12 June 2019

Before HM Assistant Coroner Catherine Wood
West London Coroners Court
3rd – 12th June 2019

The inquest into the death of Marcin Gwozdzinski today concluded finding serious failings which contributed to his death at Heathrow Immigration Removal Centre (IRC), including missing “significant warning signs” and inadequate risk assessments by untrained staff. Ultimately the jury concluded the main contributing factor to Marcin’s death was the premature closure of suicide and self-harm prevention procedures (ACDT) days prior to his death.

Marcin died on 6 September 2017, three days after he was found hanging in his room at Heathrow IRC, run by private security company Mitie. Marcin’s was one of eleven deaths of immigration detainees in 2017, the highest number on record. Marcin had been in immigration detention for nine months, and the jury also noted that this “prolonged period of detention” was a possible cause of death.

Marcin was a 28 year old Polish national who had been in the UK for five years and was living and working in South West London. His family describe him as a free spirit who loved travel and was a happy person with no known history of mental ill health.

On 31 August 2017, Marcin told a Detention Officer at Heathrow IRC that he could not take detention anymore and wanted to die. He was placed on an ACDT (suicide and self-harm prevention procedures) where it was noted that his mood was very low and he was worried about his mental health. Marcin was initially subject to hourly observations and a support plan.

The following day on 1 September, after a risk assessment interview lasting just nine minutes and a case review lasting a mere three minutes, the ACDT was closed with detention staff concluding that Marcin’s only problem was toothache. No input had been sought from healthcare staff, contrary to national guidance.

On 2 September 2017, Marcin telephoned London Ambulance Service (LAS) numerous times requesting assistance. In one of the confused calls played to the jury, Marcin asked the operator through an interpreter to come to the centre to save his life. He stated that “he could not take it anymore”. The LAS operator is heard calling the control room at the IRC and is told Marcin has been making hoax calls.

The same day Marcin attended healthcare and asked a nurse for an ambulance. The nurse made a mental health referral noting that Marcin was “extremely irate and threatening” and that he had been unable to placate him. This nurse had been working in the centre for four months but had not received the mandatory training in suicide and self-harm prevention. He had been unaware that Marcin had been on an ACDT the day before. In his evidence, the nurse confirmed that he still had not had training despite over 20 months passing since Marcin’s death.

On 3 September 2017, prior to lock up for lunchtime, a detainee took one of the Detention Officers to one side and expressed concern about Marcin. He took the Officer to Marcin’s room and showed him he had been smashing things up. The Officer did not think there was any cause for concern and Marcin was locked in his room alone over lunch.

Marcin’s room was unlocked at 2pm but no one conducted a welfare check. The Officer gave evidence stating that she was unaware Marcin had recently been on an ACDT, and explained she
would have looked in had she known. Marcin’s fellow detainees found him hanging in his room at around 2.15pm. Marcin was taken to hospital where he died three days later.

After hearing five days of evidence the jury in a lengthy narrative conclusion noted the following failures probably contributed to Marcin’s death;

  • The failure of several detention staff to take due care in following their own suicide and self-harm prevention procedures ‘with more than just the minimum administrative effort’;
  • The failure of detention staff to consult with healthcare staff whilst Marcin was on an ACDT;
  • The reason for opening an ACDT was not properly addressed during assessments and at the point of closure of the ACDT;
  • Systemic failure of administrative systems to work together and share information between healthcare and detention staff;
  • Despite concerns regarding Marcin’s mental health he was never seen by a mental health professional;
  • Failure to sufficiently train healthcare agency staff in ACDT processes especially when it was clear they would be working at the IRC regularly; and
  • A number of significant warning signs were missed on Saturday 2 September which should have been escalated in the context of Marcin’s recently closed ACDT.

In addition, the jury found the following failings possibly contributed to Marcin’s death;

  • The failure to recognise that a limited grasp of English might be to blame for Marcin not being able to communicate his state of mind;
  • Marcin’s prolonged period of detention was a contributing factor in his deteriorating mental health; and
  • The handover processes were inadequate as staff were unaware of events during the preceding days.

