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  1. The footage of events on 6 July 2017 shows tense and aggressive interactions between D728 and Mr Francis and Mr Webb. There was frequent swearing and raised voices and the interactions appeared fraught with frustration.
  2. I have considered D728’s state of mental and physical health and whether it made him more vulnerable to mistreatment. D728 had recently climbed onto the safety netting on A Wing and placed a ligature around his neck. He had been moved into the CSU under Rule 40 and placed on constant supervision because his risk of self-harm was considered to be very high. Both Mr Webb and Mr Francis directly threatened to make D728’s life difficult for him while inside his cell.1 Mr Francis suggested that he would prolong D728’s time on E Wing if he had to return to the cell again, and Mr Webb stated that if D728 did anything to annoy him he would not be permitted to shower. Separately, Mr Stokes talked about hitting D728 and referred to him as “an absolute cunt”.2 I agree with Professor Bosworth that the words Mr Stokes used in his conversation with Mr Tulley suggested that he had become desensitised to the distress of the men in his care.3 The speed at which Mr Webb and Mr Francis resorted to making threats, and the casual and uninhibited manner in which all the officers used aggressive, threatening and derogatory language, suggests to me that such language had been normalised by all three officers. They appeared to lose sight of their responsibilities towards the detained person in their care. In relation to their treatment of D728, Mr Webb and Mr Francis appeared to view D728 as manipulative, obstructive and not worthy of compassion. I do not accept that Mr Webb was using a mirroring technique when he swore at detained people.
  3. D728 was asking the officers for a shower specifically because he is a Muslim and he needed to pray. Ablution before prayer is a fundamental part of ritual purity in Islam. As such, denying him the means to wash is likely to have had a particularly negative impact on him. Mr Webb told the Inquiry that he did not believe that his actions as a manager would have influenced other officers, although he acknowledged his regret that Mr Francis “got tied up” in what he said to D728.4 Although Mr Francis began to argue with D728 before Mr Webb became involved, his evidence indicated that he felt influenced by the more senior member of staff. Mr Francis told the Inquiry in his written statement:

“Effectively, I was joining in with what Steve Webb had said. On reflection, I should not have done so. I can see that my support for his comment might have encouraged further abuse of this detained person, which I regret.”5

  1. In my view, Mr Webb’s conduct showed a lack of appreciation of the power imbalance between him and a detained person, or of the influence he exerted on more junior staff. It is particularly striking that Mr Webb did not appear to have had regard to this power imbalance, despite D728 being held subject to Rule 40 and being on constant supervision following an attempt to self-harm. I consider such issues further in Chapter D.9 in Volume II of this Report.
  2. I acknowledge that staff on the CSU on 6 July 2017 described being faced with a highly charged and challenging environment that day. Mr Tulley noted that there were six detained people on constant supervision.6 Mr Webb described multiple urgent incidents to which he needed to respond, and stated that there was no other manager available to step in and talk to D728 – an approach that Mr Webb thought might have de-escalated the situation.7 Mr Francis told the Inquiry that he was following the lead of Mr Webb in how he spoke to D728. Mr Francis also said that he was still “a little annoyed” with D728 because D728 had thrown something over him earlier that day.8 Both Mr Webb and Mr Francis asserted that their interactions with D728 were ultimately aimed at getting him to comply with the rules.9
  3. The covert footage shows that D728 swore at staff and repeatedly covered the observation panel in his cell door. However, it is also clear from the footage that both Mr Webb and Mr Francis were aggressive and confrontational towards D728, and did not deal with the situation calmly or professionally. They did not attempt to de-escalate, and instead allowed their frustration to affect their conduct. While the covertly recorded footage shows that the threats to hit D728 were made when he was on the other side of the cell door, I do not accept that the officers knew for certain that D728 could not hear them.
  4. It is clear from the officers’ evidence and the footage that there were a small number of officers dealing with detained people with particularly demanding needs and challenging behaviours.10 The staff working on the CSU did not seek advice or guidance from senior managers, even though they felt unable to deal calmly with the demands they faced that day. A BBC Incident Log recorded Mr Tulley’s account that staff were “losing their cool” and that the centre “was not coping with the amount of difficulty”.6 It is plain, therefore, that there were insufficient staff to meet the needs of the detention centre that day.
  5. The officers were ill equipped to deal with the complex needs of the detained people in the CSU. There is no excuse for the language that was used towards and about D728. However, in my view, the treatment of D728 did not occur in a vacuum. The low number of staff – inadequately trained to deal with the challenges on the CSU – coupled with a lack of senior manager oversight, contributed to an environment where such treatment took place (discussed in Chapter D.9 in Volume II). Regardless of the reasons, the treatment of D728 was unacceptable.
  6. I have considered D728’s mental and physical health at the time of the incident. He had earlier expressed his intention to self-harm and had been placed on constant observations as a result. This means that D728 was considered to be in need of the most intense level of support because of his extreme vulnerability to self-harm and suicide at the time this incident occurred. Despite this, the officers repeatedly used aggressive and threatening language to D728, and it is plain from the footage that D728 felt bullied by them. Indeed, he specifically said, “I’ve tried to take my life and you bully me.” This, combined with D728 being entirely dependent on staff permitting him to shower so that he could perform rituals fundamental to his religion, left him particularly vulnerable to mistreatment. Taken together, the behaviour of the officers showed a lack of respect for D728’s human dignity. In my view, there is credible evidence that D728’s treatment during the incident was capable of amounting to degrading treatment.


  1. Day 2 PM 24 November 2021 00:38:58-00:53:30 (KENCOV1044 – V2017070600007)[]
  2. TRN0000094_047[]
  3. INQ000064_009-010 paras 2.17-2.18[]
  4. Stephen Webb 8 March 2022 198/14-199/21[]
  5. HOW000001_017 para cii[]
  6. CPS000025_037[][]
  7. Stephen Webb 8 March 2022 202/16-203/17[]
  8. Charles Francis 3 March 2022 86/7-87/7[]
  9. Stephen Webb 8 March 2022 200/17-201/18; HOW000001_017-018 para 14di[]
  10. IPA000001_005 para 34; IPA000001_008 paras 60-66; SER000449_007-009; BFA000002_004;DL0000141_043 paras 127-129; SER000456_009 para 21; INQ000122 002 para 10; SER000433_006 para 38; MAR000001_002 paras 14-15; HOW000001_010 paras ei-eiii; INQ000052_037 para 147; INQ000052_060 para 230[]