Unfortunately, such deaths are becoming ever more frequent - as the report Driven to desperate measures attests. And often, because asylum seekers are far from home, usually moved away from community support systems and have no family or friends to represent their interests or adequate legal representation, the deaths get cursory attention. But in the case of Kenny Peter, the Fulham coroner allowed a week-long inquest, calling twenty-seven witnesses - including the NGO Bail for Immigration Detainees (BID) - allowing nine statements to be read out and exhibits including CCTV footage. The details that emerged revealed a system in confusion, with a failure to pass crucial information on Kenny's mental health between agencies and of professionals to take responsibility.
Piecing together Kenny's story at the inquest (his family have still not been located) it appears that his mother was Nigerian and father Liberian and that though born in Liberia, he had lived in Nigeria. Kenny feared being returned to Nigeria because of his prior involvement in a religious cult.
He had set out from Gabon and stowed away with others on a ship, his brother is believed to have drowned during the journey, which called at Spanish ports (where officials were made aware of the men, but did not act) and went on to Ghent in Belgium, where the men were taken to the Nigerian embassy to secure travel documents that would enable their return home. As the authorities refused to house the men, they were returned to the ship, which travelled on to Liverpool. There, the men were served with the papers to enable their return. But a disturbance broke out, the police were called and the men arrested. At the police station, they claimed asylum on 4 November 2003. Kenny was taken to Oakington reception centre where, twenty days later, his claim was refused. He was released into National Asylum Support Service accommodation in Ipswich pending an application to appeal. This was refused.
And Kenny was liable for removal and ended up in a Harwich short-term detention facility which, because of his health problems, including mental health issues, was deemed unsuitable. He was able to gain 'temporary admission' on health grounds and was later admitted to an Ipswich psychiatric hospital to deal with his mental problems. The hospital notes suggested both that his destitution was adding to deterioration in his mental health and that it was possible he was suffering from post-traumatic stress disorder.
Because, after seven weeks, he had stopped reporting regularly to the police (a condition of his release into the community) when picked up in a van-stop operation looking for illegal agricultural workers, Kenny was arrested and transferred to Colnbrook for removal as a failed asylum seeker - a doctor having decided that, despite his having been recently discharged from psychiatric hospital, he was fit to be detained. (The Immigration Service was, at the time, hoping to remove Liberians and was in the process of setting up a documentation scheme for Nigerians. It was not clear to the authorities if Kenny was Liberian or Nigerian and this was to be established while he was held at Colnbrook.)
At the privately run Colnbrook removal centre , Kenny explained in the initial health check on 28 September that he had mental problems and was on anti-depressants . The nurse took the pills away, after giving him one tablet. He was to have seen a doctor the next day - but did not in fact see the doctor till eleven days later (after three days of stomach pain). Then, Kenny spoke about hanging himself and a 'self-harm at risk' form (SHARF) was opened. The anti-depressant Mirtazapine was only then reinstated. (It is possible that a sudden break in taking anti-depressants can contribute to severe mood swings.)
Between his admission to Colnbrook and the doctor's visit, attempts had been made by solicitors and BID to get him 'temporary admission' on compassionate grounds because of his mental state. Meanwhile, immigration officers at Colnbrook had been asking Kenny questions about his schooling and family with a view to returning him to Nigeria in October. Kenny was clearly confused by the questioning and thought at every stage that his release was imminent.
It emerged at the inquest that the fact that Kenny had been placed on SHARF on 9 October was not noted on his file at Colnbrook. Neither was it on his Felixstowe immigration file though the immigration staff at Felixstowe were responsible for authorising and reviewing Kenny's detention, and under immigration detention rules, should be notified of any change in the case (a concern already raised by the prisons ombudsman in his report on the death). The doctor who saw him on 9 October and again the next day, noted both times that Kenny should be referred to a psychiatrist. But it did not happen - no one on the medical team seemed to take responsibility for following this up. And Kenny's notes from the Ipswich hospital were never requested either.
On 12 October, after he made a serious attempt to take his life by jumping from a landing with a ligature round his neck, (he landed unhurt on netting) Kenny was placed under constant supervision and a note was made that he should see a psychiatrist. Meanwhile, the suicide attempt unknown, BID was still trying, despite a refusal on 13 October, to get Kenny out of detention on mental health grounds - speaking to former solicitors and the Ipswich hospital for more information to support his case. The same day, Kenny was told by an immigration officer at Colnbrook: 'It will reduce the time spent in detention if you admit your true identity and nationality. Even your legal representatives state you are Nigerian.'
