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Response to serious misconduct complaints

  1. Complaints involving serious misconduct by staff at Brook House were required to be allocated to the PSU for investigation.1 Such a complaint would only proceed further if a PSU senior investigating officer assessed that it met the threshold for investigation. If it did not, it would be reallocated to G4S.2
  2. If a complainant was dissatisfied with the outcome of a PSU investigation, they could complain to the Prisons and Probation Ombudsman (PPO).3 The PPO is wholly independent of the Home Office.4 In relation to allegations of inappropriate treatment during the relevant period at Brook House, the PPO appears to have received three complaints.5 In response to complaints on behalf of D1527 and D687 against some of the findings of the PSU investigations into their original complaints, the PPO ultimately decided that a PPO investigation would not be worthwhile because this public inquiry had been set up and it would amount to a duplication of work.6 In response to a complaint by D2034, the PPO concluded that the PSU’s earlier investigation was complete and thorough, and that the decision not to substantiate D2034’s complaint was reasonable.7 There was also a complaint about staff bringing drugs into Brook House prior to the relevant period, which the PPO did not investigate on the basis that it was outside its remit.8
  3. Having reviewed all investigations carried out into allegations of serious misconduct during the relevant period, the Inquiry has identified a number of issues regarding the role and conduct of the Home Office and the PSU in relation to complaints.

Problems in the handling of serious misconduct complaints

  1. Although most cases appear to have been allocated for investigation correctly, the Inquiry has seen a number of instances in which cases were not progressed as they should have been.
  2. There were cases wrongly allocated by the Home Office Detention Services Customer Service Unit to G4S for investigation, rather than being forwarded to the PSU.9

31.1 This happened, for example, in response to a complaint on behalf of D1538 regarding assault and homophobic abuse in August 2017.10 Because of this misallocation, G4S carried out an initial investigation and the eventual PSU investigation, commissioned in November 2017, only amounted to a review of G4S’s investigation.11

31.2 Similarly, following the Panorama programme, the Home Office should have immediately commissioned the PSU or an external body to carry out the investigations into G4S staff, instead of choosing to rely on G4S to carry out its own investigations.12 As Mr Mark Hartley-King (Assistant Director at the PSU during the relevant period) noted, this was “less than ideal”.13 The consequence was that, by the time the PSU was commissioned to investigate allegations (such as by D1527), many of the relevant officers were no longer employed by G4S and therefore were not obliged to participate in the investigation.14 This reduced the ability for there to be a proper investigation in these cases, and reflects one of the ongoing difficulties with PSU investigations, namely that former staff are not obliged to participate.

  1. Both G4S and the Home Office failed to take any meaningful action on multiple occasions following complaints made by D2953, which are also discussed in Chapter C.10 in Volume I. D2953’s complaints were regarding serious misconduct and therefore should have been referred promptly to the PSU.

32.1 D2953 called the Equality Advisory and Support Service (EASS) helpline, which was managed by G4S Government and Outsourcing Services (UK) Ltd, on 40 occasions between 10 June and 17 July 2017.15)

He had been given the EASS number by G4S staff.16 In the last of seven calls to the helpline on 16 June 2017, D2953 said:

“Guard hit me three times … That man was aggressive to me, he apologised after. After [the] third time he hit me he sat on the bed next to me and was explaining something.”17

32.2 The helpline call handler asked if they should call Brook House, to which D2953 said, “I don’t want to make things worse but you can.” The call handler did not contact Brook House.18 Having offered to do so, the EASS call handler should have contacted someone at Brook House, who in turn should have referred the complaints to the PSU.

32.3 D2953 also made verbal complaints to staff (on 20 June, 29 June and 3 July 2017) that he had been “hit”, “bitten” or assaulted by a member of staff.19) There is no evidence of any action taken by Ms Donna Batchelor, a Registered General Nurse, to raise these serious allegations with a manager or the Home Office. I also consider DCM Philip Page’s actions (ie including the allegation in a large body of text about a different incident on 29 June 2017 rather than completing a separate incident report or Security Information Report) to have been insufficient.20 Only DCO Kerry Copping responded adequately, passing the matter on to DCM Carrie Dance-Jones, who requested that DCM Steven Dix follow this up.21 There is no contemporaneous evidence of any response. I think it is likely that Mr Dix did not in fact follow it up.22) Regardless, the matter was not passed to the Home Office or the PSU, nor was it investigated internally by G4S.

32.4 D2953’s written complaint, submitted on 23 June 2017, contained allegations of repeated assaults by a member of staff (later identified as DCO Derek Murphy) over the previous two weeks, as well as complaints about his treatment by Healthcare staff.23 The Home Office’s Detention Services Customer Service Unit failed to allocate this to the PSU for investigation at the time or at all.24) Mr Paul Gasson (Home Office Contract Monitor) described this as an “oversight”.25 It was not until subsequent complaints were made that the matter was investigated, two to three months later. This was a significant failing by the Home Office that may have allowed an abusive member of staff to continue their conduct unchallenged.

32.5 By the time the PSU began investigating D2953’s allegations in October 2017 (after a separate complaint had been made in September 2017), some potential witnesses could not be interviewed.26 Three members of staff had left G4S and could not be compelled to cooperate with the investigation.27 I do not accept G4S’s submission that this was because the allegations were not raised until September 2017.28 These witnesses could not be interviewed because of failings from G4S and the Home Office to promptly refer the initial complaints, made in June 2017, to the PSU.