The inquest heard evidence that an internal investigation following Marcin’s death, conducted by Mitie, concluded that the notes of the assessment and case review were “poor” and “limited”; and that a quality case review could not be completed in such a short time. They recommended that those involved should not be allowed to have any further involvement in ACDTs until managers were satisfied with the quality of their work. They further recommended the previous Head of Safer Communities who took part in the three minute case review be removed from his role.

Extraordinarily, during the course of the inquest it became apparent that the results of the review had not been fed back to those involved, and whilst the previous Head of Safer Communities had been removed from his role another Residential Manager had continued to take part in ACDT case reviews. Staff involved in the ACDT continued to consider the actions they had taken were appropriate.

Whilst Marcin was in hospital fellow detainees signed a petition expressing concern that “for a long time he asked for officers, psychologist and doctors for help. He was ignored”. In reference to the BBC Panorama documentary about treatment at Brook House IRC, which was shown on BBC on 4th September 2017, the detainees noted “It is a disgrace that nobody has been held accountable for such care we are human beings not animals.”

Following the conclusion of his inquest, Marcin’s family said: “We are disappointed that many mental health referrals were made but Marcin did not see anyone and we are disappointed that the resuscitation was messed up. There were people without training deciding whether Marcin posed a risk to himself.  He was in a cell on his own and no one thought that was a risk. Not only was he stuck in the detention centre but staff did not use an interpreter to communicate with him, I don’t believe he would be able to understand or make himself understood. When Marcin died he had no idea when he was getting out and nor did we, it’s worse than prison. At least in prison you know there is an end. I am angry that they did not help him.”

Clair Hilder of Deighton Pierce Glynn, the family’s solicitor said; “They call them Immigration Removal Centres but Harmondsworth was designed as a Category B prison and detainees on Marcin’s wing were locked up for 13 hours a day. The inquest revealed serious gaps in staff training, inadequate risk assessments and a lack of care.

It is important lessons are learnt however we have little confidence Mitie Care and Custody will make the necessary improvements in light of their failure to follow up on the recommendations they made in their own investigation of the incident completed in November 2017. It is important that the Home Office steps in to ensure detainees are safe.” 

Taimour Lay of Garden Court Chambers, counsel for the family said: “Marcin had been in immigration detention for over 9 months and repeatedly expressed concern over the effect it was having on his mental health. Whilst it was a private company who failed to keep Marcin safe it was the Home Office who ultimately detained him.”

Natasha Thompson, INQUEST caseworker said: “Marcin was desperately crying out for help in the last few days of his life. His pleas, as well as those of other detainees who recognised his distress, were ignored, leading to his tragic and preventable death.

Marcin was one of 11 people to die in immigration detention in 2017, a record high. Successive inquests have highlighted fundamental failings in treatment and care as well as unsafe systems and practices. These deaths are evidence of the unnecessary harms caused by immigration detention and illustrate the human cost of UK immigration policies."



For more information and photos of Marcin please contact Lucy McKay on 020 7263 1111 or email.

The family were represented by Clair Hilder of Deighton Pierce Glynn and Taimour Lay of Garden Court Chambers. Other interested persons represented at the inquest were Mitie Care and Custody, Central and North West London NHS Foundation Trust, The Home Office and an individual nurse.

Following Marcin’s death, his family spoke to the Observer for the artcle: ‘Marcin was crying, begging for help’: crisis of EU migrants detained in the UK, pubished in December 2017.

Heathrow IRC was previously run as two separate centres, Harmondsworth and Colnbrook, managed by different providers. Both centres are now run in combination by the private provider Mitie.

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 release. In 2018 there were two further deaths of immigration detainees.

This marks an unprecedented and dramatic rise and the highest annual number of deaths on record. More than half of the deaths in 2017 were of EU citizens, (five Polish men and one Slovenian man). See INQUEST Submission to Immigration Detention Inquiry 2018 for more information. 

INQUEST publishes lives data on the deaths of immigration detainees in England and Wales.

Recent inquest conclusions on deaths of immigration detainees:  

  • 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.