The Home Office has been forced to disclose the results of a damning internal inquiry into the treatment of a seriously ill immigration detainee who was handcuffed and chained in hospital until shortly before he died.

The report, which has been passed to the Guardian, raises fundamental questions about the treatment of ill and vulnerable detainees. It identifies a failure in the Home Office’s duty of care towards a 43-year-old man with a heart condition who was handcuffed while he was sedated, criticises a “serious breakdown in communication” and calls for significant changes in the use of restraints on detainees in hospital.

A Home Office spokesman welcomed the report and said that following the death new guidance had been issued relating to the restraint of detainees while under escort and for medical visits, along with new guidance about the reporting of serious incidents and deaths in detention.

The report, written by the Home Office’s professional standards unit, examines the treatment of a foreign national who was married with three children and was detained at Harmondsworth immigration removal centre near Heathrow on 10 August 2012. The man’s name is known to the Guardian, but his family requested that it not be used. He was not deemed to be a risk to the public. He was detained because he had failed to report according to the conditions of his bail.

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He became seriously unwell while in detention and was admitted to Harefield hospital in Middlesex suffering from heart problems on 9 November 2012. He died at the hospital on 17 November 2012, before he could have the aortic valve replacement surgery he needed.

He was attached by his wrists to a two-metre closet chain for almost his entire stay in hospital. Handcuffs were used for some of the time. He was only released from restraints once and was not unchained until seven hours before he died.

According to the report, the man asked to be released from detention and from hospital so that he could go home to die surrounded by his family. The Home Office declined his request, and two approaches from his solicitors. The man said he wanted to highlight the fact that he was dying while chained in the media, but this did not happen before he died.

The report paints a picture of serious confusion and poor communication between the various Home Office departments overseeing the case and GEO, the private contractors at Harmondsworth, especially in the hours before the man’s death.

“There would appear to be a serious breakdown in communication under the current detention reporting process,” the report states.

The man died at 1.25am on 17 November, but as late as 15.45pm on 16 November, when officials knew he was dying, GEO refused to remove the restraints despite the Home Office asking it to do so. A GEO manager said the use of handcuffs had been appropriate.

One Home Office official was not made aware of the fact that the man was being restrained until two days before his death. According to the report, the official said the information had horrified her.

Among the reasons for GEO’s reluctance to remove the restraints from the dying man, the report identified the potential for a £10,000 fine if anyone absconded. One GEO officer interviewed in the report said he feared losing his job if that happened.

The report states: “It is likely that GEO have a cautious approach to assessing the risk of a detainee absconding as this would result in a £10,000 fine.”

The report calls for improved guidance on the restraint of detainees who need hospital treatment and better oversight of such cases by senior Home Office managers. It also suggests that new national guidance about handcuffing immigration detainees in hospital may be required.

The case echoes that of Alois Dvorzac, a Canadian man with dementia who died in shackles after being detained at Heathrow airport while on his way to being reunited with his daughter in Slovenia. The prisons and probation ombudsman described his death as shameful and wholly unacceptable.

The charity Medical Justice, which works to improve the health of immigration detainees, saw a brief reference to the man’s death in a 2012 report by the prison inspectorate into Harmondsworth and made a freedom of information request to obtain it.

When the Home Office rejected the request on the grounds that the report would be too distressing for the man’s family, the charity appealed to the first tier tribunal. The appeal was successful and the tribunal deemed in the public interest for the Home Office to release the report to the charity. It was disclosed to Medical Justice on 7 July 2016.

The report states that being restrained did not affect the outcome for the man but adds: “However, the fact that [the man] remained in a closet chain during his angioplasty when he would have been sedated and having a medical operation may be considered as a failing of our duty of care towards [the man] and therefore improved oversight is recommended.”

Theresa Schleicher, the acting director of Medical Justice, said: “It is shocking that a dying man was chained to officers while having heart surgery. It is even more shocking that those responsible for reviewing and authorising his detention did not know that he was chained and that the Home Office contract appears to encourage this practice.”



A Home Office spokesperson said: “New guidance on the use of restraints on detainees under escort was issued in 2014, with a presumption against their use for medical visits. Contractors must now complete a full risk assessment before their use and they must only be used as a last resort.

“The use of restraints is closely monitored by the Home Office to ensure that it is reasonable, necessary and proportionate and in accordance with approved techniques. On top of this, we have revised our guidance to make improvements to the reporting of serious incidents and the handling of deaths in detention.”

GEO did not respond to a request for comment.

