The underlying facts

2. D728’s medical records stated that he had disclosed a history of misuse of drugs, and that he heard voices in his head, had difficulty sleeping, and had been taking methadone and an antidepressant.¹ He was referred to a Registered Mental Health Nurse (RMN) on 5 June 2017 because he had disclosed that he was hearing voices and wanted to kill himself, and he had been verbally abusive to officers.² An RMN visited D728 twice that day but he declined mental health support.³ The Inquiry has not seen any evidence of a mental health assessment, although D728 was subject to an Assessment Care in Detention and Teamwork (ACDT) plan.³
3. On 6 July 2017, D728 climbed onto the safety netting on A Wing and placed a ligature around his neck.⁴ Officers removed him from A Wing to the Care and Separation Unit (CSU) within E Wing under the provisions of Rule 40 of the Detention Centre Rules 2001.⁵ It appears that D728 was placed on constant supervision under the ACDT suicide prevention measures.⁴ On that day there were six detained people (including D728) on constant supervision. However, Brook House only had two cells with large viewing windows designed to allow officers to maintain constant observation of those inside. As such, four detained people were in cells with only a narrow slit through which officers could maintain constant supervision. D728 was one of those four.⁶
4. Detention Custody Officer (DCO) Callum Tulley was working on the CSU on 6 July 2017 and covertly recorded events there. In the footage, Mr Tulley attempted to carry out constant observations of D728 but was unable to do so because D728 was using toilet tissue to block the observation panel from the inside of the cell.⁷ Mr Tulley asked D728 to remove the toilet paper but D728 refused and told Mr Tulley to stop staring at him and to “Shut the fuck up.” He also told Mr Tulley that he wanted to take a shower.⁸ Mr Tulley recorded in a BBC Incident Log that D728 had blocked the observation panel 15 times over a 3-hour period.⁹

Figure 28: Toilet tissue blocking the constant observation panel

5. After 1 hour 40 minutes, Mr Tulley called for a manager to assist. DCO Charles Francis and Detention Custody Manager (DCM) Stephen Webb arrived shortly afterwards.¹⁰
6. Mr Francis entered D728’s cell first and immediately said, “Right. If I have to come back here again. You won’t be going anywhere today. You’ll be staying down here permanently. You understand?”. Mr Tulley and Mr Webb then entered the cell, and D728 can be seen in his bed, under the duvet.
7. Mr Webb and Mr Francis stood next to D728’s bed and over D728.D728 complained in a raised voice that he was not being given his medication. Mr Francis started to argue with D728, commenting that D728 had agreed with the doctor that he would wait until the morning. Mr Francis spoke over D728 in a raised voice and pointed down at him. D728 said that he was not feeling well and that he did not want to be in Brook House. Mr Webb said, also in a raised voice, “it’s not unlawful” and “no-one wants to fucking be here, I don’t want to fucking be here”.
8. D728 replied, “I’m not allowed to smoke, I’m not allowed to fucking shower.” Mr Webb told D728 that he could have a shower once enough staff were available but “it depends on your behaviour”. Mr Francis shouted, “Right [D728] when did I say you could have a shower … I said it would be about an hour” and moved to leave the cell. D728 explained, “I’m a Muslim, I need to clean myself, I need to pray, I got nothing in this room, none of my property is here”, to which Mr Francis retorted, “You should have thought of that before you got lippy.” D728 started to talk about his suicide attempt the night before, but both Mr Webb and Mr Francis groaned, one of the officers said, “yeah, yeah, yeah” and both officers left the cell.
9. Mr Tulley closed the door to D728’s cell behind him, but within five seconds D728 had covered the viewing panel again. Mr Francis reopened the cell door and removed the toilet tissue from the viewing panel. D728 stood behind Mr Francis and said that he needed to smoke. Mr Francis stood at the door of the cell and began to argue with D728 about what time the shop opened. D728 made it clear that he thought it opened at 8:30 but Mr Francis shouted, “the shop opens at nine … Okay. You’re so fucking clever … give it a rest, give it a fucking rest.” Mr Francis’s body language was aggressive throughout the argument. For example, he leaned towards D728 and used his arms to gesture at him.
10. Mr Webb joined in the argument and said, “Listen, listen” before shouting:

“right shut up a minute! … your fucking attitude, depends on how this is gonna go for you, this is how this is gonna go for you. Piss us off, you won’t have a shower, you won’t have nothing!”