32.6 Even when an investigation into the June 2017 complaints was eventually begun by G4S in September 2017, those conducting that investigation failed to refer the matter to the PSU until November 2017. A reason given for not referring the matter earlier was that G4S “had no evidence that an assault had taken place”.29 This was the wrong test to apply. It was an allegation of serious misconduct and therefore required investigation by the PSU.30 Ms Rukshana Rafique, who became the PSU’s investigating officer for the case, noted: “It raises some real questions including; how and why this matter was not referred to Detention Services and in turn PSU back in June 2017.31

  1. Mr Hartley-King said, “The way things are being mishandled at Brook is not great.29 I agree.

Problems in the handling of complaints by the Home Office Professional Standards Unit

  1. I have not considered the adequacy of each of the PSU’s investigations into allegations during the relevant period. I do not consider it proportionate to do so under the Inquiry’s Terms of Reference, which require me to investigate the adequacy of the complaints and monitoring mechanisms as a whole. During the relevant period, a number of investigations were conducted by the PSU where the approach seems to have been reasonably thorough and about which I make no specific criticisms.32) However, I have identified a number of concerning themes arising from the PSU’s investigations spanning the investigation process, the decision-making process and the communication of outcomes.

The investigation process

  1. Once the PSU has accepted a complaint, it is allocated to an investigating officer.33) That officer is responsible for identifying any relevant evidence and interviewing relevant witnesses (including the complainant and any staff who are subjects of the complaint, although only current employees can be required to attend).34 On conclusion of the investigation, the investigating officer prepares a comprehensive report that reaches a finding about whether each aspect of the complaint is substantiated on the balance of probabilities.35 The report is reviewed by a senior investigating officer who has supervised the case, before being finalised.36
  2. There were several failures in the process by which some PSU investigations in the relevant period were carried out.
  3. In his complaint in June 2017 concerning verbal abuse and physical assault by a member of staff, D1747 referred to two fellow detained people who he said had witnessed him being assaulted by Mr Murphy.37 Inexplicably, instead of seeking to interview the witnesses himself, the PSU’s investigating officer (Mr John Adamson) requested that G4S staff obtain statements from them.38 The consequence was that one witness (D1686) apparently declined to give a statement when questioned by DCM Christopher Donnelly and DCO Aminul Hoque, despite remembering the incident.39 In D71’s case, the statement was written by DCM Dean Brackenridge.40 Neither the Inquiry nor the investigating officer had any way of knowing what conversation went on with the witness in each case. It was, in any event, inappropriate for G4S staff to be asked to obtain or record statements about whether a detained person supported D1747’s allegations, particularly when they involved the conduct of a colleague.41) This was not an isolated incident. In a similar vein, in the investigation into D1538’s complaints, Mr Adamson relied on the evidence obtained by G4S instead of interviewing those subject to the complaints himself.42
  4. The investigation into D1538’s complaints also did not include interviews with any of the detained people who had witnessed an allegedly excessive use of force incident in the IT suite.43 The PSU should have considered the accounts of the other detained people who witnessed the interaction between D1538 and the two officers. Given the lack of audio on the closed-circuit television (CCTV) footage, this was particularly important.44
  5. Some of those against whom D687 had made allegations of verbal and racist abuse between June and November 2016 (namely DCO Babatunde Fagbo and DCO Luke Instone-Brewer) were not invited to be interviewed by investigating officer Ms Helen Wilkinson.45)Ms Wilkinson could not recall the reasons for this, but suggested she may not have invited them because there was nothing substantiated against them.46 If this was her reason, it was illogical. As Mr Mohammed Khan (the PSU’s Head of Operations) said, all those subject to allegations were expected to be invited to interview.47 Interviewing those against whom allegations were made should have been a key part of the investigation process, in order to assess whether allegations were substantiated.
  6. There was also inappropriate conduct during the interviewing of witnesses.

40.1 As part of the PSU investigation into D87’s complaints of excessive use of force in June 2017, investigating officer Ms Kim Shipp noted at the outset of interviews with three witnesses that she had “no issue” with the way that officers had dealt with D87, or the Control and Restraint (C&R) used.48) As Mr Khan accepted, it was not appropriate for this level of information to be given to a witness.49 The investigating officer also inappropriately shared with one interviewee her analysis of D87’s allegation that DCO Sean Sayers and DCO Aaron Stokes had come to see him afterwards, apologised for the C&R and told him that they had been threatened with disciplinary action if they refused to be involved.50 During an interview of Ms Sara Edwards (Brook House Duty Director on the day of the incident), the investigating officer expressed the view that “it had probably been taken out of context.51 It is of concern that the investigating officer had reached a conclusion about key issues (whether force used was excessive and whether it was necessary) purely on the basis of the camera footage and documentation, before interviewing all relevant witnesses.

