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Concerning themes

  1. At the end of 2016, HM Inspectorate of Prisons (HMIP) recommended that “all use of force should be necessary, proportionate and competently applied”.1 The inspectors concluded that “there was a mixed practice” at Brook House in November 2016, as Dr Hindpal Singh Bhui (Inspection Team Leader at HMIP) confirmed in his oral evidence to the Inquiry.2 Such a basic recommendation on such a fundamental issue ought not to be necessary. However, unfortunately the evidence provided to the Inquiry demonstrates that these issues, and many more, were prevalent during the relevant period, a few months after HMIP made this recommendation.
  2. A number of concerning themes arise from the evidence. These include the nature and purpose of the use of force, those against whom force was used, the monitoring and oversight of its use, and the rules currently in place for using force in IRCs.

Force used in order to provoke and punish

  1. The most serious use of force incident took place on 25 April 2017 against D1527, and was the centrepiece for the Panorama programme.

18.1 During this incident, force was used on D1527 despite the fact that he was vulnerable due to suffering from mental ill health, and despite his obviously distressed state.

18.2 I consider that DCO Ioannis (Yan) Paschali deliberately, and with an intention to provoke and punish D1527 for what Mr Paschali considered poor behaviour, placed his hands around D1527’s neck while threatening to harm him, uttering in D1527’s ear, “You fucking piece of shit, because I’m going to put you to fucking sleep.”3 Mr Collier’s view was that this language was “provoking, disrespectful and unprofessional”.4 Rule 41 of the Detention Centre Rules 2001 forbids an officer from acting in a way that deliberately provokes a detained person.

18.3 Concerningly, none of the officers filled out any use of force paperwork. As discussed below, there was a widespread issue with officers not completing Use of Force reports, even when they participated in use of force incidents. DCO Charles Francis and DCO Clayton Fraser, who were involved in the incident, accepted that they had not completed Use of Force reports but said that this was not because Mr Paschali, or anyone else, instructed them not to.5 However, Mr Tulley, who was also involved in the incident, told the Inquiry that he interpreted Mr Paschali’s comment “no use of force, as it stands” as an instruction not to fill out a Use of Force report.6 In addition, staff who were involved in or witnessed the incident did not make any serious attempt to intervene, nor did they report Mr Paschali’s actions after the incident occurred. As noted in Chapter C.4 in Volume I, I consider this to be the most extreme and disturbing incident involving a detained person at Brook House about which the Inquiry heard evidence.

Use of an unauthorised technique and staff incompetence

  1. In a number of use of force incidents, staff struggled with “basic techniques”.7 Mr Collier noted that often there was poor understanding and execution of techniques within the training syllabus, notwithstanding that mistakes may be made when transferring skills from the classroom to the operational environment.8
  2. On several occasions, staff used an unauthorised technique that had been removed from the Use of Force Training Manual because it had been found to be dangerous – namely, the handcuffing of detained people with their hands secured behind their back when seated.
  3. This practice was removed from the Use of Force Training Manual in 2015, following the death of Mr Jimmy Mubenga on 12 October 2010, after being restrained by G4S officers.9 In his evidence to the Inquiry, Mr Collier explained that, by forcing the torso forwards, there is a risk of restricting oxygen to the detained person and thereby causing serious injury or death (this is sometimes referred to as ‘positional asphyxia’, whereby a person’s ability to breathe is impeded because of the way they are being restrained).10 Before Mr Mubenga’s death, an instruction had been issued by G4S staff to all DCOs directing that they were not to leave a detained person handcuffed to the rear for this reason.11 From January 2016, the fact that this technique had been removed from the Use of Force Training Manual would have been included in the instructor revalidation course and the initial training and yearly refresher training for DCOs. Therefore, from at least 2016 officers ought to have known of this change.12 Despite this, G4S officers continued to use this technique at Brook House during or close to the relevant period, including against D1234 on 28 March 2017, D1914 on 27 May 2017, D149 on 31 May 2017 and D2054 on 28 June 2017.13 No reason has been given as to why this dangerous technique continued to be used by G4S officers. It is also concerning that, even when the Professional Standards Unit (PSU) investigated complaints about incidents where the technique was used, it did not identify the dangers that were associated with it.14
  4. Additionally, at times, staff used authorised techniques that became dangerous due to their incompetent application. Mr Collier reported:

“the lack of knowledge [of officers] does not help in providing a safe environment and as evidenced can be potentially injurious during difficult restraints”.15

  1. The use of force against D149 on 31 May 2017 included staff employing a variety of techniques wrongly and incompetently, which could have caused injury.

