The role of healthcare staff in relation to use of force

43. Use of force is a serious intervention, with potential to cause harm to vulnerable detained people, and is open to a risk of abuse. While broader issues regarding the use of force are considered in detail in Chapter D.7, this chapter focuses on the role of healthcare staff in relation to such incidents. Prison Service Order 1600: Use of Force states that a member of healthcare staff “must, whenever reasonably practicable, attend every incident where staff are deployed to restrain violent or disturbed prisoners”.¹
44. Contrary to the established principle that the use of force in a custodial environment should be a response of last resort, the Inquiry heard that restraint was used inappropriately at Brook House as a risk management tool and for convenience.² Dr Hard described use of force as the “go to option”.³ This extended to responses to incidents of self-harm, managing behaviour (including of those with mental ill health) and moving or segregating detained people.⁴

Safeguarding role

45. Healthcare staff have an important safeguarding role in the context of the use of force on a detained person.⁵ The first important safeguarding role is the need to raise concerns about any use of force and contraindications (clinical reasons not to use force on a particular detained person), both in advance of a planned use of force and during any use of force (whether planned or unplanned).⁶
46. D1914 was subject to a planned use of force to move him to E Wing on 27 May 2017, in advance of a planned flight to remove him from the country. (The use of force for the sole reason of moving D1914 in preparation for removal was inappropriate in itself.⁷ This is considered separately in Chapter C.6 in Volume I.)

46.1 In addition to a history of self-harm, D1914 had a serious heart condition that was documented in his medical records.⁸ He had undergone two coronary artery bypass surgeries prior to his detention.⁹ While at Brook House, he experienced cardiac symptoms including chest pain and palpitations. He had been taken to hospital by ambulance, including on 17 May 2017 due to abnormal blood results.¹⁰ He was awaiting a cardiac catheter procedure due to an abnormal heart rhythm.

46.2 This was ample information to demonstrate contraindications to a planned use of force on D1914, although Dr Oozeerally was adamant that there were no such contraindications.¹¹As Dr Hard and Dr Bingham confirmed, Dr Oozeerally, when asked to write a ‘fit to fly and fit for detention’ letter, should have explicitly raised D1914’s complex medical history (particularly his cardiac condition) as contraindications in advance of the planned use of force. Instead he wrote: “I am happy for reasonable force to be used (C and R) in order to facilitate the removal.”¹² He did not raise any concerns or contraindications. I consider that Dr Oozeerally failed in his safeguarding role in this regard.

46.3 As shown by handheld camera footage viewed by the Inquiry, the use of force lasted for just over 18 minutes.¹³The footage began with officers standing outside D1914’s cell in full Personal Protective Equipment (PPE). They entered the cell and D1914 was checked by a nurse. Within 14 seconds, D1914 was told he was moving to E Wing (to which he replied he did not want to go and refused twice) and DCM Steven Dix authorised the use of force.

47. In my view, it was not in D1914’s best interests to be subject to a useof force in these circumstances. Indeed, it was positively harmful to D1914 and put him at further risk.
48. In his evidence to the Inquiry, Dr Oozeerally was intransigent in his view that he was acting in the interests of his patient, although he accepted that it would never be in the best interests of a patient to have force used against them (except in the very limited circumstances of an immediately life- threatening situation in order to save their life).¹⁴ Self-evidently, a use of force to move someone from one area to another in preparation for removal from the country does not qualify as an immediately life-threatening situation. Dr Oozeerally did not acknowledge the potential harm his attitude towards detained people’s safety and welfare could cause, and the risk at which he had placed D1914.¹⁵
49. There is a tension between the healthcare professional’s obligation to act in the best interests of the patient and their involvement in a use of force incident in circumstances other than those that pose an immediate threat to life. This does not form part of the standard role of a healthcare professional in the general context of the doctor/patient or nurse/patient relationship in the community, and is peculiar to custodial settings. All healthcare staff should be vigilant in acting on concerns about their patients.
50. The second important safeguarding role of healthcare staff during the course of a use of force incident is to monitor the safety and wellbeing of a detained person.¹⁶ Medical staff have the power, and indeed the duty, in certain circumstances to intervene or declare a medical emergency, and to issue an instruction to immediately stop restraint or other use of force.¹⁷ The Inquiry heard evidence that some Healthcare staff had intervened in the past in such a way during a use of force.¹⁸
51. This monitoring role encompasses intervention to raise concerns prior to and during the course of the use of force. During the relevant period, there did not seem to be an understanding or recognition among Healthcare staff of this aspect of the role, or that they should be intervening prior to the moment a use of force became an emergency situation.¹⁹

