A Scottish Fatal Accident Inquiry has held that a number of defects in the system of working in Dungavel Immigration Removal Centre led to the death of a 54-year old Chinese man which could have reasonably been avoided.

A Fatal Accident Inquiry, similar to an inquest in England, is an inquiry into the circumstances surrounding a death and to establish what steps might be taken to prevent deaths in similar circumstances.

Mr Xi Biao Huang had relocated from China and resided in the UK until his detention by immigration officers in August 2017 initially in an English immigration removal centre. When Mr Huang was brought to Dungavel in Scotland, he was incorrectly noted as speaking Mandarin (a language of which he had no knowledge). He was in fact a Taishanese speaker. His English was extremely limited. His name and his date of birth were also incorrectly recorded. 

A few days after arriving, Mr Huang, with the aid of his roommate, tried to explain he was suffering from chest pain. His complaint was noted as “gastric” and he was given indigestion medication without any record of his vital signs being taken.

The following day, Mr Huang was found dead in his cell.

The cause of death was noted as Ischaemic Heart Disease. The post-mortem indicated he had suffered a heart attack approximately two weeks earlier and again a day or two before his death. Expert medical evidence in the case said that if Mr Huang had been taken to the hospital at any time before his second heart attack, his chances of dying would have been significantly reduced.

The Sheriff, in a 147-page judgment, was critical of the system in place for the use of interpreters, describing it as “vague, haphazard and ambiguous”. He was also critical of fellow detainees being allowed to act as interpreters without a reasoned decision.

The Sheriff further noted that the system for booking GP appointments was not properly documented and the standard of medical record-keeping was not compliant with the requirements of the Nursing and Midwifery Council.

In total, 14 separate recommendations were made, the most notable of which were:

• All medical assessments should be carried out with the use of a professional interpreter. Fellow detainees should not be interpreters except in emergencies;
• All medical assessments with patients should be fully recorded and available to future healthcare staff when examining patients;
• All clinical assessments should take place in a consultation room and not in open corridors in view of other detainees;
• There should be a system of automatic triggers for GP assessment following repeat prescriptions within a short period of time; and
• Custody staff should receive training in processing arriving detainees to ensure that accurate details of the languages spoken are obtained.

This is certainly not the first time that systematic issues have been raised in the operation of immigration removal centres. According to the charity Inquest, 56 immigration detainees have died in detention since 2000. A couple of years ago, I wrote about the BBC’s Panorama episode which revealed a “culture of abuse” in many removal centres and there being a toxic mix of inadequately trained staff, attempted suicides and asylum seekers being forced to share cells with foreign criminals. The only light at the end of the tunnel in this case was that a number of changes has already been brought into force by Med-Co, the company subcontracted to provide healthcare services at Dungavel.

Although the purpose of a Fatal Accident Inquiry is not to establish civil and criminal liability, it will very often be possible for actions of damage to be brought by the families of the deceased following any critical findings of negligence or fault by those involved. It seems likely that Mr Huang’s family may now be able to seek damages.