Inadequate monitoring and oversight of uses of force

65. The monitoring and oversight of the use of force at Brook House was inadequate and led to dangerous situations for detained people and staff. Use of force, at times, caused significant harm to detained people, as outlined in my findings concerning specific incidents in Part C in Volume I. There were serious failings in the way in which use of force incidents were managed and reviewed.

Lack of presence of senior management

66. Senior managers, above DCM level, were not sufficiently visible and available on wings. The lack of managers to supervise and witness how staff were behaving was particularly acute during use of force incidents. Mr Collier described DCMs being “almost left to their own devices”, without input or guidance from duty managers.¹ The Use of Force PSO requires that a duty manager (the most senior manager on shift) should, where possible, attend use of force incidents or respond to a general alarm for staff assistance.² In my view, their absence allowed (and in some cases may have encouraged) DCOs and DCMs to act with impunity.
67. The Inquiry heard evidence about staff telling others that they had been violent towards detained people, such as when Mr David Webb told Mr Tulley that he had deliberately hurt D149.³ There was also evidence that Mr Murphy bragged about kneeing a detained person in the face during a restraint.⁴ Boasting about hurting detained people on purpose fostered a “culture of silence” where officers did not complain about other officers’ wrongdoing.⁵

Failure to activate body worn cameras or failure to film

68. Prison Service Instruction 04/2017: Body Worn Video Cameras was in place from March 2017. It stated:

“In situations where it is difficult to commence recording prior to force being applied, such as when users face spontaneous and/or unexpected violence for example, the user should activate theBWVC [body worn video camera] as soon as it is practicable to do so. In such circumstances users should explain why earlier recording was impracticable on the BWVC device and within their written statement.”⁶

Where a use of force incident was planned, “the member of staff planning this type of physical intervention must prioritise the use of their handheld video cameras where available and not rely solely on BWVCs”.⁷

69. The G4S Guiding Principles for Use of Body Worn Camera Systems (dated May 2012) stated:

“Detainee Custody Managers will wear BWCS [body worn camera systems] for the duration of their shift. The camera should be switched on when footage might support ‘professional observation’ or would corroborate what would be written in a Use of Force Report, Incident report or witness statement. The decision to record or not to record any incident remains with the user. The user should be mindful that failing to record incidents that are of evidential value may require explanation in court.”

They also noted:

“it is evidentially important to record as much of an incident as possible … recording should begin at the earliest opportunity from the start of an incident”.⁸