23.1 D149 was kept in the ‘prone position’ (lying flat on his stomach) longer than necessary.16 The prone position should only be used if necessary, and time spent in the position must be minimised as there is a risk of positional asphyxia.17 Indeed, Mr Collier warned: “Prolonged restraint in the prone position has been identified by medical experts as a contributing factor in restraint related deaths.”18 Similar to using handcuffs on a detained person who is seated, this is a medical risk, given its potential for serious harm or death. The review process did not identify this as an issue, and lessons were not learned. In my view, Mr Stephen Webb’s review of this particular incident (as C&R coordinator) was perfunctory and wholly inadequate. Mr Webb ought to have identified training needs and lessons learned. Without additional training, a similar situation at a later date could have resulted in serious injury or, as had already occurred in the case of Mr Mubenga, a fatality.19

23.3 Staff appeared unsure how to exit safely with D149 from the cell where the restraint took place, and positioned themselves incorrectly. Because of this, officers tried to compensate by forcibly pulling on the detained person’s legs, which also meant his feet were twisted, causing pain. Officers appeared to be “lost and lacking in knowledge” about how to carry out the techniques.20

23.3 Although it was reasonable for DCO David Webb to use a pain-inducing technique (PIT) to bend D149’s hand towards his wrist (known as a ‘wrist flexion’), it was not applied in accordance with the guidance in the Use of Force Training Manual.21 No warning was given beforehand explaining that Mr Webb would apply the PIT, and the relevant instruction was not repeated before applying it.22

23.4 After the incident, Mr Tulley asked Mr Webb: “Did you manage to get any digs in?”, and he replied:

“I fucking hurt him bruv, big time. I put him in a restraint hold and they heard him in the office downstairs screaming. Put my weight behind him. Nothing personal but if you’re going to be a fucking dick it’s going to hurt isn’t it.”23

It is possible that, in making these comments, Mr Webb was saying that he had used the PIT, and force more generally, deliberately to inflict pain above and beyond what is permitted in the Use of Force Training Manual. I cannot be sure whether he was simply posturing about this incident, or whether in fact he was betraying his true actions and intentions. Either way, Mr Webb’s attitude and comments were completely inappropriate.

(A detailed summary of the Inquiry’s factual findings regarding this incident can be found in Chapter C.7 in Volume I.)

  1. A refresher course for new joiners after six months in the role, as Mr Collier suggested, may be helpful.24 However, a lack of refresher training for new joiners cannot account for all incidents in which staff employed techniques wrongly, since all were supervised by a more senior DCM.25 Given the number of troubling incidents, it may be that a poor standard of training contributed to the low level of staff competency when employing particular techniques.
  2. On several occasions, staff at Brook House used an unauthorised technique to handcuff detained people with their hands secured behind their back when seated, which poses a risk of causing positional asphyxia. Officers ought to have known that this was unauthorised by at least 2016, but it was used against D1234 on 28 March 2017, D1914 on 27 May 2017 and D2054 on 28 June 2017 (as discussed in Chapters C.2, C.6 and C.13 in Volume I, respectively). No reason has been given as to why this dangerous technique continued to be used by G4S officers. Therefore, I am recommending that the Home Office ensure that staff at all IRCs are aware that the application of handcuffs behind the back while a person is seated is not permitted.
Recommendation 14: Handcuffing behind backs while seated

The Home Office and contractors operating immigration removal centres must ensure that all staff are aware that the technique of handcuffing detained people with their hands behind their back while seated is not permitted, given its association with positional asphyxia.

Use of force not as a last resort

  1. There was considerable evidence that, during many incidents, officers were too quick to employ force. Indeed, force was used on these occasions as a first resort rather than a last resort. During the relevant period, de-escalation techniques were either not used at all or were not used for long enough. It appears that, even at DCM level, there was a lack of understanding of how to de-escalate a situation and explore all other reasonable options before using force.26 Two incidents exemplify this.
  2. The first incident is the use of force on D1978 on 23 May 2017, after D1978 apparently refused to move to the Care and Separation Unit (CSU).

