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The underlying facts

  1. On 21 June 2017, D2054 was made aware that directions had been issued for his removal on a charter flight. Later that day, Detention Custody Manager (DCM) David Aldis opened an Assessment Care in Detention and Teamwork (ACDT) plan for D2054. The plan recorded that D2054 had stated that he “CANNOT go back to Nigeria due to his previous torture he suffered there”.1
  2. On 26 June 2017, Ms Christine Williams (Clinical Lead) made an urgent mental health referral for D2054 as he had disclosed low mood and thoughts of self-harm.2
  3. Two days later, on 28 June 2017, D2054 was informed that he would be removed from the UK later that day.
  4. At around 13:45, D2054 was found by Detention Custody Officer (DCO) Luke Odey with cuts to his upper left arm. He told Mr Odey: “I do not want to live this life anymore.”3 Mr Aldis, who was performing the role of ‘Oscar 1’ (the operational manager on duty) that day, increased D2054’s required observations under the ACDT to constant supervision.4 D2054 was attended to by four members of Healthcare, who checked him and dressed his wounds. He was then walked to a constant supervision cell on E Wing.3 On arrival at E Wing, a full search was authorised by Ms Michelle Brown (a member of the Senior Management Team acting as Duty Director) and carried out by DCO Derek Murphy and Mr Odey.5) A razor blade was found during this search.3
  5. Mr Aldis briefed a team of officers to carry out a planned removal of D2054 to Reception where a Tascor escort team would meet him to transfer him to his removal flight. The officers assigned to remove D2054 were Mr Murphy, DCO Jonathan Martin, DCO Ben Shadbolt and DCO Daniella Di-Tella, all of whom were wearing full Personal Protective Equipment (PPE). They were joined by Ms Williams and DCM Christopher Donnelly. The latter was to operate the handheld camera.6
  6. The Inquiry saw the footage from the body worn camera worn by Mr Aldis during the use of force.7 The handheld camera footage of the use of force recorded by Mr Donnelly is 9 minutes 19 seconds long.8 In combination, the footage provides a clear and unambiguous account of what took place during the removal.
  7. The body worn camera footage shows that at 22:23 Mr Aldis opened the door to D2054’s cell, which was in darkness. Mr Aldis turned the lights on and a substance which appeared to be blood could be seen on the floor at the foot of D2054’s bed. He informed D2054 that escort officers had arrived to take him to his removal flight.
  8. D2054, who was sitting in bed with a cover over him to the waist, responded, “I’m not okay, my blood pressure is high.” Mr Aldis said that he understood but asked D2054 to walk to Reception with the officers. D2054 responded that he was “not okay”. From the audio on the footage, it appears that he had started to cry. Mr Aldis repeated that he understood, and referenced that he had a member of Healthcare staff with him (Ms Williams). He did not ask Ms Williams to examine D2054.
  9. Mr Aldis asked D2054 to accompany him compliantly a further five times. Mr Aldis told D2054 twice that officers would be sent into his cell to remove him by force if he did not do so. D2054 indicated that he would not come willingly, saying, “I’m not okay, boss.” Mr Aldis then said, “okay, force” and gestured with his hand to the officers to enter. Mr Aldis attempted to persuade D2054 to comply for approximately 60 seconds before instructing the officers to use force. In his incident report, Mr Aldis recorded that D2054 started to cry when he was told that he needed to walk to Reception for his flight.9
  10. Mr Murphy entered the cell holding a shield, supported by Mr Shadbolt and Mr Martin. The footage does not show the officers’ movements or D2054 for approximately five seconds but a loud crash is heard, directly followed by screams from D2054. When the camera was redirected into the cell, two officers were seen at the side of D2054’s bed, leaning over and taking control of him, while another officer was kneeling on the bed. D2054 continued to scream loudly.
  11. Mr Murphy handed the shield to Mr Aldis, who passed it out of the cell to Ms Di-Tella. As Mr Aldis turned, Ms Williams was outside the cell holding a green medical bag.
  12. A hand was placed over the lens briefly. D2054 is then shown lying naked on the floor of the cell, on top of the bedcovers and with his feet facing the cell door. An item of clothing, which appeared to be boxer shorts, was next to him on the floor. D2054 was screaming, repeatedly wailing, “Jesus, Jesus, where are you Jesus” and kicking out with his legs in a cycling motion. Mr Shadbolt held D2054’s head and Mr Murphy and Mr Martin restrained D2054’s arms. Mr Aldis instructed Ms Di-Tella to take control of D2054’s legs and assisted her in applying the correct technique.
  13. Approximately 1 minute 19 seconds after the officers were first instructed to use force, DCO Andrew Simmonds placed a towel over D2054’s genitals. Until this point, D2054 was entirely naked.
  14. Once Ms Di-Tella had controlled D2054’s legs, Mr Aldis instructed the officers to move D2054 into a seated position. D2054 continued to cry out for Jesus. His face was distorted and he appeared to be in significant distress. As D2054 sat upright, a dressing on his arm can be clearly seen. This was covering the injuries to D2054’s upper arm caused by his attempts to self- harm earlier that day. Blood at the edge of the dressing can also be seen. The officers pushed D2054’s upper body forwards and moved his hands around to his back to enable Mr Simmonds to apply handcuffs. While in this position, D2054’s verbal protests became more strained and he appeared to be breathing more deeply. In total, D2054 remained in this position for approximately 45 seconds.