51.1 D812 was the subject of a use of force in response to a suicide attempt in which he had placed a bag over his head. Force was used to remove the bag. However, the use of force continued after the life-threatening situation had ended and the bag had been removed. There was, nevertheless, no intervention by Healthcare staff when there should have been.²⁰

51.2 As discussed in Chapter C.13 in Volume I, force was used against D2054 to move him to Reception for his removal flight on 28 June 2017. During the use of force, D2054 was naked or near-naked and handcuffs were inappropriately applied to D2054 behind his back while seated. This could potentially have created serious medical risks caused by being bent forwards for prolonged periods of time, including compression of the chest, interference with normal breathing and possibly death. ²¹ Ms Williams was present throughout the use of force and restraint upon D2054 but did not raise any concerns. She should have challenged the actions of the other staff, in particular in handcuffing him inappropriately behind his back while seated. She should have reported the incident immediately afterwards. If she could not observe the incident adequately, she should have moved so as to be able to monitor his safety. She could also have raised a concern with the officers that she could not adequately monitor his safety or intervened immediately to stop the restraint.

52. Force was also used against D2159 in order to move him to E Wing on 5 April 2017.

52.1 Medical records noted that he was unwell and had been refusing food and fluids for approximately 11 days.²² He was being managed through an open ACDT document. No referral for a Rule 35 report was considered by any member of the Healthcare department in relation to D2159’s food and fluid refusal, despite the deterioration in his physical health.

52.2 A nurse became concerned about him and his general welfare, and asked if a psychiatrist ought to assess him.²³ Ms Williams saw D2159 a few hours later that same day, and felt that it was in his interests to move him to E Wing so that he could be observed closely. The medical records note that he was not engaging with anyone, it was difficult to assess him, he appeared to have lost weight and he had not showered. Ms Williams recorded that “restraints may be used”, by which she had meant, as she explained in evidence, “holding his hand”.²⁴ No contraindications or concerns were raised prior to the planned use of force, in particular in relation to the effect of D2159’s food and fluid refusal or his physical state generally. They should have been. In this instance, Ms Williams failed to fulfil her safeguarding role.

52.3 In fact, considerably more force was used.²⁵ A planned use of force occurred (as opposed to a spontaneous or unplanned use of force). This was recorded as being required to prevent self-harm.²⁶Nothing further was recorded about the nature of the self-harm or the risk of self-harm. It was unclear if this referred to the fact of his refusing food and fluids. Ms Williams told the Inquiry that no ‘in person’ risk assessment was carried out prior to the planned use of force in this case, nor did these routinely occur prior to a use of force.²⁷

52.4 D2159 was put in an inverted wrist hold and an arm hold/lock, and was then handcuffed for five minutes. A four-man Control and Restraint team was used, in full PPE, including the use of a shield.²⁸ At one point, D2159 appeared to be resisting because he dropped to his knees, but this could also have been because he was too weak to stand as a result of his food and fluid refusal.²⁹ As noted by Mr Jonathan Collier, the Inquiry’s use of force expert, the use of such force on someone who was physically weak was unnecessary and disproportionate to the risk. ³⁰ There was no intervention by Healthcare staff, despite D2159’s obviously weakened physical state, which was an abject failure in their monitoring role during the use of force. Ms Williams accepted in evidence that force should not have been used on D2159 to move him to E Wing, and that she should have intervened to raise contraindications prior to the use of force and the use of handcuffs. She also agreed that she should have raised concerns about his physical state at the time.³¹ This contributed to an unnecessary and disproportionate use of force on a vulnerable detained person.

52.5 The next entry in the medical records – made by Raymond Little (RGN) – stated that D2159 was moved from D Wing to E Wing, and that no force was required, as he was “fairly weak”.³² This was clearly inaccurate. The disconnect between the medical record and the Use of Force documentation is of serious concern.

52.6 More generally, there appeared to be a lack of engagement in the process on the part of Healthcare staff. Instead, the custodial management of the detained person was prioritised and Healthcare staff showed a deference to detention staff and security issues, as opposed to a focus upon patient welfare. The safeguards, which should have operated to protect D2159, failed.

53. On 25 April 2017, D1527 was the subject of an unplanned use of force as a result of his attempting to strangle himself with his own hands.