27.1 Video footage shows DCM Steven Dix going to the doorway of D1978’s cell and saying to D1978 that he had “one last chance to come out and walk. Yes or no?”.27 However, the footage does not show D1978 being offered a chance to walk prior to this. When Mr Dix received no reply, he turned his back towards the door. At this point, other officers rushed in wearing full PPE, including shields. Mr Dix said “no, no, no” to the officers, indicating that he knew it was too soon for the officers to go in. D1978 was led out while saying to the officers, “why are you doing this?” Force was not used as a last resort on this occasion, and was unnecessary and disproportionate in the circumstances, as D1978 was being compliant.

27.2 Mr Dix should have been more assertive when telling staff what to do. He also ought to have given D1978 more time and opportunity to walk out of the door compliantly. As Mr Collier noted, Mr Dix “mismanaged” the situation by allowing staff to enter and restrain D1978.28 Mr Dix agreed that he had controlled the situation poorly, but said that he had been trying to stop the officers going into the cell because the detained person was complying.29

  1. Another troubling feature about Mr Dix’s behaviour in this incident is that, in both his incident statement and the debrief following the incident, he gave a very different version of events from what can be seen in the footage.

28.1 In the incident statement, he justified force by stating that it was necessary because D1978 was not complying.30 In the debrief, he said that D1978 started to “encroach” towards him and he had “no option” but to deploy the team.31 In his oral evidence to the Inquiry, Mr Dix claimed what he had said on the debrief was a “mistake” and that it had “slipped [his] mind” that he had told officers not to go in.32 When asked how that was possible, he blamed a lack of training on how to be a supervisor and said that it would not have happened had there been a proper review of the situation.33

28.2 His explanation is not credible. It is unclear how additional training might have helped him tell the truth about what had happened. The fact that D1978 was complying is unlikely to have slipped his mind when providing the debrief, given that the incident had only just happened – it was a crucial feature of the incident. It is also unclear how a “proper review” of the incident could explain why he gave a different version of events in the debrief. A review of the officers’ witness statements and footage would have come after the debrief, and therefore this would not have changed Mr Dix’s behaviour in the debrief, which would have already happened.

28.3 This incident brings into question Mr Dix’s honesty and integrity. As mentioned above, the video footage clearly does not show D1978 “encroaching” officers as Mr Dix claimed in the debrief. It shows Mr Dix trying to stop officers who were rushing into the cell because force was not necessary. It is clear to me that Mr Dix lied in the incident statement and debrief to cover up the fact that force was not used as a last resort and was disproportionate. This calls into question whether other witness statements and debriefs written or led by Mr Dix may also be unreliable. It is particularly troubling that such a senior member of staff, both then as a DCM and now as Assistant Director of Brook House, should lie about such a significant event. It provides little confidence that the issues this Inquiry has investigated have since been addressed.

28.4 Had there been a proper procedure for reviewing incidents, a reviewer would most likely have quickly concluded that the account given in the incident statement and debrief was not aligned with the actual events.34 However, a comprehensive review did not occur and so this lie was not exposed.

  1. Another concerning example of where force was not used as a last resort was during an incident involving D687 on 13 May 2017 (also discussed in Chapter C.5 in Volume I).

29.1 D687 was due to be transferred from Brook House to another IRC. Staff from Tascor, an escort contractor, were ready and waiting to transfer him. Covert footage shows D687 being found in an accessible toilet sitting on the edge of the toilet holding a ligature around his neck.35 The ligature was attached to the wall behind him approximately a foot above his head. He told G4S staff that he no longer wanted to live, expressed frustration at the length of time he had been detained, and said he did not want to be moved. This conversation lasted around 11 minutes.

29.2 At this point, Mr Daniel Haughton, Support Services Manager acting as Duty Director, leant towards D687 and offered to light his cigarette as a ploy to move closer to him and initiate a restraint. Force was then initiated and D687 was handcuffed.

