Written evidence submitted by Dr Frank Arnold (COR0244)
[Note: This evidence has been redacted by the Committee. “***” represents redacted text.]
Health consequences of current arrangements for accommodation of migrants in army barracks:
a preliminary survey
Casalotti S, Jones DR, Arnold FW
Forrest Medico-Legal Services CIC
As submitted to the Home Affairs Select Committee of the British House of Commons on 16/02/2021
Images of Penally barracks, taken January-February 2021
1. We report preliminary results of extensive medical interviews of 17 men who have been transferred to Penally barracks, conducted by doctors to whom they were referred via Forrest Medico-legal Services (FMLS) (1). These Vulnerability Assessments (VAs) were conducted remotely.
2. Our evidence strongly suggests that the conditions and healthcare arrangements in the barracks are avoidably harmful to the health of residents and potentially hazardous to the wider public health.
3. This evidence raises numerous questions about these accommodation arrangements. Although we can pose them and do so below, answers to these questions lie beyond the remit of medical competence alone.
4. The Penally Barracks have been used since late September 2020 to house asylum seekers in interim accommodation during the COVID-19 pandemic, with analogous accommodation being used in Napier Barracks in Folkestone, Kent. The management of these barracks is subcontracted by the Home Office to Clearsprings Ready Homes Ltd. Asylum seekers within the camp (hereinafter referred to as ‘residents’) have been relocated to Penally having previously been housed in hotels in conurbations. Healthcare provision in Penally constitutes a complicated arrangement involving the local Hywell Dda University Health Board, local NHS services and referral via on-site Clearsprings and Migrant Help staff.
5. Contact with the local health board and residents of Penally raised significant concerns regarding access to healthcare within the barracks, which is discussed below. In response to this, Forrest Medico Legal Service CIC (FMLS) undertook individual Vulnerability Assessments (VA) of residents within the barracks. Procedures for conducting VAs were established following consultations with a consortium of other NGOs with relevant expertise including the Helen Bamber Foundation, Freedom from Torture, and Doctors of the World as well as local organisations with more direct experience of the residents of the barracks.
6. The primary function of the VAs was to document evidence of physical and mental health need, evidence of previous human rights abuses, and evidence of COVID-19 risk. In light of the evidence obtained we decided to analyse these VAs to form this initial report.
7. VAs were performed using semi-structured interviews conducted between 05/01/21 and 05/02/21. All interviews were conducted remotely via telephone or video call software. Assessments were conducted by English speaking clinicians. 15 of 17 VAs required interpreting, which was performed by a professional interpreter (via Clear Voice Interpreters & Translation Limited), except for two assessments which were aided by an informal interpreter. As much as was feasible in the barracks environment which has limited WIFI accessibility, arrangements were made so as to ensure the privacy of the resident being interviewed.
8. Doctors conducting assessments were all trained medico-legal report writers, and registered with FMLS. Tailored training for writing VAs was given before a doctor conducted the assessment.
9. VAs were completed using a standardised VA form which contains a mixture of direct (Yes/No) questions and free text areas (see Appendix). Each case was allocated a unique reference number. The VA form has been produced by FMLS, with input from the Helen Bamber Foundation and Doctors of the World.
10. After VAs were completed by doctors all forms underwent quality assurance and data extraction by a trained FMLS volunteer. All VA forms were sent to the resident in question as well as any other organisation requested by the resident. Only anonymised VA forms have been used for data analysis.
11. Interviews were limited to two hours at most due to restrictions on the available time for professional interpreting. In some cases, physicians performing assessments were not able to ask all questions from the VA tool during the constrained time. Additionally, many of the interviewees showed evidence of pressured speech which further complicated completing assessments within the allotted hours. Where evidence of long-term environmental hazards and their effect on health arose, we pursued this to the extent possible during such an interview.
12. All interviewees are asylum seeking men under the age of 45 who, at time of interview were resident in the barrack accommodation in Penally, Wales. Interviewees were referred to FMLS either by their lawyers, via the Migrant Health on-site staff, or via CRoP (Camp Residents of Penally - the self-organising body of residents of Penally). The basis of the assessment was explained to all interviewees before the start of the interview. They were told the purposes of the assessment and the ways in which a completed VA could be used by them. Each interviewee was asked for and gave their express consent for use of the contents of the VA for data analysis and reporting in wholly anonymised form as used here.
