25 April: the second incident

The underlying facts

50. The footage covering the second incident recorded by Mr Tulley is approximately 28 minutes long.¹ It begins at approximately 20:30 with Mr Tulley sitting in the staff office, talking to another member of staff about D1527’s earlier attempt to self-strangulate with a ligature. Mr Tulley then walked through E Wing to D1527’s cell, the door to which was closed. There were four staff members, including Ms Buss and Mr Fraser, standing directly outside the door looking in and discussing D1527’s attempts to smash the light in his cell.
51. Mr Tulley asked Ms Buss what D1527’s problem was and she replied, “He’s an arse, basically. He can’t get what he wants and I can’t get what he wants.” Ms Buss speculated that D1527 might be attempting to get water into the light fitting, at which point Mr Ring asked if the cell still had running water.²
52. After approximately three minutes, Mr Ring, Mr Tulley, Mr Fraser and Ms Buss went into D1527’s cell. The footage does not show D1527 but, from the positions of Mr Tulley and the other staff, it is evident that he was on the floor in the toilet area where he had previously attempted to self-strangulate. D1527 did not speak. Mr Ring leaned over him and said:

“Still breathing, nothing ’round his neck, I’ve checked. If he’s sucking a battery, he’s sucking a battery.”

He added, in a mocking tone of voice, “So he wants to use it as his dummy, fine, I’m okay with that.” Mr Ring then asked Mr Tulley to watch D1527, which he agreed to do.

53. Shortly after the other staff left the cell, Mr Tulley heard D1527 choking, heaving and gasping for breath with his hands around his throat – he was trying to choke himself.³ The footage demonstrates that Mr Tulley asked D1527, “what are you doing?”, and then repeatedly told him, “Stop it. Stop. Mate, don’t – don’t do that. Don’t do that.” He tried pulling D1527’s hands away and pulled him into the middle of the cell. He then called out for assistance from other staff, who entered the cell shortly afterwards.
54. D1527 was still heaving, and Mr Fraser appeared behind him but did nothing. D1527 was on his back with his hands clasped around his neck. Mr Tulley and Mr Francis attempted to pull them away by taking hold of D1527’s arms. Mr Fraser then took hold of D1527’s legs. D1527 was struggling against the officers and making choking sounds.
55. At this point, Mr Paschali entered the cell. He knelt on the floor, straddling D1527, with D1527’s head between his knees, and placed his hands either side of D1527’s neck. D1527 stopped struggling but remained on his back, at which point Mr Paschali released his grip, removed his hands from D1527’s neck and placed his left hand on his own left thigh. D1527 began breathing heavily and sounded distressed. Mr Tulley told him to relax, but D1527 started to scream and resist as Mr Paschali leaned forward over him, with his hands around D1527’s neck and his chest over D1527’s face. The footage shows Mr Paschali’s hands placed firmly around D1527’s neck, with his thumbs on the front of the throat around the area of the Adam’s apple, and he appeared to be applying pressure. His fingers were down the side and back of D1527’s neck. D1527 suddenly stopped screaming and started to make a guttural sound. Mr Paschali looked back to D1527, who was underneath him, and said to D1527 in a low voice:

“You fucking piece of shit, because I’m going to put you to fucking sleep.”

It was only when Mr Tulley said, “Yan, Yan, easy”, approximately 14 seconds later that Mr Paschali released his grip and D1527 gasped for breath. At this time, Ms Buss’s shoes are visible in the footage where she is walking around behind Mr Paschali.