40.2 When the investigating officer was interviewing Ms Edwards, it is clear that Ms Michelle Brown, a member of the Brook House Senior Management Team (SMT), was present only as a “Colleague”.52 Ms Brown was also the subject of complaints, yet gave substantive answers to several of the investigating officer’s questions. As Mr Khan accepted, the risk of effectively interviewing two people at the same time is that the evidence becomes contaminated.53

  1. There was no consistent practice by PSU investigators of showing relevant evidence to a complainant and allowing them to comment on it.54

41.1 Ms Wilkinson said that she would show a complainant documentation or footage if it was inconsistent with their account to give them the opportunity to comment on it.55

41.2 In his investigation into D1538’s complaints, Mr Adamson relied heavily on CCTV footage of the incident but did not give D1538 or his representatives the opportunity to see or comment on this.56 The PSU’s report recorded that the CCTV showed DCO Edmund Fiddy raising his arm and pushing D1538 away with his open palm on three occasions.57 However, when questioned by the Inquiry, Mr Fiddy accepted that the CCTV appeared to show that he had made contact with D1538’s neck and that he had failed to put that in his incident report.58

In my view, where there are inconsistencies between the accounts given of events, any evidence relating to those accounts (including footage and documentation) obtained by an investigating officer should be shown to the complainant and the subject of the complaint prior to reaching a conclusion. This would ensure fairness and may shed further light on what happened.

  1. The nature and breadth of these issues suggest that the level of training given to investigating officers was inadequate for an organisation tasked with investigating serious misconduct against vulnerable people. Mr Khan told the Inquiry that PSU investigating officers have a baseline professional qualification and receive training on witness interviewing techniques, statement-taking, the use of force and areas such as harassment and discrimination.59 Ms Wilkinson recalled having “one lot of training” at the beginning of her employment.60 There was no specific training on the type of complaints she would be investigating, but rather she received general training in interview techniques.61 Ms Wilkinson also said that she had not had any training or guidance on interviewing vulnerable witnesses, which she thought would have been helpful.62 Mr Philip Riley, Director of DES, accepted that this was something to be considered.63


  1. Based on a number of examples reviewed by the Inquiry, I have concerns about the decision-making of PSU investigators when determining whether allegations were substantiated or not.
  2. There was no requirement for investigating officers to obtain or be provided with information about previous complaints against staff they were investigating – even where they concerned similar matters.64 The consequences of this can be seen, for example, in the investigation into D1538’s allegation that Mr Tomsett had made a homophobic comment to him. The investigating officer did not identify that more than 10 allegations had been made against Mr Tomsett during the previous two years, including several of verbal abuse and discriminatory attitudes. His considerations, including “the likelyhood [sic] of such comments being made by a DCO to a detainee”, therefore failed to take into account relevant information.65 Mr Khan accepted that there was merit in the PSU having information about previous complaints.66 Mr Riley was surprised that the PSU was not given that information, as the Home Office “keep a very clear log that is discussed monthly about patterns of complaints against DCOs”.67 Investigating officers can decide what, if any, weight to attach to previous complaints (and the PSU may wish to issue guidance about this), but consideration of previous complaints reduces the risk that patterns are missed. It may tip the balance in situations where it is the detained person’s word against that of a staff member.
  3. In July 2020, the Home Office said that it was seeking to require contractors to “notify the Home Office of all cases where a staff member has been identified as being the subject of substantiated and repeated complaints”.68 However, no such requirement is included in the most recent Complaints DSO dated April 2023.69) In any event, it would not go far enough. In my view, unsubstantiated complaints should also be notified to the Home Office so that this information can be provided to the PSU.
  4. Even where some information about previous complaints was known, it was not always properly taken into account. For example, D668 complained that Mr Tomsett was rude to him, mocked him and frisked him aggressively.70 The investigating officer was Ms Wilkinson, who carried out some checks for previous complaints against Mr Tomsett but received incomplete information and was not aware of their full extent.71 Ms Wilkinson said in her statement that “there was no record of other complaints or misconduct in relation to him”.72 This was not accurate. In oral evidence to the Inquiry, she explained that she was focusing on racial or verbal abuse, but this was also not accurate, as Ms Wilkinson was aware of at least one allegation of racism and one of a homophobic comment.73 She then sought to clarify that she meant substantiated complaints.74 If true, this was not an adequate approach to analysing the evidence, as unsubstantiated complaints were also relevant.
  5. Conversely, in the PSU’s investigation into D191’s complaint about excessive use of force in April 2017, the investigating officer considered it noteworthy that, during his time in detention, D191 had completed two complaint forms in 2016. The report noted that both complaints were dealt with by G4S and that D191 had received responses. The investigating officer therefore concluded that D191 was fully aware of the complaint procedure prior to the use of force on 27 April 2017 and “chose not to raise this matter at the time”.75While it is correct that he had used the complaints procedures before with a positive outcome, D191’s previous complaints had related to missing money and procedures around visits.76 It is concerning that the investigating officer did not appear to appreciate the difference between a detained person complaining about procedures and administrative matters at Brook House on the one hand, and having sufficient faith in the complaints process to make an allegation of physical assault against a specific member of staff on the other. I consider it likely that a detained person would be more concerned about the potential consequences of making the latter type of complaint.
  6. There were also instances where an investigator failed to take into account previous disciplinary action. In the PSU’s report into D687’s allegations, and then again in oral evidence, Ms Wilkinson said she was not aware that Mr Fagbo, one of the people against whom D687 made allegations of verbal and racist abuse, had been dismissed for verbal abuse towards a detained person.77 I have some scepticism about that, given that she knew he was dismissed for “inappropriate conduct with a detainee (heated exchange and waving hand movement)”.78 At the very least, she should have made further enquiries as to whether the “heated exchange” included verbal abuse.78 In any event, Mr Fagbo was in fact dismissed for verbal abuse, as discussed in Chapter D.9. Ms Wilkinson accepted that this was important to know and would have affected her decision regarding D687’s allegations against Mr Fagbo.79 Ms Wilkinson also knew that DCM Stephen Webb left G4S after admitting to making three inappropriate comments to a detained person.80 Despite this, she did not appear to take these matters into account as evidence supportive of D687’s allegations of verbal abuse, and instead relied on specific dates and times of incidents not being provided as a basis for finding the allegation unsubstantiated.81 In my view, this set too high a bar for substantiating an allegation. Given the seriousness of the allegations she was investigating, as Ms Wilkinson accepted, she should have considered the nature of the allegations in the round when investigating complaints of verbal or racist abuse.82
  7. Also of concern was the fact that the Inquiry identified failures to look for potentially supportive evidence and a tendency to afford unequal weight to the evidence of staff and detained people.

