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6 June 2017: Conclusions

  1. I agree with Mr Collier that it was reasonable for Mr Bromley and Mr London to restrain D1538 by his arms, as he was agitated. While the technique used by Mr Farrell to restrain D1538 may have been technically correct, having reviewed the evidence as a whole I do not agree with Mr Collier that it was necessary to apply it at the point at which Mr Farrell did, or that he used only necessary force when he did so.
  2. In my opinion, Mr Farrell made an error of judgement.

46.1 There was no immediate need to use more force against D1538. While D1538 was struggling, he was being held securely by Mr Bromley and Mr London, and he was not in any danger of hitting his head. As stated above, this was accepted by Mr Farrell.

46.2 It is my view that Mr Farrell used more force than was necessary in applying the head support technique. His initial restraint appeared to exert real force, and his quick release of D1538, some four seconds after he first restrained him, suggests that he realised this. It is notable that when he restrained D1538’s head the second time, he did so with more control and to a lesser angle.

46.3 This is corroborated by the immediate reactions and accounts of other people physically present in the room at the time, who had a clear view of what happened and an ability to gauge the atmosphere following the use of force in a way that is not possible from a simple review of the footage. For example:

  • Mr Bromley commented to Mr Tulley shortly after the incident that Mr Farrell took D1538’s “head clean off” and “pulled his neck right down.1
  • The other detained people in the room shouted, moved towards the restraint and raised their arms immediately after Mr Farrell applied the head support, rather than leaving as requested.
  • At the end of his shift, Mr Tulley recorded his view of how the incident had unfolded. He explained that Mr Farrell grabbed D1538’s head and pulled it down, and that the reaction of the other detained people was due to the actions of Mr Farrell. It is not audible on the footage of the incident itself, but in this clip Mr Tulley says that the other detained people were shouting, “Get off him!”, “Get off him!”, “What are you doing to him?”, “What are you doing to him?”, as a result of Mr Farrell grabbing D1538’s head.2 Given the reaction of the detained people on the footage, which is described in paragraph 29, I think this is highly likely to be accurate.
  1. Mr Bromley’s assertion in his oral evidence that, at the time, he thought Mr Farrell’s actions in restraining D1538 were “textbook” is not credible. I found his evidence to be evasive and self-serving. The informal conversation with Mr Tulley, during which Mr Bromley was unaware that he was being filmed, indicates that Mr Bromley was concerned by what he had witnessed and did not in fact view Mr Farrell’s actions to be in line with restraint training. I cannot be sure why he did not report any of his concerns, but note that this Inquiry found evidence of a culture that did not encourage or support constructive challenge of colleagues and, in fact, characterised this as ‘grassing’. The staff culture in relation to reporting concerns at Brook House is examined in more detail in Chapter D.9 in Volume II.
  2. The effect of Mr Farrell using excessive force was that he escalated the situation. I accept that D1538 felt “a lot more frustrated, stressed and scared” as a result of Mr Farrell’s actions, and I also accept that he felt the use of force was unfair in circumstances where he had been the victim of a physical attack by another detained person, rather than the aggressor.3 Taking these things together, I consider it likely that he also experienced the use of force as humiliating.
  3. After D1538 was released from the restraint, action was not taken swiftly enough to establish what had happened and to offer D1538 support. Ms Walpole, who had witnessed the attack on D1538, immediately informed the officers and managers in the room that D1538 had not instigated the violence.4 It was reasonable to allow D1538 time to calm down before returning him to a wing. While it is understandable that he perceived being moved to E Wing as a punishment rather than a measure intended to support him in the aftermath of a physical attack, E Wing was also used to accommodate detained people subject to Rule 40 during the relevant period and I have found that Rule 40 was inappropriately used as punishment. (The multi-purpose nature of E Wing during the relevant period is discussed further in Chapter D.7 in Volume II.)
  4. As a result of the Panorama programme, in December 2017 the PSU was carrying out investigations into multiple incidents that occurred during the relevant period, including several that related to the use of force. These investigations did not include D1538’s complaint about events on 6 June 2017. However, as discussed above, they did include investigations into allegations made by him regarding events on 3 June 2017 and 28 June 2017.
  5. I considered D1538’s state of mental health at the time of the restraint on 6 June 2017 and whether he was more vulnerable to mistreatment as a result. D1538 had been physically attacked by another detained person and was agitated and upset. I accept D1538’s evidence that the head restraint had the effect of making him feel more frustrated, stressed and scared, and that the sudden pushing down of his head caused him pain. I find that this was likely to cause him intense mental suffering. Therefore, there is credible evidence that this incident alone was capable of amounting to inhuman and degrading treatment.


  1. KENCOV1033 – V2017061000007[]
  2. TRN0000064_008[]
  3. DL0000231_018 para 72[]
  4. TRN0000089_010[]