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The role of this Inquiry

  1. On 5 November 2019, the Home Secretary announced that a special investigation (discussed below) by the PPO would be converted to a statutory inquiry under section 15 of the Inquiries Act 2005, and that I was to be appointed as the Chair of the Inquiry.1

The scope of the Inquiry

  1. The Terms of Reference required the Inquiry to investigate into and report “on the decisions, actions and circumstances surrounding the mistreatment” of detained people at Brook House, and to make recommendations as appropriate.2 The Inquiry was also required to investigate a range of other key issues, including the wider treatment of detained people, whether any clinical care issues caused or contributed to any mistreatment identified, and the adequacy of the complaints and monitoring mechanisms. In addition, the Inquiry was specifically required to “include investigation in to the mistreatment of … MA [D1527] and BB [D687]”.3 The key period to be considered by the Inquiry was 1 April 2017 to 31 August 2017 (the relevant period).
  2. I am required by the Terms of Reference to reach specific conclusions about the treatment of detained people, particularly where I find that there has been credible evidence of acts or omissions that are capable of amounting to “mistreatment” with reference to Article 3, which states: “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.4 I have identified the facts underlying that mistreatment and who is responsible for it.5 In addition, there are a number of key issues to be addressed in order to fulfil the Terms of Reference:
  • the extent to which policies, practices, staffing and management arrangements at Brook House caused or contributed to any identified mistreatment (that required a consideration of a number of issues, including staffing levels, staff and management culture, the use of control and restraint techniques, the use of segregation, and the management of self-harm and food refusal);
  • the adequacy of the safeguards designed to protect detained people from mistreatment; and
  • changes made in response to the Panorama programme, and the adequacy of those changes.6
  1. On 6 January 2021, I set out the Inquiry’s scope in more detail.7 I decided that the starting point would be to examine the evidence to establish what happened to detained people at Brook House during the relevant period. I kept that scope under review throughout the Inquiry’s investigation and I have followed where the evidence has led me.
  2. Although the focus of this Report is on the relevant period, it was also necessary for me to consider evidence about previous years. I have addressed the construction and purpose of Brook House, early warning signs, staffing levels and capacity, as well as allegations of misconduct. The reasons for this are:
  • This evidence provides context for what happened during the relevant period.
  • Some staff members started working at Brook House between 2010 and 2016, and remained employed during the relevant period.
  • Many of the physical and contractual structures that were in place during the relevant period were set up and developed over the preceding years.
  • This evidence is relevant to the question of whether the relevant period was uniquely problematic, or whether any other five-month period might have revealed similar issues.

In fact, the evidence suggests that the level of mistreatment during the relevant period was far from uncommon. The covert filming by Mr Tulley documented and recorded it in a way that is indisputable.

  1. I am also required by the Terms of Reference to consider whether “any changes to these methods, policies, practices and management arrangements would help to prevent a recurrence of any identified mistreatment” and whether “any changes to clinical care would help to prevent a recurrence of any identified mistreatment”.5 The Inquiry therefore heard evidence about changes since the relevant period, in order to examine current practice both at Brook House and in the immigration detention estate more generally.


  1. Immigration Statement, Priti Patel MP (Home Secretary), 5 November 2019[]
  2. Purpose, Terms of Reference, Brook House Inquiry. See Appendix 1 in Volume III for further information[]
  3. Scope, Terms of Reference, Brook House Inquiry[]
  4. Purpose, Terms of Reference, Brook House Inquiry; European Convention on Human Rights, Article 3[]
  5. Purpose, Terms of Reference, Brook House Inquiry[][]
  6. Chair’s Opening Statement, Brook House Inquiry, 21 April 2020[]
  7. Notice of Determination Inquiry Scope, Brook House Inquiry, 6 January 2021[]