Cultural issues continued

Abusive and derogatory language

90. The Inquiry heard numerous examples of abusive and derogatory language – as well as childish behaviour – by G4S staff towards and about detained people. These ranged from demeaning comments about detained people in conversations between staff to direct verbal abuse towards detained people.
91. It was commonplace for staff to talk about detained people in an abusive and derogatory manner. Various members of staff, including Mr Paschali, Mr Small, Mr Lake and Mr Francis, acknowledged that verbal abuse and swearing towards detained people were widespread.¹ It was described as “prolific”, “commonplace” and “the norm”.² This was noted by Professor Bosworth, who commented that, in Mr Tulley’s covert footage, “All of the officers swore all of the time.”³ She described this as “completely unacceptable”.⁴ One DCO who had previously worked in a prison was recorded saying, “It’s unprofessional here … you get staff that call detainees dickheads to their faces and stuff like that.”⁵
92. Some of the most pernicious examples of staff talking about detained people in this way included staff talking about past violence, verbal abuse and threats to detained people, or describing future intentions to use violence.

92.1 In relation to an incident involving D1527 on 25 April 2017 (discussed in Chapter C.4 in Volume I of this Report), Mr Stokes was recorded on 4 May 2017 saying to Mr Tulley about D1527, “Did you not have the urge to just punch him in his face as he’s gone up and ‘bang’.”⁶ In oral evidence, Mr Stokes apologised for any upset or insensitivity arising from what he had said, and explained that he was “letting off steam” among colleagues.⁷ On 9 May 2017, Mr Derek Murphy and Mr Paschali had a conversation about D87 in the presence of Mr Tulley. Mr Paschali said:

“I’d love to get in the ring with him. Put the gloves on and see what he’s fucking made of. I would love to … He’s just got some shoulders and a bit of height. Fucking crack him straight in the ribs.”⁸

Mr Murphy replied, “Straight in the solar.” They both went on to discuss incidents of violence they had been involved in outside Brook House. Mr Murphy claimed in oral evidence that they were exchanging “tall stories” made up for Mr Tulley’s benefit.⁹

92.2 On 31 May 2017, Mr Paschali was discussing with Mr Tulley the possibility of a detained person returning to Brook House, saying, “If he comes up to you just fucking floor him. Don’t restrain him give him the hardest kick you fucking can.”¹⁰

92.3 On 20 June 2017, DCM Nathan Harris spoke with Mr Derek Murphy, Mr Sayers and Mr Tulley about what should happen with people who were deported, saying, “I reckon they should do what they do on Con Air masking tape, bag ’em, job done … Just tape over the mouth, bag over the head.” He added:

“We should just go back to putting them to sleep mate really … Get the gas, chuck it in there, they’re all knocked out … needle in, he wakes up in fucking wherever.”¹¹

Neither Mr Sayers nor Mr Murphy reported any of these comments at the time. In oral evidence to the Inquiry, Mr Sayers said he did not recall this conversation but accepted that it was the sort of thing he should have reported.¹²

92.4 On 13 August 2017, Mr Derek Murphy described to a fellow officer how he had gone into the cell of a detained person (understood to be D149), who he described as a “fucking arsehole”, and said:

“Oy, get the fuck out of bed. Clean this shit up. You ain’t going nowhere until you clean this up, you little prick … If you don’t clean it up within the hour, I’m going to come and smash the fucking shit out of you and you ain’t doing no flying.”¹³

He also described throwing a quilt at D149, saying “Get the fuck out” and “Put it in a fucking bag before you go.”¹³ When investigated by G4S, Mr Murphy did not contest the allegations about this comment, but said he had a good relationship with D149 and therefore D149 would have known he did not mean it.¹⁴ In oral evidence, Mr Murphy said he could not recall this incident but accepted that the language was inappropriate and sounded “like a threat”.¹⁵

92.5 On 19 June 2017, Mr Tomsett described D693 as a “horrible bastard”.¹⁶ On the same day, he recounted to Mr Tulley that he had said to D693:

“You throw the first one, and I’ll fucking put you out of your misery. If you throw the first one, I’ll fucking put you out of this office. So, it’s up to you mate. Stinking attitude.”2¹⁷

Although he said in his statement that he would never threaten a detained person, and in oral evidence he stated, “I was just standing up for myself”, he accepted that it went beyond that.¹⁸ I consider this to have been an example of threatening behaviour.

93. There were also multiple occasions on which staff were recorded by Mr Tulley being directly abusive towards detained people. While these are likely to have been only a small proportion of the occasions on which abusive language was used during the relevant period, they reflect a pattern of demeaning and threatening conduct from staff directed at detained people.
94. Troubling examples of abuse towards detained people include the following.

94.1 There were multiple examples of abusive language used by Mr Derek Murphy towards detained people. On 14 June 2017, Mr Murphy said to a detained person: “You look like a fucking mong. Get in your room.” He then said: “He looks like a right cunt doesn’t he?”.¹⁹ In his evidence to the Inquiry, Mr Murphy accepted that the language was inappropriate and unprofessional.²⁰ On the same day, he was filmed telling D149 to “stop fucking about” and said:

“Listen, I don’t want to come back in this room again. You will be in trouble, all right? … You understand? You don’t want to be in trouble with me. Trust me.”²¹

94.2 On 19 June 2017, Mr Sayers was recorded calling D720 a “cunt” and a “fucking dick”, threatening him with a “fucking warning” and saying to him “I am going to skull fuck you like the little bitch you are.”²²

This was said in front of other detained people and members of staff. Nobody reported the incident at the time. In his evidence to the Inquiry, Mr Sayers accepted that this was an aggressive use of language and sounded like a threat, but maintained that it was not an aggressive situation and was not in fact a threat. He described D720 laughing and asserted that he had a rapport with him.²³

94.4 On 2 June 2017, Mr Fiddy was recorded describing a detained person as an “absolute poofter”.²⁴ Although he said he had no recollection of the incident, he accepted subsequently that it was “terrible language and behaviour, and I’m sorry”.²⁵

94.5 As discussed in Chapter C.9 in Volume I, I found that Mr Tomsett probably told D1538 that he needed to change his clothes as he “looked gay”, and this led to him being mocked by other detained people for days after the comment.²⁶ This incident was not recorded by Mr Tulley and Mr Tomsett denied the allegations.²⁷

95. Inappropriate behaviour by staff also included, on some occasions, a callous disregard for the lives of detained people.

