Teh Full 2010 Armadale Report

I :N<D P,X
Pages
Presentation 1
1. Declaration and terms of reference 2
Introduction 3-7
Rules of Procedure 4-5
Appearances 6-7
2. Report 8-127
Armadale 8
Housing of the Children 9 -11
Office Dormitory - its origin 11-16
Office Dormitory - space
accommodation 16 -19
3. Summary of Findings 19 - 31
4. Reasons for findings 31 - 107
4.1 Life in the Office dormitory at Armadale prior to
22nct May 2009 31-38
4.2 Life in the Office dormitory immediately prior to
22 May 2009 38 - 53
5. Other areas of neglect at Armadale 53-56
6. Other concerns expressed re Armadale 56-64
6.2 The events of 22nct May 2009 prior to the fire 64 - 65
7. The circumstances and causes of the fire 65-76
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REPORT OF THE COMMISSIONER
1.1 I, PAUL HARRISON, O.J., C.D., J.P., PRESIDENT OF THE COURT OF APPEAL
(RETIRED) HAVING BEEN APPOINTED BY YOUR ExCELLENCY'S PROCLAMATION
TO CONDUCT AN ENQUIRY WITHIN THE FOLLOWING TERMS OF REFERENCE:
"(a) The causes and circumstances of the fire on the
night of Friday, May 22, 2009 at the Armadale
Juvenile Correctional Centre at Alexandria in the
parish of St. Ann;
(b) the response by the management of the institution
to the outbreak of the fire including established
evacuation procedures and the availability and
readiness of fire prevention and firefighting
equipment at the institution;
(c) the behaviour of the juvenile detainees occupying
the institution before and at the time of the fire,
the response of the emergency services including
the police, fire and medical services and the effect
these had on the origin, control and consequences
of the fire·"I
Do HUMBLY SUBMIT To YOUR EXCELLENCY THE FOLLOWING REPORT
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INTRODUCTION
1.2 On the 28th day of May 2009, Your Excellency, by proclamation, issued a
Commission under the Commissions of Enquiry Act (''the Act"). In
accordance with section 2 of the Act, Your Excellency appointed The
Honourable Mr. Justice Paul Harrison, 0.J., C.D., J.P., (Retired President
of the Court of Appeal) to be the sole Commissioner.
1.3 Your Excellency also, in accordance with the provisions of section 6 of the
Act, appointed Mrs. Pauline Rosemarie Farquharson-Stewart as Secretary
to the Commission.
1.4 Your Excellency's Sole Commissioner, the Ministry of National Security and
the Secretary proceeded to finalize the administrative arrangements to
secure suitable premises to hold the enquiry. The secretary gave public
notice, published in the daily newspapers that the enquiry would
commence public sittings on Wednesday thEt 1st day of July 2009 at 10:00
a.m. but subsequently published a further notice for commencement on
Tuesday the 3oth day of June 2009, at 10:00 a.m. at the Police Officers'
Club, Hope Road, Kingston. The subject of the enquiry was also published
inviting 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 issued
on the commencement of the enquiry on 3oth June 2009, the rules and
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procedure to be applied throughout the enquiry. The rules of evidence
were liberally applied, for the purpose of the enquiry.
They read:
RULES AND PROCEDURE
1. These are non-adversary proceedings in the nature of an
inquisitorial 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 the
interests and actions of individuals or entities. In that
event, counsel may be allowed to ask questions in
clarification.
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 break
and continuing at 12:30 !).m. to 2:00 p.m.
5. Counsel from the Solicitor General's office will marshal!
the evidence. Any wish that the Commission consider
any evidence should be communicated to the
Commissioner. The statements of the witnesses
concerned shall be handed to the Secretary, Mrs. Stewart
for use of counsel marshalling the evidence.
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6. This Enquiry is governed by the Commissions of Enquiry
Act ("the Act"). The boundaries of the enquiry are
circumscribed by the terms of reference issued in the
Commission 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 with
the Act and all its provisions.
I invite the co-operation of all to assist this enquiry into
the circumstances and events of the 22nd May 2009 and I
anticipate. the genuine assistance of all.
COMMISSIONER
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1.6 Scores of statements were submitted to the Commission from various
sources including the Office of the Children's Advocate, the Public
Defender, the Police, the Fire Department, the Ministry of Health and the
Ministry of National Security, particularly the Department of Correctional
Services. The statements were taken from persons directly involved in
the events of the 22nd May 2009, or concerned with the organization and
management of the Armadale Juvenile Correctional Centre.
1.7 Legal representation was permitted on behalf of several persons and
entities.
• Mr. Hugh Salmon,· Divisional Director, Mr. Peter Wilson, Assistant
Attorney General and Mrs. Hazel Edwards, Assistant Crown Counsel of
the Attorney General's Chambers marshalled the evidence.
• Mr. Jermaine Spence and Mr. Courtney Williams, Attorneys-at-law of
Messrs. DunnCox appeared for the Ministry of National Security.
• Mrs. Jacqueline Samuels-Brown, Miss Lois Nelson and Miss Nicole
Wright, Legal Policy Officer, appeared for the Office of the Children's
Advocate.
attorneys-at-law appeared for the office of the Public Defender on
l• 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),
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Prudence 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 the
Police 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 National
Volunteer 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 were
tendered in evidence. ,The hearing was conducted over a period of
thirty-three (33) days ending on the 10th day of September 2009.
1.9. I am mindful of Your Excellency's further directive to me which reads,
inter alia -
"And I do further direct you to report to me in writing as
soon as practicable the result of such Enquiry and to furnish
to me a full statement of the proceedings and of the reasons
leading to the conclusions arrived at or reported;
And I do further direct that should you find it necessary to
do so, you may submit Interim Reports before the
submission of your full and final report;"
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REPORT
2. ARMADALE
2.1 The Armadale Juvenile Correctional Centre ("Armadale") situated at
Alexandria in the parish of St. Ann, was declared to be a Juvenile
Correctional Centre on 25th September 1991 by the Minister in accordance
with the provisions of the Correctional Institutions (Declaration) (Juvenile
Correctional Centres) Order, 1991, under the authority of section 47 of
the Corrections Act.
Where a child is found guilty of any offence before a Children's Court,
that court may make an order sending the child to a juvenile correctional
centre - section 76(1)(f) of the Child Care and Protection Act (''the CC&P
Act''). A "child" is defined in the latter Act as"... a person under the age
of 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 of
children; ..."
The "best interest of the child is the paramount consideration," thereby
entitling the child to protection from abuse, neglect, harm, or the threat of
harm, recognizing that a family is the preferred environment and the
protection of the children rests primarily with the parents, with support
services where applicable, and taking into account the views of the child
in certain circumstances, section 2(3) of the Act.
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2.2 Armadale - the housing of the child detainees
Armadale, 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 south
of the Armadale compound, called the "Upstairs Dorm". As a result of a
fire started by the girls, some of them were moved, in November 2006, to
a building, to the northern end of the compound, called thereafter the
Cottage Dorm. This building was previously occupied as the residence of
the 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 20th
November 2006. (See ,Exhibit no. 8). There were therefore two (2)
dormitories, the newly created Cottage dormitory with thirty (30) girls
'
and the rest of the girls approximately thirty-five (35), were left in the
Upstairs dormitory.
The maximum capacity of Armadale was then accepted to be forty-five
(45) girls, however, approximately 65 girls were then in residence. The
Department of Correctional Services Annual report for 2007 reveals that
on 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 and
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appointed August 2009, said in evidence, of the Upstairs dormitory in
2007,
"I aware Upstairs dorm girls had no bathroom facilities
after locked at nights - continued awhile, so we put in
facilities ... first became aware in May 2007."
Mr. Neilson Anderson, the Property Manager for the Correctional
Department had so advised her, then Deputy Commissioner, by
memorandum dated 26th May 2007 (See Exhibit 13).
Mr. Anderson visited Armadale on 26th May 2007 along with an engineer
Mr. Williams, Mr. Ramdatt, the Property Manager of the Ministry of
National Security and Mr. Clarke, the Building Engineer at the National
Works Agency and inspected the Upstairs dormitory, principally to solve
the problem of sanitary conveniences for the girls in the said dormitory.
The engineer Mr. Clarke reported,. inter alia, that, because of termite
presence and the state of the building, it would be too costly to repair and
maintain. He recommended that it be abandoned.
He added that the external bathroom used by the girls was in a deplorable
and insanitary state. The toilets, damaged and leaking, were inadequate
(See Exhibit 14).
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Mr. Anderson, in his said memorandum to Mrs. Spence-Jarrett (Exhibit
13), advised that,
"the original building is now structurally unsound ... now
a fire hazard ... girls have no bathroom to use at nights
when ... locked in ... the bathroom used in the day is in
very bad condition ... is woefully inadequate ... and is
contributing to health risks ..."
He further commented with some degree of analytical opinion that,
"The dissatisfactory physical conditions under which the
wards are housed were major contributors to the unrest
that resulted in major damage to the plant early this
month."
Recommending the repair of the bathroom currently t1sed and the
installation of new bathrooms, he added, "... from then Armadale was an
emergency 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 those
conditions for over one year up to March 2008.
2.4 The Office dormitory - its origin
