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Part C: Incidents of mistreatment

  1. As set out in greater detail in Part C, in order to fulfil the Inquiry’s Terms of Reference I must reach conclusions about the mistreatment of detained people where there is credible evidence. Having analysed the evidence, and by application of the two-stage test I explain in Part C.1, I found 19 incidents in which there was credible evidence of acts or omissions that were capable of amounting to mistreatment “contrary to Article 3” of the European Convention on Human Rights, which states: “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.” The relevant period of this Inquiry is relatively short (five months). It is therefore of significant concern that, within a limited time frame, I identified 19 such incidents.
  2. One of the most shocking incidents I considered, which was central to the Panorama programme, was the moment Detention Custody Officer (DCO) Ioannis (Yan) Paschali placed his hands firmly around the neck of one detained person (referred to by the Inquiry as D1527), leaned forward over him and said in a quiet voice:

“You fucking piece of shit, because I’m going to put you to fucking sleep.”

(Footage: Day 2 AM 24 November 2021 00:53:00-01:23:53(KENCOV1007 – V2017042500021).)

The experience for D1527 of being restrained by staff and having pressure applied to his neck must have been terrifying and could have resulted in serious injury.

  1. I also received concerning evidence about other incidents during the relevant period.

15.1 Force was used inappropriately against D1234, D2416, D1527, D687, D1914, D149, D390, D1851, D1538 and D2054. D687 was attempting self-harm at the time.

15.2 D1234, D2416 and D2054 were all forcibly removed from their cells and presented to escort staff while naked or near-naked.

15.3 Pain was unnecessarily inflicted upon D1234, D687, D149 and D1538 during use of force on them.

15.4 An inherently dangerous restraint technique was used on D1234, D1914, D149 and D2054.

15.5 D1527, D2953 and D313 were subjected to physical violence.

15.6 Staff made inappropriate and humiliating comments towards D1527 and D687 as they were attempting to take their own lives.

15.7 D1527, D1914 and D1538 were all inappropriately segregated in a separate part of Brook House.

15.8 In a one-month period, staff used inappropriate force towards D1538 causing him pain, likely made a homophobic comment towards him, and failed to provide him with adequate support after he witnessed his cell mate self-harm.

15.9 When D865 was found unconscious having attempted to self-harm by hanging himself from a ligature, staff initially stood and looked at him without trying to help him.

15.10 Staff made derogatory and humiliating remarks towards D1275 while he was receiving emergency medical treatment due to the effects of a drug overdose.

15.11 Staff repeatedly used aggressive and threatening language to D728 while he was under constant supervision and had therefore been identified as being extremely vulnerable to self-harm and suicide. They also denied D728 access to a shower and therefore prevented him from performing cleansing rituals fundamental to his religion.

  1. While I do not make recommendations specifically in relation to the incidents described in Part C, many of the themes that emerge – for example, the inappropriate use of force, the lack of compassion and desensitisation of staff, and the inappropriate use of isolation – are explored more widely in Part D in Volume II. These incidents have been at the forefront of my mind when determining the lessons that should be learned and the measures required to ensure that other detained people do not experience similar treatment in the future.