An immigration detainee took his life at a Home Office deportation centre following “multiple failings” in his care after he suffered a mental health collapse in custody, an inquest has ruled.
The body of Frank Ospina, a Colombian national who was being held on suspicion of working illegally in Britain, lay undiscovered for at least two hours on the night of his death on 26 March, 2023.
He had been placed on a suicide watch, during which he was supposed to be monitored every 30 minutes.
An inquest jury has ruled that Mr Ospina, a civil engineer, died by suicide after “missed opportunities” to provide “more appropriate and responsive care” while being held at the Colnbrook Immigration Removal Centre, near Heathrow airport in west London.
They found that there had been failures to implement safeguarding processes which could have triggered a review of Mr Ospina’s detention.
The 39-year-old had also been subjected to an “inappropriate and unnecessary” visiting restriction, which meant that he was separated from his mother by a glass screen when she came to visit him after an apparent suicide attempt four days before his death.
Maria Ospina, 59, described the agony of being unable to embrace her “loving and happy” son for what turned out to be their last ever meeting together.
In a statement, she said: “I was horrified as I did not recognise my son. He was staring at me as if I was not there.
“I was desperate to just give him a hug as I believed this was a way to bring him back to reality. That would have been the last opportunity I had to embrace my son but I couldn’t because we were separated by a glass screen… I left more distraught than before I arrived.”
Mrs Ospina, who lives in Britain, said her son came to visit her in late 2022 before he was due to go to Spain to study for a master’s degree.
He took on a short-term job washing dishes, according to his family, before he was arrested in an immigration raid.
Mr Ospina had been held in the Colnbrook facility, run on behalf of the Home Office by private contractor Mitie, for less than a month when he suffered a sharp deterioration in his mental health.
In the days before his death he made repeated attempts to self-harm. On 22 March, he jumped over a set of second-floor railings only to be saved from injury by protective netting.
In a narrative verdict delivered following the two-week inquest, jurors identified “multiple failings that contributed to [Mr Ospina’s] death”.
These included “unacceptably inadequate” observations by the detention officer in charge of monitoring him in the facility’s “care suite” – a separate unit for detainees experiencing a mental health crisis – in the hours before his death
The jurors ruled: “There were a number of missed opportunities to provide more appropriate and responsive care given the severity of his mental health crisis.”
The inquest was told that Mr Ospina’s deteriorating condition could have entitled him to a clinical assessment from a doctor, who would consider whether factors such as suicide risk meant he was “injuriously affected” by being held in custody.
This process, known as a Rule 35(2) report, can trigger a “detention review” under which Home Office officials must decide whether the individual should be released.
As his condition worsened, Mr Ospina was observed hitting his head against a wall and beating himself with a television cable. But the Rule 35 process was not triggered in this case.
The jurors found: “The failure to submit a Rule 35(2) [report], despite Frank Ospina meeting the Home Office’s criteria, deprived him the opportunity of detention review.”
The hearing, which took place before Senior Coroner Lydia Brown at the West London Coroner’s Court, was told that, at the time of Mr Ospina’s death, the Colnbrook facility had a waiting list of up to four weeks for Rule 35 appointments.
Practice Plus Group, a private contractor providing healthcare at Colnbrook, said the wait for Rule 35 appointments varies according to patient need and currently stands at one to two weeks at Colnbrook. It pointed out that Mr Ospina was not a waiting list for a Rule 35 appointment at the time of his death.
The provider added that the procedure was not “intended to address urgent mental health issues”, which were instead addressed through clinical care.
In a statement, Practice Plus Group said: “Our healthcare team provided urgent support, [Mr Ospina] was treated for depression and monitored closely under the appropriate process.”
The court heard that Mr Ospina was also not considered for release under a second safeguarding mechanism for immigration detainees, whereby custody officers at removal centres notify the Home Office to “material changes” in the circumstances of detainees, such as a suicide attempt.
Frances Hardy, deputy director of detention services for the Home Office, told jurors that four of these notices sent in the days before Mr Ospina’s death had arrived at the department but staff had failed to forward them to his case worker and no assessment of his condition had been made.
Ms Hardy said that an internal Home Office investigation had been unable to establish the reason for this error.
The jury said the failure meant Mr Ospina had been deprived of a second opportunity to trigger a detention review which might have resulted in his release.
The verdict highlighted several other issues, including a failure to itemise Mr Ospina’s possessions when he arrived at the care suite. The inquest was told that the Colombian had brought in a scarf which was later used as a ligature.
The jurors added: “Frank Ospina did not receive sufficient urgent mental health care considering he was at high risk of self harm.”
The Home Office said it “deeply regretted” any missed opportunities to respond to Mr Ospina’s mental health needs and will listen to recommendations provided by the coroner.
In a statement, the Home Office said: “Since Mr Ospina’s death, we have taken a number of actions to improve the safeguards for individuals in detention. This includes an increase in staffing numbers, training and guidance for staff.”
Mitie said it placed the “utmost importance” on the physical and mental wellbeing of detainees and had implemented measures to address concerns.
The company said: “We accept that the decision to place Mr Ospina’s family in a closed room for their visit was wrong and not in accordance with our policies and procedures, and we have apologised for this.”
Liberty Investigates contributed reporting
Anyone affected by any of the issues in this article can call the Samaritans for free at any time on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch
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