56. Mr Tulley told Sussex Police that Mr Paschali had:

“exerted an extremely high amount of pressure on to [D1527’s] neck. It was a phenomenal amount of pressure which appeared to be concentrated on to [D1527’s] airways.”⁴

Figure 11: Mr Paschali applying pressure to D1527’s neck

57. Mr Francis then said, “Right, you’re going to stop being a tool now, yeah? You’re going to stop being an idiot? Yes or no? Yes or no? Yes or no?” Mr Paschali was still holding D1527’s neck. D1527 said, “my neck”, to which Mr Francis responded, “Are you going to stop being a tool? Yes? Yes, or no?” D1527 referred twice more to his neck but some of what he said is not audible on the footage. He was breathing deeply, and making whimpering and crying sounds. D1527 was then put into the recovery position and held there by Mr Paschali and Mr Francis. He began screaming and appeared to be in significant distress; he was still breathing heavily and making noises which suggested he was panicking. Both Mr Francis and Mr Paschali instructed him to calm down, but D1527 did not respond and continued to scream out unabated. He was plainly in severe distress.
58. Mr Fraser, Mr Tulley and Ms Buss were also in the cell. D1527 remained on the floor of the cell surrounded by the staff, during which time his top was removed. This was presumably so Ms Buss could carry out medical observations, albeit the only evidence of any observations was an attempt to obtain an oxygen saturation reading by placing a pulse oximeter on D1527’s finger. Mr Francis repeatedly talked to D1527, shouting so that he could be heard over D1527’s screams. On some occasions Mr Francis told him to calm down, but he also said, “Come on, stop being a baby” and “Come on, we’re getting bored.” He also asked, “What are you, a man or a mouse?” Mr Tulley commented, “It would be nice if we had a manager in.”
59. Approximately seven minutes after D1527 was put into the recovery position, the staff turned him onto his back and exited the cell. D1527 was left lying on the floor. Only then did he stop crying and screaming. Mr Tulley then left E Wing; he went to a staff toilet and cried.
60. When Mr Tulley returned to E Wing he discussed the incident with Mr Paschali, who said, “no use of force, as it stands”. Shortly afterwards, Ms Buss approached Mr Tulley and he relayed Mr Paschali’s words to her.
61. None of the officers involved submitted a Use of Force report in relation to this incident. Ms Mariola Makucka, an RGN, completed section 3 of a F213 form on behalf of Ms Buss (who had an injured hand and was unable to write – such forms were completed in hard copy at Brook House).⁵ It recorded:

“Seen on E Wing room by RGN Jo. Detainee had placed a ligature around his neck, removed by staff. After this he went to [sic] toilet and attempt [sic] to self-strangulate. Hands removed from his neck. Slight redness noted on his neck.”⁶

62. Ms Buss also made an entry in D1527’s medical records:

“Examination: placed on rule 40 constant supervision as he refused to return to E wing.

called to E wing at approx 19.00 constant watch.

had placed a ligature around his neck. removed by staff

staff trying to engage with him.

RMN Dalia tried to engage with him with minimal effect.

put mobile phone battery in his mouth which he later removed battery removed from his room.

went to toilet and attemted [sic] to self-strangulate. angry and not engaging with staff.

hands removed from his neck by staff.

salivating ++

unable to take any observations visual obs resps 16

slight redness noted on his neck.

20.00 got up and walked around room taken a small drink

restless. constant watch continues not engaging with staff.

Plan: pls review later this evening.”⁷

63. In the ongoing observations section of D1527’s ACDT record, Ms Buss recorded for 19:40:

“Seen in room 7. Constant watch. D1527 had tied a T-shirt around his neck. Angry, upset. Had mobile phone battery in his mouth. Attempted to self-strangulate in toilet. Visual obs due to demeanour. Resp 16.”⁸

64. According to D1527, he tried to strangle himself shortly after the battery had been removed from his mouth.⁹ He said that, after he tried to strangle himself, one member of staff called “Yan” sat on his head and that Yan strangled him.¹⁰ As he was being strangled, D1527 explained that someone said something threatening to him, but that he does not remember what it was.¹¹ At that time, D1527 thought:

“that I was going to die, that the man doing this to me was going to kill me. I remember having a panic attack, and hyperventilating. I felt like I was having a heart attack.”¹¹

65. After this incident, D1527 stated that he was left on the floor of his cell, where he remained for about 30 minutes.¹² No one said anything to him, and only a nurse checked on him for a minute or so.¹³ He said:

“I just thought to myself after this that I wanted to die. I wanted to die more than I had before. I was already making regular attempts to try and end my life, but I just felt more and more hopeless. I felt so hopeless and alone in my cell after all the officers left.”¹⁴

