Jury highlight Morton Hall multiple staff failures as inquest concludes on death of immigration detainee Carlington Spencer

Before HM Senior Coroner Timothy Brennand
Lincolnshire County Council
7 October – 8 November 2019

The inquest into the death of Carlington Spencer, known to his family as ‘Jammy’, concluded on Friday 8 November. Carlington was an immigration detainee at Morton Hall Immigration Removal Centre. The inquest jury found that he died on 3 October 2017 as a consequence of a stroke, and identified series of failings which possibly contributed to his death, including:

• inadequate management of his type 1 diabetes;
• numerous missed opportunities by discipline staff to sufficiently monitor Mr Spencer and;
• failure of medical staff to identify symptoms of stroke and take appropriate actions in a timely manner.

Carlington, 38, grew up in Jamaica and had numerous successful businesses. After moving to Derby with his wife in 2010, he suffered a series of difficult bereavements and developed a troubled relationship with alcohol. After separating from his wife, he became homeless for periods and struggled with mental and physical ill health. In April 2016 he was imprisoned for drug related offences and was transferred to Morton Hall IRC around May 2017 shortly after the conclusion of his sentence.

Between 3.45pm on 28 September 2017 and 12.45 pm on 29 September, fellow immigration detainees repeatedly brought to the attention of discipline staff that Carlington was suffering from a stroke or other physical ailment, not connected with consumption of the synthetic drug known as ‘Spice’. The jury concluded that there was a lack of communication between healthcare staff and officers and that staff were dismissive of detainee’s concerns about Carlington’s health.

On 28 September 2017 Carlington became increasingly unwell. Other detainees told the inquest that he was slurring his words, he was “fire hot”, the left side of his face was drooping, and he was dribbling. He was found collapsed on the floor twice and complained of a headache and pain in his eyes. They alerted healthcare staff about their concerns about Carlington’s health.

The inquest heard that the healthcare staff did not think to assess for stroke related symptoms, despite Carlington’s pre-existing conditions. Morton Hall staff and nurses told the inquest that they believed Carlington was suffering from a physical attack related to spice. They opened an illicit substances log at 3.40pm and placed Carlington under regular observation. The illicit substances log was closed by healthcare staff after verbal discussion with an officer at 8.45pm, without reviewing Carlington’s wellbeing. No welfare checks were carried out overnight.

Despite the belief of staff that Carlington had consumed spice, no searches of his room had been carried out and therefore no paraphernalia or spice was found or removed. The jury found there was no evidence to prove that Carlington had taken Spice on the 28 and 29 September. The jury found that the interpretation by the healthcare staff of his presenting condition was not reasonable and on multiple occasions healthcare staff ‘failed to assess the situation correctly, resulting in confirmatory bias, non-consideration of differential diagnoses’.

The next morning on 29 September, detainees noticed that Carlington’s health had not improved. He was still unable to move his left arm, the left side of his face was drooping, he was dribbling and complaining of a headache. They set off the emergency alarm bells in the detention centre and banged on the healthcare centre's windows at around 12.45pm until staff arrived.

Around 1.09pm, staff at the detention centre called a "non-emergency" ambulance which arrived at 2.15pm. The inquest heard that it took some time to get through security at Morton Hall and the ambulance staff eventually arrived with Carlington at 2.25pm. The jury found there was a failure to follow correct emergency procedures causing unnecessary delays in arranging an ambulance. Carlington arrived at Lincoln County hospital at 3.32pm and died three days later at Queens Medical Centre in Nottingham on 3 October 2017.

The Senior Coroner informed the family, in front of the jury, that he was preparing a Report to Prevent Future Deaths to send to Morton Hall IRC and Nottingham NHS in which he will identify the ‘practical’ steps that he suggests they take, when responding to emergency calls to detainees, to prevent ‘confirmatory bias’ interfering with a proper analysis of the detainee’s symptoms.

Shameika Spencer, Carlington’s sister, said on behalf of the family:

“We the family of Carlington Spencer, who we call Jammy, want to thank the jury for their conclusions. It was evident that they were 100% engaged as they overlooked nothing. From their answers to the questions left to them by the coroner, one would think that they were a group of accredited medical professional rather than random members of society from varying backgrounds. We could see that their hearts and soul were involved. It goes to show the big difference when people care and are of a pure heart; as the jury’s attitude towards Jammy and their reasoning, far surpassed that of the actual medical professionals at Morton Hall detention centre. 

"Special thanks to Carlington’s friends and fellow detainees who showed how much they cared and valued him by showing up at the hearing to be his voice from the grave, things would have been so difficult if not for them.

"Our lives will never be the same again, because in spite of this success Carlington is still not here. Nevertheless we find some peace in knowing his death was not in vain.”

Laura Burkey, Carlington’s former wife and life partner:

“I would like to thank everyone for their help and support during this inquest process. My family, friends, Sean Horstead our barrister and solicitors from Birnberg Pierce. Myself and Carlington’s family have waited over two years to get the answers we needed about the circumstances in which Carlington died during being detained at Morton Hall Detention Centre.

"I will never stop loving Carlington, we believed we would be together forever after overcoming so much together. Two years have passed since he died and it all still feels like yesterday. Its hard to believe he is no longer with us. He is missed so much. There is not one day that goes by where I don’t think of him. It upsets me that I can’t talk to him when I just want to talk to him so much. Carlington will never be forgotten, he will always have my heart.”

Deborah Coles, Director of INQUEST said:

“Carlington’s death once again exposes the fatal consequences of a culture of dismissal and disbelief in immigration detention. Serious warning signs indicated that he was in need of urgent medical attention, yet were repeatedly ignored by detention and healthcare staff, despite the persistent efforts of fellow detainees.

Carlington was one of 11 people to die in immigration detention in 2017, a record high. Successive inquests have highlighted fundamental failings in treatment and care as well as unsafe systems and practices. These deaths are at the sharp end of the harm and anguish caused by immigration detention and illustrate the human cost of UK immigration policies."

Irène Nembhard of Birnberg Peirce solicitors who represented the family said:

“Were it not for the strength of Jammy’s family to see this through to the end and to sit through weeks of evidence listening to a series of missed opportunities to alter the outcome of the stroke that Jammy suffered in Morton Hall; the resolve of the former detainees to ensure that the public knew of the failures of Morton Hall to respond to their calls for assistance for Jammy; the decisive steps taken by the Lincolnshire Senior Coroner to ensure that the detainees were not removed from the UK before giving their evidence; the skilled questioning of the witnesses by Sean Horstead, counsel for the family, and the diligence and humanity of the jury, then the missed opportunities that possibly contributed to Jammy’s death wouldn’t have been exposed and lessons wouldn’t have been learnt by Morton Hall. It is unlikely that all of this would have been achieved if Jammy’s family hadn’t been granted legal aid to pay for the legal team.”

Sean Horstead is a member of the Garden Court Chambers Inquests and Inquiries Team.