29.3 It is difficult to see from the footage what exactly happened during the restraint. In his statement, D687 said that after Mr Haughton removed the ligature, all the other officers then “instantly charged” at him.36

29.4 After approximately 90 seconds, D687 said, with some urgency, “Get off my fucking arm, bruv. I’m on the cuffs.” For approximately 40 seconds he told DCM Shane Farrell to stop resting on his arm and that he was going to break it. D687 said in his statement that he did not understand why the officers were still on top of him when he was calm and was already handcuffed.37 D687 wrote that it appeared to him that the officers were “prolonging the incident, during which I was in pain and struggling to breathe”.38 D687 added that it was at this point that he recalled what he described as: “Someone putting what felt like all their body weight through my arm, which is behind my back.”39 He added:

“The pain was really intense and completely unnecessary. As I say, I had already been restrained and was in handcuffs. I think it was done just to cause me pain.”40

29.5 After being held face down on the floor, D687 was then brought to his feet and led to Reception.

29.6 In his statement, D687 stated that the officers made efforts to talk with him but that he felt: “None of them got it.”41 He described some of the officers as calm but recalled DCM Christopher Donnelly commenting that if D687 dropped his weight onto the ligature: “Then we’ll wait for a minute until you pass out and then we’ll cut you down.” This comment can be heard on the footage. D687 said in his statement that this remark “added to my feeling of worthlessness”.42

  1. Having reviewed this incident, Mr Collier found that force was not used as a last resort, since Mr Haughton was:

“intent on resolving the situation by any means possible, evidenced by him taking a colleague’s fish knife and using a diversionary tactic to cut the noose. Staff appeared surprised by his actions which lead me to assume there was no warning of his intentions. Negotiation and persuasion should have continued, especially as the incident was contained and not effecting [sic] the regime … I do not believe that the restraint was necessary in the first place as engagement was taking place and staff could react if the threat to D687 escalated.”43

Mr Collier concluded:

“In order for force to be lawful it has to be when there is an imminent risk of harm and that all other options have been exhausted. The engagement should have continued with an aim for D687 to remove the ligature and be escorted peacefully. It is accepted that escort staff were waiting but negotiation and persuasion must always be the prime resolution option.”44

  1. I agree. Staff, and in particular Mr Haughton, having begun a conversation with D687, should have continued with efforts to de-escalate the situation. In his oral evidence to the Inquiry, Mr Haughton said he had intended to act in the “best interests of everyone there to sort of bring that to a quick and safe resolution”.45 He accepted that, because of the way the ligature was secured to the wall, the risk of self-strangulation was low if D687 had released his weight onto it.46 It is clear from the covert footage of the incident that D687 was not posing a threat to the safety of the officers who were talking to him. It is also clear from their positions in the room that they were not anticipating that force was needed. Mr Haughton accepted that, in failing to communicate his intentions to his colleagues, he placed them in a situation where they had to react spontaneously. He maintained that it had never been his intention to use force against D687 but merely to remove the ligature.47 Force, in these circumstances, was not used as a last resort, and may well have made D687 feel humiliated and frightened.
  2. Evidence that the same officers were repeatedly being chosen to conduct planned use of force incidents is also troubling.48 This was a contributory factor to some elements of the toxic culture that is discussed in Chapter D.9. Staff who carried out repeated uses of force because they were the ‘go-to‘ officers were at risk of becoming traumatised and desensitised. This reinforced the ‘us and them’ culture, in which officers felt alienated from the detained people who were in their care. Force may have been more readily used as a consequence. Having the same officers involved in use of force incidents also reinforced cliques among staff, since they did not feel that all officers were doing their “fair share” of use of force incidents.49 The Inquiry was encouraged to learn from the 2022 HMIP inspection report that officers who repeatedly use force now have a formal review.50
  3. It is clear that force was sometimes used at Brook House against detained people as the first, rather than last, resort. Alternatives to force, such as de-escalation techniques and negotiation skills, should be prioritised and emphasised in training. Force should only be used when these alternatives have been exhausted. It is a coercive tool which, even if used correctly, carries a risk of injury. The Inquiry is therefore recommending that these principles are confirmed through the issue of further instructions.