95.1 On 20 April 2017, Mr Tulley noted that Mr Paschali had said words to the effect of “I don’t care if he lives or die[s]” about a detained person for whom he was performing constant supervision duties, that he bragged about having once broken someone’s arm in three places during a restraint and that he said of a detained person that he would like to “fucking do him”.²⁸

95.2 During the same incident described above, Mr Stokes was recorded on 4 May 2017 saying that the best way to deal with someone like D1527 was “Turn away and hopefully he’s swinging, probably.”²⁹

95.3 In discussions about a planned use of force against D1914 on 28 May 2017, several staff members made derogatory comments about him. After discussion of D1914’s medical history, including the fact that he was scheduled to undergo heart bypass surgery, Mr Lake speculated that D1914 may fake having a heart attack and said, laughing, “If he dies, he dies.”³⁰ When Mr Tulley said that he was nervous about the use of force, Mr Paschali responded: “Oh relax man, you will be fine.” Mr Webb added: “If he dies, he dies … It’s nothing on us.”³¹ Mr Webb also referred to D1914 as a “cunt”.³²

96. Despite all of the above, only two members of staff – Mr Fagbo and Ms Munroe – were dismissed for directing abusive language at a detained person that was not shown on the Panorama programme.³³ Both incidents involved D119.

96.1 It was alleged that, on 21 April 2017, Mr Fagbo called D119 a “dickhead” or a “fucking dickhead” and used other derogatory language towards him, such as saying, “I get to go home and you are stuck here.”³⁴ Both D119 and D720³⁵ complained about this incident and, during a disciplinary investigation, at least two members of staff said that Mr Fagbo had called D119 a “fucking dickhead”, was being aggressive and was antagonising D119.³⁶ Mr Fagbo accepted at the time,³⁷ and in oral evidence to the Inquiry,³⁸ that he had called D119 a “dickhead” in response to what D119 was saying to him.

96.2 D119 also alleged that, on 22 April 2017, the day after the incident with Mr Fagbo, he had been subjected to abusive comments from Ms Munroe.³⁹ Ms Munroe denied much of what she was alleged to have said⁴⁰ and told the Inquiry of highly offensive remarks made to her by D119.⁴¹ In oral evidence, she accepted saying something along the lines of “fuck you”, “fuck off” or “shut the fuck up” in response.⁴² There was an investigation, and a letter of dismissal from Mr Skitt concluded that both Ms Munroe and D119 were using inappropriate and offensive language and were shouting and screaming at each other.⁴³

97. In both incidents, the staff members accepted using inappropriate language towards D119 after having received racist and other verbal abuse from him.⁴⁴ Although other former members of staff told the Inquiry about receiving verbal abuse from detained people, ethnic minority staff also faced racist abuse and were thus particularly affected.⁴⁵ Nevertheless, there remained a power imbalance between those staff members and detained people. Staff members should not have responded by using abusive language towards detained people.
98. There were concerns raised by both Mr Fagbo and Ms Munroe in relation to both investigations.

98.1 There were four or five months between suspension and disciplinary hearings (without any identifiable reasons for this) despite initial investigation interviews happening soon after the incidents. More broadly, delays are likely to have had a negative impact both on staffing levels and on staff morale, as well as being suggestive of an organisation that was unable to run proper investigations.⁴⁶

98.2 Both Mr Fagbo and Ms Munroe thought that their dismissals were related to the Panorama programme.⁴⁷ Mr Fagbo was informed of his dismissal on 16 August 2017, before G4S learned of the Panorama programme on 24 August.⁴⁸ Ms Munroe’s dismissal occurred soon after the broadcast, and therefore it may well have played some role in the decision to dismiss her, although the outcome is consistent with that reached for Mr Fagbo.

98.3 Both officers are Black and felt that their race had some impact on the decision to dismiss them. Mr Fagbo gave an example of a White female officer who swore at a detained person but was not disciplined.⁴⁹ Ms Munroe suggested that covert racism played a part, noting that there were “a lot of accusations of officers using bad language”.⁵⁰ She gave DCO Bonnie Spark, who was still working at Brook House, as an example of this – although I note that the recorded instance of Ms Spark using bad language was directed at a fellow officer (Ms Munroe) rather than at a detained person.⁵¹ Mr Skitt denied that race had any role in the dismissals and said that both officers were treated in line with what was presented to him at the disciplinary hearings.⁵² While I do not think there is sufficient evidence to make a finding on this issue, I am conscious that two of the few Black members of staff were the only two staff members dismissed for verbal abuse during the relevant period, separate to that shown on the Panorama programme.

