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Teh Full 2010 Armadale Report

Teh Full 2010 Armadale Report






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    Teh Full 2010 Armadale Report Teh Full 2010 Armadale Report Presentation Transcript

    • I :N<D P,XPagesPresentation 11. Declaration and terms of reference 2Introduction 3-7Rules of Procedure 4-5Appearances 6-72. Report 8-127Armadale 8Housing of the Children 9 -11Office Dormitory - its origin 11-16Office Dormitory - spaceaccommodation 16 -193. Summary of Findings 19 - 314. Reasons for findings 31 - 1074.1 Life in the Office dormitory at Armadale prior to22nct May 2009 31-384.2 Life in the Office dormitory immediately prior to22 May 2009 38 - 535. Other areas of neglect at Armadale 53-566. Other concerns expressed re Armadale 56-646.2 The events of 22nct May 2009 prior to the fire 64 - 657. The circumstances and causes of the fire 65-76I
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    • REPORT OF THE COMMISSIONER1.1 I, PAUL HARRISON, O.J., C.D., J.P., PRESIDENT OF THE COURT OF APPEAL(RETIRED) HAVING BEEN APPOINTED BY YOUR ExCELLENCYS PROCLAMATIONTO CONDUCT AN ENQUIRY WITHIN THE FOLLOWING TERMS OF REFERENCE:"(a) The causes and circumstances of the fire on thenight of Friday, May 22, 2009 at the ArmadaleJuvenile Correctional Centre at Alexandria in theparish of St. Ann;(b) the response by the management of the institutionto the outbreak of the fire including establishedevacuation procedures and the availability andreadiness of fire prevention and firefightingequipment at the institution;(c) the behaviour of the juvenile detainees occupyingthe institution before and at the time of the fire,the response of the emergency services includingthe police, fire and medical services and the effectthese had on the origin, control and consequencesof the fire·"IDo HUMBLY SUBMIT To YOUR EXCELLENCY THE FOLLOWING REPORT2~~----------.............
    • INTRODUCTION1.2 On the 28th day of May 2009, Your Excellency, by proclamation, issued aCommission under the Commissions of Enquiry Act (the Act"). Inaccordance with section 2 of the Act, Your Excellency appointed TheHonourable Mr. Justice Paul Harrison, 0.J., C.D., J.P., (Retired Presidentof the Court of Appeal) to be the sole Commissioner.1.3 Your Excellency also, in accordance with the provisions of section 6 of theAct, appointed Mrs. Pauline Rosemarie Farquharson-Stewart as Secretaryto the Commission.1.4 Your Excellencys Sole Commissioner, the Ministry of National Security andthe Secretary proceeded to finalize the administrative arrangements tosecure suitable premises to hold the enquiry. The secretary gave publicnotice, published in the daily newspapers that the enquiry wouldcommence public sittings on Wednesday thEt 1st day of July 2009 at 10:00a.m. but subsequently published a further notice for commencement onTuesday the 3oth day of June 2009, at 10:00 a.m. at the Police OfficersClub, Hope Road, Kingston. The subject of the enquiry was also publishedinviting all persons who wished to be heard to be in attendance.1.5 By virtue of section 9 of the Act, the Commissioner formulated and issuedon the commencement of the enquiry on 3oth June 2009, the rules and3
    • procedure to be applied throughout the enquiry. The rules of evidencewere liberally applied, for the purpose of the enquiry.They read:RULES AND PROCEDURE1. These are non-adversary proceedings in the nature of aninquisitorial enquiry to find facts and ascertain the truth.It is not a case of one side against the other.2. The evidence may reveal facts which may concern theinterests and actions of individuals or entities. In thatevent, counsel may be allowed to ask questions inclarification.3. No entity or individual is on trial.4. Hearings will continue from day to day, until completion,commencing daily at 10:00 a.m. to 12 noon with a breakand continuing at 12:30 !).m. to 2:00 p.m.5. Counsel from the Solicitor Generals office will marshal!the evidence. Any wish that the Commission considerany evidence should be communicated to theCommissioner. The statements of the witnessesconcerned shall be handed to the Secretary, Mrs. Stewartfor use of counsel marshalling the evidence.4I
    • 6. This Enquiry is governed by the Commissions of EnquiryAct ("the Act"). The boundaries of the enquiry arecircumscribed by the terms of reference issued in theCommission to me by His Excellency the Governor-General.7. Witnesses will be invited to appear to give evidence but,if necessary they will. be summoned in accordance withthe Act and all its provisions.I invite the co-operation of all to assist this enquiry intothe circumstances and events of the 22nd May 2009 and Ianticipate. the genuine assistance of all.COMMISSIONER5
    • 1.6 Scores of statements were submitted to the Commission from varioussources including the Office of the Childrens Advocate, the PublicDefender, the Police, the Fire Department, the Ministry of Health and theMinistry of National Security, particularly the Department of CorrectionalServices. The statements were taken from persons directly involved inthe events of the 22nd May 2009, or concerned with the organization andmanagement of the Armadale Juvenile Correctional Centre.1.7 Legal representation was permitted on behalf of several persons andentities.• Mr. Hugh Salmon,· Divisional Director, Mr. Peter Wilson, AssistantAttorney General and Mrs. Hazel Edwards, Assistant Crown Counsel ofthe Attorney Generals Chambers marshalled the evidence.• Mr. Jermaine Spence and Mr. Courtney Williams, Attorneys-at-law ofMessrs. DunnCox appeared for the Ministry of National Security.• Mrs. Jacqueline Samuels-Brown, Miss Lois Nelson and Miss NicoleWright, Legal Policy Officer, appeared for the Office of the ChildrensAdvocate.attorneys-at-law appeared for the office of the Public Defender onl• Mr. Howard Hamilton, Q.C., Mr. David Batts and Miss Joan Jackson,behalf of the parents of some wards. The parents are Jennifer Brown(Rochelle King, ward), Joan Mitchell (Georgiana Saunders, ward),6 I
    • IIII1Prudence Doeman (Shaunnalee Kerr, ward) Novelette Harding(Annmarie Samuels, ward) and another unnamed parent.1.8 The proceedings commenced on the 3oth June 2009 at 10:00 a.m. at thePolice Officers Club at 34 Hope Road, Kingston 6 in the parish of St.Andrew, and resumed on the 27th July 2009 at 10.00 a.m. at the NationalVolunteer Centre, at 2D Camp Road, Kingston 4 in the parish of St.Andrew.The Commission heard the testimony of a total of forty-one (41)witnesses on various dates. A total of forty-nine (49) exhibits weretendered in evidence. ,The hearing was conducted over a period ofthirty-three (33) days ending on the 10th day of September 2009.1.9. I am mindful of Your Excellencys further directive to me which reads,inter alia -"And I do further direct you to report to me in writing assoon as practicable the result of such Enquiry and to furnishto me a full statement of the proceedings and of the reasonsleading to the conclusions arrived at or reported;And I do further direct that should you find it necessary todo so, you may submit Interim Reports before thesubmission of your full and final report;"I
    • REPORT2. ARMADALE2.1 The Armadale Juvenile Correctional Centre ("Armadale") situated atAlexandria in the parish of St. Ann, was declared to be a JuvenileCorrectional Centre on 25th September 1991 by the Minister in accordancewith the provisions of the Correctional Institutions (Declaration) (JuvenileCorrectional Centres) Order, 1991, under the authority of section 47 ofthe Corrections Act.Where a child is found guilty of any offence before a Childrens Court,that court may make an order sending the child to a juvenile correctionalcentre - section 76(1)(f) of the Child Care and Protection Act (the CC&PAct). A "child" is defined in the latter Act as"... a person under the ageof eighteen years."The objects of the said Act as stated in section 3 are, inter alia -"(a) to promote the best interests, safety and well-being ofchildren; ..."The "best interest of the child is the paramount consideration," therebyentitling the child to protection from abuse, neglect, harm, or the threat ofharm, recognizing that a family is the preferred environment and theprotection of the children rests primarily with the parents, with supportservices where applicable, and taking into account the views of the childin certain circumstances, section 2(3) of the Act.8
    • 2.2 Armadale - the housing of the child detaineesArmadale, originally a great house, was prior to 1991, a place of safety.Up to 2006, all the girls were housed in a two-storey building to the southof the Armadale compound, called the "Upstairs Dorm". As a result of afire started by the girls, some of them were moved, in November 2006, toa building, to the northern end of the compound, called thereafter theCottage Dorm. This building was previously occupied as the residence ofthe Assistant Superintendent at Armadale. The Cottage Dorm consisted of,,three rooms with beds to accommodate an additional thirty (30) girls.The building was renovated and rededicated as a dormitory on 20thNovember 2006. (See ,Exhibit no. 8). There were therefore two (2)dormitories, the newly created Cottage dormitory with thirty (30) girlsand the rest of the girls approximately thirty-five (35), were left in theUpstairs dormitory.The maximum capacity of Armadale was then accepted to be forty-five(45) girls, however, approximately 65 girls were then in residence. TheDepartment of Correctional Services Annual report for 2007 reveals thaton 1st January 2007 the total population at Armadale was sixty-five (65)girls - (see Table 25 on page 35 of Exhibit 34).2.3 The Upstairs dormitory had no bathroom facilities. Mrs. June Spence-Jarrett, Commissioner of Corrections, acting since December 2008 and9
    • appointed August 2009, said in evidence, of the Upstairs dormitory in2007,"I aware Upstairs dorm girls had no bathroom facilitiesafter locked at nights - continued awhile, so we put infacilities ... first became aware in May 2007."Mr. Neilson Anderson, the Property Manager for the CorrectionalDepartment had so advised her, then Deputy Commissioner, bymemorandum dated 26th May 2007 (See Exhibit 13).Mr. Anderson visited Armadale on 26th May 2007 along with an engineerMr. Williams, Mr. Ramdatt, the Property Manager of the Ministry ofNational Security and Mr. Clarke, the Building Engineer at the NationalWorks Agency and inspected the Upstairs dormitory, principally to solvethe problem of sanitary conveniences for the girls in the said dormitory.The engineer Mr. Clarke reported,. inter alia, that, because of termitepresence and the state of the building, it would be too costly to repair andmaintain. He recommended that it be abandoned.He added that the external bathroom used by the girls was in a deplorableand insanitary state. The toilets, damaged and leaking, were inadequate(See Exhibit 14).10
    • Mr. Anderson, in his said memorandum to Mrs. Spence-Jarrett (Exhibit13), advised that,"the original building is now structurally unsound ... nowa fire hazard ... girls have no bathroom to use at nightswhen ... locked in ... the bathroom used in the day is invery bad condition ... is woefully inadequate ... and iscontributing to health risks ..."He further commented with some degree of analytical opinion that,"The dissatisfactory physical conditions under which thewards are housed were major contributors to the unrestthat resulted in major damage to the plant early thismonth."Recommending the repair of the bathroom currently t1sed and theinstallation of new bathrooms, he added, "... from then Armadale was anemergency until now." The bathroom facilities were improved.Despite this poor state of the building in which the girls were housed,and its recommended abandonment, they remained in occupation in thoseconditions for over one year up to March 2008.2.4 The Office dormitory - its originIn March 2008, the girls in the Upstairs dormitory, condemned from May2007 as unfit for habitation, caused a fire by lighting mattresses inside the11
    • •dormitory. The decision was made to remove all the girls from theUpstairs dormitory to a room in the office building to the east of thepremises, between the Cottage dormitory and the Upstairs dormitory.This room came to be known as the Office dormitory. Its dimensionswere twenty (20) feet long by twelve (12) feet wide and ten (10) feethigh. It had three sets of windows, to the front, (west), to the back(east) and double windows (north), facing the Cottage dormitory. Allthe windows were of wooden louvre blades with burglar bars on theinside.In March 2008 "..; a few days after the fire" in the Upstairs building Mrs.Spence-Jarrett, then Deputy Commissioner, Mr. Everton Hesson, Directorof Juvenile Services and Mr. Anderson travelled to Armadale. Mr.Anderson, inter alia, said,"I saw the size of the room that day before the girlswere put into the Office dorm ... over twenty (20)wards ... bunk beds were put in very close, not muchspace for movement."Hesson said,"[after the] fire ... some girls moved to Office dorm ...not remember how many ... beds double decker ...dense ... close to each other."12
    • Mrs. Spence-Jarrett recalled travelling to Armadale after the fire withMessrs Hesson and Anderson and she said,"Office dorm was brought into use in March 2008. Idont think that 20 girls were put into Office dorm atonce. I think 10 initially"Later in evidence she said, "I understood about 12 girls would be in the[Office] dorm ... 6 bunk beds ... 12 mattresses ... one girl to a bed ... theDirector of Juvenile Services [Mr. Hesson] told me."Mrs. Spence-Jarrett asserted that she did not go into the Office dormitoryto see if it was suitable but Mr. Hesson did.If Mrs. Spence-Jarrett did not go into the said dormitory to observe,inspect and approve of the facilities and conditions under which the girlswere to be housed, those were irresponsible and negligent acts ofomission on her part. If she was aware of the lack of adequate space andinsufficient beds in the said dormitory, which I find she was, her decisionv/ to house the girls there was unfortunate, uncaring and inhumane.I accept Mr. Anderson, as a forthright truthful witness, on whoseevidence, I could rely.13
    • I find that twenty-three (23) girls were moved into the Office dormitory inMarch 2008. The size of the dormitory was 20 feet by 12 feet inmeasurement. That accommodation was inadequate, from the outset.Both Mrs. Spence-Jarrett and Mr. Hesson were evasive and less thantruthful on the issues of the number of girls placed in the dormitory andwhose decision it was to place the twenty-three (23) wards into the Officedormitory in March 2008.Mrs. Spence-Jarrett denied that at Armadale in March 2008, she instructedthat the twenty-three (23) girls be placed in the Office dormitory or thatshe participated in the removal of the girls. Quite curiously, she said,"I did not give any instructions; the superintendent is incharge of the plant." (Emphasis added)She later said,"The Director [Mr. Hesson]. had discussions with theSuperintendent [Mrs. Ferreira] and he maderecommendation to me. I telephoned the Commissioner[Major Reece] and told him.We made the decision."In contrast, Mr. Anderson said,"I participated in moving 23 girls to Office dormitory ...not sure whose decision ... I was aware of the size of14
    • the room and the number of wards ... I saw the size ofthe room before the girls were put in ... over 20 wards... I was of the view that a decision had been taken torelocate the girls. Deputy Commissioner Mrs. Jarretttold us that we would be relocating the girls to theother location. She told us what was to be done."(Emphasis added)Mr. Anderson said that there was no "structured discussion" nor was thereany "formal meeting". The decision was taken and he was informed. Hesaid that that was not unusual in his case as Property Manager.He agreed that the girls in the Office dormitory were "actually packedinside," and it was obviously overcrowded and insufficient. He wasconcerned that there was only one door, the bunk beds were put in veryclose "not much room for movement" apd "It did strike me as a potentialhazard in an emergency." However, he did not express any reservation"hardly any alternative the Department had."He was aware of the National Building Code of Jamaica and of theminimum occupancy of institutional buildings, open wards anddormitories. He said, it was,"1 person for each 50 Sq. ft. (5 m2) floor area" (Exhibit 15)15
    • Mrs. Spence-Jarrett, in evidence, tellingly, emphasized that, in herfunctions she had,"... a hands-on approach, I always have."2.5 I find that in March 2008, Mrs. Spence-Jarrett, then DeputyCommissioner, unwisely, did make the fateful decision to house thetwenty-three (23) girls in the Office dormitory measuring 20 feet by 12feet and with seven (7) double bunk beds only, containing fourteen (14)mattresses. That decision was a patent breach of the duty to promote thebest interests of children, violated the statutory requirements and wasaccordingly negligent, in all the circumstances.2.6 Space accommodation in the Office dormitoryi. The National Building Code of Jamaica, 1983 (tile Code") adoptedfrom the Building Regulations issued under the Kingston and St.Andrew Act (second edition.1992, metric units), provides in Table1, paragraph 2.2.1 Group B, institutional buildings open wards anddormitories that the minimum occupancy should be -1 person for each 50 sq. ft (5 m2) floor area(Exhibit 15).The flOOLareaofthe Office dormitory was 240 sq. n.Legally, therefore, no:more than five (5) persons should properlyhavebeenaccommodateci inthatdormitory 20.ft. by 12 ft. Twenty-16
    • three (23) girls were there on 22nct May 2009. Mr. Neilson wasaware of the provisions of the Code.In reality, assuming that each mattress measured 6 ft 3 ins by 2 ft6 ins (Mrs. Hortense Higgins, a Correctional Officer, said that eachmattress measured 5 ft by 2 112 ft), the seven (7) bunk beds wouldcover a floor area of approximately 108 sq. ft. The walking arearemaining in the dormitory was therefore 132 sq. ft.If each of the twenty-three (23) girls was standing in the dormitoryat the same time - she could only occupy a space of a mere 6 sq.ft., that is, for example, one floor tile measuring 2 1/2 ft. by 2 1/2 ft!!It is inconceivable · to accept that of the senior managementpersonnel of the Department of Corrections, neither Mr. Hesson nor;Mr. Neilson, raised even a whimper of protest or a contrary opinionat the decision of Mrs. Spence-Jarrett to house over twenty (20)girls in that dormitory on that day in March 2008. This representeda major failure and breach of duty on the part of the said seniormanagement personnel of the Department.ii. Having only fourteen (14) mattresses, in some instances, therewere two (2) girls to one bed in the Office dormitory.iii. The Code also provides in Table 25 "minimum requirements foremployee sanitary facilities/ page 52 (Exhibit 16), that for every "1- 10 female employees," there ought to be provided1 one toilet.
