"It is not uncommon for detainees to react aggressively to the death of a fellow detainee and to suspect foul play by staff. Staff might have been expected to anticipate this and to have taken action to defuse the situation." Sue McAllister, Head of Security Group H M Prison Service

    A disturbance at Harmondsworth Removal Centre in July of this year, one of many that have occurred since it opened in 2001, can be squarely blamed on the Home Office and UKDS who manage the centre.

    Sergey Baranuyck an asylum seeker from the Ukraine detained at the time of the event, died on the 19th July 2004. Staff at the centre on the day knew that Sergey was required to attend a legal visit. They began to look for Sergey at about 13.45 hrs and did not find him until 19.50 hrs, some six hours later in the shower on C wing, hanging by a shoelace from the shower control button.

    Staff immediately began to clear C wing of detainees, seemingly without any explanation, and this was to be the catalyst that started the disturbance.  The detainees immediately and correctly suspected that a detainee had died. Having absolutely no trust in the staff and suspecting foul play, they demanded to see the body.  Staff refused, only fueling the suspicion. Detainees became angry and very vociferous.

    By 23.00 hrs, the situation had escalated, no reassurance from management and a change over of staff, the situation then descended into complete disorder. At some stage staff withdrew from C wing and the disturbance spread to O and B wings.  Again the staff withdrew.

    Staff abandoned four detainees who were locked in the health care centre.  No one was aware that this had happened and even though the four set off the alarms, there was no response from management - they were not released until the next day. Another seven detainees who were locked in their rooms and abandoned by staff, were freed by the detainees.

    Detainees used talcum powder and small fires, to trigger fire alarms which automatically opened doors, and allowed them access to other parts of the centre. By 12.00 am on the 20th July the detainees were effectively in control of the centre.

    Police and Prison Service personnel at some stage were brought in to take back control and this was effected fairly easily with out any harm to detainees/staff or police and prison service personnel. There was some dispute between the various authorities as to how control was to be taken back. The Prison Service wanted to do a complete lock down, (bunging detainees in to any room with a lock on it) until they had control. UKDs management objected to this, in that there was a danger from fire, despite the fact that UKDS had locked eleven detainees up and abandoned them.

    In her report on the disturbance, Sue McAllister (Head of Security Group H M Prison Service) is quite clear that trouble had been brewing in the centre for some weeks before July the 19th, and that not all the lessons of the disturbance at Yarl's Wood had been learned.  That "Internal controls within the centre were inadequate to provide an environment which was safe for staff and detainees."

    She was also quite clear that UKDS opinion of their relationship between themselves and the detainees, which UKDS said was good, was not shared by the Home Office representative on site. "Senior UKDS managers believed staff - detainee relationships to be very good; although the contract monitor was more critical and described a culture where staff were likely to base themselves in wing offices and engage with detainees less readily and that "There is no evidence of any real attempt by staff on C wing at the time to de-escalate the situation"  "Internal controls within the centre were inadequate to provide an environment which was safe for staff and detainees."


Below are some selected extracts in relation to above, they are purely the choice of NCADC, the full report can be downloaded from:
http://www.official-documents.co.uk/document/deps/hc/hc1265/1265.htm

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Report of an Investigation into the Disturbance at Harmondsworth Immigration Removal Centre on 19th & 20th July 2004

1 .1 On 1 9 July 2004 detainees at Harmondsworth Immigration Removal Centre staged a disturbance, possibly in reaction to the death of a detainee, Sergey Baranuyck, whose body had been found earlier that evening, hanging in a shower room on C wing. The incident started in one of the wings at about 2300 hrs and spread rapidly across the whole centre. Prison Service and police resources were deployed to support UKDS, the contractors who operate Harmondsworth on behalf of the Immigration and Nationality Department (IND).