In March 2008, the girls in the Upstairs dormitory, condemned from May
2007 as unfit for habitation, caused a fire by lighting mattresses inside the
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dormitory. The decision was made to remove all the girls from the
Upstairs dormitory to a room in the office building to the east of the
premises, between the Cottage dormitory and the Upstairs dormitory.
This room came to be known as the Office dormitory. Its dimensions
were twenty (20) feet long by twelve (12) feet wide and ten (10) feet
high. It had three sets of windows, to the front, (west), to the back
(east) and double windows (north), facing the Cottage dormitory. All
the windows were of wooden louvre blades with burglar bars on the
inside.
In March 2008 "..; a few days after the fire" in the Upstairs building Mrs.
Spence-Jarrett, then Deputy Commissioner, Mr. Everton Hesson, Director
of Juvenile Services and Mr. Anderson travelled to Armadale. Mr.
Anderson, inter alia, said,
"I saw the size of the room that day before the girls
were put into the Office dorm ... over twenty (20)
wards ... bunk beds were put in very close, not much
space 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."
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Mrs. Spence-Jarrett recalled travelling to Armadale after the fire with
Messrs Hesson and Anderson and she said,
"Office dorm was brought into use in March 2008. I
don't think that 20 girls were put into Office dorm at
once. 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 ... the
Director of Juvenile Services [Mr. Hesson] told me."
Mrs. Spence-Jarrett asserted that she did not go into the Office dormitory
to 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 girls
were to be housed, those were irresponsible and negligent acts of
omission on her part. If she was aware of the lack of adequate space and
insufficient beds in the said dormitory, which I find she was, her decision
v/ to house the girls there was unfortunate, uncaring and inhumane.
I accept Mr. Anderson, as a forthright truthful witness, on whose
evidence, I could rely.
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I find that twenty-three (23) girls were moved into the Office dormitory in
March 2008. The size of the dormitory was 20 feet by 12 feet in
measurement. That accommodation was inadequate, from the outset.
Both Mrs. Spence-Jarrett and Mr. Hesson were evasive and less than
truthful on the issues of the number of girls placed in the dormitory and
whose decision it was to place the twenty-three (23) wards into the Office
dormitory in March 2008.
Mrs. Spence-Jarrett denied that at Armadale in March 2008, she instructed
that the twenty-three (23) girls be placed in the Office dormitory or that
she participated in the removal of the girls. Quite curiously, she said,
"I did not give any instructions; the superintendent is in
charge of the plant." (Emphasis added)
She later said,
"The Director [Mr. Hesson]. had discussions with the
Superintendent [Mrs. Ferreira] and he made
recommendation 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 of
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the room and the number of wards ... I saw the size of
the room before the girls were put in ... over 20 wards
... I was of the view that a decision had been taken to
relocate the girls. Deputy Commissioner Mrs. Jarrett
told us that we would be relocating the girls to the
other location. She told us what was to be done."
(Emphasis added)
Mr. Anderson said that there was no "structured discussion" nor was there
any "formal meeting". The decision was taken and he was informed. He
said that that was not unusual in his case as Property Manager.
He agreed that the girls in the Office dormitory were "actually packed
inside," and it was obviously overcrowded and insufficient. He was
concerned that there was only one door, the bunk beds were put in very
close "not much room for movement" apd "It did strike me as a potential
hazard 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 the
minimum occupancy of institutional buildings, open wards and
dormitories. He said, it was,
"1 person for each 50 Sq. ft. (5 m2
) floor area" (Exhibit 15)
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Mrs. Spence-Jarrett, in evidence, tellingly, emphasized that, in her
functions she had,
"... a hands-on approach, I always have."
2.5 I find that in March 2008, Mrs. Spence-Jarrett, then Deputy
Commissioner, unwisely, did make the fateful decision to house the
twenty-three (23) girls in the Office dormitory measuring 20 feet by 12
feet and with seven (7) double bunk beds only, containing fourteen (14)
mattresses. That decision was a patent breach of the duty to promote the
best interests of children, violated the statutory requirements and was
accordingly negligent, in all the circumstances.
2.6 Space accommodation in the Office dormitory
i. The National Building Code of Jamaica, 1983 (''ti'le Code") adopted
from the Building Regulations issued under the Kingston and St.
Andrew Act (second edition.1992, metric units), provides in Table
1, paragraph 2.2.1 'Group B, institutional buildings open wards and
dormitories' 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 properly
havebeenaccommodateci inthatdormitory 20.ft. by 12 ft. Twenty-
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three (23) girls were there on 22nct May 2009. Mr. Neilson was
aware of the provisions of the Code.
In reality, assuming that each mattress measured 6 ft 3 ins by 2 ft
6 ins (Mrs. Hortense Higgins, a Correctional Officer, said that each
mattress measured 5 ft by 2 112 ft), the seven (7) bunk beds would
cover a floor area of approximately 108 sq. ft. The walking area
remaining in the dormitory was therefore 132 sq. ft.
If each of the twenty-three (23) girls was standing in the dormitory
at 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 management
personnel of the Department of Corrections, neither Mr. Hesson nor;
Mr. Neilson, raised even a whimper of protest or a contrary opinion
at the decision of Mrs. Spence-Jarrett to house over twenty (20)
girls in that dormitory on that day in March 2008. This represented
a major failure and breach of duty on the part of the said senior
management personnel of the Department.
ii. Having only fourteen (14) mattresses, in some instances, there
were two (2) girls to one bed in the Office dormitory.
iii. The Code also provides in Table 25 "minimum requirements for
employee 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 the
Office dormitory!
iv. The "minimum number of means of escape and exit required per
storey" - the Code, Table 9, paragraph 3.2.2.1, page 16 (Exhibit
17), is 2 exits for 1 to 100 persons. The dormitory had one door
for all purposes.
Commenting on the various breaches of the Code at Armadale, Mr.
Anderson, boldly said:
"The Correctional Services does not seem to fit into
that category - none of our institutions fit that"'
Mrs. Spence-Jarrett admitted that she had a safety concern that there was
only one entrance to the Office dormitory and said,
" ... an additional entrance could not have been put
in that Office dormitory.."
Mr. Anderson observed that,
"The girls at Armadale were troubled girls, there for
care, security and rehabilitation. Armadale fell short
of providing proper care, rehabilitation and security
for the girls."
He said that before moving the girls into the Office dormitory,
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"I did see the need for a fire escape - knocking out
a wall and putting in a door would have served that
purpose."
He did not do so nor did he recommend that it be done.
There was in that regard, patent neglect and apathy concerning the
welfare of the girls at Armadale, by the senior administration of the
Department.
Under these stressful conditions, in addition to extended periods of
confinement, as I shall point out subsequently, the girls in the Office
dormitory continued their painful existence up to the 22nd day of May
2009.
3. Summary of Findings and conclusion - in the context' of the
terms of reference
(a) The causes and circumstances of the fire on the night of
Friday, May 22, 2009 at the Armadale Juvenile Correctional
Centre at Alexandria in the parish of St. Ann.
(i) There was a planned and attempted break out of the girls from
the 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 the
Alexandria police station arrived. A C S teargas canister was
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initiated by Cons. Lawrence Burrell of the Alexandria police
station and from this canister, flames and smoke were emitted.
He threw it into the Office dormitory where it fell onto a bunk
bed with a mattress of foam material, immediately starting the
fire - one of the seats of fire. Acting impulsively and reacting
irrationally to the angry behaviour of the girls, who were cursing
him, Cons. Burrell, without consulting his superior, Woman Cpl.
Shawnette Dunkley, had gone back to the said police station
and 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 of
hydrocarbons, as found by the scientific experts Mrs. Tanya Kerr
and Mr. Fitzmore Coates to have been there, which ignited, and
together with the foam mattresses, created a second seat of
fire. This resulted in the. rapid spread of the fire. In addition,
there were the noxious fumes of the C S teargas, the smoke
and toxic substances, namely, hydrogen cyanide, carbon
dioxide, carbon monoxide, hydrogen chloride and phosgene
given off by the burning mattresses. Some of the girls probably
had the accelerant in the dormitory, in preparation for the
planned escape.
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(iii) The girls, breathing in these toxic fumes and subjected to the
intense heat of the fire in the darkness of the dormitory, all,
with the exception of three girls who jumped through the front
window of the dormitory, rushed to the back window, the only
visible means of escape. There was utter confusion. Probably,
in panic and disoriented, they fought each other at this back
window 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 was
limited. Mrs. Caldeen Shaw-Slack, a Correctional Officer, who
placed a ladder at the back window - at a height 7 feet from
the ground outside, was assisted by Miss Dian Gilbert and Miss
Lucille Hamilton in pulling out some of the girls. Contrary to the
contention of Cons. Burrell and Woman Cpl. Dunkley, Miss
Shaw-Slack said "... the police did not help us at the back
window in pulling out the girls." A Cons. Mccalla from the
Brown's Town police station assisted in doing so, as well as
helping the said ladies to throw water onto the fire through the
back window. The dormitory was overcrowded. Space to
manoeuvre was limited or in some instances non-existent.
Chaos reigned.

