An inquest jury has found “multiple failings” and “missed opportunities” at an immigration detention centre contributed to a Colombian man taking his own life in 2023.
The coroner examining the death of Frank Ospina said he had been let down by the state “in numerous ways” which were “utterly regretful”.
Last year the BBC revealed Frank Ospina had died in the detention removal facility despite being willing to return home to Colombia.
The jury found his case should have been reviewed because of his worsening mental health, which could have led to him being released.
Offering its condolences, the Home Office said steps had been taken since Mr Ospina’s death to improve safeguards for individuals in detention.
Frank Ospina, 39, an engineering graduate, came to the UK in late 2022 to visit his mother, who had settled here, and to visit prospective universities.
Having decided to instead enrol on a master’s course in Spain, which was due to begin in May 2023, he took a short-term job washing dishes, his family say. But as a foreign national Mr Ospina did not have the right to work in the UK.
He was arrested in an immigration raid and taken to the Heathrow detention centres.
Behind bars he suffered a mental health crisis and on 26 March 2023 was found dead at the Harmondsworth facility, having strangled himself.
The inquest jury concluded that he had killed himself.
The jury’s key finding centred on a detention centre rule that medical staff should report any detainee suspected of having suicidal intentions.
The failure to submit a rule 35.2 report meant Frank Ospina’s release from detention was never considered by the Home Office, the jury concluded.
His mother visited him but was separated from him by a glass wall which the jury described as “inappropriate and unnecessary”.
It “contributed to the deterioration of his mental health and incurred further stress”, the jury decided.
Staff on duty that night made “unacceptably inadequate observations” of Frank Ospina, failing to spot he was not in his bed.
He was found out of sight, having strangled himself.
The Coroner, Lydia Brown, offered her condolences to his family telling the court “the state took Frank Ospina into detention and this jury found they let him down in numerous ways and of course his family down that is utterly regretful and now irretrievable.”
Frank Ospina was detained at Harmondsworth alongside failed asylum seekers and former foreign criminals.
He told a charity he was prepared to be removed from the UK under a voluntary return scheme and was not trying to avoid deportation.
His brother-in-law, Julian Llano, told the BBC: “He kept insisting that he felt very bad, mentally, that he needed to get out of there.
“He didn’t ask for help – he begged for help, not only to us, but also to the people there.”
Immigration detention centres are run like prisons, but many of those detained have committed no crime. They are held while the authorities prepare for them to be removed from the UK.
The Ospina case highlighted ongoing concerns about the management of immigration centres, six years after a BBC investigation revealed the abuse of detainees at Brook House near Gatwick.
The chair of a public inquiry into that scandal said in September only one of her 33 recommended changes had been carried out by the government.
Yet the centres are under growing pressure because the government is planning to remove more failed asylum seekers as part of a plan to reduce small boat crossings.
A spokesperson for Mitie, which runs the Harmondsworth facility, said “the physical and mental wellbeing of those in our care is of the utmost importance to us”.
“We accept that the decision to place Mr Ospina’s family in a closed room for their visit was wrong and not in accordance with our policies and procedures, and we have apologised for this.”
“A number of measures have already been implemented and we will continue working with the Home Office and Practice Plus Group to address the matters raised by the Coroner.”
A Home Office spokesperson said: “We offer our sincere condolences to Mr Ospina’s loved ones, and since his death in 2023 a number of actions have been taken to improve the safeguards for individuals in detention, including an increase in staffing numbers, training and guidance for staff.
“The new government is focused on ensuring actions are taken to improve conditions in detention facilities, including reviewing the current process for communicating risk and vulnerability of detained individuals.
“We will carefully consider the coroner’s recommendations.”