Lack of de-escalation: inappropriate use of Personal Protective Equipment

  1. PPE is described in the Use of Force PSO as:
  • Short shield / mini shield (may be carried by the number 1
  • Helmets
  • Shin / knee guards
  • Forearm guards
  • Gloves
  • Flame retardant overalls (if required).51

Figure 33: Examples of officers wearing PPE

  1. The guidance on the use of PPE in the Use of Force PSO states:

“It is recommended that all staff are provided with, and wear protective equipment in planned C&R incidents.”52

  1. C&R is the practice of the techniques described in the Use of Force Training Manual.53 Basic C&R techniques are used by a team of three officers (with the option of having another person involved to control the legs) in order to manage a violent or refractory prisoner.54 The Use of Force Training Manual provides that “there may be occasions” when PPE “must” be used, such as where the person is behaving aggressively, is known to be aggressive or has, or is likely to have, weapons.55 The Use of Force PSO provides that:

“The Supervising Officer will decide whether to remove some items of protective equipment (eg. helmet, shield) before escorting a prisoner through an establishment. Normal practice would be to remove shields and helmets.”56

  1. However, during planned incidents at Brook House during the relevant period, full PPE was routinely worn – even where the detained person offered little threat of violence to officers but simply was not complying with an order. Mr Collier provided examples of at least five incidents where, in his view, PPE could have been removed during the incident to de-escalate the situation.57
  2. It is difficult to communicate effectively while wearing helmets and visors, and it can give a frightening impression to the detained person subject to force and to the rest of the detained population.58 Wearing balaclavas during use of force incidents is not appropriate for “local planned interventions” as they are intended only to be used by specially trained HM Prison Service staff responding to serious incidents of concerted indiscipline (such as a riot).59 Despite this, DCO Derek Murphy wore a balaclava in an incident involving D1234 on 28 March 2017 (see Chapter C.2 in Volume I). In my opinion, this was entirely inappropriate and suggests a disregard for the impact that it would have on a detained person. Each incident should be judged individually and PPE should be worn only when necessary. The removal by staff of PPE – particularly helmets, shields and gloves – is also a tool for de-escalation following the initial intervention in a use of force incident.60
  3. Mr Collier also expressed concern that there was a “cultural process of automatically resorting to PPE” among Brook House staff.61 The Inquiry heard evidence from DCM Stephen Loughton and DCM Nathan Ring that they believed PPE should always be worn for planned use of force incidents, and that only “full” PPE was ever worn – as Mr Ring put it, “no half measures”.62 This understanding is misconceived.63 Once any risk of violence had been reduced, PPE should have been removed. Mr Collier suggested that, as an absolute minimum, the helmet and gloves should be removed when moving through Brook House.64
  4. In the footage reviewed by the Inquiry, PPE was never removed during an incident in order to de-escalate a situation.65 In my view, the wearing of full PPE appeared to have the opposite effect on detained people – escalating the tension when this was unnecessary. There should always have been a dynamic assessment of risk to consider whether full PPE was in fact necessary, so that full PPE was not resorted to when partial or no PPE could be worn.
  5. Mr Collier made a recommendation that scenario-based training should include training on planned use of force incidents and where it is not appropriate to wear PPE, or where PPE can be removed as a de-escalation technique.66 Mr Steven Hewer (current Director of Brook House and Tinsley House immigration removal centre, known together as Gatwick IRCs) told the Inquiry that there is a “blanket policy” in place so that full PPE is still used for every incident for all planned uses of force.67 While Mr Hewer explained that he considered this was necessary in order to protect staff, I am disappointed that he did not address the significance of PPE from a detained person’s perspective.
  6. The use of PPE (particularly helmet, gloves and shield) by IRC staff during use of force incidents can be unnecessarily intimidating for detained people and can hamper communication and efforts to de-escalate a situation. The removal of PPE during an incident can be effective in de-escalating the incident.

Use of force against naked detained people

  1. Force was used inappropriately against naked detained people. In his oral evidence, Mr Collier commented that there were “unusually high” instances of this – possibly due to the timing of removals (eg early morning when a detained person was more likely to be in a state of undress).68 It is important that there are guidelines in place to protect the dignity of detained people in these circumstances. It is clear that a strategy did not exist, which resulted in what may otherwise have been unproblematic use of force incidents becoming humiliating for the detained person.
  2. Mr Collier told the Inquiry that he considered Brook House should have identified that using force against detained people who were naked was a frequent issue. He said that local measures should have been developed to preserve the dignity of detained people being restrained.69 There is no specific policy or guidance regarding what to do with detained people who are naked when using force.70 I agree that this is something that G4S should have identified and taken steps to address.
  3. The purpose of use of force reviews should include identifying issues of concern relating to individual incidents, but they should also provide an insight into any recurring challenges that need to be addressed. As discussed below, the oversight of use of force was wholly inadequate during the relevant period and so the problematic nature of using force on naked detained people was not highlighted and addressed.
  4. Three use of force incidents (which are considered in greater detail in Chapters C.3, C.13 and C.2, respectively, in Volume I) involving naked or near- naked detained people during the relevant period demonstrate this.

