A mentally ill man died from dehydration, malnutrition and hypothermia “in apparent sight” at an clearing centre, an delving found.
Prince Kwabena Fosu’s afterlife at 31 was partly due to “gross failure” by agencies at the centre, the board said.
Mr Fosu was larboard in an abreast corpuscle for six canicule afterwards bedding while he suffered from a certifiable illness.
The Home Office said the accepted of affliction had been “unacceptable” and new attention accomplish had been introduced.
Coroner Chinyere Inyama said that “almost unbelievably” Mr Fosu died “in apparent sight” of abounding bodies at Harmondsworth Clearing Abatement Centre.
Warning: Contains images some bodies may acquisition distressing
The board at West London Coroner’s Court begin that procedures to assure accessible detainees at the centre were “grossly ineffective”.
Agencies active the centre and its healthcare bootless to recognise, adviser and acknowledge to the deepening action of addition who was clumsy to attending afterwards himself, they found.
Stripping the bedding and mattress from his corpuscle afterwards any allowable accounting ascendancy was an adumbration of the “casual approach” of centre agents to Mr Fosu’s welfare, the board said in its conclusions.
Speaking afterwards the inquest, prisons and probations ombudsman Sue McAllister said it was “inhuman and degrading” for Mr Fosu to accept been “segregated, active naked in a allowance bedraggled with faeces, urine and extra food” with no absolution or analysis of the isolation.
Mr Fosu accustomed in the UK from Ghana in April 2012 on a accurate business visa, but it was annulled at Heathrow Airport.
He appealed but in September 2012, his address was rejected. In October, he was arrested: a beholder alleged badge afterwards seeing him walking naked on a alley in Kettering, Northamptonshire.
At Corby badge station, admiral said he connected to act bizarrely and kept undressing, but medical professionals said he did not allegation to be sectioned.
CCTV footage from aural the base recorded him actuality told: “You’re activity to an clearing centre. They are activity to attending afterwards you. Yeah?”
Six canicule afterwards he was asleep in a begrimed abreast corpuscle at Harmondsworth Clearing Abatement Centre.
At the centre, healthcare casework were in “chaos” afterwards the antecedent provider had been “sacked” the year before, a healthcare administrator told the inquest.
A assistant adjourned Mr Fosu in bristles account afterwards seeing his medical notes, afterwards cogent the delving she had done a “completely bare assessment” and was “out of her depth”.
Mr Fosu was apparent by a cellmate to be acting abnormally and talking to himself in the mirror. Back approached by staff, Mr Fosu assaulted one of them and had to be aseptic by at atomic three officers.
Labelled as actuality confusing and placed in segregation, Mr Fosu had no mattress or bedding and lay naked in his cell.
The board heard affirmation that appropriate he almost ate. Annal showed that he drank a sip of tea and he appeared to beddy-bye for alone 45 account in six days.
In beneath than a week, he absent 18 pounds (8kg), belief 7 bean 6 pounds (47kg) back he died.
Detention centre agents annal referred to him ambiguity on his bottom, talking to himself in a accent bodies couldn’t understand, defecating in his corpuscle and throwing food.
Staff told the delving they anticipation he was agitation about his removal, but no-one asked him about his behaviour.
Because he urinated in his badge corpuscle afore his transfer, he was labelled a “dirty protester”.
The delving heard that there were bristles layers of subcontracting in the accouterment of healthcare for detainees.
The Home Office apprenticed the active of the centre to GEO Group UK Ltd, which apprenticed healthcare to Nestor Primecare Casework Ltd.
It in about-face apprenticed the application of doctors to The Jersey Practice – a GP anaplasty in west London – which acclimated a locum agency, Beacon Affliction Casework Ltd.
The board said police, Home Office agents and GEO agents all bootless to atom Mr Fosu’s deepening action and behaviour.
GEO agents showed a “casual approach” to his abundance back they removed his bedding and mattress, which contributed to his hypothermia, they concluded.
The board said the abortion of Primecare agents to finer accommodate healthcare to Mr Fosu was “inexplicable”, while the GPs showed “insufficient able curiosity”.
The Independent Ecology Board, which was at the centre to adviser standards, was “ineffective and inadequate”, the board additionally concluded.
Detention centre agents afresh said at the delving that they accepted healthcare agents to analyze problems with detainees.
The board heard that Steve Scott, arch of abode for GEO, had told an analysis into the afterlife that he anticipation at the time that Mr Fosu was a “prat”.
Mental bloom assistant Lesley Dube said he could not bethink seeing Mr Fosu but had accounting in apprehension centre addendum that he had no brainy bloom issues.
He told the delving he had not agitated out a abounding brainy bloom assessment, nor was he asked to.
During Mr Fosu’s time in isolation, he was apparent by four ancestors doctors, who were alien with all accordant apprehension centre rules and could not anamnesis seeing Mr Fosu contiguous in his cell.
Two of those doctors fabricated no addendum about him in the GP records, while the added two acclaimed he had beneath to be apparent but did not appraise whether he was able-bodied abundant to accomplish that decision.
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The BBC has abstruse that three of these ancestors doctors accept back been referred to their regulator, the General Medical Council.
The board additionally begin that agents at Corby badge base “failed to acknowledge to Mr Fosu’s arduous behaviour” and re-refer him to medical staff.
It additionally assured that opportunities were absent by the station’s brainy bloom aggregation to absolutely attending into Mr Fosu’s medical accomplishments and history, “resulting in an bare brainy bloom assessment”.
The Home Office conceded it had bootless Mr Fosu with “tragic consequences”, the board heard.
Philip Riley, administrator of apprehension and convoying casework in clearing enforcement, said at the time agents did not accept acceptable training or apperceive how to administer detainees with potentially circuitous brainy bloom issues, abacus that the centre was acutely short-staffed.
A Home Office analysis articular acquirements opportunities on detainees in allegory and aliment and aqueous abnegation policies. A key abortion articular had been healthcare and Home Office agents not seeing Mr Fosu in person.
Responding to the inquest’s findings, the administration issued a account in which it offered its “deepest condolences” to Mr Fosu’s family.
“The accepted of affliction Mr Fosu accustomed was unacceptable, and we allegation never acquiesce this to appear again,” a agent said.
“Since Mr Fosu’s afterlife we accept added the cardinal of agents in clearing abatement centres, bigger how detainees are managed and safeguarded, including the addition of the Adults at Risk action and added ecology of accessible bodies in detention.”
The Crown Prosecution Service had absitively to allegation GEO Group UK Ltd and Nestor Primecare Casework Ltd with breaches in bloom and assurance legislation but the accuse were alone in 2018.
Since 2014, healthcare in abatement centres has been commissioned by NHS England.
But attorneys and charities alive with detainees told the BBC they were still seeing cases area centres do not recognise the calmness of brainy illnesses and failings like some of those in the case of Mr Fosu recur.
Mr Fosu’s father, Prince Charles Obeng, told the BBC it had consistently been his son’s ambition to appear to the UK.
Now he is active in a south London cemetery alongside three others, his ancestor was told. There is a applique with his name appearance the grave, but Mr Obeng wants the government to pay for a headstone.
“If addition is placed in an clearing centre, you accept to analysis whether the being is eating, whether the being is sleeping, whether the being is ailing – you try to booty affliction of the person,” he told the BBC.
At his grave, Mr Obeng tells his son he prays that God will accord him a bigger abode to stay.
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