53.1 Four officers dressed in full PPE forcibly restrained D1527 on the floor of his cell in order to prevent him harming himself. There was a physical struggle that lasted some time, during which D1527 was distressed. DCO Ioannis (Yan) Paschali took up a position kneeling at D1527’s head facing his feet with his knees either side of D1527’s head. In the course of Mr Paschali’s restraint, he placed his hands on D1527’s neck in what has sometimes been described as a ‘chokehold’. D1527 was heard to make a choking noise and to say, several times, “my neck”. Mr Paschali told D1527, “I’m going to put you to fucking sleep.” Mr Tulley was heard to say, “Yan, easy.” Ms Joanne Buss (RGN) was present in the cell throughout the restraint. Eventually, D1527 was forcibly put into the recovery position and subsequently the officers left the cell and the restraint ended.

53.2 Ms Buss was referred to the Nursing and Midwifery Council (NMC), the regulatory body for the nursing professions, by G4S Health Services as a result of this incident. Disciplinary proceedings were brought against her; she admitted all charges, and was removed from the register in February 2021, although she had already retired from nursing.³³

53.3 By the time she gave evidence to the Inquiry, her position had changed from that in the NMC proceedings. Ms Buss did not accept that she had:

• seen Mr Paschali applying a ‘chokehold’, where his hands were on D1527’s neck;
• heard any choking noise;³⁴
• heard Mr Paschali say: “I’m going to put you to fucking sleep”;³⁵
• heard D1527 say “my neck” any of the five times he said those words;³⁶or
• heard Mr Tulley’s intervention with Mr Paschali.³⁷

53.4 Ms Buss told the Inquiry that she had no memory of the incident, stating that if she had seen or heard the above, she would have reported it or stopped it.³⁸ This assertion was made and maintained despite the incident being captured on covert footage filmed by Mr Tulley.³⁹ This footage clearly showed the actions and comments detailed above, with Ms Buss directly next to D1527 and Mr Paschali at the time, as she can be identified from footage walking around Mr Paschali because her shoes are visible, as she accepted in her evidence.⁴⁰

53.5 Ms Buss told the Inquiry that she “couldn’t see hardly anything”.⁴¹ Based upon both the video and documentary evidence, I have concluded that Ms Buss was in a position to see or hear the incident as set out above, and I consider it probable that she did witness this inappropriate conduct without challenging or reporting it.⁴² She had a duty to do both.⁴³ She did not raise any concerns throughout the entirety of the use of force and restraint upon D1527. She should have challenged the actions of the other staff at the time in the strongest possible terms, and reported the incident immediately to relevant managers.

53.6 Even if I had been persuaded that Ms Buss was not in a position to see or hear what was happening, I would have concluded that she should have moved so as to be able to monitor his safety, raised a concern with the officers that she could not adequately monitor his safety, or acted immediately to stop the restraint. Ms Buss did not do any of those things. She did not intervene at any stage of the use of force or restraint on D1527, despite being aware of the length of time the restraint had continued and of four officers struggling with him on the ground, and despite hearing the noises he was making. She should have taken action immediately, decisively and as a matter of urgency. At the very least, Ms Buss should have raised a concern with the officers, stating that there was no immediate risk to his life and therefore use of force was no longer necessary. The safeguards designed to protect D1527, keep him safe and ensure his welfare were the subject of an egregious failure. The inaction of Ms Buss allowed D1527 to be exposed to appalling treatment by detention staff and a terrifying ordeal.

53.7 Despite this, having reviewed the video footage, Ms Buss denied any inappropriate behaviour on her part, except that she accepted referring to D1527 as an “arse”. She apologised for this, although she said that the door to his cell was shut and there was no possibility that he could have heard it.⁴⁴

53.8 D1527 was forcibly put into the recovery position and the restraint continued. Ms Buss accepted that he was very distressed at this stage and she considered him to be unwell. Nevertheless, she raised no concerns then or afterwards.⁴⁵ I agree with Dr Hard that she should have stopped the restraint and shown “some level of concern for the welfare of the detained person who is lying on the floor in a very distressed state”.⁴⁶ Dr Hard said, “But I don’t see anything other than what appears to be disdain.”⁴⁷I consider this demonstrated a total disregard for D1527’s welfare during an intense and prolonged use of force against him.

