4 October 2019

Before HM Senior Coroner Timothy Brennand
Lincolnshire County Council, County Offices

Opening 7 October 2019
Scheduled for 3 weeks

Carlington Spencer was 38 when he died following detention at Morton Hall Immigration Removal Centre (IRC) in Lincolnshire. He suffered a stroke in detention and was hospitalised. He died three days later on 3 October 2017. His death was one of eleven deaths of immigration detainees in the UK in 2017, the highest number on record.

Carlington grew up in Jamaica and had numerous successful businesses. He was a community oriented man who was very close with his family. He moved to Derby with his British wife in 2010, but found it hard to adjust to life in the UK. He suffered numerous difficult bereavements in his adult life and developed a troubled relationship with alcohol. After separating from his wife he became homeless for periods and struggled with mental and physical ill health.  

Carlington was imprisoned for drug related offences in April 2016. At the conclusion of his sentence in May 2017 he remained at HMP Moorland for a few weeks and was then transferred to Morton Hall IRC. At this stage he got in touch with family, who say he was excited about preparing for a new life at home but growing frustrated at being held in limbo without information about his case.

He had diabetes and a history of high cholesterol and high blood pressure. On 28 September 2017, he became unwell and was seen by healthcare staff following alerts by fellow detainees. He complained of being unwell and experiencing a headache and a pulling sensation behind his eyes. He experienced weakness in his limbs and had to be helped into bed from the floor by staff on the night of 28 September. Medical staff did not to assess for stroke related symptoms, despite his pre-existing conditions. They suspected that his symptoms were related to consumption of spice.

The following day, on 29 September 2017 at around 9.30am, an alarm code was called as Carlington was unwell. This was later stood down. At or about 12.30pm, witnesses who were also detained report that Carlington appeared very unwell and unable to move in his locked cell. The witnesses alerted medical staff, telling them they suspected he was having a stroke. Medical staff attended and an ambulance was called. It arrived over an hour later at 2.25pm. Carlington was then hospitalised and died in the early hours of the morning at Queens Medical Centre, Nottinghamshire, on 3 October 2017.

Carlington’s family hope the inquest will explore whether staff at Morton Hall failed to take steps which could have prevented his death, including:

  • Whether and why signs of a stroke were not assessed or acted upon from 28 September or on the morning of 29 September,
  • Whether Carlington’s condition was appropriately checked overnight on 28 September and during the day on 29 September,
  • Whether and why there was a delay in calling and arrival of an ambulance.


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Carlinton’s family are represented by INQUEST Lawyers Group members Irène Nembhard and Tolu Agbelusi of Birnberg Peirce solicitors and Sean Horstead of Garden Court Chambers. The INQUEST caseworker is Natasha Thompson. Other Interested persons represented are the Home Office, The Ministry of Justice and Nottinghamshire NHS Trust.

For more information about Carlington’s life see this OpenDemocracy article, written in collaboration with his former partner and friend and published in August 2018.

In April 2018, the deportation by the Home Office of a key witness to this case was stopped following a high court case.

Data on deaths of immigration detainees
Since 2000 the annual number of deaths of immigration detainees has ranged between one and five. Yet in 2017, there were a total of 11 deaths of immigration detainees held in immigration detention, prison, during deportation, or within four days of leaving detention. In 2018 there were two further deaths of immigration detainees and in 2019 there has been one death. See INQUEST Submission to Immigration Detention Inquiry 2018 for more information. Also see INQUEST data on the deaths of immigration detainees in England and Wales.

Recent inquests into deaths of immigration detainees:

  • Bai Bai Ahmed Kabia, 49, who was originally from Sierra Leone and had long had indefinite leave to remain in the UK, died in hospital on 6 December 2016, following his collapse at Morton Hall IRC. The inquest in September 2019 concluded his death was a result of a brain haemorrhage. The jury identified missed opportunities that could possibly have prevented his death. See media release, September 2019.
  • Marcin Gwozdzinski, a 28 year old Polish national died at Heathrow Immigration Removal Centre in September 2017. The inquest in June found serious failings which contributed to his death. See media release, June 2019.
  • 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, May 2019.
  • 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 finding that the man who killed Tarek had been inappropriately placed in immigration detention, alongside numerous other critical failings. See media release, March 2019.
  • 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 finding with serious criticisms of the immigration deportation process. See media release, Dember 2018.
  • Branko Zdravkovic, a 43 year old Slovenian national, died a self-inflicted death at The Verne IRC. The inquest concluded in November 2018 and identified serious failings, with the coroner writing a critical report to prevent future deathshighlighting failings in ACDT and Rule 35 procedures.