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I I I' - ARMADALE .REPORT

Teh Full 2010 Armadale Report

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Page 1: Teh Full 2010 Armadale Report

I I I' -

·~ ARMADALE

.REPORT

Page 2: 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

Armada le 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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Page 3: Teh Full 2010 Armadale Report

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Page 4: Teh Full 2010 Armadale Report

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

2

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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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I I I I 1

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 Armada le - 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 1 st January 2007 the total population at Armada le 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 flOOLareaof the 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.

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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.

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(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 ,

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 Armada le, 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 Armada le 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.

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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.

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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 21 st 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

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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.

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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.

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I I I I I

' l 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;

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I I I I I

' l 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;

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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 I

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I I I

"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

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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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' --1 I I I ~

I I

I I I

I

"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,

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" ... 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

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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

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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)

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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 21 st 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."

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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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I

'

-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.

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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 Armada le, 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.

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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

Armada le.

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

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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."

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\

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

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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 Armada le.

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.

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I I I t

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 1 st 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.

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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

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"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

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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

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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,. ..

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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 Armada le 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.

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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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I I ,

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

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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 31 st 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 Armada le 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

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I 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

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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 1 st 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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l I I I I I I I I I I

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

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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, 11 th August, 2008 to 24th August, 2008, 13th November

2008 to 13th December 2008, 14th November 2008 to 31st

December 2008, 1st January 2009 to 31 st 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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rm

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

Armada le 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.

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6.1.3 Both Mrs. Clarke as Children's Advocate and Mrs. Ferreira, as WelfantCijse

Manager, exercising the supervisory roles of Assistant Superintendent 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 21 st 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.

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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

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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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r n

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."

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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,

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"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 '

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."

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(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

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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

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·;. 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.

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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 C S

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

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(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.

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"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."

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"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 spalling 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 23rd May 2009 and again on 24th May 2009. On 23rd 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."

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He saw also that the wall adjacent to the seat of the fire "which was just

below the window was severely burnt."

He saw " ... in the same vicinity ... ," beside another bunk bed " ... a small

crater .. . beside the bed on the concrete tile flooring . .. about 3 to 4

centimeters deep ... about one foot across," with severe burn marks on

the floor around the area.

I find that this "crater" in the concrete was the condition that Mr. Rowe

described also as spalling and was in the south-western corner of the

room, near the bookshelf referred to by Mr. Rowe.

Mr. Coates, having drained the water from the room, made a thorough

search and took samples of material "around the crater in the area of tl;le

seat of the fire." He said he carried out tests,

"On sample number 7, the pieces of partially burnt

cloth taken from the south-eastern section of the room

adjacent to the window ... in the area near the seat of

the fire."

The tests revealed " the presence of gasoline, a highly flammable

hydrocarbon accelerant." He also said that the tests on sample number 8,

" ... the remains of a Bible, found in the area of the crater on the north-

eastern section of the room ... adjacent to the seat of the fire," revealed

the presence of " ... highly flammable hydrocarbon accelerant-gasoline."

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----------------~-- -

I find that although Mr. Coates refers to "the seat of the fire to be on the

south-eastern section" and on another occasion as the "north-eastern

section" of the room, he agrees with Mr. Rowe, that it was in the vicinity

of the front window to the playfield. (See analyst's chart, exhibit 22.)

Both witnesses found the presence of an accelerant in the area of the seat

of the fire. This area was in fact the south-western part of the Office

dormitory - between the front window and the front closet.

Significantly, Mr. Coates said that he did not find "any incendiary devices

or the remains of anything of that nature."

9.0.0 The effect on, and reaction of the girls to the teargas and fire in

the dormitory

9.1.1.The girls had dug from the wall, the grill to the back window of the

dormitory, during the course of the day, but left it in place, supported by

one of the beds, in order that it would appear normal. They had two (2)

screwdrivers. After supper, some of the girls were making noise, singing

and cursing the patrolling staff and throwing urine and water on them

from the buckets in the dormitory. They used a piece of iron from the

closet and started to hit off the grill from the front window. Some of the

girls merely sat and watched. The lights in the dormitory were being

turned on and off. Both the making of the noise and the turning off of the

lights were intended to conceal their actions. Mrs. Higgins used her

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cellular phone. The male and female police officers came. The female

officer spoke to the girls. The male police man said "Talk can't help"

drove out and returned. One girl said they were "creating disturbance to

get the staff dem come in." They removed the grill from the back window

and some attempted to go out. Mrs. Shaw-Slack brought a piece of board

and attempted to block the window. Mrs. Higgins, Mrs. Shaw-Slack and

other officers, with sticks, were hitting at the girls to keep them inside.

The girls then removed the grill from the front window. Some of the

officers, including Mrs. Higgins came to the front window, and again were

hitting at the girls who attempted to leave the dormitory. Witness M. C.

jumped out through the front window; but was chased and held by Miss

Hamilton and placed in the Cottage dormitory. Cons. Burrell then came to

the front window and threw the teargas canister through the front

window, the lights were then off. The canister hit child C.G. in her chest.

She "boxed it off" and it fell on the bed. Flames and smoke came out of

the canister. The smoke filled the room, burning the nostrils and eyes of

the girls. The fire started on the bed nearest to the front window. The

girls shouting "fire" and "help", rushed to the back window "to get air."

The girls, bigger in size blocked the back window - some girls came out.

S.F. jumped out through the front window - but she was hit by Mrs.

Higgins and told to go back inside. S.J. went into an upper cupboard to

"try to get air", it was futile. She jumped through the front window. Mrs.

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Shaw-Slack and Mrs. Gilbert helped girls out of the back window of the

Office dormitory, by which time a blazing fire and teargas filled the room.

The girls were in a panic and had difficulty breathing. They fought each

other to escape through the back window - some were pushed to the

ground and were stepped on. M.M. asthmatic and suffocating suffered a

nose bleed and burning on her skin. She was helped to the back window

by K.N. who said "Come M. mind you asthma." The fire consumed several

of the mattress, made of a "foam like" material, giving off harmful fumes.

Forensic analyst Mr. Coates said,

"Foam mattress burning would give off hydrogen

cyanide, carbon dioxide, carbon monoxide, hydrogen

chloride and phosgene - all toxic substances ... burning

of foam would generate a lot of heat and rapid

consumption of oxygen in a room that size."

