Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of formal procedure for informing the Home Office when a detainee is placed on ACDT
The earlier warning
Branko Zdravkovic · 13 Feb 2019 · Stephen Nicholls, Dorset
“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.”
What was promised
Stated action 1 · response to Branko Zdravkovic (13 Feb 2019) · stated 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 recurred
- 28 Aug 2019 · Amir Siman-Tov · Sean Cummings · Closely related · confidence 0.90 (high)
- 25 Oct 2024 · Frank Ospina · Lydia Brown · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No evidence found either way · stated action 1
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No evidence found does not mean the action did not happen.