70. Mr Gordon Brockington, Managing Director of Justice and Government Chief Commercial Officer at G4S, relied on a Standard Operating Procedure on Body Worn Video Cameras which was effective only from December 2017 to support his evidence that body worn cameras were only “introduced post- Panorama”.⁹ However, this is not correct. A substantial amount of body worn camera footage taken by DCMs during the relevant period was disclosed by G4S to the Inquiry, and therefore body worn cameras must have been utilised to some extent during that time.¹⁰ Indeed, in much of the footage received by the Inquiry, DCMs can be seen wearing body worn cameras. In addition, the Standard Operating Procedure refers to an “expanded roll-out of the use of Body Worn Video Cameras” and not simply their introduction.¹¹ Furthermore, as set out above, G4S’s own Guiding Principles demonstrate that it was mandatory for body worn cameras to be worn by DCMs during the relevant period.
71. Despite the policies in place during the relevant period, the Inquiry found that there was no body worn or handheld camera footage for a large number of use of force incidents during the relevant period.¹² For DCMs who were wearing body worn cameras, failing to switch them on was of particular concern.¹³ For example, Mr Stephen Webb explained that he did not turn on his body worn camera during an incident involving D642 on 3 August 2017 because he was not “in the habit” of doing so.¹⁴ In addition, Mr Dix did not turn on his body worn camera during a use of force incident on 4 May 2017 in which a PIT was used on D1527.
72. Another example which highlights the importance of video footage is the use of force incident involving D52 on 22 May 2017. Mr Collier revised his initial view concerning the appropriateness of force being used during this incident once body worn camera footage was made available to the Inquiry, just before the second phase of its hearings. This footage showed that D52 had in fact offered minimal threat to officers, and more effort ought to have been made to negotiate before force was used – the period of pre-force discussion lasted 6 minutes 30 seconds.¹⁵ On reviewing previously missing footage in relation to this and three other incidents, Mr Collier expressed the view that the force used was unnecessary.¹⁶ Without this footage, the Inquiry would not have known about the serious issues that have arisen from these incidents, and an opportunity to learn from them would have been lost – as happened repeatedly during the relevant period at Brook House.
73. Another troubling aspect of the incident concerning D52 is that DCM David Aldis appears to have deliberately obscured body worn footage of this use of force incident. As soon as the restraint started (at time stamp 07:05), the camera was obscured by fingers which appear to come towards it and the lens was covered so that the viewer cannot see what is happening. A few seconds later, the camera appears to slip down into a white pocket, which was probably Mr Aldis’s given his location both before and after the camera is obscured. Screaming can be heard from 07:10 to 07:50 on the time stamp, during which time the camera was obscured. It is likely, although it cannot be seen, that this screaming came from D52. The picture is only restored and visible at 08:48, at which point D52 was being restrained on the floor.
74. In a witness statement to the Inquiry, Mr Aldis provided an implausible account as to why he did not record the entire incident. He said that he could not recall the incident but suggested that the head of the camera may have twisted when he handed the camera to a colleague, possibly DCM Dean Brackenridge.¹⁷ He said he did this because Mr Brackenridge “was less likely to be involved in the incident … [which would] enable [him] to video the incident much clearer than me”.¹⁸ However, the footage shows that the camera seems to capture the incident from the same viewpoint in the cell both immediately before the camera is obscured and immediately afterwards. It does not appear to have been handed to another officer before the camera is obscured. Mr Aldis’s account is also inconsistent with what Mr Brackenridge stated in his Use of Force report,¹⁹ which was that Mr Aldis instructed him to go into the cell and assist the officers to take control of D52 who was “lashing out”.²⁰ Mr Brackenridge also gave an account of his “hands on” involvement in the use of force incident. This is supported by the footage, which demonstrates that Mr Brackenridge could not have been holding the camera at 07:10 while the camera is obscured since he was involved in the restraint. It seems that Mr Aldis is correct to say that the camera was passed to others at some point during the filming: first to Ms Karen Churcher (Registered Mental Health Nurse) at 08:50 and then to Mr Brackenridge at 10:15. This is long after the use of force incident occurred and after the camera was uncovered at 08:48.
75. It appears to me that Mr Aldis covered the camera deliberately. In my view, it is unlikely that the camera was accidentally dislodged. I take into consideration:

• the timing of the hand being placed in front of the camera;
• the position of the camera throughout filming;
• the inconsistencies between Mr Aldis’s account, Mr Brackenridge’s Use of Force report and the footage which shows when the camera was passed to him;
• Mr Brackenridge’s involvement in the use of force incident itself; and
• that Mr Aldis did not physically participate in the restraint and therefore did not have a reason to pass the camera to another officer immediately before force was used.

Generally, body worn camera users “should record entire encounters from beginning to end without the recording being interrupted”, unless the nature of the incident makes it unnecessary to record it entirely – for example, if it is of a sensitive nature.²¹ However, this was not the case here. I find it deeply concerning that a member of staff behaved in such a way, which resulted in valuable footage of the main part of the use of force incident being unviewable.

76. However, I am encouraged that the policy applicable to IRCs on body worn footage appears to have been strengthened after the relevant period. The Standard Operating Procedure on Body Worn Video Cameras (effective from December 2017) states that body worn cameras “are made available to all designated operational front line staff e.g. Residential Units, Dep Rep, Visits, Activities, Healthcare, Education and searching Security Officers” and not just to DCMs as was previously the case.²²
77. Detention Services Order 04/2017: Surveillance Camera Systems (introduced in February 2018, the Surveillance Camera DSO) states that body worn cameras should be used:

• “When spontaneous use of force is required against a detainee(s)
• On a planned relocation where the use of force is assessed as a possibility – see also paragraph 23
• If the wearer believes the interaction presents, or is likely to present, a risk to the safety of the wearer, other members of staff, detainee or other persons present
• If the wearer considers the use of BWC [body worn camera] to be a necessary and proportionate means of recording any other interaction or event
• When available, consideration should be given by officers to activating a BWC at a detainee’s request.”²³

Where body worn cameras should routinely have been used but were not used, records of the reasons why should have been kept.²⁴ The Surveillance Camera DSO also states:

“Centre suppliers must have in place effective procedures to manage BWC assets. These procedures should accurately record who a device is assigned to, the location of the device and its operational status.”