49.1 Following allegations by D687 (discussed above), the investigating officer asked members of G4S staff (DCOs, DCMs and Healthcare) and staff from Forward Trust, a substance misuse charity, whether they had witnessed verbal or racist abuse, which they denied. These denials were not challenged by the investigating officer. She did not ask other detained people whether they had ever experienced racist comments from members of staff.83 She also did not take into account the racist comments and verbal abuse shown on the Panorama programme, despite the investigation occurring some months after it was broadcast.84 The PSU subsequently concluded that allegations were unsubstantiated.85

49.2 In relation to D687’s allegation that he had been pushed into his cell from the outside, the PSU concluded:

“Given that [D687] said these two DCOs had called for assistance and four other DCOs had attended, I am satisfied that if this had occurred then one of these staff would have reported it.”86

In my view, this assertion showed naivety and a lack of rigour. The investigating officer, Ms Wilkinson, subsequently accepted – “on reflection” – that she should have been “a bit more cynical” about this evidence.87

49.3 When the investigating officer was considering the allegations of verbal abuse and assault against Mr Murphy by D1747 (discussed above), he did not consider the Panorama programme broadcast one week earlier for potentially supportive evidence. Instead, he found the allegation to be unsubstantiated, concluding that Mr Murphy’s:

“experience as a DCO lends further credence to his assertion that he recognises the difference between nervous shouting and true anger and aggression. Available evidence supports his conviction that [D1747] constituted a threat and [Mr Murphy] was justified in pushing him.”88

49.4 In contrast, in an investigation into D2953’s allegations of assault also against Mr Murphy (discussed above), the investigating officer took into account Mr Murphy’s conduct as shown on the Panorama programme.89) This was a good example of the PSU looking more widely for supportive evidence.

  1. There were also examples of irrelevant considerations being taken into account. For example, when considering allegations that D687 had been verbally abused by staff, the investigating officer took account of the fact that D687 had been verbally abusive towards staff.90 It is difficult to see how this was relevant to the conduct of the staff.91
  2. It is particularly concerning that there was a tendency to find that use of force was justified. As a result, complaints about unjustified or excessive force were usually found to be unsubstantiated, unless there was video footage showing otherwise.

51.1 In relation to the use of force against D687 on 13 May 2017, also discussed in Chapter C.5 in Volume I, the PSU concluded that the restraint was reasonable, necessary and proportionate.92 Despite noting that Mr Daniel Haughton (G4S Support Services Manager during the relevant period) had stated that his intention had not been to use force but only to remove the ligature, the investigating officer concluded that the force used was necessary.93 The Inquiry’s use of force expert, Mr Jonathan Collier, concluded that force was not used as a last resort.94

51.2 D1527 alleged unlawful use of force on 4 May 2017. Ms Galvin, the PSU’s investigating officer, concluded that use by DCM Michael Yates of pain control (or a pain-inducing technique, discussed in more detail in Chapter C.4 in Volume I and Chapter D.7) was justified on the basis that CCTV supported his account of the level of disruption at that time.95 In his evidence to the Inquiry, Mr Collier set out the limited circumstances in which pain-inducing techniques may be justifiable, and concluded that there was no evidence to suggest that “there was such risk or such potential risk to staff or risk of harm that it was justified”.96

51.3 In relation to D2054’s allegations of excessive use of force when being moved from his cell to Reception, the PSU concluded in the September 2017 investigation report that force was reasonable, necessary, proportionate and applied using approved techniques.97 As Mr Collier noted, handcuffs were applied to D2054 when he was in the seated position.98 This technique was removed from the training syllabus in 2015 due to concerns about its safety.99 Mr Collier also noted that staff should have given consideration to removing their Personal Protective Equipment once initial control had been achieved, and that they could have de-escalated the situation by removing the head support position. He therefore concluded that continued use of force was not necessary or proportionate.100

51.4 In contrast to Mr Collier’s expert evidence to the Inquiry, the PSU’s investigation into D1234’s complaints about the use of force against him did not conclude that an incorrect technique was used to carry D1234, that his head was pushed downwards or that there was an incorrect application of the handcuffs.101) Nor did it address the inappropriate wearing of a balaclava by Mr Murphy during the restraint. Instead, the investigation relied on the overall conclusion of the expert evidence from the National Tactical Response Group that the force used was reasonable, proportionate and justified in the circumstances.102 It is concerning that, although it noted that handcuffing behind the back when seated had been removed from Home Office approved techniques, the investigation went on to justify its use on D1234, stating: “due to your continued resistance and non-compliance the video evidence showed that the officers struggled to apply approved locks on your arms”.103 This finding shows a lack of either understanding or recognition of the reason why this handcuffing technique should not be used. As the organisation responsible for investigating such serious incidents, the PSU’s finding on this issue is worrying.

