The underlying facts

2. D1914 suffered from ischaemic heart disease, which was recorded in his medical notes on his admission to Brook House.¹ D1914 did not report any significant mental health issues prior to 27 May 2017, but he was reported to have a history of self-harm and to have been aggressive towards medical staff on eight occasions.² On 6 May 2017, D1914 complained to Ms Emily Parr, a Registered General Nurse, that he was experiencing regular chest pain, and on 15 May 2017 he reported that his symptoms also included chest tightness.³ In his witness statement to the Inquiry, D1914 explained that the exacerbation of these symptoms caused him to fear that he would have a heart attack.⁴ D1914’s medical history provides important background to what occurred on 27 May 2017.
3. On 27 May 2017, Dr Husein Oozeerally, lead GP at Brook House during the relevant period and at the time of the Inquiry’s public hearings, wrote to G4S and the Home Office:

“The above detainee [D1914] is fit to fly and fit for detention. He will need a medical escort due to the nature of his medical condition. I am happy for reasonable force to be used (C and R) in order to facilitate the removal.”⁵

4. Detention Custody Manager (DCM) Steven Dix told the Inquiry that he spoke to D1914 on 27 May 2017 regarding his removal directions for a flight the following day.⁶ DCM Nick London authorised D1914’s move to E Wing under Rule 40 of the Detention Centre Rules 2001 (removal of association). Mr London recorded that the justification for the move was “to maintain good order and discipline of the centre” and that D1914 was “refusing to relocate to Eden Wing”.⁷ However, an IS.91RA Part C form submitted the same day records that D1914 “stated that he would kill himself rather than return to Romania, because of this threat he has now been placed onto ACDT [Assessment Care in Detention and Teamwork] constant supervision and is now on Rule 40”.⁸
5. The Inquiry heard and saw evidence of a number of conversations between staff about the planned use of force on D1914 that day. Footage covertly recorded by Detention Custody Officer (DCO) Callum Tulley shows him talking to DCO David Webb and DCO Ioannis (Yan) Paschali in a staff room with a film playing in the background.⁹ Mr Tulley asked Mr Webb to show him how to use the shield. Mr Webb stood up and held a shield at an angle of approximately 45 degrees away from himself. He told Mr Tulley to “Hit with the edge, anywhere between the knee and the throat”, and then added, “just keep fucking going. Keep going until you can’t go any further.”
6. A further clip appears to follow on shortly after this conversation, as Mr Tulley, Mr Webb and Mr Paschali were still in the staff room, Mr Tulley was in the same position and the same film was playing in the background.⁹ The footage starts with DCM Stephen Loughton reading the letter from Dr Oozeerally to the Home Office. Mr Loughton informed the officers that D1914 had had a “bypass. Triple bypass, heart attack, triple bypass booking in for August” and told them to meet in the staff room in Personal Protective Equipment (PPE) at 19:00. Mr Loughton then left the room and Mr Tulley, Mr Webb and Mr Paschali continued the conversation. The Inquiry obtained a transcript of this conversation:

“Callum Tulley: Now you’ve got me nervous for slightly different reasons now.

Yan Paschali: Oh, relax man. you will be fine.

Unknown Male Speaker: If he dies, he dies.

Yan Paschali: Yeah, exactly.

Unknown Male Speaker: It’s nothing on us.

Dave Webb: At the end of the day [inaudible] rolling his fucking head

[inaudible] with the shield, so I wouldn’t worry about it.

Yan Paschali: I was here all night [inaudible], mate. Just leave it. Yan Paschali: I was just here all night. [inaudible].

Dave Webb: Just don’t choke him out, without it will be fine. Unknown Male Speaker: Or punch him in the chest.

Dave Webb: Yeah, yeah.

