The underlying facts

3. The Inquiry understands that on 28 March 2017 D1234 was due to leave Brook House on escorted removal directions. (These are directions given by an immigration officer or the Secretary of State for the removal of a person from the UK, in accordance with section 10 of the Immigration and Asylum Act 1999.¹
4. Detention Custody Manager (DCM) Steven Dix held a briefing at 20:00 for officers to be involved in the use of force. In this briefing, the officers were informed that Mr Dix and DCM Graham Purnell had spoken to D1234 several times, but that D1234 had refused to leave his cell compliantly, citing ill health, and had stripped naked.² Despite this, D1234 had refused offers to see Healthcare and a medic from another contractor, Tascor. Mr Dix briefed officers that Ms Michelle Brown, Duty Director, had approved the use of force as a last resort.³
5. The Inquiry saw footage relating to a use of force on D1234 on 28 March 2017.⁴
6. One piece of footage was filmed with a handheld camera and lasts for 17 minutes 30 seconds.⁵ It begins with Mr Dix opening the door to D1234’s cell. D1234, who was sitting on the edge of a bed, was naked, shouting and in clear distress. For approximately 15 seconds, Mr Dix attempted to persuade D1234 to leave the cell.
7. Thereafter, Mr Dix authorised four officers wearing Personal Protective Equipment (PPE), who had been waiting outside the cell, to enter and use force on D1234. Three officers – Detention Custody Officer (DCO) Derek Murphy, DCO Jordan Rowley and DCO Gus Olyaie – entered the cell. Mr Murphy entered first and was carrying a shield.
8. The officers immediately restrained D1234 on the ground and a fourth officer, DCO Sean Sayers, then entered the cell and moved towards D1234 holding a sheet. As this happened, D1234 called out for “Allah” and “Jesus”. Mr Dix instructed the officer holding the handheld camera to direct it away from D1234 because he was naked.
9. The camera was directed to the ceiling for approximately 30 seconds. D1234 was screaming in apparent pain, and continually calling out for Jesus and Allah. After approximately 11 seconds, one of the officers shouted over D1234.
10. When the camera was directed back to D1234, he was lying on his back on the floor of the cell with Mr Olyaie restraining his head, Mr Murphy and Mr Rowley restraining each of his arms and Mr Sayers restraining his legs. D1234 was visibly distressed, wailing and shouting “fire”.
11. Mr Dix, who was not wearing PPE, walked into the cell and held a sheet over D1234’s genitals while he attempted to talk the officers through the use of force. The officers tried to move D1234 to his feet, but were unable to do so. As they made their attempt, Mr Dix dropped the sheet. D1234 was screaming in apparent pain and then continued to call out. At one point, while the officers had their hands on D1234’s arms, head and legs, he appeared to be breathless.
12. Mr Dix instructed the officers to sit D1234 up. As they did so, D1234’s protests became louder. Mr Purnell entered the cell and attempted to demonstrate to the officers how to bring D1234’s hands around to his back. As this was happening, Mr Olyaie appeared to be trying to force D1234’s head down.
13. Approximately two minutes after Mr Dix first entered the cell, he applied handcuffs to D1234, behind his back. The position of the officers’ helmets prevented an unobstructed view of D1234, but it is clear from the footage that he was in a seated position. Again, Mr Purnell leaned in to provide direction.
14. Mr Dix then directed the officers to move D1234 into a standing position, and cautioned Mr Olyaie and Mr Sayers that only one person should be at D1234’s head. Mr Olyaie let go of D1234 and backed out of the cell. Mr Purnell moved outside the door of the cell, but maintained his observation of the incident.
15. The officers moved D1234 to his feet, and held him bent forwards at a 90-degree angle. Mr Dix picked up a sheet and crouched down to speak to D1234. At that time, D1234 was calling out “oh Lord”. Mr Dix asked D1234 if he wanted to get dressed, but D1234 did not respond or acknowledge the question. He continued to shout “oh Lord”. Mr Olyaie then re-entered the cell and Mr Dix instructed him to tie a sheet around D1234’s waist. Mr Olyaie struggled to do this and so Mr Dix assisted, resulting in five officers surrounding and controlling D1234 at once.
16. The officers struggled with D1234 in this position for another minute before they moved him out of the cell. Mr Sayers, Mr Murphy and Mr Rowley were controlling D1234, while Mr Olyaie was holding the sheet around his genitals. D1234 was still bent over but appeared to be holding his own weight rather than being lifted. Shortly after, D1234 screamed out repeatedly in apparent pain. The officers looked tired. Mr Murphy, who was wearing a balaclava underneath his helmet, called over to someone called ‘Steve’ and appeared to gesture for his balaclava to be removed. After leaning in to clarify what Mr Murphy was saying, ‘Steve’ and Mr Dix removed Mr Murphy’s helmet and balaclava before replacing his helmet.