As these examples demonstrate, some investigating officers did not have the depth of understanding or expertise to examine these allegations of excessive use of force in any meaningful way. Investigators had the option of seeking expert advice if necessary, but in the cases reviewed by the Inquiry they rarely did so.

Communication of outcomes

  1. In most cases, the report detailing the outcome of a PSU investigation would be sent to DES and a separate, shorter letter would be sent to the complainant.104 Ms Wilkinson, for example, did not know the reasons for having two separate documents.105 Having a separate report and letter – where the letter truncates a full report – poses a risk that the complainant will not know the full basis for the decision. It also reduces the transparency of the investigation process and therefore potentially affects complainants’ confidence in that process. In my view, full reports should be sent to complainants (and their solicitors if applicable). Mr Khan also saw merit in this idea and indicated that it would be considered.106
  2. The Inquiry also received evidence about an outcome letter being amended by the Home Office before being sent. Ms Wilkinson drafted an outcome letter to be sent to D668, but sent it in draft to the DES team for them to send to him (as occurred in cases in which the investigation was commissioned by the Home Office). Two paragraphs at the end of the draft letter were unfinished, relating to policy issues on the use of the new psychoactive substance known as ‘spice’, Rule 35 of the Detention Centre Rules 2001 (regarding medical reports), toilet facilities, lock-up, and control of drugs coming into Brook House.107 Ms Wilkinson said that she was anticipating others finalising those paragraphs before sending them out, but in fact the paragraphs were removed before the letter was sent to D668’s solicitors by DES in April 2018.108 Mr Khan said he was not happy in principle with somebody taking out paragraphs or inserting them into a letter issued in the PSU’s name.109 I agree. It risks undermining the independence of the PSU.
  3. There was also an example of an outcome being shown to G4S before being sent to a complainant. Once Ms Rafique had decided to find D2953’s complaints substantiated in March 2018, she emailed the report to Mr Ian Castle (Home Office DES Area Manager for Brook House and Tinsley House IRC (Gatwick IRCs)) and then to Ms Michelle Smith (Home Office Service Delivery Manager for Gatwick IRCs during the relevant period) to enable them to give “advance warning” of the outcome to Mr Lee Hanford (Interim Director of Gatwick IRCs) “so that they can make any necessary contingency arrangements if required.110 The PSU did not agree to the report itself being shared with G4S, on the basis that this was not the purpose of giving advance notice.111 Despite this, G4S did in fact have sight of the report before it was sent to D2953.112
  4. Where an investigation had been commissioned by the Home Office (as was the case with the complaints made, for example, by D668, D687, D1527 and D1538), the outcome letter was sent to the complainant by DES rather than by the PSU investigator.113) In the Home Office’s Closing Statement, the PSU accepted that the way these letters were provided “may have given the wrong appearance that Detention & Escorting Services were involved in the investigatory process”.114 Such situations also increase the risk of compromising the independence of the PSU.
  5. Overall, it is crucial that allegations of serious misconduct are referred to the PSU promptly and that adequate investigations are carried out, which reach robust and accurate conclusions. If this does not happen, there is a risk that staff who have been responsible for serious misconduct may remain in their roles and potentially cause further harm to detained people.
  6. A number of concerning themes arose from the PSU’s investigations, spanning the investigation process, the decision-making process and the communication of outcomes. These are likely to reflect, at least in part, the inadequate training of investigators. I am therefore recommending steps to improve the quality of investigations conducted by the PSU.
Recommendation 29: Improving investigations by the Home Office Professional Standards Unit

The Home Office must update Detention Services Order 03/2015: Handling of Complaints to clarify that, in investigations carried out by the Professional Standards Unit into allegations of serious misconduct against contractor staff:

●  Professional Standards Unit investigators must carry out interviews themselves and not rely on contractors to do so.
●  All staff against whom allegations are made must be invited to interview.
●  Where there are inconsistencies between any accounts given of events, any evidence relating to those accounts (including footage and documentation) obtained by an investigating officer must be shown to the complainant and to the subject of the complaint prior to reaching a conclusion.
●  The Professional Standards Unit must be given information about previous complaints made against alleged perpetrators, including unsubstantiated complaints.
●  Previous disciplinary action against alleged perpetrators must be taken into account.
●  Investigators must look for evidence that is both supportive and undermining of the complaint.
●  Full reports must be sent to complainants (and their solicitors if applicable).
●  Investigation reports and/or outcome letters must be sent directly from the Professional Standards Unit to complainants (and their solicitors if applicable).

The Home Office Professional Standards Unit must ensure that training about the updated guidance takes place on a regular (at least annual) basis for staff dealing with investigations, as well as those responsible for managing them. The training must be subject to an assessment.