46.1 The first is when force was used on 11 April 2017 against D2416, who was naked or near-naked throughout the incident. Body worn camera footage shows staff only engaging verbally with D2416 for 26 seconds before force was used.71 Staff had moved D2416 to the bottom of the stairs, where staff from Tascor were waiting to escort him to the airport. D2416 was left naked or near-naked in the presence of several staff for almost nine minutes while they tried to find a sheet to cover him, or a pack of clothing for him to put on.72 This was unacceptable and, in my opinion, likely to be humiliating.

46.2 The second incident involved D2054 being restrained during a prolonged use of force incident on 28 June 2017.73 During the incident, D2054 only had a towel wrapped around his waist. D2054 had experienced mental health problems and was awaiting an urgent mental health assessment.74 Earlier that morning, he had self-harmed and had been moved to E Wing where he was put on constant observation.75 In my view, the fact that D2054 was suffering from mental ill health was likely to have increased the detrimental impact on him.

46.3 The third example is the alarming footage of the lengthy use of force incident on 28 March 2017 concerning D1234.76 I found that the force used against D1234 while he was naked and surrounded by a large number of staff was likely to have caused him humiliation.

Inappropriate application of a Prison Service Order

  1. Many of the above issues demonstrate that the application of the Use of Force PSO to govern the use of force inside IRCs is inappropriate. IRCs have a different purpose to prisons and a different type of population, and so different types of issues arise.
  2. The justifications for force provided by the Use of Force PSO demonstrate why, in particular, its application is unsuitable. There are specified justifications for the use of force in IRCs in the Detention Services Operating Standards Manual, as set out above. For example, force can be justified in IRCs in order to remove a person to another country. This is not covered in the Use of Force PSO.
  3. As stated above, G4S staff recorded “maintain[ing] good order and discipline” as a justification for force in the vast majority of incidents.77 However, this is not listed as a justification for force in Rule 41 or any other Detention Centre Rule, nor is it mentioned in the Detention Services Operating Standards Manual.78 Maintaining “good order and discipline” is a reason why a person can be removed from association where it is necessary for the security or safety of other detained people (Rule 40) or confined temporarily in special accommodation if the person is being disruptive or violent (Rule 42).
  4. The Use of Force PSO refers to “good order of the establishment” (but not to “good order and discipline”). The Use of Force PSO states:

It is important to take into account the type of harm that the member of staff is trying to prevent – this will help to determine whether force is necessary in the particular circumstances they are faced with. ‘Harm’ may cover all of the following risks:

  • Risk to life
  • Risk to limb
  • Risk to property
  • Risk to the good order of the establishment.

It is clearly easier to justify force as ‘necessary’ if there is a risk to life or limb.”79

  1. In reality, the “good order and discipline” justification used by detention staff at Brook House meant force was used to justify the removal of detained people, or in order to move them to a different part of the centre (usually to the CSU or E Wing).
  2. In my view, there is a danger that “good order and discipline”, which was relied on by officers so heavily when justifying force at Brook House, became a catch-all and did not properly reflect why force was used. Furthermore, reviews of use of force incidents become more difficult when the justification is so general.
  3. Reliance by IRC staff on a variety of sources for rules and guidance on use of force (including the Use of Force PSO, the Detention Centre Rules 2001 and the Detention Services Operating Standards Manual) has created unnecessary complexity and thus confusion among IRC staff. The application of a PSO to the use of force inside IRCs is inappropriate. In my view, permissible justifications for force should be clear. They should be set out in one provision. That provision should be specifically addressed to the use of force in immigration detention, rather than drawing on practices from other secure settings. The provision should be consulted upon with stakeholders, including representatives of detained people. The Inquiry therefore recommends that there should be new mandatory guidance about the use of force in detention settings.