Just four days after his suicide attempt, Kenny, asked to be moved from the medical centre to a wing where he would be under a less stringent SHARF supervision. Yet another note was made that he should see a psychiatrist (his records revealed that this request had been made at least six times in all but was never actioned). Three days later, at 11.15am, Kenny walked from his ground floor room, up to the second floor where he tied a sheet to railings to act as a noose, and jumped. The sheet gave way but remained round his neck as he hit his head and slipped through a netting gap to the floor.
Kenny Peter, a vulnerable, asylum seeker with mental health problems died as a result of a self-harm attempt. After being detained, he apparently never understood what was happening to him. Confused, with nothing made clear, the last words he is reported to have mumbled as he convulsed on the floor, with blood round his mouth, were, 'leave me alone'.
Comments on the inquest and verdict
Sarah Cutler of BID told IRR News: 'Kenny Peters was failed by the Immigration Service and the private company responsible for his care whilst in detention. His case is tragic but not isolated - HMIP's report published today on healthcare in Yarl's Wood found that there is no means of systematically considering health when reviewing detention. Detainees are locked up on the basis of an administrative decision and there simply are not enough safeguards to ensure that they are safely or justly detained.'
INQUEST, the organisation that helps the families of those who die in custody, told IRR News: 'It is vital there is thorough public scrutiny of deaths in immigration detention. In the absence of any family, INQUEST applied to the coroner to be allowed to represent Kenny Peter's interests at the inquest. This was rejected by the coroner. Though the coroner in this case took on board many of the issues raised in our submission and held a thorough inquest, we believe it is essential that when someone dies who has no family, organisations with expertise, such as INQUEST, should be allowed to represent their interests. It can not be a lottery based upon the willingness of a coroner to properly and fearlessly carry out an inquest.'
Cornelius Katona, a psychiatrist working in east Kent and a professor at the University of Kent, told IRR News: 'There are important lessons to be learned from Kenny Peter's tragic and unnecessary death. Mental health problems, particularly depression and post-traumatic stress disorder are very common in asylum seekers, particularly those who are detained. There is clear evidence that the detention process itself worsens their mental health. It can be very difficult for detained asylum seekers to access NHS specialist mental health services, particularly those detained in removal centres run by private organisations rather than directly by the Home Office. These factors as well as poor communication between services may have contributed to Kenny Peter's sad death. Above all his death calls into question the practice of detaining asylum seekers with severe mental health problems and thereby increasing their risk of suicide.'
The last two pages of the jury's 12-page inquisition (the legal document which establishes the circumstances around a death) listed numerous deficiencies, failures and missed opportunities including:
* A failure in the healthcare unit of Colnbrook to pursue the matter of prescribed anti-depressants;
* A failure in the healthcare unit to ensure Kenny was seen by a doctor within 24 hours of admission;
* A failure in the healthcare unit to arrange assessment by a psychiatrist, counsellor or Registered Mental Nurse (RMN) following referrals and the first suicide attempt;
* A failure of communication within the healthcare department;
* A failure to assume professional responsibility for follow-up within the healthcare department;
* A failure in the continuity of care and personal handover (both Healthcare staff and custodial staff);
* A failure to seek out Kenny's previous medial records;
* 'Deficiencies in the system' resulted in 'missed opportunities' (by the immigration service) to review Kenny's detention;
* Failure in communications within Colnbrook (in general), after medical staff suspected 'suicidal ideation' yet failed to inform the centre manager;
* Failure in communications between Colnbrook staff and immigration staff on issues surrounding Kenny's mental health;
* Failure of Colnbrook immigration staff to make further enquiries of Colnbrook healthcare staff after they knew that Kenny was under SHARF review;
* Failure in communications between Colnbrook immigration officers and Felixstowe immigration officers about Kenny being under SHARF review.
- Many thanks to Catherine Hayes, a caseworker at Inquest, for help with this report.
 The centre is run by Serco, which also operates Dungavel removal centre in Scotland. Colnbrook was opened in September 2004 and was designed and built by Serco under an eight-year contract.
 Healthcare at Colnbrook is 'contracted out' and is currently provided by Primecare Ltd, a subsidiary of Serco.
The Institute of Race Relations is precluded from expressing a corporate view: any opinions expressed are therefore those of the authors.