(iv) The discharge of the teargas canister into the dormitory by
Cons. Burrell was harsh and unnecessary. No use of such force,
even in light of the insulting language used and the excrement
thrown by some of the girls, should have attracted such a
response. It was an unlawful use of force by the police officer.
(v) The Office dormitory door, the most obvious means of exit, as
an escape, was locked and unavailable to the girls. The girls
were burnt and scarred, mentally and physically and
traumatized. The dormitory door should have been promptly
unlocked by Mrs. Higgins or on her instructions, at the sign of
discomfort in the dormitory. In that respect, she was dilatory
and consequently negligent in her conduct.
{b) The response by the management of the institution to the
outbreak of the fire including established evacuation
procedures and the availability and readiness of fire
prevention ·and firefighting equipment at the institution.
(i) The initial aim of the persons at Armadale on that night, was one
of containment of the girls in the Office dormitory, to prevent any
escape. Miss Carlene Coleman, the security officer, confirms that
she, Miss Gilbert and Miss Hamilton all had sticks in their hands.
Mrs. Higgins' comment "Nothing we can do but let them stay
inside," describes that primary intent. After the outbreak of the
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fire, there was no manifest change of attitude by the institution
personnel present. There was no spontaneous reaction to release
the girls, as there should have been, in view of the obvious
discomfort and danger. It was the girls' own frantic attempts to
escape the "fiery inferno" within, that triggered the staff to assist
in their evacuation.
(ii) Mrs. Higgins, as the supervisor, at the first moment of hearing
the sound "like air letting out," and seeing "the policeman going
to the side of the dorm going towards the back" as she ran to the
front window, and seeing black smoke inside the Office
dormitory," shoutd have opened the dormitory door, instantly, or
if ·she did not have the keys, should have ordered that it be
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opened immediately. She did neither. She thereby failed and
accordingly, negligently contributed to the ultimate fatal outcome
to the girls.
(iii) There was no established evacuation procedure or practiced
exercise in existence at Armadale to deal with the outbreak of a
fire. This was a further instance of an organizational indifference
and failure, seeing that there had been fires previously at
Armadale in 2008, for example, at the Upstairs dormitory. Mrs.
Ferreira relates that on that latter occasion "wards were running
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around discharging fire extinguishers. I do not know if they were
recharged." Most of them were not.
(iv) The need for fire extinguishers at Armadale was consistently
expressed by Mrs. Hamilton, Acting Superintendent, in November
and December 2008, (see Exhibits 3 and 4) by memoranda,
respectively, to the Commissioner, Department of Correctional
Services (see Exhibit 2). These requests were not satisfied.
Consequently, on the night of the fire, Mrs. Higgins had to go to
the house mother in the dining room got the key and went to the
Home Economics room, from which she took a fire extinguisher
and gave it' to a policeman at the side of the Office dormitory.
That fire extinguisher, only partially charged, was ineffective. Fire
extinguishers should have been available C!nd more readily
accessible. Mrs. Higgins stated in evidence, that she had only
seen one fire extinguisher. in the storeroom and another in the
dining room - the latter had been emptied of the foam by the
girls in 2008.
• 4he only occasion previous to the fire when a fire drill. was
£onducted at Armadale, was in 2004;. Mrs; Higgins confirms
that n©ne was held since then. This is a further
demonstration of official neglect.
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• Mrs. Ferreira had in March 2009 invited the Superintendent
of the St. Ann Fire Department in celebration of Fire Safety
Week 2009 "to give a talk and conduct a fire drill for both
the staff and wards" (see Exhibit no. 5). Her request was
not granted.
• At Armadale fourteen (14) fire extinguishers were counted
as being there, after the fire, eleven (11) of which were
non-functional, stated Mrs. Ferreira. They were not
serviced since 2007.
Armadale was ill-equipped and not prepared, in any manner to deal
effectively with a fire at the institution or at all. There were no fire
extinguishers readily available for the dormitory and th6se that were
otherwise available were neglected and not serviced. Furthermore,
despite the experience of previous fires at the institution, no
procedure was introduced to deal with such an emergency. This was
a demonstration of marked indifference.
(c) The behaviour of the juvenile detainees occupying the
institution before and at the time of the fire, the response of
the emergency services including the police, fire and medical
services and the effect these had on the origin, control and
consequences of the fire;"
(i) Juvenile behaviour before the fire.
' '

Some of the girls were undoubtedly behaving unruly, on 22°d May
2009 before the fire. The perpetrators, about six (6) or seven (7)
in number, had planned to escape from the institution. One of
the other girls had advised Mrs. Higgins of the plan. Mrs. Higgins
merely made a note of it in the institution's 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 more
frequently and watching the Office dormitory more closely, began
to sing, make noise and drumming, in order to conceal the
sounds caused by the screwdrivers extracting the grills covering
the windows. At about 7:30 p.m. it was discm~·ered that the girls
had taken out the back window blades. Told to put them back in,
the girls instead removed the grill which they had unscrewed
earlier. The officers ran to the back window and then the girls
began throwing faeces, urine, water and other objects at them,
accompanied by boisterous behaviour and expletives. The girls
then removed the grill from the front window. Woman Cpl.
Dunkley and Cons. Burrell had come from the Alexandria police
station. Their arrival served to aggravate the conduct of the girls,
some of whom blamed the police for having been the cause of
them being at Armadale.

The girl M. C. jumped through the front window. She was chased
and held. She said "mi have fi come out ... me nah stay in there
... something going to happen in there." That was an expression
of the tense troubling expectancy that existed within the
dormitory.
The conciliatory approach of Woman Cpl. Dunkley did not help to
calm the girls. Cons. Burrell left and returned. The girls were not
relenting. 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 of
'
2008, were confined in this dormitory 20 feet by 12 feet - a
cramped, unhealthy existence and were condemned to the use of
buckets to perform all their body functions, at nights. The entire
Office dormitory was on "lockdown" from ih May 2009 because
seven (7) girls escaped from the Cottage dormitory. Previously
they were also on "lockdown" because one girl jumped over the
perimeter 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 themselves
to their fate, for a period in excess of one year. Others were not
so compliant and did not. The latter group is deserving of some
I

degree of understanding. There is a level below which no human
being should be persistently forced and expected to exist. The
girls in the Office dormitory, on 22nd May 2009, had been
degraded to that level.
{ii) Juveniles' behaviour at the time of the fire
On seeing the smoke and fire in the dormitory, the girls, in panic,
rushed to the back window, some fell, causing others to step on
them. Survival was their prime aim. They tried to get air to
breathe at the said window, hitting and shoving each other to do
so. The bigger-bodied girls blocked the window, in order to get
air themselves. The girls' eyes and throats burned from the
teargas and burning material and the heat from the fire was
intense. Three girls jumped through the front window near the
seats of fire. Some of the girl's fainted. There was screaming and
shouting for "help" and "fire". The officers, Mrs. Shaw-Slack and
Miss Gilbert and "a police officer" were helping to take out the
girls. 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 the
window and helped her to jump out - she went to the playfield
and 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 to
alleviate the crisis.
(ii) The fire services. The fire engine arrived at Armadale at about
9: 15 or 9:20 p.m. having received the call for assistance at 8:53
p.m. The fire had by then engulfed the entire dormitory. The
firemen eventually got the fire under control, but not before five
(5) girls succumbed. The firemen should have, initially, forced
open the dormitory door with their "axes, pry bars and cutting
saws" which fire officer witness Patrick Robinson said they had, to
effect a rapid exit of the girls from the fire in the dormitory. To
leave the door unopened and return "about a minute after" as he
stated, may have been an unwise and ultimately fatal choice.
(iii) The medical services. Dr. Micas Campbell was the first
medical officer to arrive at Armadale, after she had been
assisting some of the girls at the St. Ann's Bay Hospital. Her
examination at about 3:00 a.m. revealed that one of the
deceased five (5) girls in the dormitory may have been alive "up
to 1:00 a.m." The absence of any medical personnel before
then, or any first aid assistance unit with the firemen,
prevented an earlier examination of the girls and probably
contributed to the failure to save one other person in the
dormitory.
30
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4.
4.1
My findings, based on the evidence, reveal a wide range of shortcomings.
There were breaches of duty and administrative errors by the Department
of Correctional Services, indifferent and insensitive actions by public
officials, troubled and unruly girls further traumatized by some uncaring
adults, unjust treatment of girls, impulsive and unlawful action by a police
officer and the absence of any structured safety system in an emergency
at Armadale. Those factors, among others, combined with the negligent
actions of the public officials, made inevitable, the tragedy of Armadale on
the night of 22nd May 2009.
Reasons for findings
Life 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 the
dormitory for extended periods, sometimes for days or weeks and
deprived of all outdoor activities, as punishment for an infraction or
disturbance. The principal consequences were,
i. girls remained in the dormitory, except those who were taken out
to do chores. Two or three were taken out to go to classes. The
others watched television, read and played games, while confined;
31