The girls consequently suffered, in th0se circumstances, great discomfort

and stress, difficulty breathing due to insufficient oxygen and intense heat

from the fire. In addition to· those conditions, the girls in that

overcrowded dormitory, each with at most, barely two and one half feet

squared of standing space between the bunk beds, could not fail to be

handicapped, utterly confused by the fire, smoke and teargas fumes and

unable to manoeuvre safely in such a tightly packed space. It was chaotic

by any standard. Several of them experienced extensive burns to their

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bodies and a "peeling off" of the skin. Once outside, one girl went to the

refrigerator to "cool my skin", others were fanning themselves and each

other, many ran around the playfield or allowed water to run over their

bodies to keep cool and almost all were crying and distressed.

About fifteen (15) girls were helped through the back window of the

Office dormitory. Both Mrs. Shaw-Slack and Mrs. Gilbert were outstanding

in helping girls to get out through the window. Mrs. Hamilton and Miss

Coleman also helped.

9.1.2 An ambulance arrived and took about 10 girls, burnt and crying, to the St.

Ann's Bay hospital. Mr. Joseph Small~ the overseer, having received three

telephone calls from Mrs. Higgins, arrived at Armadale at about 8:40 p.m.

' He saw the Office dormitory with "a lot of black smoke and fire ... the

building engulfed." He enquired whether any other wards were in the

building. The security guards were crying and confused. He took to the

hospital in his motor car, some of the girls " ... burnt skin stripped off

[and] crying." He saw the fire truck arrive about ten (10) minutes after

he did. Before then, Mrs. Higgins and others were carrying water in

containers and throwing it through the front window to put out the fire.

He saw a Sergeant of Police there speaking on his cellular phone and

whom he sought to speak to. The officer did not respond. He saw no

police officers assisting to put out the fire while he was there.

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10.0. Errors and lost opportunities by staff and fire officers at the

outbreak of fire

10.1 After the realization that there was a fire in the dormitory, Mrs. Higgins, a

Correctional Officer 1, and the supervisor of the shift- 4:00 p.m. to 11:00

p.m., was more intent on containment of the girls within the dormitory,

than a quick and effective release therefrom. She continued hitting them

to stay in. Mrs. Higgins had heard a sound inside the dormitory " ... like air

letting out." She ran from the side to the front window and passed Cons.

Burrell "going to the side of the dormitory going towards the back." She

saw "black smoke ins_ide the dormitory." The girl S.F. jumped through the

front window onto Mrs. Higgins' chest. Mrs. Higgins said,

"... ward [F] jumped through front window ontq my

chest ... eyes and nose burning me ... placed her on the

grass. I ran and drank water at pipe ... another girl

jumped through ... knew Shaw-Slack had keys.

I considered opening [the door to the dorm] ... I just

wanted some water to drink and cool down my face ...

heading back to the front of the office building ... I saw

girls outside running up and down! ... some with burns

... I saw Miss Slack at the front on the grass coughing.

I got the keys from her, run up the passage and I

pulled the padlocks from the grille ... two ... I went up

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to the door made of board ... with two padlocks ... glass

at the top. I saw fire ... inside ... and smoke coming

through the jamb. I could not go any further, it was

hot ... I did not attempt to open either one .. . I ran

back to the dining room to find a fire extinguisher."

I find that Mrs. Higgins, as the supervisor of the staff on that shift, having

first seen black smoke in the dormitory, should have promptly opened the

door, at least to ease the discomfort from inhalation of smoke.

Assuming that she did not have the keys, which as supervisor she was

required to, she should have retrieved them promptly from Mrs. Shaw­

Slack, who did attempt, unsuccessfully, to release the girls through the

door. Mrs. Higgins, having been outside, at the window, was neyer

exposed to the inhalation of the noxious air in the dormitory. There was

no necessity, in my view, for her to leave to drink water and "cool down

my face," as she claims, before opening the door. By her unnecessary

delay, she lost valuable time and opportunity to assist the girls enclosed

and entrapped in the dormitory. She added to their peril.

10.2 I reject the evidence of Cons. Burrell that he saw someone inside the

dormitory" ... light something ... and dropped it on one of the beds ... fire

blazed up ... I shouted fire where is the keys ... " and he "got a bunch of

keys from someone ... I can't say who," and "I walked down the passage

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way through thick black smoke and opened the padlock on the second

grille" in an attempt to release the girls. Nor do I believe him when he

said that he kicked open the wooden door " ... and a large flame came out

... it opened halfway ... ". He said that that door was locked with a "dead

bolt at the bottom." (Emphasis added)

I find that,

(i) The two padlocks on the grill door had already been unlocked

by Mrs. Higgins after she got the keys from Mrs. Shaw-Slack.

He could not therefore have unlocked "the padlock" on the

grill door.

(ii) Because of the "thick black smoke" in the passageway, he

could not have known nor would have been able to see which '

of the keys from the "bunch of keys", was the one to open the

padlocks on the grill door.

(iii) Mrs. Higgins said that she did not give the keys to anyone else

after she got it from Mrs. Shaw-Slack.

(iv) He said that the door was locked with a dead bolt at the

bottom but failed to realize that there were two padlocks also,

locking that wooden door - with hasps and staples.

(v) He said that the grill door that he opened was "very close" to

the wooden door "right against it." Det. Cpl. Samuel Brown of

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the Major Investigation Task Force, a crime analyst trained in

the use of software to reproduce scenes, said that the

distance from the door of the Office dormitory to the grill gate

was eight feet seven inches (8'7"). (See Exhibits 1 and 10).

Other witnesses agree with that distance.

I find that Cons. Burrell did not at any time enter that passageway, with

or without the door keys, nor did he attempt to open the door to the

dormitory.

10.3 District Officer Patrick Robinson of the Jamaica Fire Brigade, stationed at

Brown's Town, St. Ann, received. a telephone call from the Alexandria

police at approximately 8.53 p.m. and went to Armadale with six (6)

others. The ambulance was then leaving the premises. He saw the "thjck

black smoke" coming from the building and was told of "... the wards

inside." He assessed the situation and entered the building through the

passage. He said:

" ... we could not gain entry to the dormitory because of

a blocked door . . . So we retreated and went to the

windows where we started fighting the fire from the

. d " wrn ows ...