“When involved in any incident which would normally cause BWC to be activated (as set out in the local policy) the user should commence recording at the earliest opportunity. The member of staff recording the incident should state out loud the reason for turning on the BWC. This ensures that there is a formal record of the decision to use the BWC and also notifies detainees and staff in the area that they are being recorded by both video and audio surveillance (if applicable).

Staff dressed in personal protective equipment (PPE) should also identify themselves to camera, ensuring that their protective helmets (with numbers) are visible to camera before carrying out any actions. This will ensure that they are identifiable when incidents are reviewed.”“When surveillance cameras are used to record an incident involving the use of force. The use of force report must contain a log or reference number of the footage.”²⁵

78. The Inquiry also heard evidence that Serco’s current policy is that body worn cameras “must be activated without exception” where a member of staff is responding to an incident or finds it necessary to use force of any kind.²⁶ The Inquiry is encouraged to learn from HMIP’s 2022 inspection report that body worn cameras are now “well used”.²⁷ The importance of body worn camera footage is clear. Without it, this Inquiry would not have known about the serious issues that have arisen from these incidents, and an opportunity to learn from them would have been lost – as happened repeatedly during the relevant period at Brook House.

Inaccurate, undetailed and missing reports

79. The reports that officers submitted about incidents were sometimes inaccurate as to the justification for the use of force. In the use of force against D2416 on 11 April 2017 (discussed above), two officers stated that D2416 was refusing to comply before the head restraint was applied and they started to move down the stairs, and that this justified force being used.²⁸ However, the footage shows that, at the time the DCM insisted that a head support (where the ‘number 1’ officer supports the detained person’s head) be applied when moving down the stairs, D2416 was in fact compliant and offering no threat.²⁹
80. Similarly, in the use of force against D2559 on 28 April 2017, Mr Paschali stated that D2559 was banging on the cell door. Mr Paschali had struggled to open the door, and he pushed the door open as he was worried something had happened to D2559.³⁰ This appeared to be a justification for entering the cell and then using force as, he said, D2559 became aggressive. However, the footage does not show Mr Paschali having any difficulty opening the door.³¹ This is all the more concerning because Mr Paschali entered the cell without first checking how D2559 was behaving or summoning others if necessary.³² This is another example of inaccurate report writing.
81. Reports from officers were also often lacking in detail. I agree with Mr Collier that the overall standard of post-incident witness statements written by officers was poor in “most” cases, due to lack of detail about the events prior to, during and after the use of force was applied.³³ Mr Collier told the Inquiry that this was a “huge issue”.³⁴ Some officers, including Mr Paschali, claimed that they did not have enough time to complete Use of Force reports.³⁵
82. Some DCOs thought that it was only officers who had physically put their hands on the detained person during the use of force incident who should complete a report.³⁶ When asked about why he did not complete Use of Force reports for four incidents that he supervised, Mr Dix told the Inquiry that it was a “misconception at the time, not just by myself, by many other managers there”.³⁷ The policy in place at the time stated that all those “involved” in the use of force must complete a report.³⁸ This included every officer who used force in any way (every member of a C&R team), including the supervising officer.³⁹ The term “involved” seems to have been applied too narrowly by officers. Clearly, it is important that an accurate account of a use of force incident can be obtained. In my view, either the Use of Force PSO ought to be changed to state “all those who witness or participate in the use of force must fill out a report”, or additional training which further defines “involvement” in a use of force incident ought to be provided.
83. The accurate and detailed writing of Use of Force reports by all officers who witness or participate in use of force incidents is crucial for the proper review and monitoring of the use of force. Sufficient time must be allowed to write these reports. Additionally, though this should be obvious from training and guidance, it is imperative that when only one officer is involved in an incident and uses force against a detained person, they complete a Use of Force report. Failure to do so means that there is no record available of any incident occurring and thus no scrutiny, as was demonstrated by, for example, the incident involving DCO Sean Sayers and D313 discussed in Chapter C.12 in Volume I.