66. D1527 said that he did suffer some injuries as a result of the use of force, including “stiffness, soreness, and pain and redness in [his] neck”. However, he explained that the more serious injury had been to his mental health. He described his symptoms as follows:

“I still suffer from flashbacks to this day, and to being [sic] strangled. He said he was going to kill me. I thought I would die. It was so traumatic for me. This is inside my head and isn’t going to leave any time soon. Anything that happens to the outside of the body can heal easily, but anything inside your head is very difficult to get better.”¹⁵

67. Two weeks later, Mr Tulley covertly recorded a conversation between himself, Mr Paschali and another officer, DCO Derek Murphy. Mr Paschali described the use of force on D1527 as “so funny” and then said:

“I’m choking him and I thought ten more seconds and you’re going to sleep. He’s like ‘Yan, Yan, I think that’s enough’ and I’m like ‘no, I’ve got this, it’s proper, don’t worry about it’.”

Mr Paschali mimicked what he had done to D1527. Mr Tulley laughed and said, “I shat myself, I’m not going to lie but the nurse was right behind you Yan”, to which Mr Paschali responded “that’s why I didn’t though so yeah obviously that’s good”.¹⁶

68. Mr Paschali provided the Inquiry with the same explanation he had given to both the PSU and Sussex Police in his interviews with them as part of their investigations following the broadcast of the Panorama programme, ie that he placed his hands on D1527’s neck in order to brace it.¹⁷ He explained that he did so to prevent D1527 from swallowing whatever was in his mouth.¹⁸ Mr Paschali said that he did not believe it was necessary to communicate with the other officers during the restraint because D1527 had self-harmed by attempting to swallow items before, and the staff therefore “all knew what we were dealing with”.¹⁹ He sought to rely on Mr Francis’s question during the restraint – “Has he swallowed the battery?” – as evidence of the fact that he was not alone in believing that D1527 had something in his mouth.²⁰
69. Mr Paschali explained that he initially released his grip because D1527 had “calmed down”,²¹ but also said that he did not know at what point the battery came out of D1527’s mouth.²² Mr Paschali’s oral evidence was that he used the words “You fucking piece of shit, because I’m going to put you to fucking sleep” as a command to gain D1527’s compliance, although he did also accept that the language was “provoking, disrespectful and unprofessional”.²³ Mr Paschali said that he had deliberately given a false impression of what had happened on 25 April 2017 when he described “choking” D1527 two weeks later in order to “wind up” Mr Tulley, who was always seeking out stories.²⁴
70. Under questioning by Counsel to the Inquiry, Mr Paschali alleged that the footage of the incident had been edited to present a misleading picture of the events.²⁵
71. Mr Tulley told the Inquiry that he had interpreted Mr Paschali’s words – “no use of force, as it stands” – as an instruction from a more experienced officer.²⁶ Mr Paschali said he merely meant that the documentation did not need to be completed there and then.²⁷ Mr Paschali also told the Inquiry that he had completed a Use of Force report and left it in the E Wing office. He alleged that Mr Tulley had removed this to give a misleadingly negative impression.²⁸
72. Mr Francis told Sussex Police that, although he thought someone had mentioned a battery during this incident, he did not see it or know of its location.²⁹ He told the Inquiry that he recognised the inappropriateness of the way he spoke to D1527.³⁰ He described his approach to D1527 as trying to “shake him back to reality, get him back to reality, so he’s not focusing on what had happened and trying to get him – a response out of him”.³¹ Mr Francis told the Inquiry that the account Mr Tulley gave to Sussex Police was accurate and that he did not agree with Mr Paschali’s assertion that he was bracing D1527’s neck.³² Reflecting on why he did not report Mr Paschali’s actions, he could not explain other than to say “my only answer would be I was shocked, I was shocked and mortified what I’d just seen”.³³
73. Mr Fraser told the Inquiry that he did not see Mr Paschali put his hands on D1527’s neck and did not hear him use verbally abusive words towards D1527.³⁴ He explained that he mistakenly held D1527’s legs while facing with his head towards D1527’s feet (rather than facing towards his head as he had been trained to do).³⁵
74. Mr Francis and Mr Fraser told the Inquiry that they accepted that they had not completed Use of Force reports, but that this was not because Mr Paschali, or anyone else, had instructed them not to.³⁶
75. Ms Buss accepted that the pair of shoes seen on the footage walking around Mr Paschali were hers.³⁷ Despite this, she maintained that she was unaware of what was taking place.³⁸ Ms Buss told the Inquiry that she did not see Mr Paschali put his hands on D1527’s neck, did not hear any choking noise, did not hear Mr Paschali say, “I’m going to put you to fucking sleep”, did not hear D1527 repeatedly refer to his neck, and did not hear Mr Tulley saying to Mr Paschali, “Yan, Yan, easy”.³⁹ Ms Buss said that, had she witnessed any of these things, she would have stopped the restraint.³⁹