He said that he and another fireman, subsequently " ... returned to the

door ... we managed to shub the door ... there was a bed blocking the

door, ... we pressure the door ... it just came off into our hands ... we put

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it on the outside." When asked, Mr. Robinson said" ... it was very hard to

remove the door at that time ... it would take some time to really smash

the door."

The District Officer and the other fireman should not have failed to open

the dormitory door when they went to it on the first occasion. By leaving

the door unopened and going to the windows before returning and

opening the said door they chose the wrong option and probably lost the

opportunity to save a life or lives.

11.0 Falsification of Alexandria Police Station diary concerning the

issuing of teargas device

11.1 On 22nd May 2009 Constable Roogae Rowland, station guard at the

Alexandria police station, made diary entry no. 26 in the station diary at

5.55 p.m., recording Government property in a strong pan in his

possession. He "checked and accounted for," items, including firearms

with their serial numbers and ammunition, and "Eight tear smoke

canisters ... " (Exhibit 18)

He also recorded, as diary entry no. 29, at 8:00 p.m. the receipt of the

report from Armadale and entry no. 30 at 8:00 p.m., the dispatch of

Woman Cpl. Dunkley and Cons. Burrell to Armadale. (Exhibit 18)

On 23rd May 2009 Cons. Rowland, by diary entry no. 2 at 8:00 a.m.

recorded that he handed over duties to Cons. Wisdom, as station guard,

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and Government property, including, firearms with serial numbers and

ammunition and also,

"Eight (8) tear smoke canisters." (Exhibit 18)

He said that he counted them. There were seven (7) but he wrote "eight"

and it was a "honest mistake."

11.2 Constable Wisdom by diary entry no. 3 at 8:00 a.m. on 23rd May 2009

recorded receiving from Cons. Rowland, firearms, stating their serial nos.

and ammunition, and also, inter alia,

" ... eight tear smoke canisters ... " (Exhibit 18)

11.3 Cons. Rowland said, in evidence, that on 22nd May 2009 at 8:00 p.m.

Cons. Burrell requested a tear smoke booming ball and a baton and he

handed them to him and,

"Woman Cpl Dunkley could have heard and seen."

He did not record the issue of the canister to Cons. Burrell, because he did

not remember and he was busy with telephone calls and the radio. He

said that Woman Cpl. Dunkley later telephoned and asked for Cons.

Wisdom neither did he record that request in the diary. He said that

Cons. Burrell returned to the station between 8:00 p.m. and midnight and

asked him for Cons. Wisdom - neither, did he not record that fact in the

station diary.

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Cons. Rowland, in answer to me, said that when Cons. Burrell came back

to the station he,

(i) did not come inside the guard room

(ii) he did not ask for Cons. Wisdom

(iii) he parked the motor vehicle for a few seconds at the gate of

the station and Cons. Wisdom was standing at the gate and

(iv) Cons. Burrell took Cons. Wisdom whom he Cons. Rowland saw

go into the vehicle with Cons. Burrell.

No entry of all this was made in the station diary. This latter answer is

in contradiction of his ~arlier evidence that Cons. Burrell asked him for

Cons. Wisdom. This also contradicts Cons. Burrell's evidence that he

Cons. Burrell did not see Cons. Wisdom at the station. W /Cpl. Dunkley's

evidence is that Cons. Burrell returned to Armadale alone.

I find that Cons. Rowland is an untruthful witness. Both in respect of his

answers concerning Cons. Wisdom and by his falsification of entry no. 2

on 23rct May 2009 that he handed over "Eight (8) tear smoke canisters",

well knowing that he had handed one canister to Cons. Burrell on the

night of 22nct May 2009.

11.4 Cons. Wisdom also falsified the station diary. In evidence he said, that,

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(i) on 22nct May 2009 at 6:00 a.m. he physically counted eight

teargas canisters and at 6:00 p.m. he handed over station

guard duties to Cons. Rowland;

(ii) on 23rd May 2009 at 8:00 a.m. he made a diary entry no. 3

(Exhibit 18) that he received "eight tear smoke canisters"

but he had not counted them - because he saw no entry

that any had been issued. This was at least reckless, not

caring whether or not it was true.

(iii) On 22nct May 2009 he had received a call from W/Cpl.

Dunkley, but he did not go to the Alexandria police station

until about 10:00 p.m. He did not see Cons. Burrell and did

not go into a motor vehicle at the gate of the police station

and leave with Cons. Burrell. He thereby contradicted Cons.

Rowland's evidence on these matters.

Cpl. Donovan Campbell, said that, as supervisor; he checked the

Alexandria police station strong box on 23rd May 2009 at 12:30 p.m. and

saw seven (7) teargas canisters. Cons. Rowland told him that he had

issued a teargas device to Cons. Burrell. He said he spoke to Sergeant

Heath about the conflict. Cpl. Campbell gave evidence at the Enquiry on

26th August 2009 and he said that up to then there was no entry in the

station diary of the issue of the teargas device to Cons. Burrell on 22nd

May 2009.

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11.5 The significance of the entry "Eight (8) teargas canisters" in the station

diary is, that it confirms that the teargas device issued to Cons. Burrell by

Cons. Rowland was a teargas canister and not a teargas han-ball or

"bombing ball" as he Cons. Burrell describes it. The fact that it was a

canister would be supported by the child evidence of the witness M.M.

which I accept, and who said,

"I ... on the floor ... looked at the thing thrown ... army

green in colour round not like ball ... like a bottle -

Tropical Rythms . .. Red Stripe Bottle." (Emphasis

added)

Further confirmation of the teargas canister is provided by the evidence of

the tests by Asst. Commissioner Robinson who said that "for the grenades ,

[the canisters] every time we saw flames exiting as they initiate" but not

so with the han-balls tested. Child witness S.G. saw "sparks drop out," on

initiation.

I find that Cons. Burrell never had a black rubber han-ball or any

"bombing ball" at all. Nothing was "hooked to his shirt", as he claims.