99. Multiple witnesses to the Inquiry and several other former staff members said that they did not witness any direct verbal abuse of detained people.⁵³ Given the examples set out above, I do not find it credible that so many staff members genuinely did not witness verbal abuse.⁵⁴ Those who said that they did not hear direct verbal abuse largely accepted that abusive language about detained people was used by staff members among themselves.⁵⁵ In any event, I am confident that the examples of which the Inquiry is aware were not the full extent of the use of such language during the relevant period. There would have been countless other conversations between staff during which it is likely such language was used.
100. The suggestion by some that this was just about swearing is, at best, a mischaracterisation of the evidence received by the Inquiry. I also reject attempts to justify the language used on the basis that Brook House was not a normal workplace and that swearing was common and inoffensive.⁵⁶ First, this was not restricted to swearing but, as set out above, included shocking language towards and about detained people. Second, in a setting in which staff have a duty to care for vulnerable detained people and where there is an imbalance of power, the language used is even more important in contributing to a relationship of trust between them. It does not mean that a more lenient approach to abusive and derogatory language is needed; in fact, it means the opposite.
101. There is no such thing as “consensual banter” in such a setting.⁵⁷ Swearing or offensive language among the detained population or by them towards staff does not excuse or permit the same by staff. Similarly, as noted above, there was evidence of verbal abuse and threats made by detained people towards staff.⁵⁸ However, this does not justify staff verbally abusing detained people. The nature of discussions about detained people or interactions with them was indicative of the way in which some staff thought about detained people. It is likely to have affected the way staff treated detained people.
102. The nature of discussions about detained people or interactions with them was indicative of the way in which some staff thought about detained people. It is likely to have affected the way staff treated detained people. This was not only unprofessional but deeply troubling. It was harmful, unacceptable and has no place in an IRC, in which staff should be conducting themselves professionally. As Professor Bosworth noted, the language used towards and around detained people was “corrosive”, contributed to an “us and them” mentality and “played quite a large role in the physical manifestation” of abuse.⁵⁹
103. The reasons for the prevalence and nature of abusive and derogatory language are varied, and it is likely that different motivations applied to different members of staff at different times. I have considered potential explanations that may be relevant to any actions taken to address these behaviours.

103.1 Reaction to stressful conditions: The evidence of some members of staff showed that, when faced with detained people in distress, they responded with mockery or anger. Mr Instone-Brewer thought that verbal abuse of detained people was caused or contributed to by staff morale being so low and staff being tired and under considerable pressure.⁶⁰ Mr Tulley noted that Mr Tomsett’s workload was very heavy, and that when he was stressed he would take it out on detained people, “probably as a way of venting off his anger and his stress”.⁶¹ Professor Bosworth expressed a similar view in her report, noting: “The coarse language evident in the footage could be evidence of high levels of frustration among the staff.”⁵ One response by some staff to the challenges of their job is to create an “emotional barrier” between them and detained people, which can lead to them not appreciating the difficulties that detained people are facing.⁶²

103.2 A culture of dehumanisation of detained people: Some staff appeared to view detained people as being less human, making those staff more likely to use abusive language.⁶³ Dr Brodie Paterson (on behalf of Medical Justice) and Professor Bosworth agreed that such dehumanisation is more likely to happen where the subjects are already part of a marginalised group, such as asylum seekers and foreign nationals facing removal.⁶⁴

103.3 An attempt to fit in: One reason given by DCO Kalvin Sanders and Mr Small for making derogatory comments was that they were trying to fit in with their colleagues.⁶⁵ I agree with Professor Bosworth that Mr Sanders “said and did lots of terrible things and to say he was just trying to fit in is a little bit denying his responsibility for that”.⁶⁶ Mr Small said: “everyone made such comments. It’s not something I’m proud of. I think it’s horrific. I am ashamed and embarrassed to be honest with you.”⁶⁷

103.4 Effects of the environment at Brook House: It is clear that some members of staff felt that it was the effect of working at Brook House that had caused them to use derogatory language. Mr Small was recorded during the relevant period as saying, “This job has made me racist, man.”⁶⁸ In evidence to the Inquiry, he also explained that he had started to “mould to” the environment around him.⁶⁹ While this clearly does not relieve Mr Small or other officers of responsibility for their actions, certain ways of talking to and about detained people in a derogatory and often racist manner were “clearly encouraged” by a group of officers, which made other staff more inured to the impact of that conduct.⁷⁰ This accords with the evidence of Mr Francis, who said that he was led into using derogatory language by more dominant staff members.⁷¹

103.5 Lack of concern about being reported: Ultimately, staff were not deterred from using abusive and derogatory language, in part because there was no robust approach to challenging it, but also because there was a low prospect of it ever being reported. Professor Bosworth considered that such language being so widespread suggested that nobody was worried that they would be reported for its usage.⁷²

104. Mr Petherick said that, if he had heard any inappropriate language, he would have addressed it immediately and followed it up via disciplinary action.⁷³ That may be true, but it is of limited relevance, given the infrequency with which he walked around the corridors of Brook House and the likelihood that staff would have been more careful about what they said in front of him.
     There is some evidence that G4S took disciplinary action when abusive language was reported (such as in the cases of Ms Munroe and Mr Fagbo), but on many other occasions this does not appear to have been the case (such as with the allegations against Mr Tomsett).⁷⁴

Grievances

105. The extent to which staff raised grievances about one another appears to have been a significant aspect of the culture at Brook House. These grievances are important because of their content and what they show about the staff culture at Brook House and the failure of management to heed warning signs.
106. In the years prior to the relevant period, there was a widespread culture of senior managers at Brook House raising grievances against one another rather than resolving issues through discussion.⁷⁵ The majority of grievances related to complaints about the treatment of staff by other members of staff, and concerns about decision-making.⁷⁶ For example:

• In September 2014, Mr Duncan Partridge (Deputy Director) raised a grievance against Mr Saunders for bullying Mr Partridge and others.⁷⁷
• Mr Wayne Debnam (Head of Safety and Security) raised a grievance against Mr Partridge and Mr Saunders for bullying.⁷⁸
• Ms Stacie Dean (Head of Tinsley House) raised her first grievance in 2014 about Mr Saunders, workload and policy issues, and a subsequent grievance about various other issues.⁷⁹

