Conclusions

18. D313’s evidence to the Inquiry was detailed, and it was consistent with the accounts given by Mr Lake to Mr Tulley and by Mr Sayers himself later the same day. The Inquiry saw and heard evidence that force was used inappropriately in other situations during the relevant period (between 1 April and 31 August 2017), and that staff routinely did not report this.¹) The Inquiry also heard evidence of assaults on detained people taking place in cells to avoid CCTV; indeed, it was Mr Tulley’s evidence that this is where much of the abuse took place.² I took account of this evidence when considering the credibility of the account D313 provided. D313 did not give oral evidence to the Inquiry and therefore his account was not tested under questioning. No criticism is made of D313 by my recording this fact here. However, it is a factor that I bore in mind when considering the credibility of his account.
19. The covertly recorded conversations are themselves compelling. Mr Tulley’s account of the incident in a BBC incident log is consistent with those evidence sources, and further supports what the Inquiry saw and heard about this incident.
20. In the circumstances, I am sure that on 15 June 2017 Mr Sayers picked up D313 in a ‘bear hug’ and threw him onto the bed in his cell on E Wing. Mr Sayers then struck D313 in the form of a slap, punch or ‘back-handing’ to his face, and pushed himself up on D313’s face. Mr Sayers’ explanation that he felt unable to rely on his colleagues to assist him in managing D313’s aggression does not excuse his actions. I consider it more likely that Mr Sayers was seeking to punish D313 for calling him a “fat cunt”.
21. I am also sure that Mr Sayers caused the injuries to D313 that he described. Given the findings that I have made in respect of Mr Sayers’ actions, it is beyond question that some injury was caused to D313, and I have no reason to doubt his account of the injuries that he sustained. I do not consider that the absence of any reference to those injuries in D313’s medical records is determinative of what happened. From the evidence available, it is not possible to determine whether the incident took place before or after the final set of medical notes for the day were made by the Healthcare team, who were observing D313 for the purpose of monitoring the effects of spice. D313 did not report this incident to the Healthcare team, which I accept was due to fear. I do not find it credible that Mr Sayers was unaware that D313 had been injured by him, a much larger man, falling onto him and putting his weight onto D313’s face. In my view, it is likely that Mr Sayers failed to call for a nurse because he was attempting to avoid scrutiny.
22. I am sure that Mr Lake witnessed what happened to D313 inside his cell. I do not find it credible that Mr Lake remembered the events clearly enough to describe them to Mr Tulley five minutes later on 15 June 2017, but then had no subsequent recollection of what had happened. However, if Mr Lake was genuinely unable to recollect an incident where a colleague picked up and then struck a detained person only three months after it occurred, this indicates a concerning picture about the insignificance of it to him and his desensitisation to such an incident.
23. I find it likely that Mr Croucher was also a witness, although the Inquiry did not hear any evidence to suggest that he relayed what he had seen to others in the way that Mr Lake did.³
24. The casual way in which the incident was discussed among some DCOs indicates to me that there was an acceptance within that group that this kind of behaviour would not be reported by other staff. I have found this to be a recurring theme throughout the evidence heard by the Inquiry.⁴ I am sure that some former and current Brook House staff have ‘closed ranks’ with those accused of wrongdoing in order to protect them.
25. As discussed in Chapter D.7 in Volume II, the Inquiry heard evidence from multiple sources that failure to comply with the requirements of Prison Service Order 1600 – which requires that anyone “involved” in the use of force completes a Use of Force report – was widespread at Brook House in the relevant period.⁵ The absence of any Use of Force reports may indicate that some staff were deliberately concealing what took place on 15 June 2017, but I cannot be sure of this. I heard evidence from numerous other staff about the pressures they faced on the wings, and that there was not enough time to complete the necessary reports.⁶ It is also possible that Mr Sayers chose not to complete a Use of Force report in order to avoid scrutiny.
26. I considered D313’s physical and mental health at the time of the incident and whether he was particularly vulnerable to mistreatment. D313 was recovering from the effects of spice when he was forcibly carried to his cell in an unauthorised and inappropriate manner. More concerningly, he was hit in the face by an officer who was responsible for his care and safety. This blow appears to have been the result of a desire to retaliate against or punish D313 for his perceived challenging behaviour. I accept that D313 was fearful as a result of this experience, and that this prevented him from reporting what had happened to any of the Brook House staff. In my opinion, there is credible evidence that this incident was capable of amounting to degrading treatment.

1. For example, see my discussions regarding the use of force in Chapter C.4 (in relation to an incident on 24 April 2017), Chapter C.10 and Chapter D.7 (in Volume II) (under the heading ‘Inaccurate, undetailed and missing reports’[↩]
2. DPG000021_0067-0069 paras 186-194; BHM000029_0010 para 37; Callum Tulley 29 November  2021 113/14-16[↩]
3. CJS005937_004-005[↩]
4. See, for example, Reverend Nathan Ward 7 December 2021 189/15-191/2; Daniel Lake 1 March 2022 53/21-54/16; Daniel Small 28 February 2022 163/24-164/10[↩]
5. Prison Service Order 1600: Use of Force (INQ000185), HM Prisons Service, August 2005[↩]
6. Ioannis (Yan) Paschali 24 February 2022 47/23-25; Clayton Fraser 28 February 2022 86/10-19; Derek Murphy 2 March 2022 120/18-121/9; Sean Sayers 10 March 2022 168/24-169/20[↩]