13. Below are data extracted on 13/02/29. At point of extraction, 18 people in Penally had been assessed and 17 VAs had been produced, which are reported here.
14. 11 interviewees displayed significant organic medical need whilst in the camp, including cases of potential epilepsy, haemoptysis, and passing blood per rectum. Significant (“organic”) health here is defined as that which warrants at least an in person GP assessment for physical symptoms including pain.
15. 13 interviewees expressed that their physical health deteriorated since being housed in Penally. Of the 17 cases reported here, data regarding ability to access healthcare are available for ten. Six had been taken to be seen by a nurse or doctor employed by the Hywel Dda University Health Board; four had attempted, but failed, to secure such an appointment. All interviewees expressed that they felt their organic medical needs had not been met whilst in Penally.
“While in Penally, he has made several attempts to secure a dental appointment via Clearsprings staff, but these have not been successful.”
16. All 17 interviewees displayed features indicative of a diagnosis of Post-Traumatic Stress Disorder. 15 additionally displayed features indicative of a diagnosis of depression. Four interviewees disclosed suicidal ideation and many residents expressed having had suicidal thoughts for the first time since being housed in Penally. All interviewees expressed significant deterioration of their mental health since being in the barracks accommodation. Many residents expressed specifically that the conditions in Penally were redolent of previous ill-treatment, contributing the frequency and intensity of psychological symptoms felt.
“His mental health … has particularly deteriorated while he is accommodated at Penally, which he finds redolent of being in custody before coming to the UK. ”
“[He] feels restricted to his room by fear of socialising and fear of abuse from racist taunts and attacks by dogs if he ventures outside Penally.”
“At Penally, he feels like he is in prison despite not being a criminal, though he says he is made to feel like one.”
17. 15 interviewees reported a history of significant ill-treatment and/or torture either in their home country or en route to the UK. Five residents disclosed having been victims of modern slavery, and two disclosed having been trafficked, according to internationally accepted legal definitions. Many interviewees attributed their physical symptoms, in addition to their psychological symptoms, to previous ill-treatment.
“He is frightened to leave Penally barracks as he endured insulting behaviour when he recently visited a supermarket, and similar negative experiences have been reported by other inmates at Penally.”
“He has frequent bad memories of his detainment especially when [he sees] uniformed guards in the camp, and [has] to sign in and out.”
18. One interviewee displayed symptoms potentially due to COVID-19 or tuberculosis whilst in Penally and required hospital transfer. Only two interviewees were identified to have self-isolated or tested for COVID-19 before being transferred to Penally. No interviewees reported having had a COVID-19 test whilst in the barracks.
19. All interviewees were screened for specific vulnerability to COVID-19 as per the NHS guidance. No individuals were identified as high or moderate risk on grounds of pre-existing medical conditions known to be associated with severely adverse outcomes of infection with SARS-CoV-2.
20. The modal number of people living and sleeping in one room was six (mean=5). Interviewees reported having access to communal toilet and shower facilities shared by residents who were sleeping in other rooms. All interviewees were provided with masks while in Penally and were encouraged to wear these in communal spaces and the dining room.
“Residents asked to wear masks when they go to the canteen. But [he] reports there is no effective social distancing, everyone masses in groups/crowds regardless.”
“[He] finds the long queues to use the wash basins at Penally very uncomfortable.”
21. People seeking asylum and who have fled persecution are an inherently more vulnerable population because of their experiences of war, conflict, torture, human trafficking, and other forms of abuse.
22. We understand that the Home Office recognises much of what is said above and has endeavoured to ‘screen’ to ensure that ‘the most vulnerable’ are not sent to Penally. The evidence from our data would indicate that, for whatever reason, the Home Office screening processes are not working. It would appear that the Home Office do acknowledge the fallibility of their processes and have established the presence of Migrant Help at Penally to alert them to the presence of those who may have fallen through the net. We are aware that five out of the 17 interviewed have subsequently been moved out of Penally as of 15/02/21.