    • For residential purposes, as in the Office dormitory at Armadale,there should be no less provision. There was only one toilet for theOffice dormitory!iv. The "minimum number of means of escape and exit required perstorey" - the Code, Table 9, paragraph, page 16 (Exhibit17), is 2 exits for 1 to 100 persons. The dormitory had one doorfor all purposes.Commenting on the various breaches of the Code at Armadale, Mr.Anderson, boldly said:"The Correctional Services does not seem to fit intothat category - none of our institutions fit that"Mrs. Spence-Jarrett admitted that she had a safety concern that there wasonly one entrance to the Office dormitory and said," ... an additional entrance could not have been putin that Office dormitory.."Mr. Anderson observed that,"The girls at Armadale were troubled girls, there forcare, security and rehabilitation. Armadale fell shortof providing proper care, rehabilitation and securityfor the girls."He said that before moving the girls into the Office dormitory,18I
    • "I did see the need for a fire escape - knocking outa wall and putting in a door would have served thatpurpose."He did not do so nor did he recommend that it be done.There was in that regard, patent neglect and apathy concerning thewelfare of the girls at Armadale, by the senior administration of theDepartment.Under these stressful conditions, in addition to extended periods ofconfinement, as I shall point out subsequently, the girls in the Officedormitory continued their painful existence up to the 22nd day of May2009.3. Summary of Findings and conclusion - in the context of theterms of reference(a) The causes and circumstances of the fire on the night ofFriday, May 22, 2009 at the Armadale Juvenile CorrectionalCentre at Alexandria in the parish of St. Ann.(i) There was a planned and attempted break out of the girls fromthe Office dormitory on the night of 22nd May 2009. Mrs.Hortense Higgins, the supervising Correctional Officer, on duty,summoned for assistance. Two police officers from theAlexandria police station arrived. A C S teargas canister was19I
    • initiated by Cons. Lawrence Burrell of the Alexandria policestation and from this canister, flames and smoke were emitted.He threw it into the Office dormitory where it fell onto a bunkbed with a mattress of foam material, immediately starting thefire - one of the seats of fire. Acting impulsively and reactingirrationally to the angry behaviour of the girls, who were cursinghim, Cons. Burrell, without consulting his superior, Woman Cpl.Shawnette Dunkley, had gone back to the said police stationand returned to Armadale with the C S teargas canister to"chastise" the girls, in retaliation.(ii) There was in the dormitory an accelerant, at least in the form ofhydrocarbons, as found by the scientific experts Mrs. Tanya Kerrand Mr. Fitzmore Coates to have been there, which ignited, andtogether with the foam mattresses, created a second seat offire. This resulted in the. rapid spread of the fire. In addition,there were the noxious fumes of the C S teargas, the smokeand toxic substances, namely, hydrogen cyanide, carbondioxide, carbon monoxide, hydrogen chloride and phosgenegiven off by the burning mattresses. Some of the girls probablyhad the accelerant in the dormitory, in preparation for theplanned escape.20
    • (iii) The girls, breathing in these toxic fumes and subjected to theintense heat of the fire in the darkness of the dormitory, all,with the exception of three girls who jumped through the frontwindow of the dormitory, rushed to the back window, the onlyvisible means of escape. There was utter confusion. Probably,in panic and disoriented, they fought each other at this backwindow in their effort to escape. There were cries for "help",trampling of each other and fainting of some of the girls.Assistance from outside the dormitory, to aid in the escape waslimited. Mrs. Caldeen Shaw-Slack, a Correctional Officer, whoplaced a ladder at the back window - at a height 7 feet fromthe ground outside, was assisted by Miss Dian Gilbert and MissLucille Hamilton in pulling out some of the girls. Contrary to thecontention of Cons. Burrell and Woman Cpl. Dunkley, MissShaw-Slack said "... the police did not help us at the backwindow in pulling out the girls." A Cons. Mccalla from theBrowns Town police station assisted in doing so, as well ashelping the said ladies to throw water onto the fire through theback window. The dormitory was overcrowded. Space tomanoeuvre was limited or in some instances non-existent.Chaos reigned.
    • (iv) The discharge of the teargas canister into the dormitory byCons. Burrell was harsh and unnecessary. No use of such force,even in light of the insulting language used and the excrementthrown by some of the girls, should have attracted such aresponse. It was an unlawful use of force by the police officer.(v) The Office dormitory door, the most obvious means of exit, asan escape, was locked and unavailable to the girls. The girlswere burnt and scarred, mentally and physically andtraumatized. The dormitory door should have been promptlyunlocked by Mrs. Higgins or on her instructions, at the sign ofdiscomfort in the dormitory. In that respect, she was dilatoryand consequently negligent in her conduct.{b) The response by the management of the institution to theoutbreak of the fire including established evacuationprocedures and the availability and readiness of fireprevention ·and firefighting equipment at the institution.(i) The initial aim of the persons at Armadale on that night, was oneof containment of the girls in the Office dormitory, to prevent anyescape. Miss Carlene Coleman, the security officer, confirms thatshe, Miss Gilbert and Miss Hamilton all had sticks in their hands.Mrs. Higgins comment "Nothing we can do but let them stayinside," describes that primary intent. After the outbreak of the22
    • fire, there was no manifest change of attitude by the institutionpersonnel present. There was no spontaneous reaction to releasethe girls, as there should have been, in view of the obviousdiscomfort and danger. It was the girls own frantic attempts toescape the "fiery inferno" within, that triggered the staff to assistin their evacuation.(ii) Mrs. Higgins, as the supervisor, at the first moment of hearingthe sound "like air letting out," and seeing "the policeman goingto the side of the dorm going towards the back" as she ran to thefront window, and seeing black smoke inside the Officedormitory," shoutd have opened the dormitory door, instantly, orif ·she did not have the keys, should have ordered that it be,opened immediately. She did neither. She thereby failed andaccordingly, negligently contributed to the ultimate fatal outcometo the girls.(iii) There was no established evacuation procedure or practicedexercise in existence at Armadale to deal with the outbreak of afire. This was a further instance of an organizational indifferenceand failure, seeing that there had been fires previously atArmadale in 2008, for example, at the Upstairs dormitory. Mrs.Ferreira relates that on that latter occasion "wards were running23
    • around discharging fire extinguishers. I do not know if they wererecharged." Most of them were not.(iv) The need for fire extinguishers at Armadale was consistentlyexpressed by Mrs. Hamilton, Acting Superintendent, in Novemberand December 2008, (see Exhibits 3 and 4) by memoranda,respectively, to the Commissioner, Department of CorrectionalServices (see Exhibit 2). These requests were not satisfied.Consequently, on the night of the fire, Mrs. Higgins had to go tothe house mother in the dining room got the key and went to theHome Economics room, from which she took a fire extinguisherand gave it to a policeman at the side of the Office dormitory.That fire extinguisher, only partially charged, was ineffective. Fireextinguishers should have been available C!nd more readilyaccessible. Mrs. Higgins stated in evidence, that she had onlyseen one fire extinguisher. in the storeroom and another in thedining room - the latter had been emptied of the foam by thegirls in 2008.• 4he only occasion previous to the fire when a fire drill. was£onducted at Armadale, was in 2004;. Mrs; Higgins confirmsthat n©ne was held since then. This is a furtherdemonstration of official neglect.. 24
    • • Mrs. Ferreira had in March 2009 invited the Superintendentof the St. Ann Fire Department in celebration of Fire SafetyWeek 2009 "to give a talk and conduct a fire drill for boththe staff and wards" (see Exhibit no. 5). Her request wasnot granted.• At Armadale fourteen (14) fire extinguishers were countedas being there, after the fire, eleven (11) of which werenon-functional, stated Mrs. Ferreira. They were notserviced since 2007.Armadale was ill-equipped and not prepared, in any manner to dealeffectively with a fire at the institution or at all. There were no fireextinguishers readily available for the dormitory and th6se that wereotherwise available were neglected and not serviced. Furthermore,despite the experience of previous fires at the institution, noprocedure was introduced to deal with such an emergency. This wasa demonstration of marked indifference.(c) The behaviour of the juvenile detainees occupying theinstitution before and at the time of the fire, the response ofthe emergency services including the police, fire and medicalservices and the effect these had on the origin, control andconsequences of the fire;"(i) Juvenile behaviour before the fire.
    • Some of the girls were undoubtedly behaving unruly, on 22°d May2009 before the fire. The perpetrators, about six (6) or seven (7)in number, had planned to escape from the institution. One ofthe other girls had advised Mrs. Higgins of the plan. Mrs. Higginsmerely made a note of it in the institutions log book, but,unwisely, did not advise her superiors.The potential escapees, and others, observing that after supper,the Correctional Officers and security guards were patrolling morefrequently and watching the Office dormitory more closely, beganto sing, make noise and drumming, in order to conceal thesounds caused by the screwdrivers extracting the grills coveringthe windows. At about 7:30 p.m. it was discm~·ered that the girlshad taken out the back window blades. Told to put them back in,the girls instead removed the grill which they had unscrewedearlier. The officers ran to the back window and then the girlsbegan throwing faeces, urine, water and other objects at them,accompanied by boisterous behaviour and expletives. The girlsthen removed the grill from the front window. Woman Cpl.Dunkley and Cons. Burrell had come from the Alexandria policestation. Their arrival served to aggravate the conduct of the girls,some of whom blamed the police for having been the cause ofthem being at Armadale.
    • The girl M. C. jumped through the front window. She was chasedand held. She said "mi have fi come out ... me nah stay in there... something going to happen in there." That was an expressionof the tense troubling expectancy that existed within thedormitory.The conciliatory approach of Woman Cpl. Dunkley did not help tocalm the girls. Cons. Burrell left and returned. The girls were notrelenting. He threw the teargas canister into the dormitory,starting the fire. There was no means of mass exit therefrom.It cannot be ignored that these were girls who, since March of2008, were confined in this dormitory 20 feet by 12 feet - acramped, unhealthy existence and were condemned to the use ofbuckets to perform all their body functions, at nights. The entireOffice dormitory was on "lockdown" from ih May 2009 becauseseven (7) girls escaped from the Cottage dormitory. Previouslythey were also on "lockdown" because one girl jumped over theperimeter fence on Sports Day the 21st April 2009.This was the injustice of collective punishment in operation.Some of the girls were compliant and meekly resigned themselvesto their fate, for a period in excess of one year. Others were notso compliant and did not. The latter group is deserving of someI
    • degree of understanding. There is a level below which no humanbeing should be persistently forced and expected to exist. Thegirls in the Office dormitory, on 22nd May 2009, had beendegraded to that level.{ii) Juveniles behaviour at the time of the fireOn seeing the smoke and fire in the dormitory, the girls, in panic,rushed to the back window, some fell, causing others to step onthem. Survival was their prime aim. They tried to get air tobreathe at the said window, hitting and shoving each other to doso. The bigger-bodied girls blocked the window, in order to getair themselves. The girls eyes and throats burned from theteargas and burning material and the heat from the fire wasintense. Three girls jumped through the front window near theseats of fire. Some of the girls fainted. There was screaming andshouting for "help" and "fire". The officers, Mrs. Shaw-Slack andMiss Gilbert and "a police officer" were helping to take out thegirls. The child witness M. M. said that she fell and "blacked out"while she was at the back window, hitting at girls to get out. K.N. said to her "Come M. mind you asthma" and took her to thewindow and helped her to jump out - she went to the playfieldand then to the refrigerator to cool off. She did not see K. N.The latter was one of the five (5) girls who died in the dormitory.
    • there was varied assistance by police officers in seeking toalleviate the crisis.(ii) The fire services. The fire engine arrived at Armadale at about9: 15 or 9:20 p.m. having received the call for assistance at 8:53p.m. The fire had by then engulfed the entire dormitory. Thefiremen eventually got the fire under control, but not before five(5) girls succumbed. The firemen should have, initially, forcedopen the dormitory door with their "axes, pry bars and cuttingsaws" which fire officer witness Patrick Robinson said they had, toeffect a rapid exit of the girls from the fire in the dormitory. Toleave the door unopened and return "about a minute after" as hestated, may have been an unwise and ultimately fatal choice.(iii) The medical services. Dr. Micas Campbell was the firstmedical officer to arrive at Armadale, after she had beenassisting some of the girls at the St. Anns Bay Hospital. Herexamination at about 3:00 a.m. revealed that one of thedeceased five (5) girls in the dormitory may have been alive "upto 1:00 a.m." The absence of any medical personnel beforethen, or any first aid assistance unit with the firemen,prevented an earlier examination of the girls and probablycontributed to the failure to save one other person in thedormitory.30I
    • IIIIIl4.4.1My findings, based on the evidence, reveal a wide range of shortcomings.There were breaches of duty and administrative errors by the Departmentof Correctional Services, indifferent and insensitive actions by publicofficials, troubled and unruly girls further traumatized by some uncaringadults, unjust treatment of girls, impulsive and unlawful action by a policeofficer and the absence of any structured safety system in an emergencyat Armadale. Those factors, among others, combined with the negligentactions of the public officials, made inevitable, the tragedy of Armadale onthe night of 22nd May 2009.Reasons for findingsLife in the Office dormitory - prior to 22"d May 2009(a) "Lockdown" was instituted at Armadale.This was the practice in which the girls were confined to thedormitory for extended periods, sometimes for days or weeks anddeprived of all outdoor activities, as punishment for an infraction ordisturbance. The principal consequences were,i. girls remained in the dormitory, except those who were taken outto do chores. Two or three were taken out to go to classes. Theothers watched television, read and played games, while confined;31
    • IIIIIl4.4.1My findings, based on the evidence, reveal a wide range of shortcomings.There were breaches of duty and administrative errors by the Departmentof Correctional Services, indifferent and insensitive actions by publicofficials, troubled and unruly girls further traumatized by some uncaringadults, unjust treatment of girls, impulsive and unlawful action by a policeofficer and the absence of any structured safety system in an emergencyat Armadale. Those factors, among others, combined with the negligentactions of the public officials, made inevitable, the tragedy of Armadale onthe night of 22nd May 2009.Reasons for findingsLife in the Office dormitory - prior to 22"d May 2009(a) "Lockdown" was instituted at Armadale.This was the practice in which the girls were confined to thedormitory for extended periods, sometimes for days or weeks anddeprived of all outdoor activities, as punishment for an infraction ordisturbance. The principal consequences were,i. girls remained in the dormitory, except those who were taken outto do chores. Two or three were taken out to go to classes. Theothers watched television, read and played games, while confined;31
    • ii. all meals were served in the dormitory. The girls ate with theirfingers, because no knives, forks nor spoons were allowed inthe dormitory, unlike when meals were served in the dining room.iii. The duration was uncertain - it would continue for days orweeks, as Mrs. Ferreira said, "...until peace is restored."iv. The use of the bathroom, adjoining the Office dormitory, wasrestricted to one hour in the mornings, after which the water wasturned off. Consequently, some of the 20 odd girls had personalbuckets and pans in which they all collected water in order tocomplete their baths in the dormitory.v. New girls on arrival at Armadale were placed on "lockdown" for twoweeks.vi. Most classes ceased during "lockdown."Mrs. Ferreira, who came to Armadale in 2007, as a welfare case manager,was asked to act as Assistant Superintendent in May 2008, and took overduties as Superintendent in January 2009. She as Superintendent, had theauthority to impose "lockdowns" and said,"Generally, since I came to Armadale any form ofdisturbance we have lockdown."She said, when a "lockdown" is imposed she would brief her superior. A"lockdown" was imposed for the two (2) weeks prior to 22nd May 2009. Shesaid,32I
    • IIIIII"I briefed the Director, Mr. Hesson, two weeks before the22nd day of May 2009."Mr. Joseph Small, the overseer at Armadale, admitted that once a"lockdown" is imposed, he would be advised.Curiously, all of the senior administrators of the Correctional Departmentwho gave evidence, including Mr. Hesson, whom Mrs. Ferreira said she hadbriefed of the "lockdown" two weeks prior to 22nd May 2009, deniedknowledge of the existence of the practice of "lockdown."Mrs. Spence-Jarrett stated that she was not advised that lockdown "was inuse at Armadale" generally or for new girls. "Isolation" was permitted but itwas not to exceed 72 hours.The evidence reveals, that meetings were held by the Department ofCorrectional Services, with "executive members, central administration,medical doctors, welfare case managers and superintendents of adult andjuvenile institutions" at its Head Office, on 16th May 2008, 2otti June 2008,4th July 2008 and 18th July 2008 (Exhibit 37). Mrs. Jarrett, then DeputyCommissioner, as chairperson, on each occasion,"... reminded the meeting that no child should be keptin isolation for over seventy-two (72) hours ..."In my view, the necessity for this repeated reminder indicates that Mrs.Jarrett was well aware, despite her protestations, that children in the
    • institutions were being held in isolated confinement for multiple days. Thisis so, although even "isolation", in any event, was not listed as anacceptable punishment in the document, Exhibit 6.Mr., Hesson said that he was not aware of the practice of "lockdowns" atArmadale, or of new wards placed on "lockdown" for two weeks prior to22nct May 2009. He was aware of "isolation", imposed when a childabsconded or was disruptive, but that would be for a period of 48 hours,"no longer." Here, he contradicted Mrs. Jarrett on the duration. Thequestion is, Was that rule so loose and flexible?Mrs. Shirley Johnson, Deputy Commissioner, since January 2009, statedthat "lockdowns" were not permissible, however, in rare <;ases, "isolation"from recreation or watching television was utilized. She was aware of theinternational treaties, including the Beijing Rules and her duties includedseeing that the rules governing the welfare of the girls were applied,including their human rights. This was a noble ideal expressed, indeed.The evidence of this witness was repetitive and hesitant. I found a greatdifficulty in believing her. As a witness, she appeared to have been"coached."Mrs. Sylvia Passerley, the Director of Rehabilitation since December 2008and responsible for policy, stated that she was not advised of the use of
    • --1III~IIIIII"lockdown" at Armadale and admitted that suspension of classes or"lockdown" was not conducive to rehabilitation. She was of the opinion thattwenty-three (23) girls being locked down in the room 20 ft. x 12 ft. for 2weeks would result in frustration. I accepted her as a frank and forthrightwitness.I find that the practice of "lockdown" was routinely practiced at Armadale tothe knowledge of all, including the senior administrators. The official list ofbreaches and consequential sanctions, in use, Exhibit 6, revealed breaches,such as, using indecent language, fighting and disrespect of staff, resultingin sanctions, for example, ban on visits, loss of certain benefits or additionalchores. "Isolation" although it was not listed as a sanction was endorsedand acquiesced in by the senior members of the administ~ation who hadknowledge of its use. I so find, despite their denials.This is a clear instance of an abuse of· rules and the infringement of therights of the girls.(b) The governing Rules and statutes and breaches thereof(i) The United Nations Standard Minimum Rules for the Administrationof Juvenile Justice ("The Beijing Rules) adopted by the GeneralAssembly on 29th November 1985 and to which Jamaica is asignatory, recites generally, "the well-being of the juvenile" andthat the aims of juvenile justice,35