Poor quality of debrief

84. The Inquiry was not provided with many videos of debriefs conducted by officers after use of force incidents. It is unclear whether this is because the debriefs did not occur or because they were not filmed. The quality of the debriefs that were filmed was very poor. They were cursory and demonstrated a complete lack of reflection. Their purpose – to act as a review of use of force incidents – was hindered by their brevity and the absence of any discussion about whether anything could or should have been managed differently.
85. An example of an inadequate debrief following a use of force is that carried out following the use of force on D390 on 6 June 2017. In this instance, force was not used as a last resort as D390 was fully compliant, and the force used, particularly the use of a shield, was not necessary or proportionate.⁴⁰ DCM Stewart Povey-Meier conducted a very quick debrief, which simply involved asking the officers if they had any injuries and the officers confirming that they did not.⁴¹ The debrief did not address whether there were any wider issues or staff concerns, or provide any feedback to staff from Mr Povey-Meier on their performance. A proper debrief might have prevented force being resorted to so quickly in subsequent incidents.
86. Mr Collier stated that, in all the debriefs he had seen during the Inquiry, none of the staff involved had identified recommendations, suggestions for improvement or additional training needs.⁴² They should have done so. He said that, even in the 43 incidents that he reviewed, there were “many” training needs that ought to have been identified.⁴³ Staff should be properly trained in how to conduct debriefs so that lessons can be learned from them.⁴⁴

Lack of proper review and governance

87. None of the issues relating to how force was used were highlighted by any review process.
88. The review process consisted of Mr Stephen Webb sitting alone (as C&R coordinator), on his days off, reviewing Use of Force documents completed by officers involved in the incidents and filling in a one-page, mainly tick-box, Use of Force review meeting form.⁴⁵ This review process was cursory and of poor quality, and there were long delays between the incident occurring and the review. There was also a conflict of interest on occasions when Mr Webb reviewed an incident he had taken part in.
89. There should also have been two more layers of governance to ensure effective oversight.

89.1 At ‘scrutiny’ meetings or Use of Force Committee meetings, the C&R coordinator and the C&R trainers were supposed to review all reports staff filed after their involvement in a use of force incident.

89.2 At weekly use of force meetings, the C&R coordinator and senior managers should have considered any concerns about the use of force identified in the reviews conducted by Mr Webb to decide on any further action, including disciplinary proceedings. They also ought to have considered any wider strategic issues in relation to use of force.⁴⁶

However, these meetings appeared largely to have been cancelled due to a lack of another C&R coordinator and C&R trainers to view the footage.⁴⁷ As discussed in Chapter D.11, it is unlikely that the scrutiny meetings happened at all during the relevant period.

90. Furthermore, each month, the agenda of the security meeting indicated that G4S reviewed, among other things, the number, type and reason why force was used against detained people.⁴⁸ However, upon review of the minutes of the security meetings, the Inquiry found that use of force was rarely discussed and issues with use of force were not identified.⁴⁹
91. Mr Webb described the title ‘Use of Force review meeting form’ as misleading since there was no meeting to discuss the particular incidents. He alone reviewed the footage.⁵⁰ He did not characterise this as a “tick-box exercise” as Mr Collier had done, in the colloquial sense, but said it involved going through the form, ticking boxes, and reviewing the officers’ witness statements and the footage.⁵¹ He added that he had so much to do on the wings that he had to come in on his days off in order to conduct the reviews.⁵² He did not accept that he may not have given as much attention to the reviews as he ought to have done.⁵³
92. In my view, there were several problems with the reviews. These had an impact on their effectiveness and impartiality.
93. None of the reviews were carried out in a timely manner. They were all conducted more than two months after the use of force incident.⁵⁴ For example, the use of force against D191 on 27 April 2017 was not reviewed by Mr Webb until 17 July 2017, almost three months later.⁵⁵ Mr Webb did not know why the delay occurred, but told the Inquiry that senior management “panicked and dumped it on my desk and said ‘sort that’”.⁵⁶ The delay in reviewing use of force incidents gives rise to two principal concerns. The first is that staff members’ recollections were likely to have faded over the time it took to review these incidents. The second is that if reviews were not timely, with an intervening lengthy period between the incident and the review, inappropriate behaviour might be repeated in the interim. The delay is of particular concern where unauthorised techniques risking death or injury were used and then not highlighted on review.⁵⁷
94. Having made enquiries about a large number of missing review meeting forms, the Inquiry was told by G4S that use of force incidents were not reviewed at all after September 2017 (ie for those incidents occurring from June 2017). Staff members who would have conducted the reviews had been suspended or sacked, and were not subsequently replaced.⁵⁸ This means that for over half of the relevant period, use of force incidents were not being reviewed at all.⁵⁹ This is unacceptable. In my judgement, it created a potentially dangerous situation over a prolonged period.
95. I am also concerned about the quality of the review process. Mr Collier told the Inquiry that he had significant concerns about staff competence in around 25 per cent of the incidents that he reviewed.⁶⁰ The Inquiry was provided with all the review forms that Mr Webb conducted over a two-day period between 17 and 18 July 2017.⁶¹ Not a single review form from this period suggested that any further investigation was required, that any lessons should be learned, or that further training was indicated. It seems highly unlikely that, in all the 30 incidents reviewed, none was worthy of comment by the reviewer.⁶²
96. In my view, the review process was undoubtedly a ‘tick box’ exercise that did not amount to an effective monitoring system. Mr Webb did not approach it with the necessary rigour and he did not assess adequately whether lessons ought to be learned or recommendations made.
97. Furthermore, Mr Webb was not provided with enough time or support to conduct these reviews. Senior managers at G4S should have ensured that Mr Webb had sufficient time and resources to undertake a proper review of each use of force incident.
98. The Inquiry also found that Mr Webb conducted several reviews of use of force incidents in which he had personally been involved. One such incident was the use of force against D191 on 27 April 2017, in which there were several failings.⁶³

