A report by the Prisons and Probation Ombudsman has criticised the medical care of Tahir Mehmood, a 43 year old man from Pakistan who died at Pennine House Short Term Holding Centre, Manchester Airport, just two days before he was due to fly home.
The PPO’s clinical care review concluded that Tahir Mehmood’s care fell below the standard he could have been expected to have received from NHS care in the community. Mehmood’s brother-in-law told the PPO investigator that Tahir, who died at Pennine House in July 2013, felt no-one at the centre had understood him when he became ill. A post mortem showed that he died of coronary heart disease.
The report from the Ombudsman Nigel Newcomen, dated June 2014, is due to be published here today. In keeping with PPO policy, publication was delayed until after the Inquest. Last week Manchester Coroner Nigel Meadows concluded that Mehmood had died of natural causes.
The PPO report makes five recommendations which have all been accepted by the Home Office.
In his introduction to the report, Nigel Newcomen says that although Mehmood’s death appears to have been sudden and unexpected there were some lessons to be learned.
“He spoke very little English and I am concerned that a professional interpretation service was not used to help obtain a medical history when he arrived at the centre or when he reported feeling unwell,” he wrote.
“The clinical assessment shortly before his death was not appropriately recorded, his case was not discussed with a GP and neither was a referral to hospital considered. The emergency response was poorly coordinated and an ambulance was not called immediately as it should have been.”
The Ombudsman was also concerned that the initial contact with Tahir Mehmood’s family after Tahir’s death was not handled more sensitively by employees of Tascor, which runs Pennine House. (Tascor is a division of the Capita outsourcing group).
Cheryl Haines, the mother-in-law of Nadeem Iqbal Gondal, Tahir Mehmood’s brother-in-law, said the family were told about Tahir’s death in a phone call from a Manchester Airport customer service officer. He was not employed by Tascor or the UK Border Agency but was asked by Pennine House staff to break the news to the family because he spoke Urdu.
The PPO report says it was “inappropriate” to ask the customer service officer to notify Mehmood's family about his death, and that this is something which is usually done by the police.
The report’s recommendations to the Director General of Immigration Enforcement relate to:
The maintenance of medical records
Guidance on seeking the input of a GP and when to use the emergency service
A protocol to be introduced at all immigration detention centres setting out staff responsibilities in an emergency
Staff liaison with families
When Tahir Mehmood was first arrested and taken to Dallas Court Home Office Reporting Centre, Salford, Home Office staff used a professional telephone interpreting service to interview him. But an interpreting service was not used by Tascor staff at Pennine House. Staff assumed that Mehmood understood English even though a custody officer who spoke Urdu assisted for some of the reception procedures at the centre and another detainee helped interpret for the custody officer who carried out Mehmood’s induction at the centre.
The PPO report raises particular concerns that an interpreter was not used during Mehmood's contact with healthcare staff. “It is difficult to see how staff can be sure that they have accurate information from a detainee if they cannot communicate with them effectively.
“This is even more important when the detainee presents with a medical issue. We have been unable to establish how frequently staff at Pennine House use the approved interpreting service as they do not record it in a log.”
At Pennine House’s last inspection, HM Inspectorate of Prisons found that professional interpreting services were not used when they needed to be.
Maintenance of Medical Records:
The clinical records at Pennine House were paper-based and the PPO said Tahir Mehmood’s document contained some poor and illegible entries.
On 26th July, the day he died, the nurse checked his basic observations twice during a 26 minute consultation, but she did not make a record of the consultation and the results of the observations until after his death.
The report says observations should be documented at the time or as soon as possible afterwards and should follow Nursing and Midwifery Council guidelines. Tascor’s own guidance says all clinicians should maintain comprehensive and contemporaneous medical records.
“Good record keeping skills are important as this reduces misunderstandings and misinterpretations,” the report adds.
Guidance on seeking input of GP and when to use emergency services:
When detainees report chest pain indicative of cardiac problems, an emergency ambulance should be called immediately, the PPO report says.
The nurse did not consider that Mehmood had the symptoms of a heart attack but, as she could not communicate properly with him, she may not have had a full and accurate account of his symptoms. “Her assessment was significantly hampered by the lack of reliable information about how he was feeling,” the report says.
The investigator found there was no clear guidance to nurses at Pennine House outlining circumstances in which they should seek the advice of a GP. The report says the healthcare provider at Pennine House should give guidance to nurses, outlining the circumstances when they should seek the input of a GP and when they should use emergency services.
Protocol setting out staff responsibilities:
The PPO found that Tascor’s own procedures did not clearly set out the steps staff should follow when discovering and responding to an emergency. As a result, the custody officers did not use an emergency code when Tahir Mehmood was found unresponsive, and an ambulance was not called for several minutes afterwards.
The report says: “It is essential that there are clear emergency procedures which all staff understand. This is a matter we have raised in a number of previous deaths in immigration detention.”
Protocol should be introduced at all detention centres, setting out staff responsibilities in emergencies. A Medical Emergency Response Code protocol should be introduced which:
- • Provides guidance to staff on efficiently communicating the nature of a medical emergency;
- • Ensures staff called to the scene bring the relevant equipment;
- • Ensures there are no delays in calling, directing or discharging ambulances
Tascor’s admission procedures did not require staff to record contact details for detainees’ next of kin. Pennine House staff had to ring Dallas Court for this information.
Following a death in an immigration removal centre in 2011, the PPO recommended that detainees in removal centres should be encouraged to give next of kin details on arrival – this repeated a previous recommendation in response to a death in 2005. A Detention Service Order was issued in November 2013, four months after Tahir Mehmood's death, requiring reception staff to ask for emergency contact details.
Tahir Mehmood gave his brother-in-law’s contact details when he was taken to Dallas Court. However, he was not asked for the information at Pennine House, and it was not immediately available when needed.
Detention Services Order 02/2012 says the head of operations should be the main contact for the family. As an interim measure, the on-call senior manager for detention services can act on behalf of the head of operations until they are available. The order notes that, in most cases, the police should notify the next of kin.
Family member Cheryl Haines said: “When Nadeem received the phone call from the customer service officer, we couldn't believe they were talking about Tahir. A few of us went to Pennine House but we weren't allowed in because the police were carrying out an investigation.”
In keeping with normal PPO practice, the family and the Coroner received copies of the PPO report before the inquest. Cheryl Haines said: “We were appalled when we received the copy of the PPO report as there did not seem to be any procedures in place. This is a holding facility for people who are detained, there should be proper procedures covering all detention centres.”
Haines went on: “We knew all these things had gone wrong, that there had been a problem with communication because Tahir did not speak much English, and there was initial confusion about whether it was a medical emergency. We were very disappointed that some of the detail in the PPO report did not come out in the inquest.”
For more information, please contact Kath Grant 07758386208 or Rhetta Moran 07776264646
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