A new framework for the use of force for immigration detention

  1. Given the breadth of significant issues identified by the Inquiry, I am recommending the introduction of a DSO that sets out comprehensive and mandatory guidance about the appropriate use of force in IRCs. In addition to the issues set out above, it should set out the circumstances in which force can be used against vulnerable detained people experiencing mental ill health. It should also set out the framework for monitoring and oversight (about which I make further specific recommendations below).
Recommendation 15: A new detention services order about the use of force

The Home Office must introduce, as a matter of urgency, a new and comprehensive detention services order to address use of force in immigration removal centres.
The detention services order must include the following issues:
●  the permissible justifications for the use of force within immigration removal centres, based on the key principle that force must not be used unnecessarily and must be used only as a last resort;
●  the use of Personal Protective Equipment (PPE), including that it must be subject to a dynamic risk assessment before and during any use of force incident;
●  the protection of dignity when force is used on a naked or near-naked detained person;
●  the circumstances in which force can be used against a detained person with mental ill health; and
●  monitoring, oversight and reporting of use of force by contractors and by the Home Office.
The Home Office must ensure that training about the application of the new detention services order and use of force techniques takes place on a regular (at least annual) basis for all detention staff as well as healthcare staff. Attendance must be mandatory for all staff working in immigration removal centres and those responsible for managing them. The training must be subject to an assessment.
In anticipation of a new detention services order on the use of force in immigration detention, the Home Office must issue an immediate instruction to its contractors managing immigration removal centres that force must be used only as a last resort, using approved techniques.