54. Following the incident, Ms Buss had a conversation with Mr Tulley. As a result, she understood that neither he nor any other DCO involved was going to complete the requisite Use of Force report. Although she was aware that this was mandatory, she did not raise any concern with Mr Tulley or anyone else. Ms Buss had no convincing explanation as to why she did not do so.⁴⁸ As a healthcare professional, she, and any member of staff, had a duty to challenge this inappropriate behaviour and report it to management.⁴⁹
55. Ms Buss did complete other documentation.

55.1 Within the ‘ongoing observations’ section of the ACDT document, she recorded:

“Seen in room 7. Constant watch. D1527 had tied a T-shirt around his neck. Angry, upset. Had mobile phone battery in his mouth. Attempted to self-strangulate in toilet. Visual obs due to demeanour. Resp 16.”⁵⁰

There is no mention of a use of force or restraint. There is no record of D1527’s presentation or demeanour, other than that he was “angry” and “upset”. This description does not begin to accurately record the events or capture the severity of D1527’s distress, or consider that it was likely to be a result of underlying mental ill health.⁵¹ I agree with Dr Hard that the entry does “not remotely” accurately convey D1527’s presentation and the restraint on him and that the ACDT record was “not adequate at all”.⁵² Its effect was positively misleading.

55.2 Ms Buss’s entry in D1527’s medical record noted:

“Examination: placed on rule 40 constant supervision as he refused to return to E wing. Called to E wing at [approximately] 19:00. Constant watch. Had placed a ligature around his neck. Removed by staff. Staff trying to engage with him. RMN Dalia tried to engage with him with minimal effect. Put mobile phone battery in his mouth which he later removed battery removed from his room. Went to toilet and attempted to self-strangulate. Angry and not engaging with staff. Hands removed from his neck by staff. Salivating ++. Unable to take any observations. Visual obs resps 16. Slight redness noted on his neck. 20:00 got up and walked around room. Taken a small drink. Restless. Constant watch continues. Not engaging with staff. Plan: pls review later this evening.”((CJS001002_038))

Again, there is no mention of a use of force or restraint on D1527, other than to say that a ligature and his hands had been “removed” from his neck by staff. I agree with Dr Hard that there should have been.⁵³ There is no record of D1527’s clinical presentation, as might be expected to ensure appropriate future treatment, other than that he was “angry and not engaging with staff”.⁵⁴ As Dr Hard noted, it does “not even remotely” convey the totality of the nature of the incident and “it feels somewhat blaming of the detained person for the incident”.⁵⁵ The language used in this record again minimised the severity of the incident and the nature, degree and duration of the use of force on D1527.⁵⁶

56. Ms Mariola Makucka (RGN) completed the Healthcare staff member’s section of a ‘Report of Injury to Detainee’ form (F213) on behalf of Ms Buss.⁵⁷ It records:

“Seen on E Wing room by RGN Jo. Detainee had placed a ligature around his neck, removed by staff. After this he went to toilet and attempt [sic] to self-strangulate. Hands removed from his neck. Slightly [sic] redness noted on his neck.”⁵⁸

This language again completely obscured the true nature of what happened to D1527 in this incident.

57. Ms Buss maintained to the Inquiry that she completed her documentation appropriately. She did not expressly accept that the notes minimised the seriousness of the incident and the nature of the force used against D1527, although she did accept that her notes could have been “fuller” and “better”.⁵⁹ I consider that the medical records – which should have been clear and accurate in order to support safe and effective care – were entirely inadequate. This was a significant failure on her part to fulfil her duties as a nurse towards her patient.⁶⁰
58. The only evidence of any Healthcare monitoring of D1527’s condition and welfare following this serious incident was a visit by Dr Oozeerally on E Wing for a review under Rule 40 on 26 April 2017. There was no further record in the medical notes by any member of Healthcare staff on that night or the following day. In the circumstances, in my view, D1527 should have been reviewed by Healthcare staff overnight prior to Dr Oozeerally seeing D1527 and thereafter. Dr Oozeerally’s note in the medical record, timed at 10:36 on 26 April 2017, reads:

“History: seen in E wing. He says he feels well today and no medical problems. I believe he presented with challenging behaviour overnight but settled and later became co-operative.”⁶¹

This note is so brief as to be of little assistance in ascertaining the nature of his review of D1527. There is no evidence of any physical or mental state examination of D1527, which, in the circumstances, was required.