1.5 The investigation into the disturbance identified some issues relating to the management of an incident where a number of agencies are involved and where there Is the potential for those agencies to have conflicting priorities. There is, following this incident, an opportunity to review and improve the protocols which exist for joint working between agencies and to give more clarity to the command arrangements which should pertain.

1.6 This was a successful operation; there were no escapes from the centre and, other than the tragic death of Sergey Baranuyck, there were no injuries to staff or to detainees. There are lessons to be learned, both in the way the incident was managed and in the way accommodation is used across the Secure Immigration estate.


3.5 A serious Incident of concerted indiscipline at Yarl's Wood IRC on 14 February 2002 identified shortcomings in the physical security of those centres, including Harmondsworth, required to hold an increasing number of individuals detained under the Immigration Act who were considered to have the potential, or the will, to cause disruption within the Immigration Removal Estate.

3.6 Following the Yarl's Wood incident physical security at Harmondsworth was upgraded at a total cost of £22.5m. The upgrade included the installation of sprinkler systems in all areas of the centre, the expansion of CCTV coverage, and the strengthening of parts of the centre's infrastructure in order to create zones which could be isolated from one another in the event of a widescale disturbance.

3.7 The centre's fire alarm system is linked to fire doors, which grant access to external courtyards. In the event of a fire alarm, these external doors are automatically unlocked; we were told that the alarms were easily activated, for example by detainees throwing talcum powder at the overhead sprinklers. This gave detainees ready access, in large numbers and at any time of day or night to courtyards. Once in the courtyards, which are enclosed on all sides, it is possible to gain access to other wings, or to the central spine of the building by smashing windows and prizing open the window bars.

3.10 It was clear that staff could not easily account for the whereabouts of detainees within the establishment at any time. We became aware that it could take several hours to find a detainee required to attend a legal visit or an interview with Immigration Officers. Although detainees were issued with pagers which would notify them if they were needed at a particular time or place, it appeared that co-operation with this system was patchy.

3.11 The Operational Specification requires that Harmondsworth's Contingency Plans are tested at the level of six exercises per year, and that these exercises allow for the testing of all plans annually. We did not have access to the records of these exercises and so cannot comment on compliance or effectiveness

3.13 The Operational Specification includes a requirement for detainees to have the opportunity to spend 24 hours per week in purposeful activity. This activity includes education classes, PE, and more general 'leisure' activities; however of the 51 0 activity places available only 40 places offer work, on either a paid or voluntary basis.

3.14 Detainees could not be required to participate in the activities available; a culture of involvement was said to be encouraged but in reality many detainees chose to associate in an unstructured way, sitting around, watching television with time to dwell on what must often have seemed a hopeless situation.

3.15 In the context of this aimless, arguably hopeless, existence, there is scant potential to incentivise good behaviour or participation in regime activities. There is no meaningful lncentives/Earned Privileges system, as detainees are automatically given access to all available privileges such as television, free incoming telephone calls and full association. Loss of any of these was impossible to police In the absence of the ability to confine the affected individual to his room.

3.16 The operational specification includes requirements for all detainees to be admitted and for adequate staffing to be provided and to maintain safety, order and control. Each wing is staffed by four Detention Custody Officers, one of whom Is a first line manager grade. Wing staff were encouraged to Interact with detainees, staff and detainees ate their meals together in the wing dining rooms and the open nature of the regime meant that detainees had 24 hour access to staff. Senior UKDS managers believed staff - detainee relationships to be very good; although the contract monitor was more critical and described a culture where staff were likely to base themselves in wing offices and engage with detainees less readily.
 
4.2 Staff reported an increase in graffiti across the establishment in the weeks leading. up to the incident. The graffiti was offensive in its content and indicative of a mis-trust of the authorities on the part of the detainees. No action was taken in response to the increase, which was reported in SIRs.

4.3 In the week preceding the incident, detainees found they were required to pay for drinking water from vending machines. The water had previously been dispensed free of charge and the move to levy a charge was made without evidence of consultation - with staff or detainees - and with no apparent consideration of any potential reaction.