  1. CJS000761_026 para 1.58[]
  2. Dr Hindpal Singh Bhui 24 March 2022 133/15-19; CJS000761_026 para 1.53[]
  3. Day 2 AM 24 November 2021 00:53:55-01:23:53 (KENCOV1007 – V2017042500021)[]
  4. INQ000111_018 para 51[]
  5. Charles Francis 3 March 2022 71/12-76/8; Clayton Fraser 28 February 2022 85/7-92/15[]
  6. Day 2 AM 24 November 2021 00:53:55-01:23:53 (KENCOV1007 – V2017042500021); Callum Tulley 9 March 2022 106/14-107/13; TRN0000002_014[]
  7. INQ000111_159 para 667[]
  8. INQ000111_013 para 29; INQ000111_146 para 637[]
  9. Jonathan Collier 30 March 2022 51/24-52/25; NOM000001_080-081 166; INQ000111_044, 075, 158 paras 166, 300 and 662[]
  10. Jonathan Collier 30 March 2022 51/24-25, 52/1-25, 53/1-12; Inquest into the Death of Jimmy Kelenda Mubenga Report by the Assistant Deputy Coroner, Karon Monaghan QC Under the Coroner’s Rules 1984, Rule 43p25 para 68[]
  11. Inquest into the Death of Jimmy Kelenda Mubenga Report by the Assistant Deputy Coroner, Karon Monaghan QC Under the Coroner’s Rules 1984, Rule 43p25 para 68[]
  12. Jonathan Collier 30 March 2022 52/18-25, 53/1-12[]
  13. HOM002496; CJS005574; INQ000111_027 paras 86, 88; INQ000111_042 para 151; INQ000111_075 para 300; CJS0073730 [Disk 23 S1940003]; Disk 50 UOF 134.17 cam 3; CJS0074062 [Disk 53 S2120003]; CJS0073736 [Disk 27 28 June 2017 2221BWVC DCM Aldis][]
  14. Helen Wilkinson 24 March 2022 59/9-24; HOM002750_009 para 6.2.15; HOM002750_026 para 6.16.10, HOM002750_029 para 7.2.6; HOM002750_036 para 8.1; CJS005991_022-024 paras 7.5-7.5.12[]
  15. INQ000111_146 para 637[]
  16. INQ000111_027 para 86[]
  17. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, paras 3.1 and 3.10, Annex D p34[]
  18. INQ000111_024 para 69[]
  19. INQ000111_024 para 69; INQ000111_027 para 88[]
  20. INQ000111_023 para 66[]
  21. NOM000001_022-023, 185-198[]
  22. INQ000111_026 para 89; NOM000001_022-023, 185-198[]
  23. TRN0000088_020[]
  24. INQ000111_146[]
  25. See in particular where an unauthorised technique was used in Chapters C.2, C.6 and C.13 in Volume I[]
  26. INQ000177_016 para 82[]
  27. Disk 48[]
  28. INQ000111_097 para 398[]
  29. Steven Dix 9 March 2022, 70/7-71/14, 74/8-12[]
  30. CJS0074374_003[]
  31. Disk 48 V20170523210142_E1606N_0013[]
  32. Steven Dix 9 March 2022 71/18-74/7[]
  33. Steven Dix 9 March 2022 73/5-74/7[]
  34. Jonathan Collier 30 March 2022 89/20-24[]
  35. Day 2 PM 24 November 2021 14:37-32:06 KENCOV1016 V2017051300011[]
  36. DPG000021_073-074 para 210[]
  37. DPG000021_074 para 211[]
  38. DPG000021_074 para 211 []
  39. DPG000021_074 para 211 []
  40. DPG000021_074 Para 211[]
  41. DPG000021_073 para 209[]
  42. DPG000021_073 Para 209 []
  43. INQ000111_60-61 paras 238-239[]
  44. INQ000111_055-057 para 220[]
  45. Daniel Haughton 16 March 2022 110/25-111/3[]
  46. Daniel Haughton 16 March 2022 111/18-112/3[]
  47. Daniel Haughton 16 March 2022 110/2-11[]
  48. For example, John Connolly 2 March 2022 165/14-167/7, 205/22-207/3; Derek Murphy 2 March 2022 6/20-10/11; IPA000001_002 para 11[]
  49. For example, Ioannis Paschali 24 February 2022 31/5-12; Daniel Small 28 February 2022 160/4-11[]
  50. Report on an Unannounced Inspection of Brook House Immigration Removal Centre, 30 May–16 June2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022, p12, para 1.13[]
  51. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, p39[]
  52. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service August 2005, p39[]
  53. NOM000001[]
  54. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, p10 paras 4.22-4.23[]
  55. NOM000001_201 para 8.1[]
  56. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, Annex F[]
  57. INQ000111_145-146 para 636 (use of force incidents involving D1914 on 27 May 2017 [134/17], D1234 on 28 March 2017 [81/17], D2054 on 28 June 2017 [162/17, 86/17 and 108/17][]
  58. Jonathan Collier 30 March 2022 78/19-79/20; DL0000143_012 para 44[]
  59. Jonathan Collier 30 March 2022 79/21-80/18; Callum Tulley 1 December 2021 23/7-24/1 and 42/1-16; INQ000111_042 para 153; Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, p13 para 4.58[]
  60. INQ000111_029 para 101[]
  61. INQ000111_156 para 658 (incidents 164/17 and 165/17[]
  62. Stephen Loughton 1 March 2022 109/19-110/20; Nathan Ring 25 February 2022 107/8-15[]
  63. Jonathan Collier 30 March 2022 75/20-76/15[]
  64. INQ000111_152-153 para 650[]
  65. Jonathan Collier 30 March 2022 79/21-80/24[]
  66. INQ000111_152 recommendation 6, para 650[]
  67. Steven Hewer 1 April 2022 144/20-146/9[]
  68. Jonathan Collier 30 March 2022 61/22-62/8[]
  69. Jonathan Collier 30 March 2022 71/4-10[]
  70. Steven Dix 9 March 2022 30/8-13[]
  71. Day 41 AM 30 March 2022 (CJS0074115 UOF 88.17 BWC)[]
  72. Day 41 AM 30 March 2022 (CJS0074115 UOF 88.17 BWC), 8:50-17:35 of the footage[]
  73. INQ000111_076 para 302[]
  74. HOM002389_014[]
  75. CJS005991_009 para 6.2.3[]
  76. CJS0073730 [Disk 23 S1940003]; CJS0073731 [Disk 23 S1940004]; CJS0073732 [Disk 24 28 March 2017]; CJS0073729 [Disk 23 S1940002][]
  77. CJS000905_006; CJS000908_010; CJS000914_008; CJS000910_010; CJS000619_010[]
  78. HOM002395_075[]
  79. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, p5[]