Yan Paschali: He’s stupid like that. Which we’ve seen. Unknown Male Speaker: Leaning knee on his chest, I might. Dave Webb: Walk over his back.”¹⁰

7. Later that day Mr Tulley spoke to DCO Daniel Lake in the library; this conversation was also caught on camera.¹¹ Mr Lake used the computer there to access information about D1914 and read his prior convictions to Mr Tulley. Mr Lake told Mr Tulley that D1914 was a “nutter”. The two officers discussed D1914’s medical history, including the fact that he was scheduled to undergo heart bypass surgery. Mr Lake referred to the fact that a doctor had said the officers could use force on D1914, despite his medical issues, and speculated that D1914 might fake having a heart attack. The conversation ended with Mr Lake laughing and saying, “If he dies, he dies.” Under questioning by Counsel to the Inquiry, Mr Lake stated that he believed people detained in Brook House might fake health problems to postpone their removal.¹² He said that he could not remember saying “If he dies, he dies” but that, if he had said it, it would have been because of “the culture at Brook House”.¹³
8. A fourth clip of footage, again filmed later that day, shows a conversation between Mr Tulley and Mr Webb regarding the planned use of force against D1914. Mr Tulley asked “What if he dies?” and Mr Webb responded, “No, we’ve got that disclaimer.” He told Mr Tulley that he would get copies of the document so that “You’ve actually got a fucking copy of the doctor’s letter.”¹⁴
9. The final clip of footage shows Mr Tulley, Mr Paschali, Mr Webb and DCO Alice Brown in a staff room putting on their PPE.¹⁵ Approximately 7 minutes 35 seconds into the footage, Mr Tulley’s covert camera was covered as he put on his overalls, but the conversations in the room could still be heard. Approximately 40 seconds later, Mr Webb said that D1914 had obtained “a shit load of spice” and was intending to smoke it. Mr Webb said that he thought this was the reason why D1914 would be subjected to a full search.¹⁶ In a later conversation, approximately 15 minutes into the footage, Mr Webb joked with the other officers that D1914 might have or pretend to have a heart attack. Mr Webb referred to D1914 as a “cunt”.
10. The Inquiry saw a recording of the briefing provided by Mr Dix to the officers who were going to restrain D1914, and a recording of the conversation immediately before the briefing as captured by Mr Tulley.¹⁷ As can be seen from Mr Tulley’s covert footage, the briefing was formally recorded on a handheld camera by DCM Nathan Ring, who had been designated as the officer responsible for recording the use of force.
11. In the conversation prior to the briefing, Mr Dix explained to Mr Tulley that, as soon as the door of the cell was opened, Mr Tulley was to enter and stand right in front of D1914 with the shield in order to stop D1914 “doing anything [to himself]”. Mr Tulley sought clarification as to whether or not he was expected to use the shield and Mr Dix confirmed, “Anything you feel or anything Yan feels or anything like that, and I miss it, then you just deal with it as normal.” Mr Dix then said, “At the end of the day you lot have got to justify it.”
12. In the briefing that followed, Mr Dix told the officers that D1914 had removal directions for the following day. Mr Dix added:

“He is refusing to go on this flight and is refusing to relocate to Eden Wing. The estimated pickup time is 09:00 and this is during the core regime time hence why the move needs to be done before.”

Mr Dix told the officers, “Despite negotiations by myself and DCO Sean Sayers it has not been possible to resolve the situation peacefully.” He informed them that D1914’s cell mate had reported that D1914 “had bought some spice and he was planning to smoke it so he ends up dying or ends up in hospital to stop his removal directions”. This was said to be another reason why the move to E Wing could not wait.¹⁸

13. The Inquiry saw the handheld camera footage of the use of force, which lasted for just over 18 minutes and was recorded by Mr Ring.¹⁹ The footage begins with the officers standing outside D1914’s cell in full PPE. Mr Tulley entered D1914’s cell and instructed him not to move. Mr Webb, DCO Sean Sayers, DCO Ryan Bromley, DCO Jonathan Edon, Mr Lake, Mr Dix and another unidentified manager followed closely behind. D1914’s cell mate, who was sitting on the bed at the left-hand side of the cell, stood up and walked out of the cell with Mr Bromley, Mr Edon, Mr Lake and Mr Sayers. D1914 was lying on the bed at the right-hand side of the cell and was naked from the waist up. Mr Dix remarked that D1914 was holding his chest and asked that a member of Healthcare staff check him. D1914 was quiet and Mr Paschali asked him to walk to E Wing, which he verbally refused to do. Mr Paschali and Mr Webb helped D1914 to a seated position. Mr Webb held D1914’s hand while Mr Paschali held his forearm, and D1914 was bent forwards, audibly breathing heavily. Medical observations were carried out by two members of Healthcare staff, who discussed D1914’s oxygen saturation and blood pressure. While the observations were made, D1914 leaned towards Mr Paschali and rested his head on his arm. He then sat up and explained to the staff around him that he did not want to fly back to his country, that he had “bail next week” and that his family were in the UK. He also informed the staff that he had suffered three heart attacks and mentioned an operation. Mr Paschali told D1914 that he was just being moved to E Wing and reassured him that he was not being placed on a flight. D1914 said that he did not want to go. The atmosphere appeared calm and neither D1914 nor any staff were speaking in raised voices.

