10 September 2019

Before HM Senior Coroner for Lincolnshire Timothy Brennand 
Sleaford Coroners Court
2-6 September 2019

The inquest into the death of Bai Bai Ahmed Kabia, 49, has concluded that he died as a result of a brain haemorrhage arising from an undiagnosed malformation of blood vessels in the brain. The jury found that there was a missed opportunity for his ill health to be diagnosed and treated; and that treatment could possibly have prevented his death.

Known to his family as Ahmed, he died on 6 December 2016 at Lincoln County Hospital following his collapse at Morton Hall immigration removal centre on 5 December 2016. He was born in Sierra Leone and had qualified as a medical doctor in Russia. He had lived in the UK since 1994 and was granted indefinite leave to remain in 2005. However, in 2014 he received a 15 month prison sentence. Ahmed was due to be released from prison on 15 November 2014 but was instead detained by the Home Office as an immigration detainee. He was transferred to Morton Hall on 26 November 2014 where he remained until his collapse and subsequent death.  

It was heard at the inquest that on 10 May 2015 detainees had reported concerns to healthcare staff that Ahmed may have suffered a seizure. Ahmed was not referred to a doctor for review and evidence was heard that healthcare staff may have thought that his presentation was explained by the ingestion of illicit substances. The consultant neurosurgeon told the inquest that the 10 May 2015 episode should have been reported to a doctor and Ahmed should have been referred to a neurologist. The neurology investigations that would have identified the malformation of blood vessels which could have been successfully treated.

In March 2019 Nottinghamshire NHS formally admitted that Ahmed should have been referred for medical review by either calling an emergency ambulance or GP following the reported episode on 10 May 2015. The jury recorded Nottinghamshire NHS’s admission and concluded that this failure resulted in a missed opportunity for the malformation of blood vessels to be diagnosed and treated.

The inquest heard that on 2 November 2016 the Home Office reviewed Ahmed’s detention and recommended his release as there was no timescale for when his appeal against his conviction would be resolved. It was only after the Home Office was notified of Ahmed’s collapse on 5 December 2016 that his release was finally authorised. Release paperwork was faxed to Morton Hall but by this point Ahmed’s condition was irreversible and it was not possible to communicate or implement the release decision before his death.

Winston Kabia, Ahmed’s nephew said: “Ahmed was a father, brother and uncle, and his death has been absolutely devastating for the family. The fact that he died alone in a detention centre far away from those who loved him and the jury’s conclusion that his death could have been prevented makes his death all the more difficult for us to come to terms with.

We do not understand why the Home Office had to keep Ahmed locked up for nearly two years after he had served seven and a half months in prison. Since Ahmed’s death, the Home Office has not sought to explain why he was detained for so long or expressed any regret for this.

While the family welcome the admission by Nottinghamshire NHS that Ahmed should have been referred for medical review after he became unwell on 10 May 2015, we are very disappointed that the admission only came more than one year after expert reports the family pushed for were obtained, and we were hurt by the earlier denials and what we saw as attempts to smear Ahmed by suggesting he may have taken illicit drugs.

We are also very disappointed and upset at the obstacles to justice placed in our way by the Legal Aid Agency’s repeatedly refusing us legal aid, and the PPO’s decision to discontinue their investigation, which we were only able to overcome by our lawyers threatening judicial review.”

Selen Cavcav, Senior Caseworker at INQUEST said: “Ahmed’s preventable death exposes not only the dismissive culture of healthcare staff in immigration removal centres, but also the human cost of indefinite detention. It took Ahmed being hospitalised, after two years of needless waiting in detention, for the Home Office to grant his release. Unfortunately, it was too late.

This family had to fight each step of the way to get to truth of what happened to him. They would not have been able to do so without funding for legal representation, an opportunity which was initially denied to them. In the light of the successive damning jury findings from the unprecedented increase of deaths of immigration detainees in 2017, it is shameful that there has been no demonstrable change in terms tackling unsafe systems and practices.”



For further information, interview requests please contact INQUEST Communications on 020 7263 1111 or [email protected] or [email protected]  

The family is represented by INQUEST Lawyers Group members Owen Greenhall of Garden Court Chambers instructed by Jed Pennington of Bhatt Murphy Solicitors. INQUEST has been working alongside the family since Ahmed’s death.

Other interested persons represented at the inquest were the Home Office, the Ministry of Justice and Nottinghamshire NHS.

The family were faced with repeated refusals of legal aid funding by the Legal Aid Agency, despite the Ministry of Justice, the Home Office and the NHS being represented at public expense. Funding was only secured after a significant amount of pro bono work was undertaken by counsel and the family threatened judicial review.

The Prison and Probation Ombudsman (PPO) commenced an investigation but decided to discontinue it after learning of the Home Office’s decision to authorise Ahmed’s release following his collapse. It was only following a threat of judicial review by the family that the PPO agreed to re-open their investigation.

Recent inquest conclusions following deaths in immigration detention:

  • Marcin Gwozdzinski, a 28 year old Polish national died at Heathrow Immigration Removal Centre in September 2017. The inquest in June this year found serious failings which contributed to his death. See media release.
  • 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 concluded on 30 May 2019, finding that he died as a result of ‘misadventure’ with a critical narrative conclusion. See media release.
  • 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 in March 2019, finding that the man who killed Tarek had been inappropriately placed in immigration detention, alongside numerous other critical failings. See media release.
  • 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 in December 2018 with serious criticisms of the immigration deportation process. See media release.
  • Branko Zdravkovic, a 43 year old Slovenian national, died a self-inflicted death at The Verne IRC. The inquest identified serious failings, with the coroner writing a critical report to prevent future deaths highlighting failings in ACDT and Rule 35 procedures, published recently.