Relevant expert evidence

76. The Inquiry’s use of force expert, Mr Jonathan Collier, confirmed in a report to Sussex Police that the position of Mr Paschali’s knees alongside D1527’s head was as described and taught during use of force training. He described Mr Paschali’s hands, however, as being around D1527’s neck and his thumbs being driven into D1527’s “neck/throat area”.⁴⁰ Mr Collier considered whether Mr Paschali could have been misapplying an approved mandibular angle technique, but ultimately concluded that this is not evidenced by the footage.⁴¹
77. Mr Collier explained to the Inquiry:

“There is no guidance within the 2015 version of the training manual on how to either forcibly remove an object from the mouth, or how to prevent swallowing an object in the mouth.”⁴²

However, he said that all members of Brook House staff would have been shown a medical DVD in their use of force training, which states that pressure should not be put on the throat or neck area during a restraint.⁴³ Mr Collier explained that doing so “can result in serious injury and techniques of this type form no part of the restraint syllabus”.⁴⁴

78. Mr Collier was clear that, in the circumstances, he would have expected Mr Paschali to communicate with the other members of staff present, and with D1527 himself, to explain that he was placing pressure on D1527’s throat in order to prevent D1527 from swallowing a battery. Mr Paschali did not do this. Mr Collier said that such communication was “vital so that all parties understand what is happening and what needs to be done”.⁴⁵
79. Dr James Hard, the Inquiry’s medical expert, was critical of Ms Buss’s failure to intervene in this incident. He observed that, during the use of force, he would have expected a reasonably competent nurse to be:

• “observing the process of restraint/use of force for any signs of injury arising from any form of excessive control or restraint. This would include, but not be limited to, observing for any hold or application of pressure resulting in excessive pain or injury, i.e. that which went beyond what was necessary in order to obtain compliance from the detained person in submitting to the instructions being provided by the custodial officers”;
• “observing for anything that might indicate or suggest any form or signs of life-threatening injury, including but not limited to signs or symptoms of chest pain or airway compromise and be prepared to intervene accordingly”;
• “monitoring the heart rate and respiratory rate as a minimum and to have been making a record of the observations she had obtained. Given the level of distress of the detained person, it may have been too difficult to obtain peripheral oxygen saturation and blood pressure readings, but these should have been obtained as soon as practicably possible following the de-escalation of the incident. In the event that the nurse did not monitor the detained person as outlined then this would fall below the expected standard”; and
• in the event that inappropriate or unauthorised techniques were being utilised, “providing a verbal command to the member of staff to adjust, withdraw or stop the observed manoeuvre in order to make clear to that member of staff and any other witnesses to the event that the guidance was not being adhered to properly”.⁴⁶

80. Dr Hard also stated that, given the complexity of what was happening, Ms Buss’s duty as a nurse was to:

“get amongst it and see what was going on and to take the relevant actions and the relevant steps at the relevant points, rather than to be a passenger in the situation”.47

He agreed with Counsel to the Inquiry that Ms Buss had a duty to intervene in this incident, and that this should have been at the forefront of her mind when Mr Paschali said, “I’m going to put you to fucking sleep”; when Mr Tulley said, “Yan, Yan, easy”; and when Mr Paschali put his hands around D1527’s neck. Such interventions could, and should, have included stopping the restraint.⁴⁸