The Professional Standards Unit must also review the training provided to investigators and ensure that investigators receive regular and adequate training, from a variety of perspectives, on issues including:

●  the nature of immigration removal centres and issues that may arise;
●  obstacles that detained people may face in making complaints;
●  interviewing vulnerable witnesses; and
●  use of force and assessing reasonableness of force.

The independence of the Home Office Professional Standards Unit

  1. Given that its role is to investigate serious misconduct complaints, the independence of the PSU is therefore important for creating a fair process that detained people can have confidence in and that reaches reasonable decisions based on all the evidence.
  2. The PSU is the responsibility of the Home Secretary, who is also responsible for IRCs. Despite this, the PSU asserted that it is independent from DES, pointing out that the PSU sits in a different division, under a different senior manager.115 In a joint Closing Statement to the Inquiry, the Home Office and the PSU said:

“Whilst the Home Office is content to address issues relating to the PSU in this Closing Statement, it is vital to note that the PSU is independent from Immigration Enforcement.”116

  1. Although the Inquiry did not see any evidence of PSU decision-making being improperly influenced by the Home Office, there may be a reasonable perception held by detained people or formerly detained people that the PSU was not and arguably still is not independent.117)This was compounded by the way in which the outcome of some PSU investigations was communicated, as discussed above. Some of my general concerns about PSU investigations, particularly the tendencies not to seek potentially supporting evidence and not to afford equal weight to evidence from staff members and detained people, may have been, albeit not consciously, affected by the fact that the PSU was part of the Home Office. Additionally, the Head of the PSU is a Grade 7 civil servant.118 This is considerably more junior than the Heads of the relevant Home Office Immigration Enforcement teams. This may give the perception that the Home Office places insufficient importance on the role of the PSU.
  2. There was a reasonable perception that the PSU was insufficiently independent from the Home Office to carry out its role in investigating serious misconduct complaints. I am therefore recommending improvements to enhance its independence.
Recommendation 30: Improving the independence of the Home Office Professional Standards Unit

The Home Office must:

●  take steps to enhance the independence of the Professional Standards Unit from the Home Office and the perception of this independence; and
●  increase the seniority of the Head of the Professional Standards Unit so that they are closer in status to the Heads of the relevant Home Office Immigration Enforcement teams.

Home Office Professional Standards Unit recommendations and lessons learned

  1. Investigating officers included a range of recommendations at the conclusions of their reports. These included the following:
  • G4S and DES should ensure that the complaints-handling process is sufficiently robust.119
  • Staff should be reminded of their responsibilities when a complaint is raised with them and when they are alerted to relevant allegations.120
  • Accurate reports regarding use of force should be produced and thoroughly checked, as well as consideration given to who needs to complete incident reports.121
  • Body worn cameras should be used and the footage obtained from incidents monitored.122
  • Alternatives should be thoroughly explored prior to planning for use of force on individuals other than the main subject (eg a cell mate).123
  • Planned uses of force should be subject to a full and independent risk assessment, including a request for relevant health conditions.(HOM0332029 row 29))
  1. These recommendations, along with the response of the Home Office and its contractors, and the status of that response, were recorded by DES on a ‘Lessons Learned’ spreadsheet.124 The Inquiry was told that, from late 2019, the DES Audit and Assurance Team (DESAAT) took over the Lessons Learned role and has been collating recommendations arising out of PSU investigations and checking on the progress being made in implementing them.125
  2. The breadth and depth of the recommendations made by the PSU in relation to these investigations were impressive. The fact that most of them were implemented, though some only partially, is positive.126
  3. However, the extent to which those lessons were disseminated to staff at Brook House by either G4S or the Home Office is unclear, and in some cases it evidently did not happen. For example, DCM Shane Farrell was not spoken to after a recommendation was made relating to his failure to switch on his body worn camera and the need for officers to be reminded of the G4S policy on body worn cameras and monitored to ensure that they were wearing and utilising them.127
  4. Additionally, I have seen little evidence to suggest any more holistic consideration by the Home Office of the lessons to be learned from investigation reports, as opposed to the simple tracking of each individual recommendation. This was a missed opportunity to consider patterns relating to complaints and to address the underlying issues causing them. It would have been helpful for there to be, for example, a regular meeting at which the Home Office analysed patterns and themes arising from the PSU’s findings and recommendations in relation to IRCs and considered whether any broader changes were required. The Home Office described a Borders, Immigration and Citizenship System Complaints and Correspondence Steering Group – formed in 2019 to share good practice, improve performance and drive quality standards – addressing recommendations made by the Independent Chief Inspector of Borders and Immigration (ICIBI).128 However, the Inquiry received no evidence of any output from it, and it is unclear whether it is supposed to deal with PSU recommendations.
  5. There also appears to have been very little external oversight of the PSU’s complaint investigations (unless a complainant chose to appeal), or of the Home Office’s response to the findings and recommendations made within them, during the relevant period. The ICIBI has conducted at least three inspections into the Home Office’s handling of complaints.129 However, these did not cover complaints of serious misconduct or those about healthcare in IRCs.130 Further detail regarding monitoring and oversight of complaint processes by external bodies such as HMIP and the IMB is considered in Chapter D.11.


