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D1538 and D865 on 4 July 2017: The underlying facts

  1. D865 arrived at Brook House on 4 December 2016. He was first brought to the attention of the mental health team on 18 May 2017, when DCM David Aldis, who was acting as Oscar 1, reported that D865 was tearful and requested a Registered Mental Health Nurse (RMN) appointment for him. Mr Aldis said that D865 was tearful because he had been in detention for a long time and he wanted to be released.1 D865 was given talking therapy on 22 May 2017 by Mr James Newlands (an RMN). In that appointment, D865 denied suffering with mental health issues but described himself as being anxious and unhappy with his present situation. A follow-up appointment was not arranged, because “he does not think this will help him”.2
  2. On 4 July 2017, D865 attempted to hang himself. The Inquiry saw an incident report completed by DCO Ben Opoku on 4 July 2017. Mr Opoku recorded that he had unlocked the door of D865’s cell at around 12:20 so that D865 could attend his job as a wing cleaner. Mr Opoku wrote that D1538, who shared a cell with D865, shouted that D865 was on the floor and had tried to harm himself. Mr Opoku then used his radio to request assistance, and Healthcare staff and other officers arrived at the cell.3
  3. The Inquiry saw footage covertly recorded by Mr Tulley on 4 July 2017.4 The footage, which is just under 19 minutes long, begins with Mr Tulley running along A Wing to respond to the incident. As Mr Tulley approached the end of the wing, several people were standing outside looking into one of the cells. D1538 (one of those outside the cell) told officers that he had been in the toilet, had heard a crash, and had then found D865 lying on the floor with something around his neck.
  4. D865 was face down on the floor inside the cell. Mr Tulley indicated that he thought he could still see something tied around D865’s neck. DCM Christopher Donnelly, who was standing close to D865, initially disagreed that there was a ligature but then took a fish knife from his belt and cut what appeared to be a dark cable or shoestring from D865’s neck. D865 was unresponsive.

Figure 24: D865 unresponsive on the floor of the cell as Mr Donnelly removes the ligature from his neck

  1. Members of Healthcare attended to D865, who did not move or respond for approximately three minutes after the ligature had been removed. While D865 was unresponsive, an officer said that he did not think D865 had suspended himself, but that the bracket had broken.
  2. Approximately four minutes into the footage, D865 lifted his head and the Healthcare staff explained to him that they were checking his blood pressure. D865 appeared disorientated and could be seen wiping tears from his face. Radio messages can be heard asking that a cell be prepared for constant observations of D865. D865 slowly sat himself up and quietly asked, “what’s happening?”. The Healthcare staff explained that they were there to help him, and he allowed them to take his blood pressure. D865 began to cry.
  3. D1538 can be heard outside the cell attempting to explain to the officers what he had witnessed.
  4. D865 got up and walked to sit on the bed. Mr Donnelly told D865 that he was going to be moved to E Wing “to keep him safe”. Mr Donnelly asked D865 what he had been thinking, to which D865 quietly responded, “don’t know”. Mr Donnelly asked D865 if he was trying to kill himself, and again D865 responded, “don’t know”. He was still crying and a red mark could be seen on his neck. A nurse knelt down beside D865 and gently tried to ascertain what had happened, but D865 started to sob harder and he appeared unable to respond to her.
  5. The officers started to gather D865’s belongings so that he could be moved. D1538 can be heard saying that he wanted to see a doctor, adding, “I’m shaking, I’m not alright.” Mr Donnelly responded, “that’s what I asked you”, but without turning towards D1538 or stopping what he was doing. Mr Tulley and another officer continued to pack up D865’s belongings while he sat on the bed and smoked a cigarette. Interaction between the staff and D865 was minimal and related only to identifying his possessions.
  6. As D865 left the cell to walk to E Wing, Mr Tulley asked him why he had self-harmed and whether this was caused by him receiving bad news. D865 responded, “Bad news is I’m here. I’ve been here two years, it is no good news.” He then added, “I came back, I want to kill myself. I have no – I lose everything. I don’t care about life anymore.
  7. On his arrival at E Wing, an Assessment Care in Detention and Teamwork (ACDT) plan was opened for D865 and he was placed on constant observation.5 Ms Christine Williams, the Clinical Lead, completed section 3 of the F213 form (this is used to record Healthcare staff’s observations of a use of force incident from a clinical perspective, as well as any injuries to the detained person, and is usually attached to the Use of Force report). She recorded that D865 had red marks around his neck following an attempt to hang himself. D865 said that he wanted an appointment with an RMN.6 Entries in D865’s medical records indicate that he was seen by Ms Karen Churcher, an RMN, the following day. D865 remained on an ACDT plan until 2 August 2017.7
  8. Following the Panorama programme, G4S investigating officers interviewed Mr Opoku regarding his actions on 4 July 2017.8 Mr Opoku initially told the officers that he had seen D865 lying on the floor with a ligature around his neck, and that a TV bracket had come away from the wall. He said that he had waited at the cell door for a first response team to arrive. Later in his interview, after consulting with a workplace colleague, Mr Opoku said that he had not in fact seen a ligature. He said that he had been in a state of shock upon seeing D865 and that this had been the reason why he had not acted.9 Mr Opoku was issued with a written warning by G4S and was required to attend refresher training in first aid.10
  9. The Inquiry saw a second piece of footage covertly recorded by Mr Tulley.11 The footage is approximately 30 seconds long and begins with Mr Tulley asking D1538 what happened to D865. D1538 explained that he heard the TV fall to the ground while he was in the toilet area of the cell and that he saw D865 “shaking on the floor”. He added, “I swear I’m so scared man.” D1538 told Mr Tulley that he could not watch, which is why he pressed the alarm bell and ran to fetch the officers.
  10. Ms Churcher made an entry in D1538’s medical records dated 5 July 2017. She recorded that she had seen D1538 on the wing at the request of Mr Donnelly. She wrote:

“He shares a room with fellow detainee who attempted to hang himself yesterday. States he is shaken and has recurrent thoughts and dreams about. Is also stressed about being detained and has been placed on a raised concern.”

