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25 April: the first incident

  1. D1527 has provided four consistent accounts of what happened to him on 25 April 2017.1
  2. On the afternoon and evening of 25 April 2017, D1527 remained on constant supervision on E Wing. During that time, D1527 made two separate attempts to harm himself while inside his cell. As set out below, some members of staff were involved in responding to both incidents while others were present for only one or the other. For clarity, I refer to the two incidents that day as ‘the first incident’ and ‘the second incident’.

The First Incident

The underlying facts

  1. Mr Fraser, the officer constantly supervising D1527 at the time, recorded in D1527’s ACDT record that, at 19:01, he was “kicking and banging” the cell door.2 Mr Loughton, who was attending E Wing in his capacity as ‘Oscar 1’ (the operational manager on duty) that day, approached D1527’s cell to carry out a routine management check of detained people refusing food and fluids.3 Mr Fraser told Mr Loughton that he had not seen D1527 for a few minutes.4 They went into D1527’s cell and found D1527 curled around the toilet, which was separated from the rest of the cell by a solid screen (a ‘privacy screen’), holding a ripped T-shirt around his neck.3
  2. In his witness statement to the police and in response to questions asked by the Inquiry under Rule 9 of the Inquiry Rules 2006, D1527 described cutting his T-shirt and tying it around his neck because he did not want to live anymore.5
  3. Mr Tulley was also on E Wing that day, constantly supervising another detained person. He heard noises coming from D1527’s cell and went over to try to assist.6 The Inquiry saw footage recorded covertly by Mr Tulley, which shows a continuous period of approximately 18 minutes on E Wing.7 The footage begins with Mr Tulley walking a short distance across E Wing and into D1527’s cell. The time at that point was approximately 19:08. Mr Fraser was standing in the middle of the cell, and Mr Loughton was leaning over the toilet area. Mr Tulley shouted, “get staff, we need some help in here” to officers outside the cell. Mr Loughton appeared to be unable to loosen the ligature around D1527’s neck and asked for a fish knife, which Mr Fraser provided. Mr Loughton used this to cut the ligature off, and the officers pulled D1527 out of the toilet area and told him to get up and sit on the bed.8

Figure 10: Mr Loughton removing the ligature from around D1527’s neck

  1. D1527 does remember that an officer cut the T-shirt away from him, and he remembers being forcefully moved into the centre of the cell. However, he says that he was having flashbacks at the time, which he describes as seeing himself somewhere else and not noticing what the people around him were saying or doing. As such, he recognises that he does not remember everything that was happening.9
  2. D1527 explained in his witness statements that he remained there for a few minutes before getting up onto the bed, taking a battery out of his phone and putting it in his mouth.10 D1527 does not remember much about putting the battery in his mouth, but remembers that it was taken out by force.11 He said:

“I know that people were talking about me and being rude to me, but I don’t remember any of this. I wasn’t listening to them, I did not feel like I was there in that room. I felt like I was somewhere else. I just wanted to die, I didn’t care about anyone else or what they were saying.”12

  1. The footage shows D1527 get up off the floor after a couple of seconds and start pacing in the cell.7 A female member of staff, who appeared to be from Healthcare, stood in the doorway and DCO Charles Francis joined the other officers inside the cell. Mr Loughton and Mr Francis asked D1527 what he had inside his mouth. Mr Loughton radioed for Healthcare staff to attend immediately and both officers continued to ask D1527 what was in his mouth. D1527 did not respond to the officers, and continued to pace the width of the cell. Mr Francis then moved towards a table underneath a window at the back of the cell, said the word “battery” and appeared to hold up a small item in the direction of Mr Loughton before placing it back down. Mr Loughton responded but his words are not audible on the footage.
  2. Mr Loughton instructed D1527 to sit down, which he did briefly before he stood back up and started shouting at officers:

“I will die here today … I asked nicely for everything, you said no … Don’t believe it? I will go there … noose on my head, pull the knot here… I will die here. Don’t worry … I will die, I will die again.”

As D1527 shouted he raised his arms above his head and paced back and forth; he was obviously distressed. After around a minute, D1527 put one hand to his chest and sat back down on the bed, which appeared not to have a mattress on it.

