The underlying facts

2. D149 arrived at Brook House on an open Assessment Care in Detention and Teamwork plan following an incident during which he had taken spice, climbed onto the safety netting on level 2 of Colnbrook immigration removal centre and threatened to jump.¹ He had attempted to self-ligature approximately one month earlier.² D149 attended an initial health assessment at Brook House on 22 May 2017. During this assessment, he disclosed that he had been abused when he was eight years old and that he had a diagnosis of mixed personality disorder. He was allocated a single occupancy cell until he could be assessed by a GP or Registered Mental Health Nurse.³ D149 attended an appointment with Dr Husein Oozeerally on 23 May 2017, following which he was prescribed antidepressant medication. He failed to attend a mental health appointment scheduled for 29 May 2017.³
3. The Inquiry saw covertly recorded footage of a conversation that took place on 31 May 2017 between Detention Custody Officer (DCO) Callum Tulley, Detention Custody Manager (DCM) Jason Miller and DCM Carrie Dance-Jones.⁴ Ms Dance-Jones was the assigned Duty Director at the time. Mr Tulley told the DCMs that a detained person had just attempted to remove his keys by pulling on the security chain that attached them to his belt. After Mr Tulley had described the detained person as D149, Mr Miller accessed details about him on his computer and told his colleagues that D149 had been identified as posing a risk of escape. Ms Dance-Jones made a call and can be heard saying:

“D149. He just tried to grab an officer’s key, um, oh is he? What you doing today? We need to block him. He’s an escape risk and he’s tried to grab an officer’s keys. So I think we need to, need to stick him down there.”

She finished the call and said to Mr Tulley and Mr Miller, “Right, he’s going down the block.”

4. Mr Tulley completed a Security Information Report (used to record matters relevant to the safety and security of the immigration detention estate, and collated by the Security department at Brook House) about D149. In it, he wrote that he believed D149 had been attempting to take his keys. Mr Tulley signed and dated the report, indicating that the time was 13:55.⁵
5. DCM Stephen Loughton wrote in an incident report that Ms Dance-Jones had spoken to him at 14:30 on 31 May 2017 and informed him what had happened. Mr Loughton said that he spoke to D149, who was “irate” when Mr Loughton explained that the decision had been taken to move him to the Care and Separation Unit (CSU). D149 refused to go. Mr Loughton explained that he waited until 17:00 to remove D149 to the CSU, as this was when the centre would be in lockdown for roll count. He assembled a team of officers and a nurse at 16:45.⁶
6. There are three clips of footage showing force being used on D149 on 31 May 2017. The first is from a body worn camera showing the incident from the other side of D Wing. It is approximately 20 minutes long.⁷ The second clip is from a handheld camera operated by DCM David Aldis and is approximately 22 minutes long.⁸ The third clip is also from the handheld camera and lasts for approximately one minute.⁹ Taken together, the three clips show the immediate lead-up to the use of force on D149 and the use of force itself. This includes D149 being moved from D Wing and through E Wing, and relocated in a cell in the CSU.
7. The body worn camera footage begins with five officers approaching D149’s cell on D Wing. Mr Loughton was leading the group, and DCO Kirstie Freeburn, DCO Ryan Tait, DCO Jonathan Edon and DCO David Webb followed behind, wearing Personal Protective Equipment (PPE). Ms Freeburn was at the back of the group, and Mr Webb and Mr Edon were supporting Mr Tait, who was holding the shield in a defensive position.

Figure 16: Officers approaching D149’s cell

8. The second clip shows Mr Loughton opening the cell door and speaking to D149. D149 was in bed and Mr Loughton asked him to come out of his cell and walk to E Wing. As D149 got up from his bed he appeared to see the officers braced at the door of the cell. D149 asked “What have you got them for?” and accused Mr Loughton of “Setting me up”.
9. D149 walked out of his cell and, in response to Mr Loughton’s instruction, stood with his back to the wall next to the cell door.

Figure 17: D149 leaving his cell

10. D149, who appeared and sounded agitated, asked Mr Loughton repeatedly why he was being moved to E Wing, but Mr Loughton did not directly respond, saying, “you know the reason”. D149 told the officers surrounding him not to touch him, and asked Mr Webb why he was standing with his fists clenched. He refused to walk with the officers and said, “Do what you got to do”, so Mr Loughton instructed the officers to use force. There was a gap of around 100 seconds between Mr Loughton entering D149’s cell and his authorisation of the use of force.
11. The four officers in PPE moved forward and restrained D149, with an officer taking hold of each arm. As one officer put D149’s arm behind his back, D149 could be heard shouting out in pain and saying, “You’re breaking my arm”.
12. The officer bent D149 forwards and then attempted to hold him in this position so that handcuffs could be applied. D149 strongly resisted the restraint, struggled against the officers, dropped his weight and attempted to hook his legs around theirs and kick them. He shouted at and verbally threatened the officers.