ii. all meals were served in the dormitory. The girls ate with their
fingers, because no knives, forks nor spoons were allowed in
the dormitory, unlike when meals were served in the dining room.
iii. The duration was uncertain - it would continue for days or
weeks, as Mrs. Ferreira said, "...until peace is restored."
iv. The use of the bathroom, adjoining the Office dormitory, was
restricted to one hour in the mornings, after which the water was
turned off. Consequently, some of the 20 odd girls had personal
buckets and pans in which they all collected water in order to
complete their baths in the dormitory.
v. New girls on arrival at Armadale were placed on "lockdown" for two
weeks.
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 over
duties as Superintendent in January 2009. She as Superintendent, had the
authority to impose "lockdowns" and said,
"Generally, since I came to Armadale any form of
disturbance 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. She
said,
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"I briefed the Director, Mr. Hesson, two weeks before the
22nd 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 Department
who gave evidence, including Mr. Hesson, whom Mrs. Ferreira said she had
briefed of the "lockdown" two weeks prior to 22nd May 2009, denied
knowledge of the existence of the practice of "lockdown."
Mrs. Spence-Jarrett stated that she was not advised that lockdown "was in
use at Armadale" generally or for new girls. "Isolation" was permitted but it
was not to exceed 72 hours.
The evidence reveals, that meetings were held by the Department of
Correctional Services, with "executive members, central administration,
medical doctors, welfare case managers and superintendents of adult and
juvenile institutions" at its Head Office, on 16th May 2008, 2otti June 2008,
4th July 2008 and 18th July 2008 (Exhibit 37). Mrs. Jarrett, then Deputy
Commissioner, as chairperson, on each occasion,
"... reminded the meeting that no child should be kept
in 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. This
is so, although even "isolation", in any event, was not listed as an
acceptable punishment in the document, Exhibit 6.
Mr., Hesson said that he was not aware of the practice of "lockdowns" at
Armadale, or of new wards placed on "lockdown" for two weeks prior to
22nct May 2009. He was aware of "isolation", imposed when a child
absconded or was disruptive, but that would be for a period of 48 hours,
"no longer." Here, he contradicted Mrs. Jarrett on the duration. The
question is, Was that rule so loose and flexible?
Mrs. Shirley Johnson, Deputy Commissioner, since January 2009, stated
that "lockdowns" were not permissible, however, in rare <;ases, "isolation"
from recreation or watching television was utilized. She was aware of the
international treaties, including the Beijing Rules and her duties included
seeing 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 great
difficulty in believing her. As a witness, she appeared to have been
"coached."
Mrs. Sylvia Passerley, the Director of Rehabilitation since December 2008
and responsible for policy, stated that she was not advised of the use of

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"lockdown" at Armadale and admitted that suspension of classes or
"lockdown" was not conducive to rehabilitation. She was of the opinion that
twenty-three (23) girls being locked down in the room 20 ft. x 12 ft. for 2
weeks would result in frustration. I accepted her as a frank and forthright
witness.
I find that the practice of "lockdown" was routinely practiced at Armadale to
the knowledge of all, including the senior administrators. The official list of
breaches and consequential sanctions, in use, Exhibit 6, revealed breaches,
such as, using indecent language, fighting and disrespect of staff, resulting
in sanctions, for example, ban on visits, loss of certain benefits or additional
chores. "Isolation" although it was not listed as a sanction was endorsed
and acquiesced in by the senior members of the administ~ation who had
knowledge of its use. I so find, despite their denials.
This is a clear instance of an abuse of· rules and the infringement of the
rights of the girls.
(b) The governing Rules and statutes and breaches thereof
(i) The United Nations Standard Minimum Rules for the Administration
of Juvenile Justice ("The Beijing Rules'') adopted by the General
Assembly on 29th November 1985 and to which Jamaica is a
signatory, recites generally, "the well-being of the juvenile" and
that the aims of juvenile justice,
35

"... shall emphasize the well-being of the juvenile and
shall ensure that any reaction to juvenile offenders shall
always be in proportion to the circumstances both of
the offender and the offence."
. (ii) The General Assembly on 14th December 1990, bearing in mind all
the international instruments "relating to the protection of the
rights and well-being of young persons" and the Beijing Rules,
formulated the United Nations Rules for the Protection of Juveniles
deprived of their Liberty ("the 1990 Rules"). They provide, in rule
31 and 33,
"31. Juveniles deprived of their liberty have the right
to facilities and services that meet all the
requirements of health and human dignity ... and
33. Sleeping accommodation should normally consist
of small group dormitories or individual
bedrooms, account being taken of local
standards Every juvenile should, in
accordance with local or national standard, be
provided with separate and sufficient bedding ..."
(iii) The Child Care and Protection Act which by virtue of section 76
(l)(f) authorizes a Children's Court which has found a child guilty of
36
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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 of
action that is available and appropriate in
a particular case to help a child should be
followed;
... [and]
(c) to recognize the special needs of children in conflict
with the law."
Mrs. Spence-Jarrett, Mr. Hesson and Mrs. !ohnson were statutorily bound
by the requirements of the Child Care and Protection Act, and were aware
of and embraced the principles of the Beijing Rules and the 1990 Rules.
However, their acquiescence in the housing of the girls numbering over
twenty (20), in the Office dormitory measuring 20 feet by 12 feet was a
flagrant breach of above principles and patently inhumane, in all the
circumstances. The recurring complaint of "lack resources" though
understandable, cannot be a rational nor acceptable reason for some of the
'J,7

unlawful actions and breaches of rules by the Department of Correctional
Services.
4.2 Life in the Office dormitory immediately prior to 22"d May 2009
4.2.1 The space for manoeuvring in the dormitory was extremely limited, as I
have found. The roof and ceiling were made of concrete and consequently
quite uncomfortable and in particular, during "lockdown" when the girls
were so confined for an entire day and night for periods of two weeks at
intervals.
(i) Child witness, S. G. confirmed that each new arrival at Armadale was
on lockdown for two weeks during which she doe;; not attend
classes.
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 do
subjects in classes. She conceded that the confinement for extended
periods could "trigger off" the girls into fighting, the staff had to be
more alert and agreed that activities, such as, art, craft and cooking
relieved stress.
All thirteen (13) girls who gave evidence, confirmed the practice of
"lockdowns" and the absence from classes. Witness S. F. described
the adverse conditions in the Office dormitory which· were, two (2)
38
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girls to occupy one (1) bed, not much space, no use of the bathroom
in 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 Sports
Oay on 21st April 2009 when one D. jumped over the fence and
escaped. There was also a confinement earlier in 2009. Child
witness M. M. said, that the plan to escape in May 2009 was because
"[we] can't tek the stress no more, everyday lockdown-boring,"
Child witness M. C. said it was "hot in the days and there was no
furniture 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 at
nights. They were provided by the staff with one or two buckets into
which they were forced to perform all their body functions. Some girls
used newspaper or plastic bags into which they defecated in the nights.
Mrs. Ferreira said that she came to Armadale and saw that practice in
force. Mrs. Passerley said that that practice was not conducive to
rehabilitation. Child witness S.T. said "it smelled bad." She said that the
dormitory was small for twenty-three (23) girls. She would "go and sit in
the passage and look through the grill."

