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  1. The footage of this incident shows staff struggling to gain control of and move D149 for a prolonged period. Once force was used, D149 resisted staff and was verbally abusive. The footage demonstrates that he was distressed and, at times, in pain.
  2. The decision to move D149 was justifiable based on the intelligence that staff had available to them. Mr Loughton’s attempt to persuade D149 to walk to E Wing at around 14:30 was appropriate. In light of D149’s refusal to comply, Mr Loughton was right to make arrangements for a planned removal in the event that a use of force became necessary.
  3. Once the staff attended D149’s cell to move him to E Wing, there were a number of failures in how the incident was managed. Mr Loughton allowed only 100 seconds to negotiate with D149 before instructing the other officers to use force. I do not consider this to have been an adequate amount of time. The negotiation was held in circumstances where D149 could see the team of officers in full PPE, extremely close to him and poised to use force on him. Finally, during the negotiation Mr Loughton refused to answer D149’s questions as to why he was being moved. It is my impression from the footage that there appeared to be an assumption of the inevitability of a use of force on the part of the officers assembled to move D149, meaning that the attempts to engage with him were superficial. In the circumstances, force was not used as a last resort.
  4. As identified by Mr Collier and discussed above, the officers failed to apply the techniques as instructed in the Use of Force Training Manual. As force should only ever be used as a last resort, it ought to be common for the use of force to be met with a degree of resistance. Indeed, it is hard to imagine a scenario where force is legitimately used in circumstances where the subject is not resisting. Officers who are up to date with their training ought to be capable of managing this. However, the movement of D149 was clearly challenging for staff and, in my view, Mr Loughton should have taken decisive action – such as summoning additional or more experienced staff, or pausing the restraint to allow a more meaningful conversation to take place with D149 – once it became apparent that Mr Webb, Mr Tait and Mr Edon were unable to carry out the use of force swiftly and safely.
  5. The misapplication of the techniques resulted in D149 being restrained for an extended period of time and experiencing pain. For example, the incorrect application of the handcuffs resulted in pain to D149 that could not be controlled. It is my opinion that the pain was probably applied unintentionally and as a result of the officers’ incompetence and inexperience rather than as a PIT. In any event, if they had intended to apply this technique, there are clear guidelines on how to do so, which the officers did not follow.
  6. As the group reached the top of the stairs, Mr Bromley and Mr Sayers were instructed to act as anchors. However, this formation was set up as D149 was on the edge of the stairs, and at one point he appeared to start moving, front on, down the stairs before the officers were ready. Indeed, one officer could be heard saying, “woah, woah, woah” before D149 was brought back under control and then moved so that his back was facing the wall. I agree with Mr Collier that the formation should have been set up earlier, and away from the stairs, in order to avoid unnecessary risk being caused to D149 and the officers themselves.
  7. I agree with Mr Collier’s assessment of the attempts to restrain D149’s legs. Most concerningly, the difficulties encountered in correctly applying the restraint techniques meant that D149 spent an unnecessary amount of time restrained in the prone position, which is associated with a risk of positional asphyxia.1 As a result, the force used was neither proportionate nor justified. Ms Batchelor, as the attending member of Healthcare staff, should have alerted officers to the dangers of restraining D149 in this position.
  8. While derogatory language was not used in front of D149, I find that the words used by Mr Webb, Mr Bromley, Mr Sayers and the unidentified female officer both before and after the use of force were highly unprofessional.
  9. The incompetence and inexperience of the staff restraining D149 created an avoidable risk to his and their safety during the use of force, and increased the likelihood of injuries being sustained. Force was used against D149 for at least 20 minutes and, for a significant period of that time, the incorrect application of techniques resulted in the officers causing needless pain to D149. It is notable that he screamed at the officers that they were breaking his arm multiple times during the use of force. I consider that – particularly due to the duration of the restraint and the clear distress that D149 suffered throughout – his treatment was likely to cause him intense physical and mental suffering. I also consider that being dragged along the floor, together with the prolonged periods of time during which he was kept in the prone position, risking positional asphyxia, was likely to be a humiliating experience for D149. Consequently, I find that there is credible evidence that these acts are capable of amounting to inhuman and degrading treatment.


  1. INQ000158_006 para 1.3; Jonathan Collier 30 March 2022 44/8-15[]