    • "... shall emphasize the well-being of the juvenile andshall ensure that any reaction to juvenile offenders shallalways be in proportion to the circumstances both ofthe offender and the offence.". (ii) The General Assembly on 14th December 1990, bearing in mind allthe international instruments "relating to the protection of therights and well-being of young persons" and the Beijing Rules,formulated the United Nations Rules for the Protection of Juvenilesdeprived of their Liberty ("the 1990 Rules"). They provide, in rule31 and 33,"31. Juveniles deprived of their liberty have the rightto facilities and services that meet all therequirements of health and human dignity ... and33. Sleeping accommodation should normally consistof small group dormitories or individualbedrooms, account being taken of localstandards Every juvenile should, inaccordance with local or national standard, beprovided with separate and sufficient bedding ..."(iii) The Child Care and Protection Act which by virtue of section 76(l)(f) authorizes a Childrens Court which has found a child guilty of36I
    • any offence to send that child to a juvenile correctional centre,maintains as its objects1 inter alia, in section 3,"(a) to protect the best interests, safety and well-being of children;(b) to recognize that -(ii) the least restrictive or disruptive course ofaction that is available and appropriate ina particular case to help a child should befollowed;... [and](c) to recognize the special needs of children in conflictwith the law."Mrs. Spence-Jarrett, Mr. Hesson and Mrs. !ohnson were statutorily boundby the requirements of the Child Care and Protection Act, and were awareof and embraced the principles of the Beijing Rules and the 1990 Rules.However, their acquiescence in the housing of the girls numbering overtwenty (20), in the Office dormitory measuring 20 feet by 12 feet was aflagrant breach of above principles and patently inhumane, in all thecircumstances. The recurring complaint of "lack resources" thoughunderstandable, cannot be a rational nor acceptable reason for some of theJ,7
    • unlawful actions and breaches of rules by the Department of CorrectionalServices.4.2 Life in the Office dormitory immediately prior to 22"d May 20094.2.1 The space for manoeuvring in the dormitory was extremely limited, as Ihave found. The roof and ceiling were made of concrete and consequentlyquite uncomfortable and in particular, during "lockdown" when the girlswere so confined for an entire day and night for periods of two weeks atintervals.(i) Child witness, S. G. confirmed that each new arrival at Armadale wason lockdown for two weeks during which she doe;; not attendclasses.Child witness S. F. confirms that for the two weeks of confinement,she read the Bible and slept.Mrs. Ferreira stated that some girls were taken out by teachers to dosubjects in classes. She conceded that the confinement for extendedperiods could "trigger off" the girls into fighting, the staff had to bemore alert and agreed that activities, such as, art, craft and cookingrelieved stress.All thirteen (13) girls who gave evidence, confirmed the practice of"lockdowns" and the absence from classes. Witness S. F. describedthe adverse conditions in the Office dormitory which· were, two (2)38I
    • girls to occupy one (1) bed, not much space, no use of the bathroomin the nights and buckets in which to defecate and urinate.(ii) The girls had to eat their meals with their fingers.(iii) There were other "lockdowns," for example, immediately after SportsOay on 21st April 2009 when one D. jumped over the fence andescaped. There was also a confinement earlier in 2009. Childwitness M. M. said, that the plan to escape in May 2009 was because"[we] cant tek the stress no more, everyday lockdown-boring,"Child witness M. C. said it was "hot in the days and there was nofurniture no chairs."These were depressing conditions suffered by the girls.4.2.2 The girls in the Office dormitory were denied the use of a bathroom atnights. They were provided by the staff with one or two buckets intowhich they were forced to perform all their body functions. Some girlsused newspaper or plastic bags into which they defecated in the nights.Mrs. Ferreira said that she came to Armadale and saw that practice inforce. Mrs. Passerley said that that practice was not conducive torehabilitation. Child witness S.T. said "it smelled bad." She said that thedormitory was small for twenty-three (23) girls. She would "go and sit inthe passage and look through the grill."
    • There was a bathroom adjoining the Office dormitory on the left side ofthe passageway as one leaves the Office dormitory (See Exhibit lH andlJ) to which the girls had access during the days. At nig~ts, however, thewooden door to the dormitory was locked, denying access to thatbathroom. Mrs. Spence-Jarrett said that the dormitory door should nothave been locked at nights. She did not know it was so locked with ahasp and staple and padlock. Mr. Hesson said he was not aware that thegirls did not have use of the bathroom at nights in May 2009. He agreedthat even two bathrooms for twenty-three (23) girls was inadequate,Rule 34 of the 1990 Rules reads:"34. Sanitary installations should be so located and of asufficient standard to enable every juvenile to compl_Y, asrequired, with their physical needs in privacy and in aclean and decent manner."I find that the absence of the provision of these basic bathroom facilitieswould only have served to further dehumanize and embarrass these girlsand create stress and frustration among them. These were clearbreaches of the 1990 Rules. Surprisingly, the senior management officialsof the Correctional Services Department said that they "embraced" theseRules!!40
    • I-4.2.3 Housing, additional to the Office dormitory, was proposed by Mrs.Ferreira, to relieve the congestion in that dormitory. She was providedwith a room, as the welfare officer, adjacent to the Office dormitory. Sheoffered to give up that room measuring 16 ft. by 10 ft. in which some ofth~ girls from the Office dormitory could be housed. Mrs. Ferreiradiscussed with Mrs. Spence-Jarrett and Mr. Hesson, utilizing the room,and told Mr. Hesson that there was no grill to the door. Mr. Hesson saidthat he spoke to Mr. Anderson, the property manager in March 2009, to"have the room properly secured so that wards could use it." He, Hesson,saw no action taken. Mr. Anderson said that the installation of a grill doorwas a small job which could be done in one day and paid for from pettycash. Such installation was a structural change that was his responsibility.I find that it is unlikely that Mr. Hesson was concerned enough to utilizeMrs. Ferreiras room as she suggested, to ease the congestion in theOffice dormitory, and probably failed to advise Mr. Anderson to effect theinstallation of the grill. In addition, there were four (4) other rooms inthat building, the secretarys office, Mr. Smalls office, theSuperintendents office and an office where records were kept. Any ofthese should have been renovated and used to relieve the girls of thediscomfort and stress of living in the Office dormitory (See Exhibit lH).The Department of Corrections/Ministry of National Security demonstrateda marked indifference to the girls plight in that respect.41
    • 4.2.4 Montpelier, a property consisting of ten (10) acres in the parish of St.James was acquired in 2006 by the Ministry of National Security on behalfof the Department of Correctional Services, for the purpose of reducingthe over-crowding in "the entire juvenile section." Mrs. Spence-Jarrettstated that Commissioner Major Reece having spoken to the PermanentSecretary in the Ministry, a committee was formed and submissions weremade to the Ministry. The repairs to make the premises functionallyhabitable would have cost $60,000,000.00!! It was planned to removethe boys from the Rio Cobre institution to Montpelier and to relocate thegirls at Armadale to Rio Cobre. Mr. Anderson said that Montpelier wasapproved, acquired and gazetted. Montpelier, according to Mrs. Jarrett,currently has a skeleton staff consisting of an administrator and a securityguard, and is "used for some training."The cost of keeping Montpelier since 2006, including salaries, is$300.000.00 per month, plus utilities!!In May 2008, because of the concerns at Armadale, in respect of the smallsize of the Office dormitory, the closeness of the bunk beds and "thepotential hazard in an emergency," Mr. Anderson had discussions withMajor Reece in respect of removing the girls from Armadale to premises at24 South Camp Road in Kingston. This was not realized.42
    • I find that the senior administration of the Department of CorrectionalServices and the Ministry of National Security, were devoid of the requisitesense of urgency in respect of the continuing inhumane housing of thegirls in the Office dormitory. They failed to grasp the opportunity to showa degree of compassion in their duty, to utilize the other rooms on theoffice building or the premises at South Camp Road or the ever-presentfacility at Montpelier, to house the girls in safe, healthy and normal livingfacilities. They committed both a statutory and a moral breach of dutythereby. There were beneficial committees in existence at Armadale, suchas the Behaviour Modification Committee, the Case ConferencingCommittee, which was non-functional due to lack of persons to serve andthe Disciplinary Committee. The committees failed to neutralize the ills ofArmadale.4.2.5 The educational needs of the girls should be satisfied and ongoing despitebeing in the institution. ·Mrs. Ferreira, as welfare manager would interview new arrivals atArmadale, advise them of the rules, and a test would be given todetermine the girls placement in classes. The primary subjects such asEnglish, Mathematics, History, Social Studies, Art and Craft and basicScience were taught. The supplies were sometimes insufficient orinadequate, and both she and other teachers provided supplies from their
    • own private resources. The windows of the classrooms were "boardedup" and the only natural light was through the door. Mrs. Passerley,Director of Rehabilitation, who supervised the education coordinator, oneMr. Gordon, stated that he was aware that all girls who were ininstitutions should attend school. There was a syllabus and teachers wereexpected to evaluate the girls and instruct them in high school andremedial work, the girls would sit both CXC and SSC subjects. Theeducational coordinator who should visit the institutions should report toher any deficiencies or void in the system. She received no adversereports that the system was not functioning and particularly, none sinceDecember 2008. .There were only eight (8) teachers to serve the four (4) juvenileinstitution islandwide. Mrs. Kay Barnett, the only teacher at Armadale,taught all the subjects; there were no specialist teachers. Mrs. Barnettalso had duties ·as Welfare Manager, because Mrs. Ferreira wasperforming the duties of the Assistant Superintendent and also that ofSuperintendent. Mrs. Spence-Jarrett was aware of the deficiencies. Shesaid,"We found out the deficiency in the educational systemand we were doing a full management audit ... startedin April 2009."44
    • However, she was unaware that teachers had to supplement the suppliesor that Mrs. Barnett was burdened having the additional duties of welfaremanager. She also, was aware of the 1990 Rules as it concerned theeducation of children.The Child Care and Protection Act places an obligation on "every personhaving the custody1 charge or care of a child between the ages of fourand sixteen years..." to ensure that the child is educated at school. Thereis no exception because the child is in an institution. The 1990 Rules,provide a comprehensive guide in the educational needs of children, inrules 38 to 46. Rule 38, inter alia, reads,"38. Every juvenile of compulsory age has the right to ,education suited to his or her needs and abilities anddesigned to prepare him or her for return to society..."The educational needs of the girls at Armadale were marginally andinsufficiently satisfied. A "management audit ... started [in] April 2009"instead .of an immediate increase in teaching staff was too little too late.This academic deprivation could have created frustration and a sense ofbeing neglected among the girls. The systemic non-attendance at classesdue to "lockdown" would aggravate further those emotions. Some girlswere however taken out to attend classes. The Correctional authorities
    • failed in their obligation to ensure the proper and continuing education ofall the girls.4.2.6 Recreational activities were usually scheduled weekly. Mrs. Ferreira saidthat there were clubs, namely, cultural and environmental, the Duke ofEdinburgh Club, Inter-Schools Christian Fellowship Club (ISCF) and GirlGuides. A 4H Club was started but discontinued due to lack of resources.Parties were allowed on some weekends, involving music and dancing tohelp the girls to unwind. See also rule 47 of the 1990 Rules. Clearly, theimpositions of the "lockdowns" would have nullified these benefits to thegirls.Mrs. Ferreira was of the opinion that up to 22nd May 2009, the girls atArmadale did not have the "correct mix" of discipline, instruction and love,which if present could have moulded their minds and corrected them.I find that Mrs. Ferreira showed genuine compassion, concern and anunderstanding of the needs of the girls at Armadale.4.2.7 Medical services were provided to the girls at Armadale - helpful at itsbest but wholly inadequate.New arrivals were interviewed by the welfare manager, given toiletries bythe house mother and her meal preferences ascertained. She should thenbe examined, initially, by a doctor and a psychiatrist.46
    • IIItDr. Terrence Bernard, a psychiatrist, attached to the St. Anns BayHospital and assigned to Armadale, visited Armadale twice - betweenJanuary and April 2009. Mrs. Sophia Leslie, the psychologist, betweenJanuary and May 2009, visited Armadale - 6 times. Dr. Micas Campbell, amedical doctor, between January and May 2009, visited Armadale 13times. The medical personnel was .never able to see all the wards onthese visits.Dr. Donna Royer-Powe, appointed as Director of Medical Services in theDepartment of Correctional Services assumed duties on 1st July 2008.This was a new post. She was required to ensure that there was medicalcoverage for twelve institutions, including four (4) juvenile institutions,liase with the Ministry of Health and guide the Commissioner ofCorrections on medical issues. There were then, for the entire Island,three (3) full-time and three (3) sessional _physicians and three (3)sessional psychiatrists. A session was a four (4) hour period.Dr. Royer-Powe would assign the physicians by roster, but thepsychiatrists would give her their schedule. Dr. Bernard could visit onlytwice per month. Dr. Royer-Powe, saw this as unsatisfactory and ·on Dr.Bernards recommendation, Dr. Micas Campbell, a physician who assistedDr. Bernard with psychiatric patients in St. Anns Bay Hospital wasappointed in November 2008.
    • No physician visited the girls at Armadale between April 2008 andNovember 2008, on which latter date Dr. Campbell assumed duties. Theprevious physician resigned in April 2008.Dr. Campbell observed girls suffering from (a) physical injuries includinglacerations and (b) fungal infections to the toes and nails.Two of the wards had the communicable disease, HIV and were exposingit to the other girls. Each of the two involved in deviant sexual activities,was "caught in compromising positions involving exchange of blood ..."with another girl. Of the said two (2) girls, one was, before arrivalalready on anti-retroviral drugs and the other was tested at the St. AnnsBay Hospital and awaiting results, due after an interval of six (6) to eight(8) weeks.4.2.8 (i) Dr. Campbell and Mrs. Ferreira decided that it was best and urgentthat the girl be removed from the facility. Dr. Campbell told Dr. Royer-Powe on 19th April 2009. Dr. Royer-Powe, knowing that there was anempty holding area at Horizon Centre told the Deputy Commissioner,Mrs. Spence-Jarrett, that because of the deviant behaviour, the girlwith HIV should be removed to an alternate location as a medicalintervention. Mrs. Spence-Jarrett turned down the request stating that48
    • "because of the rules" it could not be done. The girl remained. Sheperished in the fire.(ii) The psychiatric health of the girls was poor. In February or March2009, Dr. Campbell found that 90% of them showed psychoticfeatures of depression, personality disorders (borderline sociopathicand anti-social) and hallucinations, hearing or believing they wereseeing strange things. They were agitated and uneasy. Drs. Royer-Powe and Bernard recommended and asked that Dr. Campbell beallowed three sessions per week to deal with the treatment of thepsychiatric problem of the girls. Mrs. Spence-Jarrett said that it couldnot be allowed "due to budgetary constraints;" only one session perweek was allowed. One of the two girls had a severe psychiatricproblem and was also refused transfer; she also perished in the fire.I find that, in refusing to remove the girls who were both unwell and indenying the increased sessions to treat the urgent psychiatric problems inApril 2009, both on considered medical advice, the Deputy Commissioner Mrs.Spence-Jarrett, was less than understanding, exhibited a degree ofindifference and displayed poor judgment on her part. In addition, byrefusing the requested transfer, she showed a lack of awareness of theexpress statutory provisions of the Corrections Act. Paragraphs 3 and 7 ofthe Second Schedule, provide,49
    • "3. If it appears to the managers of a juvenilecorrectional centre -(b) that a person detained in the centre requiressuch [medical] attention, they may makearrangements for him to be received into anddetained in any hospital, home or otherinstitution, where he can receive the necessaryattention ...7. (1) The Minister may at any time order a personunder the care of the managers of a juvenilecorrectional centre to be transferred to thecare of the managers of another such centre."(Emphasis added)For this reason also, Mrs. Spence-J.arrett was undeniably in error, and inbreach of the statutory duty to address the welfare of the girls.4.2.9 Medication prescribed by Dr. Campbell for girls suffering from depression,psychoses and anxiety was not received as they should. The medicationtime at Armadale was 10:00 p.m. Non-receipt of medication on time, fortreating depression, some over a 24-hour period, would result in violenceand aggression and increased depression. Miss Fowler, a medical orderlywas not available, for the required 24-hour period. A full time nurse could50
    • have solved the problem. Dr. Campbell spoke to Mrs. Ferreira of this.Nothing was corrected. Dr. Campbell gave whatever dosage she couldgive, in the evenings, and told Mrs. Fowler to give what she could.Referrals in writing to specialists by Dr. Campbell, to see thegyna~cologist, ophthalmologist or the ENT surgeon, were at times delayedfor months, because of lack of transportation. There was one bus andinsufficient staff to accompany the girls."Lockdown" was spoken of by the girls to Dr. Campbell. She was of theview that such confinement for two (2) weeks would create furtherproblems but her opinion was not sought. The use of buckets, pails,paper and plastic bags for disposal of excrement in a dormitory by twenty-three (23) girls, in her view, was unhygienic and unhealthy., The girlswere becoming increasingly agitated, there was no separate room atArmadale for disruptive girls and the boisterous aggressive nature of somegirls who were not able to sleep would affect the others.5.0.0 Uncontrollable behaviour was the major complaint attributable to most ofthe girls detained at Armadale, yet there was no structured programme tocorrect this "fault" and very limited personnel!Dr. Royer-Powe was unaware, in 2008, of the fact that the majority of thegirls at Armadale were in detention for uncontrollable behaviour. She saidthat no one in the upper administration of the Department of Corrections51!:II
    • informed her of it. Had she been aware, it would have "signalled to me apsychological dysfunction," and she would have dealt with it. She had theadministrative responsibility to supervise psychiatrists and psychologists.The Senior Medical Officer at Bellevue Hospital, Dr. Oo, a psychiatrist, wasemployed by the Department to provide treatment in sessions. The onlypsychological assistance was provided by Mrs. Wint-Leslie, a ProbationOfficer, who had obtained a Masters degree in forensic psychology andwho visited Armadale from Hanover. Between January and May 2009 shevisited six (6) times. She assisted in counseling, anger management andany psychological issues. However, she did not report to the Director ofMedical Services Dr. Royer-Powe, but was authorized by the DeputyCommissioner to visit and do certain interventions - a spilt project.There was no programme for the girls in attitude adjustment or behaviourmodification. Shown Exhibit 9, the Syllabus Outline for Security Methodsand Operational Procedures in Custodial Functions for CorrectionalOfficers, Dr. Royer-Powe said that,"Nothing in exhibit 9 suggests that training inpsychology is to be involved in the training ofCorrectional Officers in dealing with young children."Mr. Hesson said in evidence that he had participated in training of>Correctional Officers who deal with children and he produced exhibit 9,...
