Conclusions

33. D2054’s level of distress was very clear from the footage. Force was used on him for a minimum of 9 minutes 19 seconds, and he wailed and cried out throughout. The footage was difficult to watch and to listen to.
34. In my view, the footage provides a clear and detailed account of what happened during the use of force against D2054. In the circumstances, I have not found it necessary to rely on the report by the PSU in order to draw my conclusions and I have not done so.
35. It is concerning that D2054 was not offered any opportunity to get dressed prior to or during the use of force against him. The issue of the use of force against naked detained people is discussed further in Chapter D.7 in Volume II.
36. Given the late hour, Mr Aldis should have anticipated that D2054 was likely to be asleep and potentially undressed. It is not acceptable that there was no foresight or planning for such a situation. For example, the officers should have taken a clothing pack (a pack of clothing provided to detained people who arrive at Brook House without any clothing of their own) to D2054’s cell in case it was needed. There is no evidence that they did. Mr Aldis should have given D2054 an opportunity to get dressed before force was authorised. It is unacceptable that he did not. I note that there was a pair of boxer shorts on the floor of the cell which D2054 could have put on within a matter of seconds. If D2054 did not have any other clothes, these could then have been supplemented by a clothing pack had one been made available. In my view, it is not acceptable to restrain naked detained people except in the most exceptional circumstances and as a last resort, due to the inevitable humiliation that it entails. This was not the case here. I note that when D2054 was eventually offered the chance to get dressed, he did so willingly.
37. In my view, the use of force against D2054 was not justified. I do not agree with Mr Collier that force was used as a last resort. Although Mr Aldis asked multiple times if D2054 would walk with him, these requests were in quick succession and no time was allowed for D2054 to orientate himself. Mr Aldis remained at the door of the cell, far away from D2054, and with officers in full PPE standing behind him. He did not enter the cell to speak to D2054 one-to-one. D2054 repeatedly said that he was “not okay”, but Mr Aldis failed to enquire what was wrong with him and simply referenced the fact that he had Healthcare available. He did not ask Healthcare to examine D2054. Within approximately one minute of opening the door, Mr Aldis authorised the use of force. Moreover, and as stated above, D2054 was not given any opportunity to get dressed prior to the use of force. As such, insufficient efforts were made to engage with D2054 and to persuade him to accompany the officers, and force was not used as a last resort when all other options had been exhausted.
38. Too little consideration was given to D2054’s vulnerabilities (in particular, his account of torture, his low mood, the urgent referral to mental health services and the earlier incident of self-harming that day), which were known to the staff ahead of the use of force. This is specifically true of Mr Aldis, to whom D2054 had disclosed a history of torture, and who had responded to D2054 self-harming shortly after he had been told that he was due to leave the UK that day.¹
39. Once force had been instigated, handcuffs were inappropriately applied to D2054 behind his back and while he was seated. This was unacceptable, given that the reason for rescinding this method of restraint from the Use of Force Training Manual was that a detained person had died (as discussed in Chapter D.7 in Volume II). It is my impression from the footage that this had an impact on D2054, as his vocal protests became strained and he appeared to start breathing more deeply. It is deeply concerning that this was not noticed by any of the officers. They should have been aware of the risks and should have responded appropriately to the condition of D2054 during the use of force.
40. Ms Williams did not raise any concerns throughout the entirety of the use of force and restraint on D2054. As the attending member of Healthcare staff, she should have challenged the actions of the other staff, in particular in handcuffing him inappropriately behind his back while seated. She should have reported the incident immediately afterwards. If she could not observe the incident adequately, she should have moved so as to be able to monitor D2054’s safety, raised a concern with the officers that she could not adequately monitor his safety or intervened immediately to stop the restraint. I am concerned that Ms Williams did not take her safeguarding responsibilities more seriously. She only appeared to reflect upon issues such as the propriety of restraining detained people while they were naked when under scrutiny by this Inquiry, suggesting a desensitisation to the distress of vulnerable detained people in her care. Such matters are discussed further in Chapter D.8 in Volume II.
41. Ms Wilkinson told the Inquiry that she might have reached a different conclusion had she been aware that the potentially dangerous technique of handcuffing behind the back while seated had been removed from the Use of Force Training Manual. In circumstances in which it was her role, and that of the PSU, to reach conclusions on the appropriateness of the use of force, it is concerning that the PSU did not ensure that its investigating officers had sufficient and up-to-date knowledge regarding use of force techniques.
42. Insufficient consideration was given to de-escalation as D2054 was moved from his cell to Reception. I agree with Mr Collier’s analysis that the PPE and head support technique ought to have been removed at this point. While D2054 was verbally challenging, there is no evidence to suggest that he was physically resisting the officers. Further, there were no other attempts made to de-escalate the situation, such as by answering D2054’s questions and explaining to him why force was being used. Both factors resulted in D2054 being restrained excessively and unnecessarily.
43. The Inquiry did not see evidence to support D2054’s account that the cuts on his arms bled during the restraint on 28 June 2017. Nor did the Inquiry see evidence to support the account that he lost consciousness during the use of force.
44. In my view, given that D2054 was clearly highly distressed about the prospect of his removal – and had self-harmed that day – the force used
45. against him was likely to have caused him intense mental suffering. Indeed, his serious anguish is plain from his reaction to the use of force and the distress that he demonstrated throughout. In my view, force was not used as a last resort when all other alternatives had been exhausted, and it
46. was therefore not justified. In addition, the fact that D2054 was naked or near-naked for the duration of the use of force was likely to have resulted in this incident being a humiliating experience for him. Therefore, there is credible evidence that D2054’s treatment was capable of amounting to inhuman and degrading treatment.

1. HOM002384_003-004[↩]