There was a bathroom adjoining the Office dormitory on the left side of
the passageway as one leaves the Office dormitory (See Exhibit lH and
lJ) to which the girls had access during the days. At nig~ts, however, the
wooden door to the dormitory was locked, denying access to that
bathroom. Mrs. Spence-Jarrett said that the dormitory door should not
have been locked at nights. She did not know it was so locked with a
hasp and staple and padlock. Mr. Hesson said he was not aware that the
girls did not have use of the bathroom at nights in May 2009. He agreed
that 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 a
sufficient standard to enable every juvenile to compl_Y, as
required, with their physical needs in privacy and in a
clean and decent manner."
I find that the absence of the provision of these basic bathroom facilities
would only have served to further dehumanize and embarrass these girls
and create stress and frustration among them. These were clear
breaches of the 1990 Rules. Surprisingly, the senior management officials
of the Correctional Services Department said that they "embraced" these
Rules!!
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4.2.3 Housing, additional to the Office dormitory, was proposed by Mrs.
Ferreira, to relieve the congestion in that dormitory. She was provided
with a room, as the welfare officer, adjacent to the Office dormitory. She
offered to give up that room measuring 16 ft. by 10 ft. in which some of
th~ girls from the Office dormitory could be housed. Mrs. Ferreira
discussed with Mrs. Spence-Jarrett and Mr. Hesson, utilizing the room,
and told Mr. Hesson that there was no grill to the door. Mr. Hesson said
that 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 door
was a small job which could be done in one day and paid for from petty
cash. Such installation was a structural change that was his responsibility.
I find that it is unlikely that Mr. Hesson was concerned enough to utilize
Mrs. Ferreira's room as she suggested, to ease the congestion in the
Office dormitory, and probably failed to advise Mr. Anderson to effect the
installation of the grill. In addition, there were four (4) other rooms in
that building, the secretary's office, Mr. Small's office, the
Superintendent's office and an office where records were kept. Any of
these should have been renovated and used to relieve the girls of the
discomfort and stress of living in the Office dormitory (See Exhibit lH).
The Department of Corrections/Ministry of National Security demonstrated
a 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 behalf
of the Department of Correctional Services, for the purpose of reducing
the over-crowding in "the entire juvenile section." Mrs. Spence-Jarrett
stated that Commissioner Major Reece having spoken to the Permanent
Secretary in the Ministry, a committee was formed and submissions were
made to the Ministry. The repairs to make the premises functionally
habitable would have cost $60,000,000.00!! It was planned to remove
the boys from the Rio Cobre institution to Montpelier and to relocate the
girls at Armadale to Rio Cobre. Mr. Anderson said that Montpelier was
approved, acquired and gazetted. Montpelier, according to Mrs. Jarrett,
currently has a skeleton staff consisting of an administrator and a security
'
guard, 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 small
size of the Office dormitory, the closeness of the bunk beds and "the
potential hazard in an emergency," Mr. Anderson had discussions with
Major Reece in respect of removing the girls from Armadale to premises at
24 South Camp Road in Kingston. This was not realized.
42

I find that the senior administration of the Department of Correctional
Services and the Ministry of National Security, were devoid of the requisite
sense of urgency in respect of the continuing inhumane housing of the
girls in the Office dormitory. They failed to grasp the opportunity to show
a degree of compassion in their duty, to utilize the other rooms on the
office building or the premises at South Camp Road or the ever-present
facility at Montpelier, to house the girls in safe, healthy and normal living
facilities. They committed both a statutory and a moral breach of duty
thereby. There were beneficial committees in existence at Armadale, such
as the Behaviour Modification Committee, the Case Conferencing
Committee, which was non-functional due to lack of persons to serve and
the Disciplinary Committee. The committees failed to neutralize the ills of
Armadale.
4.2.5 The educational needs of the girls should be satisfied and ongoing despite
being in the institution. ·
Mrs. Ferreira, as welfare manager would interview new arrivals at
Armadale, advise them of the rules, and a test would be given to
determine the girl's placement in classes. The primary subjects such as
English, Mathematics, History, Social Studies, Art and Craft and basic
Science were taught. The supplies were sometimes insufficient or
inadequate, and both she and other teachers provided supplies from their

own private resources. The windows of the classrooms were "boarded
up" and the only natural light was through the door. Mrs. Passerley,
Director of Rehabilitation, who supervised the education coordinator, one
Mr. Gordon, stated that he was aware that all girls who were in
institutions should attend school. There was a syllabus and teachers were
expected to evaluate the girls and instruct them in high school and
remedial work, the girls would sit both CXC and SSC subjects. The
educational coordinator who should visit the institutions should report to
her any deficiencies or void in the system. She received no adverse
reports that the system was not functioning and particularly, none since
December 2008. .
There were only eight (8) teachers to serve the four (4) juvenile
institution islandwide. Mrs. Kay Barnett, the only teacher at Armadale,
taught all the subjects; there were no specialist teachers. Mrs. Barnett
also had duties ·as Welfare Manager, because Mrs. Ferreira was
performing the duties of the Assistant Superintendent and also that of
Superintendent. Mrs. Spence-Jarrett was aware of the deficiencies. She
said,
"We found out the deficiency in the educational system
and we were doing a full management audit ... started
in April 2009."
44

However, she was unaware that teachers had to supplement the supplies
or that Mrs. Barnett was burdened having the additional duties of welfare
manager. She also, was aware of the 1990 Rules as it concerned the
education of children.
The Child Care and Protection Act places an obligation on "every person
having the custody1 charge or care of a child between the ages of four
and sixteen years..." to ensure that the child is educated at school. There
is no exception because the child is in an institution. The 1990 Rules,
provide a comprehensive guide in the educational needs of children, in
rules 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 and
designed to prepare him or her for return to society..."
The educational needs of the girls at Armadale were marginally and
insufficiently 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 of
being neglected among the girls. The systemic non-attendance at classes
due to "lockdown" would aggravate further those emotions. Some girls
were however taken out to attend classes. The Correctional authorities

failed in their obligation to ensure the proper and continuing education of
all the girls.
4.2.6 Recreational activities were usually scheduled weekly. Mrs. Ferreira said
that there were clubs, namely, cultural and environmental, the Duke of
Edinburgh Club, Inter-Schools Christian Fellowship Club (ISCF) and Girl
Guides. A 4H Club was started but discontinued due to lack of resources.
Parties were allowed on some weekends, involving music and dancing to
help the girls to unwind. See also rule 47 of the 1990 Rules. Clearly, the
impositions of the "lockdowns" would have nullified these benefits to the
girls.
Mrs. Ferreira was of the opinion that up to 22nd May 2009, the girls at
Armadale 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 an
understanding of the needs of the girls at Armadale.
4.2.7 Medical services were provided to the girls at Armadale - helpful at its
best but wholly inadequate.
New arrivals were interviewed by the welfare manager, given toiletries by
the house mother and her meal preferences ascertained. She should then
be examined, initially, by a doctor and a psychiatrist.
46

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Dr. Terrence Bernard, a psychiatrist, attached to the St. Ann's Bay
Hospital and assigned to Armadale, visited Armadale twice - between
January and April 2009. Mrs. Sophia Leslie, the psychologist, between
January and May 2009, visited Armadale - 6 times. Dr. Micas Campbell, a
medical doctor, between January and May 2009, visited Armadale 13
times. The medical personnel was .never able to see all the wards on
these visits.
Dr. Donna Royer-Powe, appointed as Director of Medical Services in the
Department of Correctional Services assumed duties on 1st July 2008.
This was a new post. She was required to ensure that there was medical
coverage for twelve institutions, including four (4) juvenile institutions,
liase with the Ministry of Health and guide the Commissioner of
Corrections 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 the
psychiatrists would give her their schedule. Dr. Bernard could visit only
twice per month. Dr. Royer-Powe, saw this as unsatisfactory and ·on Dr.
Bernard's recommendation, Dr. Micas Campbell, a physician who assisted
Dr. Bernard with psychiatric patients in St. Ann's Bay Hospital was
appointed in November 2008.

No physician visited the girls at Armadale between April 2008 and
November 2008, on which latter date Dr. Campbell assumed duties. The
previous physician resigned in April 2008.
Dr. Campbell observed girls suffering from (a) physical injuries including
lacerations and (b) fungal infections to the toes and nails.
Two of the wards had the communicable disease, HIV and were exposing
it 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 arrival
already on anti-retroviral drugs and the other was tested at the St. Ann's
Bay 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 urgent
that the girl be removed from the facility. Dr. Campbell told Dr. Royer-
Powe on 19th April 2009. Dr. Royer-Powe, knowing that there was an
empty holding area at Horizon Centre told the Deputy Commissioner,
Mrs. Spence-Jarrett, that because of the deviant behaviour, the girl
with HIV should be removed to an alternate location as a medical
intervention. Mrs. Spence-Jarrett turned down the request stating that
48