    • undated, as "... [the] syllabus ... trainee Correctional Officers would havedone - general training for Correctional Officers."The need for psychologists at Armadale was voiced by SuperintendentGardener on 24th September 2007 at a meeting at the Department ofCorrectional Services, chaired by Commissioner Major Reece. Inattendance were, Mrs. Mary Clarke and members of her staff, Mr. Hessonand the Superintendent of Fort Augusta Adult Correctional Centre. Supt.Gardener said that there was only one (1) psychologist and there was aserious need for at least five (5) psychologists who should work on shifts.She said also, that although Armadale was equipped to hold forty (40)girls it was accommodating seventy (70)" (Exhibit 11).Since September 2007 despite the recommendation, there has been noincrease in that number of psychologists resulting in a major deficiency inpsychological care of the obviously troubled girls at Armadale. This wasan obvious need left unattended and continuing up to May 2009.5.1 Other areas of neglect at Armadale5.1.1 There were insufficient fire extinguishers functioning at Armadale for use inthe event of a fire. There were two fires set by the girls previously atArmadale, one (1) in 2007 and the other is 2008. The girls were seen byMrs. Ferreira discharging the fire extinguishers.53
    • Mrs. Claudette Hamilton, Acting Superintendent at Armadale, bymemorandum dated 18th November 2008 to the Commissioner, advisedthflt)~~.(~,, ~tcl~·d.~~nzye,t?i2:w;itJJ6i..ltsdme ·we.It f1eeoed, fire extinguishers>·· The···-·-.• ,;~,•• ,, , • > - • • , • • ., • • »> •v ., • o " - · •amount,isrtwelve {!~)."(Exhibit 3). There was obviously no response.She repeated her request by memorandum dated 4th December 2008(Exhibit 4) adding that"... Presently there are four (4) but they need to berefilled ... there is a need for an extra eight (8) ...)". Mr. Neilson Andersonadmitted seeing Exhibits 3 and 4 from Mrs. Hamilton. He said that herequested that the four (4) fire extinguishers be serviced, but admittedthat he did not attend to the provision of the eight (8) new fireextinguishers. Mrs. Spence-Jarrett said that she saw the request, Exhibit4, and passed it to Mr. Neilson Anderson who told her that "it was done."Mrs. Ferreira as Acting Assistant Superintendent, oy letter dated llthMarch 2009 (Exhibit 5) to the Superintendent, Fire Department, St. AnnsBay, stated:"In celebration of Fire Safety Week 2009, [Armadale] ...invites members of the Fire Prevention Team toconduct a Fire Drill and Fire Prevention Awareness talkwith both staff and wards."The Fire Department failed to honour this request.This gross neglect by both the senior administrators of the CorrectionalDepartment and the Fire Department in respect of fire fighting equipment54
    • II,and fire drill instructions, respectively, may well have contributed to theineffectiveness of the response of all parties at the crucial moment of thesubsequent fire.5.1.2 There was no observation or supervision of the girls in the dormitories inthe nights. The door to the Office dormitory was locked and was onlyopened in an emergency. The wooden door with an area of glass at thetop was not adequate to provide proper viewing from the outside. Mrs.Ferreira stated that she suggested that the door be left open at nights,seeing that the grill door within the passage installed November toDecember 2008, was locked, but the Correctional Officers did not agree.Mrs. Spence-Jarrett stated that she was unaware that the Office dormitorydoor was locked at nights with hasp and staple and padlock - it shouldhave been left open and the girls were to be viewed from the grill door.It seems to me that not much of the inside 0f the dormitory could be seenviewing it through the wooden door from a grill door approximately 8 feetaway. She was aware of rule 33 of the 1990 Rules, namely,"... During sleeping hours there. shoulq be regulaF,unobtrusive supervisio[J of all sleeping area, ·includingindividual rooms and group. dormitorie,s, in orqer tpensure the. protection pfe9chJL1venile:tIn relation to this, Mrs. Spence-Jarrett suggested that it was"... difficult tohave unobtrusive viewing of the wards at nights in the Office dorm." This
    • was a further breach of the rules and a failure to observe the needs ofand attention to ensure the safety of the girls. Any such "difficulty" couldbe overcome by a re-configuration of the glass area of the wooden doorand a genuine will to protect them.6.0.0, Other concerns expressed concerning Armadale6.1.1 The Office of the Childrens Advocate, a Commission of Parliament, wascreated under the Child Care and Protection Act (section 4), "For thepurpose of protecting and enforcing the rights of children". Mrs. MaryClarke was appointed Childrens Advocate in February 2006. Shearticulated consistently the deficiencies in the treatment of children inJamaica generally and voiced her concern for the ills of Armadale. Inparticular,(i) On 31st January 2007 Mrs. Clarke convened a meeting at the Officeof the Childrens Advocate. Among those present were MajorReece, Commissioner, Mrs. spence-Jarrett, Deputy Commissioner,Mr. Hesson and Mrs. Passerley. (Exhibit 26)The capacity of Armadale was stated to be forty-five (45) girls andthere were then sixty-seven (67) in that institution. Mrs. Clarkerecommended "long term counseling with specialist intervention,, forthe girls. Mrs. Spence-Jarrett noted that 95% of the children whocome into the institutions have uncontrollable traits. The ChildDevelopment Agency, which is responsible for childrens homes and56
    • I1 places of safety, does not have the space to accommodateremandees, so they are placed, as a consequence, in the correctionalcentres. Mrs. Spence-Jarrett stated that the children then becomethe responsibility of the Department of Corrections, and the ChildDevelopment Agency "never usually follow up."(ii) On 24th September 2007 at a meeting at the Department ofCorrectional Services chaired by Major Reece, the issue of Armadalehaving the seventy (70) girls was raised by Mrs. Gardener,Superintendent. She also voiced the need for five (5) psychologistsworking on shifts, and a nurse during the day and at nights. Mrs.Clarke queried "when Montpelier ... would be opened?" Major Reeceresponded that it would be opened when repairs were done and"staffing, facilities and vehicles are in place." (Exhibit 27).(iii) On 23rct October 2007, at a meeting held at Medallion Hall, andchaired by Mrs. Clarke, in attendance were the Minister of Justiceand Attorney-General, the Minister of State in the Ministry of NationalSecurity, Major Reece and other Department of Correctional Servicesofficers and a representative of the Child Development Agency,among others. The issues of children in lock-ups, places of safetyand correctional centres were discussed. The need for specialiststaff in such institutions and the over-crowding at Armadale werealso discussed. Mrs. Clarke appealed to all, including the Ministers of
    • Government for their assistance in resolving "... some of theproblems relating to juveniles under the care of the state." (Exhibit28)(iv) By letter dated 28th March 2008, Mrs. Clar~e welcomed the proposalin a draft Cabinet submission, to open Montpelier, as being in "thebest interests of children ... in conflict with the law". She soughtresponses from Major Reece in respect of the provision ofpsychologists and psychiatrists, ratio of teachers and instructors towards, lack of development and recreational activities and facilitiesfor wards with serious mental health problems. (Exhibit 29)Major Reece responded by letter dated 1st April 2008 addressing eachquery. (Exhibit 30)The Childrens Advocate, Mrs. Clarke, embracing and admittedly boundby the Beijing Rules and the 199.0 Rules, gave lecturers to CorrectionalOfficers in February and August 2007, visited institutions such as FortAugusta and Horizon where children were kept, visited, along with herstaff, several schools and investigated reports received in respect of anyabuse of children. The latter investigation led to the closure of three (3)childrens facilities. An investigating officer Mr. Courtney Berry was sentby her to Armadale in March 2008, as a result of a report of abuse shereceived. The girls were interviewed and wrote complaints in sealed58
    • lIIIIIIIIII6.1.2envelopes. As a consequence, she made a written report to theCommissioner of Corrections. She admitted not doing a physicalinspection of Armadale.With only a staff of seventeen (17) persons, limited resources, includingthe unavailability of an official means of transport since 2008, Mrs. Clarkehas exhibited a sincere and active involvement in pursuing the concept ofacting in the best interests of the child, as mandated by the CC&P Act.She has submitted, since her appointment, two annual reports toParliament, as required by the CC&P Act, but has not been summoned upto September 2009 by any sub-committee, as promised.Mrs. Ferreira, a trained teacher, was appointed Welfare case Manager ofArmadale, but has been acting as Assistant Superintendent andoverseeing the duties of Superintendent since early 2009, all at the sametime. She is still paid only as a Welfare Case Manager. She was anoverburdened public official. She interacted well with the girls and hadtheir confidence, trust and respect. She was of the opinion that with thecorrect combination of discipline, instruction and love to mould the mindsof the girls, Armadale could have functioned well. She repeatedly advisedthe senior administration of the deficiencies and the urgent needs atArmadale. She said, in evidence, with "23 wards in the Office dorm it was59
    • not comfortable" and despite her "recommendations written every month- no response - no changes".On the second Monday in each month, a meeting was held at theDepartment of Correctional Services, Head Office, presided over by theCommissioner and at which the Deputy Commissioner, Directors andSuperintendents were present. Mrs. Ferreira produced in evidence, Exhibit2, showing the monthly reports on Armadale, to the meetings,documenting its needs.• For the period 30th June 2008 to 1oth July 2008 the needswere-(a) Additional security officers needed(b) Medical orderly needed(c) Rest room for staff and(d) Holding area for disruptive wards (Exhibit 2A)• For succeeding periods, namely, 2st11 July to 1ot11 August,2008, 11th August, 2008 to 24th August, 2008, 13th November2008 to 13th December 2008, 14th November 2008 to 31stDecember 2008, 1st January 2009 to 31st January, 2009 and1st February 2009 to 2ot11 February 2009, the said needs,presumably unsatisfied, were repeatedly requested, withadditional requirements of, spraying of dormitory, relocation60
    • IIItrmof generator, tools for groundsmen and more importantly,"additional space for wards."Commencing with her performance of the duties as Superintendent ofArmadale in January 2009, Mrs. Ferreira had been requesting repeatedly"additional space for wards", in keeping with her concern that theovercrowded living conditions of the girls were wholly unacceptable. Mr.Hesson admitted that he did not make any specific attempt to deal withMrs. Ferreiras recommendations in respect of an area for disruptive wardsand the additional security.In early May 2009 an additional three (3) girls were sent to Armadale.Mrs. Ferreira told Mr. Hesson that there was no room for them, however,she would choose four (4) well behaved girls and place them in herassigned room. No final decision was made. On 22nd May 2009 Mrs.Ferreira again complained of the over-crowding to Mrs. Spence-Jarrett,the Commissioner. Mrs. Spence-Jarrett said that she was "coming toArmadale on Saturday ... tomorrow" and that she intended to move theadministrative office and "open up the dormitory to the girls." The fireintervened on that night!! Here was Mrs. Spence-Jarrett, with her "hands-1 on" approach, unilaterally, making again a housing decision. It was tooJlate.
    • 6.1.3 Both Mrs. Clarke as Childrens Advocate and Mrs. Ferreira, as WelfantCijseManager, exercising the supervisory roles of AssistantSuperintendent andSuperintendent, perceived the shortcomings of the overcrowding ofArmadale and voiced their concerns. The senior administration of theDepartment of Correctional Services failed to deal directly with the specificdeficiencies which were amply articulated, and was quite dilatory in itsresponse to urgent needs.Mrs. Spence-Jarrett, as Deputy Commissioner did, in 2006, re-introduce,for all institutions, the code of conduct rules for juveniles, (See Exhibits 35and 36). In addition, in a meeting held on 16th May 2008, attended byMr. Hesson, Dr. Vassell, a medical doctor, Mrs. Hamilton, a psychologist,Superintendents and Welfare Case Managers of both adult and juvenileinstitutions, among others, (See Exhibit 37), she "placed emphasis inregards to the manner in which children are kept in isolation at the FortAugusta Adult Correctional Centre..." reminded them that "... no childshould be kept in isolation for over seventy-two (72) hours" and "imploredthem to abide by the Child Care and Protection Act."This meeting was described by Mrs. Spence-Jarrett, as a PopulationReduction Strategy Meeting and other meetings were also held on zothJune 2008, 4th July 2008 and 18th July 2008, principally to see to therelease of girls "on licence" and other related issues.62
    • II16.1.4 Immediately prior to 22°d May 2009 the climate existing at Armadale wasone of sixty-one (61) troubled girls, twenty-three (23) of whom weresubjected to a most inhumane existence in over-crowded, unhealthy andunhygienic conditions. It was a climate of tension and apprehensionamong the girls in the Office dormitory. Some of them were very ill, asdemonstrated by Dr. Campbell, and suffered from various psychoticconditions which were largely untreated. The girls had been kept in closeconfinement for three (3) weeks, on "lockdown", in the above conditions.On the 21st April 2009, Sports Day, one girl jumped over the fence atArmadale and escaped. She was recaptured and "lockdown" wasimposed. On 7th May 2009 seven (7) girls escaped from the Cottagedormitory by cutting through the ceiling. They were recaptured and"lockdown" was imposed. It was still in force up to 22nd May 2009.Because there was no separate ~re~ for keeping sut1 disobeo.J.entgirl~,.-.,::;-_--cc.--,,-,."the entire dormitory was pl)ni~hed withth§ pain of "lockdownA{ ...•jVlr$:Ferteita~~ .report containi.~;g ~tne i;,~~u1~St·fqr·t...•holoing area .for di~rµpti{e . - "- .· - ,,. ,_;,c._.•.- >.•- ;, -,-. .•• - • ·". •..: •·• ~Wards~(Exhibit 2) was intended to resolve this.This practice of imposing punishment on all the girls for the acts of a fewis collective punishment at its worst. It was unjust. Instinctively, it musthave invoked in the girls, so subjected, a sense of grievance and injustice.