Dr Oozeerally’s note is indicative of an extremely cursory review, which in effect was likely to have consisted merely of asking D1527 how he was. This was wholly inadequate and is indicative of the system designed to safeguard vulnerable detained people failing once again.⁶¹

59. Dr Hard suggested that better training and a more robust approach towards use of force are needed so that healthcare staff fully understand and fulfil both their safeguarding and monitoring roles.146 In his 2016 report, Mr Shaw noted that nursing staff in IRCs attended all planned use of force incidents but had no formal training for their role and responsibilities in relation to the use of force.⁶² Ms Calver stated that she was responsible for “looking after all the nursing staff and leading the nursing team, so being in charge of all the nursing roles, giving them supervision”.⁶³ She also told the Inquiry that “at the time” it did not concern her that force was being used on vulnerable detained people, although it was of concern to her when she gave evidence.⁶⁴ In my view, given her important role at Brook House, Ms Calver should have made sure that she and her staff understood their safeguarding and monitoring roles in relation to the use of force and that they were fulfilling those roles in practice wherever force was used against vulnerable detained people. They could have done this by raising concerns or contraindications to the use of force with detention custody staff where necessary.
60. Dr Bromley told the Inquiry that PPG’s healthcare staff are not trained in use of force but can attend the refresher training given to detention staff to observe and see what the response from healthcare staff should be.⁶⁵ The Inquiry understands that more bespoke training is planned.⁶⁶ Dr Bromley also stated that monthly use of force meetings – at which all use of force incidents in the previous month are reviewed and footage of one or two cases is examined – are attended by a member of healthcare management and a clinical staff member. At the time of the Inquiry’s public hearings, it remained unclear whether these meetings adequately enabled healthcare staff to fully understand the nature and extent of their safeguarding role in relation to the use of force on vulnerable detained people, and the importance of this role in protecting vulnerable detained people from harm.
61. In all the circumstances, it is unclear whether sufficient action has been taken to address the deficiencies relating to the role of healthcare staff in use of force incidents. I remain concerned that a risk of the inappropriate use of force on vulnerable detained people may well persist. I am therefore recommending that guidance and mandatory training be introduced for healthcare staff in immigration removal centres in order to ensure that they fulfil their role in relation to use of force, both prior to and during an incident.

Recommendation 19: Guidance and training for healthcare staff on the use of force The Home Office must ensure that guidance is issued to healthcare staff in immigration removal centres clarifying their role in use of force incidents. It must liaise as necessary with NHS England and any relevant medical regulators. The Home Office must ensure that mandatory training is introduced for healthcare staff, and those responsible for managing them, on their roles and responsibilities in relation to planned and unplanned use of force (liaising with NHS England and any other relevant parties). The training must be subject to an assessment.

1. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, paras 6.7- 6.8[↩]
2. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, paras 4.24-4.26; Detention Centre Rules 2001, Rule 41; INQ000111_013 para 28; Dr James Hard 28 March 2022 87/2-8[↩]
3. Dr James Hard 28 March 2022 137/11-138/9[↩]
4. Dr Rachel Bingham 14 March 2022 50/5-51/5; Theresa Schleicher 14 March 2022 89/7-25, 90/1-12, 97/25-98/22; Theresa Schleicher 14 March 2022 89/7-25; Dr James Hard 28 March 2022 163/19- 164/16[↩]
5. Prison Service Order 1600: Use of Force (INQ000185), HM Prison Service, August 2005, paras 6.3-6.8; BHM000033_49 para 130; Joanne Buss 14 March 2022 118/17-23[↩]
6. Dr James Hard 28 March 2022 89/5-9[↩]
7. Dr James Hard 28 March 2022 90/16-24[↩]
8. Dr Rachel Bingham 14 March 2022 44/3-45/19; CJS000990_001[↩]
9. CJS000990_003[↩]
10. CJS000990_013-014[↩]
11. Dr Husein Oozeerally 11 March 2022 136/9-138/15[↩]
12. Dr James Hard 28 March 2022 90/6-92/18, 93/25-95/25; Dr Rachel Bingham 14 March 2022 44/3- 45/10, 48/5-48/16[↩]
13. Day 8 AM 2 December 2021 03:11:15-03:17:53 (Disk 50 UOF 134.17 cam 3)[↩]
14. Dr Husein Oozeerally 11 March 2022 134/21-135/11[↩]
15. Dr Husein Oozeerally 11 March 2022 136/9-138/15[↩]
16. Dr James Hard 28 March 2022 88/25-89/4 and 89/10-14; Prison Service Order 1600: Use of Force  (INQ000185), HM Prison Service, August 2005, paras 6.7-6.8[↩]
17. Sandra Calver 1 March 2022 251/2-14; Joanne Buss 14 March 2022 142/14-20[↩]
18. Christine Williams 10 March 2022 86/13-22; Joanne Buss 14 March 2022 138/10-14[↩]
19. Christine Williams 10 March 2022 109/21-110/22, 111/6-116/4[↩]
20. Dr Rachel Bingham 14 March 2022 50/20-52/10[↩]
21. INQ000111_075 para 300[↩]
22.  CJS006999[↩]
23. CJS007001[↩]
24. CJS007001 ; Christine Williams 10 March 2022 107/11-22[↩]
25. Christine Williams 10 March 2022 108/12-109/5[↩]
26. CJS005529_002-003[↩]
27. Christine Williams 10 March 2022 105/2-22[↩]
28. CJS005529_003[↩]
29. Christine Williams 10 March 2022 109/9-13[↩]
30. INQ000111_035 para 128; INQ000111_036 para 130; INQ000111_036 para 133[↩]
31. Christine Williams 10 March 2022 109/21-110/22[↩]
32. CJS007001[↩]
33. INN000025_031-035 paras 50-53[↩]
34. Joanne Buss 14 March 2022 132/16-133/15[↩]
35. Joanne Buss 14 March 2022 136/10-25[↩]
36. Joanne Buss 14 March 2022 139/14-140/25[↩]
37. Joanne Buss 14 March 2022 137/1-11[↩]
38. Joanne Buss 14 March 2022 133/23-135/10[↩]
39. Day 2 AM 24 November 2021 00:34:29-00:53:24 (KENCOV1007 – V2017042500020) and 00:53:55-01:23:53 (KENCOV1007 – V201704200021[↩]
40. Joanne Buss 14 March 2022 137/12-138/9[↩]
41. Joanne Buss 14 March 2022 135/17-136/7[↩]
42. Joanne Buss 14 March 2022 123/15-124/21, 126/17-128/3, 131/10-132/5[↩]
43. Dr James Hard 28 March 2022 121/6-123/6[↩]
44. Joanne Buss 14 March 2022 110/9-112/7[↩]
45. Joanne Buss 14 March 2022 145/20-147/16[↩]
46. Dr James Hard 28 March 2022 128/14-130/8[↩]
47. Dr James Hard 28 March 2022 128/14-130/8 [↩]
48. Joanne Buss 14 March 2022 148/13-150/22, 151/22-153/9[↩]
49. Raising Concerns: Guidance for Nurses, Midwives and Nursing Associates, Nursing and Midwifery Council, updated January 2019. The Inquiry understands that the same guidance was in place in 2017[↩]
50. CJS001085_017[↩]
51. Joanne Buss 14 March 2022 133/23-135/10[↩]
52. Dr James Hard 28 March 2022 131/8-132/25[↩]
53. Dr James Hard 28 March 2022 133/1-134/5[↩]
54. Dr Rachel Bingham 14 March 2022 17/18-18/22[↩]
55. Dr James Hard 28 March 2022 134/6-19[↩]
56. Dr James Hard 28 March 2022 134/6-135/5[↩]
57. The F213 form is routinely annexed to the Use of Force – DCF 02 form and section 3 is used to record healthcare staff’s observations from a clinical perspective on the use of force incident and any injuries to the detained person. The detention custody sections (sections 1 and 2) of the F213 form were blank because they were not filled in by any of the detention custody staff involved in the use of force, as they should have been. The reader is able to understand that force was used upon D1527 from this documentation because it forms part of the Use of Force documentation as a whole[↩]
58. CJS005534_010-011[↩]
59. Joanne Buss 14 March 2022 153/1-155/5, 156/9-157/25[↩]
60. Dr James Hard 28 March 2022 131/8-136/24; Dr Rachel Bingham 14 March 2022 15/4-18/2[↩]
61. For examples of the GP reviews, see: KENCOV1034 – V2017061100005[↩][↩]
62. INQ000060; Sandra Calver 1 March 2022 249/20-251/5[↩]
63.  Sandra Calver 1 March 2022 142/1-5[↩]
64. Sandra Calver 1 March 2022 247/22-248/25[↩]
65. PPG000172_004 para 20[↩]
66. PPG000204_007 paras 29-30[↩]