What happened
Alois Dvorzac, 84, was a Canadian electrical engineer travelling from Vancouver to Slovenia to be reunited with his daughter. On 23 January 2013 immigration officials stopped him at Gatwick because he could not give a clear account of his onward travel plans. He was refused entry.
He spent a night sleeping on chairs at the airport, then was taken to East Surrey hospital for a medical assessment. After four days he was returned to immigration custody and detained at Harmondsworth.
On 30 January a doctor declared him unfit for detention or deportation and said he required social care. On 6 February an attempt was made to deport him, and another doctor halted it because he was unfit to fly.
He died on 10 February 2013 in hospital, having been handcuffed and chained to a custody officer for around five hours. The handcuffs were removed after his heart had stopped.
The outcome
A nine-day inquest at West London Coroner’s Court concluded on 29 October 2015. The jury found that he died of natural causes, from acute coronary heart disease and type 2 diabetes, with borderline and varying mental capacity.
In a short-form conclusion the jury recorded failings at Harmondsworth: a lack of unified procedures, training and access to records for a person of his age and capacity. No prosecution is recorded.
In January 2014 HM Chief Inspector of Prisons had reported that handcuffing at the centre was grossly excessive. The immigration minister said the restraint seemed “completely unjustified and must not be repeated”.
What went wrong
Security staff made assumptions about him in the risk assessment, and those assumptions produced the handcuffs and the chain. Five doctors found him unfit for detention at Harmondsworth. None of that reached the escort decision.
The Chief Inspector’s finding was structural. A lack of intelligent, individual risk assessment meant most detainees were handcuffed on escort. He found at least two occasions when elderly, vulnerable and incapacitated detainees were needlessly handcuffed “in an excessive and unacceptable manner”.
What it teaches
Handcuffing is restraint, and a blanket escort policy is a restraint policy. An 84-year-old with dementia who cannot give an account of his journey and has refused most of his medication is not a flight risk. He is a clinical risk, and the escort assessment has to say so.
Restraint decisions have to be individual, written down and revisable when someone’s health changes. The health information in his case existed. The escort ran on an assumption.
Questions for the room
- He had been declared unfit to fly before he was taken to hospital in handcuffs. What does that tell you about who held the risk assessment?
- You are the escort officer at the ward. The nurse says he is dying. What do you do, and who do you ring?
- The Chief Inspector found that most detainees were handcuffed on escort. What kind of policy produces that, and who owns it?
Evidence and limits
Confidence: confirmed, on the press reports. Two Guardian reports and a BBC report were read and agree on the sequence and the five-hour period; the record says about five hours and the BBC says almost five. The HM Chief Inspector of Prisons report itself was not read, only the press reports of it.
The précis and the record differ on when the escort began. The précis dates the first restrained hospital visit to two days before his death; the record describes him taken to hospital handcuffed and restrained until after his heart stopped, without dating the start. This page gives the duration and the date of death only.
Our vulnerable and volatile persons training covers individual risk assessment and restraint decisions that can be revised when someone’s health changes.
Sources
Reviewed 20 October 2026.