    • On 2oth May 2009 Mr. Small the overseer at Armadale read from an entryin the log book that the screws from the hasp and staple on the door ofthe Office dormitory had been removed. He replaced them. The recordalso revealed that a girl had been seen with a screwdriver. It wasr~trieved with the help of another girl. Mr. Small made a report of bothmatters to Mr. Hesson.The climate in existence in the Office dormitory immediately prior to 22ndMay 2009 was not devoid of tension and apprehension, to say the least.It was the precursor to the impending proverbial storm.6.1.5 The events of 22"d May 2009 prior to the fireSeveral of the girls had made plans to escape from the Office dormitoryon 22nd May 2009. One of the girls had told this to Mrs. Hortense Higgins,one of the Correctional Officers and supervisor on two shifts, 8:00 a.m. to4:00 p.m. and 4:00 p.m. to 11:00 p.m. Mrs. Higgins, unwisely, did notdisclose this to Mrs. Ferreira who left Armadale at 5:30 p.m. Mrs. Ferreirasaid in evidence,"Mrs. Higgins did not tell me she knew of the plan.[to escape] Had she I would have made calls andreturned to Armadale. I have done so in the past."The girl had told Mrs. Higgins that the girls had a screwdriver in thedormitory and planned to "dig out the window joints." The girls did in64
    • IIIIIIIIfact, during the day, unscrew the grill covering the back window of thedormitory, but left it in place supported by a bunk bed.Child witness M. M. said, in evidence, that one of the girls said, "Cant tekthe stress, every day we lockdown, boring ...." During the day M. M.,who heard that K. N. planned to escape, told her not to do so, becauseshe was "to be released on 15th December, dont spoil your opportunity."K. N. replied "M. me nah stay ya so."On the 4:00 p.m. to 11:00 p.m. shift were Correctional Officers, Mrs.Carlene Shaw-Slack and Miss Dian Gilbert and security officers Miss LucilleHamilton and Miss Carlene Coleman. Mrs. Higgins told them that "weneed to beef up security with more patrols than normal."It was a serious misjudgment on Mrs. Higgins part to have chosen not toadvise her superiors of the girls plans to es.cape. Her reason that therewas no search of the dormitory because the staff was insufficient isinexcusable.7.0.0 The circumstances and causes of the fire7.1.1 At about 7:30 p.m. on 22nd May 2009 Miss Coleman heard a knocking.They all went to the back window of the Office dormitory and saw that alouvre blade had been taken out. The girls were told to "put it back in".Mrs. Higgins telephoned Mrs. Ferreira, Mr. Small, as well as Mr. Hesson, to
    • whom she spoke. She telephoned also the Operations Room in Kingstonand Mrs. Jarrett, who was at the Horizon Centre and out ofcommunication. Mrs. Shaw-Slack was placed at the back window and MissGilbert at the side of the dormitory. The girls P.E., S. S. and S.K.managed to take out the grill from the back window and threw at theofficers, faeces, urine, water and various other articles. They also dug offthe grill from the front window. They became boisterous, singing andchanting and shouting expletives at the officers. Girls were trying to comeout through the back window. Correctional officers and the securityguards had sticks, hitting at the girls to keep them inside. Attempting tocome out through the front window, the girls were restrained in a similarfashion. Mrs. Higgins called the Alexandria police station and two policeofficers came in a police motor vehicle, Woman Corporal ShawnetteDunkley, in uniform, and Cons. Lawrence Burrell, in plain clothes, wearinga police vest. The girls became noisier. They were drumming, chanting,singing, and shouting expletives at the police officers. Standing near theback window, Woman Corporal Dunkley, smiling, asked the girls "What isthe problem, what is wrong? You need to calm down." The girlsresponded with expletives. Woman Corporal Dunkley told one of the girlsto get the girls to calm down so that she can deal with the situation. Thenoise did not abate. The girls shouted "Wey dem call the police fah?" andcursed the officers.66
    • IIIIItIr nNot all twenty-three (23) girls were involved in this intention and attemptto escape from the dormitory. The main planners and participants wereS.K., S.S., P.E. and T.W.Constable Burrell stood at the back fence behind the dormitory and thenmoved to the side near to the Cottage dormitory where Mrs. Higgins wasstanding. He asked her what she was going to do. She replied, "Nothingwe can do, but let them stay inside until I hear from the Superintendent."He said, "But they cant continue to go on like that ...talk cant help."Cons. Burrell drove the police vehicle from the compound and returned inabout five (5) minutes.7.1.2 Cons. Burrell came out of the police motor vehicle with a tear gas canisterin his hand and went and stood at the back fence.Miss Coleman said,"I saw him with teargas thing ... roundish with neck inhis hand ... come boasty with it in his right hand ...him not hide it ... not in his shirt." (Emphasis added)Miss Hamilton said, "the policeman returned ... had in his hand a armygreenish thing." Child witness C.W. said that the policeman returned witha grey object in his hand. Child witness P.E. saw the policeman with "inhis hand ... a round, dark greenish thing ... something on top of it."67
    • I do not believe Cons. Burrell, who said that he had a teargas device,which he called a "bombing ball," which is usually kept in the policevehicles along with batons, and that he had casually taken up thebombing ball and hooked it between the two front buttons of the polo. shirt he was wearing. He said that he took it out at Armadale rather thanleaving it in the police vehicle, because it is normal to do so. He said,"... we would not normally just leave it in the vehiclebecause sometimes you would have suspects orwhoever you pick up on the road, it is always betweenthe two front seats so you dont want to leave it and if Ishould put someone in the vehicle, when you reach tothe station it is not there, so I normally take it out andhave it in my hand."This was a curious tale!I do not believe Cons. Burrell when he said that he discovered that thebombing ball was no longer attached to his shirt "after the firefighterscame and the area was cooled down." It is further unlikely that, as hesaid,"I alerted Cpl. Dunkley and the senior officers thatcome, I told them that I had a bombing ball teargas onmy shirt but dont know where it is."68
    • IlW/Cpl. Dunkley said in evidence, that it was not normal for a teargas ballto be kept in the motor vehicle.I find that Cons. Burrell, annoyed and enraged by the disorderly conductof the girls and the continuing expletives directed at him, left Armadalewith the express purpose to obtain a teargas device and returned with atear gas canister. He did not have a teargas ball.Child witness M. M. said of the teargas device,"I ... on the floor looked at the thing thrown ... armygreen colour round ... not like ball ...like a bottle ...Tropical Rhythms ... Red Stripe bottle." (Emphasisadded)The girls, on seeing Cons. Burrell with the teargas canister, wereknowingly apprehensive.(i) M.C. said,"... policeman said Talk cant help, drove out and returned ...took something out of [his] car and went to the back."(ii) CJ. said,"... Police ... drove out and returned. One ward said Policecome back with bomb. Another said, You a idiot, him caanthrew it in yah pon we. "(iii) Child witness M.M. said,
    • "Chamala said Them a come with bomb. The policeman a gobomb we up in here."(iv) Witness Carlene Shaw-Slack said, "Police jeep left and returnedin a few minutes ... saw him with tear gas thing-roundish withneck, in his hand. Wards said you think we fraid a dat teargas and used bad words."7.1.3 Cons. Burrell, well aware that there were twenty three (23) girls in theroom, knowing that the teargas device should not be thrown into anenclosed room, unconcerned with the means by which the girls couldmake a safe, hasty exit from the room, deliberately threw the tear gascanister into the Office dormitory, through the front window, to the west.(i) Witness Shaw-Slack, Correctional officer said, "The policemanasked, How many officers? We said seven (7). He asked, Howmany wards? We told him twenty-three (23). He went and stoodat the water tank, the thing in his hand, the girls were boisterous."(ii) Carlene Coleman, one of the security officers, said,"I saw policeman pull something he had in his hand and throwthrough the front window of the Office dorm, he was 4 to 5 feetfrom me."(iii) Child witness M.C. said, "Policeman came to front, took somethingoff his shirt, draw it up like the sausage tin you pull up and throw itinto the building through the window. I see fire. It start to blaze."70
    • (iv) Child wintess C.J., C.W., J. L., K.W. and S.F. in addition, allconfirmed seeing Cons. Burrell throw the teargas canisterthrough the front window.(v) Denying that he threw the teargas container, Cons. Burrell said,"Teargas is used to disperse crowd - rioters - smokeinduces vomiting. We would not normally throwteargas into a room - used it in open spaces. Notproper police procedure to throw teargas into a room."(Emphasis added)Assistant Commissioner of Police, Paul Robinson, commenting on the useof force by the throwing of teargas, said that the Jamaica ConstabularyForce manual places a responsibility on the particular police officer tojustify its use and provides that he,"... is accountable ultimately to the law and also to theCommissioner for [the use of force] ." ·He further said that whenever this method of force is used,"it should be a part of an overall plan and that plan, Ibelieve should include the evacuation ... of any personsdetained in any premises."Cons. Burrell, with his knowledge of the enclosed room, particularly withchildren and well aware that there was no apparent exit therefrom,without the authority or knowledge of his superior officer W/Cpl. Dunkley,71I
    • nevertheless discharged the teargas, knowing, at least, that it would haveharmful effects and discomfort from the smoke, for example, vomiting.His main purpose was to chastise the girls for their behaviour.His comments, "Talk cant help" (M.C.s evidence), "No talk to them ... younuh see a bad breed" (S.T.s evidence), "A bad pickney dem ... low demyou no see dem no waan hear" (J. Ls evidence,) "Dern bad a dat dem feget" (S.G.s evidence), reveal his attitude. W/Cpl. Dunkley was seeking,on the contrary, to reason with the girls.7.1.4 The discharge of the teargas canister by Cons. Burrell was the immediatecause of the fire.(i) Child witness S.G. who was standing on the "top decker" of thebed near to the front window said,"I ... felt something come in through the frontwindow and hit me on my chest. I box it off fastand it fell on the bed, Moniques, smoke came outand sparks drop out ..." (Emphasis added)(ii) Child witness M.C. who had jumped through the front windowand was chased held and placed in the Cottage dormitory, sawfire when the teargas device landed. She said,"The policeman took something off his shirt ... drawit up like the sausage tin you pull up and throw it
    • into the building through the front window ... I seefire it start to blaze (Emphasis added)(iii) Child witness C.J. said," ... the police did have something in a him hand and,him throw it into the dormitory through the frontwindow ... hear like something a fry ... landed onbottom decker ... me see smoke come out ... Ijumped off the bed to the back window ... a try getair fi breathe ... by the time me turn round me seethe fire pon the bed where the policeman throw thething ... fire ... small ... me bawl out ... fire in a dedorm." (Emphasis added)(iv) Child witness S.J. said,"I see like smoke and fire come inside and hit C.G.and she box it off. It land on the botton decker ofStacy Anns bed close to mine." (Emphasis added)The significance of these bits of evidence of the girls is that, in the initialseconds after the discharge or initiation of the teargas device, smoke andflames or sparks were emitted. In contrast, only smoke but no flameswere discharged when a teargas han-ball was initiated.7.1.S Assistant Commissioner Paul Robinson conducted tests at the JamaicaPolice Academy, at Twickenham Park with teargas devices. The73
    • ·;. teargas canisters which he tested, on initiation, discharged flames orsparks and smoke on initiation. He said,"... from a visual observation, that from the han-ballwe never saw flames exiting from it at all other than ashort period, but for the grenades [the canisters] everytime we saw flames exiting as they initiate." (Emphasisadded)Assistant Commissioner Robinson conducted tests to show the effectscaused by the devices when activated,(i) _On 14th August 2009 - 8 experiments using"Han-ball" CS (Chlorobenzalmalononitrile)teargas grenades (of rubber) taken from thePolice armoury at Elletson Road - None of thesehan-balls emitted flames or sparks, on initiation.(See Exhibit 40-DVD disc-videotaped by Sgt.Janet Williams-Richards) (Emphasis added)(ii) On 26th August 2009 - 3 experiments usingmetal C N (Chloroacetophenone) teargasgrenades, taken from the armoury at ElletsonRoad. Flames, in the first two, and sparks, inthe third experiment, were seen ejecting fromeach device on initiation - followed by smoke.I
    • The evidence above of the girls, who saw flames and sparks initially, whenthe teargas device was thrown into the dormitory, is supported by theexperiments of Assistant Commissioner Robinson. I find that it was a CSteargas metal canister, and not a rubber han-ball, that was thrown byCons. Burrell and which canister emitted flames and fell onto the mattressof M.s bed which was close to the front window and which started the firein the Office dormitory. That was where the girls initially saw the fire.8.0.0 Scientific evidence supporting the cause of the fire.8.1.1 Mr. Fitzroy Rowe, Assistant Superintendent, a fireman, stationed at thePort Antonio Fire Station in the parish of Portland, and a fire investigatorsince 1997, visited Armadale on 24th May 2009, along with other fireinvestigators. He observed six (6) metal double de,cker bed frames burntand twisted and mattresses "completely burnt off." A book shelf attachedto the southern wall of the room and near to the front window wasseverely burnt as also a bed beneath the shelf. There was severe burningalso at the front window of the dormitory, as well as to a bed near thewindow. There was "heavy spalling" on the floor near to the severelyburnt book shelf and also on the floor near to the front window."Spalling," explained Mr. Rowe, is the condition observed where,"... the floor chip up and pull up, pull up ... theconcrete there dig up, pull up, especially the tile andthose things ... a crater is similar to spalling ... the76I
    • (See Exhibit 41 - DVD disc-videotaped by Cpl.Richard Minott) (Emphasis added)(iii) On 2sth August 2009-five (5) experiments. Hehad taken from the Alexandria police station, St.Ann, seven (7) teargas grenades canisters - six(6) of them "... were considerably old, rusty andin poor condition"- C S grenades, "manufacturedin 1980," and the seventh was a C N Grenade,similar to that tested on 26th August 2009.(See Exhibit 42 - DVD disc-videographed by Cpl.Richard Minott).The five (5) experiments were conducted using five (5) C S grenadecanisters. Three (3) of the grenade canisters emitted flames and sparks,(one of them only after 5 minutes). Of the other two (2) one failed toactivate, its port hole was taped over, apparently old and defective, andfrom the other, only teargas smoke emerged. (Emphasis added)The experiments were conducted by throwing each teargas device onto amattress, similar in type to that used in public institutions, such asArmadale. The grenades that emitted flames ignited the mattress,destroying it by fire completely.
    • "I heard it said if a fire lit it would attract attention ofthe Correctional Officers and they would open up theplace ... not know who said it they gathered around ...girls said if we light staff wi run come and we cancut."In that respect the girls miscalculated. They were unaware of and couldnot have predicted the ineptness and indifference of some members ofstaff which resulted in the girls inconvenience, suffering and eventualfatalities. Some of the girls probably had an accelerant in the dormitorywith the intention to start a fire, but the unwarranted intervention ofCons. Burrells action removed their opportunity to do so.8.1.2 The presence of an accelerant and the spatting on the, floor near to thewindow and the front bookshelf was also detected by Mr. FitzmoreCoates, retired Chief Forensic Officer, forensic analyst. He visitedArmadale on 23rct May 2009 and again on 24th May 2009. On 23rct May2009 on entering the Office dormitory, he saw the remains of six two-tierbunk beds burnt, mattresses burnt, clothing scattered on the floor andwater on the floor. He saw spalling on the ceiling near to the frontwindow to the playfield. In his opinion that was the seat of the fire, co-inciding with the evidence of Mr. Rowe. He observed that that area was"severely burnt," and "the concrete [was] removed in a circular manner."78
    • "I heard it said if a fire lit it would attract attention ofthe Correctional Officers and they would open up theplace ... not know who said it they gathered around ...girls said if we light staff wi run come and we cancut."In that respect the girls miscalculated. They were unaware of and couldnot have predicted the ineptness and indifference of some members ofstaff which resulted in the girls inconvenience, suffering and eventualfatalities. Some of the girls probably had an accelerant in the dormitorywith the intention to start a fire, but the unwarranted intervention ofCons. Burrells action removed their opportunity to do so.8.1.2 The presence of an accelerant and the spalling on the floor near to the,window and the front bookshelf was also detected by Mr. FitzmoreCoates, retired Chief Forensic Officer, forensic analyst. He visitedArmadale on 23rd May 2009 and again on 24th May 2009. On 23rd May2009 on entering the Office dormitory, he saw the remains of six two-tierbunk beds burnt, mattresses burnt, clothing scattered on the floor andwater on the floor. He saw spalling on the ceiling near to the frontwindow to the playfield. In his opinion that was the seat of the fire, co-inciding with the evidence of Mr. Rowe. He observed that that area was"severely burnt," and "the concrete [was] removed in a circular manner."78
    • He saw also that the wall adjacent to the seat of the fire "which was justbelow the window was severely burnt."He saw "... in the same vicinity...," beside another bunk bed "... a smallcrater ... beside the bed on the concrete tile flooring ... about 3 to 4centimeters deep ... about one foot across," with severe burn marks onthe floor around the area.I find that this "crater" in the concrete was the condition that Mr. Rowedescribed also as spalling and was in the south-western corner of theroom, near the bookshelf referred to by Mr. Rowe.Mr. Coates, having drained the water from the room, made a thoroughsearch and took samples of material "around the crater in the area of tl;leseat of the fire." He said he carried out tests,"On sample number 7, the pieces of partially burntcloth taken from the south-eastern section of the roomadjacent to the window ... in the area near the seat ofthe fire."The tests revealed " the presence of gasoline, a highly flammablehydrocarbon accelerant." He also said that the tests on sample number 8,"... the remains of a Bible, found in the area of the crater on the north-eastern section of the room ... adjacent to the seat of the fire," revealedthe presence of "...highly flammable hydrocarbon accelerant-gasoline."
