw video footage and photographs of how Prince was found. He was said to be cold and stiff. This meant that he had either been dead for some time (despite apparent checks) or that he was hypothermic.

Jury conclusions

The inquest jury concluded that the medical cause of Prince’s death was “A sudden death following hypothermia, dehydration and malnourishment in a man with psychotic illness”, contributed to by neglect and multiple serious failures. In a narrative conclusion the jury also highlighted multiple failures by every agency involved. Overall, they concluded that:

• The control points put in place to control vulnerable detainees at Harmondsworth IRC were grossly ineffective.
• There was gross failures across all agencies to recognise the need for and to provide appropriate care to a person who was unable to look after himself.
• Prince’s death was in part due to the failure to assess, recognise, monitor and respond to his deteriorating condition.

With a detailed break down of failures across agencies, the jury found the Home office assessment under Rule 40 and 42 (intended to protect vulnerable detainees and remove them from detention) was inadequate. They failed to effectively monitor the service provided by contractor staff, who run the majority of services in detention, and to spot and respond to Prince’s deteriorating condition. They noted staffing issues contributed to these failures.

At Corby Police station the jury found “opportunities were missed by the mental health team” to fully consider Prince’s medical background, resulting in an inadequate mental health assessment. They also found police “failed to react to the challenging behaviour” and “re-refer to medical staff”.

GEO Group UK Ltd were responsible for running Harmondsworth at the time. The jury found:

• The training, knowledge and awareness of the GEO detention officers and management around mental health was “inadequate and unsatisfactory”.
• A failure of GEO staff and management to recognise Prince’s deteriorating condition.
• The removal of the bedding and mattress from Prince’s cell, in the absence of any lawful authority to do so, and was “indicative of the casual approach to the welfare of Mr Fosu” and contributed to his hypothermia.
• GEO staff failed to monitor and escalate Prince’s fluid and food refusal, resulting in dehydration and malnutrition.
• The quality and monitoring of records by GEO was inadequate.

The jury further commented “The flexible GEO management structure at Harmondsworth IRC lead to an absence in continuity of care.”

Nestor Primecare Services Ltd, or ‘Primecare’ provided healthcare services at Harmondsworth at the time. The jury found their initial healthcare assessment was inadequate, as was record keeping by all staff. They found an “unsatisfactory approach to multidisciplinary record keeping” which resulted in a “complete failure of any member of the healthcare team having a full picture”. They found that “the standard and levels of GP care provided was inadequately monitored by Primecare managers.” And that, “The failure of Primecare Staff to effectively see, assess and provide healthcare to Mr Fosu is inexplicable.”

The Jersey Practice GP services were also criticised, with the jury finding: “Doctors contracted by the Jersey Practice showed insufficient professional curiosity throughout Mr Fosu’s detention”, which resulted in “an absence of any kind of medical intervention which in turn contributed to Mr Fosu’s deterioration”. The jury were also critical of the IMB, finding their monitoring of Mr Fosu was ineffective and inadequate.

Prince Obeng, Prince Fosu’s father, said: “It has taken us eight good years now to get answers as to the circumstances in which my son died. What we have found out is shocking. Prince was failed by everyone at every level at Harmondsworth, the doctors, the nurses, the Home Office staff, the detention officers and managers, and the Independent Monitoring Board.

Prince was segregated for being non-compliant and on a ‘dirty protest’, but nobody assessed whether he had the mental capacity to choose his behaviour. Prince was unwell and obviously needed medical attention but instead he died in the most degrading and painful way on a cold cell floor, surrounded by debris. He was left without bedding for six days and there is no positive record of him eating or drinking. Staff had observed him in these conditions but none of those tasked to ensure his welfare helped him.

Prince’s death was entirely preventable. Food, fluids and warmth would have saved him.  It is still inexplicable how all of these people walked away and left him to die like that. My son came here to the UK on a valid business visa but was refused entry to the UK. If you detain someone you have to look after them. I now have to return to Ghana and try to explain to Prince’s wife and child how he died. I am not sure I can.”

Deborah Coles, Director of INQUEST, said: “It is unconscionable that someone entrusted to the care of the state can die in this way. The jury have delivered a damning indictment of all of those responsible. Prince was failed at every level, by individuals and agencies who owed him a duty of care. He was treated in dehumanising way and as a discipline problem rather than as a seriously unwell man in need of compassion and medical care.

His death comes as a direct result of the UK’s hostile immigration policies. This reinforced a toxic culture of indifference and neglect, where professionals who came into contact with Prince were simply unable to see the human being before them.” 

Kate Maynard of Hickman and Rose solicitors, who represents the family, said: “There are many learning points arising out of this case. The process of GP recruitment and induction is a key one. GP after GP at Harmondsworth told us that they were unaware of their key obligations under Detention Centre Rules. This is astonishing because we know that the same point arose in a death 15 months earlier.

However, the real point is the wholesale failure of all those professionals to take personal professional responsibility for the welfare checks they should have been conducting. What should have been checks turned out to be the opposite, assumptions that someone else had done their job.