"because of the rules" it could not be done. The girl remained. She
perished in the fire.
(ii) The psychiatric health of the girls was poor. In February or March
2009, Dr. Campbell found that 90% of them showed psychotic
features of depression, personality disorders (borderline sociopathic
and anti-social) and hallucinations, hearing or believing they were
seeing strange things. They were agitated and uneasy. Drs. Royer-
Powe and Bernard recommended and asked that Dr. Campbell be
allowed three sessions per week to deal with the treatment of the
psychiatric problem of the girls. Mrs. Spence-Jarrett said that it could
not be allowed "due to budgetary constraints;" only one session per
week was allowed. One of the two girls had a severe psychiatric
problem 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 in
denying the increased sessions to treat the urgent psychiatric problems in
April 2009, both on considered medical advice, the Deputy Commissioner Mrs.
Spence-Jarrett, was less than understanding, exhibited a degree of
indifference and displayed poor judgment on her part. In addition, by
refusing the requested transfer, she showed a lack of awareness of the
express statutory provisions of the Corrections Act. Paragraphs 3 and 7 of
the Second Schedule, provide,
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"3. If it appears to the managers of a juvenile
correctional centre -
(b) that a person detained in the centre requires
such [medical] attention, they may make
arrangements for him to be received into and
detained in any hospital, home or other
institution, where he can receive the necessary
attention ...
7. (1) The Minister may at any time order a person
under the care of the managers of a juvenile
correctional centre to be transferred to the
care of the managers of another such centre."
(Emphasis added)
For this reason also, Mrs. Spence-J.arrett was undeniably in error, and in
breach 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 medication
time at Armadale was 10:00 p.m. Non-receipt of medication on time, for
treating depression, some over a 24-hour period, would result in violence
and aggression and increased depression. Miss Fowler, a medical orderly
was not available, for the required 24-hour period. A full time nurse could
50

have solved the problem. Dr. Campbell spoke to Mrs. Ferreira of this.
Nothing was corrected. Dr. Campbell gave whatever dosage she could
give, in the evenings, and told Mrs. Fowler to give what she could.
Referrals in writing to specialists by Dr. Campbell, to see the
gyna~cologist, ophthalmologist or the ENT surgeon, were at times delayed
for months, because of lack of transportation. There was one bus and
insufficient staff to accompany the girls.
"Lockdown" was spoken of by the girls to Dr. Campbell. She was of the
view that such confinement for two (2) weeks would create further
problems 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 girls
were becoming increasingly agitated, there was no separate room at
Armadale for disruptive girls and the boisterous aggressive nature of some
girls who were not able to sleep would affect the others.
5.0.0 Uncontrollable behaviour was the major complaint attributable to most of
the girls detained at Armadale, yet there was no structured programme to
correct this "fault" and very limited personnel!
Dr. Royer-Powe was unaware, in 2008, of the fact that the majority of the
girls at Armadale were in detention for uncontrollable behaviour. She said
that no one in the upper administration of the Department of Corrections
51
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informed her of it. Had she been aware, it would have "signalled to me a
psychological dysfunction," and she would have dealt with it. She had the
administrative responsibility to supervise psychiatrists and psychologists.
The Senior Medical Officer at Bellevue Hospital, Dr. Oo, a psychiatrist, was
employed by the Department to provide treatment in sessions. The only
psychological assistance was provided by Mrs. Wint-Leslie, a Probation
Officer, who had obtained a Masters degree in forensic psychology and
who visited Armadale from Hanover. Between January and May 2009 she
visited six (6) times. She assisted in counseling, anger management and
any psychological issues. However, she did not report to the Director of
Medical Services Dr. Royer-Powe, but was authorized by the Deputy
Commissioner to visit and do certain interventions - a spilt project.
There was no programme for the girls in attitude adjustment or behaviour
modification. Shown Exhibit 9, the Syllabus Outline for Security Methods
and Operational Procedures in Custodial Functions for Correctional
Officers, Dr. Royer-Powe said that,
"Nothing in exhibit 9 suggests that training in
psychology is to be involved in the training of
Correctional 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 have
done - general training for Correctional Officers."
The need for psychologists at Armadale was voiced by Superintendent
Gardener on 24th September 2007 at a meeting at the Department of
Correctional Services, chaired by Commissioner Major Reece. In
attendance were, Mrs. Mary Clarke and members of her staff, Mr. Hesson
and the Superintendent of Fort Augusta Adult Correctional Centre. Supt.
Gardener said that there was only one (1) psychologist and there was a
serious 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 no
increase in that number of psychologists resulting in a major deficiency in
psychological care of the obviously troubled girls at Armadale. This was
an obvious need left unattended and continuing up to May 2009.
5.1 Other areas of neglect at Armadale
5.1.1 There were insufficient fire extinguishers functioning at Armadale for use in
the event of a fire. There were two fires set by the girls previously at
Armadale, one (1) in 2007 and the other is 2008. The girls were seen by
Mrs. Ferreira discharging the fire extinguishers.
53

Mrs. Claudette Hamilton, Acting Superintendent at Armadale, by
memorandum dated 18th November 2008 to the Commissioner, advised
thfl't)~~.(~,, ~tcl~·d.'~~nzye,t?i2:w;itJJ6i..lt'sdme ·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 be
refilled ... there is a need for an extra eight (8) ...)". Mr. Neilson Anderson
admitted seeing Exhibits 3 and 4 from Mrs. Hamilton. He said that he
requested that the four (4) fire extinguishers be serviced, but admitted
that he did not attend to the provision of the eight (8) new fire
extinguishers. Mrs. Spence-Jarrett said that she saw the request, Exhibit
4, and passed it to Mr. Neilson Anderson who told her that "it was done."
Mrs. Ferreira as Acting Assistant Superintendent, oy letter dated llth
March 2009 (Exhibit 5) to the Superintendent, Fire Department, St. Ann's
Bay, stated:
"In celebration of Fire Safety Week 2009, [Armadale] ...
invites members of the Fire Prevention Team to
conduct a Fire Drill and Fire Prevention Awareness talk
with both staff and wards."
The Fire Department failed to honour this request.
This gross neglect by both the senior administrators of the Correctional
Department and the Fire Department in respect of fire fighting equipment
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and fire drill instructions, respectively, may well have contributed to the
ineffectiveness of the response of all parties at the crucial moment of the
subsequent fire.
5.1.2 There was no observation or supervision of the girls in the dormitories in
the nights. The door to the Office dormitory was locked and was only
opened in an emergency. The wooden door with an area of glass at the
top 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 to
December 2008, was locked, but the Correctional Officers did not agree.
Mrs. Spence-Jarrett stated that she was unaware that the Office dormitory
door was locked at nights with hasp and staple and padlock - it should
have 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 seen
viewing it through the wooden door from a grill door approximately 8 feet
away. 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, ·including
individual rooms and group. dormitorie,s, in orqer tp
ensure the. protection pfe9chJL1venile:t
In relation to this, Mrs. Spence-Jarrett suggested that it was"... difficult to
have 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 of
and attention to ensure the safety of the girls. Any such "difficulty" could
be overcome by a re-configuration of the glass area of the wooden door
and a genuine will to protect them.
6.0.0, Other concerns expressed concerning Armadale
6.1.1 The Office of the Children's Advocate, a Commission of Parliament, was
created under the Child Care and Protection Act (section 4), "For the
purpose of protecting and enforcing the rights of children". Mrs. Mary
Clarke was appointed Children's Advocate in February 2006. She
articulated consistently the deficiencies in the treatment of children in
Jamaica generally and voiced her concern for the ills of Armadale. In
particular,
'
(i) On 31st January 2007 Mrs. Clarke convened a meeting at the Office
of the Children's Advocate. Among those present were Major
Reece, Commissioner, Mrs. s'pence-Jarrett, Deputy Commissioner,
Mr. Hesson and Mrs. Passerley. (Exhibit 26)
The capacity of Armadale was stated to be forty-five (45) girls and
there were then sixty-seven (67) in that institution. Mrs. Clarke
recommended "long term counseling with specialist intervention,, for
the girls. Mrs. Spence-Jarrett noted that 95% of the children who
come into the institutions have uncontrollable traits. The Child
Development Agency, which is responsible for children's homes and
56

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1 places of safety, does not have the space to accommodate
remandees, so they are placed, as a consequence, in the correctional
centres. Mrs. Spence-Jarrett stated that the children then become
the responsibility of the Department of Corrections, and the Child
Development Agency "never usually follow up."
(ii) On 24th September 2007 at a meeting at the Department of
Correctional Services chaired by Major Reece, the issue of Armadale
having the seventy (70) girls was raised by Mrs. Gardener,
Superintendent. She also voiced the need for five (5) psychologists
working on shifts, and a nurse during the day and at nights. Mrs.
Clarke queried "when Montpelier ... would be opened?" Major Reece
responded 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, and
chaired by Mrs. Clarke, in attendance were the Minister of Justice
and Attorney-General, the Minister of State in the Ministry of National
Security, Major Reece and other Department of Correctional Services
officers and a representative of the Child Development Agency,
among others. The issues of children in lock-ups, places of safety
and correctional centres were discussed. The need for specialist
staff in such institutions and the over-crowding at Armadale were
also discussed. Mrs. Clarke appealed to all, including the Ministers of