12.0 Evidential effect of the entry "canisters" in the station diary

The station diary is a book in which should be faithfully recorded by

police officers, all activities, events and reports, items of government

property and at times, prisoner's property, in relation to or affecting the

particular police station. The particular entry in the diary by a police

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officer may be used to support or to discredit his testimony; it is not

however a public document (see R v White v Jones (1976) 15 JLR 20).

Oral evidence cannot be used to "vary, add to or subtract from" the

contents of the diary, it being a document.

I reject, as untrue, and evidentially invalid, the oral evidence of Cons.

Wisdom, that on 22nd May 2009 there were "seven canisters and one

black bomb." He wrote "eight teargas canisters" (Exhibit 18). Equally,

invalid is Cons. Rowland's oral evidence that Cons. Burrell requested and

he handed him a "bombing ball". Cons. Rowland wrote in the station

diary that he received "Eight tear smoke canisters."

Alphanso Heath, Sergeant of Police and sub-officer at the Alexandria

police station, obligingly, said,

" ... there is a difference between a cylinder and a

round-like ball."

but, inexplicably, he volunteered,

"We do not differentiate ball from canister, call

everything canister. (Emphasis added)

That latter statement defies common sense and rational reason.

W/Cpl. Dunkley, who displayed commendable compassion and patience in

dealing with the girls on her arrival at Armadale, sullied her credibility

somewhat, in giving evidence, when she was recalled on 25th August 2009

and said,

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"Entry 26 - (22. 5. 09 5:55p.m.] I recorded in the

station diary eight tear smoke canisters . . . did a

physical check ... there were seven of the can ones and

one bumming ball ... canisters ... silver and a light

'greenish colour ... the ball black." (Emphasis added)

I do not accept that there was any other than as she wrote, "eight tear

smoke canisters." Sgt. Campbell said " ... to write down canister and

mean bombing ball, sometimes we make mistakes".

It plainly defies common sense that the police officers at the Alexandria

police station, would routinely, all, choose to record a "ball" as a "canister"

in the diary. A "canister" is cylindrical and metallic and a "ball" is spherical

and of rubber. The police officers at the Alexandria police station, in that

respect, did themselves no credit. Their futile accounts in sta'ting verbally

that there was a han-ball, thereby attempting to cover-up the use of the

flame-emitting teargas canister, put ·at grave risk the evidential

presumption of omnia praesumuntur rite esse acta, "all official acts are

deemed to have been properly done." They failed in that respect.

Woman Cpl. Dunkley, was further discredited, in her testimony -

(i) On 28th July 2009 when she gave evidence, she was asked,

"Q .... the first time you know anything about any

teargas bombing ball .. was after the fire was

all over? (Emphasis added)

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A. Yes."

(ii) On 25th August 2009 when she was recalled, to give evidence

she was asked by me,

"His Lordship: So when you were leaving the

station at 8 o'clock you did not

know that he [Cons. Burrell] had

requested a bombing ball?

A: I saw it in the vehicle whilst we

were going to Armadale but I did

not know if it was there before or

that cons. Burrell had

requested it." (Emphasis added)

This latter answer, in direct contradiction of her former answer on 28th

July 2009, was disappointing, but not surprising, in the circumstances. It

was an attempt to a cover-up, an untruth. I reject her testimony on that

point.

This confirmed my view that Cons. Burrell did not have the teargas

canister when he was leaving the Alexandria police station at 8:00 p.m. on

22nd May 2009. He had not asked for it then nor was it given to him then

by Cons. Rowland.

Cons. Burrell had left Armadale hurriedly and returned to the police

station, quickly requested and obtained a teargas canister and returned

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with it to the Armadale facility on the second occasion, openly, to

"chastise" the girls. The girls saw him with it, on that occasion.

Further confirmation of this is found in the fact that Woman Cpl. Dunkley

said that she had sent Cons. Burrell to the police station to pick up Cons.

Wisdom. She said, in evidence in cross-examination, that on her way to

Armadale she telephoned Cons. Wisdom, but "did not get through to him/'

He telephoned her whilst she was at Armadale and she told him what was

happening and asked him to return to the station to assist. He said he

was "ten minutes away." She told him that she would send Cons. Burrell

for him. She said,

"I told him [Cons. Burrell] to go and pick up Mr.

Wisdom because he said he was near to the station, so ;

by the time he left Armadale he would have reached

the station." (Emphasis added)

Cons. Burrell, in evidence said,

I went to the Police Station but Constable Wisdom was

not there. As a result I went back to Armadale ...

within five minutes or less."

The questions that arise are,

(i) Why did Cons. Burrell not wait, even briefly, for

Cons. Wisdom who was "near to the station" and by

then "would have reached the station"?

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(ii) Why did Cons. Rowland say that he saw Cons.

Burrell stop the motor vehicle at the police station

gate and he saw Cons. Wisdom, who was at the

gate, go into the motor vehicle and leave with Cons.

Burrell?

(iii) Why was it on his return to Armadale, Cons. Burrell

said nothing to Woman Cpl. Dunkley about not

seeing Cons. Wisdom, nor did she enquire of him?

Cons. Wisdom said that on 22nd May 2009,

"I went back to the station about 10:00 o'clock when I

received a call from Woman Corporal Dunkley."

I find that Cons. Burrell did not leave Armadale for the purpose of picking

up Cons. Wisdom. If that had been the purpose he would have waited at

least, for a few minutes for Cons. Wisdom who "was near to the station"

or telephoned him. He would also on return to Arma.dale, have reported

to Woman Cpl. Dunkley, his senior officer, the fact that he did not find

him.

In my view Cons. Burrell, impatient with the cursing and boisterous

behaviour of the "bad pickney dem" and convinced that "Talk can't help",

left Armadale with the express purpose to return to the station for a

teargas canister. He obtained it within the station from Cons. Rowland,

returned to Armadale and without any compassion or thought for the

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health or safety of these young girls or their means of exit, activated and

threw the teargas canister through the front window and into the Office

dormitory. This caused panic and chaos within the dormitory, and

discomfort, harm and ultimately the death of some of the girls in the

dormitory. This was quite an irrational, harsh, unnecessary and unlawful

conduct on his part.

I would recommend that the relevant statements, notes of evidence and

my report be forwarded to the Director of Public Prosecutions for

consideration whether or not his conduct gives rise to any criminal acts.

