A review of the mistreatment of individuals detained at the Brook House Immigration Removal Centre, in the grounds of Gatwick Airport, has identified 19 instances over a five-month period which amounted to mistreatment contrary to Article 3 of the European Convention on Human Rights.

In its final report, published on Tuesday, chairwoman Kate Eves accused the Home Office of handing out contracts that fell short of welfare standards and prioritising cost-effectiveness over the care of detained people.

"Under the Home Office and its contractor, G4S, Brook House was not sufficiently decent, secure or caring for detained people or its staff," she said.

"An environment flourished in which unacceptable treatment became more likely."

Use of force on detained individuals was too often "unnecessary, inappropriate and excessive", she said.

The inquiry was launched in 2019 after disturbing footage in a BBC Panorama programme portrayed Brook House as "violent, dysfunctional and unsafe".

It showed the use of abusive, racist and derogatory language by some staff towards those in their care.

It also found people were routinely held for lengthy periods of time in what was meant to be a short-term holding facility.

One person spent 563 days at Brook House.

Another individual was visually impaired but given no assistance to move around the facility. One man required hospital treatment after his hands were cut during a restraint. Another man, who was seriously mentally ill, was used as a guinea pig to test drugs on - something officers were aware of.

Who could I complain to?

The report raises concerns about a lack of monitoring and process for complaints.

One individual who was held at Brook House said: "I was told that the man who attacked me was just doing his job. Who could I complain to? There was so much happening I just thought it was part of being in detention. I didn't know what was normal in this country."

Examples of failures include excessive use of force against vulnerable people, degrading and humiliating those in detention by sometimes stripping them naked, unnecessary infliction of pain and dangerous restraint techniques.

On one occasion, officers stood by when someone was found unconscious after attempting to take their own life. The report highlights another instance when pressure was applied to a detained man's neck while he was already in extreme distress.

The Home Office has since transferred the management of Brook House from G4S Care and Justice Service but the chair says the contract should never have been awarded in the first place.

"Cost-effectiveness was prioritised over the care and welfare of detailed people," Ms Eves said as she described the way in which the Home Office awarded the contract.

The site is now managed by Serco, with the inquiry warning that many of the issues present during the period of its investigation persist under the new administration.

"I am particularly concerned by the lack of reflection by some of those who remain working at Brook House, a number of whom are now in more senior roles," Ms Eves said.

"It inevitably casts doubt on how far the cultural changes described by Serco can be said to have been embedded. There is more to do."

More than 'lip service' required

Ms Eves rejected the Home Office narrative that the failures were down to a small minority of staff and said it cannot continue to delegate its responsibility to care for and protect detained individuals.

She also accused the Home Office of an over-reliance on external organisations regarding monitoring and inspections.

Among her 33 recommendations, Ms Eves said the government must introduce a time limit of 28 days for people to be detained in immigration removal centres and adopt robust monitoring of contract performance.

She urged the Home Office to publish its response within six months after criticising it for failing to learn lessons from previous investigations of immigration detention centres and their recommendations.

"It is my sincere hope that more than mere lip service will be paid to this report," she said.

"The events that occurred at Brook House cannot be repeated.

"It is unacceptable for the Home Office to attempt to delegate its fundamental role of caring for and protecting some of society's most vulnerable people to its contractors."

Sky News has contacted the Home Office, G4S and Serco for comment.