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4 May: the underlying facts

  1. D1527 gave an account of the events that took place on D Wing on 4 May 2017 in his written statements to the Inquiry.1 He said that he had asked DCO Precious Okolie Nwokeji for a plate and that she had mistakenly thought he was asking for more food, had refused him and had been confrontational and aggressive.2 D1527 said that her reaction had made him angry and so he returned to his cell, threw his food into the bin and closed the door. D1527 said that an officer brought him a plate that he then broke and put into the bin.3 He then left his cell and was surrounded by officers, which made him anxious. He panicked and jumped onto the safety netting to escape. D1527 described holding a piece of the broken plate to his neck and telling Mr Tulley that if he came up the stairs towards him, he would jump from the netting.4 He described officers and nurses running to speak to him and that this had the effect of making him more stressed.5
  2. The Inquiry saw footage covertly recorded by Mr Tulley on 4 May 2017. The first piece of footage is approximately 12 minutes long and begins with Mr Tulley asking Ms Okolie Nwokeji what was causing all the noise on D Wing.6 A substantial amount of commotion and shouting can be heard in the background. Ms Okolie Nwokeji responded that D1527 was “[inaudible] like a bitch because he was told about a plate”. Mr Tulley then walked on to D Wing to where the second-floor railings met the safety netting. D1527 was distressed. He was on the netting, shouting and screaming in both Arabic and English, making gestures with his arms and intermittently running and pacing around the netting. The wing was noisy with both staff and detained people leaning on the railings surrounding the netting and shouting to D1527. As a result, much of what D1527 was saying is not decipherable, although he can be heard repeatedly shouting “Leave me alone” and “Nobody talk to me”. Some staff and detained people talked to D1527 and appeared to be trying to persuade him to come down from the safety netting, while other detained people can be heard laughing at D1527 and making jokes about the situation. There were a large number of people, both detained people and staff, present on the wing and no one appeared to know what to do.
  3. Approximately six minutes after he arrived on D Wing, Mr Tulley and other officers discussed whether the wing should be ‘locked down’ (meaning that the detained people would be locked into their cells). Mr Tulley asked the manager in attendance, DCM Steven Dix, whether this should happen. Mr Dix’s response cannot be heard on the footage but he did not appear to agree that the wing should be locked down. In response, an officer identified to the Inquiry only as ‘Sunil’ said to Mr Tulley, “ridiculous, we should be locking up”. Mr Tulley responded, “I know.” Mr Tulley and Sunil continued to stand where the second-floor railings met the safety netting and watched D1527. Other officers and detained people can be seen on the footage leaning on the railings of the second floor, also watching and shouting to D1527. D1527 continued to shout and pace around the netting.
  4. Approximately 10 minutes into the footage, Sunil commented to Mr Tulley that he had attempted to start locking up the wing but had been told not to. Sunil commented to Mr Tulley that the presence of other detained people was “Making it worse. Mr Tulley responded, “Yeah, I suppose.
  5. The Inquiry saw a further piece of footage, which is nine minutes long, beginning with D1527, Mr Tulley and Sunil in the same locations they were in at the end of the earlier footage.7 The wing was still extremely loud and a large number of detained people were milling around. There remained some confusion among the officers regarding whether or not they ought to have been locking the wing down. After approximately 4 minutes 25 seconds a detained person began loudly singing the lyrics of the song ‘I Believe I Can Fly’. This continued intermittently for four minutes.
  6. After approximately nine minutes, Mr Dix told Mr Tulley to go to C Wing. When Mr Tulley returned to D Wing, as shown in another piece of footage, it was quieter and all the detained people appeared to have been locked into their cells.8 D1527, however, was still standing on the netting, shouting and screaming in Arabic. While he could not be seen, he sounded as though his distress had increased as his shouting was louder and the speed at which he was speaking had significantly increased. Mr Tulley spoke to Mr Fraser, one of the officers who had been involved in the restraint of D1527 nine days earlier on 25 April. Mr Tulley asked, “What is the best way to deal with someone like this?” Mr Fraser laughed and said, “What Yan did.