98.1 Mr Webb and DCO Slim Bessaoud used force against D191 after he struck D356 on the head with a remote control. They then escorted him to the CSU.⁶⁴

98.2 CCTV footage of this incident shows that only Mr Webb and Mr Bessaoud escorted D191 down a set of stairs.⁶⁵ However, the Use of Force Training Manual in effect from December 2015 states that a four-person team is required as the starting point for navigating a staircase with a person under restraint.⁶⁶ D191 was therefore restrained and moved to E Wing by an insufficient number of staff. This put both D191 and the officers at risk of injury. Mr Collier, with whom I agree, said:

“by not summoning assistance the staff are left with insufficient numbers to properly carry out the approved method for moving. This put D191 and staff at a risk of falling and should not have taken place until such time as additional staff were in attendance.”⁶⁷

98.3 The CCTV footage also shows that Mr Webb maintained hold of D191’s arm in a wrist flexion position (a pain-inducing technique) throughout the use of force, rather than using handcuffs. I agree with Mr Collier that this was unnecessary, and did not promote de-escalation.⁶⁸

98.4 D191 complained to the PSU that Mr Webb held his left hand aggressively, bent his fingers and pulled his arm with increased force. He said that he screamed in pain and asked the officer to stop but he did not. He said that Mr Webb told him that the officers would hurt him more if he did not stop shouting.⁶⁹ Mr Webb told the Inquiry that he had not inflicted pain on D191’s wrist, and that he could not recall telling D191 that if he did not stop screaming he would feel more pain.⁷⁰ Mr Bessaoud told the PSU that he did not recall Mr Webb saying this, but accepted that it was possible that D191 was told that if he did not comply, he would feel more pressure through his wrist.⁷¹ In my view, Mr Webb probably did inflict pain on D191’s wrist and he did not follow the correct protocol in doing so. As stated by Mr Collier in his second report to the Inquiry:

“There is a correct protocol for using a PIT where the member of staff gives a clear indication of what is expected, a chance for the information to be processed by the detainee, and a final order. The terminology should not be aggressive and should be delivered calmly but assertive [sic].”⁷²

