The underlying facts

2. On 7 March 2017, Ms Daliah Dowd, a Registered Mental Health Nurse (RMN), completed a mental health assessment of D687 during which he disclosed that he had been a victim of childhood sexual abuse. D687 remained under the review of the mental health team at Brook House; however, his mental health appeared to deteriorate.¹ On 24 April 2017, D687 reported that he had considered suicide and had started writing a note.² On 5 May 2017, D687 threatened to take an overdose.³ He was placed on an Assessment Care in Detention and Teamwork (ACDT) plan, and was to be assessed hourly by a Detention Custody Manager (DCM).⁴
3. On 6 May 2017, observations of D687 were reduced to once every three hours during the day and once every two hours at night.⁵ On 8 May 2017, D687 disclosed that he had thoughts of harming himself but said that he would not act on those thoughts.8 He subsequently missed three scheduled follow-up appointments, two with the Brook House GP and one with an RMN.⁶ His observations were not increased.
4. The Inquiry saw footage covertly recorded by Detention Custody Officer (DCO) Callum Tulley on 13 May 2017.⁷ The footage begins with Mr Tulley approaching an accessible toilet in the Reception of Brook House. DCM Christopher Donnelly, DCM Shane Farrell and DCO Jonathan Martin were standing at the door to the toilet. D687 was inside the toilet and can be heard saying:

“I have had enough, I’m taking my own life, you lot can put me in a body bag and take me out of here, that’s the only way I’m leaving this toilet.”

5. Mr Tulley moved into the accessible toilet. D687 reacted strongly and shouted:

“what the fuck you doing, I swear to God I’ll kill myself … don’t come near me, I swear to God I’ll let myself go”.

He was sitting on the edge of the toilet with a ligature around his neck. The ligature was secured to the wall behind him at a point approximately one foot above his head. D687 was holding onto the ligature with his right hand and had an unlit cigarette in his left hand.

Figure 12: D687 in the accessible toilet with a ligature around his neck

6. For approximately 11 minutes, D687 told the staff that he no longer wanted to live and explained why. He said that he did not want to be transferred to another immigration centre (he was about to be moved to The Verne immigration removal centre in Dorset) and expressed frustration at the length of time he had been detained. He also complained that he had not had access to a doctor and that his mental health had deteriorated since he arrived at Brook House. He said that his identity had been taken away from him, that he had been moved away from his loved ones, and that he felt alienated. He repeated multiple times that he had had enough and explained to the officers where he wanted to be buried.
7. The footage shows that D687 was upset but coherent. He remained sitting on the toilet with the ligature around his neck while the officers engaged him in conversation and attempted to de-escalate the situation. D687 told the staff not to come near him and that, if they did, he would allow himself to drop onto the ligature. In response, Mr Donnelly said:

“Well, we’ll wait for a minute until you pass out and then we’ll cut you down.”

8. Approximately 11 minutes into the footage, Mr Daniel Haughton (the G4S Support Services Manager who was acting as Duty Director) can be heard speaking to D687. Approximately one minute later, Mr Haughton walked into the accessible toilet, where he offered D687 a light for his unlit cigarette. D687 stood, but kept hold of the ligature. Mr Haughton then made a sudden movement towards D687 and appeared to take hold of him. The other officers in the accessible toilet immediately joined in the restraint and, as Mr Tulley was involved in the struggle, it is not clear from the footage exactly what took place. Mr Haughton did not say anything to D687 or to his colleagues. After four seconds, an officer said, “ok, it’s off”, but this was shortly followed by another officer saying that “it” was in fact still around D687’s neck.
9. Thirty-four seconds after the restraint began, Mr Haughton said, “Right, the ligature is away.” Shortly afterwards, both D687 and the staff stopped moving. D687 calmly and repeatedly told staff to get off him, and that it was still his intention to die. He said “This ain’t over” and promised “I will be leaving here in a box.” At this time, the camera was angled towards the basin of the toilet and D687 and the other officers cannot be seen, as Mr Tulley was still involved in the restraint.
10. Approximately 90 seconds after force was first initiated, there was a sudden change to D687’s tone of voice. He said, with some urgency and in a raised tone, “Get off my fucking arm, bruv! Get off bruv. Look, I’m on the cuffs.” For a period of approximately 40 seconds, D687 repeatedly referred to his arm, asking one of the officers to stop resting on it and telling him, “you’re breaking my fucking arm”. D687’s tone changed from being calm and polite, saying “can you get off my arm please”, to making threats to bite and spit if the officer did not do so. There was no audible response. D687 also complained that his head was in the toilet.
11. After some movement, the camera reveals that D687 was restrained face down on the floor. Later, as Mr Tulley stands up, it becomes clear that he was restraining D687’s legs. D687 was then helped to his feet and led from the accessible toilet into an adjoining area within Reception. His hands were still handcuffed behind his back and Mr Haughton told him to sit down on a chair, which he did without physical resistance.
12. Once seated in Reception, D687 continued to voice his frustrations and also repeated his intention to take his own life.
13. An F213 form (a form completed by healthcare staff following the use of force, to record any injuries that have been sustained by the detained person) was completed by Ms Emily Parr, a Registered General Nurse. Ms Parr recorded:

“Minimal force used, refused to show hands/ arms, slight red mark to neck. No other physical health issues when seen.”⁸

14. Later that day, D687 was taken to Dorset County Hospital with a suspected rib fracture.⁹ In his witness statement to the Inquiry, D687 explained that he did not tell Ms Parr about his ribs, as the pain was not initially noticeable, but that he started to experience bad pain about one hour into his transfer to The Verne.¹⁰ D687’s medical records indicate that officers informed healthcare staff at The Verne that D687 had been diagnosed with bruised ribs when he returned there after being discharged from hospital.¹¹
15. Following the Panorama broadcast, D687 complained to the Home Office Professional Standards Unit (PSU) about the use of force against him on 13 May 2017.¹² He alleged that he was verbally abused, including being told to “Fuck off back to your own country”, and that, in response to his threats to hang himself, an officer told him, “Do it if you are going to do it.”¹³ D687 also said that he was physically abused during the restraint and that his arms were twisted, his legs pinned down, his neck grabbed and his face pushed into the ground. He also said that he had been kneed,¹⁴ and then later punched, in the ribs.¹⁵ D687 added that he told a nurse that his chest was hurting and that he could not breathe.¹⁶ The PSU carried out an investigation and determined that the restraint was reasonable, necessary, proportionate and used for the minimum amount of time.¹⁷ The PSU commented that it found D687’s account to lack credibility.¹⁸
16. In his written statement to the Inquiry, D687 said that he was told on 13 May 2017 that he was being transferred to another immigration centre. He was moved to Reception in preparation for the transfer and placed in an area with an adjacent accessible toilet. D687 described sitting alone for at least 30 minutes and thinking about the events in his life that had led to this situation.¹⁹ He said:

“I felt worthless and scared. I didn’t know anything about the centre where I was being taken except that it was far away. I had had enough of it all. I felt I’d been through too much.”²⁰

17. In his statement, D687 described entering the accessible toilet and believing that he had locked the door. He then used the T-shirt that he was wearing as a ligature, attaching one end to the support rail on the wall and placing the other end around his neck.²¹ D687 described saying prayers in preparation to hang himself but that, before he could do so, Mr Martin came into the toilet area. D687 recalled Mr Martin calling for other staff to assist. Mr Tulley arrived first and then left to locate other officers, with whom he returned.²²
18. D687 wrote in his statement that the officers made efforts to talk with him but that he felt “None of them got it.” He described some of the officers as calm but recalled Mr Donnelly’s comment that, if D687 dropped his weight onto the ligature, “Then we’ll wait for a minute until you pass out and then we’ll cut you down.” D687 said in his statement that this remark “added to my feeling of worthlessness”.²³
19. In his statement, D687 described his recollection of the use of force. He said that an officer who he now knew to be Mr Haughton offered him a light for his cigarette and then, as he got closer, “Lunged for my neck”. D687 stated that all the other officers then “instantly charged” at him.²⁴ He said that he felt unable to breathe while the ligature was being removed from his neck and that, even once the T-shirt had been removed, the weight of the officers upon him meant that he still felt unable to breathe.²⁵ He described the incident as “frightening”.²⁶ D687 said that he did not understand why the officers were still on top of him when he was calm and already handcuffed. He wrote that it appeared to him that the officers were “prolonging the incident, during which I was in pain and struggling to breathe” and recalled that he said, “Get off my fucking arm … look I’m on the cuffs.”²⁶ D687 added that it was at this point that he recalled “Someone putting what felt like all their body weight through my arm, which is behind my back.” He added:

“The pain was really intense and completely unnecessary. As I say, I had already been restrained and was in handcuffs. I think it was done just to cause me pain.”²⁷

20. Mr Haughton wrote in his Use of Force report that there had been concerns that D687 would be resistant to the transfer that was planned for 13 May 2017.²⁸ He described seeing D687 sitting on the toilet with a T-shirt tied loosely around his neck, with part of it attached to the handrail on the wall. He wrote that, if D687 had dropped his weight onto the ligature, the knot would have dropped to the lowest part of the rail and would not have applied pressure.²⁹ Mr Haughton did not explain in his report that he offered D687 a light for his cigarette in order to get closer to him. Mr Haughton described in his report how he had asked another officer, DCO Darren Bulled, for his fish knife (a knife with a protected blade that can be used to cut a ligature without any hazard to the operator or the person restrained) while out of D687’s sight in order to prepare to remove the T-shirt from D687’s neck. He said that he then tried to engage with D687 and asked if he wanted a light for his cigarette. When D687 said yes, he moved a little closer and, as D687’s “attention was on the lighter [I] grabbed the knot attached to the handrail. With this [D687] dropped to the floor and the knot attached to the handrail came away.” He added that he removed the ligature from around D687’s neck when the other officers restrained D687, without the need for the fish knife.²⁹
21. Mr Haughton said that his motivation to get closer to D687 was to remove the ligature from his neck and not to instigate force against him.³⁰ In his oral evidence, Mr Haughton accepted that, by not communicating his intentions to his colleagues, he placed them in a situation where they had to react spontaneously.³¹ Mr Haughton said he had intended to act in the “best interests of everyone there to sort of bring that to a quick and safe resolution”.³² He justified his actions to deceive D687, saying:

“The risk was still relatively low. It might not have strangled him. I couldn’t be 100 per cent sure. Hence why when I had the opportunity to secure it and remove that risk, I did. Who is to know what would have happened if he’d dropped. He could have banged his head on the toilet bowl and suffered a severe head injury. I don’t know.”³³

In his statement, Mr Haughton accepted that he could have taken a more strategic approach to managing the incident with D687. He conceded that, now he is more experienced, “I would probably deal with a similar situation differently, for example, through a planned intervention.”³⁴

22. In Mr Martin’s Use of Force report, he wrote that he discovered D687 sitting on the toilet with the ligature and a cigarette, and that he contacted the control room and asked for a manager and more staff to assist. He said that Mr Farrell and Mr Donnelly arrived and tried to reason with D687.³⁵
23. Mr Tulley recorded in his Use of Force report that Mr Donnelly had asked him to accompany him to Reception, where D687 had entered the toilet and attached a ligature. He said that Mr Martin and Mr Bulled were monitoring D687, who had the ligature around his neck and attached to a handrail.³⁶
24. In Mr Farrell’s Use of Force report, he wrote that he had taken control of D687’s right arm because Mr Tulley appeared to be struggling. He also ticked a box to indicate that he had used an inverted wrist hold technique against D687.³⁷ In an interview with the PSU, which conducted an investigation into D687’s complaint, Mr Farrell acknowledged that an inverted wrist hold affects people’s pain threshold at different levels but said that he did not apply any pressure. Mr Farrell also stated that D687 had not said that his wrist was hurting at any point.³⁸
25. In his oral evidence to the Inquiry, Mr Donnelly accepted that he should not have said “we’ll wait for a minute until you pass out and then we’ll cut you down”. He said that the intention behind his comment had been to point out to D687 the futility of him harming himself. Mr Donnelly added, “I was trying to persuade him to give up the ligature.”³⁹ In his oral evidence to the Inquiry, Mr Farrell said that he could not recall Mr Donnelly’s comment to D687 but that, if he had heard it, he would have challenged it.⁴⁰

1. CJS001139_007-009[↩]
2. CJS001139_009[↩]
3. CJS001139_010[↩]
4. CJS000993_006-007. Detention Services Order 01/2022: Assessment Care in Detention and Teamwork (ACDT) (INQ000214), Home Office, October 2022, provides mandatory operational guidance for implementing “a holistic approach to self harm and suicide prevention within the broader context of decency and safety”; see p5[↩]
5. CJS000993_012[↩]
6. CJS000993_013[↩]
7. KENCOV1016 – V2017051300011[↩]
8. CJS005652_028[↩]
9. DPG000014_061[↩]
10. DPG000021_075 para 213[↩]
11. (DPG000014_062[↩]
12. HOM002725_011 paras 6.1.17-6.1.32[↩]
13. HOM002725_012 para 6.1.21; HOM002725_013 para 6.1.24[↩]
14. HOM002725_011 para 6.1.20[↩]
15. HOM002725_011 para 6.1.26[↩]
16. HOM002725_011 para 6.1.21[↩]
17. HOM002725_045-046 paras 7.5.37-7.5.42[↩]
18. HOM002725_040 para 7.5.10; HOM002725_041 para 7.5.13[↩]
19. HOM002725_071-072 paras 202 and 203[↩]
20. DPG000021_071-072 para 203[↩]
21. DPG000021_072 para 204[↩]
22. DPG000021_072 paras 205 and 206[↩]
23. DPG000021_073 para 209[↩]
24. DPG000021_073-074 para 210[↩]
25. DPG000021_074 para 211a[↩]
26. DPG000021_074 para 211b[↩][↩]
27. DPG000021_074 para 211c[↩]
28. CJS005652_008[↩]
29. CJS005652_009[↩][↩]
30. Daniel Haughton 16 March 2022 109/4-111/11; SER000543_036 para 164[↩]
31. Daniel Haughton 16 March 2022 110/20-23[↩]
32. Daniel Haughton 16 March 2022 110/25-111/3[↩]
33. Daniel Haughton 16 March 2022 111/22-112/3[↩]
34. SER000453_037 para 166[↩]
35. CJS005652_020[↩]
36. CJS005652_012[↩]
37. CJS005652_025[↩]
38. HOM002725_022 para 6.4.17[↩]
39. Christopher Donnelly 23 February 2022 148/19-149/8[↩]
40. Shane Farrell 8 March 2022 105/11-23[↩]