The background to this is contracting and sub-contracting in the immigration estate and the fragmentation of services and accountability. We saw some of this continue into the inquest and indeed up until final submissions where some parties were still trying to suggest that blame lay on others and even that this was a natural death. This has caused my client real distress.”

ENDS

NOTES TO EDITORS

For further information and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected].

The family of Prince Kwabena Fosu is represented by INQUEST Lawyers Group members Kate Maynard of Hickman and Rose solicitors and Nick Armstrong of Matrix Chambers. They are working with INQUEST Senior Caseworker, Selen Cavcav.

Other Interested persons represented are GEO, The Home Office, The Chief Constable of Northamptonshire Police, the Independent Monitoring Board, Jersey Practice, Dr Wesley Joseph, Dr Sharif, Dr Singh, Dr Navqi, Central and North West London NHS Foundation Trust, Mitie.

Medical Justice, a charity who work with voluntary, independent doctors to support people in immigration detention, have also released a media statement, available here.

BACKGROUND
Over a year before Prince’s death, Brian Dalrymple, 35, died in Colnbrook IRC in July 2011, having been transferred there from Harmondsworth just a few days earlier. His death occurred in strikingly similar circumstances and even involved many of the same staff. Some witnesses at this inquest however did not recall having been questioned at the inquest into this previous death, and maintained that they were still unaware of relevant issues despite this experience. The inquest into Brian’s death concluded in 2014, finding his death was by natural causes also contributed to by neglect.

Criminal Charges following Prince’s death
The inquest into Prince’s death been postponed pending consideration by the Crown Prosecution Service (CPS) of criminal charges against the private companies responsible for Prince’s care. The CPS declined to bring corporate manslaughter charges, but on 14 April 2017 authorised criminal charges against GEO Group UK Ltd, which then ran Harmondsworth, and Nestor Primecare Services Ltd, which provided healthcare services. The charges were for a breach to section 3 of the Health and Safety at Work Act 1974. However, that decision was reversed 18 months later meaning that no criminal proceedings would be brought. Primecare has since gone into administration.

Timeline:

• On 21 October 2012, Prince Fosu was arrested by police running down the road naked in Kettering, he was detained in Corby police station dfxz\
• On 24 October 2012 Prince was transferred to Harmondsworth IRC from Corby police station
• On 30 October 2012 Prince Fosu died in Harmondsworth Immigration Removal Centre
• On 30 September 2013 the coroner released Prince’s body for burial
• On 15 May 2014 the Metropolitan Police Service provided the CPS with a case file, for consideration of criminal charges.
• On 3 April 2017 the CPS announced their decision that criminal charges will be brought against GEO and Primecare under the Health and Safety at Work Act.
• On 30 October 2018 the CPS reversed that decision.

Data on deaths of immigration detainees

• Since 2000 the annual number of deaths of immigration detainees has ranged between one and five. Yet in 2017, there were a total of 11 deaths of immigration detaineesheld in immigration detention, prison, during deportation, or within four days of leaving detention.
• In 2018 there were two further deaths of immigration detainees and in 2019 there was one death. See INQUEST Submission to Immigration Detention Inquiry 2018for more information. Also see INQUEST data on the deaths of immigration detainees in England and Wales.

Recent inquests into deaths of immigration detainees:

• Carlington Spencer, 38, was originally from Jamaica. He was transferred to Morton Hall IRC around May 2017, shortly after the conclusion of a short prison sentence. The inquest jury found that he died on 3 October 2017 as a consequence of a stroke and identified series of failings which possibly contributed. See media releases, November 2019.
• Bai Bai Ahmed Kabia, 49, who was originally from Sierra Leone and had indefinite leave to remain in the UK, died in hospital on 6 December 2016, following his collapse at Morton Hall IRC. The inquest concluded his death was a result of a brain haemorrhage, identifying missed opportunities that could possibly have prevented his death. See media release, September 2019.
• Marcin Gwozdzinski, a 28 year old Polish national died at Heathrow Immigration Removal Centre in September 2017. The inquest in June found serious failings which contributed to his death. See media release, June 2019.
• Amir Siman-Tov, a 41 year old Moroccan national, was being held at Colnbrook IRC when he died in the early hours of 17 February 2016, having ingested painkillers the day before. An inquest found that he died as a result of ‘misadventure’ with a critical narrative conclusion. See media release, May 2019.
• Tarek Chowdhury, 64, was killed by another detainee who was experiencing serious mental ill health in Colnbrook IRC on 1 December 2017. The inquest concluded finding that the man who killed Tarek had been inappropriately placed in immigration detention, alongside numerous other critical failings. See media release, March 2019.
• Michal Netyks, a 35 year old Polish national, was being held as an immigration detainee in G4S run HMP Altcourse and died a self-inflicted death on 7 December. The inquest concluded finding with serious criticisms of the immigration deportation process. See media release, December 2018.
• Branko Zdravkovic, a 43 year old Slovenian national, died a self-inflicted death at The Verne IRC. The inquest identifying serious failings, with the coroner writing a critical report to prevent future deaths highlighting failings in ACDT and Rule 35 procedures. See media release, November 2018.