D1538 and D865 on 4 July 2017: Conclusions in relation to D865

84. The footage of this incident is difficult to watch. D865’s subdued distress following his self-harm is very evident. D1538 is also clearly disturbed by the incident.
85. It is not clear from the footage how tightly the ligature was secured around D865’s neck. Regardless, it is extremely concerning that neither Mr Opoku nor Mr Donnelly immediately checked whether the ligature was still in place. It is clear from Mr Tulley’s covertly recorded footage that he was in a position that afforded him a less direct view than Mr Donnelly’s, yet he saw the ligature within seconds of arriving at the cell door.
86. It is hard to understand how Mr Donnelly missed the ligature around D865’s neck. His explanation that he assumed another more junior officer had already checked is concerning in itself. As the manager carrying out the role of Oscar 1, he was in charge of the incident and had a duty to assure himself that there was no ligature. I cannot be sure why Mr Donnelly failed to see the ligature, but I consider it likely that he had become desensitised to self-harm to such an extent that he did not pay sufficient attention. Staff desensitisation is discussed a number of times in this Report (see, for example, Chapters C.5 and C.14, and Chapters D.7 and D.9 in Volume II).
87. I considered D865’s mental and physical health at the time he was found on 4 July 2017. He had just attempted to self-harm by hanging himself from a ligature, and remained unresponsive on the floor for a period of around three minutes. Prior to Mr Tulley’s intervention, the officers were simply standing looking at D865 without examining him or trying to help him. This is despite them having been called to an incident of self-harm, and it being clear from the conversation among the officers prior to the ligature eventually being removed that D865 had attached himself to the TV in some way. There was a prominent red mark around D865’s neck after the ligature had been removed. Had the ligature been secured more tightly, it is possible that this inaction could have resulted in life-threatening harm being caused to D865. In my view, the inadequacy of the response to D865’s self-harm demonstrated a disregard for his wellbeing and a lack of respect for his human dignity. As a result, I find that there is credible evidence that this incident was capable of amounting to degrading treatment.