99. That notwithstanding, when Mr Webb reviewed this incident, he identified no issues or learning points whatsoever.⁷³ In oral evidence, Mr Webb eventually conceded that he should not have been “marking [his] own homework”.⁷⁴ There was clear potential for a conflict of interest that he ought to have recognised at the time, and which managers should have identified if there had been a proper system of monitoring. Mr Webb told the Inquiry that he had to work on his rest days in order to carry out the use of force reviews that senior managers had asked him to complete.⁷⁵ The implication is that senior managers were not concerned that Mr Webb conducted the reviews alone or that he reviewed incidents in which he had been personally involved.
100. The ineffectiveness of Mr Webb’s reviews should have been identified by other layers of governance – that is to say, the weekly use of force meetings and security meetings. However, the weekly use of force meetings between the C&R coordinator and senior managers “were usually cancelled”.⁴⁷ Two use of force meetings took place in late 2017 or early 2018, but these were “largely concerned with administrative matters”.⁷⁶ The Inquiry was not provided with any evidence of those meetings. At the security meetings, use of force was rarely discussed and, when it was, none of the issues detailed in this Report were identified.⁷⁷ The concerns about use of force the evidence gives rise to were compounded by the failures in the review and monitoring process. The quality of internal monitoring and governance by G4S during the relevant period at Brook House was extremely poor.
101. The Home Office’s role in the oversight of use of force was inadequate. The National Audit Office noted that the Home Office measured the timeliness of the Use of Force reports (or ‘forms’ as G4S described them) that G4S was required to produce each time its staff used force against detained people, and reviewed a sample of incidents each week, including video footage and reports on incidents.⁷⁸ However, inappropriate use of force incidents were not themselves contractual performance measures.⁷⁹ The Inquiry received evidence that most of the uses of force by staff against detained people shown in the Panorama programme were already known to G4S and the Home Office:

“Of the 84 incidents, the majority had not been previously reported under the contractual performance and incident reporting, but the Home Office agreed G4S did not have a responsibility to report most of them. The Home Office and G4S agreed penalties for eight incidents, four of which should have been reported under the contract.”⁸⁰

102. The contract between the Home Office and Serco now contains a provision imposing a financial penalty in the event of failures relating to use of force techniques, and the recording, reporting and scrutiny of use of force incidents.⁸¹ The Inquiry was informed of a number of changes under Serco’s management of Brook House.

102.1 Mr Hewer, who became Director of Gatwick IRCs when Serco took over the contract on 21 May 2020, told the Inquiry that he set up a Use of Force Committee.⁸² The Committee is chaired and attended by senior management, the Use of Force Coordinator and other key stakeholders (the Home Office and the Independent Monitoring Board at Brook House (Brook House IMB)).⁸³ He confirmed that representatives of detained people were not currently included but said he would consider this.⁸⁴ The Committee meets monthly. It reviews trends and agrees actions to reduce use of force, and does so by reviewing one use of force from the previous month.⁸⁵ In my view, meeting once a month is not enough. Mr Hewer told the Inquiry there was insufficient time to meet more often.⁸⁶ I find this unimpressive.

102.2 According to Mr Hewer, there is now managerial oversight of use of force debriefs.⁸⁷

102.3 Mr Hewer also stated that every use of force was reviewed within 24 hours by the Assistant Director Security and the Use of Force Coordinator.⁸⁸ Home Office representatives and Brook House IMB members are also invited to attend.⁸⁹

103. The Inquiry has not reviewed footage of recent use of force events and therefore I cannot reach specific conclusions about the appropriateness of use of force methods deployed in Brook House today (nor would this fall within the Inquiry’s Terms of Reference). However, while I welcome the increased oversight and monitoring of the use of force, I consider that more can be done by the Home Office and Serco to ensure that force is used only as a last resort and in a way that is as safe and transparent as possible. This is particularly important in relation to the use of force in response to incidents of self-harm and to manage the behaviour of those with mental health issues.⁹⁰ The 2020 Brook House IMB report noted that 37 per cent of the use of force incidents at Brook House during 2020 were in response to incidents of self-harm (which had also increased).⁹¹ This remains of considerable concern.⁹²
104. Use of force incidents must be comprehensively reviewed to ensure that force has been used appropriately and to identify any necessary improvements to practice or training. This is of critical importance as a general principle, but there is also an important practical purpose, given the range of issues identified above by the Inquiry with key aspects of uses of force in the relevant period. The oversight of use of force was wholly inadequate during the relevant period and so the problematic nature of some incidents was not highlighted and addressed. Reviews of individual incidents were perfunctory and, as a result, some poor practice was not identified and challenged. I am therefore recommending urgent action to address how uses of force are reviewed, in advance of the introduction of a new DSO.