It is of note that Section 26 of the Offences Against the Person Act reads,

"26. Whosoever shall unlawfully and maliciously

administer to, or cause to be administered to or taken

by any other person, any poison or other destructive or

noxious thing, with intent to injure, aggrieve, or annoy

such person, shall be guilty of a misdemeanour, and,

being convicted thereof, shall be liable to be imprisoned

for a term not exceeding three years, with or without

hard labour." (Emphasis added)

Section 25 concerns such an act which, committed "with intent to

endanger life or to inflict upon such person any grievous bodily harm"

creates a felony - See R v Cunningham [1957] 2 Q.B. 396; 41 Cr. App.

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R. 155. In that case the appellant broke off and stole a gas meter and its

contents in a house, unknowingly fracturing the gas main and caused coal

gas to seep next door. The gas was inhaled by the occupant causing her

life to be endangered. The appellant was convicted but succeeded in the

Court of Criminal Appeal because of a misdirection by the trial judge.

In addition, Cons. Burrell's action may have been negligent. See Rigby v

Chief Constable of North Hampshire [1985] 1 WLR p. 1242, a

judgment of Taylor J. at first instance, to which Messrs. Hamilton, Q.C.,

and Batts, Attorneys-at-law referred me. The defendant a police officer

was held liable in negligence for damage caused to the plaintiff's shop and

goods by a fire caused by a C S gas canrster thrown by the police creating

a known fire risk without ensuring the presence and availability of fire

fighting equipment.

Asst. Commissioner Robinson testified that the effect of the teargas

smoke was a severe irritation of the eyes causing streaming and a burning

sensation of the eyes and nose, as well as choking and coughing, and can

cause vomiting. There was ample evidence of its adverse effect on the

occupants of the Office dormitory .

. 0 Further scientific evidence of the presence of C S teargas

The scientific evidence of witnesses, Mrs. Tanya Kerr and Mr. Fitzmore

Coates, along with the evidence of the tests conducted by Asst.

Commissioner Robinson and the eyewitness accounts, confirm that the

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teargas device thrown into the Office dormitory by Cons. Burrell on 22nd

May 2009 was a C S teargas canister. "C S" is the designation for

chlorobenzalmalononitrile, the main ingredient of C S teargas.

Mrs. Kerr, possesses a B.Sc. degree in Chemistry and Physics (UWI), MPhil

degree in Physics (UWI), Certificate in Analytical Chemistry from VERIFIN,

University of Helsinki, a research institute, Certificate in Fire Investigation,

University of Strathclyde, Scotland, and other certificates in forensic

science and related topics.

On 3rd June 2009 she received from Det. Sgt. Thomas, nine (9) sealed

envelopes containing, inter alia, the clothing of the five (5) girls) who had

been found lying on the floor of the dormitory after the fire and had been

pronounced dead at Armadale. Sgt. Thomas had received the' clothing on

29th May 2009 at the Spanish Town Hospital morgue from Dr. E. Seshaiah,

the Consultant Forensic Pathologist who !:lad performed the post mortem

examination on each.

Mrs. Kerr conducted tests on each set of clothing. She placed the clothing

with charcoal strips in a nylon bag which was then heated, and the strips

were then placed into a GCMS machine (gas chromatography mass

spectrometry). The machine revealed, and the analyst Mrs. Kerr

concluded that, extracted from each set of clothing onto the said strips,

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was a light hydrocarbon accelerant. There were not enough peaks shown

on the machine to identify the hydrocarbon as gasoline. She said,

"It looks similar to the characteristic pattern of

gasoline, however, some of the peaks were

characte~istic, but there weren't enough characteristic

peaks for me to positively identify it [as gasoline]."

Gasolene, she said, is made up of a series of hydrocarbons, and so

burning or evaporation will reduce some of the hydrocarbons. The

collecting and storing of the samples, after a fire, are important. The

presence of hydrocarbons in an ignitable liquid "diminishes as time

progresses."

Mr. Coates, who had gone to Armadale shortly after the fire on 23rd M~y

2009, drained the water from the room and took several samples. From

the tests conducted at the Forensic Laboratory, he found on the samples

which he numbered 7 and 8 "the presence of gasoline, a highly flammable

hydrocarbon accelerant".

Mrs. Kerr found on the clothing of the deceased girls Rochelle King and

Shaunnalee Kerr, which clothing were in envelopes marked "D" and "J"

respectively, and subjected to the GCMS test, the presence of compounds,

(a) 4 chlorobenzealehyde and

(b) 2 ethylhexylcyanoacetate

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respectively. These are two different compounds each resulting from the

degradation of 2 chlorobenzalmalononitrile, which is C S teargas. She

explained that when heat is applied to C S teargas or with hydrolysis, that

is, exposure to moisture, such as water, "... you can have a

rearrangement in the chlorine compounds in the C S ... " causing the

degradation of the C S teargas into the two compounds she found,

namely, 4 chlorobenzealdelyde and 2 ethlyhexylcyanoacetate ..

The seven (7) teargas canisters that Asst. Commissioner Robinson took

from the Alexandria police station on 27th August 2009 were, six (6) CS

canisters manufactured in 1980 by Smith & Wesson and the seventh was

a C N canister manufactured by Defense Technology Federal Laboratories.

The C S canisters were old, rusty and in poor condition with "much of the '

blue paint outer coating flaked off".

Mr. Coates, who was also trained in fire tnvestigation and certification at

Strathclyde University, Scotland, on testing a sample of water, sample no.

4, taken near the seat of the fire near the front window, found a

compound called chloroacetophenone. This is the breakdown product of

C N teargas. Questioned, he said that he would not rule out C S but he

found C N.

Mrs. Kerr explained that the C S teargas structure represented chlorine on

a ring and when intense heat or moisture is applied, there is a shift on the

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ring, causing the degradation of C S into the compounds that she found.

C N is not on that ring but can be found on a branch extending from that

ring. Therefore, she said, with some other chemical interaction the

breakdown product of C N, chlorocetophenone, could be produced from C

S teargas. Although it is difficult and unlikely that chlorocetophenone

could be formed from C S teargas it was possible, said Mrs. Kerr.