    • ----------------~-- -I find that although Mr. Coates refers to "the seat of the fire to be on thesouth-eastern section" and on another occasion as the "north-easternsection" of the room, he agrees with Mr. Rowe, that it was in the vicinityof the front window to the playfield. (See analysts chart, exhibit 22.)Both witnesses found the presence of an accelerant in the area of the seatof the fire. This area was in fact the south-western part of the Officedormitory - between the front window and the front closet.Significantly, Mr. Coates said that he did not find "any incendiary devicesor the remains of anything of that nature."9.0.0 The effect on, and reaction of the girls to the teargas and fire inthe dormitory9.1.1.The girls had dug from the wall, the grill to the back window of thedormitory, during the course of the day, but left it in place, supported byone of the beds, in order that it would appear normal. They had two (2)screwdrivers. After supper, some of the girls were making noise, singingand cursing the patrolling staff and throwing urine and water on themfrom the buckets in the dormitory. They used a piece of iron from thecloset and started to hit off the grill from the front window. Some of thegirls merely sat and watched. The lights in the dormitory were beingturned on and off. Both the making of the noise and the turning off of thelights were intended to conceal their actions. Mrs. Higgins used her80I
    • cellular phone. The male and female police officers came. The femaleofficer spoke to the girls. The male police man said "Talk cant help"drove out and returned. One girl said they were "creating disturbance toget the staff dem come in." They removed the grill from the back windowand some attempted to go out. Mrs. Shaw-Slack brought a piece of boardand attempted to block the window. Mrs. Higgins, Mrs. Shaw-Slack andother officers, with sticks, were hitting at the girls to keep them inside.The girls then removed the grill from the front window. Some of theofficers, including Mrs. Higgins came to the front window, and again werehitting at the girls who attempted to leave the dormitory. Witness M. C.jumped out through the front window; but was chased and held by MissHamilton and placed in the Cottage dormitory. Cons. Burrell then came tothe front window and threw the teargas canister through the frontwindow, the lights were then off. The canister hit child C.G. in her chest.She "boxed it off" and it fell on the bed. Flames and smoke came out ofthe canister. The smoke filled the room, burning the nostrils and eyes ofthe girls. The fire started on the bed nearest to the front window. Thegirls shouting "fire" and "help", rushed to the back window "to get air."The girls, bigger in size blocked the back window - some girls came out.S.F. jumped out through the front window - but she was hit by Mrs.Higgins and told to go back inside. S.J. went into an upper cupboard to"try to get air", it was futile. She jumped through the front window. Mrs.81
    • Shaw-Slack and Mrs. Gilbert helped girls out of the back window of theOffice dormitory, by which time a blazing fire and teargas filled the room.The girls were in a panic and had difficulty breathing. They fought eachother to escape through the back window - some were pushed to theground and were stepped on. M.M. asthmatic and suffocating suffered anose bleed and burning on her skin. She was helped to the back windowby K.N. who said "Come M. mind you asthma." The fire consumed severalof the mattress, made of a "foam like" material, giving off harmful fumes.Forensic analyst Mr. Coates said,"Foam mattress burning would give off hydrogencyanide, carbon dioxide, carbon monoxide, hydrogenchloride and phosgene - all toxic substances ... burningof foam would generate a lot of heat and rapidconsumption of oxygen in a room that size."The girls consequently suffered, in th0se circumstances, great discomfortand stress, difficulty breathing due to insufficient oxygen and intense heatfrom the fire. In addition to· those conditions, the girls in thatovercrowded dormitory, each with at most, barely two and one half feetsquared of standing space between the bunk beds, could not fail to behandicapped, utterly confused by the fire, smoke and teargas fumes andunable to manoeuvre safely in such a tightly packed space. It was chaoticby any standard. Several of them experienced extensive burns to their82
    • bodies and a "peeling off" of the skin. Once outside, one girl went to therefrigerator to "cool my skin", others were fanning themselves and eachother, many ran around the playfield or allowed water to run over theirbodies to keep cool and almost all were crying and distressed.About fifteen (15) girls were helped through the back window of theOffice dormitory. Both Mrs. Shaw-Slack and Mrs. Gilbert were outstandingin helping girls to get out through the window. Mrs. Hamilton and MissColeman also helped.9.1.2 An ambulance arrived and took about 10 girls, burnt and crying, to the St.Anns Bay hospital. Mr. Joseph Small~ the overseer, having received threetelephone calls from Mrs. Higgins, arrived at Armadale at about 8:40 p.m.He saw the Office dormitory with "a lot of black smoke and fire ... thebuilding engulfed." He enquired whether any other wards were in thebuilding. The security guards were crying and confused. He took to thehospital in his motor car, some of the girls "... burnt skin stripped off[and] crying." He saw the fire truck arrive about ten (10) minutes afterhe did. Before then, Mrs. Higgins and others were carrying water incontainers and throwing it through the front window to put out the fire.He saw a Sergeant of Police there speaking on his cellular phone andwhom he sought to speak to. The officer did not respond. He saw nopolice officers assisting to put out the fire while he was there.83
    • 10.0. Errors and lost opportunities by staff and fire officers at theoutbreak of fire10.1 After the realization that there was a fire in the dormitory, Mrs. Higgins, aCorrectional Officer 1, and the supervisor of the shift- 4:00 p.m. to 11:00p.m., was more intent on containment of the girls within the dormitory,than a quick and effective release therefrom. She continued hitting themto stay in. Mrs. Higgins had heard a sound inside the dormitory "... like airletting out." She ran from the side to the front window and passed Cons.Burrell "going to the side of the dormitory going towards the back." Shesaw "black smoke ins_ide the dormitory." The girl S.F. jumped through thefront window onto Mrs. Higgins chest. Mrs. Higgins said,"... ward [F] jumped through front window ontq mychest ... eyes and nose burning me ... placed her on thegrass. I ran and drank water at pipe ... another girljumped through ... knew Shaw-Slack had keys.I considered opening [the door to the dorm] ... I justwanted some water to drink and cool down my face ...heading back to the front of the office building ... I sawgirls outside running up and down! ... some with burns... I saw Miss Slack at the front on the grass coughing.I got the keys from her, run up the passage and Ipulled the padlocks from the grille ... two ... I went up84
    • to the door made of board ... with two padlocks ... glassat the top. I saw fire ... inside ... and smoke comingthrough the jamb. I could not go any further, it washot ... I did not attempt to open either one ... I ranback to the dining room to find a fire extinguisher."I find that Mrs. Higgins, as the supervisor of the staff on that shift, havingfirst seen black smoke in the dormitory, should have promptly opened thedoor, at least to ease the discomfort from inhalation of smoke.Assuming that she did not have the keys, which as supervisor she wasrequired to, she should have retrieved them promptly from Mrs. Shaw-Slack, who did attempt, unsuccessfully, to release the girls through thedoor. Mrs. Higgins, having been outside, at the window, was neyerexposed to the inhalation of the noxious air in the dormitory. There wasno necessity, in my view, for her to leave to drink water and "cool downmy face," as she claims, before opening the door. By her unnecessarydelay, she lost valuable time and opportunity to assist the girls enclosedand entrapped in the dormitory. She added to their peril.10.2 I reject the evidence of Cons. Burrell that he saw someone inside thedormitory"... light something ... and dropped it on one of the beds ... fireblazed up ... I shouted fire where is the keys ..." and he "got a bunch ofkeys from someone ... I cant say who," and "I walked down the passage85
    • way through thick black smoke and opened the padlock on the secondgrille" in an attempt to release the girls. Nor do I believe him when hesaid that he kicked open the wooden door "... and a large flame came out... it opened halfway ...". He said that that door was locked with a "deadbolt at the bottom." (Emphasis added)I find that,(i) The two padlocks on the grill door had already been unlockedby Mrs. Higgins after she got the keys from Mrs. Shaw-Slack.He could not therefore have unlocked "the padlock" on thegrill door.(ii) Because of the "thick black smoke" in the passageway, hecould not have known nor would have been able to see whichof the keys from the "bunch of keys", was the one to open thepadlocks on the grill door.(iii) Mrs. Higgins said that she did not give the keys to anyone elseafter she got it from Mrs. Shaw-Slack.(iv) He said that the door was locked with a dead bolt at thebottom but failed to realize that there were two padlocks also,locking that wooden door - with hasps and staples.(v) He said that the grill door that he opened was "very close" tothe wooden door "right against it." Det. Cpl. Samuel Brown of86IIf
    • the Major Investigation Task Force, a crime analyst trained inthe use of software to reproduce scenes, said that thedistance from the door of the Office dormitory to the grill gatewas eight feet seven inches (87"). (See Exhibits 1 and 10).Other witnesses agree with that distance.I find that Cons. Burrell did not at any time enter that passageway, withor without the door keys, nor did he attempt to open the door to thedormitory.10.3 District Officer Patrick Robinson of the Jamaica Fire Brigade, stationed atBrowns Town, St. Ann, received. a telephone call from the Alexandriapolice at approximately 8.53 p.m. and went to Armadale with six (6)others. The ambulance was then leaving the premises. He saw the "thjckblack smoke" coming from the building and was told of "... the wardsinside." He assessed the situation and entered the building through thepassage. He said:"... we could not gain entry to the dormitory because ofa blocked door ... So we retreated and went to thewindows where we started fighting the fire from the. d "wrn ows...He said that he and another fireman, subsequently "... returned to thedoor ... we managed to shub the door ... there was a bed blocking thedoor, ... we pressure the door ... it just came off into our hands ... we put87
    • it on the outside." When asked, Mr. Robinson said"... it was very hard toremove the door at that time ... it would take some time to really smashthe door."The District Officer and the other fireman should not have failed to openthe dormitory door when they went to it on the first occasion. By leavingthe door unopened and going to the windows before returning andopening the said door they chose the wrong option and probably lost theopportunity to save a life or lives.11.0 Falsification of Alexandria Police Station diary concerning theissuing of teargas device11.1 On 22nd May 2009 Constable Roogae Rowland, station guard at theAlexandria police station, made diary entry no. 26 in the station diary at5.55 p.m., recording Government property in a strong pan in hispossession. He "checked and accounted for," items, including firearmswith their serial numbers and ammunition, and "Eight tear smokecanisters..." (Exhibit 18)He also recorded, as diary entry no. 29, at 8:00 p.m. the receipt of thereport from Armadale and entry no. 30 at 8:00 p.m., the dispatch ofWoman Cpl. Dunkley and Cons. Burrell to Armadale. (Exhibit 18)On 23rd May 2009 Cons. Rowland, by diary entry no. 2 at 8:00 a.m.recorded that he handed over duties to Cons. Wisdom, as station guard,88IIIIIJ}
    • and Government property, including, firearms with serial numbers andammunition and also,"Eight (8) tear smoke canisters." (Exhibit 18)He said that he counted them. There were seven (7) but he wrote "eight"and it was a "honest mistake."11.2 Constable Wisdom by diary entry no. 3 at 8:00 a.m. on 23rd May 2009recorded receiving from Cons. Rowland, firearms, stating their serial nos.and ammunition, and also, inter alia,"... eight tear smoke canisters ..." (Exhibit 18)11.3 Cons. Rowland said, in evidence, that on 22nd May 2009 at 8:00 p.m.Cons. Burrell requested a tear smoke booming ball and a baton and hehanded them to him and,"Woman Cpl Dunkley could have heard and seen."He did not record the issue of the canister to Cons. Burrell, because he didnot remember and he was busy with telephone calls and the radio. Hesaid that Woman Cpl. Dunkley later telephoned and asked for Cons.Wisdom neither did he record that request in the diary. He said thatCons. Burrell returned to the station between 8:00 p.m. and midnight andasked him for Cons. Wisdom - neither, did he not record that fact in thestation diary.89
    • Cons. Rowland, in answer to me, said that when Cons. Burrell came backto the station he,(i) did not come inside the guard room(ii) he did not ask for Cons. Wisdom(iii) he parked the motor vehicle for a few seconds at the gate ofthe station and Cons. Wisdom was standing at the gate and(iv) Cons. Burrell took Cons. Wisdom whom he Cons. Rowland sawgo into the vehicle with Cons. Burrell.No entry of all this was made in the station diary. This latter answer isin contradiction of his ~arlier evidence that Cons. Burrell asked him forCons. Wisdom. This also contradicts Cons. Burrells evidence that heCons. Burrell did not see Cons. Wisdom at the station. W/Cpl. Dunkleysevidence is that Cons. Burrell returned to Armadale alone.I find that Cons. Rowland is an untruthful witness. Both in respect of hisanswers concerning Cons. Wisdom and by his falsification of entry no. 2on 23rct May 2009 that he handed over "Eight (8) tear smoke canisters",well knowing that he had handed one canister to Cons. Burrell on thenight of 22nct May 2009.11.4 Cons. Wisdom also falsified the station diary. In evidence he said, that,90IIIIIIJ~
    • (i) on 22nct May 2009 at 6:00 a.m. he physically counted eightteargas canisters and at 6:00 p.m. he handed over stationguard duties to Cons. Rowland;(ii) on 23rd May 2009 at 8:00 a.m. he made a diary entry no. 3(Exhibit 18) that he received "eight tear smoke canisters"but he had not counted them - because he saw no entrythat any had been issued. This was at least reckless, notcaring whether or not it was true.(iii) On 22nct May 2009 he had received a call from W/Cpl.Dunkley, but he did not go to the Alexandria police stationuntil about 10:00 p.m. He did not see Cons. Burrell and didnot go into a motor vehicle at the gate of the police stationand leave with Cons. Burrell. He thereby contradicted Cons.Rowlands evidence on these matters.Cpl. Donovan Campbell, said that, as supervisor; he checked theAlexandria police station strong box on 23rd May 2009 at 12:30 p.m. andsaw seven (7) teargas canisters. Cons. Rowland told him that he hadissued a teargas device to Cons. Burrell. He said he spoke to SergeantHeath about the conflict. Cpl. Campbell gave evidence at the Enquiry on26th August 2009 and he said that up to then there was no entry in thestation diary of the issue of the teargas device to Cons. Burrell on 22ndMay 2009.91
    • 11.5 The significance of the entry "Eight (8) teargas canisters" in the stationdiary is, that it confirms that the teargas device issued to Cons. Burrell byCons. Rowland was a teargas canister and not a teargas han-ball or"bombing ball" as he Cons. Burrell describes it. The fact that it was acanister would be supported by the child evidence of the witness M.M.which I accept, and who said,"I ... on the floor ... looked at the thing thrown ... armygreen in colour round not like ball ... like a bottle -Tropical Rythms ... Red Stripe Bottle." (Emphasisadded)Further confirmation of the teargas canister is provided by the evidence ofthe tests by Asst. Commissioner Robinson who said that "for the grenades,[the canisters] every time we saw flames exiting as they initiate" but notso with the han-balls tested. Child witness S.G. saw "sparks drop out," oninitiation.I find that Cons. Burrell never had a black rubber han-ball or any"bombing ball" at all. Nothing was "hooked to his shirt", as he claims.12.0 Evidential effect of the entry "canisters" in the station diaryThe station diary is a book in which should be faithfully recorded bypolice officers, all activities, events and reports, items of governmentproperty and at times, prisoners property, in relation to or affecting theparticular police station. The particular entry in the diary by a police92I
    • officer may be used to support or to discredit his testimony; it is nothowever a public document (see R v White v Jones (1976) 15 JLR 20).Oral evidence cannot be used to "vary, add to or subtract from" thecontents of the diary, it being a document.I reject, as untrue, and evidentially invalid, the oral evidence of Cons.Wisdom, that on 22nd May 2009 there were "seven canisters and oneblack bomb." He wrote "eight teargas canisters" (Exhibit 18). Equally,invalid is Cons. Rowlands oral evidence that Cons. Burrell requested andhe handed him a "bombing ball". Cons. Rowland wrote in the stationdiary that he received "Eight tear smoke canisters."Alphanso Heath, Sergeant of Police and sub-officer at the Alexandriapolice station, obligingly, said,"... there is a difference between a cylinder and around-like ball."but, inexplicably, he volunteered,"We do not differentiate ball from canister, calleverything canister. (Emphasis added)That latter statement defies common sense and rational reason.W/Cpl. Dunkley, who displayed commendable compassion and patience indealing with the girls on her arrival at Armadale, sullied her credibilitysomewhat, in giving evidence, when she was recalled on 25th August 2009and said,93Il !iiIi11IlIljI,fl·11!:hiI! ~! lirli,1;J/;>]111.1li jIJ iiI
    • "Entry 26 - (22. 5. 09 5:55p.m.] I recorded in thestation diary eight tear smoke canisters ... did aphysical check ... there were seven of the can ones andone bumming ball ... canisters ... silver and a lightgreenish colour ... the ball black." (Emphasis added)I do not accept that there was any other than as she wrote, "eight tearsmoke canisters." Sgt. Campbell said "... to write down canister andmean bombing ball, sometimes we make mistakes".It plainly defies common sense that the police officers at the Alexandriapolice station, would routinely, all, choose to record a "ball" as a "canister"in the diary. A "canister" is cylindrical and metallic and a "ball" is sphericaland of rubber. The police officers at the Alexandria police station, in thatrespect, did themselves no credit. Their futile accounts in stating verballythat there was a han-ball, thereby attempting to cover-up the use of theflame-emitting teargas canister, put ·at grave risk the evidentialpresumption of omnia praesumuntur rite esse acta, "all official acts aredeemed to have been properly done." They failed in that respect.Woman Cpl. Dunkley, was further discredited, in her testimony -(i) On 28th July 2009 when she gave evidence, she was asked,"Q.... the first time you know anything about anyteargas bombing ball .. was after the fire wasall over? (Emphasis added)94I,,f.IIlj