  7. Mr Tulley then walked towards Mr Dix and other staff, who were leaning on the railings of the wing and discussing D1527, who was still on the safety netting in front of them. Next to the staff, two detained people were talking in Arabic to D1527, who was still shouting. Mr Tulley said to Mr Dix, “What if he jumps?”, to which Mr Dix replied, “It’s his own choice, isn’t it?”. Mr Dix told Mr Tulley to go with Sunil to Reception to assist DCM Shane Farrell, the manager based in that unit. Mr Farrell then arrived on D Wing and told Mr Tulley that he should remain there and assist with locking detained people in their cells. As Mr Tulley and Sunil discussed the confused directions that they had been given, a large group of staff were standing staring at D1527.
  8. After approximately four minutes, another group of staff, including Mr Dix, then walked down to the lower landing. Mr Dix addressed the group of staff and, although some of what he said was inaudible, he can be heard saying, “Rule 40 [of the Detention Centre Rules 2001], bring him down, let him know about the escorts.
  9. While the group of staff were standing with Mr Dix on the lower landing, D1527 left the safety netting. Several officers moved quickly up the stairs towards the second floor and can be heard discussing which officers were to act as a team. Mr Dix asked if someone could locate D1527’s ACDT record. A small number of officers were outside a cell on the second-floor landing. Ms Churcher had arrived on D Wing and she asked Mr Tulley, “Is he okay? Do we know?” and laughed. Mr Tulley replied, “I don’t know. Your guess is as good as mine.” Sunil, Mr Tulley and Ms Churcher talked with another member of staff about the event that led to D1527 climbing onto the netting. Ms Churcher said, “If he didn’t have to do the washing up, he didn’t have to go that far, did he?” Sunil told the other staff that D1527 had wanted a clean plate and Ms Churcher asked incredulously, “Is that what this has been about?
  10. Mr Tulley called up to DCO Ryan Bromley, one of the officers on the second-floor landing, and asked what was happening. Mr Bromley replied that D1527’s ACDT observations were being increased to ‘constant’. The footage ends with Mr Tulley leaving D Wing.
  11. The Inquiry also saw footage of two conversations about D1527, both of which were covertly recorded by Mr Tulley on that same day, 4 May 2017.9 These conversations included Mr Sanders telling other officers that he had assaulted D1527, and Mr Stokes saying that the best way to deal with D1527 was to “turn away and hopefully he’s swinging”. These conversations, and the related findings, are discussed at the beginning of this chapter.
  12. The closed-circuit television (CCTV) footage does not cover the restraint itself, as this took place within the cell.10 It does show Mr Dix, Mr Bromley, DCO Mohammed Shaukat and DCM Michael Yates assembled outside the cell that D1527 was in. Mr Dix and Mr Yates entered the cell first, and the other officers waited outside. They were then joined by DCO Ben Wright and one other officer. Some 8 minutes 30 seconds later, Mr Bromley, Mr Wright and Mr Shaukat entered the cell. Healthcare arrived two minutes later, and the officers left the cell with D1527 walking in handcuffs and held by Mr Bromley and Mr Yates. Mr Dix was walking alongside the group.
  13. The footage then shows the officers walking D1527 through the corridors to the stairs. D1527 walked compliantly with the officers, but appeared to be agitated. At the top of the stairs, D1527 appeared to focus his frustration on Mr Yates. Mr Dix appeared to try to engage with D1527 for roughly 1 minute 40 seconds. However, when this did not work, Mr Dix replaced Mr Yates on D1527’s right arm. D1527 then moved compliantly down the stairs with the officers. When the group arrived in E Wing, D1527 appeared calmer and waited patiently with Mr Dix and Mr Bromley for an officer to open a cell.
  14. A Use of Force report was completed by four officers, who reported attending the cell where D1527 went after he had climbed down from the safety netting.11 These officers were Mr Dix, Mr Bromley, Mr Shaukat and Mr Yates.