Mr. Coates found chlorocetophenone. However, the evidence of, the

description of the canister" like a Tropical Rhythms bottle, Red Stripe

bottle," and the flame and sparks seen when it was thrown into the room,

and the flame emitted on initiation, characteristic of the test done by Asst.

Commissioner Robinson on the C S teargas canister, rules out, in my view,

the presence of any "han-ball," device used, as claimed by Cons. Burrell.

On the contrary, it confirms the discharge of the C S teargas canister into

the Office dormitory on that fateful night emitting flame and sparks which

started the fire.

Where any conflict arises in this respect I accept the evidence of Mrs. Kerr

in preference to that of Mr. Coates.

14.0 Negligent treatment by non-examination of the five (5) girls.

On 22nd May 2009 Friday night at about 10:00 p.m., Dr. Campbell, having

been summoned, went to the St. Ann's Bay Hospital. She observed girls,

some with burns, screaming and crying ~ she treated them. Some were

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admitted and two (2) were sent to the Kingston Public Hospital. Having

spoken to Mrs. Spence-Jarrett, Dr. Campbell arrived at Armadale between

1:00 a.m. to 2:00 a.m. on 23rct May 2009. The bodies were brought out

to her then, from the Office dormitory and placed on the grass outside.

She pronounced dead, Rochelle King, Ann marie Samuels, Shaunnalee

Kerr, Kaychell Nelson and Nerissa Gooden. All the bodies, except that of

Nerissa Gooden, were in the state of rigor mortis, (stiffness), which occurs

three (3) hours after death and showed corneal clouding (of the eyes)

which occurs two (2) hours after death.

Nerissa Gooden's body which Dr. Campbell examined at 3:00 a.m. was

flacid, (no rigor mortis) and her eyes were clear. The conclusion is that

she died less than two (2) hours before 3:00 a.m.!!

Nerissa Gooden was probably alive up to 1 :00 a.m. With diligence on the

part of the several personnel at Armadale, she could have survived. Dr.

Campbell conceded that she was not a pathologist and therefore there

may have been other factors involved. She was of the view that the

burns she saw were not serious enough to cause death. Death may have

been caused by smoke inhalation, suffocation or trampling.

District Officer Robinson of the Brown's Town Fire Department went into

the Office dormitory, having put out the fire. He entered and with the aid

of a flash light, he saw the five (5) bodies on the floor near the back

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window. He did not examine the bodies, nor did any other person from

his department do so. He had received, at training school, instructions in

first aid. But, curiously, stated that it is not normal to ascertain whether

or not a victim at a fire requires first aid. This is because, he said " ... we

have an Emergency Medical Service ... we don't have that facility in St.

Ann." He said that the other reason why he did not examine the bodies

was,

"because at the time we get the fire call and the time

we reach there, the time it took us to control the fire,

you know, anybody in that building suppose to die ...

the bodies were motionless." (Emphasis added)

This in my view, was an unprofessional and negligent approach to victims

of a fire. It was a wrongful assumption that may have caused a loss or a

further loss of an opportunity to save a life or lives. Mr. Robinson said

that he got the call at Brown's Town at 8:53 p.m. arrived at Armadale at

about 9: 15 p.m. and had the fire under control in about "ten to fifteen

minutes." The Cummings Funeral Home personnel arrived at Armadale at

about 10:30 p.m., waited about "an hour and a half" while a police officer

videographed the scene and thereafter they removed the bodies from the

dormitory, onto the grass outside. Dr. Campbell examined the bodies as

they were brought out of the dormitory to her between 1:00 a.m. to 3:00

a.m.

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Deceased Nerissa Gooden was probably alive when Mr. Robinson saw the

bodies at about 9:30 p.m. on 22nd May 2009. With diligence, urgent

attention and some degree of "first aid" examination, she, probably, could

have survived.

15.0 Postmortem examination and cause of deaths.

15.1 On the 29th May 2009 postmortem examinations were performed by Dr.

Ere Seshaiah, Consultant Forensic Pathologist at the Spanish Town

Hospital morgue, on the bodies of,

(1) Shaunnalee Kerr, 15 years old

(2) Kaychell Nelson, 15 years old

(3) Ann marie Samuels, 16 years old

(4) Rochelle King, 16 years old

(5) Nerissa King, 16 years old

The cause of death in each case was given, tersely)1 as "due to burns"

(See Exhibits 43 - 47).

On 30th June 2009 postmortem examination were performed by Dr. S. N.

Prasad Kadiyala, Consultant Forensic Pathologist, on the bodies of,

(6) Georgina Saunders, 16 years old and

(7) Stephanie Smith, 17 years old (see Exhibits 48 and 49)

The cause of death in each of the latter two cases was due to

(a} Sepsis and (b} flame burns.

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Both girls had been transferred to the Kingston Public Hospital where,

after some days, they died.

In all the circumstances, I feel compelled to make some observations and

recommendations, which I hope may assist.

16.0 Observations and recommendations

(1) The housing accommodation in the Office dormitory,

from its inception, was grossly inadequate, overcrowded,

cramped and unhealthy and its adjacent sanitary

conveniences, insufficient and unhygienic.

Housing decisions for children "deprived" of their

liberty in such institutions -

(a) should be made to conform with international

standards, namely the Beijing Rules and the

1990 Rules and the National Building Code of

Jamaica, and

(b) should be decided by a committee established in

the Department of Correctional Services, in

consultation with the management staff of the

particular institution. It should not be imposed

arbitrarily, as was done in the instant case;

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( c) specialist and professional advice should be

employed in the provision of secure but

comfortable housing facilities for juveniles in

detention. Emphasis should be placed on means

of "unobstrusive observation" of the juveniles

within the facility and safe, speedy evacuation,

in the event of an emergency. The technology is

available.

(2) The Montpelier facility, currently, a potentially

wasting asset, has been available to the

Department, since 2006, incurring a costly monthly

maintenance and unutilized.

Montpelier should be repaired immediately, with

appropriate fixtures, as a comfortable facility for

children. Our youth deserve no less, if the true and

sincere object of institution life is the "welfare of the

child" and the aim is "to return the girls to society

better than when they come in".

The girls housed in the Office dormitory ranged

from hostile ones, who had committed violent or

anti-social offences, to those who were merely

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deemed to be "in need of care and protection." The

latter were bullied and cowed.