107. The consequences of this were “difficult dynamics”, a “hostile and awkward” environment between members of the SMT at that time and a poor management culture.⁸⁰ This impact was sufficiently serious for there to be an “amnesty from grievance” at one point, and for Mr Petherick to become personally involved.⁸¹ Mr Hanford said that he had not seen “so many grievances from colleague to colleague and manager to manager together” in 31 years in the custodial environment.⁸² This reinforces a picture of an unhealthy working environment and a G4S management team that did not recognise the grievance culture as a symptom of a wider problem with staff culture and that was distracted from the core business of detaining people safely and decently.
108. There were also a number of grievances about matters similar to those subsequently shown on the Panorama programme, demonstrating that these issues were present and known to senior management prior to the relevant period. For example, Ms Dean raised a grievance in writing to Mr Neden around November 2016 and in a subsequent meeting with Mr Petherick in January 2017.⁸³ The grievance raised concerns about a failure to investigate the bullying of detained people by staff, staff bullying, the close relationship between members of the SMT and DCMs about whom complaints had been made, a toxic staff culture, a focus on profit by G4S and under-reporting of incidents. A follow-up email from Ms Dean also alleged that staff were known to have been supplying drugs to detained people.⁸⁴ All of these issues remained a concern during the relevant period. There was no evidence of any investigation or outcome regarding most of the issues raised in Ms Dean’s grievance.⁸⁵ The only outcome recorded was as follows:

“There were no under-reporting concerns discovered regarding incident reports or any intention to avoid financial penalties. There were no under-reporting concerns identified regarding internal reporting, which follows the C&DS [Custodial and Detention Services] model.”⁸⁶

109. During the relevant period, there were continued investigations of some grievances raised prior to the relevant period about bullying.⁸⁷ There were, however, very few new grievances raised by staff, suggesting that the earlier grievance culture may have been largely resolved.⁸⁸ The reasons for this are unclear. One exception is a grievance raised by DCO Kye Clarke alleging that, while he was on suspension in relation to a use of force incident with a detained person, people said that he would be sacked.⁸⁹ Mr Clarke resigned on the day of his disciplinary hearing and before any grievance investigation could be carried out.⁸⁸ Mr Clarke also said in his statement to the Inquiry that he raised a grievance around April 2017 about bullying by two DCOs.⁹⁰ However, there is no record of this grievance.⁸⁸
110. Overall, there appears to have been a dysfunctional SMT that likely paved the way for a toxic culture among staff during the relevant period. G4S managers at Brook House during the relevant period did not always take appropriate action when concerns were raised about the conduct of staff members, as is considered further in Chapter D.10.

Current staff culture

111. In 2019, in the wake of the Panorama programme, the Home Affairs Committee called on the Home Office urgently to monitor more closely the policies, procedures and practices of contractors to expose inappropriate behaviour, and to ensure that Home Office staff also received training on promoting a healthy staff culture.⁹¹
112. When Serco took over the contract to run Brook House, a large number of former G4S staff were transferred to continue, in effect, their existing roles under Serco. The Inquiry was told about a number of efforts that Serco has made to improve culture.

112.1 The current Serco contract for the management of Brook House contains provisions relating to “healthy staff culture”, including a key performance indicator (KPI) on the issue.⁹² However, there was a ‘relief period’ on all KPIs, including this one, between May and August 2020, such that no penalties would be applied for failure to comply.⁹³ From July 2021 and continuing in April 2022 when Mr Steven Hewer (the current Director of Gatwick IRCs under Serco) gave evidence, a “derogation” had also been agreed with the Home Office in respect of multiple KPIs including that related to staff culture.⁹⁴ Mr Hewer called this a “temporary arrangement” that had “gone on a bit longer than anticipated, from a Home Office perspective”.⁹⁵

112.2 All SMT members and Detention Operations Managers (DOMs) completed ‘Culture Development’ programmes.⁹⁶ Mr Hewer described a “Positive Detention Culture programme”, which he said:

“assesses the culture and conduct within the IRC against specific criteria … to create healthy behaviours amongst staff by encouraging positive role modelling and effective leadership”.⁹⁷

112.3 Serco’s current recruitment advertisements for DCO positions also place significant emphasis on the role being one of “supporting” people and helping to ensure that “residents are treated with decency and respect from the moment they arrive”.⁹⁸ The emphasis on attracting those with skills in relationship-building, and the need for emotional intelligence, patience and “a genuine commitment to helping people”, is appropriate and sets the correct tone at an early stage in recruitment.⁹⁹

112.4 The Inquiry heard that there is now a framework for investigating staff who are involved in three instances of misconduct or alleged misconduct in a three-month period. This ‘three in three’ approach was said to allow Serco to “monitor and record patterns of behaviour, identify trends and more importantly, ensure early intervention is applied, where needed, to maintain a healthy staff culture”.¹⁰⁰ While it is no doubt difficult to measure ‘culture’ in a quantifiable manner, the threshold of three concerning incidents in three months may be unnecessarily high and may risk overlooking infrequent behaviour or acts falling short of ‘misconduct’ that are nevertheless concerning.

112.5 A ‘House Rules’ document provided to detained people on arrival appropriately emphasises that they should expect “to be treated with dignity and respect”, and provides information about the Brook House IMB, GDWG and other external organisations, as well as how to complain, whether internally or to the Safer Community team.¹⁰¹

113. An HMIP report on an unannounced inspection of Brook House between 30 May and 16 June 2022 noted that “promising” work commissioned by Serco to understand staff culture was in “its early stages of implementation”, and recorded that “a large number” of staff were “inexperienced and operational leaders did not provide them with enough support in the unit”.¹⁰²
114. While I have seen evidence that steps have been taken by Serco in terms of protocols, training, and provision of a whistleblowing service, the derogation from the culture-focused KPI, high threshold for the ‘three in three’ programme and outdated materials (discussed above) are troubling. Serco has recognised that further reflection may be required and has stated that, once the Inquiry’s recommendations are published, it “intends to address the issues contained within the[m] … whilst reflecting on the evidence”.¹⁰³ I am concerned that insufficient progress has been made to address culture within Brook House.
115. More fundamentally, however, evidence heard during the Inquiry undermined Serco’s assurances that a culture is developing where unethical behaviour is not tolerated and that there is “complete transparency” in self- reporting failures.¹⁰⁴ Evidence from the following staff, in particular, caused concern.