Government for their assistance in resolving "... some of the
problems relating to juveniles under the care of the state." (Exhibit
28)
(iv) By letter dated 28th March 2008, Mrs. Clar~e welcomed the proposal
in a draft Cabinet submission, to open Montpelier, as being in "the
best interests of children ... in conflict with the law". She sought
responses from Major Reece in respect of the provision of
psychologists and psychiatrists, ratio of teachers and instructors to
wards, lack of development and recreational activities and facilities
for wards with serious mental health problems. (Exhibit 29)
Major Reece responded by letter dated 1st April 2008 addressing each
query. (Exhibit 30)
The Children's Advocate, Mrs. Clarke, embracing and admittedly bound
by the Beijing Rules and the 199.0 Rules, gave lecturers to Correctional
Officers in February and August 2007, visited institutions such as Fort
Augusta and Horizon where children were kept, visited, along with her
staff, several schools and investigated reports received in respect of any
abuse of children. The latter investigation led to the closure of three (3)
children's facilities. An investigating officer Mr. Courtney Berry was sent
by her to Armadale in March 2008, as a result of a report of abuse she
received. The girls were interviewed and wrote complaints in sealed
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6.1.2
envelopes. As a consequence, she made a written report to the
Commissioner of Corrections. She admitted not doing a physical
inspection of Armadale.
With only a staff of seventeen (17) persons, limited resources, including
'the unavailability of an official means of transport since 2008, Mrs. Clarke
has exhibited a sincere and active involvement in pursuing the concept of
acting in the best interests of the child, as mandated by the CC&P Act.
She has submitted, since her appointment, two annual reports to
Parliament, as required by the CC&P Act, but has not been summoned up
to September 2009 by any sub-committee, as promised.
Mrs. Ferreira, a trained teacher, was appointed Welfare case Manager of
Armadale, but has been acting as Assistant Superintendent and
overseeing the duties of Superintendent since early 2009, all at the same
time. She is still paid only as a Welfare Case Manager. She was an
overburdened public official. She interacted well with the girls and had
their confidence, trust and respect. She was of the opinion that with the
correct combination of discipline, instruction and love to mould the minds
of the girls, Armadale could have functioned well. She repeatedly advised
the senior administration of the deficiencies and the urgent needs at
Armadale. She said, in evidence, with "23 wards in the Office dorm it was
59

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 the
Department of Correctional Services, Head Office, presided over by the
Commissioner and at which the Deputy Commissioner, Directors and
Superintendents were present. Mrs. Ferreira produced in evidence, Exhibit
2, showing the monthly reports on Armadale, to the meetings,
documenting its needs.
• For the period 30th June 2008 to 1oth July 2008 the needs
were-
(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 November
2008 to 13th December 2008, 14th November 2008 to 31st
December 2008, 1st January 2009 to 31st January, 2009 and
1st February 2009 to 2ot11 February 2009, the said needs,
presumably unsatisfied, were repeatedly requested, with
additional requirements of, spraying of dormitory, relocation
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of generator, tools for groundsmen and more importantly,
"additional space for wards."
Commencing with her performance of the duties as Superintendent of
Armadale in January 2009, Mrs. Ferreira had been requesting repeatedly
"additional space for wards", in keeping with her concern that the
overcrowded living conditions of the girls were wholly unacceptable. Mr.
Hesson admitted that he did not make any specific attempt to deal with
Mrs. Ferreira's recommendations in respect of an area for disruptive wards
and 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 her
assigned 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 to
Armadale on Saturday ... tomorrow" and that she intended to move the
administrative office and "open up the dormitory to the girls." The fire
intervened on that night!! Here was Mrs. Spence-Jarrett, with her "hands-
1 on" approach, unilaterally, making again a housing decision. It was too
J
late.
'

6.1.3 Both Mrs. Clarke as Children's Advocate and Mrs. Ferreira, as WelfantCijse
Manager, exercising the supervisory roles of AssistantSuperintendent and
'Superintendent, perceived the shortcomings of the overcrowding of
Armadale and voiced their concerns. The senior administration of the
Department of Correctional Services failed to deal directly with the specific
deficiencies which were amply articulated, and was quite dilatory in its
response 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 35
and 36). In addition, in a meeting held on 16th May 2008, attended by
Mr. Hesson, Dr. Vassell, a medical doctor, Mrs. Hamilton, a psychologist,
Superintendents and Welfare Case Managers of both adult and juvenile
'
institutions, among others, (See Exhibit 37), she "placed emphasis in
regards to the manner in which children are kept in isolation at the Fort
Augusta Adult Correctional Centre..." reminded them that "... no child
should be kept in isolation for over seventy-two (72) hours" and "implored
them to abide by the Child Care and Protection Act."
This meeting was described by Mrs. Spence-Jarrett, as a Population
Reduction Strategy Meeting and other meetings were also held on zoth
June 2008, 4th July 2008 and 18th July 2008, principally to see to the
release of girls "on licence" and other related issues.
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6.1.4 Immediately prior to 22°d May 2009 the climate existing at Armadale was
one of sixty-one (61) troubled girls, twenty-three (23) of whom were
subjected to a most inhumane existence in over-crowded, unhealthy and
unhygienic conditions. It was a climate of tension and apprehension
among the girls in the Office dormitory. Some of them were very ill, as
demonstrated by Dr. Campbell, and suffered from various psychotic
conditions which were largely untreated. The girls had been kept in close
confinement for three (3) weeks, on "lockdown", in the above conditions.
On the 21st April 2009, Sports Day, one girl jumped over the fence at
Armadale and escaped. She was recaptured and "lockdown" was
imposed. On 7th May 2009 seven (7) girls escaped from the Cottage
dormitory 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 sut'1 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 few
is collective punishment at its worst. It was unjust. Instinctively, it must
have 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 entry
in the log book that the screws from the hasp and staple on the door of
the Office dormitory had been removed. He replaced them. The record
also revealed that a girl had been seen with a screwdriver. It was
r~trieved with the help of another girl. Mr. Small made a report of both
matters to Mr. Hesson.
The climate in existence in the Office dormitory immediately prior to 22nd
May 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 fire
Several of the girls had made plans to escape from the Office dormitory
on 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. to
4:00 p.m. and 4:00 p.m. to 11:00 p.m. Mrs. Higgins, unwisely, did not
disclose this to Mrs. Ferreira who left Armadale at 5:30 p.m. Mrs. Ferreira
said in evidence,
"Mrs. Higgins did not tell me she knew of the plan.
[to escape] Had she I would have made calls and
returned to Armadale. I have done so in the past."
The girl had told Mrs. Higgins that the girls had a screwdriver in the
dormitory and planned to "dig out the window joints." The girls did in
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fact, during the day, unscrew the grill covering the back window of the
dormitory, but left it in place supported by a bunk bed.
Child witness M. M. said, in evidence, that one of the girls said, "Can't tek
the 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, because
she was "to be released on 15th December, don't 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 Lucille
Hamilton and Miss Carlene Coleman. Mrs. Higgins told them that "we
need to 'beef up' security with more patrols than normal."
It was a serious misjudgment on Mrs. Higgins' part to have chosen not to
advise her superiors of the girls' plans to es.cape. Her reason that there
was no search of the dormitory because the staff was insufficient is
inexcusable.
7.0.0 The circumstances and causes of the fire
7.1.1 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 a
louvre 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 Kingston
and Mrs. Jarrett, who was at the Horizon Centre and out of
communication. Mrs. Shaw-Slack was placed at the back window and Miss
Gilbert 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 the
officers, faeces, urine, water and various other articles. They also dug off
the grill from the front window. They became boisterous, singing and
chanting and shouting expletives at the officers. Girls were trying to come
out through the back window. Correctional officers and the security
guards had sticks, hitting at the girls to keep them inside. Attempting to
come out through the front window, the girls were restrained in a similar
fashion. Mrs. Higgins called the Alexandria police station and two police
officers came in a police motor vehicle, Woman Corporal Shawnette
Dunkley, in uniform, and Cons. Lawrence Burrell, in plain clothes, wearing
a police vest. The girls became noisier. They were drumming, chanting,
singing, and shouting expletives at the police officers. Standing near the
back window, Woman Corporal Dunkley, smiling, asked the girls "What is
the problem, what is wrong? You need to calm down." The girls
responded with expletives. Woman Corporal Dunkley told one of the girls
to get the girls to calm down so that she can deal with the situation. The
noise did not abate. The girls shouted "Wey dem call the police fah?" and
cursed the officers.
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Not all twenty-three (23) girls were involved in this intention and attempt
to escape from the dormitory. The main planners and participants were
S.K., S.S., P.E. and T.W.
Constable Burrell stood at the back fence behind the dormitory and then
moved to the side near to the Cottage dormitory where Mrs. Higgins was
standing. He asked her what she was going to do. She replied, "Nothing
we can do, but let them stay inside until I hear from the Superintendent."
He said, "But they can't continue to go on like that ...talk can't help."
Cons. Burrell drove the police vehicle from the compound and returned in
about five (5) minutes.
7.1.2 Cons. Burrell came out of the police motor vehicle with a tear gas canister
in his hand and went and stood at the back fence.
Miss Coleman said,
"I saw him with teargas thing ... roundish with neck in
his 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 army
greenish thing." Child witness C.W. said that the policeman returned with
a grey object in his hand. Child witness P.E. saw the policeman with "in
his 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 police
vehicles along with batons, and that he had casually taken up the
bombing 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 than
leaving it in the police vehicle, because it is normal to do so. He said,
"... we would not normally just leave it in the vehicle
because sometimes you would have suspects or
whoever you pick up on the road, it is always between
the two front seats so you don't want to leave it and if I
should put someone in the vehicle, when you reach to
the station it is not there, so I normally take it out and
have it in my hand."
This was a curious tale!
I do not believe Cons. Burrell when he said that he discovered that the
bombing ball was no longer attached to his shirt "after the firefighters
came and the area was cooled down." It is further unlikely that, as he
said,
"I alerted Cpl. Dunkley and the senior officers that
come, I told them that I had a bombing ball teargas on
my shirt but don't know where it is."
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W/Cpl. Dunkley said in evidence, that it was not normal for a teargas ball
to be kept in the motor vehicle.
I find that Cons. Burrell, annoyed and enraged by the disorderly conduct
of the girls and the continuing expletives directed at him, left Armadale
with the express purpose to obtain a teargas device and returned with a
tear 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 ... army
green colour round ... not like ball ...like a bottle ...
Tropical Rhythms ... Red Stripe bottle." (Emphasis
added)
The girls, on seeing Cons. Burrell with the teargas canister, were
knowingly apprehensive.
(i) M.C. said,
"... policeman said 'Talk can't 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 'Police
come back with bomb.' Another said, 'You a idiot, him caan
threw it in yah pon we.' "
(iii) Child witness M.M. said,

