The underlying facts

3. The Inquiry became aware of D2953’s allegations through disclosure by G4S and Home Office Professional Standards Unit (PSU) investigations into assaults that he alleged had taken place.¹ The Inquiry was not provided with any recorded footage of the incidents.
4. D2953 arrived at Brook House at approximately 06:00 on 9 June 2017. His initial assessment records that he displayed unusual behaviour, but no physical or mental health concerns were raised, despite D2953 stating that he was taking 15mg of mirtazapine per day “for sleeping”.² D2953 was given an appointment with the Brook House GP later that day, but he failed to attend.² D2953’s medical records, which were not available to Brook House staff at the time, noted that he was taking mirtazapine to treat depression.³
5. On 9 June 2017, D2953 was made subject to Rule 40 of the Detention Centre Rules 2001 for “smashing his room up … spitting at staff” and flooding his room.⁴ He was assessed on E Wing by Mr Christopher Paynter, a Staff Nurse, to whom D2953 disclosed that he had mental health issues and was taking medication. On 11 June 2017, Ms Lyn O’Doherty, another Staff Nurse, received a phone call from a paramedic at NHS 111 who informed her that D2953 had called four times that day stating that he needed medication.⁵ On 12 June 2017, D2953 was seen by Dr Husein Oozeerally, the lead GP at Brook House, who recorded that D2953 was taking three “lots of medication”, but that he was unclear which medication. D2953 was then seen by Ms Karen Churcher, a Registered Mental Health Nurse (RMN), on 14 June 2017. However, D2953 refused to engage with her, saying that he was “not mentally ill” but that he wanted his medication in order to sleep.⁵ Ms Churcher discharged D2953 from the RMN service, but later that day Dr Saeed Chaudhary, another GP at Brook House, noted on D2953’s records “MENTAL HEALTH TEAM TO KEEP TRYING WITH PATIENT” and commented that D2953’s signature had been obtained in order to procure his GP records. D2953 was prescribed mirtazapine by Dr Chaudhary on 16 June 2017 when his medical notes arrived.⁶
6. D2953 called the Equality Advisory and Support Service (EASS) helpline 40 times between 10 June and 17 July 2017.⁷ Some of these calls were short and there was usually no interpreter on the line. D2953 did not speak English as his first language. In a call on 16 June 2017, through an interpreter, D2953 was noted as having told the call handler, “Guards hit me 3 times.”⁸ The note continued:

“Haven’t been given my anti-depressant tablets, I can’t sleep at night… That man was aggressive to me, he apologised after. After third time he hit me he sat on the bed next to me and was explaining something… That guard hit me 3 times.” ⁸

D2953 told the call handler that, although he was concerned that it might make things worse, he was content for her to call Brook House about the incidents.⁹ The call handler did not do so (as discussed in Chapter D.10 in Volume II).

7. On 20 June 2017, D2953 told a member of the library staff at Brook House that he had been “bitten” three times by a member of staff.¹⁰ The member of staff completed a Security Information Report (SIR), a report that records matters relevant to the safety and security of the immigration detention estate, collated by the Security Department at Brook House.¹¹ The Security Manager, Detention Custody Manager (DCM) Carrie Dance-Jones, asked DCM Steven Dix to investigate D2953’s allegations.
8. On 24 June 2017, G4S received a written complaint from D2953 about his healthcare and alleging that he had been assaulted three times by an officer.¹²
9. Five days later, on 29 June 2017, D2953 spoke to the EASS helpline three times. In the first call, the call handler noted that D2953 again reported that he had been “bit” or “hit” three times, and that D2953 sounded agitated and as though he was banging on a hard surface and shouting. In the second call, the call handler noted that D2953 said that he had been bitten three times. In the final call, the call handler told him to call the police if he had been abused.¹³
10. That same day, 29 June 2017, force was used on D2953 to move him to E Wing because he was wearing boxer shorts when collecting his lunch and refused to get dressed. During this use of force, D2953 told one of the officers involved (DCM Philip Page) that he had previously been assaulted on 16 June 2017. Mr Page recorded the information in his Use of Force report and also in an incident report (used for ‘reportable incidents’ including assaults, escapes, suicides and full searches).¹⁴ Mr Page did not complete an SIR or a separate incident report about D2953’s disclosure to him, and instead simply included it within a large body of text about the different incident on 29 June 2017, without ticking the box for ‘Assault on Detainee’.¹⁵ A member of Healthcare staff assessed D2953, as was required after a use of force. She found no current injuries but noted multiple scars from surgeries and possible previous injuries.¹⁶ She also recorded in D2953’s medical notes that “he states he has been punched and hit by officers, states hit around side of head, no bruising or red marks noted”, but did not flag these allegations to her manager or to the Home Office.¹⁷
11. On 3 July 2017, an incident report recorded D2953’s allegation that he had been bitten by staff three times.¹⁸ On 8 July 2017, D2953 dialled NHS 111 and asked for help because he felt as though he was not being treated fairly at Brook House. ¹⁹
12. On 24 September 2017, more than three months after D2953 had reported the assaults, Mr Dix wrote in an email to Ms Dance-Jones:

“I am pretty sure that I did speak to him in his room, from what I recall he did not seem bothered.”²⁰

The Inquiry saw no evidence to suggest that an investigation was in fact carried out by Mr Dix or anyone else at Brook House until September 2017, when G4S became aware of the allegations against Detention Custody Officer (DCO) Derek Murphy in relation to other detained people.⁷

13. Following the Panorama programme, the PSU conducted an investigation into D2953’s allegations. In summary, these allegations were:

• On 10 June 2017, Mr Murphy hit D2953 on his left thigh in E Wing because he was shouting, hitting and kicking the cell door.
• On 11 June 2017, Mr Murphy hit D2953 on his left side (in his kidney area) because he was shouting, punching and kicking.
• On 16 June 2017, Mr Murphy hit D2953 on the left side of his head because he was shouting.²¹

14. Mr Murphy denied to the PSU that he assaulted D2953. In his view, the allegations might have been made because the officers sometimes had to say ‘no’ to D2953.²² The PSU investigation concluded that, on the balance of probabilities, there was substance to D2953’s allegations and therefore his complaints were substantiated.²³ Investigating officers were unable to locate closed-circuit television (CCTV) footage to verify the details of D2953’s account, including whether any other officers had witnessed the incidents. They did confirm that Mr Murphy was on duty on the days that D2953 alleged that Mr Murphy hit him.²⁴
15. The PSU investigation found that, based upon evidence of Mr Murphy’s abusive conduct in other situations captured in footage recorded covertly by DCO Callum Tulley, it was credible that Mr Murphy had assaulted D2953 on the three occasions that D2953 alleged.²⁵ In addition, the PSU concluded that there were failings in how D2953’s complaints were responded to following the assaults.²⁶
16. In his evidence to the Inquiry, Mr Murphy denied any knowledge of these incidents or the resulting PSU investigation.²⁷ He maintained that he did not punch D2953.²⁸

1. CJS001506[↩]
2. CJS002196_010-011[↩][↩]
3. CJS002196_010[↩]
4. CJS001506_030[↩]
5. CJS002196_013[↩][↩]
6. CJS002196_013-014[↩]
7. HOM032609_002[↩][↩]
8. HOM032609_003[↩][↩]
9. HOM032609_003[↩]
10. CJS0073642_0002[↩]
11. CJS0073642[↩]
12. CJS001616[↩]
13. HOM032609_004[↩]
14. CJS0073644_008-009; CJS0073644_015; CJS0073643[↩]
15. CJS0073643_001[↩]
16. CJS0073644_014-015[↩]
17. HOM032247_009[↩]
18. CJS001506_030-031 para 6.7.4[↩]
19. HOM004886_013[↩]
20. CJS0073657_001[↩]
21. CJS0073658[↩]
22. CJS001506_028 para 6.2.2[↩]
23. CJS001506_035-036 paras 7.2.1-7.2.4[↩]
24. CJS0073655_001[↩]
25. CJS001506_035-036 para 7.2.1[↩]
26. CJS001506_035-036 para 7.2.2[↩]
27. INQ000121_010-011 paras 34-36; Derek Murphy 2 March 2022 106/6-112/6[↩]
28. INQ000121_010 para 34[↩]