Conclusions

81. The footage of the second incident on 25 April 2017 is among the most disturbing I have seen during the Inquiry. D1527 appeared profoundly distressed for a long period but was most acutely so following the application of Mr Paschali’s hands around his neck. For the reasons set out below, I am sure that Mr Paschali applied pressure to D1527’s neck.
82. Mr Paschali’s account that he believed D1527 to be attempting to swallow a battery does not stand up to scrutiny. I am sure that Mr Paschali did not believe that D1527 had any item in his mouth at the time that he placed his hands around D1527’s neck. It was a dishonest invention by him in a vain attempt to excuse why he had done so.

82.1 While it is clear from the conversations between staff throughout the afternoon and early evening of 25 April 2017 that many of them were aware that D1527 had placed a battery into his mouth at some point that day, I do not think Mr Tulley, Mr Fraser or Mr Paschali believed that he still had a battery in his mouth as he attempted to manually self- strangulate. Mr Francis asked, “has he swallowed the battery?” after Mr Paschali had already released D1527’s neck, and Mr Francis told Sussex Police that, although he thought someone had mentioned a battery during this incident, he did not see it or know of its location. No one else present mentioned a battery until after Mr Paschali had released the pressure on D1527’s neck.

82.2 If Mr Paschali had genuinely been trying to brace D1527’s neck to prevent him from swallowing a foreign object, it makes little sense for him to have removed his hand unless the object was clearly no longer in D1527’s mouth. Mr Paschali accepted that he did not know when the battery came out of D1527’s mouth, and was unable to provide an explanation as to why he felt it safe to remove his left hand from D1527’s neck in response to D1527 calming down, if his intention had been to brace his neck to prevent him from swallowing a foreign object.²² This is illogical if he was genuinely bracing D1527’s neck to prevent him from swallowing something. Moreover, Mr Paschali did not tell D1527 not to swallow or instruct him to stop struggling. Nor did he communicate with the other officers about what he was doing. In a situation where there is a genuine belief that a detained person’s life is in imminent danger from choking on a foreign object, and there is no known technique to safely remove it, it is unfathomable that no conversation took place between staff about what they should do.

82.3 Mr Paschali provided no evidence to support his allegation that the footage of this incident had been edited, and I do not accept that there is any credibility to his claim.