Figure 13: D1914 sitting on his bed being held by Mr Paschali and Mr Webb, and attended to by Healthcare

14. After approximately 5 minutes 15 seconds, Mr Dix asked the Healthcare staff, “Happy?”, to which Mr Eddie Omoraka (a Registered Mental Health Nurse) replied, “Yeah.” Mr Dix then said, “Okay. So, [D1914], you’re going to go to E Wing.” D1914 replied that he did not want to go and Mr Dix asked him twice more to walk compliantly, with the warning that the officers would “assist” him if he refused. On both occasions, D1914 responded, “No.” Mr Dix then gave the other officers an instruction to use force. There were 14 seconds between Mr Omoraka saying that he was happy with D1914’s medical observations and Mr Dix authorising the use of force.
15. Mr Webb and Mr Paschali moved D1914 from the bed and he immediately sank to the floor. Multiple officers told him to stand up. Mr Dix continued to ask D1914 to stand and walk, and he appeared to get partially to his feet with the assistance of the officers, but then to sink back to the floor. As he did so, Mr Tulley took control of his head. D1914 shouted “help me” and “I am no criminal, why you do this?”. He told the officers, “if I die you are responsible”. D1914 remained on the floor and Mr Dix told him that if he did not stand up and walk he would be placed in handcuffs and carried, which would cause him pain. D1914 asked to call his wife, which Mr Dix confirmed he could do once he was on E Wing.
16. D1914 tried to stand up a second time, with the support of the officers, but then appeared to sink back to the ground. Mr Dix gave D1914 one last chance to stand up, and said that he would be placed in handcuffs and lifted if he did not. D1914 asked why he was being restrained and said that he had had three heart attacks. He spoke with a raised voice, and was audibly upset. Mr Dix said “I’m not discussing it with you now” and asked D1914 twice more if he would stand and walk. D1914 again asked why he was being moved, and so Mr Dix instructed the other officers to “put his hands behind his back”.
17. At that time, D1914 was seated on the floor of his cell with his right leg tucked underneath him and his left leg stretched out to the side. In order to move D1914’s hands behind his back, Mr Paschali and Mr Webb pushed D1914 forwards on top of his right leg so that his head and neck were parallel to the ground. Mr Tulley maintained control of D1914’s head. D1914 remained in this position for a total of 1 minute 35 seconds. D1914 cried out in apparent pain, and could be heard breathing deeply and saying, “Please, I have died. I am tired.” After one minute in this position D1914 said, “please I’m good, I finish, sorry”. He could be heard panting. Neither the officers nor the Healthcare staff raised any concerns regarding D1914 being held in this position.

Figure 14: Officers restraining D1914 on the floor as handcuffs are applied behind his back

18. When the handcuffs had been applied to D1914, he was allowed to sit back up and the head restraint was removed. D1914 could be heard panting heavily, and was still positioned with his chest leaning forwards over his right leg.

