Awareness of concerns

41. There was evidence of issues arising at Brook House from at least 2012. These issues should have provided early warning signs for G4S senior management and the Home Office, but they were not heeded and they had a lasting impact during the relevant period.

External sources

42. Litigation regarding Brook House should have alerted the Home Office and G4S to possible problems. In 2012, two High Court judgments found that people detained there had been subjected to treatment that violated Article 3 of the European Convention on Human Rights.

42.1 In R (HA (Nigeria)) v Secretary of State for the Home Department [2012] an individual was detained at Brook House despite experiencing serious mental illness (his own condition causing him to display behaviour that violated his dignity).² v Secretary of State for the Home Department [2012] EWHC 979)) He was not given appropriate medical treatment while in detention, and force was authorised against him on several occasions.³

42.2 In R (D) v Secretary of State for the Home Department [2012] a detained person was not given adequate psychiatric treatment while at Brook House for over five months, causing his mental state to deteriorate.⁴ During this time, he was subjected to “what were in effect disciplinary sanctions under rules 40 and 42 which were unsuitable for a person with his condition”.⁵

43. There does not appear to have been any adequate process for ensuring that these judgments were disseminated among Home Office or G4S staff with responsibility for immigration policy or Brook House specifically.⁶
44. In January 2016, BBC Panorama broadcast a documentary entitled ‘Teenage Prison Abuse Exposed’ about Medway Secure Training Centre, which was also run by G4S. It showed vulnerable children in custody being physically and emotionally abused by those employed to care for them, and led to an investigation.⁷) Ms Brown recalled that, shortly after this, she warned Mr Saunders and Mr Skitt, “We’re going to have a Panorama on our hands here if we don’t learn from Medway.”⁸ She recalled no reaction or acknowledgement from either Mr Saunders or Mr Skitt.⁹ Between January 2016 and July 2016, G4S seconded Mr Saunders to the role of Interim Director of Medway Secure Training Centre, because he had previously been a director there.¹⁰ Mr Saunders told the Inquiry that he did not think that what had happened at Medway could happen at Brook House because he had “no indication” that it would.¹¹ However, if Ms Brown’s recollection is right, she forewarned him about the risk of similar abuse being uncovered at Brook House.

Internal sources

45. As the Inquiry focused on the relevant period, it did not hear detailed evidence about most allegations of misconduct during previous years.
46. There were examples of inappropriate behaviour (including bullying and goading of detained people, and racist comments by staff) prior to the relevant period that were reported or investigated at the time, as well as other matters that demonstrated that there were problems at Brook House prior to the relevant period, of which G4S was aware.

46.1 In 2012, several DCOs and a DCM were found to have acted inappropriately when they were recorded playing games and loud music outside the cell of one vulnerable detained person, when they should have been carrying out constant observations. The following evening, the same members of staff carried out their duties wearing a mask of a celebrity in front of the detained person and then woke him up while wearing the mask.¹² Several members of staff were later disciplined for dancing outside the cell of a second vulnerable detained person for whom they were carrying out constant observations, while staring at him and wearing masks of a different celebrity.¹³

46.2 In 2013, a survey of staff members recorded that some felt that they had been subjected to racist remarks and treatment, while others reported staff bullying and management failures to take action, and inappropriate comments about control and restraint.¹⁴

46.3 There were also reports about bullying of detained people by two DCOs who remained employed during the relevant period, DCO Luke Instone- Brewer and DCO Babatunde Fagbo.¹⁵ In 2015, it was alleged that they had goaded a detained person by “taking it in turn to give warnings, ignoring him and deliberately going to his room to remove items” and coming into his cell while he was asleep to shout in his face.¹⁶ This was reported by Ms Stacie Dean (Head of Tinsley House) to Mr Saunders and Mr Skitt in October 2015 and to Mr Lee Hanford (Interim Director of Gatwick IRCs at that time) in June 2016.¹⁶ In evidence to the Inquiry, Mr Instone-Brewer and Mr Fagbo denied these allegations and said that they were never raised with them at the time.¹⁷ A separate complaint against Mr Instone-Brewer and Mr Fagbo in 2016 for “poor behaviour, bullying and inappropriate behaviour” was apparently substantiated but did not lead to disciplinary action.¹⁸ Again, Mr Instone-Brewer denied the allegations and said that they had not been raised with him.¹⁹ Mr Fagbo said that he was not aware of the complaints or could not recall them or any investigation into them, albeit he could remember “faintly” being spoken to about an incident in 2016.²⁰ D687 had also alleged that both men had been provocative, abusive and racist towards him, which they denied in their evidence to the Inquiry.²¹ (The failure to investigate these allegations properly was also part of a grievance raised by Ms Dean, discussed in Chapter D.9 in Volume II.)