  1. CJS0074041_024[]
  2. HOM0331998_006 paras 21-22[]
  3. PPO0000034[]
  4. PPO000001_001 paras 1-2[]
  5. PPO000035[]
  6. PPO000019; PPO000035[]
  7. PPO000029[]
  8. PPO000034_006-007 paras 22-26[]
  9. HOM0332031_014-015 para 75[]
  10. CJS003348_006; DL0000067_001-002[]
  11. HOM0331946_034-035 para 66[]
  12. HOM0331946_021-022 para 47[]
  13. HOM0331946_033 para 64; HOM0332031_013 para 68[]
  14. HOM0332030_006[]
  15. HOM032609_001. The EASS helpline is a UK-wide public advice service to assist individuals on issues relating to equality and human rights (see It was operated by another G4S Group company, G4S Government and Outsourcing Services (UK) Ltd, to assist individuals on issues relating to equality and human rights. Mr Peter Neden was a director of both this company and G4S Care and Justice (see Companies House appointments, Peter Neden), but Mr Gordon Brockington (Managing Director of Justice and Government Chief Commercial Officer at G4S) stated that the former is not connected to G4S Care and Justice (CJS0074041_025-026 paras 118-120[]
  16. HOM032609_002[]
  17. HOM032609_003; CJS001506_029 para 6.65[]
  18. CJS001506_029-030 para 6.65; HOM032609_003[]
  19. CJS001506_030-031 paras 6.7.2-6.7.4; CJS0073651; CJS0073644_005; CJS0073644_008-014; HOM032247_009. There was some confusion regarding the nature of the assault. Although some of the documents refer to D2953 alleging he had been bitten, his English was poor and he said “hit” whenever he had an interpreter. He also clarified in his interview with Mr Stephen Cotter (G4S Investigation Officer) that he was trying to say he had been “hit” or punched (CJS0073658_003[]
  20. See also Chapter C.10 in Volume I[]
  21. CJS0073642[]
  22. Mr Cotter also reached the view that there were doubts about whether Mr Dix ever actually spoke to D2953 (HOM032609_008-012). Mr Dix was “pretty sure” he did speak to D2953 (see CJS0073657[]
  23. CJS001616_003-005[]
  24. HOM0332123_008-009 paras 36-38. The complaint about Healthcare staff was correctly passed to G4S Health Services for investigation and a response was provided on 5 July 2017 (CJS001616_011- 013[]
  25. Paul Gasson 15 March 2022 186/2-187/13[]
  26. See CJS001506_022 paras 1.2-1.3[]
  27. CJS001506_026 para 5.8[]
  28. CJS0074153_200-201 para 527[]
  29. HOM005049[][]
  30. Mohammed Khan 24 March 2022 26/10-15[]
  31. HOM005049_002[]
  32. For example, the investigations into complaints by D377 (CJS001651_005-017) and by D720 (CJS001526_004-012[]
  33. HOM0331946_006 para 12. Investigating officers included Ms Helen Wilkinson (HOM0332047), Ms Galvin (HOM0332030) and Ms Rafique (HOM0332123). They were Higher Executive Officers (HEOs) within the civil service structure (eg HOM0332047_001 para 3[]
  34. HOM0331946_007-008 paras 14-16; Mohammed Khan 24 March 2022 38/7-12[]
  35. HOM0331946_007 para 13; HOM0331946_007 para 18. This means considering whether the alleged incident is more likely than not to have happened[]
  36. HOM0331946_007-008 paras 13-18[]
  37. HOM003522[]
  38. HOM003522_005[]
  39. HOM003493[]
  40. HOM002419[]
  41. Which Mr Khan appeared to accept (Mohammed Khan 24 March 2022 42/3-14[]
  42. CJS003348_010 paras 6.2.1 and 6.3.1; CJS003348_015-016 para 6.7[]
  43. CJS003348_007-016[]
  44. Disk 4, UOF, 136.17 03 June 2017[]
  45. Helen Wilkinson 24 March 2022 86/2-87/13 (complaint made in October 2017[]
  46. Helen Wilkinson 24 March 2022 86/12-15[]
  47. Mohammed Khan 24 March 2022 9/21-10/19[]
  48. HOM002355_001; HOM002354_001; HOM002353_001 (complaint made in July 2017[]
  49. Mohammed Khan 24 March 2022 31/17-21[]
  50. HOM003153_025-026 paras 7.56-7.61[]
  51. HOM002355_012-013[]
  52. HOM002355_001[]
  53. Mohammed Khan 24 March 2022 32/17-19[]
  54. Mohammed Khan 24 March 2022 12/14-19[]
  55. Helen Wilkinson 24 March 2022 56/16-57/5[]
  56. CJS003348_019[]
  57. CJS003348_019 paras 7.2.30-7.2.31[]
  58. Edmund Fiddy 7 March 2022 170/21-172/11[]
  59. Mohammed Khan 24 March 2022 49/15-50/12[]
  60. Helen Wilkinson 24 March 2022 55/6-13[]
  61. Helen Wilkinson 24 March 2022 106/7-9[]
  62. Helen Wilkinson 24 March 2022 92/11-93/2[]