4.4 The Intelligence Assessment for the period 9 - 1 6 July indicated an increase for that week in the number of SIRs submitted. Previous weeks typically had between 40 - 60 SIRs; in the week 9 - 1 6 July there had been 73. An increase was also evident in the number of reported incidents. In the most recent Intelligence Assessment specific mention was made of tension amongst particular groups of detainees who were said to be targeting members of staff. No action was taken in response to this assessment.

4.5 On 1 9 July 2004 at about 13.45 hrs staff began looking for a detainee, Sergey Baranuyck, who was required to attend a legal visit. At 1530 hrs, Mr Baranuyck had still not been found; wing staff temporarily abandoned the search in order to undertake other duties. Following a resumption of the search, Mr Baranuyck was found in a shower room on C wing at about 1950 hrs; he was hanging by a shoelace from the shower control button and was, apparently, dead. Local Contingency Plans for a death in custody were activated, police were called in to attend what was, now, a potential crime scene.
 
4.6 UKDS staff at the scene acted immediately to clear the landing of all detainees. Detainees were moved to the landing below, and C3 landing was isolated by securing the doors at each end of the landing. Detainees, surmising correctly that a fellow detainee had died, became suspicious about the manner of his death and demanded to see the body in order to be satisfied that there had been no foul play on the part of UKDS staff. Owing to the need to preserve the scene, staff were unable to accede to the request. A small group of detainees became very angry and began to urge others to join in their protests. By about 2000 hrs C wing was reporting unrest amongst a large number of detainees.

4.8 Despite the heightened tension on C wing, which was reported to staff coming on duty at 21 00 hrs as part of the handover process, it appears that no arrangements were made to keep additional staff on duty, nor to activate contingency plans.

5.1 By about 2300 hours the tensions on C wing, initially confined to shouting and some jostling of staff by detainees, had escalated into a situation where detainees were running amok in the wing, damaging fixtures and fittings and arming themselves with items with which they began to try to break out of the wings into other parts of the centre, and into the courtyard areas outside.

5.2 The disturbance on C wing spread first to 0 wing and, subsequently, to B wing. As detainees joined in, UKDS staff quickly withdrew from each wing in turn.

5.6 During the incident a number of small fires were started; this appears to have been with the intention of activating fire alarms which would automatically open the external doors. This gave detainees access to courtyards, from where they also broke into the central area by smashing windows and prizing open the window bars.

5.7 Detainees did not gain access to the healthcare centre; however healthcare staff withdrew leaving behind four patients locked in the centre. Three of the four patients were known to be active self¬harmers, and were subject to close observation by staff. The four were only rescued later the next morning when the centre was calm. It is unclear who ordered the withdrawal of staff from the Healthcare Centre; the SILVER Commander was certainly not aware that detainees were left behind in the centre. The activation of alarms in the Healthcare Centre led those managing the incident to believe that the centre had been lost to the rampaging detainees. It was subsequently discovered that the alarms had been raised by the detainees who had been abandoned in there.
 
5.8 Two landings on 0 wing (02) & (03), comprise more secure accommodation; these rooms typically hold detainees for short periods where they are kept apart from the general population. During the incident, staff withdrew from 02 & 03 landings, leaving 7 detainees locked in these secure rooms. Other detainees subsequently gained access to the landing and used fire extinguishers to break into the rooms and release those held there. Fortunately, no vulnerable detainees were located in those rooms at the time, although individuals are sometimes held in this secure accommodation when they are thought to be at risk from the general population.

5.10 By 0015 hours staff had withdrawn from all wings and the centre was, effectively, in the control of detainees.
 
5.11 The Harmondsworth staff mustered in the sterile area outside the accommodation blocks.

6.2 In line with the Prison Service/I NO protocol for managing serious incidents in IRCs, the Prison Service GOLD Command Suite was opened with a Senior Prison Service Operational Manager as GOLD Commander. An IND official was present in the GOLD Suite throughout the incident.