Figure 5: Mr Murphy wearing a balaclava during the restraint of D1234

17. D1234, who was still bent forward, continued to cry out and shouted, “I don’t want to die” and “you are killing me”.
18. Mr Sayers, who was controlling D1234’s head, leaned towards D1234’s ear and shouted that if he did not walk compliantly he would be lifted. The officers then tried to walk forwards with D1234, who was still crying out. The group stopped after a few seconds and D1234 was lifted into the air in a seated position with his legs held apart and outstretched in front of him. He continued to cry out as he was carried out of the wing and spat on the ground.
19. The officers carried D1234 off the wing and through a corridor. Approximately 30 seconds after the officers first picked up D1234, Mr Dix told the officers that he could be given the opportunity to walk but that if he did not reply they should continue to carry him. D1234 did not respond to the officers and continued to cry out, so they continued to carry him.
20. Approximately eight minutes after force was first used, the officers who were carrying D1234 appeared to need to rest and Mr Dix instructed them to pause and to take their time. D1234 was placed on the floor in a seated position for approximately 50 seconds while the officers briefly rested, and two of them switched their positions before continuing the restraint.

Figure 6: D1234 being restrained on the floor with his hands handcuffed behind his back

21. Mr Dix explained to D1234 that if he was not going to get up and walk, “then the lift will have to continue”. D1234 continued to call out. As the officer attempted to pick D1234 back up, his screams intensified.
22. The footage then shows D1234 being carried through a series of doors into an area referred to as ‘Detainee Discharge’ (another area away from the wing), where staff from Tascor were waiting to escort him to his removal flight.

Figure 7: G4S officers carrying D1234 into Detainee Discharge

23. D1234 repeatedly stated “it is over” and called out to “almighty God” as they did so. The footage shows at least 14 members of staff present while D1234 was carried in and placed on the floor. At least one member of staff, who may have been a member of the Tascor escort team, could be seen smirking. D1234 was still handcuffed with his hands behind his back and was naked except for a sheet draped over his genitals. Tascor officers took over restraining D1234, applying their own handcuffs to him before Mr Dix removed the handcuffs that he had applied earlier in the restraint. One member of staff, who might have been from Tascor, could be seen holding a waist restraint belt.
24. The Inquiry also saw closed-circuit television (CCTV) footage of E Wing.⁶ The footage shows officers approaching and entering D1234’s cell, and then carrying him from his cell to Detainee Discharge. The footage ends before D1234 was carried through the door.
25. A further piece of footage shows Mr Dix leading a debrief following the use of force on D1234.⁷ The debrief lasted for approximately 1 minute 30 seconds. Mr Dix said that D1234 had been loudly chanting, had not engaged with the team and had “presented himself naked”. He said that there had been no option other than the use of force on D1234, who had resisted throughout and had had to be carried. Mr Dix said that he considered the restraint to have been a “job well done” by the staff, but added that he had spoken to some of the team individually about learning points. Mr Dix did not elaborate on the learning points that he had identified and none of the staff in attendance asked any questions. The officers other than Mr Dix only spoke to confirm their names and state that they had not sustained injuries. The member of Healthcare in attendance, Ms Grace Sihlali (a Registered General Nurse), spoke only to confirm that she had no concerns about the restraint.
26. While the Inquiry did not receive a witness statement from D1234, he did make a complaint about the force used against him, which was investigated by the PSU. In the written account he provided on 25 April 2017, D1234 said that two G4S officers had held his head and turned it violently. D1234 said that he felt a “crack” in his neck and that, despite telling the officers about this, they took no notice of him. D1234 described being pushed and hitting his head on the floor. He also said that one officer held his throat and another stamped violently on his toes. D1234 said that he was in “extreme pain” and asked the officers to stop, but that he was ignored. Although I make no findings in relation to Tascor, D1234 also described being handcuffed and having the straps of a waist restraint belt placed over a lump in his stomach for which he was awaiting surgery. He said that he was thrown into an escort van and was screaming in pain.⁸
27. D1234’s medical records show that he was seen by a Staff Nurse, Ms Janina Wingert, when he returned to Brook House at 04:03 the following morning. D1234 complained of pain all over his body, and Ms Wingert recorded the following signs of physical injury:

• redness on both of his wrists;
• a small skin peel on his right wrist;
• some redness on the right side of his trunk; and
• a skin tear on his left toe.⁹