Ms Churcher added that D1538 had said he wanted to see the mental health team. She recorded that an appointment was scheduled for 10:00 on 10 July 2017.12

  1. There were two entries made in D1538’s medical records on 10 July 2017.

78.1 In the first, which was made at 09:59, Ms Churcher wrote:

“Did not attend the mental health appointment given. This was one off appointment in response to an incident. Therefore no further appointment will be made.”

78.2 Ms Churcher also noted that D1538 could self-refer if required.13

78.3 The second entry on 10 July 2017 was attributed to Ms Churcher but, in fact, it appears to have been made by Ms Debbie Alred, a consultant occupational therapist. Ms Alred wrote:

“Emotional Health Group: attended the group for the first time. Said had not been able to sleep for six nights, that he woke up in the morning and after breakfast was able to sleep for an hour. Said that he had witnessed someone try and commit suicide.”13

  1. The Inquiry did not receive a statement from D865.
  2. In his statement to Sussex Police, Mr Tulley said:

“I could not really understand why no one else could see the ligature around his neck. I was still stood outside the room, and yet I could see it clearly. I said ‘no, what’s that tied around his neck’. At this point Chris Donnelly took his fish knife from his belt and cut the ligature off… Chris Donnelly demonstrated hatred towards the detainees. Am sure he was intent on letting the detainee suffer. I would say it was at least 2 minutes between the first response being called and Chris Donnelly removing the ligature from the detainee’s neck.14

  1. In his statement to the Inquiry, D1538 wrote that, on 4 July 2017, he had been in the bathroom area of the cell he shared with D865 when he heard a crash. When D1538 came into the main cell area he saw his cell mate lying on the floor, shaking, with something around his neck. D1538 wrote that it looked like D865 had tied something around the TV bracket.15 D1528 tried to call for help and it took staff several minutes to arrive.16 D1538 wrote that he asked to see the doctor immediately, as he was feeling scared and disturbed by what he had witnessed.17 He said that he did not recall being offered a mental health appointment, but was unsure whether this was because he had forgotten or because one was not offered.18 D1538 wrote that he did not receive any additional support as a result of his ‘raised concern’ status, and noted that he was not placed on an ACDT plan.19 D1538 said that he had previously seen his cell mate attempt to self-harm multiple times: with blades, by banging his head and by putting bags over his head.20 D1538 said that the incident on 4 July 2017 had a significant impact on him. He told the Inquiry that he suffered nightmares and disturbed sleep following the incident, and still felt tormented by the images of what he had witnessed.21
  2. In his second statement to the Inquiry, Mr Donnelly wrote that he would have expected the first member of staff on the scene to check for the presence of a ligature around D865’s neck. He did, however, accept that as a manager he should also have checked for one.22 Mr Donnelly denied Mr Tulley’s allegation that he was intent on allowing detained people to suffer,23 and that he had demonstrated hatred towards them.24
  3. In his oral evidence to the Inquiry, Mr Donnelly accepted that he did not remove the ligature until it was pointed out to him by Mr Tulley.25 Under questioning by Counsel to the Inquiry, he denied that he had become desensitised to self-harm or suicide attempts.26 He explained his failure to see the ligature as his “wrong assumption” that someone else had already checked D865 did not have anything around his neck.27 Mr Donnelly also accepted that his incident report did not mention Mr Tulley drawing his attention to the fact that D865 had a ligature around his neck, and that there was therefore a delay in removing it. Mr Donnelly accepted that his reason for the omission was “Probably because I did not want to make myself look bad.28 Mr Donnelly told the Inquiry that, at the time, he did not know what measures were in place to support detained people who had witnessed self-harm and suicide.29


  1. CJS000949_005[]
  2. CJS000949_006[]
  3. CJS004312_004[]
  4. KENCOV1043 – V2017070400007 clip 1[]
  5. CJS001034[]
  6. CJS004312_006[]
  7. CJS000949_007[]
  8. HOM001004_001-006[]
  9. HOM001004_003-004[]
  10. CJS0073449[]
  11. KENCOV1043 – V2017070400007 clip 2[]
  12. CJS007239_008-009[]
  13. CJS007239_009[][]
  14. SXP000120_008[]
  15. DL0000231_019 para 76[]
  16. DL0000231_019 para 77[]
  17. DL0000231_021 para 79[]
  18. DL0000231_022 para 80[]
  19. DL0000231_022 para 82[]
  20. DL0000231_023 para 88[]
  21. DL0000231_022-023 paras 83-85[]
  22. SER000442_005 para 6b[]
  23. Christopher Donnelly 23 February 2022 105/3-17[]
  24. SER000442_008 para 11b[]
  25. Christopher Donnelly 23 February 2022 115/6-9[]
  26. Christopher Donnelly 23 February 2022 134/21-135/1[]
  27. Christopher Donnelly 23 February 2022 135/6-11[]
  28. Christopher Donnelly 23 February 2022 123/8-127/3[]
  29. Christopher Donnelly 23 February 2022 134/2-6[]