115.1 Mr Stephen Loughton is now Assistant Director, having been a DCM during the relevant period. He was involved in an incident with D1527 discussed in Chapter C.4 in Volume I.¹⁰⁵ Despite his belief that D1527 was able to self-harm because DCO Clayton Fraser had failed to perform proper observations, Mr Loughton did not report his colleague or, as far as he could recall, take any action, as Mr Fraser “didn’t often work at Brook House”.¹⁰⁶ Mr Loughton did not accept, even with the benefit of hindsight, that there had been a ‘laddish’ culture or a culture of non- reporting.¹⁰⁷ When asked about describing D1527, immediately after his attempted self-ligature, as “sulking”, and challenged about calling him a “cock” and about offensive comments made by Mr Ring, Mr Loughton suggested that the Inquiry was “focusing on language … reading into it too much”.¹⁰⁸ I found his comment provided a damning insight into the continued lack of awareness of culture at Brook House.¹⁰⁹ His attempts to excuse other staff for using the phrase “if he dies, he dies” prior to a planned use of force on a detained person with a heart condition were completely unconvincing.¹¹⁰ He was asked for a view on D1527’s treatment by Mr Paschali, and replied, “I wasn’t there, so I can’t comment on that.”¹¹¹ Finally, his answers to questions about Mr Tulley (and his social media comments about the Panorama programme)¹¹² indicated that he felt “let down” by Mr Tulley and was in denial about what Mr Tulley had exposed, and gave the sense that he believed that the staff shown on the programme were the real victims.¹¹³

115.2 Mr Steven Dix was a DCM during the relevant period and is currently Assistant Director.¹¹⁴ He was involved in a concerning use of force incident involving D1978, also discussed in Chapter D.7. This showed mismanagement by Mr Dix resulting in force being used on a detained person who was attempting to comply. In a debrief following this event, Mr Dix lied about the rationale for using force, inaccurately stating that force was used because D1978 was “encroaching” on the team.¹¹⁵ When giving evidence to the Inquiry, Mr Dix admitted a “discrepancy”, but added, “I’m not saying I haven’t told the truth”,¹¹⁶ despite it being clear from the footage that he had lied. Rather than admitting to and apologising for fabricating his account, he gave various unconvincing explanations, blaming confusion, the moving of D1978 that followed, a lack of review of his own actions and a lack of “prior knowledge of what that footage showed”.¹¹⁷

115.3 Mr Christopher Donnelly was a DCM during the relevant period, and remains in post as a DOM.¹¹⁸ He was involved in an incident on 4 July 2017 in which, having found D865 on the floor of his cell, he failed to check for a ligature, which was therefore not removed until Mr Tulley entered and pointed it out. Mr Tulley believed that Mr Donnelly had done this intentionally and was “intent on allowing the detainee to suffer”.¹¹⁹ In his written statement (as well as in the course of an internal G4S investigation),¹²⁰ Mr Donnelly said he could not recall any detail and accepted that he “missed” the ligature but had relied on a DCO present to have seen it. It was not until his oral evidence in February 2022, following detailed questioning, that Mr Donnelly accepted that he intentionally omitted facts from documents completed on the day,¹²¹ including that there was a delay in removing the ligature and that Mr Tulley had to point it out to him, “probably because I didn’t want to make myself look bad”.¹²² Mr Donnelly also described the reaction to the Panorama programme in his written statement in terms that suggest that he and others were more concerned about Mr Tulley’s ‘betrayal’ and their own sense of injustice than by the shocking abuses shown:

“Devastatingly negative. Outraged. People felt betrayed, cheated and lied to. Overwhelmingly, every staff member said it was an outrageous travesty, unfair, biased and deceitful. They did not recognise it as the place where they worked.”¹²³

In his evidence to the Inquiry, Mr Donnelly appeared to maintain a similar view, saying that he and other staff had been outraged at “how unfair they thought it was”.¹²⁴

115.4 Mr Stewart Povey-Meier was a DCM during the relevant period and remains in the equivalent role.¹²⁵ He led a team involved in a use of force on D390 on 6 June 2017. As discussed in Chapter C.8 in Volume I, Mr Povey-Meier’s debrief was inadequate, and the use of force was not employed as a last resort.¹²⁶ When asked about this event, Mr Povey- Meier maintained that there was still “a risk” in allowing D390 a chance to comply, despite his team being safely behind a door.¹²⁷ In Use of Force documents following the event, Mr Sayers recorded that D390 refused an instruction prior to the use of force, but the footage showed that there was no such instruction and no time given to comply.¹²⁸ Mr Povey-Meier still refused to accept that this record was untrue, simply stating, “DCO Sean Sayers wrote his report based on what he believed he’d done.”¹²⁹ His failure to re-evaluate his actions, or acknowledge that his colleague was wrong, suggests a lack of willingness to learn and an ongoing effort to ‘close ranks’ rather than challenge errors or wrongdoing.

