Conclusions

36. The handheld camera footage of the use of force on D1234¹ is particularly upsetting to watch. D1234 was plainly in severe distress for the duration of the incident, which was 17 minutes 30 seconds long. He was desperately and repeatedly calling out to “Jesus” and screaming in apparent pain.
37. Mr Dix instructed officers to use force 15 seconds after he opened the door to D1234’s cell. Notwithstanding Mr Collier’s view, and regardless of what conversations had taken place with D1234 in advance, I consider that Mr Dix should have made more meaningful attempts to engage with D1234 and persuade him to comply with instructions immediately prior to any use of force. Mr Dix could not be sure that further attempts to persuade D1234 to engage would not have achieved a different outcome in circumstances where D1234’s removal was imminent.
38. Mr Dix did not command or persuade D1234 to get dressed prior to using force and only offered him one opportunity to do so during the use of force, which lasted over 15 minutes. There is no evidence from the footage that any subsequent attempts were made to allow D1234 to get dressed before his removal. He was carried into Detainee Discharge with only a sheet held around his genitals; there was a large group of staff there, some of whom appeared simply to be watching the incident and to be amused by it. This was demeaning, humiliating and disproportionate in the circumstances. At least one member of staff could be seen smirking as he observed D1234 being restrained on the floor of Detainee Discharge.

39. The footage shows a group of officers who were clearly tired and struggling to carry out the restraint of D1234 effectively. Mr Dix, as the supervising manager, should have identified a number of problems and sought immediately to remedy them. These problems included:

• inappropriate handcuffing of a detained person with their hands behind their back while seated;
• D1234’s head being pushed down with too much force;
• the incorrect execution of a carrying technique; and
• Mr Murphy wearing a balaclava.

40. It should have been obvious to Mr Dix that the staff were struggling to carry out the restraint due to their physical exertion and their inability to apply the techniques appropriately.
41. I find it completely inadequate that Mr Dix had no specific training on how to lead other officers in carrying out a restraint. That notwithstanding, I note that Mr Dix was not the only manager involved in the incident, although he was the supervising officer as recorded in the Use of Force report. Mr Purnell was also present for the duration of the incident, and even stepped in at times to provide direction to the officers using force. In light of the problems that the Inquiry has identified with the execution of the use of force, I find it unacceptable that he also failed to identify the problems that I listed. He should have done so, and should have intervened in the use of force to ensure that it was executed safely. Specifically, it is very concerning that neither manager corrected staff as they handcuffed D1234 with his hands behind his back when he was seated, a technique that had been removed from the Use of Force Training Manual because it is unsafe (as discussed in Chapter D.7 in Volume II).
42. It is concerning that Mr Murphy’s addition of a balaclava to his PPE went unchallenged by Mr Dix. In my opinion, the wearing of a balaclava was inappropriate because it had the effect of concealing Mr Murphy’s face from D1234, thus preventing D1234 from identifying him if he had wanted to complain about the restraint. It also hindered communication between Mr Murphy and those around him. This was a loud incident, with D1234 and the officers all shouting over each other. The balaclava hid Mr Murphy’s mouth, so no one involved was able to understand what he was saying by watching his lips. It is clear that ‘Steve’ did not initially know what Mr Murphy was saying when Mr Murphy asked him to remove his balaclava, as he leaned in towards Mr Murphy and raised his hand to his ear. Furthermore, while D1234 did not specifically address the balaclava in his complaint, he was clear that he found this incident frightening and that he suffers from flashbacks as a result. In the circumstances, I consider that Mr Murphy’s use of a balaclava is also likely to have appeared frightening to D1234.
43. The debrief led by Mr Dix was superficial.² While he identified that there had been some lessons to be learned, he did not elaborate. It is therefore impossible for anyone reviewing the debrief, or the staff present, to know what Mr Dix believed those lessons to have been or what remedial action ought to have been taken. This was a missed opportunity for the officers to reflect on the incident as a team, and to discuss, share and benefit from the learning that Mr Dix had identified or that the officers may have identified themselves. Moreover, in light of the issues with the use of force that have been identified in the course of this Inquiry, I consider that the manner in which Mr Dix presented the debrief minimised the importance of the lessons that ought to have been identified and learned from. While I recognise that it is important for a manager to preserve the morale of their team, this was not a “job well done”, and that ought to have been communicated.
44. It is not clear from the footage whether D1234 did suffer the injuries to his neck that he described, or whether he hit his head on the floor. There are various points where there is not a clear view of D1234’s neck or head. It is also not discernible whether Ms Sihlali would herself have had a clear view of D1234’s airway in order to ensure he was not at any medical risk. If she was unable to see D1234’s face, she should have told the officers that this was the case and put herself in a position to be able to see it. Ms Sihlali should also have alerted staff to the dangers of a handcuffing technique that is associated with positional asphyxia. D1234 cannot be heard to specifically mention his neck or head on the footage of the restraint, but much of what he said is indecipherable and so I cannot be sure that he did not make reference to them. However, it is plain from D1234’s medical records following the incident that he did suffer some injuries, even if they were not as he described in his complaint.
45. Given the errors and technical misapplications that are visible on the footage, it is possible that pain was caused to D1234’s neck during the restraint. It is also possible that his head did make contact with the floor. D1234 did not report injuries to his head or neck in the immediate aftermath of the incident, but he did complain of “pain all over” and was subsequently noted to have injuries to his wrists, right side and left toe. He was also diagnosed with a soft tissue injury to his chest. I cannot be sure how these injuries were caused because force was used by officers from both G4S and Tascor.
46. In relation to the force used by G4S officers, I consider that handcuffing D1234 behind his back while he was seated, combined with the incorrect technique used to carry him, is likely to have caused him pain (as recognised by Mr Dix in his interview with the PSU) as well as exposed him to unnecessary risk. This treatment was avoidable, and was capable of causing him intense physical and mental suffering. I also consider that the force used against D1234 was likely to humiliate him. Force was used while he was naked or near-naked, and he was at times surrounded by a large number of staff. The use of force also continued for a long period of time. I therefore find that the facts of this incident provide credible evidence of acts capable of amounting to inhuman and degrading treatment.

1. CJS0073730 [Disk 23 S1940003][↩]
2. CJS0073731 [Disk 23 S1940004][↩]