“A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he…”

The coroner’s concerns

1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the document as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process. This puts detainees at risk. 2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process. This puts detainees at risk. 3. The Consultant Forensic psychiatrist did not read the ACDT documents. This puts detainees at risk. 4. The Centre Manager gave evidence that he recognised the importance of the 2 ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated. 5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation. Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at risk. 6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16th February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed. 7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC. Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment. 8. On discharge Mr Siman-Tov in the early evening of the 16th February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital. The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at risk. 9. During the journey back to the Colnbrook IRC Mr Siman-Tov vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minibus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr Siman-Tov to the hospital for further assessment. He did not know because he did not ask and was not told. 10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given. The explanation for this was that the observations should be second nature and did not need elaboration. 11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs. This put Mr Siman-Tov at risk. 12. At approximately 3.10 on the 17th February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used. 13. Nursing and other staff arrived. A custody officer asked the nurse if Mr SimanTov should be moved to the floor for resuscitation. The nurse replied no. Dr Harris, an expert in Emergency Medicine said that he should have been moved to the floor for effective resuscitation. This puts detainees at risk. 14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates. A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given, even though had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0302

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0