Before HM Assistant Coroner Sean Cummings

Coroner for London West

West London Coroner’s Court

13 - 30 May 2019

The inquest into the death of Amir Siman-Tov concluded on Thursday 30 May, with the jury finding that he died as a result of misadventure. Amir, a 41 year old Moroccan national, was being held at Colnbrook Immigration Removal Centre when he died in the early hours of 17 February 2016, having ingested painkillers the day before.

In a critical narrative conclusion, the jury highlighted that “inadequate information sharing” resulted in several missed opportunities to prevent the hoarding and ingestion of prescribed medication, “despite Mr Siman-Tov repeatedly stating his intention to do so”, and that this contributed to his death.

Amir lived with his family in North East London. He had a history of mental ill health. He was required to attend appointments at a reporting centre as part of his immigration bail. On 25 January 2016, the Home Office detained him when he reported to Becket House.

The inquest heard evidence that Amir was afraid of being in detention and was terrified at the prospect of being deported to Morocco. He had stated his intention to store up his prescribed medication to overdose on multiple occasions, though the medical team were not made aware of this information. Throughout his time at Colnbrook, Amir was constantly supervised by custody officers as part of the suicide and self-harm monitoring procedures (known as ACDT).

At approximately 10.40am on 16 February 2016 an officer witnessed Amir take a handful of tablets. He was taken to Hillingdon Hospital where he explained that he had taken an overdose of his prescribed painkillers. A doctor told the inquest that he received a telephone call from a psychiatrist working at Colnbrook, who was skeptical that Amir had taken an overdose, suggesting that he may have taken “tic tacs”. He was discharged at approximately 16.00pm when the doctor and consultant considered that he was not showing signs of opiate toxicity.

The note provided to the custody officers simply stated that he had attended A&E and was fit for discharge. There was no information about the assessment undertaken, the care plan that should be put in place on return to Colnbrook, or the symptoms that may indicate deterioration. The custody officers returned Amir to Colnbrook, and during the journey he repeatedly vomited and appeared sleepy.

Evidence was heard that following his return, Amir was assessed by a nurse, but the escorting custody officers only told the nurse that he had vomited once. The nurse explained that if he had known that Amir had vomited repeatedly, this would have been a “red flag” and he would have arranged for him to be returned to hospital.

The nurse finished his shift at approximately 7pm and gave a verbal handover to one of the two night nurses; the nurse stated that he expected the night nurses to carry out vital medical observations every 1-2 hours but did not write this in the records. The night nurses carried out no observations. One of the nurses attended on Amir at approximately 9.10pm to administer medication (including medication he had overdosed on) but, he explained, as Amir was asleep, he did not rouse him. At approximately 3.15am Amir was found unresponsive by custody officers who were supervising him and was pronounced dead at 4.10am following the attendance of paramedics.

It was in the context of this evidence that the jury concluded that the “failure to provide a discharge summary, inadequate communication at handover and failure to establish an adequate care plan on return” contributed to Amir’s death. The jury explained: “Although Mr Siman-Tov spoke of his intention to self-harm and expressed suicidal ideation this is judged to be a cry for help rather than a desire to deliberately end his life”.

The inquest hearing was subject to repeated delays and took place more than three years after the death. It heard that many of the changes identified as necessary to prevent future deaths had only been implemented shortly before the inquest hearing, with further changes still not implemented. Despite compelling evidence to support a conclusion that neglect contributed to the death, the coroner declined to allow the jury to consider this.

The family of Amir said:Amir was loved by his family and his death has been devastating for us. The jury’s conclusions show that he did not wish to die and that if those with responsibility for his care had not failed him, he would be alive today.

We were shocked to learn that more than three years on, lessons said to have been learned have still not been implemented, and we now call on those involved – the NHS trusts and Mitie – to do so without further delay. We also call on the Home Office to end its inhumane policy of indefinite immigration detention which, as Amir’s case shows, ruins lives and has no place in a civilised society.”

Natasha Thompson, INQUEST caseworker said: “Amir’s death was entirely preventable. All the warning signs were made clear by Amir, yet he was failed by those who owed him a duty of care. It is unacceptable that his family had to wait over three years for this inquest, which was adjourned repeatedly with little explanation, and delayed the implementation of urgent changes to prevent future deaths. 

An unprecedented number of people are dying in immigration detention centres. Successive inquests have highlighted fundamental failings in treatment and care as well as unsafe systems and practices. These deaths are at the sharp end of the harm and anguish caused by immigration detention and illustrate the human cost of UK immigration policies."


For further information, photographs and to note your interest, please contact Sarah Uncles on 020 7263 1111 or [email protected]  

INQUEST has been working with the family of Amir Siman-Tov since shortly after his death. The family are represented by INQUEST Lawyers Group members Jed Pennington of Bhatt Murphy Solicitors and Nick Brown of Doughty Street Chambers.

Other Interested Persons represented at the inquest were the Home Office, Mitie and Central and North West London NHS Trust, Hillingdon Hospital, an individual nurse and an individual GP.

Mitie is a facilities management company, providing outsourced management services, including services relating to immigration management.

ACDT stands for ‘Assessment Care in Detention and Teamwork’ which is a Home Office self-harm reduction strategy.

In September 2018, INQUEST wrote a briefing for the Joint Committee on Human Rights which details the ongoing deaths and arising issues in immigration detention.

  • Branko Zdravkovic, 43, died at The Verne Immigration Removal Centre on 9 April 2017. His death was self-inflicted, 19 days after entering the Verne. The jury at the inquest concluded suicide and the coroner asked for more evidence from the Home Office on the management of vulnerable detainees.
  • Michal Netyks, 35, had been serving a short sentence at G4S run Liverpool prison. He was found dead on 7th December 2017, and was the 11th immigration detainee to die nationally in 2017. The inquest jury concluded that Michal’s death was the result of suicide, which was in part contributed to by the immigration deportation process.