(3) Girls should be classified according to the cause

of their detention, and only housed in groups

separated according to the similarity of their

categorization.

Rule 28 of the 1990 Rules read, B-e ', · ·

"28. The detention of juveniles should only take

place under conditions that take full account of

their particular needs, status and special

requirements according to their age, personality,

sex and type of offence, as well as mental and

physical health, and which ensure their protection

from harmful influences and risk situations. The

principal criterion for the separation of different

categories of juveniles deprived of their liberty

should be the provision of the type of care best

suited to the particular needs of the individuals

concerned and the protection of their physical,

mental and moral integrity and well-being."

See also Rules 27, 29 and 30.

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Jamaica wishes to be seen as a respected and

modern state in the international community. In

that regard we should avoid "lip service" only and

always adhere to and pay sincere respect to each

international treaty and convention to which we are

a signatory.

( 4) Children "in need of care and protection" as defined

in section 6 and section 8 of the CC&P Act are in

essence, children susceptible to abuse and also

devoid of the essential basic support and control of

a parent or guardian. Such a child, in my view, is

not necessarily one in respect of whom a

correctional order ought to be made, placing him or

her in a Correctional Centre. . "Correctional" is a

misnomer, in the case of the Armadale facility as

operated in May 2009. About six (6) such girls were

in Armadale then (see Exhibits 38). Sections 7 and

14 of the CC&P Act contemplate that, "the

Government agency responsible for children," the

Child Development Agency (''the CDA'') have an

ongoing involvement in the case of such children "in

need of care and protection" This was not evident

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in the Enquiry held by me, nor did such an Agency

appear or contribute to the Enquiry. The CDA is

responsible for children's homes and places of

safety. But because of lack of space some children

remandees are sent to the correctional centres.

That is unwise. As classified, they do not belong

there and that practice should be discontinued.

Listening to the evidence of some of these girls, at

the Enquiry, confirmed this, in my view.

Mrs. Spence-Jarrett, at the meeting on 31st January

2007, advised that whenever such children are

placed in the correctional institution they become

the responsibility of the Department of Correctional

Services. She observed that "CDA never usually

follow up." (See Exhibit 26)

It seems to me that the CDA has failed to

understand and to grasp and discharge its

responsibility to children under the provisions of the

CC&P Act.

The Children's Court should be mindful of the

provisions of section 14 of the CC&P Act, and utilize

in the best interest of the child, other prescribed

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- -- -----

orders, namely, guardianship order, fit person order

or supervision order by a probation and after care

officer, in preference to a correctional order, where

possible.

(5) "Lockdown" as a form of punishment is inherently

unjust - being the collective punishment of

everyone for the errors of a few, the proverbial

"good suffering for the bad. ,,

It must be -r

discontinued. (:· / 6" I , /~,.r·,,,

(a) Academic -studies, conducted by suitably

qualified teachers in the subject matter must

be provided, and not curtailed because of,

punishment. I note that the proposal of "a

ratio of one instructor/teacher to fifteen (15)

wards," in memorandum dated 1 st April 2008

(Exhibit 30) from the Commissioner of

Corrections (Major Reece) to Mrs. Mary Clarke,

in response to her queries by letter dated 28th

March 2008, (Exhibit 29), was never

implemented;

(b) only the prescribed form of punishment should

be imposed.

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(6) The level of control by the Commissioner and the

senior management staff of the Department, was

unnecessary, resulted in bureaucratic delays and

created some detriment to Armadale. Mrs. Spence­

Jarrett stated, in respect of a report from Armadale

concerning the seven (7) girls who absconded on ih

May 2009,

"I reminded him (Mr. Hesson) that all

documents were to come to Commissioner and

dispatched from there."

Mr. Anderson, the Property Manager, advised, that

if some things are required at Armadale the

information goes to "the Deputy Commissioner of

Commissioner and then passed to me." He properly

commented that " matters of property

requirements [should] first come to me but our

system [isl sort of different (Emphasis added)

Why should the need for "machete ... file ... rake ... "

as "tools for the grounds men", at Armadale be on

the "Needs lists" as a matter of "outstanding

concern" for discussion at three meetings at Head

Office for periods 14th November 2008 to 31 st

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December 2008 and again for period 1 st January

2009 to 31 st January 2009 and for period 1 st

February 2009 to 2oth February 2009? (See Exhibit

2). A machete, file or rake should have been

bought locally, in St. Ann.

Why was the installation of the grill door to the

room offered by Mrs. Ferreira to relieve the

overcrowding not dealt with locally? Mr. Anderson

said it could be" ... done in a day." Mr. Hesson, said

that he "told ... property manager Neilson Anderson

at Head Office between March to April 2009 no

action ... I did not follow up."

(a) Greater autonomy should be given to the,

management at the institution level, in minor

matters, e.g. installation of a door, instead of

the bureaucratic "micro management" from the

head office.

(b) This retention of control and power "from the

top", in the Department of Correctional

Services, in some operational areas, is counter-

productive and demotivating. A conscious and

reasoned review of the necessity for some of

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the senior posts in the hierarchical structure of

the Department is now necessary. A1•1

(7) A trained medical orderly or a trained nurse in

attendance could have satisfied the problem of

prescribed medications not given to the girls at

Armadale, as identified by Dr. Campbell. Such a

person would in addition be of immense assistance

in identifying early, mental and psychological

problems in between visits, for the attention of the

medical personnel.

(a) A medical orderly or trained nurse is required

to be assigned and resident full time at such

institutions; ' \~

(b) increased visits by medical and psychiatric

personnel, as recommended, should be

implemented. Children, in such institutions,

need them; they are at a vulnerable stage of

their existence.

(8) Members of staff and security personnel reacted in

a confrontational mood from the outset to the

unruly, expletive- filled conduct of the girls instead

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of acting with balance, restraint and understanding

despite that conduct. Despite the views of the male

police officer, force was the least of the options. A

calm but firm approach may have been preferable.

Both Mrs. Shaw-Slack and Miss Gilbert testified that

they received basic training as Correctional Officers,

which did not include any training involved with the

treatment of juveniles. They did however attend a

one-day seminar at Rio Cobre in 2008 which was

concerned with juveniles. That was inadequate.