Figure 18: D149 struggling against the restraint

13. D149 was bent forwards for a total of 1 minute 30 seconds before the officers took him to the floor, in part due to the officers’ inability to resist and control his struggles. D149 continued to shout and demand that his arm be released.
14. Officers then held D149 with his chest to the floor and his knees tucked underneath him. He was kept in this position for 1 minute 15 seconds.Mr Loughton instructed Ms Freeburn to straighten D149’s legs out, which she attempted but failed to do. D149 screamed, “let me go”. Ms Freeburn then attempted to apply handcuffs to D149, but Mr Loughton took them from her and applied them to D149 with his hands behind his back. D149 swore at the officers, threatened to kill them and screamed out in apparent pain. He was plainly very distressed.
15. D149 was then helped to his feet and began to kick out and attempt to wrap his legs around those of the officers. The officers attempted to escort D149 along the wing but he began to drag his legs and sink back to the ground. It is not possible to tell what he was saying on the footage, but his voice was high in pitch and he appeared to be in pain. As the officers tried to move him forward, the footage clearly shows that he had been handcuffed with one palm facing his back and the other palm facing outwards. Other detained people were banging on the doors of their cells.

Figure 19: The handcuff position on D149

16. Mr Webb and Mr Edon then dragged D149 along the wing, supporting him under his arms. D149 tried to obstruct this by putting one leg against the wall on his right side and his other leg against the railings to his left. The officers were saying, “walk, walk” and “watch his feet … get in front of him”. After 20 seconds, the group paused again as D149 tried to drop towards the floor. One officer could be heard saying “you need to stand him up”, and the officers brought D149 to his feet. They managed to walk him to the end of the wing, despite D149 continuing to kick out at them and trying to wrap his legs around them.
17. Once they had reached the end of the wing, D149 dropped his weight again. Mr Loughton told the officers that they needed to lift D149. The body worn footage from this time shows that Mr Aldis gestured towards Mr Loughton, beckoning him over to the group. Mr Loughton approached and Mr Aldis pointed towards the handcuffs on D149. Mr Loughton bent over D149 and appeared to attempt to adjust the handcuffs, but when he stood back up D149’s hands were still in the same position.
18. As Mr Loughton moved away, D149 could be heard panting heavily. Mr Loughton called out “Nurse, you alright?” and the attending nurse, Ms Donna Batchelor, responded “yep, yep [inaudible]”. Mr Webb tried to talk to D149 and persuade him to start walking. D149 refused, so Mr Webb took hold of his left hand and flexed his wrist. D149 screamed out in pain until Mr Webb let him go five seconds later.
19. Following this infliction of pain, D149 continued to shout at and verbally abuse officers, and his resistance to the officers’ attempts to persuade him to stand up and walk became even stronger. The officers brought him to his feet, but D149 threatened to bite the officers, and hooked his leg around Mr Edon’s leg in such a way that Mr Edon could no longer place it on the floor. Mr Loughton instructed Ms Freeburn to intervene and unhook Mr Edon’s leg. As she did this, the officers and D149 went to the ground again. Once Mr Edon’s leg was freed, Mr Webb appeared to move D149’s left hand a second time, causing him to scream out in pain.
20. D149 called the officers “cunts” and appeared to be attempting to bite Mr Tait, the officer controlling his head. Mr Loughton then said, “Dave, you need to get him up, we can’t leave him like this”, and the officers brought D149 back to his feet. As soon as they had done this, D149 recommenced kicking the officers. They told him to stop, but D149 responded “I am not giving up lightly, I am pissed off” and went to the ground a fourth time.
21. In total, it took the officers over 10 minutes to move D149 from D Wing into the adjoining corridor. Once in the corridor, D149 could be heard threatening officers and saying, “get off you’re hurting me”. At one point he was being dragged on his knees, and Mr Loughton instructed, “you can’t drag him”. The group then stopped, and the officers held D149 bent forwards over his knees.
22. D149 made threats to torture the officers, and to make their families pay for what they were doing. Ms Batchelor asked D149 to sit up for her, but D149 responded by shouting, “get the fuck off me, don’t touch me, because you don’t know whats going through my head right now”. The nurse told the officers to carry on.
23. Mr Loughton instructed the officers to get D149 up, which they did, and they managed to move D149 to the top of the stairs. Two additional officers, DCO Sean Sayers and DCO Ryan Bromley, were called over to assist and act as ‘anchors’ while D149 was taken down the stairs. D149 was originally taken down the stairs facing forwards, and screamed, “you’re breaking my arm”. Halfway down the first set of stairs, the officers repositioned D149 so that his back was facing the wall. D149 continued to scream out, complain about his arm and make threats to the officers. An officer can be heard saying, “Stop fighting and it will stop hurting. You’re the one that’s making it hurt.”
24. Once at the bottom of the stairs, D149 became more compliant and walked without shouting. He began shouting and making threats to the officers again as he and the officers approached E Wing.
25. Once in the CSU, D149 began to kick out at the officers’ legs as they attempted to search him. He was then taken inside a cell and seen by Ms Batchelor. D149 told Ms Batchelor that he had injuries to his arms; she responded that he probably had some muscle damage from when he had been fighting. She recorded in the Use of Force documentation that D149 had “sustained redness and marks from handcuffs to wrists”.¹⁰
26. Mr Webb told the other officers how to release the restraint on D149 and exit the cell. D149 was face down on the floor of the cell with his knees tucked under his chest.
27. Mr Webb instructed D149 to straighten out his legs, which he did compliantly. Mr Tait then let go of D149’s head, and Ms Freeburn leaned in to remove D149’s handcuffs. However, due to the amount of time it was taking her, Mr Loughton stepped in and removed one of the cuffs. As D149 started to struggle, Mr Tait stepped in to restrain his legs. D149 was screaming in apparent pain and Mr Webb shouted, “release your arm”. Ms Freeburn attempted to remove the other handcuff but was unable to do so, and Mr Loughton again took over and removed it. Mr Webb then instructed Mr Tait to put D149’s legs into a figure of four lock.¹¹ As he did so, he appeared to force D149’s legs and D149 screamed out in pain. The footage ends with Mr Webb, Mr Tait and Mr Edon still restraining D149. By this time, D149 had been face down on the floor with his hands behind his back for over four minutes. In his oral evidence to the Inquiry, Mr Webb accepted that Mr Tait was not in the correct position to execute the leg restraint; he explained that he was not a use of force instructor at the time of the incident.¹²
28. The third and final clip of footage of the use of force appears to follow immediately on from where the second clip ends.⁹ It shows D149 in the prone position on the floor of the CSU cell. Mr Webb continued to instruct Mr Tait on how to take control of D149’s legs, and Mr Edon and Mr Webb then released D149 and left the cell. Mr Tait was the final officer to release D149; he then ran out of the cell. The cell door was locked behind him. Once released, D149 immediately got to his feet and ran to the cell door, which he started hitting as he shouted abuse at the officers. The footage ends with Ms Batchelor telling D149 through the cell door that she would come and see him in half an hour.
29. The Inquiry also saw two clips of footage covertly recorded by Mr Tulley. The first shows a conversation between Mr Tulley, Mr Bromley, Mr Sayers and an unidentified female member of staff prior to the use of force taking place. The officers were discussing D149. Mr Sayers and Mr Bromley both referred to D149 as “a fucker”, and the female officer could be heard referring to D149 as a “little shit”.¹³ The second piece of covert footage shows a conversation between Mr Tulley and Mr Webb on the day after the use of force. Mr Webb can be heard referring to the use of force on D149 and saying, “Fucking hurt [inaudible]. Big time. When I put him in a straight hold [inaudible] in the office downstairs heard screaming.” Mr Webb also said, “Nothing personal but if you’re going to be a fucking dick, it’s going to hurt innit?”¹⁴ In his oral evidence to the Inquiry, Mr Webb denied intentionally causing D149 pain. He acknowledged that he had described his comments to G4S investigators as “locker room talk”.¹⁵
30. Mr Loughton wrote in his Use of Force report:

“At approximately half past two on the afternoon of 31st May 2017 I was informed by Duty Director of the day Caz Dance-Jones that she had received a report that a detainee by the name of [D149] … had attempted to grab an officers [sic] keys in the library and that he has done this before in a previous centre so for the safety and security of the centre he is to be moved to our care and separation unit and be placed onto Rule 40 [of the Detention Centre Rules 2001].”¹⁶

31. Mr Loughton then explained that he had spoken to D149 about the decision to make him subject to Rule 40 on two occasions, once shortly after 14:30 and again between 16:45 and 17:00. During the first conversation, Mr Loughton recorded that D149 said he would not be going to the “block”, and on both occasions he recorded that D149 became “aggressive” or “irate”.
32. It appears that D149 was initially held in the CSU under Rule 42 of the Detention Centre Rules 2001, although the Inquiry did not see evidence of when and by whom this was authorised before DCM Stephen Pearson authorised holding D149 under Rule 40 at 21:52.¹⁷ The Rule 40 documentation indicates that the Home Office, Independent Monitoring Board, Healthcare and Religious Affairs were not informed until 23:00.¹⁸

1. CJS000972_013-019[↩]
2. HOM018812_007[↩]
3. CJS000984_002-003[↩][↩]
4. KENCOV1027 – V2017053100010[↩]
5. CJS004298_002[↩]
6. CJS004352_002[↩]
7. CJS0073778 [Disk 52 UOF 135 17 BWC][↩]
8. CJS0074114 [Disk 53 S2120002][↩]
9. CJS0074062 [Disk 53 S2120003][↩][↩]
10. CJS005650_034[↩]
11. For teaching points on the application of this technique, see NOM000001_245[↩]
12. David Webb 3 March 2022 159/18-160/11[↩]
13. KENCOV1027 – V2017053100016[↩]
14. KENCOV1028 – V2017060100017 clip 1; TRN0000088_002[↩]
15. David Webb 3 March 2022 163/22-164/20, 165/22-166/24[↩]
16. CJS005650_008[↩]
17. CJS001820_002[↩]
18. CJS001820_001[↩]