In the days after Rubel Ahmed died, there were two competing stories about what happened.
Authorities at Morton Hall immigration detention centre, where the 26-year-old was held, said he had committed suicide. There had been no cries for help. He had sat alone in his cell and killed himself. Fellow detainees at the centre said he had been banging on the walls and complaining about pains in his chest, but that no-one came.
I wrote at the time that whichever story was true, he was killed by Morton Hall. But that's not quite right. It wasn't just Morton Hall. It was the system of detention, of stuffing ordinary people into prison buildings, often among foreign criminals, with no sense of how long they'll be there and no sense that anyone is really listening to them. It was the Home Office, which presides over this system and refuses to even allow a maximum time limit on detention. And because of our continued tolerance of this state of affairs, it was Britain which killed him too. In so far as we allow this situation to continue, we are responsible.
Now that the coroners' court has delivered its verdict, we know which of the stories was strictly true. Ahmed committed suicide. But we also know that Morton Hall did indeed kill him. The open verdict delivered by the jury highlights a systematic failure to look after detainees.
I'm told management are shocked by the outcome, as are staff. They're hoping management cops the flack for what happened, although that seems unlikely, given the centre's track record.
Ahmed had been told he was about to be deported to Bangladesh just a few days before he hung himself.
He'd been locked in the room for hours when he did it. In court, the detention centre manager admitted that locking up detainees in their rooms was a risk factor. But an inspectorate report calling on Morton Hall to stop locking detainees up in the evening and overnight from two years ago has still not been implemented.
As Ajmal Ali, Ahmed's cousin, said after the verdict:
"Locking Rubel up in his room early in the evening prevented him from being able to talk to his fellow detainees in the hours before his death, leaving him alone with his own thoughts and worries. We believe that being unlocked would have made a difference to him that night."
The evening lock-up is typical of Morton Hall. It's a former category B prison, with many of the features of its previous function intact. It holds a disproportionate number of foreign criminals.
As a guard, who wished to remain anonymous, told me at the time:
"It's very tribal. The Vietnamese hang together, the Afghans, the Nigerians. If one Nigerian has a problem with an Afghan, then it's the Nigerians versus the Afghans. We don't get a lot of trouble, but when we do, we get carnage. The incidents have gone up since the Home Office decided to send us former foreign national prisoners. We're getting far too many."
An all-party parliamentary inquiry panel and HM Inspectorate of Prisons have raised concerns about detainees being held in prison-like conditions. Nothing has been done.
Ahmed got lost in the system. As another cousin said, he was considered "irrelevant" by those detaining him. The jury found "inadequate" communication between the teams meant to be overseeing him. There was no system in place for checking on how he was once he learned he was going to be removed. Staff were supposed to check on changes in behaviour, but they didn't even know who he was. An off-duty member of staff had to be called to identify him.
As the guard said:
"No-one knows who he was. He'd never come to our attention for any reason. He wasn't being watched closely because he wasn't a suicide risk."
Once he was found, experienced staff had not been trained in resuscitation techniques for years and couldn't remember what to do in the case of hanging.
Clare Richardson, the family’s solicitor, said:
"The jury heard that two of those responsible for Rubel’s welfare had not received training in resuscitation techniques for over ten years, and none of them could remember much of what they had been taught about working with immigration detainees. This reflected a wider malaise in the training regime at Morton Hall which needs to be addressed urgently by the Ministry of Justice."
Even news of his death got lost in the system. The coroner said there had been a "very significant" delay in confirming the death to the family.
As I wrote at the time about the centre's response to the death:
"Not only did they not announce it, but they failed to even get in contact with journalists until hours after the story had broken. Morton Hall directed calls to the Ministry of Justice, who answered an hour later and passed the call on to the Home Office, who did not answer until several hours later."
This was how the British state acted when confirming reports of a death under its care.
Even the facts we now have at our fingers are not completely reliable. As the guard said of the management:
"They are fucking liars. They don't tell the truth, not by a long way. I've been in this job a long time and I know it's a load of bollocks. We're being told no-one is in the frame for this. Whatever the truth is, it's never going to come out."
But even with the details we have, the ultimate truth is clear: Ahmed's death is the responsibility of this country, where we lock people up indefinitely among hardened criminals, without trial or information about when they will be released. Where we care so little for the people in our care that we don't bother checking on them when we know they are going through a traumatic experience. Where we leave it to detainees to secretly tell journalists about the death and solicitors to tell the person's family.
It's not the guards' fault. It's management's fault. But the blame for their indifference must ultimately be laid at the door of the Home Office. And the Home Office only gets away with it because we don't cause a fuss.
Britain killed Rubel Ahmed.