Conclusions

32. It is clear from the covert footage of the incident that D687’s life was not imminently at risk and he was not posing a threat to the safety of the officers. Although D687 was upset, he was responding calmly to the staff, who were successfully engaging with him. As such, there was no justification for the use of force and the officers should have continued in their efforts to de-escalate the situation.
33. It is incumbent on every officer only to use force when it is necessary. It is clear from the position of the officers in the accessible toilet that they were not anticipating that force would be needed. However, in my opinion, once Mr Haughton had moved towards D687 and taken hold of the ligature, he had effectively instigated a use of force. The other officers did not therefore initially act unreasonably in how they responded.
34. Mr Haughton failed to assess the situation and to consider and exhaust all options available to him before using force against D687. The force was therefore unnecessary. In my opinion, as the senior manager in attendance, Mr Haughton should have ensured that Healthcare staff were present and that either Mr Donnelly or Mr Farrell had activated their body worn cameras, owing to the risk that force would be used. Mr Haughton’s use of the lighter to get close to D687 was underhand and deceptive, and I consider that it was likely to have had the effect of eroding trust between D687 and the staff. I agree with Mr Collier’s comment on this issue.
35. Mr Donnelly’s comment to D687 was completely inappropriate and demonstrated both a lack of professionalism and a disregard for D687’s distress. I consider it probable that Mr Farrell did hear what Mr Donnelly said to D687, and therefore he ought to have challenged it. The footage shows that Mr Donnelly made this comment within one minute of arriving at the scene with Mr Farrell and Mr Tulley. Even if Mr Farrell was not in the accessible toilet at the time, the acoustics at the start of the footage demonstrate that what is being said inside the toilet can clearly be heard by those outside.
36. There is no evidence that D687 was using his legs to resist the use of force. I agree with Mr Collier that Mr Tulley’s restraint of D687’s legs was therefore unnecessary and disproportionate.
37. Mr Farrell’s application of an inverted wrist hold was also unnecessary and disproportionate. It is clear from the audio of the covert footage that there was a sudden change in D687’s demeanour at the point when he felt pain in his arm. The effect of the wrist hold was to increase D687’s distress and prolong the need to restrain him. Before the application of the wrist hold, D687 was talking calmly and reiterating his intention to take his own life. After the wrist hold was applied, he began threatening to spit at and bite staff. Mr Farrell’s action therefore appeared to have the effect of escalating rather than de-escalating the situation.
38. With the exception of Mr Donnelly’s unacceptable comment to D687, the interactions between the officers and D687 while he was seated on the toilet were appropriate and professional, and appeared to be aimed at de-escalating the situation. I did not hear evidence of abusive language towards D687 before or during his restraint. However, I do not consider that the force used against D687 was necessary as a last resort. The use of the inverted wrist hold was disproportionate and had the effect of causing unnecessary pain to a detained person who was clearly in distress. The failure on the part of any manager to activate their body worn camera was unacceptable.
39. It is not clear from the footage whether force was applied to D687’s ribs or torso. D687 clearly alerted staff to the pain in his arm during the restraint but did not voice any complaint about other pain or discomfort at this time. However, in his witness statement D687 said that he was only aware of rib pain some time later, once his transfer to The Verne was under way.¹ His medical records indicate that he was diagnosed with bruising to his ribs following examination at Dorset County Hospital later that day.² In my view, it is likely that the injury to D687’s ribs resulted from the use of force against him at Brook House.
40. D687 disclosed thoughts of self-harm in the days preceding the incident on 13 May 2017. He missed three scheduled appointments with the mental health team between 5 May 2017 and 13 May 2017, and there were no apparent attempts to follow these up with D687, despite him being subject to an ACDT at the time.³ In my opinion, he was left more vulnerable as a result. I discuss the issue of missed mental health team appointments in Chapter D.8 in Volume II.
41. I considered D687’s likely state of mind at the time of the incident and the impact that these events would therefore have had on him. D687 was subject to an ACDT, was expressing his intention to take his own life and had taken steps to prepare to do so. In my view, he was therefore more vulnerable to mistreatment. I accept that Mr Donnelly’s comment added to his feelings of worthlessness and that he was frightened by the restraint. I consider that D687 probably felt humiliated both by his restraint and by the comment made by Mr Donnelly in these circumstances. I also accept D687’s evidence to the Inquiry that he experienced intense pain: a PIT was used, he could be heard complaining about pain to his arms and he was later diagnosed with bruised ribs. In my view, there is credible evidence that D687 was treated in a way that is capable of amounting to inhuman and degrading treatment.

1. DPG000021_075 para 213[↩]
2. DPG000014_062[↩]
3. CJS001139_010-012; CJS000993[↩]