  63. Philip Riley 4 April 2022 164/2-165/8[]
  64. Mohammed Khan 24 March 2022 7/23-8/4[]
  65. CJS003348_021 para 7.3.9[]
  66. Mohammed Khan 24 March 2022 8/11-9/20[]
  67. Philip Riley 4 April 2022 157/3-23[]
  68. HOM0331998_013 para 48vi[]
  69. See Detention Services Order 03/2015: Handling of Complaints (CJS000727), Home Office, February 2017 (updated April 2023[]
  70. HOM002748_027; HOM002748_031[]
  71. Helen Wilkinson 24 March 2022 61/1-69/8; HOM002190[]
  72. HOM0332047_011-012 para 41[]
  73. Helen Wilkinson 24 March 2022 68/16-17; HOM002748_032 para 7.4.5[]
  74. Helen Wilkinson 24 March 2022 69/1-8[]
  75. HOM006052_024 paras 7.1.35-7.1.36[]
  76. HOM006052_010 para 6.2.3[]
  77. HOM002725_015 para 6.2.6; HOM002725_032 para 7.1.1; Helen Wilkinson 24 March 2022 84/9-11[]
  78. HOM002725_015 para 6.2.6; HOM002725_032 para 7.1.1[][]
  79. Helen Wilkinson 24 March 2022 84/9-21[]
  80. HOM002725_032 para 7.1.4; Helen Wilkinson 24 March 2022 85/16-19[]
  81. Helen Wilkinson 24 March 2022 88/5-89/2[]
  82. Helen Wilkinson 24 March 2022 80/21-24, 88/16-89/2[]
  83. Helen Wilkinson 24 March 2022 77/6-78/1[]
  84. Helen Wilkinson 24 March 2022 78/2-79/14[]
  85. HOM002725_032 para 7.1.3[]
  86. HOM002725_033[]
  87. Helen Wilkinson 24 March 2022 91/15[]
  88. HOM003522_017 paras 7.3.13-7.3.14[]
  89. CJS001506_035 para 7.1.12. Mr Khan was supportive of this (Mohammed Khan 24 March 2022 30/9-11[]
  90. HOM002725_038[]
  91. Helen Wilkinson 24 March 2022 89/9-90/5[]
  92. HOM002725_045-046 paras 7.5.37-7.5.42[]
  93. HOM002725_020 para 6.4.8[]
  94. INQ000111_059 para 238[]
  95. CJS001107_030 para 7.88[]
  96. Jonathan Collier 30 March 2022 135/10-136/8[]
  97. CJS005991_023[]
  98. INQ000111_075 para 300[]
  99. INQ000111_044 para 166; INQ000111_075 para 300; INQ000111_158 para 662[]
  100. INQ000111_075 para 301[]
  101. As discussed in Chapter C.2 in Volume I (see also INQ000111_037-044; Jonathan Collier 30 March 2022 50/15-56/10, 71/24-73/1[]
  102. HOM002750_031-032 para 7.2.21[]
  103. CAP000519_002[]
  104. HOM0331946_013 para 29[]
  105. Helen Wilkinson 24 March 2022 101/13-25[]
  106. Mohammed Khan 24 March 2022 17/21-19/14[]
  107. HOM002747_018[]
  108. HOM0332047_016 para 50; Helen Wilkinson 24 March 2022 102/15-104/19; HOM0332165_057-058 para 186[]
  109. Mohammed Khan 24 March 2022 25/10-14[]
  110. HOM005200_003[]
  111. Mohammed Khan 24 March 2022 22/18-20[]
  112. HOM005200_001[]
  113. HOM0331946_014 para 31; HOM0332047_004 para 17 (see VER000031[]
  114. HOM0332165_057 para 185[]
  115. Mohammed Khan 24 March 2022 5/6-10; HOM0332165_055 para 178; HOM0331946_002 para 5. The relevant senior manager is called a Director General[]
  116. HOM0332165_055 para 178[]
  117. See the Closing Statement from Bhatt Murphy, legal representatives to a number of Core Participants, Brook House Inquiry, 3 May 2022 (BHM000046_148-149 para 370). In administrative law, the determination of whether decision-making bodies are sufficiently independent is of “apparent bias” as opposed to actual bias, based at least partly on the fact that a perception of apparent bias may deter people from bringing complaints or cause them to lose trust in the complaints process. The test is whether the fair-minded and informed observer would conclude that there was a real possibility of bias (see Magill v Porter [2001] UKHL 67[]
  118. HOM0331946_002 para 3; HOM0332155_001 paras 1-3[]
  119. CJS001506_036 para 8.1.3[]
  120. CJS001506_036 para 8.1.4; HOM002748_045[]
  121. HOM002725_048; CJS005991_027; CJS001107_042 paras 9.25-9.27; HOM002725_049; HOM0332029 row 41[]
  122. HOM002725_049; CJS001107_041-042 para 9.20[]
  123. HOM0332029 row 28[]
  124. HOM0332029[]
  125. HOM0331998_008 para 30[]
  126. HOM0332029 rows 29 and 31; HOM0332040[]
  127. Shane Farrell 8 March 2022 110/13-17, 128/3-11[]
  128. HOM0331998_010 para 40[]
  129. HOM0331998_008 para 31[]
  130. An Inspection of the Handling of Complaints and MP’s Correspondence by the Home Office Borders, Immigration and Citizenship System (BICS) February-May 2019, Independent Chief Inspector of Borders and Immigration, July 2020, para 1.3[]