115.5 Mr Ryan Bromley was and remains a DCO.374 When asked about his actions during the relevant period, Mr Bromley gave the impression that he valued ‘protecting’ colleagues more than providing an honest reflection on what happened. In relation to the same event involving D390, he recorded that “D390 continued to ignore instructions from DCO Sayers” once staff had entered the cell, after which, “For the safety of the team, DCO Sayers advanced, placing the shield into his chest.”¹³⁰ Footage shown to him during his oral evidence demonstrated that Mr Sayers gave no such instructions, that D390 was not given any time at that point to comply and that, rather than “placing” a shield, Mr Sayers forcefully pinned D390 to his bed. Mr Bromley, however, stood by his description. Although he had (inaccurately) recorded at the time that de-escalation had continued after staff entered the cell, he appeared to suggest in his oral evidence that there was in fact no need to attempt further de-escalation: “if a detainee is boiling the kettle, threatening officers with it, then … talking to them … they are past that”.¹³¹ While officers had discussed whether a kettle was boiling in the cell, the Inquiry saw no evidence that D390 intended to use it as a weapon, or that he was threatening anyone in any way.¹³²As Mr Collier noted, D390 went on to walk very compliantly to the discharge area.¹³³

116. Mr Hewer was asked about a number of the accounts summarised above. He disagreed that employees had ‘closed ranks’. He recognised that Mr Loughton’s evidence suggested that he (Mr Loughton) had not appropriately reflected on the events in which he was involved.¹³⁴ Although he accepted that fabricating the rationale for a use of force was very serious and said he expected “honest, truthful evidence”, inexplicably Mr Hewer had not already taken the matter up with Mr Dix, despite being provided with relevant information some time before.¹³⁵ Mr Hewer told the Inquiry he hoped that “culturally-wise and from my leadership, that the team is open, honest and fully transparent now”, but accepted that evidence considered by the Inquiry suggested this was not so.¹³⁶
117. These are only some examples of evidence that caused me concern regarding current practice under Serco’s management of Brook House. I am particularly troubled that some staff involved in problematic events during the relevant period are now in senior roles, with responsibility for setting the culture, despite showing little or no real reflection on their actions. Mr Haughton was a rare example of a remaining member of staff who gave evidence and accepted a number of his errors during the relevant period.¹³⁷
118. The defensiveness and self-preservation of a number of current Brook House staff, some very senior, suggest a failure to learn from the relevant period. This is very concerning, given that self-reporting requires a significant level of trust in the ethical behaviour of staff, and assurance that wrongdoing by some would be reported by others.
119. Cultural change must start at the top, as recognised by Ms Newland:

“Culture is … driven from senior leaders, and … the work that we’re doing on positive detention culture at Gatwick has started with the SMT and is now being driven through … the first-line managers and the officers.”¹³⁸

As Mr Hewer also rightly said, a culture does not change overnight.¹³⁹ The evidence I have seen shows that there is still a long way to go. I was disappointed that Mr Hewer had to have excerpts from the transcripts of evidence from other staff read to him before he recognised that the cultural change he described in his statement did not reflect reality.¹⁴⁰

120. The spotlight of a public inquiry should not be required to effect this change. The Panorama programme and evidence subsequently seen or heard by the Inquiry were so significant as to require more urgent action. While it is appropriate for further reflection to take place in light of the Inquiry’s Report and recommendations, Serco should have already investigated and resolved the continuing cultural issues, and the Home Office should have ensured that this was done.¹⁴¹
121. Matters such as staffing and recruitment, support from managers and the culture of a workplace are the primary responsibility of the contractor. While the Home Office does not have direct control over policies and procedures, it should ensure that these issues are addressed when contracting with private firms, through robust and suitable systems and policies. I am therefore recommending that action be taken to improve the culture among staff.

Recommendation 27: Developing a healthy culture among staff Contractors operating immigration removal centres must develop and implement an action plan to ensure a safe and healthy staff culture in immigration removal centres. The action plan must address: ●  the identification of and response to any sign of desensitisation among staff; ●  training staff on coping mechanisms and secondary trauma awareness; and ●  maintaining an appropriate balance between care and safety or security. The Home Office must regularly monitor each contractor’s compliance with its action plan.

