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24 April: Conclusions

  1. I find it probable that Mr Sanders did pull D1527’s fingers back and bang his head on a table. While I took account of the ‘macho’ culture that I found persisted in Brook House during the relevant period (see Chapter D.9 in Volume II), in this case Mr Sanders offered his accounts of these incidents spontaneously, repeatedly, and with apparent pride in his actions. Indeed, it is plain from the footage that he thought what he was describing was funny. Furthermore, people do not ordinarily admit to things they have not done.
  2. I considered the views of some of the staff witnesses who worked with Mr Sanders and who did not think that he would have mistreated D1527 in the way that he described. It is, though, important to acknowledge that, throughout the Inquiry, many staff said that they were shocked by evidence of abusive conduct by colleagues. For example, DCM Stephen Webb said that he was shocked to hear DCO John Connolly refer to a detained person as a “nigger”. He said, “that’s not the John I know”.1 DCM Daniel Haughton (Support Services Manager during the relevant period) said that he thought what was shown on Panorama was “horrific” and that prior to watching it he had not been aware of an abusive culture at Brook House.2 Furthermore, DCO Clayton Fraser said that he had never witnessed any bullying towards detained people.3 However, as discussed in Chapter D.9 in Volume II, there was undeniably a culture of aggression, bullying and bravado at Brook House during the relevant period.
  3. There was also, in my opinion, some residual denial of the seriousness of the treatment of some of the detained people in Brook House, and reluctance to accept that fellow members of staff had acted as they did. For example, DCM Christopher Donnelly said that there was no abuse of detained people at Brook House during the relevant period, despite what had been shown on Panorama, and that it was instead a small minority of detained people abusing staff.4 Mr Fraser suggested that threats made to D1527 by Mr Paschali (see below) may have been an attempt by him to de-escalate the situation.5 Regardless of the reason, I do not accept the scepticism of other staff who knew Mr Sanders as sufficient evidence to counter his own repeated claims to have mistreated D1527.
  4. Throughout the Inquiry, there was evidence that aggressive language was normalised and that officers felt able to talk freely about detained people in derogatory and abusive terms without fear of consequence.6 The Inquiry has seen evidence that compassion was not highly valued, and a narrative developed among some staff that their job was solely about managing risk and maintaining security rather than providing a safe and respectful environment for the men detained there. I discuss related issues – such as staffing levels, the experience of staff and the lack of supervision – in detail in Chapter D.9 in Volume II.
  5. Mr Sanders was the officer personally responsible for constantly supervising D1527 at the time of this incident. As such, he was responsible for the wellbeing of a highly vulnerable man whose risk of self-harm was deemed so high as to warrant him being supervised constantly. However, Mr Sanders abused his position of power over D1527 by inflicting further harm upon him. It is particularly troubling that this harm was inflicted on a man so clearly in mental distress.
  6. Given D1527’s heightened vulnerability, I consider it likely that this incident caused him intense physical or mental suffering, fear and anguish. Consequently, there is credible evidence that it was capable of amounting to inhuman and degrading treatment.


  1. Stephen Webb 8 March 2022 144/10-145/4[]
  2. Daniel Haughton 16 March 2022 148/13-149/2[]
  3. Clayton Fraser 28 February 2022 7/23-6/1[]
  4. Christopher Donnelly 23 February 2022 82/11-19[]
  5. Clayton Fraser 28 February 2022 7/12-8/2[]
  6. For example, see Chapter D.9 in Volume II under the heading ‘Abusive and derogatory language’[]