Recommendation 17: Urgent improvement of use of force reviews The Home Office must ensure, as a matter of urgency, that training is delivered on how to conduct an effective use of force incident debrief, ensuring that issues of detained person and staff welfare, as well as training needs, are covered. The training must be mandatory for all immigration removal centre contractor employees who conduct such reviews and those who manage them. The Home Office must also require that use of force incidents be reviewed, at a minimum, at the following levels: ●  Within 36 hours of each use of force incident, the Use of Force Coordinator must conduct a thorough incident review, ensuring that all documentation and footage are collated and preserved, and with a view to taking emergency action in instances of unlawful or inappropriate force. On a weekly basis, all use of force incidents must be reviewed (including all necessary paperwork and available video footage) at a formal meeting by the Use of Force Coordinator and a suitable manager in order to review each incident and to identify any issues or further action required. ●  On a monthly basis, immigration removal centre contractor senior management must arrange meetings with other stakeholders (including detained people and representatives of non-governmental organisations) to review use of force trends. ●  Periodically, the Home Office (or its Professional Standards Unit if the Home Office considers it more appropriate) must review use of force at Brook House and across the immigration detention estate, to identify trends and to direct the implementation of any changes and improvements that are required. This review process must be reflected in the new detention services order regarding the use of force – see Recommendation 15 – in respect of which additional, regular (at least annual) training must then be provided.