  1. Within 10 seconds of D1527 sitting down, Mr Loughton said, “He’s got a battery. Give me the battery”, and, seconds later, “Don’t put it in your mouth. He’s got a battery in his mouth.” A conversation then took place between Mr Loughton and other staff regarding the battery, which Mr Loughton described as a phone battery. Ms Joanne Buss, a Registered General Nurse (RGN), walked into the cell and asked D1527 if he would talk with her. However, he did not respond and remained seated on the bed.
  2. Over the course of around six minutes, Mr Loughton, Mr Tulley and Ms Buss attempted to engage with D1527, but he did not respond. Mr Tulley moved to sit opposite D1527, meaning that the others in the cell were no longer visible on the footage, though their voices could clearly be heard. Mr Loughton repeatedly told D1527 to remove the phone battery from his mouth and remarked, “It isn’t going to get you out of this wing though, is it?” and “When all we do is stuff like this, the longer you’re going to stay in here.” D1527 did not respond. Mr Loughton instructed D1527 to take the battery from his mouth again but then moved to leave the cell while complaining that he would now have to complete a Use of Force report. As he was leaving, Mr Loughton remarked, “got a battery in his mouth now, the cock”. Mr Ring, who had arrived at the cell, commented that D1527 would be “Going all night like a Duracell bunny” and said, “Swallowing batteries? You’re full of it.” Ms Buss appeared to reply “yes”. Shortly afterwards, Mr Ring said to Mr Tulley, “what are you waiting for?” and Mr Tulley left the cell with the other officers.
  3. Mr Tulley, Ms Buss, Mr Loughton, Mr Fraser and Mr Ring remained standing on the E Wing landing near D1527’s cell, the door to which was left open. A conversation took place between staff outside the cell, where Mr Ring referred to D1527 as “a child” and “just a dick”. He also remarked, “they just sit and sulk”. Mr Loughton gave the instruction, seemingly to Mr Fraser as the officer assigned to constantly watch D1527, “You need to keep an eye on him. When he goes in there, we need to be able to keep an eye on him … what’s he doing now? sulking.” Mr Fraser asked whether the cell door should be left open.
  4. Mr Tulley and Ms Buss moved back into D1527’s cell, where D1527 had returned to the toilet area and was talking with a member of Healthcare staff. Mr Loughton, who must have re-entered the cell out of view of Mr Tulley’s covert camera, was standing in the middle of the cell. D1527 asked the member of Healthcare staff to leave him alone and said, “I will die. No you don’t need to do this.” He then gestured towards Mr Loughton and said, “He doesn’t care he tried to put me here and locked me up.” D1527 said, “please, please, please let me”. A voice off-camera could then be heard saying, “bellend might be off my wing”.
  5. Mr Tulley walked away from the cell and towards the E Wing staff office. D1527 could still be heard talking to Healthcare. Mr Tulley engaged in conversation with other detained people who were on E Wing and then talked with Mr Paschali about D1527’s attempted self-harm. As they were talking, the two officers walked back towards D1527’s cell. Mr Tulley said:

“what I think he tied something around his neck, he was trying to strangle himself … Nobby [a nickname for DCM Stephen Loughton] had to get hands on … he got into – when I got into the cell, he was in the toilet. I don’t know how he got in, I don’t know how he got around into the toilet and onto the floor, do you know what I’m saying?”

Mr Paschali asked if he meant that D1527 had managed to get behind the toilet itself, but Mr Tulley clarified that he meant that D1527 had positioned himself behind the privacy screen.

  1. Mr Paschali and Mr Tulley joined Mr Ring and Mr Fraser at D1527’s cell door. Mr Ring said:

“He aint got a battery in his mouth has he – nah I said to you it’s all good … He put the battery ’round his mouth and pretended to chew it up … and when I checked it, it was all in the drain. He picked it up, put it ’round his face and [inaudible] chucked it all down the drain to look like he’d, like he’d [inaudible] the toilet.”