    • A. Yes."(ii) On 25th August 2009 when she was recalled, to give evidenceshe was asked by me,"His Lordship: So when you were leaving thestation at 8 oclock you did notknow that he [Cons. Burrell] hadrequested a bombing ball?A: I saw it in the vehicle whilst wewere going to Armadale but I didnot know if it was there before orthat cons. Burrell hadrequested it." (Emphasis added)This latter answer, in direct contradiction of her former answer on 28thJuly 2009, was disappointing, but not surprising, in the circumstances. Itwas an attempt to a cover-up, an untruth. I reject her testimony on thatpoint.This confirmed my view that Cons. Burrell did not have the teargascanister when he was leaving the Alexandria police station at 8:00 p.m. on22nd May 2009. He had not asked for it then nor was it given to him thenby Cons. Rowland.Cons. Burrell had left Armadale hurriedly and returned to the policestation, quickly requested and obtained a teargas canister and returned95
    • with it to the Armadale facility on the second occasion, openly, to"chastise" the girls. The girls saw him with it, on that occasion.Further confirmation of this is found in the fact that Woman Cpl. Dunkleysaid that she had sent Cons. Burrell to the police station to pick up Cons.Wisdom. She said, in evidence in cross-examination, that on her way toArmadale she telephoned Cons. Wisdom, but "did not get through to him/He telephoned her whilst she was at Armadale and she told him what washappening and asked him to return to the station to assist. He said hewas "ten minutes away." She told him that she would send Cons. Burrellfor him. She said,"I told him [Cons. Burrell] to go and pick up Mr.Wisdom because he said he was near to the station, so;by the time he left Armadale he would have reachedthe station." (Emphasis added)Cons. Burrell, in evidence said,I went to the Police Station but Constable Wisdom wasnot there. As a result I went back to Armadale ...within five minutes or less."The questions that arise are,(i) Why did Cons. Burrell not wait, even briefly, forCons. Wisdom who was "near to the station" and bythen "would have reached the station"?96I:IJfI
    • (ii) Why did Cons. Rowland say that he saw Cons.Burrell stop the motor vehicle at the police stationgate and he saw Cons. Wisdom, who was at thegate, go into the motor vehicle and leave with Cons.Burrell?(iii) Why was it on his return to Armadale, Cons. Burrellsaid nothing to Woman Cpl. Dunkley about notseeing Cons. Wisdom, nor did she enquire of him?Cons. Wisdom said that on 22nd May 2009,"I went back to the station about 10:00 oclock when Ireceived a call from Woman Corporal Dunkley."I find that Cons. Burrell did not leave Armadale for the purpose of pickingup Cons. Wisdom. If that had been the purpose he would have waited atleast, for a few minutes for Cons. Wisdom who "was near to the station"or telephoned him. He would also on return to Arma.dale, have reportedto Woman Cpl. Dunkley, his senior officer, the fact that he did not findhim.In my view Cons. Burrell, impatient with the cursing and boisterousbehaviour of the "bad pickney dem" and convinced that "Talk cant help",left Armadale with the express purpose to return to the station for ateargas canister. He obtained it within the station from Cons. Rowland,returned to Armadale and without any compassion or thought for the97
    • health or safety of these young girls or their means of exit, activated andthrew the teargas canister through the front window and into the Officedormitory. This caused panic and chaos within the dormitory, anddiscomfort, harm and ultimately the death of some of the girls in thedormitory. This was quite an irrational, harsh, unnecessary and unlawfulconduct on his part.I would recommend that the relevant statements, notes of evidence andmy report be forwarded to the Director of Public Prosecutions forconsideration whether or not his conduct gives rise to any criminal acts.It is of note that Section 26 of the Offences Against the Person Act reads,"26. Whosoever shall unlawfully and maliciouslyadminister to, or cause to be administered to or takenby any other person, any poison or other destructive ornoxious thing, with intent to injure, aggrieve, or annoysuch person, shall be guilty of a misdemeanour, and,being convicted thereof, shall be liable to be imprisonedfor a term not exceeding three years, with or withouthard labour." (Emphasis added)Section 25 concerns such an act which, committed "with intent toendanger life or to inflict upon such person any grievous bodily harm"creates a felony - See R v Cunningham [1957] 2 Q.B. 396; 41 Cr. App.98IIIIIIIfIIfI
    • R. 155. In that case the appellant broke off and stole a gas meter and itscontents in a house, unknowingly fracturing the gas main and caused coalgas to seep next door. The gas was inhaled by the occupant causing herlife to be endangered. The appellant was convicted but succeeded in theCourt of Criminal Appeal because of a misdirection by the trial judge.In addition, Cons. Burrells action may have been negligent. See Rigby vChief Constable of North Hampshire [1985] 1 WLR p. 1242, ajudgment of Taylor J. at first instance, to which Messrs. Hamilton, Q.C.,and Batts, Attorneys-at-law referred me. The defendant a police officerwas held liable in negligence for damage caused to the plaintiffs shop andgoods by a fire caused by a C S gas canrster thrown by the police creatinga known fire risk without ensuring the presence and availability of firefighting equipment.Asst. Commissioner Robinson testified that the effect of the teargassmoke was a severe irritation of the eyes causing streaming and a burningsensation of the eyes and nose, as well as choking and coughing, and cancause vomiting. There was ample evidence of its adverse effect on theoccupants of the Office dormitory..0 Further scientific evidence of the presence of C S teargasThe scientific evidence of witnesses, Mrs. Tanya Kerr and Mr. FitzmoreCoates, along with the evidence of the tests conducted by Asst.Commissioner Robinson and the eyewitness accounts, confirm that the99
    • teargas device thrown into the Office dormitory by Cons. Burrell on 22ndMay 2009 was a C S teargas canister. "C S" is the designation forchlorobenzalmalononitrile, the main ingredient of C S teargas.Mrs. Kerr, possesses a B.Sc. degree in Chemistry and Physics (UWI), MPhildegree in Physics (UWI), Certificate in Analytical Chemistry from VERIFIN,University of Helsinki, a research institute, Certificate in Fire Investigation,University of Strathclyde, Scotland, and other certificates in forensicscience and related topics.On 3rd June 2009 she received from Det. Sgt. Thomas, nine (9) sealedenvelopes containing, inter alia, the clothing of the five (5) girls) who hadbeen found lying on the floor of the dormitory after the fire and had beenpronounced dead at Armadale. Sgt. Thomas had received the clothing on29th May 2009 at the Spanish Town Hospital morgue from Dr. E. Seshaiah,the Consultant Forensic Pathologist who !:lad performed the post mortemexamination on each.Mrs. Kerr conducted tests on each set of clothing. She placed the clothingwith charcoal strips in a nylon bag which was then heated, and the stripswere then placed into a GCMS machine (gas chromatography massspectrometry). The machine revealed, and the analyst Mrs. Kerrconcluded that, extracted from each set of clothing onto the said strips,100IIiI-IIIIIII·IIJII1
    • was a light hydrocarbon accelerant. There were not enough peaks shownon the machine to identify the hydrocarbon as gasoline. She said,"It looks similar to the characteristic pattern ofgasoline, however, some of the peaks werecharacte~istic, but there werent enough characteristicpeaks for me to positively identify it [as gasoline]."Gasolene, she said, is made up of a series of hydrocarbons, and soburning or evaporation will reduce some of the hydrocarbons. Thecollecting and storing of the samples, after a fire, are important. Thepresence of hydrocarbons in an ignitable liquid "diminishes as timeprogresses."Mr. Coates, who had gone to Armadale shortly after the fire on 23rd M~y2009, drained the water from the room and took several samples. Fromthe tests conducted at the Forensic Laboratory, he found on the sampleswhich he numbered 7 and 8 "the presence of gasoline, a highly flammablehydrocarbon accelerant".Mrs. Kerr found on the clothing of the deceased girls Rochelle King andShaunnalee Kerr, which clothing were in envelopes marked "D" and "J"respectively, and subjected to the GCMS test, the presence of compounds,(a) 4 chlorobenzealehyde and(b) 2 ethylhexylcyanoacetate101
    • respectively. These are two different compounds each resulting from thedegradation of 2 chlorobenzalmalononitrile, which is C S teargas. Sheexplained that when heat is applied to C S teargas or with hydrolysis, thatis, exposure to moisture, such as water, "... you can have arearrangement in the chlorine compounds in the C S ..." causing thedegradation of the C S teargas into the two compounds she found,namely, 4 chlorobenzealdelyde and 2 ethlyhexylcyanoacetate..The seven (7) teargas canisters that Asst. Commissioner Robinson tookfrom the Alexandria police station on 27th August 2009 were, six (6) CScanisters manufactured in 1980 by Smith & Wesson and the seventh wasa C N canister manufactured by Defense Technology Federal Laboratories.The C S canisters were old, rusty and in poor condition with "much of theblue paint outer coating flaked off".Mr. Coates, who was also trained in fire tnvestigation and certification atStrathclyde University, Scotland, on testing a sample of water, sample no.4, taken near the seat of the fire near the front window, found acompound called chloroacetophenone. This is the breakdown product ofC N teargas. Questioned, he said that he would not rule out C S but hefound C N.Mrs. Kerr explained that the C S teargas structure represented chlorine ona ring and when intense heat or moisture is applied, there is a shift on the102IIIIIIIIIIIIJIII1J"l
    • ring, causing the degradation of C S into the compounds that she found.C N is not on that ring but can be found on a branch extending from thatring. Therefore, she said, with some other chemical interaction thebreakdown product of C N, chlorocetophenone, could be produced from CS teargas. Although it is difficult and unlikely that chlorocetophenonecould be formed from C S teargas it was possible, said Mrs. Kerr.Mr. Coates found chlorocetophenone. However, the evidence of, thedescription of the canister" like a Tropical Rhythms bottle, Red Stripebottle," and the flame and sparks seen when it was thrown into the room,and the flame emitted on initiation, characteristic of the test done by Asst.Commissioner Robinson on the C S teargas canister, rules out, in my view,the presence of any "han-ball," device used, as claimed by Cons. Burrell.On the contrary, it confirms the discharge of the C S teargas canister intothe Office dormitory on that fateful night emitting flame and sparks whichstarted the fire.Where any conflict arises in this respect I accept the evidence of Mrs. Kerrin preference to that of Mr. Coates.14.0 Negligent treatment by non-examination of the five (5) girls.On 22nd May 2009 Friday night at about 10:00 p.m., Dr. Campbell, havingbeen summoned, went to the St. Anns Bay Hospital. She observed girls,some with burns, screaming and crying ~ she treated them. Some were103
    • admitted and two (2) were sent to the Kingston Public Hospital. Havingspoken to Mrs. Spence-Jarrett, Dr. Campbell arrived at Armadale between1:00 a.m. to 2:00 a.m. on 23rct May 2009. The bodies were brought outto her then, from the Office dormitory and placed on the grass outside.She pronounced dead, Rochelle King, Ann marie Samuels, ShaunnaleeKerr, Kaychell Nelson and Nerissa Gooden. All the bodies, except that ofNerissa Gooden, were in the state of rigor mortis, (stiffness), which occursthree (3) hours after death and showed corneal clouding (of the eyes)which occurs two (2) hours after death.Nerissa Goodens body which Dr. Campbell examined at 3:00 a.m. wasflacid, (no rigor mortis) and her eyes were clear. The conclusion is thatshe died less than two (2) hours before 3:00 a.m.!!Nerissa Gooden was probably alive up to 1:00 a.m. With diligence on thepart of the several personnel at Armadale, she could have survived. Dr.Campbell conceded that she was not a pathologist and therefore theremay have been other factors involved. She was of the view that theburns she saw were not serious enough to cause death. Death may havebeen caused by smoke inhalation, suffocation or trampling.District Officer Robinson of the Browns Town Fire Department went intothe Office dormitory, having put out the fire. He entered and with the aidof a flash light, he saw the five (5) bodies on the floor near the back104IJIJJ1IJJlJIJJI1J1,j
    • window. He did not examine the bodies, nor did any other person fromhis department do so. He had received, at training school, instructions infirst aid. But, curiously, stated that it is not normal to ascertain whetheror not a victim at a fire requires first aid. This is because, he said "... wehave an Emergency Medical Service ... we dont have that facility in St.Ann." He said that the other reason why he did not examine the bodieswas,"because at the time we get the fire call and the timewe reach there, the time it took us to control the fire,you know, anybody in that building suppose to die ...the bodies were motionless." (Emphasis added)This in my view, was an unprofessional and negligent approach to victimsof a fire. It was a wrongful assumption that may have caused a loss or afurther loss of an opportunity to save a life or lives. Mr. Robinson saidthat he got the call at Browns Town at 8:53 p.m. arrived at Armadale atabout 9:15 p.m. and had the fire under control in about "ten to fifteenminutes." The Cummings Funeral Home personnel arrived at Armadale atabout 10:30 p.m., waited about "an hour and a half" while a police officervideographed the scene and thereafter they removed the bodies from thedormitory, onto the grass outside. Dr. Campbell examined the bodies asthey were brought out of the dormitory to her between 1:00 a.m. to 3:00a.m.105
    • Deceased Nerissa Gooden was probably alive when Mr. Robinson saw thebodies at about 9:30 p.m. on 22nd May 2009. With diligence, urgentattention and some degree of "first aid" examination, she, probably, couldhave survived.15.0 Postmortem examination and cause of deaths.15.1 On the 29th May 2009 postmortem examinations were performed by Dr.Ere Seshaiah, Consultant Forensic Pathologist at the Spanish TownHospital morgue, on the bodies of,(1) Shaunnalee Kerr, 15 years old(2) Kaychell Nelson, 15 years old(3) Ann marie Samuels, 16 years old(4) Rochelle King, 16 years old(5) Nerissa King, 16 years oldThe cause of death in each case was given, tersely)1 as "due to burns"(See Exhibits 43 - 47).On 30th June 2009 postmortem examination were performed by Dr. S. N.Prasad Kadiyala, Consultant Forensic Pathologist, on the bodies of,(6) Georgina Saunders, 16 years old and(7) Stephanie Smith, 17 years old (see Exhibits 48 and 49)The cause of death in each of the latter two cases was due to(a} Sepsis and (b} flame burns.106I-IiII/ "c;~•-i•:,}I•;!IIII•IIi
    • Both girls had been transferred to the Kingston Public Hospital where,after some days, they died.In all the circumstances, I feel compelled to make some observations andrecommendations, which I hope may assist.16.0 Observations and recommendations(1) The housing accommodation in the Office dormitory,from its inception, was grossly inadequate, overcrowded,cramped and unhealthy and its adjacent sanitaryconveniences, insufficient and unhygienic.Housing decisions for children "deprived" of theirliberty in such institutions -(a) should be made to conform with internationalstandards, namely the Beijing Rules and the1990 Rules and the National Building Code ofJamaica, and(b) should be decided by a committee established inthe Department of Correctional Services, inconsultation with the management staff of theparticular institution. It should not be imposedarbitrarily, as was done in the instant case;107
    • (c) specialist and professional advice should beemployed in the provision of secure butcomfortable housing facilities for juveniles indetention. Emphasis should be placed on meansof "unobstrusive observation" of the juvenileswithin the facility and safe, speedy evacuation,in the event of an emergency. The technology isavailable.(2) The Montpelier facility, currently, a potentiallywasting asset, has been available to theDepartment, since 2006, incurring a costly monthlymaintenance and unutilized.Montpelier should be repaired immediately, withappropriate fixtures, as a comfortable facility forchildren. Our youth deserve no less, if the true andsincere object of institution life is the "welfare of thechild" and the aim is "to return the girls to societybetter than when they come in".The girls housed in the Office dormitory rangedfrom hostile ones, who had committed violent oranti-social offences, to those who were merely108IiiiIIIIIIIIl1
    • deemed to be "in need of care and protection." Thelatter were bullied and cowed.(3) Girls should be classified according to the causeof their detention, and only housed in groupsseparated according to the similarity of theircategorization.Rule 28 of the 1990 Rules read, B-e , · ·"28. The detention of juveniles should only takeplace under conditions that take full account oftheir particular needs, status and specialrequirements according to their age, personality,sex and type of offence, as well as mental andphysical health, and which ensure their protectionfrom harmful influences and risk situations. Theprincipal criterion for the separation of differentcategories of juveniles deprived of their libertyshould be the provision of the type of care bestsuited to the particular needs of the individualsconcerned and the protection of their physical,mental and moral integrity and well-being."See also Rules 27, 29 and 30.109
    • Jamaica wishes to be seen as a respected andmodern state in the international community. Inthat regard we should avoid "lip service" only andalways adhere to and pay sincere respect to eachinternational treaty and convention to which we area signatory.(4) Children "in need of care and protection" as definedin section 6 and section 8 of the CC&P Act are inessence, children susceptible to abuse and alsodevoid of the essential basic support and control ofa parent or guardian. Such a child, in my view, isnot necessarily one in respect of whom acorrectional order ought to be made, placing him orher in a Correctional Centre. . "Correctional" is amisnomer, in the case of the Armadale facility asoperated in May 2009. About six (6) such girls werein Armadale then (see Exhibits 38). Sections 7 and14 of the CC&P Act contemplate that, "theGovernment agency responsible for children," theChild Development Agency (the CDA) have anongoing involvement in the case of such children "inneed of care and protection" This was not evident110IJ)J