D1234 was seen by Dr Husein Oozeerally at 15:30, who recorded that D1234 had a “tender bilateral chest wall”, both anteriorly and posteriorly, and diagnosed him with a “soft tissue injury”.¹⁰

28. Mr Sayers, Mr Dix, Mr Olyaie, Mr Rowley and Mr Murphy, who had all been involved in the restraint of D1234, recorded that he had actively resisted or refused to comply and that it had therefore been necessary to carry D1234.¹¹ In his statement to the Inquiry, Mr Murphy acknowledged that the “cuff carry” was “poorly executed”. Mr Murphy wrote that he did not think that the officers should have been instructed to carry out the lift, as it was clear that they were tired. He added that there was no second restraint team available to relieve them.¹² Mr Dix failed to mention in his Use of Force report that D1234 had complained of feeling unwell in earlier conversations, prior to the use of force.¹³
29. The PSU carried out an investigation into D1234’s complaint, led by Ms Jana Schwab.¹⁴ Mr Dix, Mr Sayers, Mr Murphy and Mr Olyaie were interviewed by the investigators, and their responses were summarised in the report.¹⁵ Each of the officers said that they did not recall D1234 saying that he was in pain during the restraint.¹⁶ However, Mr Dix accepted that D1234 “may have been in pain due to the officers having to carry him in handcuffs as this was a painful process”. ¹⁷
30. The investigation found that there was insufficient evidence to prove that the officers involved had acted unprofessionally, stating that the use of force on D1234 was reasonable, necessary and proportionate.¹⁸ The report noted that the technique of handcuffing a detained person behind their back when the detained person was seated had been “removed”.¹⁹ The report did not clarify what was meant by this, but in a letter to D1234 dated the same day, the technique was described as having been “removed from Home Office approved techniques”.²⁰ The PSU did not criticise the use of the technique on D1234. The investigation did not find any evidence that D1234 hit his head on the floor, was restrained by the throat or experienced a cracking of his neck. The report made no criticism of how D1234 was carried.²¹ In respect of D1234’s nakedness, the PSU concluded in its letter to D1234:

“The video also showed that great efforts were made to protect your dignity throughout the incident by placing a sheet around you.”22

31. The Inquiry heard evidence of other occasions where detained people were restrained when naked or near-naked. I consider two other specific incidents (see Chapter C.3 and Chapter C.13), and discuss the issue of restraint on naked detained people more extensively in Chapter D.7 in Volume II.
32. In his oral evidence to the Inquiry, Mr Dix accepted the criticisms of Mr Jonathan Collier, the Inquiry’s use of force expert, regarding the force applied to D1234’s head, the application of the handcuffs and the carry technique.²³ Mr Dix said that he had not received any specific training on how to lead other officers in carrying out a restraint.²⁴
33. Mr Rowley said that he was not aware that the technique of handcuffing detained people behind their back had been removed from authorised practice.²⁵

1. Immigration and Asylum Act 1999, section 10[↩]
2. CJS0073729 [Disk 23 S1940002][↩]
3. HOM002485_001[↩]
4. CJS0073730 [Disk 23 S1940003]; CJS0073731 [Disk 23 S1940004]; CJS0073732 [Disk 24 28 March2017]; CJS0073729 [Disk 23 S1940002][↩]
5. CJS0073730 [Disk 23 S1940003][↩]
6. CJS0073732 [Disk 24 28 March 2017][↩]
7. CJS0073731 [Disk 23 S1940004][↩]
8. HOM002492_002-003[↩]
9. HOM002492_006[↩]
10. HOM002492_005[↩]
11. HOM002496_009; HOM002496_012-013; HOM002496_016-017; HOM002496_020; HOM002496_023-024[↩]
12. INQ000121_008 para 28d[↩]
13. HOM002496_009[↩]
14. HOM002750[↩]
15. HOM002750_007-014 paras 6.2-6.5[↩]
16. HOM002750_009 para 6.2.15; HOM002750_011 paras 6.3.14-16; HOM002750_013 para 6.4.9; HOM002750_014 para 6.5.10[↩]
17. HOM002750_009 para 6.2.15[↩]
18. HOM002750_031-032 paras 7.2.18-21[↩]
19. HOM002750_026 para 6.16.10; HOM002750_029 para 7.26; HOM002750_036 para 8.1[↩]
20. CAP000519_002[↩]
21. HOM002750_029-032 para 7.2[↩]
22. CAP000519_003[↩]
23. Steven Dix 9 March 2022 33/12-34/17[↩]
24. Steven Dix 9 March 2022 33/12-34/12[↩]
25. SER000438_010[↩]