  1. In response to Mr Tulley asking D1527’s age, Mr Paschali said, “It’s kind of like he’s fucking three.
  2. After approximately five minutes, Mr Tulley went into the staff office where Mr Francis was sitting at a desk. They discussed D1527, who Mr Tulley described as having calmed down. Mr Francis asked if D1527 had given up the phone battery to staff. Mr Tulley responded:

“I didn’t see it happen, but I believe he has done, yeah because he’s chatting away in there, so.”

  1. Mr Loughton submitted a Use of Force report in relation to restraining D1527 (in order to remove the ligature) at approximately 19:08.13
  2. In his oral evidence to the Inquiry, Mr Fraser described D1527 placing a ligature around his neck while he was constantly observing him from outside the cell through the viewing panel. He said that he was “probably going over [his] notes” when D1527 moved from his bed to the toilet area and attached the ligature to his neck.14
  3. In his oral evidence to the Inquiry, Mr Ring said that he viewed his comments about D1527 as “facetious” and “silly”. He claimed that his comments were born of frustration with D1527’s behaviour, which he told the Inquiry he considered to be “childish”.15 Mr Ring also emphasised that his comments had been directed at other staff and not at D1527 himself.16 When Counsel to the Inquiry asked if Mr Ring believed that D1527’s actions that day may have been a manifestation of his mental illness, Mr Ring at first refused to comment because he said he was not medically trained. He then added that he was unsure why D1527 had been acting “childishly” because he was not trained in mental health.17
  4. Mr Loughton told the Inquiry that he thought it was putting too much emphasis on the use of language at Brook House in the relevant period.18 However, he accepted that calling D1527 a “cock” was inappropriate and apologised for it.19 Mr Loughton did also seek to explain that he had made the comment to another officer and not directly to D1527, and that he had done so as a result of the stress of the situation:

“You’ve just got to take into consideration, my adrenaline was going, I’d just potentially saved this guy’s life, removed a ligature from his neck. He was screaming in my face. I was, you know, my feelings were raised at the time.”20

  1. Mr Loughton also told the Inquiry that he did not believe that he could distinguish between a detained person being disruptive because they were mentally unwell or because they were being disruptive for some other reason. He said that he had received no training on this.21


  1. The footage of the first incident on 25 April 2017 shows D1527 in clear distress and was hard to watch.
  2. Both Mr Tulley and Mr Loughton expressed concern to other staff that D1527 had managed to attach a ligature to his neck while under constant supervision.22 However, the Inquiry did not receive any evidence to enable me to determine how quickly D1527 moved to the toilet area and applied the ligature. I cannot therefore draw any conclusion as to whether Mr Fraser might reasonably have noticed what D1527 was doing sooner than he did.
  3. Mr Ring sought to minimise the seriousness of his use of disrespectful and abusive language as a coping mechanism to deal with the sometimes traumatic nature of working at Brook House.23 He described it as “banter between officers that have been dealing with [D1527] for some time”.24 Mr Ring did not consider that staff using the terms ‘cock’ and ‘dick’ to refer to a detained person was problematic when said in private between staff.25 I disagree. The pervasiveness of derogatory and abusive language by staff at Brook House in the relevant period, and the impact it had on their treatment of the detained people in their care, is discussed in Chapter D.9 in Volume II. In any event, and regardless of who Mr Ring may have been intending to address, he made unacceptable comments within earshot of D1527 and other detained people, and it is probable that D1527 heard what was said.
  4. Mr Ring appeared to view the events of that day through the lens of how they impacted on staff. For example, in his oral evidence he referred to staff “dealing with [D1527] for some time” and to his perception that D1527 would do “something to get a reaction” when he wanted something, which he described as similar behaviour to his children.26 However, Mr Ring was an experienced officer and he should have appreciated the heightened sense of vulnerability likely to be felt by someone who had just tied a ligature around his neck. I was alarmed by the lack of compassion that he displayed towards D1527 in his interactions with him on 25 April 2017. In my view, all staff working with vulnerable detained people, such as those on E Wing, should have been trained in mental health awareness to a level that enabled them to appreciate that disruptive behaviour may be a manifestation of mental ill health, requiring a referral to a medical professional.
  5. While I make no criticism of Mr Loughton’s actions during the incident itself, his treatment of D1527 in the aftermath was far below what should be expected from any member of staff, and was particularly concerning from a manager. In his oral evidence to the Inquiry, Mr Loughton admitted to having been frustrated by the fact that Mr Fraser had not been observing D1527 as closely as constant observation requires.27 Rather than addressing this apparent failure with Mr Fraser, the footage shows that Mr Loughton directed his frustration at D1527, seemingly blaming him for causing extra work and delaying the end of his shift.7 I do not underestimate the impact on staff who carry out restraint in order to prevent self-harm or suicide by someone in their care. The potential for this to desensitise them to the distress of the people being restrained is addressed in Chapter D.9 in Volume II. However, given Mr Loughton’s role as Oscar 1, a position with authority and influence over junior staff, it is concerning that he did not conduct himself with more compassion and professionalism. Moreover, Mr Loughton’s evidence to the Inquiry was that he did not think it was possible to train staff to develop coping mechanisms in order to deal with highly stressful events.28 As Mr Loughton is a current Assistant Director at Brook House, and therefore someone with considerable influence over how Brook House operates now, I found that this demonstrated a worrying lack of insight.
  6. I considered whether D1527’s mental or physical health made him especially vulnerable to mistreatment during this incident. He had just self- harmed and, in order to remove the ligature from his neck, staff had restrained him. Given the distress that this was likely to have caused, the abusive words that were used towards him were particularly unacceptable. In my view, the words were humiliating and debasing. I consider that there is credible evidence that his treatment during this first incident was capable of amounting to degrading treatment.