1. Daniel Lake 1 March 2022 28/9-29/8; Charles Francis 3 March 2022 9/11-11/8[↩]
2. Daniel Small 28 February 2022 125/10-126/23; BDP000003_006-007 para 18; Ioannis Paschali 24 February 2022 60/19-63/2[↩]
3. Professor Mary Bosworth 29 March 2022 84/4-5[↩]
4. INQ000064_037 para 7.17[↩]
5. INQ000064_037 para 7.21[↩][↩]
6. TRN0000096_002[↩]
7. Aaron Stokes 9 March 2022 191/23-193/15[↩]
8. TRN0000077_040-041[↩]
9. Derek Murphy 2 March 2022 37/2-39/19[↩]
10. TRN0000101_026[↩]
11. TRN0000084_010[↩]
12. Sean Sayers 10 March 2022 179/1-5[↩]
13. TRN0000024_003[↩][↩]
14. Derek Murphy 2 March 2022 55/22-24; HOM005830_005[↩]
15. Derek Murphy 2 March 2022 27/9-29/14[↩]
16. TRN0000083_002[↩]
17. TRN0000083_002 [↩]
18. Darren Tomsett 7 March 2022 37/15-39/19; INN000024_47-48 paras 159-162[↩]
19. TRN0000092_028[↩]
20. Derek Murphy 2 March 2022 58/12-19[↩]
21. TRN0000092_026[↩]
22. TRN0000083_038-039; Day 28 PM 10 March 2022 01:32:55-01:35:06 (KENCOV1037 –  V2017061900011) [↩]
23. Sean Sayers 10 March 2022 172/1-175/25[↩]
24. TRN0000031_005; KENCOV1029 – V201706020013, clip 1 00:25-00:45[↩]
25. Edmund Fiddy 7 March 2022 181/11-183/11[↩]
26. DL0000231_029 para 104[↩]
27. Darren Tomsett 7 March 2022 57/19-60/13; INN000024_054-056 paras 177-181[↩]
28. CPS000025_013-014[↩]
29. TRN0000096_002[↩]
30. KENCOV1025 – V2017052700012[↩]
31. KENCOV1025 – V2017052700011; CJS001160[↩]
32. KENCOV1025 – V201705270019[↩]
33. INN000013_028 paras 85-86[↩]
34. CJS001594; CJS005888_002; CJS005880; CJS005874[↩]
35. D720 subsequently withdrew his complaint, but this was still considered as part of the disciplinary investigation (see CJS001594_013) [↩]
36. See, for example, DCO Henry Hutton-Mawdsley (CJS005894_002) and DCO Vicky Moore (CJS005889_001-002). There was also evidence to suggest that D119 had used abusive and racist language towards Mr Fagbo (see CJS005280; TRN0000099_002; Luke Instone-Brewer 8 March 2022 65/23-67/10) [↩]
37. CJS005907_006; CJS0073303; CJS0072930[↩]
38. Babatunde Fagbo 4 March 2022 93/4-94/4; BFA000001_004 para 13; BFA000001_007 para 26[↩]
39. CJS005880_002. This was also supported by at least one staff member (see CJS005894). There was no reference to Ms Munroe in D119’s initial complaint (see INN000013_027 paras 82-83;CJS001594_001-002) but he made the allegations during his interview following the complaint made against Mr Fagbo[↩]
40. CJS005880; INN000013_025-026 para 78; INN000013_030-031 para 93; Shayne Munroe 4 March 2022 49/9-50/8[↩]
41. She said that D119 had said she was a “shit mum” and that her child would die after she swore on her child’s life that she had not been speaking about D119 (INN000013_025-26 para 78). She also said that he had made abusive remarks to her a few days before the incident (see Shayne Munroe 4 March 2022 46/3-6) [↩]
42. Shayne Munroe 4 March 2022 48/20-23[↩]
43. CJS005896[↩]
44. See, for example, CJS005884_002; CJS005881_002; INN000013_024-025 paras 76-78; CJS005880_003[↩]
45. For example, see Ioannis Paschali 24 February 2022 60/25-61/1; Christopher Donnelly 23 February 2022 56/1-3, 62/13-17; SER000459_13-14 paras 67-73; Luke Instone-Brewer 8 March 2022 38/14- 39/1; MAR000002_014 para 119r. See also the evidence of Ms Munroe and Mr Fagbo below[↩]
46. Shayne Munroe 4 March 2022 54/9-16. Even longer delays were identified in the 2018 Verita report (see CJS0073709_072-073 paras 7.25-7.26) [↩]
47. Babatunde Fagbo 4 March 2022 100/16-21, 101/9-102/23; Shayne Munroe 4 March 2022 55/5-17; INN000013_029 para 88[↩]
48. BBC000031[↩]
49. Babatunde Fagbo 4 March 2022 100/4-101/8[↩]
50. INN000013_016 para 50[↩]
51. Shayne Munroe 4 March 2022 55/18-56/5[↩]
52. Stephen Skitt 17 March 2022 151/8-15[↩]
53. For example, Christopher Donnelly 23 February 2022 68/10-16, 82/11-17; MAR000002_009 para 77; David Webb 3 March 2022 116/17-18; Daniel Haughton 16 March 2022 31/2-4; MIL000002_025 para 101; SER000447_015 para 65. All of the 35 former staff members who provided questionnaire responses to the Inquiry said they had no concerns about the verbal or physical abuse of detained people by staff[↩]
54. See, for example, Christopher Donnelly 23 February 2022 169/15-174/20; CJS001415[↩]
55. For example, Edmund Fiddy 7 March 2022 185/1-188/1; David Webb 3 March 2022 112/13-16,  116/17-18; Daniel Haughton 16 March 2022 148/22-149/2; John Connolly 2 March 2022 171/18-21[↩]
56. For example, by Mr Ring (see INQ000199_011) [↩]
57. Professor Mary Bosworth 29 March 2022 84/6-19, 85/8-12[↩]
58. See also, for example, CJS005280_002, which records Mr Fagbo allegedly being called a “snake” and a “coconut”, and TRN0000093_0026, in which D313 describes a staff member as a “cunt” and says he’s “going to get his fucking head smashed up”[↩]
59. Professor Mary Bosworth 29 March 2022 92/24-93/5[↩]
60. Luke Instone-Brewer 8 March 2022 15/4-22[↩]
61. TRN0000063_002-004[↩]
62. Professor Mary Bosworth 29 March 2022 42/18-43/6[↩]
63. Professor Mary Bosworth 29 March 2022 54/15-23[↩]
64. BHM000045_024 para 106; Professor Mary Bosworth 29 March 2022 54/06-115-23[↩]
65. Kalvin Sanders 4 March 2022 124/20-126/14; BDP000003_006-007 para 18[↩]
