Amir Siman-Tov

1. 1. lack of healthcare staff participation in ACDT process

   “A GP who had seen Mr [name redacted] during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process. This puts detainees at risk.”

2. 2. uncertainty of nurses' role in ACDT process

   “The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process. This puts detainees at risk.”

3. 3. failure of consultant forensic psychiatrist to read ACDT documents

   “The Consultant [name redacted] psychiatrist did not read the ACDT documents. This puts detainees at risk.”

4. 4. inconsistent medication checks allowing overdose

   “Mr [name redacted] expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation. Mr [name redacted] was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee's at risk.”

5. 5. failure to apply TOXBASE guidance for renal impairment in codeine overdose

   “Mr [name redacted] was taken to the Hillingdon Hospital in the late morning following his overdose on the 16th February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed.”

6. 6. lack of communication about vomiting during transfer

   “During the journey back to the Colnbrook IRC Mr [name redacted] vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minibus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr [name redacted] to the hospital for further assessment. He did not know because he did not ask and was not told.”

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No published response was found on judiciary.uk.