Abdul Khan pressed the emergency button again. It was after 6 am and his roommate Muhammad Shukat was groaning in agony, clenching his chest, and sweating profusely — he had collapsed for the second time that morning. Nursing staff came in, unlocked the door to the small window-less room, picked Shukat up, put him back in his bed, took his temperature, administered medication, and left the room. After three separate similar visits by nursing staff and ten different frantic calls of the emergency button by 19-year-old immigration detainee Khan, an ambulance was called at about 7.20 am — nearly two hours after Khan's initial call for help. Paramedics attempted to resuscitate Shukat but the 47-year-old was pronounced dead on arrival to hospital. His body was flown from the UK back to his family in Pakistan. This was Kahn's account of a tragic morning at Colnbrook immigration detention centre, Middlesex, UK, at an inquest in 2012.

Serco, the company that manages the Colnbrook centre, and the Home Office's UK Border Agency (UKBA), have said that all recommendations from the inquest have been implemented. But people working in and researching health care in immigration detention centres in the UK are troubled that things are not getting better, and that more concerns are being highlighted over time.

With refugees and asylum seekers representing some of the most vulnerable people in society, with the majority of them fleeing ruthless conflict in their home countries, there is evidence that the process of detention itself can further damage their health. Many people have come from areas where there is a high incidence of HIV/AIDS, malaria, or other infectious diseases, many may have a history of torture, rape, or mental ill health, and a substantial number of people will have been separated from their family.

In the past year, concern has risen about asylum seekers with a history of being tortured being unnecessarily detained, and this breaking Rule 35 of the 2001 Detention Centre Rules. A report by Medical Justice—a charity that supports the health rights of immigration detainees—published in May, 2012, states that “Rule 35, which should prevent torture victims being locked up in all but very exceptional cases, is routinely flouted”.

In their investigation of 50 asylum seekers (36 men and 14 women) who were detained between May 2010, and May 2011, all reported some history of torture — 16 had been raped in their home countries. 43 individuals cited past torture during their screening, on their statement of evidence form, or at interview, and yet only one person was released due to the Rule 35 process.

“It [Rule 35] sounds wonderful in principle but is blatantly and repeatedly not working in practice to protect vulnerable people from detention”, said Juliette Cohen, head of doctors at the non-governmental organisation, Freedom from Torture.

“And the Chief Inspector's report of these various centres repeatedly highlights the failures of these centres to implement this practice and we have asked UK borders to audit this, which they did after years of pressure and they failed to record what we wanted them to record…they also failed to do another audit, they failed to train staff on the identification of people who have been tortured, and it's an ongoing scandal”, said Cohen.

“UKBA insist that they are learning lessons, but have not been able to say what their mechanism is for that”, explained Sabina Dosani, consultant psychiatrist and medical adviser for Medical Justice. There is a feeling among experts that the UKBA and Home Office are not taking the issue of immigration detention seriously.

In the past year, there have been three separate High Court judgments that found that three asylum seekers with mental illness were unlawfully detained in immigration centres in the UK. In one case, the High Court judgment found that Serco, by shackling a detainee in hospital for 8 days (including while using the toilet, showering, and during medical consultations), subjected the man to “inhuman and degrading treatment”.

Dosani goes on to explain that at a Detention User Group Medical Sub-Group meeting last year, the UKBA had not found time to read the High Court judgments. Furthermore, each meeting since January, 2012, has been cancelled by UKBA, “so we have not had an opportunity to ask them again about the High Court judgments”.

Over the years, concern has been expressed about the detention of children and families. The family wing at Yarl's Wood detention centre in Bedfordshire closed in December 2010 and the number of children detained has fallen, but some disturbing issues remain.

Emma Fillmore, a consultant paediatrician and designated doctor for children in care in Nottingham, points out that she knows several children who have wrongly been considered as being more than 18 years of age and are being held in detention centres. “The physical health of young people who have been through detention is often of great concern. I have recently assessed and treated at least two young people who were found to be under 18 years old. Both clearly gave a history of seizures that they had had since childhood with previous medication use. Neither had any medication whilst in detention and both developed significant seizures without any medical help. Another young person had clinical presentation of AIDS with positive HIV screen identified by our health team, but he had not been identified in detention . . . . he missed four months of treatment whilst in detention”, she says.