23. In the submission of the Immigration Law practitioner Association’s (ILPA) to the Home Affairs Committee’s inquiry into Home Office preparedness for Covid-19 (Coronavirus) dated 04/02/21 it is noted (2) that ILPA is “aware that there are issues with the initial assessment of whether or not a person can be accommodated in the barracks under the Home Office’s own guidance, ‘Suitability for contingency accommodation’. The Home Office checks, purportedly designed to ‘help ensure that anyone with indicators of vulnerability, modern slavery or exploitation, or significant health issues are not transferred to the sites’, are deficient. For example, we know that people who have been identified as potential victims of trafficking have been accommodated in the barracks.”
24. In UK primary care it is routine practice for a patient newly registered with a general practice to be offered an early appointment for screening. This is usually conducted by a nurse. Clearsprings have said publicly that they have assisted all residents to register ‘with the NHS’, however, many residents who were interviewed did not know how to access local NHS services and, we conclude, were effectively debarred from doing so directly. It is apparent that any appointments with healthcare services were booked by Clearsprings staff and took place at a clinic in Pembroke Dock or at Withybush General Hospital in Haverfordwest to which residents have been taken in small groups by Clearsprings. We understand that up to four non-emergency appointments are available twice each week for registration and initial assessment, but that this may vary.
25. The arrangements to ‘bus’ residents some distance are unusual. We understand that these arrangements were established by the Health Board [***] …the Board has been able to exercise flexibility as to how local general medical services are provided. In our opinion the Board is doing everything within their capacity to provide services, but having been given minimal notice of the imminent arrival of residents at Penally, given the numbers involved, the effects of the pandemic, and a chronic lack of resources it is not clear that these are adequate to need, particularly in the area of mental health. This aligns with our finding of widely reported subjective feeling of unmet medical need by interviewees and the inability of at least four residents to access a medical appointment after attempting to do so.
27. The arrangements by which residents are able to access necessary healthcare (or otherwise) give rise to the below concerns.
1) Medical Disconnection
Several of the people interviewed were registered with a GP in their previous temporary accommodation. Having been given no notice of transfer to Penally and/or because they did not know their NHS number or how to use the NHS, any medical information about them was unavailable in their new location.
At Penally they were registered with the local (Tenby) GP surgery and issued with a second NHS number. It is our understanding that, on transfer out of the camp, they have had to or will have to register with a new surgery and that this is likely to result in being given a new (third) NHS number.
We are informed that the decision to relocate Penally residents are made on a weekly basis in discussion between regional Home Office representatives and Clearsprings staff. However, this decision is apparently only communicated to residents very near the time of the intended transfer and, we are informed, this information is provided only retrospectively to Migrant Help. It is unclear to us when and whether the Health Board are informed at all. We understand that Health Board staff are apparently attempting to connect patients with their new GP providers (if they have been able to secure one).
This disconnect has resulted in residents leaving the camp with limited supplies of medication which should not be discontinued abruptly or without medical supervision. The risks are obvious.
2) Interposing of Clearsprings staff in doctor-patient relationships
Several interviewees stated that they had had to reveal intimate medical details to apparently untrained Clearsprings staff for these to be transmitted to Hywel Dda Health Board clinicians for triaging and prioritisation. It is apparent that appointments would not have been arranged by Clearsprings staff without residents disclosing the nature of the medical problem. Thus, in order to secure appointments, this information had to be disclosed by patients with limited English, without interpreting assistance, sometimes in the presence of third parties (e.g. other residents) to persons with no, or no appropriate, training. Several residents stated that they had had to make enquiries of the Clearsprings office on successive days in unsuccessful attempts to ascertain the outcome of their request for medical help.
In short, Clearsprings staff appear to be acting as surrogate GP receptionists. The role of GP receptionist carries responsibilities for confidentiality and precision (4). It is a role which requires training and governance. It is not clear whether or how these requirements are being met by the existing arrangements put in place by Clearsprings.
28. In theory, residents are ‘bubbled’ with the between one and five other people with whom they share sleeping quarters. They are advised to wear masks and to observe social distancing when in contact with other residents not in their bubble. In practice, arrangements in the camp are not compatible with these measures. Our data show dining, toilets and washing facilities are not segregated and photographs we have seen (see cover page) reveal poor cleaning which would suggest poor disinfectant regimes. These and other factors which virtually enforce congregation across hypothetical bubbles are not likely to be conducive to COVID-safe collective behaviour of residents. Given that no interviewees were provided a COVID-19 test at any point while in Penally, and only two of 17 interviewed stated that they had tested or isolated before being transferred there, arrangements for an outbreak must be considered. Despite these factors we are not aware of the occurrence of a case of COVID-19 within the camp thus far, however, the widely reported outbreak in Napier Barracks gives rise to fears of a similar occurrence in Penally.