Figure 15: Officers restraining D1914 on the floor following the application of handcuffs

19. Mr Dix again asked D1914 if he would stand up and walk, to which D1914 replied, “It’s not possible to walk”, still panting heavily. Mr Dix responded, “Well it is. So the officers are going to assist you.” Mr Webb then suggested the possibility of using an evacuation chair. Mr Dix asked D1914 if he would sit in a chair, but D1914 did not respond and remained leaning forwards and panting heavily. Mr Dix therefore instructed the officers to help D1914 onto the bed, which they did.
20. D1914 sat down on the edge of the bed, with his hands handcuffed behind his back. A voice could then be heard saying “Dixie, Dixie”, and Mr Dix moved to speak to someone behind Mr Ring (the camera operator), who said, “he can’t sit down, get him up”. Mr Dix responded “okay” and instructed D1914 to stand up and walk with the officers. He said that in order for the handcuffs to be removed and for D1914 to be able to sit in the evacuation chair, D1914 had to become compliant. Mr Webb said “We gotta get him moving because he’s in cuffs” and the person behind Mr Ring again tried to get Mr Dix’s attention. In total, D1914 was sitting on the bed while handcuffed for 30 seconds.
21. D1914 got to his feet with Mr Webb holding his right arm and Mr Paschali holding his left. While this was happening, the person behind Mr Ring told Mr Dix again that D1914 “has got to stay on his feet the whole time”, to which Mr Dix responded, “it’s a bit hard [inaudible]”. D1914 asked for his shoes and told the officers that he was “not feeling good”. Mr Dix responded, “Healthcare are here so the quicker we get going, the quicker we can release you.” Mr Dix then left the cell and D1914 followed, supported by Mr Webb and Mr Paschali.
22. As D1914 walked slowly and without physical resistance along the wing, he stated, “Big complain. If I die today night, all people is responsible for this.” As D1914 exited C Wing, with Mr Webb and Mr Paschali still holding his arms, he said to Mr Omoraka:

“You are a Black shit man, fuck your mother … you are responsible for me, you take my blood pressure. Today night, if I die, that’s a big problem.”

23. D1914 was walked into a cell on E Wing and told by Mr Dix that a full search was going to be carried out. Mr Dix asked D1914 if he would comply and remove his clothes himself. D1914 initially appeared not to understand what was being asked of him, but then said, “Yeah, no problem.” The cuffs were removed from D1914. Mr Ring then appeared to leave the cell, taking the camera with him. D1914’s full search is not shown on the footage.
24. Once the full search had been completed, the camera refocused on D1914. He was sitting on the bed in a cell in a pair of boxer shorts. Mr Ring asked Mr Dix if D1914 wanted to put any more clothes on, but Mr Dix confirmed that he did not. D1914 asked to see Healthcare and Mr Omoraka entered the cell. D1914 asked Mr Omoraka “why [inaudible] happen, I had three heart attacks” and showed him the scars on his arms and on his chest. D1914 said, “look what they do to people, look, this is good?”. Mr Dix then asked Mr Omoraka, “happy?”, and Mr Omoraka left the cell. The footage ends with Mr Dix agreeing to bring D1914 cigarettes, a phone and a coffee.
25. The Inquiry saw footage of the use of force debrief, led by Mr Dix.²⁰ The debrief took less than two minutes and consisted of Mr Dix briefly describing the incident and stating that D1914 had been made subject to Rule 40 due to “non-compliance and for not doing his removal directions”. Mr Dix asked staff to confirm their names, ranks and whether they had any injuries. He additionally asked the Healthcare staff if they had any concerns. Mr Omoraka said that he had no concerns. Before ending the debrief, Mr Dix asked whether anyone had anything to add, and the officers confirmed that they did not.
26. D1914 told the Inquiry in his written statement that this incident was “One of the most disturbing and distressing events during my time in Brook House”.²¹ He wrote that officers did not negotiate extensively with him prior to the planned use of force. Rather, he said, they asked him to go to E Wing and he said that he did not want to.²² D1914 said that the footage showed that officers were “pumped” and prepared to hit him with a shield if necessary.²³ He said that the comments officers made about him were disgusting and that they saw him as sub-human.²⁴ D1914 told the Inquiry that the officers did not care if they killed him because they had the protection of Dr Oozeerally’s letter.²³ D1914 wrote that the letter confirmed that Healthcare staff did not care about him.²⁵ D1914 said that he suffered sharp chest pains when the staff entered the cell to remove him; he was scared that his heart condition would worsen.²⁶ D1914 said in his statement that he did not feel safe to stand up and felt unable to do so.²⁷ He said that he could not breathe properly and that, when officers grabbed his arms, he fell to the ground in shock.²⁸ Regarding the use of force, D1914 wrote that he felt the officers might break his arms with their restraint, and that he had bruises on his wrists as a result of the handcuffs.²⁹ In his account of the full search, D1914 said it was humiliating and that the officers treated him like an animal.³⁰ D1914 said that it was not necessary to isolate him and that this had left him feeling like he had no value.³¹
27. Mr Webb told the Inquiry in his oral evidence that his ability to hear D1914’s heavy breathing might have been affected by the helmet he was wearing. When asked by Counsel to the Inquiry about the heavy breathing heard on the footage, he said, “I might not necessarily hear all that you’re hearing, breathing or not, because you’ve got a helmet on.”³²
28. Under questioning from Counsel to the Inquiry, Mr Webb accepted that his description of how to use a shield was wrong.³³
29. Both Mr Webb and Mr Lake suggested in their oral evidence that they relied on Healthcare to tell them whether a detained person was fit to have force used against them. Mr Webb said, “So medicals, if they say he’s okay, he’s okay. If not, we stop”,³⁴ and Mr Lake said, “if I was told it was okay and the doctors have said it’s okay, then it’s okay”.³⁵
30. Dr Rachel Bingham, a clinical advisor to Medical Justice (a charity that provides medico-legal reports and advice to detained people), expressed concern that GPs appeared to overstep their remit in the sanctioning of force and, in turn, failed to identify and raise clinical concerns when necessary, with reference to D1914 in particular.³⁶
31. Under questioning by Counsel to the Inquiry, Dr Oozeerally accepted that it would never be in the interests of a patient to have force used against them, except in the very limited circumstances of acting to save their life, if it was in imminent danger.³⁷

