Alois Dvorzak and his wife

Nurses were “shocked” when an 84 year old man arrived at a London hospital chained to a security guard, an inquest into the death of Alois Dvorzak heard today. The six foot long chain was removed only after he stopped breathing five hours later.

Dvorzak, a retired electrical engineer, was rushed to Hillingdon Hospital in an ambulance after complaining of chest pains at Harmondsworth immigration detention centre, near Heathrow.

The UK Border Agency had kept the elderly Canadian man detained for a fortnight after denying him entry at Gatwick airport.

Security staff at Harmondsworth handcuffed Dvorzak for hospital visits because he was an “escape risk”, the inquest has heard.

When paramedic Ricardo Ambrosino delivered Dvorzak to hospital, shocked nurses asked: “Wow, why is he chained?”

Ambrosino told the inquest he had challenged the security guards about the restraints, but was told it was Home Office policy.

“I felt it was unnecessary,” Ambrosino said. “It was an elderly person, he wasn’t going to run away.”

It was the first and last time the paramedic had seen a detainee chained to a guard in an ambulance.

Dvorzak was “very angry and upset” in the ambulance, pulling off an electrode from his chest, the jury at West London Coroner's Court heard. “He became agitated and grabbed [electrode] dots off his chest and threw them on the floor,” Ambrosino recalled.

Senior Coroner Chinyere Inyama asked: “Having seen this agitation, did it revise your view on the need for the chain?”

“Absolutely not,” the paramedic replied.

Dvorzak arrived in London from Canada in January 2013. He was trying to reach family in Slovenia. UK immigration officers were concerned that he was unfit to carry on his journey unaccompanied and wanted to send him back to Canada.

“I haven’t got much time, I need to go to see my family,” a tearful Dvorzak told Vernon Simmonds-Dunne, the Older Persons Liaison Officer at Harmondsworth, days before he died.

Simmonds-Dunne told the inquest that Dvorzak  “seemed in a world of his own”. He was always smartly dressed, in the same clothes, as if he were “ready to carry on his journey”, the officer recalled.

The jury heard that the Older Persons Liaison role had lapsed for twelve months and has only recently resumed. There are currently three detainees over the age of 65 detained at Harmondsworth.

Simmonds-Dunne, the incumbent, told the coroner he was not aware of the older persons welfare clinic at the centre and would “definitely look into it”.

At the time of Dvorzak’s death, Harmondsworth held 615 detainees and was the largest removal centre in Britain. It was run for the Home Office by GEO Group, the American prisons company.

Harmondsworth Immigration Removal Centre, 2015. Demotix/Mark Kerrison All rights reserved.

Dr Iain Brew, an independent clinical assessor, told the inquest that inspections of  Harmondsworth had “identified a number of failings including in healthcare”. He said detention officers have “mentioned a lack of mental healthcare as a concern and to some extent continue to do so”.

Dvorzak was refusing to take a dozen medications for his mental health and heart problems. “That was medication he should have been taking and as we know he was not taking it. That must have contributed to his demise,” said Brew.

He carried out a review of all medical records following Dvorzak’s death and found that one clinician, Dr Asim Navqi, had said Dvorzak was “at high risk of death in detention”. Brew added: “And sadly he turned out to be right.”

Brew found that “overall, health staff had offered a generally high standard of care and I thought this care was equivalent to what he would have received in the community”. However, more efforts should have been made to find out about Dvorzak’s medical history in Canada, he said.

Emma Donoghue, head of primary care in Harmondsworth, said staff now had to complete new risk assessment forms before handcuffing detainees. However, she said the “principles are the same, although the forms may look slightly different”. Donoghue said there was an opportunity in the old forms for healthcare staff to recommend that Dvorzak was not restrained, but they had failed to do so.

The coroner said that there was “something akin to a Chinese walls situation” at Harmondsworth, with security and healthcare staff not sharing vital information about detainees. Donoghue said a complex case meeting group was set up twelve months ago so all the stakeholders at Harmondsworth could share information about vulnerable detainees.

A juror asked Donoghue if these changes had been introduced as a result of Dvorzak’s death. “There’s lots of reasons. Performance indicators and contractual requirements have changed. Contractors must now be able to evidence things in a more robust way,” Donoghue replied.

The coroner said the jury had heard “conflicting” evidence about the system in place for training locum doctors at Harmondsworth at the time of Dvorzak’s death.

The inquest continues.