Figure 26: D2054 being restrained by three officers while another applies handcuffs behind his back

  1. Once handcuffed, the officers allowed D2054 to sit upright and he repeatedly asked, “why am I being treated like this”. The officers did not respond and brought D2054 to his feet. D2054 continued to cry out for Jesus, and the towel that had been covering his genitals fell away. It was picked up quickly by Mr Simmonds, who held it around D2054’s waist for the remainder of the use of force.
  2. Mr Shadbolt took control of D2054’s head, and at 22:25 the officers walked D2054 out of the cell, through E Wing and into Reception. As Mr Aldis walked ahead of the officers and D2054, much of this part of the use of force is not visible on the body worn footage. However, as Mr Simmons walked behind D2054, it was captured on handheld footage.10 This shows that the restraint of D2054’s head and arms was maintained throughout his relocation to Reception, and he remained handcuffed behind his back. D2054 continued to call out for Jesus.
  3. After one minute, Mr Aldis asked the officers whether D2054 was still resisting and told them to give D2054 a chance to stand up straight. Mr Shadbolt asked D2054 whether he would walk compliantly if the head restraint was removed. D2054 did not specifically respond, but continued to call out for Jesus and appeared breathless. Mr Aldis instructed the officers to continue.
  4. Shortly afterwards, Mr Aldis turned around and said, “do we still have Healthcare”. The group then appeared to wait while Ms Williams caught up with the officers and D2054. When Ms Williams arrived, Mr Aldis asked her if she had any concerns about the restraint and she replied that she did not.
  5. D2054 continued to cry out for Jesus, saying, “why am I being treated like this?”, “what have I done?” and “this is the end of my life” as he was taken into Reception. He also stated that he had been tortured in Nigeria. The officers did not respond but told him to relax.

Figure 27: D2054 being taken to Reception under restraint

  1. Once in Reception, D2054 was handed over to Tascor escorts and provided with clothes. The incident lasted approximately 10 minutes in total and this was the only opportunity D2054 was given to get dressed.
  2. D2054 made a complaint on 3 July 2017 about the force used on him. In his complaint, D2054 said that he was trying to explain his condition to the officers but they rushed him. He stated that he hit his head on the floor during the restraint and became unconscious, before regaining consciousness and shouting, “Jesus”. He also said that the use of force caused the cuts on his arm from his earlier self-harm to bleed.11 D2054 did not provide a statement to the Inquiry. Although a ‘Report of Injury to Detainee’ (section 3 of the F213 form) from earlier on 3 July 2017 referred to D2054 bleeding from cuts on his arm as a result of his self-harm, a further such report from after the use of force stated, “no injuries noted at this time”.12
  3. In response to D2054’s complaint, the Home Office Professional Standards Unit (PSU) carried out an investigation, led by investigating officer Ms Helen Wilkinson. It concluded that the force used was reasonable and proportionate.13 This conclusion was upheld by the Prisons and Probation Ombudsman.14
  4. In her evidence to the Inquiry, Ms Wilkinson accepted that she might have reached a different conclusion had she been aware that the practice of applying handcuffs to a person when they were seated was no longer included in the training syllabus.15 This was due to the risks of compressing the chest and breathing difficulties associated with being bent forward for prolonged periods of time. Ms Wilkinson was asked by Counsel to the Inquiry whether she considered staff should have removed some of their PPE to de-escalate the situation. She said that she had not, “because I’d never come across where they’d – where officers had removed PPE while the use of force was still going on”.16
  5. At the time of the use of force on D2054, Ms Williams said that she had no concerns about his wellbeing other than noting his high blood pressure.17 During her oral evidence to the Inquiry, Ms Williams was asked by Counsel to the Inquiry, “Did you consider the treatment, particularly that he was naked, to be degrading?” Ms Williams replied that she did and said that she could not explain why she did not raise this at the time.18
  6. Having considered the report from the Inquiry’s use of force expert, Mr Jonathan Collier, Mr Aldis accepted that the helmets, gloves and head support could have been removed during the restraint. Mr Aldis also accepted that the practice of handcuffing in the seated position had been withdrawn.19
  7. It appears that D2054 also complained to Sussex Police about this incident. His report was filed with no further criminal investigation to be taken following receipt of an email from Ms Wilkinson explaining the outcome of the PSU investigation.20
  8. The Inquiry did not hear oral evidence from any of the officers involved about this incident.


  1. HOM002388_004[]
  2. HOM002389_014[]
  3. HOM002397_003[][][]
  4. HOM002397_007[]
  5. CJS005991_009 para 6.2.3. A ‘full search’ is a search of an individual that requires the removal and inspection of all clothing and footwear. The search must be conducted by two officers of the same sex as the individual, and the individual must not be completely naked at any stage or in the view of others not involved in conducting the search (see CJS000713_004 para 7[]
  6. CJS0073734 [Disk 26 20170628221925_E2047N_0006][]
  7. CJS0073736 [Disk 27 28 June 2017 2221BWVC DCM Aldis][]
  8. CJS0074053 [Disk 26 20170628222251_E2047N_0007][]
  9. HOM002384_002[]
  10. CJS0074053 [Disk 26 20170628222251_E2047N_0007][]
  11. CJS001627_003-004[]
  12. HOM002389_010-013[]
  13. CJS005991_024 paras 7.5.9-7.5.12[]
  14. PPO000029[]
  15. Helen Wilkinson 24 March 2022 59/9-24[]
  16. Helen Wilkinson 24 March 2022 59/25-60/14[]
  17. CJS0073734 [Disk 26 20170628221925_E2047N_0006][]
  18. Christine Williams 10 March 2022 114/17-21[]
  19. INQ000181_019 para 90c[]
  20. SXP000018[]