1. Jonathan Collier 30 March 2022 155/23-156/16[↩]
2. INQ000111_159-160 para 668[↩]
3. TRN0000088_020[↩]
4. CPS000024_004-005[↩]
5. Callum Tulley 30 November 2021 23/11-24/15; INQ000052_042 paras 167-168[↩]
6. NOM000002_023 paras 5.1-5.2[↩]
7. NOM000002_023 paras 5.7-5.8[↩]
8. PSI 04/2017; NOM000002_023 paras 5.1-5.2; CJS0074355_001[↩]
9. CJS0074041_036 para 178; see CJS0073866[↩]
10. For example, UOF 129.17 BWC[↩]
11. CJS0073866_001[↩]
12. INQ000111_160 para 669[↩]
13. Jonathan Collier 30 March 2022 157/19-158/2[↩]
14. Stephen Webb 8 March 2022 161/8-21[↩]
15. UOF 129.17 BWC[↩]
16. INQ000177_006-008 paras 20-30[↩]
17. INQ000197_001 para 1b[↩]
18. INQ000197_001 para 1c[↩]
19. CJS005620_030-032[↩]
20. CJS005620_031[↩]
21. CJS0074355_003[↩]
22. CJS0073866[↩]
23. Detention Services Order 04/2017: Surveillance Camera Systems, Home Office, February 2018, para 20[↩]
24. Detention Services Order 04/2017: Surveillance Camera Systems, Home Office, February 2018, para 21[↩]
25. Detention Services Order 04/2017: Surveillance Camera Systems, Home Office, February 2018, paras 17, 18, 24[↩]
26. SER000170_002 para 2.0[↩]
27. Report on anUnannouncedInspection of Brook House Immigration Removal Centre, 30 May–16 June2022(HMIP000702), HM Chief Inspector of Prisons, September 2022, p12, para 1.13[↩]
28. DCO Neil Timms (CJS005630_014) and DCO Ben Wright (CJS005630_019[↩]
29. INQ000177_009 para 35[↩]
30. CJS005532_008[↩]
31. 280417 – BH 204-17, UOF 110-17, DVT 166-17.mp4” at 1:30-1:46[↩]
32. INQ000177_016 para 84[↩]
33. INQ000111_152 para 651[↩]
34. Jonathan Collier 30 March 2022 105/4-6[↩]
35. Ioannis Paschali 24 February 2022 47/23-25; Clayton Fraser 28 February 2022 86/10-19; Derek Murphy 2 March 2022 120/18-121/9; Sean Sayers 10 March 2022 168/24-169/20[↩]
36. For example, Ryan Bromley 7 March 2022 102/5-10, Shayne Munroe 4 March 2022 8/17-19 and Stephen Webb 8 March 2022 151/16-24[↩]
37. Steven Dix 9 March 2022 47/1-16[↩]
38. According to Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, paras 4.33 and 8.10; see also Amendments to Use of Force Policy (PSI 30/2015), National Offender Management Service Agency Board, November 2015 (which amends Prison Service Order 1600), paras 2.36 and 8.10. “Involved” is defined as “any role in a C&R team, any use of a baton, protective strategy etc” (para 2.36[↩]
39. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, para 8.4[↩]
40. INQ000111_065 paras 260-264[↩]
41. INQ000177_005 paras 14-17[↩]
42. Jonathan Collier 30 March 2022 176/14-20[↩]
43. Jonathan Collier 30 March 2022 176/21-177/1[↩]
44. See Mr Collier’s suggestion at INQ000177_006 para 16 and INQ000177_017 para 87[↩]
45. Stephen Webb 8 March 2022 176/19-23[↩]
46. CJS0073709_207 para 12.69; see also INQ000111_148-149[↩]
47. CJS0073709_207 para 12.70[↩][↩]
48. G4S security meeting data, April–August 2017: CJS000905, CJS000908, CJS000914, CJS000910, CJS000615[↩]
49.   CJS000915 003 (April concerning March data, which is before the relevant period); CJS000917_001 (May); CJS000911 (June); CJS000913 (August); CJS000918 (September[↩]
50. Stephen Webb 8 March 2022 175/14-176/23[↩]
51. Stephen Webb 8 March 2022 177/6-8[↩]
52. Stephen Webb 8 March 2022 176/19-23 [↩]
53. Stephen Webb 8 March 2022 175/25-179/9[↩]
54. CJS0074041_38 para 189[↩]
55. CJS000902_0033[↩]
56. Stephen Webb 8 March 2022 182/12-183/2[↩]
57. See, for example, incidents involving D1234 on 28 March 2017 (HOM002496); D2054 on 28 June 2017 (CJS005574); and D149 on 31 May 2017 (INQ000111_027 para 86[↩]
58. Counsel to the Inquiry’s Opening Statement, 23 November 2021 61/7-15[↩]
59. The Inquiry compared Mr Webb’s ‘Use of Force review meeting forms’ for 30 incidents (CJS000902) and the 109 individual Use of Force forms completed by G4S officers[↩]
60. Jonathan Collier 30 March 2022 30/2-31/19[↩]
61. CJS000902[↩]
62. Jonathan Collier 30 March 2022 179/9-18[↩]
63. CJS005549_009; INQ000111_047 para 179[↩]
64. CJS005549_009[↩]
65. Day 26 PM 8 March 2022; 00:56:25-00:59:34 (Disk 3 UOF 109.17 [CJS0074071][↩]
66. NOM000001_228[↩]
67. INQ000111_048 para 190[↩]
68. INQ000111_047-048[↩]
69. CJS002741_008-009[↩]
70. Stephen Webb 8 March 2022 173/8-175/13[↩]
71. CJS002741_013 para 6.5.10[↩]
72. INQ000158_038 para 15[↩]
73. CJS000902_003; INQ000111_047 para 179[↩]
74. Stephen Webb 8 March 2022 179/18-181/16 [↩]
75. Stephen Webb 8 March 2022 176/9-25[↩]
76. CJS0073709_207 para 12.71[↩]
77. CJS000915 009_003 (April concerning March data, which is before the relevant period); CJS000917_001 (May); CJS000911 (June); CJS000913 (August); CJS000918 (September[↩]
78. DL0000175_021 paras 2.8-2.9[↩]
79. DL0000175_021 paras 2.8 – 2.9[↩]
80. DL0000175_021 para 2.9[↩]
81. SER000226_0215 KPI 10[↩]
82. Steven Hewer 1 April 2022 2/14-16, 135/17-25[↩]
83. SER000451_014 para 61[↩]
84. Steven Hewer 1 April 2022 136/3-23[↩]
85. Standard Operating Procedure 27 April 2020, pp22-23; SER000054_016[↩]
86. Steven Hewer 1 April 2022 137/11-18[↩]
87. SER000451_015 para 65[↩]
88. SER000170_022; SER000451_014 para 61[↩]
89. SER000170_022; SER000451_014-015 paras 61-65[↩]
90. Dr Rachel Bingham 14 March 50/5-51/5; Theresa Schleicher 14 March 2022 90/1-90/12, 97/25- 98/22[↩]
91. IMB000202_016 para 4.5[↩]
92. Theresa Schleicher 14 March 2022 89/7-90/12; BHM000031_58 paras 173-174[↩]