29. It is a matter of public record that the walls of ‘Nissen hut’ style buildings (including sleeping accommodation) are clad with asbestos-cement sheeting. This is not in and of itself a serious risk so long as no asbestos fibres are released into the atmosphere and inhaled. Soldiers have been found by the courts to have contracted fatal diseases specific to asbestos exposure (mesothelioma and asbestosis) as a result of their accommodation or work in buildings similarly constructed of, and contaminated with, asbestos (5-8). This suggests that containment was not complete in the 1990s.
30. During the course of interviews, it became apparent that the walls of buildings in Penally contained asbestos. Penally has not been in use for some years prior to its being recommissioned as asylum seeker accommodation and we are concerned that the fabric of buildings may have degraded over that time exposing and potentially releasing asbestos fibres.
a) Access to medical care
b) Environmental safety
c) Long term medical consequences for residents:
31. FWA is guarantor of the data in this report. He is sometimes paid at or below legal aid rates for expert medico-legal reports about matters related to migration and asylum. However his work and that of everyone else connected with this project has been carried out on a pro bono basis.
32. This analysis was undertaken retrospectively as an audit. All interviewees gave verbal consent for the electronic storage of their confidential data, and analysis of anonymised data by Forrest clinicians.
33. We are grateful to colleagues who organised and conducted vulnerability assessment interviews, interpreters provided by Clear Voice Interpreters & Translation Limited, volunteers, members and supporters of the Camp Residents of Penally (CRoP) for their assistance, and to the Helen Bamber Foundation, Freedom from Torture and Doctors of the World for helpful discussions.
34. However, this work is the sole responsibility of the authors and any views expressed herein do not necessarily represent the views of any of the above parties or organisations.
1) FMLS is a Community Interest Company operating on a not-for profit basis. Its members and associate members are experts in the field of the assessment and documentation of clinical evidence of human rights abuses. This remit includes consideration of issues such as the lack of access to necessary care.
2) Immigration Law Practitioners’ Association. Response to the Home Affairs Committee’s inquiry into Home Office preparedness for Covid-19 (Coronavirus). 4 February 2021.
4) Job description: GP Receptionist/Administrator
5) Dyfed Archaeological Trust. Threat-related assessment of twentieth century military sites.
6) Ejegi-Memeh S, Darlison L, Moylan A, Tod A, Sherborne V, Warnock C , Taylor BH.
Living with mesothelioma: A qualitative study of the experiences of male military veterans in the UK Euro J Oncol Nurs. 2021; 50
7) Peto J, Rake C, Gilham C, Hatch J. Occupational, domestic and environmental mesothelioma risks in Britain: A case-control study
Prepared by the Institute of Cancer Research and the London School of Hygiene and Tropical Medicine for the Health and Safety Executive 2009.
8) Owen J. Asbestos: Thousands of UK soldiers who develop cancer due to exposure unfairly treated by MoD, say campaigners. Independent. 23 October 2015.
The attached Assessment Tool has been created primarily for the purposes of measuring the physical and mental health and wellbeing of residents of Penally Barracks. It is also intended as a means to collating general information concerning the health, medical, and psychosocial situation of residents of Penally barracks.
This document is a strictly confidential communication and may not be reproduced or circulated without the express written consent of Forrest Medico Legal Services CIC (FMLS). If you are not the intended recipient of this information you may not disclose or use the information in this documentation in any way, without FMLS’s prior written consent.
This Assessment Tool is not intended as an offer or solicitation with respect to any commercial engagement with either medical or legal professionals. This Assessment Tool should not be used as a substitute for competent medical or legal advice from a certified medical professional. This Assessment Tool is not an Istanbul Protocol compliant medico-legal report.
This assessment should be treated as 'an individual evaluation' for the purposes of the Asylum Seekers (Reception Conditions) Regulations 2005 regulation 4(3).