    • in the Enquiry held by me, nor did such an Agencyappear or contribute to the Enquiry. The CDA isresponsible for childrens homes and places ofsafety. But because of lack of space some childrenremandees are sent to the correctional centres.That is unwise. As classified, they do not belongthere and that practice should be discontinued.Listening to the evidence of some of these girls, atthe Enquiry, confirmed this, in my view.Mrs. Spence-Jarrett, at the meeting on 31st January2007, advised that whenever such children areplaced in the correctional institution they becomethe responsibility of the Department of CorrectionalServices. She observed that "CDA never usuallyfollow up." (See Exhibit 26)It seems to me that the CDA has failed tounderstand and to grasp and discharge itsresponsibility to children under the provisions of theCC&P Act.The Childrens Court should be mindful of theprovisions of section 14 of the CC&P Act, and utilizein the best interest of the child, other prescribed111I
    • - - - - - - - -orders, namely, guardianship order, fit person orderor supervision order by a probation and after careofficer, in preference to a correctional order, wherepossible.(5) "Lockdown" as a form of punishment is inherentlyunjust - being the collective punishment ofeveryone for the errors of a few, the proverbial"good suffering for the bad.,,It must be-rdiscontinued.(:· / 6" I , /~,.r·,,,(a) Academic -studies, conducted by suitablyqualified teachers in the subject matter mustbe provided, and not curtailed because of,punishment. I note that the proposal of "aratio of one instructor/teacher to fifteen (15)wards," in memorandum dated 1st April 2008(Exhibit 30) from the Commissioner ofCorrections (Major Reece) to Mrs. Mary Clarke,in response to her queries by letter dated 28thMarch 2008, (Exhibit 29), was neverimplemented;(b) only the prescribed form of punishment shouldbe imposed.l:IIIIIIIIIII:IIII)/_I112 I
    • (6) The level of control by the Commissioner and thesenior management staff of the Department, wasunnecessary, resulted in bureaucratic delays andcreated some detriment to Armadale. Mrs. Spence-Jarrett stated, in respect of a report from Armadaleconcerning the seven (7) girls who absconded on ihMay 2009,"I reminded him (Mr. Hesson) that alldocuments were to come to Commissioner anddispatched from there."Mr. Anderson, the Property Manager, advised, thatif some things are required at Armadale theinformation goes to "the Deputy Commissioner ofCommissioner and then passed to me." He properlycommented that " matters of propertyrequirements [should] first come to me but oursystem [isl sort of different (Emphasis added)Why should the need for "machete ... file ...rake ..."as "tools for the grounds men", at Armadale be onthe "Needs lists" as a matter of "outstandingconcern" for discussion at three meetings at HeadOffice for periods 14th November 2008 to 31st113I
    • December 2008 and again for period 1st January2009 to 31st January 2009 and for period 1stFebruary 2009 to 2oth February 2009? (See Exhibit2). A machete, file or rake should have beenbought locally, in St. Ann.Why was the installation of the grill door to theroom offered by Mrs. Ferreira to relieve theovercrowding not dealt with locally? Mr. Andersonsaid it could be"... done in a day." Mr. Hesson, saidthat he "told ... property manager Neilson Andersonat Head Office between March to April 2009 noaction ... I did not follow up."(a) Greater autonomy should be given to the,management at the institution level, in minormatters, e.g. installation of a door, instead ofthe bureaucratic "micro management" from thehead office.(b) This retention of control and power "from thetop", in the Department of CorrectionalServices, in some operational areas, is counter-productive and demotivating. A conscious andreasoned review of the necessity for some of114
    • the senior posts in the hierarchical structure ofthe Department is now necessary. A1•1(7) A trained medical orderly or a trained nurse inattendance could have satisfied the problem ofprescribed medications not given to the girls atArmadale, as identified by Dr. Campbell. Such aperson would in addition be of immense assistancein identifying early, mental and psychologicalproblems in between visits, for the attention of themedical personnel.(a) A medical orderly or trained nurse is requiredto be assigned and resident full time at suchinstitutions; ~(b) increased visits by medical and psychiatricpersonnel, as recommended, should beimplemented. Children, in such institutions,need them; they are at a vulnerable stage oftheir existence.(8) Members of staff and security personnel reacted ina confrontational mood from the outset to theunruly, expletive- filled conduct of the girls instead
    • of acting with balance, restraint and understandingdespite that conduct. Despite the views of the malepolice officer, force was the least of the options. Acalm but firm approach may have been preferable.Both Mrs. Shaw-Slack and Miss Gilbert testified thatthey received basic training as Correctional Officers,which did not include any training involved with thetreatment of juveniles. They did however attend aone-day seminar at Rio Cobre in 2008 which wasconcerned with juveniles. That was inadequate.Dr. Royer-Powe pointed out, in reference to theSyllabus Outline for the training of CorrectionalOfficers, tendered as Exhibit 9, in the evidence ofMr. Hesson, that,"... nothing in Exhibit 9 suggests that training inpsychology is to be involved in training CorrectionalOfficers in dealing with young children."(a) Training in psychology, anger management,stress control and counselling in dealing withyoung children, should be included in thesyllabus of course of training for CorrectionalOfficers at juvenile institutions and Probation116l
    • , ,~J,1li J;I f " ~Officers./Th: Bell~;~·: ~~s~ital:1~~i~h i~,,amajor psychiatric hospital in Jamaica with itsgenerous complement of psychiatrists,psychologists and mental health professionals,ought to be relied on for an input in suchtraining.(b) Correctional officers working for three shiftsconsecutively, as occurred irr some cases atArmadale, should be prohibited. Double shiftsshould be discouraged, as far as possible. Theresultant stress and fatigue on such officers iscounter-productive and, disadvantageous bothto themselves and thejuveniles they supervise.(c) Correctional officers should also bepsychologically re-evaluated periodically, inorder to ensure their continuing suitability forsuch posts.(d) The alleged misconduct in the loan of hiscellular phone to one of the girls by theCorrectional Officer Mr. Wint, should also beinvestigated by the Department andappropriately dealt with.117
    • (9) The absence of any established procedure inhandling emergencies and the absence of anystandard evacuation procedure in the event of afire or other disaster was starkly evident atArmadale. That accounted for the chaos, wrongoptions and confusion that existed at Armadale onthe night of 22nd May 2009,(a) Regular fire drills, Jnvolving both staff andjuveniles, ought to be conducted by the FireDepartment; commencing immediately andthereafter at regular .intervals at all the juveniledetention centres.(b)fire extinguishers, in sufficient numbers;Jshould. be immediately provided at suchinstitutions, readily available and should belregularly checked and serviced on the Istipulated dates.I(10) The medical personnel who treated the girls atIArmadale should be commended for their workand in particular Dr. Campbell who displayed1compassion, dedication and a sincere :1understanding of the needs of the girls.!1118;IJj~
    • Expert medical advice given by doctors in respectof the health and welfare of the girls should beaccepted by administrative officials, seeing thatthe latter are not so trained. Mrs. Spence-Jarrettas Commissioner, was at fault to have rejectedoutright, in breach of the statutory provisions, therequest of Dr. Royer-Powe, to remove and isolatethe two troubled girls, one of whom had a "severepsychiatric problem.,,(a) Regulations are needed to give to theDirector of Medical Services, the soleauthority to determine, where, due tomedical reasons, particular girls may or maynot be housed.(b) · An isolation area, as,;~~eiuestedr fq~"rG!,~t~ptivejuveniles, is urgently required, and must beprovided immediately.· This~~,wu~~~,.fa©Hitate~~op~~~.trteat~nt.(11) A Board of Visiting Justices exists for the purpose,of the adult correctional institutions,. under the:Correctional Institution (Adult Correctional :~;entre}Rules, 1991, in accorda.nce with section 74 (1) of119
    • the Gorred:ionsc:J~.ct. The said regulations providea comprehensive set of rules governing theoperations and functions of the adult correctionalcentres. Except for sections 47 to 57, (Part V) ofthe Corrections Act providing, principally, for thepowers of the Minister in respect of the JuvenileCorrectional Centres, I was unable to find anycorresponding regulations in relation to theoperations and functions of the JuvenileCorrectional Centres.1(a) Regulations should be formulated andbrought into force by the Minister, aslauthorized by section 81(1) of the ICorrections Act, to govern the operation and1functions of the Juvenile CorrectionalCentres. The authorities should consider, Ialso, reducing into the domestic law of1Jamaica, the provisions of the United NationsBeijing Rules, and the 1990 Rules for theIprotection of juveniles deprived of theirliberty. It is a simple exercise.IllfJ~120";JI
    • (b) A Board of Visiting Justices should also beappointed specifically for the JuvenileCorrectional Centres in order to performstatutory functions similar to those performedin· respect of the adult correctional centres,for the benefit and welfare of all juveniles.The emphasis should be on regular visits andreview of facilities and childrens views.(12) The living conditions of the girls in the Officedormitory for over one year culminating with theevents of the night of 22nd May 2009 must havehad a major traumatic effect on all the survivors.• The girls, the majority of whom are housednow at Diamond Crest, should each bepsychologically evaluated and each caseexamined with a view to detect any·consequential damage. The period ofdetention of each child should beproportionately shortened, if so advised.(13) The Childrens Advocate, Mrs. Mary Clarke,occupying this newly created office since 2006 has
    • demonstrated a mature grasp of theresponsibilities of that office as it relates to therelevant institutions and persons concerned withthe welfare and benefit of children islandwide.Her office is however somewhat handicapped byinsufficient staff and resources. Her meetings withMinisters of Government, talks at institutions suchas schools, investigations and annual reports toParliament, have not seemed to influence theproblems with children significantly.a. The staff of the Office of the ChildrensAdvocate should be increased, particularly,the investigating officers, with adequatetravelling facilities. Regular visits to thejuvenile institutions, routine examination ofthe facilities and interaction with the juvenilesshould be effected. This would complementthe Board of Visiting Justices.b. Her mandate of "protecting and enforcing therights of children ..." under section 4 of theCC&P Act, would be more effective if she wasgiven enforcement powers by way of judicial122IIIIIIII-IIIIIIII-
    • review in respect of government entities,which need to be compelled or prohibited inrespect of breaches of their duties tochildren. She has the proper approach - giveher the tools!(14) The police station diary is not a public document,although official entries are made therein. Thetreatment of that document by some officers atthe Alexandria police station was in breach ofsettled rules in the Jamaica Constabulary Forceand clearly wrong, by the omissions and falseentries.(a) The Commissioner of Police should berequested to notify all sub-officers and policeofficers generally, of the significance ofproper and accurate entries and theimportance of supervising its use and its safecustody. ,:·/ ,:;r{ ,,, c~....: z:_.> c";(b) The outstanding reports from the policeofficers, which were requested by SergeantHeath must now be submitted. The policeofficers misconduct concerning the events of
    • 22nd May 2009 at the police station should beenquired into and appropriately dealt with, atleast departmentally.(15) The· Senior Administrators of the Department ofCorrectional Services are largely to blame for the/ tragedy at Armadale. The "apparent" lack ofknowledge of Mrs. Spence-Jarrett, Mr. Hesson andMrs. Johnson of the accommodation, is less thar/believable and displays an inexcusable breach ofduty. How can Mrs. Johnson explain her visits toArmadale on 21st April 2009 when she "did not gointo the dormitory ... went to the doorway" and on ,7th May 2009 when she "did not go into thedormitory [she] stand at the entrance?"There should be a review of the senior posts ofthe Department - some may well be superfluousand unnecessary.(:~§:)······ e:>;~e~t~W~l~g,·}~tf~~~l;tl~~~.1.e1:;:W~s·~;1f:i;p~jor:;p[Qblem,/-Ymeirna~Irnt:Jm·petniissible:.pgJi>Ut~tronwas tts·girls; .The, ,C1Gtu9t p~cupat1g~6..Cit:i:tl01~$,,;;;..was,. ]Q;~,girls.;Serious consideration should be given to restrict124II1.III~I
    • the population to the permitted maximum. In thatregard, the Commissioner of Corrections, mustadvise herself and be aware, at all times,whenever the maximum occupancy of a juvenileinstitution is attained. The Childrens Court shouldQ_ f.-{) 0- f --~-- ~ Cl:be so advised, and no further correctional orders 1v s. c- " ,..., ( •,~ :/should be made, to receive a child into theinstitution, until a vacancy exists. Legislation isrequired to implement this. It will require closemonitoring of all such institutions islandwide andstrict enforcement. .Note,· ,for· ·example1t> by;aA,9logy, ur;ider.,the Criminal Justice. (Reform) Act, "section 10, a "court shalLnotrnake a cOmmuniqtservice order" unless; ·inter ana, arrangements can;be made, in a particular-area, for p~rforming work;and for its proper supervision of a convicted .offender.The debacle of Armadale created by some of those persons mostintimately concerned with it, displayed "a hardening of their hearts and acoarsening of their consciences." Disadvantaged children in an institution,primarily due at times to errant parents, give us the opportunity, withcompassion, understanding, love, sincerity and genuine humility to rescue1 ",.I
    • and help this segment of our youth in the society. Most of us as parents,have experienced the "rebellion" of our teenage children but our responseis not to abandon them to institution-life, but with controlled caring torecognize it probably, as an assertion of their emerging individuality. Onesolution to our problems in Jamaica, is to commence to build a conscience- the differentiation between good and bad, right and wrong - in ourchildren - from the early infant stage. Our children, from early infancyare the prime nucleus for change to a more mature, caring, humane andjust society, based on good morals. Some persons concerned withArmadale failed to grasp the opportunity. Undoubtedly, financialresources were at times unavailable to the Department of CorrectionalServices. That should not be a deterrent to humane treatment.Importantly, "Armadale" must never again occur.I extend my gratitude to all counsel who appeared, both from the SolicitorGenerals Office who marshaled the evidence and counsel who appearedon behalf of interested persons. They all assisted in this Enquiry. I thankalso the members of the Secretariat, the staff of the Ministry, stenotypists,the police officers and all persons who submitted statements for use atthe Enquiry. I am grateful also to the personnel at the National VolunteerCentre who warmly accommodated us during the several days of thehearing. They all contributed to the smooth progress of the proceedings.126
    • Dated this 15th day of January 2010Paul Harrison, OJ., C.D.,Commissioner127
    • List of~lii6itsExhibit 1 Diagrammatic plan of Armadale Juvenile Correctional Youth CentreCompound with buildings (DVD disc attached)Exhibit 2Exhibit 3Operational reports re Armadale - period 3oth June 2008 to 2othFebruary 2009Letter dated 18th November 2008 from Claudeth Hamilton re fireextinguishersExhibit 5 Letter dated 11th March 2009 from Faydene Ferreira re fire drillExhibit 6 List of infractions and sanctions re ArmadaleExhibit 7 Letter dated 20th May 2009 from Faydene Ferreira re abscondingwardsExhibit 8 Memorandum dated lSth November 2006 - rededication of CottagedormitoryExhibit 9 Syllabus of training course at Carl Rattray College for CorrectionalOfficersExhibit 10 Photographs (81 prints) on DVD disc - Armadale facility after fireon 22nd May 2009 (DVD disc attached)Exhibit 11 Minutes of meeting - 24th November 2007 - Department ofCorrectional ServicesExhibit 12 Statement of Kerry-Ann Wilson - detaineeExhibit 13 Memorandum dated 26th May 2007 from Neilson Anderson recondition of buildings at ArmadaleExhibit 14 Engineers report from Michael Clarke re condition of buildings atArmadaleExhibit 15 Extract from National Building Code (Jamaica) 1983 editionExhibit lSA Extract from National Building Code (Jamaica) 1992 2nd Edition128
    • it 16 Extract from National Building Code (Jamaica) 1983 edition - resanitary facilities·it 17 Extract from National Building Code (Jamaica) 1983 edition reescape and exits1it 18 Diary entries numbers 26 - 31 dated 22nd May 2009 and numbers 1- 10 dated 23rd May 2009 - Alexandria police station>it 19 Two (2) detonated CS teargas grenade han-ball-experiment 14thAugust 2009 (with police))it 20 One (1) detonated C N teargas canister - experiment 26th August2009 (with police):>it 21 One (1) detonated C N teargas canister - experiment 26th August2009 (with police)bit 22 Chart by analyst Coates of Office dormitory after firebit 23 C D disc - pictures of Armadale - taken 23rd May 2009(DVD disc attached)ibit 24 Letter dated 12th June 2009 re inspection at Armadale by JamaicaFire Brigade, St. Annibit 25 Diagram of office building and Office dormitory by Assistant Supt.Roweibit 26 Minutes of meeting dated 31st January 2007 between ChildrensAdvocate and Department of Correctional Services officials1ibit 27 Minutes of meeting dated 24th September 20071ibit 28 Minutes of meeting dated 23rd October 2007 at Medallion Hall Hotel1ibit 29 Letter dated 28th March 2008 from Childrens Advocate re draftCabinet submissionlibit 30 Letter dated 1st April 2008 from Commissioner of Corrections redraft Cabinet submission1ibit 31 Minutes of meeting dated 31st March 2009 - discussions re children1?QI
    • Exhibit 32 One (1) detonated CS teargas canister - experiment on 28thAugust 2009 (with police)Exhibit 33 Memorandum dated 1ih June 2005 from Commissioner ofCorrections and reporting of incidentsExhibit 34 Extracts from 2007 Department of Correctional Services Report -tables 25, 26 and 27Exhibit 35 Book of rules - wards code of conduct - Juvenile CorrectionalCentresExhibit 36 Memorandum dated 24th July 2006 from Deputy CommissionerCustodial ServicesExhibit 37 Minutes of meetings - Population Reduction - held in 2008Exhibit 38 List of girls at Armadale on 22nd May 2009, and particulars.Exhibit 39 Letter dated 29th May 2009 from Director of Medical ServicesExhibit 40 DVD disc of Han-ball demonstration on 14th August 2009(DVD disc attached)Exhibit 41 DVD disc of C N teargas canister demonstration on 28th August2009 (DVD disc attached)Exhibit 42 DVD disc of C S teargas canister demonstration on 28th August2009 (DVD disc attached)Exhibit 43 Postmortem examination report of Rochelle KingExhibit 44 Postmortem examination report of Shaunna-lee KerrExhibit 45 Postmortem examination report of Nerisa GoodenExhibit 46 Postmortem examination report of Ann Marie SamuelsExhibit 47 Postmortem examination report of Kaychelle NelsonExhibit 48 Postmortem examination report of Stephanie SmithExhibit 49 Postmortem examination report of Georgiana Saunders130