  1. The first of these statements was given to Sussex Police on 11 December 2017 (SXP000145), after it had started an investigation into some of the events shown on the Panorama programme. The second statement was provided in support of D1527’s application for permission for judicial review (HOM032221_010-013 paras 39-49). The third statement was D1527’s evidence to this Inquiry, dated 19 November 2021 (DL0000144_018-023 paras 49-61). Finally, D1527 provided a response to questions asked by the Inquiry under Rule 9 of the Inquiry Rules 2006; this document is undated (DL0000209), but was received by the Inquiry on 12 November 2021[]
  2. CJS001085_017[]
  3. CJS004316_004[][]
  4. SER000447_016 para 70[]
  5. SXP000145_001; DL0000209_0027[]
  6. SXP000120_004[]
  7. Day 2 AM 24 November 2021 00:34:29-00:53:24 (KENCOV1007 – V2017042500020 08:47-26:36)[][][]
  8. As Mr Tulley was involved in the restraint, this is not entirely clear from the footage. However, it is recorded in an incident report completed by Mr Loughton (CJS004316_004) and in Mr Tulley’s statement to Sussex Police (SXP00120_004), both of which I consider to be an accurate description of what is being shown[]
  9. SXP000145_001; HOM032221_010-011 para 39; DL0000209_027[]
  10. HOM032221_011 para 40; SXP000145_001-002[]
  11. HOM032221_011 para 41; SXP000145_002[]
  12. HOM032221_011 para 41[]
  13. CJS005534[]
  14. Clayton Fraser 28 February 2022 48/17-50/3[]
  15. Nathan Ring 25 February 2022 77/14-81/16[]
  16. Nathan Ring 25 February 2022 77/14-78/17; Nathan Ring 25 February 2022 83/24-84/20[]
  17. Nathan Ring 25 February 2022 79/13-80/5[]
  18. Stephen Loughton 1 March 2022 96/20-25[]
  19. Stephen Loughton 1 March 2022 89/23-90/4[]
  20. Stephen Loughton 1 March 2022 90/4-11[]
  21. Stephen Loughton 1 March 2022 103/5-9[]
  22. TRN0000001_002 at 24 rows 37-40; TRN0000001_011 at 170 rows 21-25[]
  23. Nathan Ring 25 February 2022 101/3-14[]
  24. Nathan Ring 25 February 2022 78/11-17[]
  25. Nathan Ring 25 February 2022 83/20-84/24[]
  26. Nathan Ring 25 February 2022 78/16-17; Nathan Ring 25 February 2022 79/16-20[]
  27. Stephen Loughton 1 March 2022 98/3-10[]
  28. Stephen Loughton 1 March 2022 139/12-140/4[]