66. Professor Mary Bosworth 29 March 2022 87/24-88/22[↩]
67. Daniel Small 28 February 2022 130/9-14[↩]
68. Daniel Small 28 February 2022 145/3-151/23; TRN000092_050[↩]
69. Daniel Small 28 February 2022 142/5-12. This reflected almost exactly the same language used by another detention officer in a book chapter published by Professor Bosworth: ‘“Working in This Place Turns You Racist”: Staff, Race, and Power in Detention’, in Race, Criminal Justice, and Migration Control, Mary Bosworth et al. (eds), 2018, pp214-228. See also Daniel Small 28 February 2022 142/1-15; BDP000003_0008 para 23[↩]
70. Professor Mary Bosworth 29 March 2022 91/6-92/4[↩]
71. Charles Francis 3 March 2022 4/13-5/13, 6/9-12[↩]
72. INQ000064_037 para 7.21 [↩]
73. Jeremy Petherick 21 March 2022 37/12-25[↩]
74. CJS0074153_031 para 89; CJS0074153_115 para 323; CJS0074153_118 paras 329 and 330[↩]
75. KEN000001_009 para 43; KEN000001_011 para 54; VER000216_014 para 176; SER000455_011para 38; Stephen Skitt 17 March 2022 77/21-82/2; Professor Mary Bosworth 29 March 2022 158/17-23[↩]
76. CJS0073666_003-006; INQ000164_009-010 para 13[↩]
77. CJS0073663_006 para 6.3[↩]
78. CJS0073663_005 para 6.1[↩]
79. CJS0073632_001[↩]
80. INQ000164_008 para 10; CJS0073709_066 para 7.3; CJS0073663_007[↩]
81. CJS000463_001; Stephen Skitt 17 March 2022 83/7-84/15; Jeremy Petherick 21 March 2022 136/9- 137/17; CJS0073663_006 para 6.4; VER000103[↩]
82. Lee Hanford 15 March 2022 71/14-20[↩]
83. CJS0073632 (this was mistakenly addressed to ‘Mr Needham’ but Mr Neden accepted in evidence that he knew it was for him: Peter Neden 22 March 2022 18/3-10); CJS0073633[↩]
84. CJS0073679_002[↩]
85. Mr Petherick said that he had asked Mr Hanford to investigate the concerns, but Mr Hanford said that this did not happen, and it is not included in the note of the meeting between the two of them: CJS0073680; CJS0073681; CJS0073663_008[↩]
86. CJS0073631_001[↩]
87. By DCO David Waldock (CJS0073243; CJS0073274) and the interrelated grievances raised by Ms Munroe, Assistant Custody Officer and DCM David Killick (CJS0073334; CJS0072840; CJS0073047; CJS0073051) [↩]
88. CJS000473 ‘Grievance Log’[↩][↩][↩]
89. CJS0073368. See INN000012_017-018 paras 69-74; CJS005927_015; CJS005618_009-010[↩]
90. INN000012_013 para 52; INN000012_018-019 para 76[↩]
91. Immigration Detention – Fourteenth Report of Session 2017–19, House of Commons Home Affairs Committee, 21 March 2019, para 61 (‘Conclusion and recommendations’). This supported an earlier recommendation by Mr Stephen Shaw; see Assessment ofGovernmentProgress inImplementingtheReport on theWelfare inDetention ofVulnerablePersons, Stephen Shaw, July 2018, Recommendation 42[↩]
92. SER000451_007 para 4[↩]
93. SER000451_007 para 23[↩]
94. Steven Hewer 1 April 2022 35/1-38/2; SER000451_007 para 23[↩]
95. Steven Hewer 1 April 2022 36/23, 37/22-24[↩]
96. Closing Statement on behalf of Serco, Brook House Inquiry, paras 29-30[↩]
97. SER000451_002 para 4; SER000451_011 para 44; SER000023[↩]
98. INQ000245[↩]
99. INQ000245 [↩]
100. SER000041[↩]
101. SER000026[↩]
102. Report on an Unannounced Inspection of Brook House Immigration Removal Centre 30 May–16 June 2022 (HMIP000702), HM Chief Inspector of Prisons, September 2022[↩]
103. Closing Statement on behalf of Serco, Brook House Inquiry, para 15[↩]
104. SER000465_006 para 20[↩]
105. SER000447_001-002 para 1[↩]
106. Stephen Loughton 1 March 2022 98/3-99/1[↩]
107. Stephen Loughton 1 March 2022 84/7-11[↩]
108. Stephen Loughton 1 March 2022 96/10-25[↩]
109. Stephen Loughton 1 March 2022 96/10-25 [↩]
110. Stephen Loughton 1 March 2022 116/6-17[↩]
111. Stephen Loughton 1 March 2022 138/10-23[↩]
112. INQ000001[↩]
113. Stephen Loughton 1 March 2022 137/2-138/5[↩]
114. SER000436_001 para 1; Steven Dix 9 March 2022 2/16-17[↩]
115. Jonathan Collier 30 March 2022 89/6-13; CJS0074374_003[↩]
116. Steven Dix 9 March 2022 73/7-15[↩]
117. Steven Dix 9 March 2022 71/20-74/7[↩]
118. SER000444_001 para 2[↩]
119. Callum Tulley 2 December 2021 26/8-10[↩]
120. CJS005952_003-004[↩]
121. CJS004312[↩]
122. Christopher Donnelly 23 February 2022 125/11-127/3; CJS004312; CJS005952_003-004[↩]
123. SER000444_016 para 85[↩]
124. Christopher Donnelly 23 February 2022 83/10-15[↩]
125. SER000456_001 para 1[↩]
126. See INQ000111_062-065[↩]
127. Stewart Povey-Meier 17 March 2022 15/18-16/17[↩]
128. CJS0074063 UOF 137.17 (2).MOV UOF 137.17 BWC.MOV[↩]
129. Stewart Povey-Meier 17 March 2022 16/25-17/3[↩]
130. CJS005624_021[↩]
131. Ryan Bromley 7 March 2022 113/10-119/1[↩]
132. This is from footage, part of which was played in closed session (CJS0074063 UOF 137.17(2) ) [↩]
133. INQ000111_065 para 257[↩]
134. Steven Hewer 1 April 2022 73/5, 81/11, 83/4-5[↩]
135. Steven Hewer 1 April 2022 76/16-77/20. Mr Hewer was provided with the transcript of Mr Dix’s evidence and with Mr Collier’s report[↩]
136. Steven Hewer 1 April 2022 78/5-10[↩]
137. Daniel Haughton 16 March 2022 73/20-155/12[↩]
138. Sarah Newland 21 March 2022 170/21-25[↩]
139. SER000451_011 para 44[↩]
140. Steven Hewer 1 April 2022 78/8-10[↩]
141. SER000465_004 para 15[↩]