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Dying detainee, 84, taken to hospital, handcuffed to a chain. Dvorzak inquest. Day 5

  • Coroner: “But Mr Dvorzak had chest pains. Why was he still handcuffed?”
  • Security company employee: “I can’t justify a comment on that.”
  • West London Coroner’s Court, 23 October 2015.
Phil Miller
24 October 2015

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

Immigration contractors put an 84 year old man in an ambulance with his hand cuffed on a “three or four foot long escort chain” to a security guard because he was an “escape risk”. The man died hours later, an inquest at West London Coroner’s Court heard yesterday.

Alois Dvorzak, a retired electrical engineer from Canada, was detained by UK immigration authorities in January 2013 when he landed at Gatwick on a one-way ticket. He was trying to visit his daughter in Slovenia but had no contact details for her, no luggage and 1,400 dollars in his pockets.

Dvorzak allegedly told border staff that he had “escaped from a mental hospital” in Canada. Concerned by his behaviour and frailty, officers at Gatwick sent him to hospital before putting him in Harmondsworth immigration detention centre, while they tried to repatriate him.

Locked up at Harmondsworth, a prison-like facility close to Heathrow, the 84 year old’s health rapidly deteriorated. Dvorzak complained of chest pains and was rushed to hospital on 10 February 2013 where he died hours later.

Stephen Scott, the Harmondsworth duty manager employed by commercial contractor Geo, gave evidence at the inquest. Senior Coroner Chinyere Inyama asked him about the decision to handcuff Dvorzak for that fateful trip to hospital.

“I would be the final decision maker if anything happened,” Scott said. “Yes, it would include the final decision on whether he would be handcuffed.” He was at home when the ambulance was called for Dvorzak and had never seen him.


Alois Dvorzak“I don’t need to know about a medical condition,” Scott told the jury, because of rules around “medical confidence” . Security records supplied to Scott indicated that the frail 84 year old was an “escape risk”, and so he had to be handcuffed.

Scott insisted that detainees should still be cuffed if they had chest pains, but claimed that ambulance staff knew they could ask for them to be taken off straight away for emergency treatment.

The coroner reminded Scott that Dvorzak had been taken to hospital in handcuffs before, on 8 February, and did not try to escape. He asked Scott why the security risk was not downgraded.

Scott replied that there had been no feedback from that trip to hospital because it was “uneventful”.

He had based his decision on a risk assessment carried out by Simon Geere, a Geo detention custody officer who worked in Harmondsworth’s security department.

Simon Geere told the jury that he received information that Dvorzak had “escaped from a mental health unit” in Canada. However, he told the duty manager that Dvorzak had “escaped from a secure mental hospital”.

Geere said: “I interpreted a mental hospital as a secure facility … I would consider mental health to be a secure location. That may be where I got the word ‘secure’ from.”


Geere had not seen Dvorzak in person. He had seen a photograph and was aware of the man’s age.

The coroner asked him why Dvorzak was attached to an escort chain with “three or four feet between handcuffs”?

“To be honest it just comes down to the history,”  Geere replied. “Medical situation does not come into it.” 

He explained: “It’s not really relevant to handcuff someone in a wheelchair. We don’t handcuff someone if they’ve broken their arm. If a person has chest pains then you don’t do it.”

The coroner said: “But Mr Dvorzak had chest pains. Why was he still handcuffed?” Geere replied: “I can’t justify a comment on that. There were officers there on the ground.”

The jury heard that after Dvorzak’s death, the Home Office issued a new policy on handcuffing detainees, which now contains a presumption that handcuffs should not be applied.

The only mental health nurse at Harmondsworth

Two nurses from the private health company Primecare gave evidence about their treatment of Dvorzak in Harmondsworth.

Nurse Nareshchandra Rami told the inquest that there was no doctor on duty at night in Harmondsworth. (The centre houses more than 600 detainees.)

All detainees are given a screening check-up when they first arrive at Harmondsworth. Rami’s assessment of Dvorzak when he arrived on 28 January lasted ten minutes.

Rami was aware that Dvorzak had been prescribed a cocktail of drugs but said he refused tests and denied having mental health problems.

He said there should have been a drugs chart from the day Dvorzak arrived at Harmondsworth, but it appeared to have gone missing. The only chart available to him started three days after Dvorzak’s arrival.

Nurse Leslie Dube told the jury that he was the only mental health nurse at Harmondsworth. He worked weekdays from nine to five. It took three days after Dvorzak arrived at Harmondsworth for Dube to see him.

“I was not made aware of him before 31 January and I saw him on the 31st after a referral had been made by a GP and the immigration officers,” said Nurse Dube. “At the time I was the only mental health nurse at Harmondsworth”

The coroner asked: “Would you expect to be called to see him as a matter of routine given the drugs he was on?” Dube replied: “Yes, that is not an unreasonable expectation.”

Dvorzak told Dube that “Being in detention was like having ‘demons tormenting him’,” and that he felt a “loss of control, felt violated, felt his rights have been taken away.”

Dvorzak had told him: “This is causing me quite a lot of distress.”

He complained of chest pains. Dube felt that Dvorak was physically unfit to be detained at Harmondsworth, ten days before he died.

Dube told the coroner that Dvorzak was on a 20mg dose of Citalopram medication that would have caused “some concerns and was worth following up … but I did not follow it up”.

He did not refer Dvorzak for a psychiatric assessment on 31 January but waited until a week later on 5 February. Immigration officers had still not supplied him with information that they possessed about Dvorzak’s history of mental illness in Canada.

Dube said those details “would have made a significant difference” and meant he would have alerted the psychiatrist sooner. “I just wish I had that information at that time,” he said.

He had seen no written policy for referring Harmondsworth detainees to psychiatric wards. He said it could take two to three weeks to section someone who was refusing treatment.

The inquest continues.

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