"Chamala said 'Them a come with bomb.' The policeman a go
bomb we up in here."
(iv) Witness Carlene Shaw-Slack said, "Police jeep left and returned
in a few minutes ... saw him with tear gas thing-roundish with
neck, in his hand. Wards said 'you think we 'fraid a dat tear
gas' and used bad words."
7.1.3 Cons. Burrell, well aware that there were twenty three (23) girls in the
room, knowing that the teargas device should not be thrown into an
enclosed room, unconcerned with the means by which the girls could
make a safe, hasty exit from the room, deliberately threw the tear gas
canister into the Office dormitory, through the front window, to the west.
(i) Witness Shaw-Slack, Correctional officer said, "The policeman
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asked, How many officers? We said seven (7). He asked, How
many wards? We told him twenty-three (23). He went and stood
at 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 throw
through the front window of the Office dorm, he was 4 to 5 feet
from me."
(iii) Child witness M.C. said, "Policeman came to front, took something
off his shirt, draw it up like the sausage tin you pull up and throw it
into 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, all
confirmed seeing Cons. Burrell throw the teargas canister
through the front window.
(v) Denying that he threw the teargas container, Cons. Burrell said,
"Teargas is used to disperse crowd - rioters - smoke
induces vomiting. We would not normally throw
teargas into a room - used it in open spaces. Not
proper police procedure to throw teargas into a room."
(Emphasis added)
Assistant Commissioner of Police, Paul Robinson, commenting on the use
of force by the throwing of teargas, said that the Jamaica Constabulary
Force manual places a responsibility on the particular police officer to
justify its use and provides that he,
"... is accountable ultimately to the law and also to the
Commissioner 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, I
believe should include the evacuation ... of any persons
detained in any premises."
Cons. Burrell, with his knowledge of the enclosed room, particularly with
children and well aware that there was no apparent exit therefrom,
without the authority or knowledge of his superior officer W/Cpl. Dunkley,
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nevertheless discharged the teargas, knowing, at least, that it would have
harmful effects and discomfort from the smoke, for example, vomiting.
His main purpose was to chastise the girls for their behaviour.
His comments, "Talk can't help" (M.C.s' evidence), "No talk to them ... you
nuh see a bad breed" (S.T.'s evidence), "A bad pickney dem ... 'low dem
you no see dem no waan hear" (J. L's evidence,) "Dern bad a dat dem fe
get" (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 immediate
cause of the fire.
(i) Child witness S.G. who was standing on the "top decker" of the
bed near to the front window said,
"I ... felt something come in through the front
window and hit me on my chest. I box it off fast
and it fell on the bed, Monique's, smoke came out
and sparks drop out ..." (Emphasis added)
(ii) Child witness M.C. who had jumped through the front window
and was chased held and placed in the Cottage dormitory, saw
fire when the teargas device landed. She said,
"The policeman took something off his shirt ... draw
it up like the sausage tin you pull up and throw it

into the building through the front window ... I see
fire 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 front
window ... hear like something a fry ... landed on
bottom decker ... me see smoke come out ... I
jumped off the bed to the back window ... a try get
air fi breathe ... by the time me turn round me see
the fire pon the bed where the policeman throw the
thing ... fire ... small ... me bawl out ... 'fire in a de
dorm.'" (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 of
Stacy Ann's bed close to mine." (Emphasis added)
The significance of these bits of evidence of the girls is that, in the initial
seconds after the discharge or initiation of the teargas device, smoke and
flames or sparks were emitted. In contrast, only smoke but no flames
were discharged when a teargas han-ball was initiated.
7.1.S Assistant Commissioner Paul Robinson conducted tests at the Jamaica
Police Academy, at Twickenham Park with teargas devices. The
73

·;. teargas canisters which he tested, on initiation, discharged flames or
sparks and smoke on initiation. He said,
"... from a visual observation, that from the 'han-ball'
we never saw flames exiting from it at all other than a
short period, but for the grenades [the canisters] every
time we saw flames exiting as they initiate." (Emphasis
added)
Assistant Commissioner Robinson conducted tests to show the effects
caused by the devices when activated,
(i) _On 14th August 2009 - 8 experiments using
"Han-ball" CS (Chlorobenzalmalononitrile)
teargas grenades (of rubber) taken from the
Police armoury at Elletson Road - None of these
han-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 using
metal C N (Chloroacetophenone) teargas
grenades, taken from the armoury at Elletson
Road. Flames, in the first two, and sparks, in
the third experiment, were seen ejecting from
each device on initiation - followed by smoke.
I

The evidence above of the girls, who saw flames and sparks initially, when
the teargas device was thrown into the dormitory, is supported by the
experiments of Assistant Commissioner Robinson. I find that it was a CS
teargas metal canister, and not a rubber han-ball, that was thrown by
Cons. Burrell and which canister emitted flames and fell onto the mattress
of M.'s bed which was close to the front window and which started the fire
in 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 the
Port Antonio Fire Station in the parish of Portland, and a fire investigator
since 1997, visited Armadale on 24th May 2009, along with other fire
investigators. He observed six (6) metal double de,cker bed frames burnt
and twisted and mattresses "completely burnt off." A book shelf attached
to the southern wall of the room and near to the front window was
severely burnt as also a bed beneath the shelf. There was severe burning
also at the front window of the dormitory, as well as to a bed near the
window. There was "heavy spalling" on the floor near to the severely
burnt 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 ... the
concrete there dig up, pull up, especially the tile and
those things ... a crater is similar to spalling ... the
76
I

(See Exhibit 41 - DVD disc-videotaped by Cpl.
Richard Minott) (Emphasis added)
(iii) On 2sth August 2009-five (5) experiments. He
had taken from the Alexandria police station, St.
Ann, seven (7) teargas grenades canisters - six
(6) of them "... were considerably old, rusty and
in poor condition"- C S grenades, "manufactured
in 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 grenade
canisters. Three (3) of the grenade canisters emitted flames and sparks,
(one of them only after 5 minutes). Of the other two (2) one failed to
activate, its port hole was taped over, apparently old and defective, and
from the other, only teargas smoke emerged. (Emphasis added)
The experiments were conducted by throwing each teargas device onto a
mattress, similar in type to that used in public institutions, such as
Armadale. 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 of
the Correctional Officers and they would open up the
place ... not know who said it they gathered around ...
girls said 'if we light staff wi run come and we can
cut'."
In that respect the girls miscalculated. They were unaware of and could
not have predicted the ineptness and indifference of some members of
staff which resulted in the girls' inconvenience, suffering and eventual
fatalities. Some of the girls probably had an accelerant in the dormitory
with the intention to start a fire, but the unwarranted intervention of
Cons. Burrell's action removed their opportunity to do so.
8.1.2 The presence of an accelerant and the spatting on the, floor near to the
window and the front bookshelf was also detected by Mr. Fitzmore
Coates, retired Chief Forensic Officer, forensic analyst. He visited
Armadale on 23rct May 2009 and again on 24th May 2009. On 23rct May
2009 on entering the Office dormitory, he saw the remains of six two-tier
bunk beds burnt, mattresses burnt, clothing scattered on the floor and
water on the floor. He saw spalling on the ceiling near to the front
window 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

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Teh Full 2010 Armadale Report