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4 May: Conclusions

  1. Mr Dix was the DCM who responded to D1527 climbing onto the safety netting. He was responsible for directing staff and making decisions about how to manage and resolve the incident. I agree with Mr Collier’s assessment that Mr Dix’s control of the incident scene was “very poor”. The covertly recorded footage shows a loud, chaotic scene where multiple staff were present but appeared unsure of their roles. Several sought instructions from Mr Dix and could not understand why they were not told to lock down the wing. It is clear from the footage that the uncontrolled environment on the wing was preventing any productive efforts to de-escalate the situation and persuade D1527 to climb down. Detained people shouted to and at D1527, and one man sang loudly for several minutes.
  2. There is no evidence that an appropriate command structure was considered or implemented, as it should have been for such an incident.1 This may have assisted Mr Dix in taking control of the situation. For example, it would have enabled him to communicate with a senior manager about what resources were needed to bring the incident to a safe conclusion. In the event, Mr Dix did not call on the support or expertise of Ms Churcher, an RMN who was present at the time, and therefore missed an opportunity to de-escalate the incident sooner. Mr Dix’s inappropriate and insensitive reference to it being D1527’s “choice” to jump was unacceptable. As he was the manager in charge, this both displayed intolerance to D1527’s distress and also suggested to more junior staff that there was no safe strategy to manage the situation.
  3. It is plain from Rule 40 documentation that Mr Dix made the decision to make D1527 subject to Rule 40 as an automatic consequence of his behaviour (being on the netting).2 There is no explanation as to why this was in and of itself sufficient for D1527 to meet the criteria, which gives the impression that Rule 40 was being used as punishment. In any event, by the time that D1527 was moved to the CSU, he was off the netting and had returned to his cell. In the circumstances, Mr Dix ought to have reassessed the situation and come to a clear recorded decision as to whether it remained necessary in the interests of security or safety for D1527 to be made subject to Rule 40 and, if so, why.
  4. Mr Dix’s decision to carry out a full search of D1527 once they were on E Wing was not unreasonable because of D1527’s history of self-harm and the fact that he had said he intended to swallow his phone earlier that day.
  5. I consider that Mr Yates did not provide an adequate explanation in his Use of Force report as to why the use of a PIT on D1527 was justified. It is notable that none of the other officers involved in the use of force recorded that a PIT was used – even Mr Dix, whose role as supervising officer was to monitor any force used. I agree with Mr Collier that there is no evidence to warrant the use of this technique. The explanation as to why D1527 protested against Mr Yates in particular is not sufficiently explored in the Use of Force reports submitted by any of the staff involved, but it can be clearly seen from the CCTV footage that D1527 was expressing his frustration verbally only. Mr Yates’s use of a PIT was not reasonable or proportionate in the circumstances. I consider that the appropriate course of action was to replace Mr Yates in the restraint, which Mr Dix subsequently did.
  6. Mr Fraser’s comment that “what Yan did” was the best way to deal with D1527 was wholly inappropriate, and had the effect of suggesting that he condoned Mr Paschali’s actions. I cannot be sure about what Mr Fraser saw during the events on 25 April 2017. However, he had clearly become aware of Mr Paschali’s actions in the meantime. Mr Fraser’s comment was made to Mr Tulley and not in the presence of D1527 or any other detained people. However, his joking reference to what amounted to a terrifying ordeal for a highly vulnerable man was callous, unprofessional and demonstrated a lack of compassion towards D1527.
  7. Ms Okolie Nwokeji’s reference to D1527 as a “bitch” was disrespectful and unprofessional. While her comment was also made to Mr Tulley and not in front of D1527, there were other detained people in the vicinity. This casual use of derogatory terms to refer to someone in distress accords with the other evidence the Inquiry has seen and heard: abusive and dismissive language was routine and ingrained. I discuss this in more detail in Chapter D.9 in Volume II.
  8. Given Ms Churcher’s explanation that she remained on D Wing because she had a relationship with D1527, it is regrettable that she did not attempt to accompany the officers who went to speak with him once he had climbed down from the safety netting. Ms Churcher should have taken the opportunity to discuss the potential that D1527’s reaction indicated the need for a mental health assessment. Instead, she entered into a casual conversation with officers during which they mocked D1527’s behaviour as irrational. As a regulated and trained healthcare professional, her behaviour was particularly inappropriate.
  9. Mr Yates was the only staff member involved in this use of force to be interviewed by the PSU. The investigator chose not to invite Mr Dix to interview on the basis that his written reports were sufficiently detailed and video footage was available,3 but in my view this did not obviate the need to question him about his control of the incident while D1527 was on the netting. There is no evidence of whether the other staff involved were invited to interview and, if not, why not.
  10. Despite the evidence of D1527’s mental health issues and his significant self-harm history, D1527’s decision to climb onto the netting was dealt with as one of wilful disruption rather than a manifestation of mental illness. In its written Closing Statement to the Inquiry, G4S describes staff at the time as being “in a bind” in relation to where to locate D1527 following this incident.4 I accept that, by the time D1527 climbed down from the netting, staff were likely to have felt that they had limited options about where he could safely be located. However, the series of decisions by those in charge of managing the incident contributed to the lack of options. For example, D Wing ought to have been locked down and staff ought to have included Ms Churcher in meaningful negotiations with D1527 while he was still on the netting. Such actions may have had the effect of de-escalating the situation, offering staff the opportunity to determine the real cause of D1527’s actions and bring the incident to a prompt and peaceful conclusion. The failure to take such actions led to a situation in which there was no opportunity to calmly resolve the incident and ultimately ended with D1527 being forcibly moved to the CSU. In Chapter D.7 in Volume II, I discuss the issue of force being used too readily in response to incidents of self-harm, to manage the behaviour of those with mental health issues, and to move detained people to E Wing or the CSU. The response to D1527 during this incident is an example of such an issue.
  11. The failure to lock down the wing led to D1527 being taunted by other detained people. In addition, there was no strategy to persuade D1527 to leave the netting (such as involving mental health colleagues or initiating a command structure). The excess time he spent on the netting surrounded by other detained people was unacceptable. Taking account of D1527’s particular vulnerabilities, I consider that this incident would have been experienced by him as humiliating. The management of the incident on 4 May 2017 resulted in D1527 being exposed to a distressing and humiliating experience for longer than was necessary. In my view, there is credible evidence that these facts are capable of amounting to degrading treatment.


  1. Lee Hanford 15 March 2022 62/16-66/7; INQ000111_154 para 656. See also Detention Services Order 05/2015: Reporting and Communicating Incidents Out of Hours in the Immigration Detention Estate, Home Office, April 2016 (updated most recently in April 2021), para 16[]
  2. HOM000319_003[]
  3. CJS001107_008 para 5.14[]
  4. G4S Closing Statement 20 May 2022 para 393[]