Mr Francis shouted, “Listen the doctor said you have enough medication in your body to last you four weeks … he thinks you don’t need it.” Both officers then left the cell, with D728 still shouting at them.

11. Mr Francis told Mr Tulley that he would have to keep going into the cell to remove items from the viewing panel. Mr Webb then said, in a quieter voice, “I’ll fucking punch the cunt. I tell ya”, to which Mr Francis replied, “If you don’t, I will.”
12. After another couple of seconds, the officers went back into D728’s cell. Mr Webb said:

“Depending on how you behave here is depending on how this is going to go for you. Be a grown up. Help us, and we’ll help you … Dick us about and we’ll make your life a living fucking misery.”

D728 said, “I want a shower and I want to fucking pray … please, please forgive me” but the officers left the cell. As Mr Tulley closed the cell door, Mr Webb remarked, “Fucking twat, he is.”

13. Approximately seven minutes later, Mr Webb noticed that D728 was continuing to cover his observation panel. He opened D728’s cell and D728 and Mr Webb spoke to each other in raised voices. Mr Webb said:

“Stop being a fucking idiot … be a fucking man yeah, not a child be a fucking man yeah … I’m not in the fucking mood for you today.”

D728 said, “I’ve tried to take my life and you try to bully me.” Mr Webb responded, “Do you think I care? I ain’t fucking in the mood for you, alright.”¹⁰ The door was then closed and D728 continued to cover the viewing panel with toilet paper. DCO Aaron Stokes was standing outside D728’s cell, and Mr Tulley asked him, “How do you deal with someone like that?” Mr Stokes responded, “Chin him.”

14. Approximately six minutes later, Mr Webb returned and Mr Tulley told him that D728 kept covering the viewing panel. Mr Webb responded, “I was gonna let him have a shower but he’s fucking blown that.” Another manager, DCM Stephen Pearson, later spoke to D728, provided him with a cigarette and told him that he could have a shower if he behaved himself.
15. Mr Tulley and Mr Stokes discussed D728 again later that day in a staff office. Mr Stokes relayed to Mr Tulley that D728 had said to him, “I’m gonna hang myself if I don’t get off here.” Mr Stokes described his response as follows:

“I just literally went – crossed my arms, you can see it on the camera, just literally went in the room: ‘Do it. Just take yourself. I’ll cut you down, fucking crack on with it’. So what? I’m bloody bored of these empty threats. Honestly, would I give a shit if you hang yourself? I can’t physically stop you from hanging yourself. I can cut you down … . Can try and stop you from doing it but I ain’t gonna get in trouble for it, so you crack on mate, you get done with it. He didn’t like it when I said, stop playing your silly games and get on with it. He’s like, they’re not silly, they’re genuine personal reasons. Like, no, you’re playing silly games, mate. Don’t start.” ¹¹

16. Under questioning by Counsel to the Inquiry, Mr Webb, Mr Francis and Mr Stokes recognised that their comments were inappropriate. However, they sought to explain them as a reaction to frustration and stress, or as just “blowing off steam”.¹² Mr Webb was reluctant to accept that there was any difference between detained people swearing at staff and staff swearing at detained people. In his oral evidence to the Inquiry, Mr Webb said that, on occasion, he adopted what he termed a “mirroring technique” that he had discussed with others at an HM Prison Service National Tactical Response Group event. Mr Webb said:

“You would go into a situation, if someone was aggressive and shouting, you would match their aggressiveness and their volume.”¹³

1. CJS000970_015[↩]
2. CJS001023[↩]
3. CJS000970_018-019[↩][↩]
4. CJS001870_002[↩][↩]
5. Rule 40 of the Detention Centre Rules 2001 allows the removal of a detained person from association where “it appears necessary in the interests of security or safety”; see Chapter D.6 in Volume II[↩]
6. CPS000025_037[↩]
7. KENCOV1044 – V2017070600006; KENCOV1044 – V2017070600007[↩]
8. KENCOV1044 – V2017070600006[↩]
9. CPS000025_037[↩]
10. Day 2 PM 24 November 2021 00:38:58-00:53:30 (KENCOV1044 – V2017070600007)[↩][↩]
11. TRN0000094_056[↩]
12. MIL000003_018; Stephen Webb 8 March 2022 195/19-196/16; Charles Francis 3 March 2022 79/18- 82/5; INQ000132_005-006 para 11[↩]
13. Stephen Webb 8 March 2022 201/1-4[↩]