83. I consider that D1527’s screaming after Mr Paschali took control of his head caused Mr Paschali to become angry with D1527 and to exert pressure on his neck. I am sure that the words Mr Paschali used – “You fucking piece of shit, because I’m going to put you to fucking sleep” – bore a particular connotation. In my opinion, Mr Paschali’s remark to D1527, given his extreme vulnerability at that moment, amounted to a deliberate threat to harm him. My impression is that Mr Paschali was seeking to punish D1527 for what Mr Paschali considered to be poor behaviour; indeed, he referred to him as “a piece of shit”. I do not accept that Mr Paschali released the pressure on D1527’s neck because he believed that the risk of him swallowing an object had subsided; he stopped because Mr Tulley exclaimed, “Yan, Yan, easy”. Moreover, I do not find Mr Paschali’s explanation of his conversation with Mr Tulley two weeks later, in which he described “choking” D1527, credible. There is no logic to fabricating a story about an event at which Mr Tulley was present. Rather, I am sure that Mr Paschali’s comments accurately conveyed his actions and words during the restraint of D1527 on 25 April 2017.
84. Mr Paschali’s actions towards D1527 on 25 April 2017 were the most extreme and disturbing example of mistreatment of any of the detained people at Brook House during the relevant period.
85. Even if I had accepted Mr Paschali’s explanation, placing hands onto the neck of a detained person cannot be considered an authorised technique in any circumstances. I note that Mr Collier states that there are no approved methods in the 2015 Use of Force Training Manual for the removal of objects from the mouth. In the circumstances, I agree with Mr Collier that Mr Paschali ought to have been communicating with both the staff and D1527.
86. As was the case with many of the other officers involved with D1527 that day, I consider that Mr Francis’s words demonstrate that he considered D1527 to be disruptive and difficult, and that he was frustrated with the additional pressure that the staff were under as a result. He viewed D1527’s actions through the lens of how they impacted on him and his colleagues, and had a disregard for D1527’s mental distress.
87. Given Mr Fraser’s position, I accept his account. He probably did not hear the words used by Mr Paschali or witness his hands around D1527’s neck. However, as discussed in my analysis of the incident on 4 May 2017 below, Mr Fraser clearly became aware of what had taken place soon afterwards.
88. Given her position in the cell at the time of the restraint, I do not find Ms Buss’s explanation that she was unaware of what was taking place credible. Based upon both the video and documentary evidence, I conclude that Ms Buss was in a position to see or hear the incident as set out above, and I consider it probable that she did witness this inappropriate conduct without challenging it or reporting it. She had a duty to do both. If, as she maintained when questioned by Counsel to the Inquiry, she could see “hardly anything”, she should have intervened to stop the restraint until she was in a position to observe and monitor D1527’s welfare.⁴⁹ I agree with Dr Hard that a reasonably competent nurse should observe the process of restraint or use of force for any signs of injury or danger to life arising from any form of excessive control or restraint.⁴⁶ Ms Buss clearly failed in that duty. I believe that her failures in this regard showed that she was desensitised to the needs of detained people, who were her patients, to an alarming degree.
89. Ms Buss’s entries in D1527’s various records did not accurately capture the reality of the event, the fact that D1527 was restrained or his distress. The medical response to D1527’s restraint on 25 April 2017 is discussed in Chapter D.8 in Volume II.
90. In relation to the missing Use of Force reports, Mr Paschali did not offer any plausible explanation as to why Mr Tulley would have removed his Use of Force report, or any evidence to support this allegation. I do not consider Mr Paschali’s account credible and, therefore, I am sure that Mr Paschali did not in fact complete a Use of Force report. That notwithstanding, I accept the evidence of Mr Francis and Mr Fraser that Mr Paschali did not tell them not to complete a Use of Force report in relation to this incident. There were widespread weaknesses in the governance of the use of force, discussed in Chapter D.7 in Volume II. I find it likely that, in that climate, Use of Force documentation was not taken sufficiently seriously and that it was not unusual for staff not to complete the documentation that was required.
91. It is concerning that D1527’s repeated and sustained attempts to self- harm that day did not prompt any of the Healthcare staff involved in his care to consider that there was an urgent need to refer D1527 to a GP for a Rule 35 report. The wing staff responding to D1527’s self-harm were seemingly left to manage these incidents as they arose, without any guidance or support from senior managers and with no input from clinical staff on how to safely manage the specific nature of D1527’s self-harm and the risks this presented. Mr Tulley’s recognition that “it would be nice if there was a manager” is all the more significant for the fact that none of the staff involved with the incident appeared to even consider that a manager would come to assist. I discuss the impact of the absence of management and support further in Chapter D.9 in Volume II.
92. I carefully considered D1527’s physical and mental health during the second incident on 25 April 2017 and whether it made him more vulnerable to mistreatment. He had just attempted to self-harm for the second time in a matter of hours and was extremely distressed. The experience of being restrained by staff and having pressure applied to his neck must have been terrifying. I am of the view that the words Mr Paschali used while his hands were around D1527’s neck were particularly menacing, and I accept D1527’s evidence that he feared for his life. Moreover, I find that the way Mr Francis spoke to D1527 was demeaning and, in the context of D1527’s highly vulnerable state, more than likely exacerbated his distress. I find that there is credible evidence that his treatment in this second incident was capable of amounting to inhuman and degrading treatment.
93. I carefully considered whether there is credible evidence that D1527’s treatment is capable of amounting to torture. Mr Paschali’s hands were around D1527’s neck for approximately two minutes and he was applying pressure for 14 seconds. This is likely to have caused D1527 intense physical and mental anguish. Given his vulnerabilities, this would have been highly traumatic. I took account of the exceptionally high threshold that mistreatment capable of amounting to torture would require. In my view, although this was an extremely serious incident, Mr Paschali’s placement of his hands around D1527’s neck and the application of pressure are not capable of meeting that threshold because they did not cause very serious and cruel suffering. This is because of their short duration and because of the lack of significant physical injury to D1527.