  15. In his Use of Force report, Mr Dix wrote that he had explained to D1527 that he could not leave him alone due to his behaviour. Mr Dix said that D1527 had refused to comply with his instructions (ie to accompany staff to E Wing) and became irate. Mr Dix said that D1527 had started to fiddle with his pockets, refusing to empty them out or remove his hands. Mr Dix wrote that, knowing D1527 had a significant history of self-harm, he feared that he might have something in his possession that could be used to harm himself or others. Force was therefore initiated to prevent this and to relocate D1527 to E Wing. Mr Dix said that he took hold of D1527’s right arm and then handed over this role to Mr Yates before placing handcuffs on D1527. He added that he took over from Mr Yates as they were leading D1527 down the stairs because “D1527 has an issue with DCM M Yates”.12
  16. Mr Yates recorded that Mr Dix had explained to D1527 that he would need to go to E Wing while there was an investigation into him having climbed onto the safety netting. Mr Yates wrote that D1527 refused and reached into his right pocket. In response to the instruction to remove his hands, Mr Yates recorded that D1527 said, “You’ll see what’s in my pocket”, and then stood up with his hands clenched. Mr Yates wrote that he took control of D1527’s right arm during the restraint. He wrote that D1527’s “level of aggression escalated” as the officers tried to lead him from the cell and that, as they were about to leave D Wing, D1527 began struggling. Mr Yates wrote that he applied a thumb flexion (a pain-inducing technique or PIT) to D1527 and that once they reached the top of the stairs Mr Dix took over his role in the restraint. Mr Yates did not describe what procedure he followed, if any, prior to using the PIT.13
  17. Mr Bromley wrote that he and Mr Shaukat waited outside the cell while Mr Dix and Mr Yates went inside to talk to D1527. He said that he went into the cell in response to hearing D1527 shouting aggressively, and saw that D1527 was reaching for his right pocket while attempting to swallow his phone. Mr Bromley recorded that he took hold of D1527’s left arm during the restraint.14
  18. Mr Shaukat also recorded that he and Mr Bromley were waiting outside the cell and went inside in response to D1527’s loud and aggressive tone towards Mr Dix. Mr Shaukat wrote that D1527 was uncooperative and described him standing up with both fists closed. He also wrote that D1527 tried to reach for something in his right pocket while attempting to swallow his phone. He wrote that he took control of D1527’s head during the restraint.15
  19. In his witness statement to the Inquiry, D1527 said that several officers came into the cell. He said that Mr Dix and Mr Yates came in first and that they were then joined by Mr Bromley, Mr Shaukat and Mr Wright. D1527 said that the officers told him that he had to go to E Wing, but he did not want to go. He said that there was no attempt to negotiate with him.16 D1527 said that he believed he may have threatened to swallow his phone but that at no time did he put his hands into his pockets.17 At the time he provided his statement as part of judicial review proceedings, D1527 said that he put the back cover of his phone into his mouth, and the officers forcibly removed it.18 D1527 said that Mr Bromley was the first to use force against him and that Mr Shaukat grabbed his neck.19 He added that Mr Yates had been aggressive and had twisted his arm back, which he believed was a deliberate attempt to hurt him.20 D1527 also stated that Mr Wright was present throughout the restraint.21 D1527 said that the officers dragged him from his cell to E Wing.22
  20. Mr Dix recorded the following reasons for removing D1527 from association on the Rule 40 documentation:

“[D1527] has been relocated to CSU on rule 40 after jumping on Delta [D] wing netting. [D1527] removed himself after approximately 30 minutes, he went to a friend’s room to calm down. I spoke to [D1527] about his behaviour and the consequences of his actions. He refused to comply with the instructions given. [D1527] was already on an ACDT and has a previous significant history of self-harm and suicide attempts, he started to get irate and started to fiddle with his pockets and refused to empty out his pockets or remove his hands. Fearing he potentially had something he could harm himself with or others, force was used to prevent this and relocate him to Eden wing. He was placed onto E008 and watched constantly for a couple of hours after the use of force, A [sic] full search was also conducted and nothing was found.”23

  1. In her evidence to the Inquiry, Ms Churcher said that she could not recall whether she had been called to attend D Wing because D1527 had jumped onto the safety netting, or whether she was already there for another reason.24 She said that she decided to stay on D Wing after D1527 had come down from the netting because she had a relationship with him.25 She told the Inquiry that she could not remember any conversations with Mr Dix about making D1527 subject to Rule 40 (removal from association) and did not believe that she had been involved in the decision to do so.26 In her written statement to the Inquiry, Ms Churcher said that it did not take much to upset D1527.27 Under questioning from Counsel to the Inquiry, she accepted that D1527’s apparently disproportionate reactions should have been taken seriously as they were a potential sign of increasing vulnerability.28
  2. In his evidence to the Inquiry, Mr Fraser said that he regretted the words he had used and the fact that he had laughed when saying them.29 He told the Inquiry that, by 4 May 2017, it was “common gossip” among officers that Mr Paschali had “restrained the guy, the gentleman, by his neck”.30 Mr Fraser maintained that he learned this from other officers and had not witnessed Mr Paschali’s actions at the time.31
  3. Following the Panorama broadcast, the PSU carried out an investigation into the circumstances of the incident on 4 May 2017.32 D1527 said that he was assaulted by six officers who came to his cell on 4 May 2017.33 He also complained that Rule 40 was inappropriately used to manage his mental illness and to punish him for his disturbed behaviour.34 The PSU found neither of these complaints to be proven.35


  1. DL0000144_025-029 paras 68-80; DL0000209_033-058 lines 47-49[]
  2. DL0000144_025-026 paras 69-70[]
  3. DL0000144_026 para 70[]
  4. DL0000144_026 para 71[]
  5. DL0000144_026 para 72[]
  6. Day 2 AM 24 November 2021 3:01:52-3:24:08 (KENCOV1012 – V201705040021 17:45 -V201705040022 09:08)[]
  7. KENCOV1012 – V201705040022 clip 1[]
  8. KENCOV1012 – V201705040022 clip 2[]
  9. KENCOV1012 – V2017050400026; KENCOV1012 – V2017050400028[]
  10. Disk 41 05 May 2017 1727 (this footage is out of sequence due to a technical issue, and shows D1527 being moved from the stairs to E Wing first, and then leaving his cell with the officers much later[]
  11. CJS005530[]
  12. CJS005530_008[]
  13. CJS005530_018[]
  14. CJS005530_014[]
  15. CJS005530_011[]
  16. DL0000144_027 para 75[]
  17. DL0000144_027 para 75; DL0000144_028 para 78[]
  18. HOM032221_013 para 48[]
  19. DL0000144_027-028 paras 76-77; DL0000144_028 para 79[]
  20. DL0000144_027 para 76[]
  21. DL0000144_028 para 77[]
  22. DL0000144_027 para 77[]
  23. CJS001026_007. A ‘full search’ is a search of an individual that requires the removal and inspection of all clothing and footwear. The search must be conducted by two officers of the same sex as the individual, and the individual must not be completely naked at any stage or in the view of others not involved in conducting the search. See CJS000713_004 para 7[]
  24. Karen Churcher 1 March 2022 32/4-9; DWF000022_018 para 83[]
  25. DWF000022_018 para 83[]
  26. DWF000022_018 paras 84-86[]
  27. DWF000022_018-019 para 91[]
  28. Karen Churcher 1 March 2022 31/9-25[]
  29. Clayton Fraser 28 February 2022 99/2-19; Clayton Fraser 28 February 2022 101/1-9[]
  30. Clayton Fraser 28 February 2022 100/4-6; Clayton Fraser 28 February 2022 102/11-103/1[]
  31. Clayton Fraser 28 February 2022 100/11-20[]
  32. CJS001107[]
  33. CJS001107_008-009 paras 6.1 and 6.13[]
  34. CJS001107_008 paras 6.1 and 6.8[]
  35. CJS001107_030 para 7.90; CJS001107_035 para 7.126[]