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

  1. I also considered the impact of the incident on D1538, who remained in the vicinity of the cell that he shared with D865 for over 10 minutes while staff attended to D865. Self-harm can be acutely distressing both for the person who is injured and for those who witness the act or its aftermath. D1538 found his cell mate unresponsive on the floor of their shared cell. Mr Tulley’s covert recording captured two separate instances where D1538 stated that he needed to see a doctor and that he did not feel right. Although D1538 was unable to recall it, his medical records suggest that he did interact with mental health professionals following the incident on 4 July 2017, and his distress at what he had witnessed was recorded in entries on 5 and 10 July 2017. However, the care he was offered was fragmented at best. I note that an entry was made in D1538’s medical records to indicate – prior to the time for which it was actually scheduled – that he had not attended his mental health appointment. There was no explanation for this, and it is not clear from his medical records what support he was actually offered, or what his treatment plan was. By his own admission, Mr Donnelly did not know what measures were in place to support D1538 or other detained people who witnessed acts of self-harm, which is concerning in and of itself given the prevalence of self-harming among detained people at Brook House during the relevant period.1
  2. In my opinion, D1538 was not provided with adequate support after he witnessed D865’s self-harm. This – combined with his vulnerabilities resulting from his experiences prior to his arrival at Brook House, the impact on him of the use of force on 6 June 2017 and the homophobic abuse he likely suffered on 28 June 2017 – left him exposed to psychological harm. In my view, D1538’s treatment on 4 July 2017 resulted in intense mental suffering capable of amounting to inhuman treatment.


  1. A total of 248 ACDT plans for individuals identified as at risk of suicide or self-harm were open at Brook House during the relevant period (Sandra Calver 1 March 2022 224/15-22). Figures originally derived from the following Brook House Independent Monitoring Board reports: IMB000021; IMB000050; IMB000011; IMB000047; IMB000019[]