1. Day 2 AM 24 November 2021 00:53:55-01:23:53 (KENCOV1007 – V2017042500021)[↩]
2. It appears that staff had the ability to turn off power in a detained person’s cell (see Chapter C.8 and Callum Tulley 1 December 2021 54/7-56/3), although it is unclear whether they could turn off running water[↩]
3. SXP000120_005[↩]
4. SXP000120_006[↩]
5. Section 3 of the F213 form is used to record healthcare staff’s observations of a use of force incident from a clinical perspective, as well as any injuries to the detained person. It is usually attached to the Use of Force report[↩]
6. CJS005534_010-011[↩]
7. CJS001002_038[↩]
8. CJS001085_017. ‘Resp 16’ is shorthand for ‘respiratory rate 16’ (Dr Rachel Bingham 14 March 2022 17/4[↩]
9. DL0000144_021 para 53[↩]
10. DL0000144_019 para 42[↩]
11. DL0000144_019 para 43[↩][↩]
12. DL0000144_019 para 44[↩]
13. DL0000144_019 para 43; SXP000145_002[↩]
14. DL0000144_022 para 57[↩]
15. DL0000144_022 para 56[↩]
16. KENCOV1015 – V2017050900018[↩]
17. CPS000019_016; CJS001107_010 paras 6.24 and 6.25; IPA000002_003 para 15; Ioannis Paschali 24 February 2022 83/15-84/15[↩]
18. CJS001107_010 paras 6.24 and 6.25; IPA000002_003 para 15; Ioannis Paschali 24 February 2022 83/15-84/15[↩]
19. Ioannis Paschali 24 February 2022 113/7-114/5[↩]
20. Ioannis Paschali 24 February 2022 120/16-22[↩]
21. Ioannis Paschali 24 February 2022 117/5-6[↩]
22. Ioannis Paschali 24 February 2022 119/16-17[↩][↩]
23. Ioannis Paschali 24 February 2022 73/5-16; Ioannis Paschali 24 February 2022 113/18-114/1[↩]
24. Ioannis Paschali 24 February 2022 164/10-166/6[↩]
25. Ioannis Paschali 24 February 2022 117/6-118/4[↩]
26. Callum Tulley 9 March 2022 106/14-107/13[↩]
27. Ioannis Paschali 24 February 2022 148/3-16[↩]
28. Ioannis Paschali 24 February 2022 149/6-154/4[↩]
29. SXP000105[↩]
30. HOW000001_011 para 13bi[↩]
31. Charles Francis 3 March 2022 63/23-64/10[↩]
32. HOW000001_014 para 13ki[↩]
33. Charles Francis 3 March 2022 53/4-10[↩]
34. Clayton Fraser 28 February 2022 62/11-64/1[↩]
35. Clayton Fraser 28 February 2022 60/14-61/23[↩]
36. Charles Francis 3 March 2022 71/12-74/19; Clayton Fraser 28 February 2022 85/7-92/15[↩]
37. Joanne Buss 14 March 2022 137/17-138/3[↩]
38. Joanne Buss 14 March 2022 138/4-14[↩]
39. Joanne Buss 14 March 2022 132/16-137/11; Joanne Buss 14 March 2022 139/14-141/2; INN000025_013-014 at 00:08:23, 00:08:30 and 00:09:09[↩][↩]
40. SXP000133_003-004 para 11[↩]
41. SXP000133_004 para 12[↩]
42. INQ000158_029 para 10[↩]
43. SXP000133_003 para 9; INQ000111_018 para 41[↩]
44. INQ000111_020 para 52[↩]
45. INQ000158_030 para 10[↩]
46. INQ000075_058[↩][↩]
47. Dr James Hard 28 March 2022 123/1-7[↩]
48. Dr James Hard 28 March 2022 121/6-122/23[↩]
49. Joanne Buss 14 March 2022 135/17-23[↩]