1. CJS0074524_001[↩]
2. CJS0074524_001, 003, 005, 006, 008, 014, 015[↩]
3. CJS0074524[↩]
4. DL0000229_005 para 10[↩]
5. CJS001160[↩]
6. SER000437_006 para 22[↩]
7. CJS001768_002[↩]
8. CJS001768_006[↩]
9. KENCOV1025 – V2T017052700011[↩][↩]
10. TRN0000087_016-017 lines 594-612. On the transcript, the words “If he dies, he dies” and “It’s nothing on us” are attributed to Mr Webb. The Inquiry accepts, however, that it was not Mr Webb who made those comments[↩]
11. KENCOV1025 – V2017052700012[↩]
12. Daniel Lake 1 March 2022 41/2-12[↩]
13. Daniel Lake 1 March 2022 42/8-22[↩]
14. TRN0000087_020[↩]
15. KENCOV1025 – V2017052700019; TRN0000087_029-030[↩]
16. A ‘full search’ is a search of an individual that requires the removal and inspection of all clothing and footwear. It 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[↩]
17. KENCOV1025 – V201705270019; TRN0000087_031-033[↩]
18. KENCOV1025 – V2017052700020(a)[↩]
19. Disk 50 UOF 134.17 cam 3[↩]
20. Day 8 PM 2 December 2021 00:20:46-00:22:34 (Disk 50 UOF 134.17 cam 2)[↩]
21. DL0000229_037 para 130[↩]
22. DL0000229_037 para 131[↩]
23. DL0000229_005 para 11[↩][↩]
24. DL0000229_039 para 138[↩]
25. DL0000229_040 para 141[↩]
26. DL0000229_041-042 paras 144-149[↩]
27. DL0000229_042 para 149[↩]
28. DL0000229_042 paras 149-150[↩]
29. DL0000229_042 para 150[↩]
30. DL0000229_043 para 155[↩]
31. DL0000229_044 para 159[↩]
32. David Webb 3 March 2022 149/21-150/2[↩]
33. David Webb 3 March 2022 137/16-140/19[↩]
34. David Webb 3 March 2022 150/13-20[↩]
35. Daniel Lake 1 March 2022 42/1-7[↩]
36. BHM000033_051 para 136; Dr Rachel Bingham 14 March 45/20-47/9[↩]
37. Dr Husein Oozeerally 11 March 2022 134/21-135/11[↩]