6.3 At about 2350 hours, the Centre Manager, Ron Oliver arrived at Harmondsworth and assumed the role of SILVER Commander. Other UKDS Managers were called in to support SILVER in the Command Suite, and to act as BRONZE Commanders. Detention Custody Officers were called in to support those already on duty and to perform some tasks not directly related to intervention in the incident.

6.8 The initial intervention plan was straightforward, and followed a model which has been successfully executed on many occasions in incidents of this type. It was proposed that Prison Service TORNADO units would sweep each wing in turn and secure detainees in rooms on the wings, leaving UKDS staff behind once each wing was secure. The operation to transfer detainees out of Harmondsworth could then be managed from this secure position.

6.9 Objections to this plan, voiced by the UKDS SILVER Commander, centred on the view that detainees could not be locked Into rooms, even in circumstances as extreme as the ones which pertained, and for a relatively short time, because of concerns about fire.

6.21 The remainder of the detainees were driven, or made their way, in front of the advancing staff, where a hardcore of about 120, some armed and most still showing some reluctance to surrender, ended up on courtyard 3.

6.28 Seventeen detainees were arrested by the police and taken to Charing Cross Police Station for questioning and, in some cases, charging others were transferred directly to prison establishments.

7.1 The routines in operation at Harmondsworth were intentionally relaxed and permitted constant association between detainees on each wing, together with the absence of any requirement, or incentive, to participate in structured activities. Many of the detainees were young, fit men, some, at least, were known to have had involvement in criminal activity or to have criminal links; the combination of a boring regime in detention, and little hope at the end of it, was likely to increase the potential for trouble.

7.2 There were no systems in place to assess the suitability of detainees for the open regime at Harmondsworth. The information staff had on detainees was patchy and, in some cases, non-existent.
 
7.4 In the weeks leading up to the events of 19120 July 2004 there were some indications of an increase in tensions within the centre. In addition to an increase in the number of SIRs of offensive graffiti, and of reported incidents, there were also reports of staff being targeted by particular groups of detainees. No management action appears to have been taken in response to this heightened tension.

7.6 The death of Sergey Baranuyck appears to have provoked the active unrest amongst detainees on C wing, which escalated into the act of concerted indiscipline. It is not uncommon for detainees to react aggressively to the death of a fellow detainee and to suspect foul play by staff. Staff might have been expected to anticipate this and to have taken action to defuse the situation.

7.7 There is no evidence of any real attempt by staff on C wing at the time to de-escalate the situation quickly, before detainees became violent and staff took the decision to withdraw from the wing. The inability to secure detainees in rooms may have influenced this decision.

7.8 The zoning arrangements were not effective against concerted action by detainees, who were able to breach the reinforced doors between wings and the central area.
 
7.9 Detainees were clearly aware that the fire doors could be opened by setting small fires to activate fire alarms. They did this at a number of sites to gain access to the outside areas.

7.10 The presence of a sprinkler system prevented fires spreading; although there is no evidence that detainees intended to set fire to large parts of the centre. The only fire of any significance appears to have been in the library within the education block. There is some suggestion that the pumps which serve the sprinkler system can only provide enough pressure for about 6 sprinklers at anytime. There is also a need to balance the cost of water damage from the sprinklers against any likely benefit from them.
 
7.11 Local contingency plans for responding to a serious incident were in place. However, there was a delay in reporting the incident via the Prison Service National Operations Unit via the Single Incident Number.
 
7.1 4 There was some tension between the Prison Service and the police at GOLD Commander level. This was due to different perceptions of priorities and a possible lack of clarity around command arrangements.
 

End of Bulletin:
Comment: NCADC

Extracts from:
 Report Of An Investigation Into The Disturbance At Harmondsworth Immigration Removal Centre On 19 & 20 July 2004
Sue Mcallister Head Of Security Group H M Prison Service