Children are not the only vulnerable people affected by the poor quality of health care in immigration detention centres. A 2011 HM Inspectorate of Prisons report of Yarl's Wood detention centre stated that “too many pregnant women, who should only have been held in exceptional circumstances, were detained”. Mary (a pseudonym), an ex-detainee who was pregnant while in detention, explained her experience to The Lancet. “The health-care level is very bad. They should be trained when it comes to medication. At that time, I was three months pregnant and they gave me antimalarial tablets.” Mary, who worked as a pharmaceutical assistant in her home country, believed that the antimalarial drugs she was given were not suitable for her during her early pregnancy, so she threw them away.

Miriam Beeks, a volunteer doctor with Medical Justice, points out that “in most parts of sub-Saharan Africa there is chloroquine resistance to malaria so this drug combination, which can normally be given in pregnancy is no use”. Mefloquin, another antimalarial drug, should not be given to women in early stages of pregnancy, and should not be given to women with a history of mental health problems as this can increase the chance of psychosis. “There were a lot of women in detention who had mental health problems, who were pregnant. In total, there were 22 women (out of an audit of 75 women who were detained between 2005 and 2011) with mental health problems, either depression or previous problems with psychosis, which would make mefloquin contraindicated.”

Beeks also talks of three pregnant women with HIV, of whom “two had missed medication”. Furthermore, “in two cases removal was attempted before they had the results of the viral load to show that the treatment was being effective in pregnancy”.

Clearly several problems still exist with the quality of health care in immigration detention centres in the UK despite the publication of several critical reports by charitable organisations and the Inspectorate of Prisons over the past few years. “It's not like this is a prison population where there is a punitive reason for justifying the detention”, says Cornelius Katona, Medical Director at The Helen Bamber Foundation, a human-rights organisation based in the UK. “In contrast with imprisonment, the only justification for immigration detention is administrative. One can perhaps understand the rationale for detaining people who would otherwise abscond. Pregnant women are at very low risk of absconding. The evidence is that the majority of pregnant women who are detained are in any case subsequently released from detention.”

A 2012 House of Commons report — Rules governing enforced removals from the UK — made several recommendations to the Home Office with regards to restraining detainees. The report also noted that there was a high level of evidence of detention staff using racist language in front of UKBA staff and the HM Inspectorate of Prisons. “It is possibly the result of a relationship between the Agency and its contractors which had become too cosy”, stated the report.

“The bottom line is that a lot of people go into detention because they go into the detached fast-track procedure and it subsequently becomes fairly obvious with 20/20 hindsight that they should not have”, says Katona. “So trying to look at these procedures, which lead to a decision to detain, and actually question that before someone is put into detention is probably a very important part of reforming the system.”

A December 2012 joint report by the inspectors of prisons and immigration stated that there was insufficient evidence for detention in about a quarter of cases. The inspectors also highlighted their concern over the number of people who were detained for lengthy periods of time. In the first quarter of 2012, 3500 people were being detained in immigration detention centres but more than 40 people had remained in detention for more than 2 years. Nick Hardwick, Chief Inspector of Prisons, and John Vine, Independent Chief Inspector of Borders and Immigration, said: “Despite much effort at improving the system, it is questionable whether the length of detention in some cases was necessary or proportionate to the legitimate aim of maintaining immigration control.”

Serco refused to comment for this piece and the Home Office declined a request from The Lancet to visit any of their immigration detention centres.

This article was first published in The Lancet, Volume 381, Issue 9860, Nayanah Siva, Time in detention, Pages 15 - 16, Copyright Elsevier, 2013.

The Detention Centre Rules 2001: Rule 35

Special illnesses and conditions (including torture claims)

35.—(1) The medical practitioner shall report to the manager on the case of any detained person whose health is likely to be injuriously affected by continued detention or any conditions of detention.

(2) The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.

(3) The medical practitioner shall report to the manager on the case of any detained person who he is concerned may have been the victim of torture.

(4) The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.

(5) The medical practitioner shall pay special attention to any detained person whose mental condition appears to require it, and make any special arrangements (including counselling arrangements) which appear necessary for his supervision or care.