46.4 Mr Owen Syred (a DCO and Welfare Officer during the relevant period) told the Inquiry of two incidents from 2014, during which he said he heard a DCO colleague, Mr Sam Gurney, making racist remarks, including use of the ‘N word’, and Mr Gurney describing himself as racist.²² Mr Syred recalled attitudes changing between his initial period at Brook House from 2009 to 2012/2013 and his return in 2014, which he attributed to staff being “radicalised into becoming racist”.²³ He reported Mr Gurney’s remarks to a DCM, leading to Mr Gurney being removed from contact with detained people. Mr Syred recalled that the consequences for reporting Mr Gurney were post-it notes being left on his locker, including one reading “Nigger lover” and another “Grass”.²⁴ Someone had also written “Grass” across a poster of Mr Syred’s face.²⁵ Mr Syred approached Mr Saunders about it, who said he would support him. However, Mr Syred described how “there was no real support”.²⁶ He said that he did not hear anything about the outcome of any investigation into Mr Gurney.

46.5 In an SMT meeting in December 2016, Mr Skitt reported:

“Investigations – huge amount of investigations currently. There is a need to look at formal words of advice instead of conducting investigations.”²⁷

47. These examples are likely to be only a fraction of the inappropriate behaviour that occurred prior to the relevant period. They provide a useful context for what happened during the relevant period and assist with the question of whether the relevant period was uniquely problematic for G4S.

1. 41. There was evidence of issues arising at Brook House from at least 2012. These issues should have provided early warning signs for G4S senior management and the Home Office, but they were not heeded and they had a lasting impact during the relevant period.

   External sources

   42. Litigation regarding Brook House should have alerted the Home Office and G4S to possible problems. In 2012, two High Court judgments found that people detained there had been subjected to treatment that violated Article 3 of the European Convention on Human Rights.

   42.1 In R (HA (Nigeria[↩]

2. R (HA (Nigeria[↩]
3. INQ000060_286-289[↩]
4. R (D) v Secretary of State for the Home Department [2012] EWHC 2501[↩]
5. INQ000060_289-292[↩]
6. Ian Cheeseman 16 March 2022 170/5-176/14; Phil Schoenenberger 23 March 2022 71/6-76/23[↩]
7. The investigation was carried out by the Medway Improvement Board, appointed by the Secretary of State for Justice, which led to a report (INQ000010[↩]
8. VER000221_016 para 232[↩]
9. Stephen Skitt 17 March 2022 200/20-202/20; INQ000164_057 para 119[↩]
10. KEN000001_002 paras 4-8[↩]
11. Ben Saunders 22 March 2022 109/6-22[↩]
12. CJS005900; DL0000141_058-059 paras 165-167[↩]
13. Callum Tulley 29 November 2021 61/13-64/12[↩]
14. DL0000142_025; DL0000142_039; DL0000142_042-043[↩]
15. Other complaints against Mr Instone-Brewer and Mr Fagbo, as well as Ms Dean’s grievances, are addressed in Chapter C.9, and Chapter D.9 in Volume II[↩]
16. CJS0073677_001-002[↩][↩]
17. Luke Instone-Brewer 8 March 2022 21/5-24/5; Babatunde Fagbo 4 March 2022 75/23-78/16[↩]
18. CJS0073671_003; INQ000164_019-020 para 30; CJS005907_009 (2016 complaint and three complaints in 2015); Daniel Haughton 16 March 2022 145/6-147/23; CJS0073671_003; INQ000164_019-020 para 30[↩]
19. Luke Instone-Brewer 8 March 2022 24/6-35/7[↩]
20. Babatunde Fagbo 4 March 2022 81/11-83/25; CJS005907_009[↩]
21. Luke Instone-Brewer 8 March 2022 36/22-37/22; Babatunde Fagbo 4 March 2022 88/23-90/17; DPG000021_026-027 paras 83 and 86[↩]
22. INN000007_030-032 paras 125-130[↩]
23. Owen Syred 7 December 2022 115/3-116/1[↩]
24. Owen Syred 7 December 2022 117/9-20[↩]
25. Owen Syred 7 December 2022 117/17-20[↩]
26. Owen Syred 7 December 2022 117/3-5, 121/2-11[↩]
27. CJS000580_004; CJS0073709_073 para 7.29[↩]