By Juliet Cohen
This week, yet another report highlights the inhumanity of the UK's system for detaining immigrants and asylum seekers. Once again, it found that the most vulnerable individuals, including torture survivors, are the victims of these failings.
Those detained have not been convicted of any crime, nor are they even on remand- this process of immigration detention is purely an administrative one. As head of doctors at the medical charity Freedom from Torture – the only charity dedicated to providing clinical care, psychological therapies and forensic documentation services for torture victims since 1985 – I consider mental health a critical issue in this situation. It's one which is often overlooked.
The severity of any mental illness can be influenced by external circumstances, particularly something as major as the act of detention. Survivors of torture, whose most traumatic experiences have often occurred in the context of detention, are particularly vulnerable as being detained can evoke powerful intrusive recall of their torture experiences.
This in turn can lead to re-traumatisation, a rapid deterioration in mental health and, in some cases, self-harm and suicide.
In recognition of this risk, rule 35 of the detention centre rules bars the Home Office from detaining anyone who has been tortured (except under very exceptional circumstances). Detention centre doctors are supposed to alert the Home Office of any detainee who they have a concern might be a victim of torture which, in turn, should lead to a review of the detention.
But rule 35 has repeatedly been shown to be failing- in inspection reports by HMIP and in the Home Office's own audit of the process. In a ruling on the legality of the detention fast track system Justice Ouserley reported that a "Home Office audit of the outcomes of Rule 35 reports showed that in only nine per cent of cases did it lead to release from detention, again covering all reports and all detainees".
Doctors' rule 35 reports are a key part of the torture safeguards
I have personally seen many rule 35 reports generated for Freedom from Torture clients in detention who have not been released as a consequence, even when the rule 35 report has noted multiple scars and deep-rooted psychological health problems. Sadly many rule 35 reports are all too brief, note only a fraction of the scars later documented by a specialist examiner or contain no mental health assessment at all.
Rule 35 reports can be dismissed by the Home Office for reasons such as lack of 'independent evidence', which implies that their own health care staff aren't objective. Sometimes they are dismissed on the basis that the medical practitioner fails to specifically recommend release, which raises what the point of a rule 35 report is in the first place. This is troubling and must be addressed, but there are other important factors which must be considered in the new review announced by the Home Office this week.
I have visited many immigration removal centres to examine detainees who need a medico-legal report to document evidence of torture. In this work I have seen at first hand the difficulties of the doctors working in such settings. They are often faced with a near impossible job, stuck between the rigid budgets and targets of their employer – the immigration detention centre contractor - and their duty to meet the complex needs and symptoms of their patients.
Doctors working in immigration removal centres need to be more than GPs with a broad base of experience in mental health conditions. They need to understand the complex ways in which detention impacts on health and the ability to forensically document the scars and mental health indicators associated with torture. In sum, they need specialist training.
The sad truth is that healthcare professionals in these very challenging detention settings are often woefully unsupported and under-resourced to act in their patient's best interest – the principle that should underpin all medical work.
Rule 35 reports are often lacking in clinical information and are dismissed by Home Ofice staff
I recently visited an IRC where, because of the high workload of the doctors, there was a delay of up to a month for a detainee to get their rule 35 report documented. These critical reports are supposed to be triggered within 48 hours of the initial assessment of the detainee's arrival.
In a detention setting, there is a risk the employer may be incentivised to provide just enough healthcare at the lowest possible cost for a highly transient population, despite the fact that the law states immigration detainees, the majority of whom are asylum seekers, have the same rights to health care as any NHS patient.
These dual obligations may put pressure on a doctor and appear to blur the lines of their professional responsibilities, even though international and national guidelines are unequivocal that the patient's needs should come first.
Identifying torture survivors is not easy. Many don't speak English, many don't feel able or ready to disclose what has happened to them, particularly when they have been violated sexually, and some will not understand that what happened to them does constitute torture and therefore entitles them to additional protection.
Doctors working in detention settings must be given the tools, training and time to do their job properly. Unless they are supported, the results of future reviews and reports are likely to continue finding that the rule 35 safeguard is failing and that we continue to lock up torture survivors.
Juliet Cohen is Freedom from Torture's head of doctors.
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