Dr. Royer-Powe pointed out, in reference to the

Syllabus Outline for the training of Correctional

' Officers, tendered as Exhibit 9, in the evidence of

Mr. Hesson, that,

"... nothing in Exhibit 9 suggests that training in

psychology is to be involved in training Correctional

Officers in dealing with young children."

(a) Training in psychology, anger management,

stress control and counselling in dealing with

young children, should be included in the

syllabus of course of training for Correctional

Officers at juvenile institutions and Probation

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,' ',~J,1 li J; I 'f " ~

Officers./ Th: Bell~;~·: ~~s~ital:1

~~i~h i~, ,a

major psychiatric hospital in Jamaica with its

generous complement of psychiatrists,

psychologists and mental health professionals,

ought to be relied on for an input in such

training.

(b) Correctional officers working for three shifts

consecutively, as occurred irr some cases at

Armadale, should be prohibited. Double shifts

should be discouraged, as far as possible. The

resultant stress and fatigue on such officers is

counter-productive and, disadvantageous both

to themselves and thejuveniles they supervise.

( c) Correctional officers should also be

psychologically re-evaluated periodically, in

order to ensure their continuing suitability for

such posts.

( d) The alleged misconduct in the loan of his

cellular phone to one of the girls by the

Correctional Officer Mr. Wint, should also be

investigated by the Department and

appropriately dealt with.

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(9) The absence of any established procedure in

handling emergencies and the absence of any

standard evacuation procedure in the event of a

fire or other disaster was starkly evident at

Armadale. That accounted for the chaos, wrong

options and confusion that existed at Armadale on

the night of 22nd May 2009,

(a) Regular fire drills, Jnvolving both staff and

juveniles, ought to be conducted by the Fire

Department;' commencing immediately and

thereafter at regular .intervals at all the juvenile

detention centres.

(b)fire extinguishers, in sufficient numbers; J

should. be immediately provided at such

institutions, readily available and should be l

regularly checked and serviced on the I stipulated dates. I

(10) The medical personnel who treated the girls at I Armadale should be commended for their work

and in particular Dr. Campbell who displayed 1

compassion, dedication and a sincere :1

understanding of the needs of the girls. !1

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Expert medical advice given by doctors in respect

of the health and welfare of the girls should be

accepted by administrative officials, seeing that

the latter are not so trained. Mrs. Spence-Jarrett

as Commissioner, was at fault to have rejected

outright, in breach of the statutory provisions, the

request of Dr. Royer-Powe, to remove and isolate

the two troubled girls, one of whom had a "severe

psychiatric problem.,,

(a) Regulations are needed to give to the

Director of Medical Services, the sole

authority to determine, where, due to

medical reasons, particular girls may or may

not be housed.

(b) · An isolation area, as,;~~eiuestedr fq~"r'G!,~t~ptive

juveniles, is urgently required, and must be

provided immediately.· This'~~,wu~~~,.fa©Hitate

~~op~~'~.trteat~nt.

(11) A Board of Visiting Justices exists for the purpose,

of the adult correctional institutions,. under the:

Correctional Institution (Adult Correctional :~;entre}

Rules, 1991, in accorda.nce with section 74 (1) of

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'the Gorred:ionsc:J~.ct. The said regulations provide

a comprehensive set of rules governing the

operations and functions of the adult correctional

centres. Except for sections 47 to 57, (Part V) of

the Corrections Act providing, principally, for the

powers of the Minister in respect of the Juvenile

Correctional Centres, I was unable to find any

corresponding regulations in relation to the

operations and functions of the Juvenile

Correctional Centres. 1 (a) Regulations should be formulated and

brought into force by the Minister, as l authorized by section 81(1) of the' I Corrections Act, to govern the operation and 1 functions of the Juvenile Correctional

Centres. The authorities should consider, I also, reducing into the domestic law of 1 Jamaica, the provisions of the United Nations'

Beijing Rules, and the 1990 Rules for the I

protection of juveniles deprived of their

liberty. It is a simple exercise.

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f'

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(b) A Board of Visiting Justices should also be

appointed specifically for the Juvenile

Correctional Centres in order to perform

statutory functions similar to those performed

in· respect of the adult correctional centres,

for the benefit and welfare of all juveniles.

The emphasis should be on regular visits and

review of facilities and children's views.

(12) The living conditions of the girls in the Office

dormitory for over one year culminating with the

events of the night of 22nd May 2009 must have

had a major traumatic effect on all the survivors.

• The girls, the majority of whom are housed

now at Diamond Crest, should each be

psychologically evaluated and each case

examined with a view to detect any

·consequential damage. The period of

detention of each child should be

proportionately shortened, if so advised.

(13) The Children's Advocate, Mrs. Mary Clarke,

occupying this newly created office since 2006 has

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demonstrated a mature grasp of the

responsibilities of that office as it relates to the

relevant institutions and persons concerned with

the welfare and benefit of children islandwide.

Her office is however somewhat handicapped by

insufficient staff and resources. Her meetings with

Ministers of Government, talks at institutions such

as schools, investigations and annual reports to

Parliament, have not seemed to influence the

problems with children significantly.

a. The staff of the Office of the Children's

Advocate should be increased, particularly,

the investigating officers, with adequate

travelling facilities. Regular visits to the

juvenile institutions, routine examination of

the facilities and interaction with the juveniles

should be effected. This would complement

the Board of Visiting Justices.

b. Her mandate of "protecting and enforcing the

rights of children ... " under section 4 of the

CC&P Act, would be more effective if she was

given enforcement powers by way of judicial

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review in respect of government entities,

which need to be compelled or prohibited in

respect of breaches of their duties to

children. She has the proper approach - give

her the tools!

(14) The police station diary is not a public document,

although official entries are made therein. The

treatment of that document by some officers at

the Alexandria police station was in breach of

settled rules in the Jamaica Constabulary Force

and clearly wrong, by the omissions and false

entries.

(a) The Commissioner of Police should be

requested to notify all sub-officers and police

officers generally, of the significance of

proper and accurate entries and the

importance of supervising its use and its safe

custody. ,:· / ,:; r'{ ,,, \ c~ ... '.: z:_.> c'"';'

(b) The outstanding reports from the police

officers, which were requested by Sergeant

Heath must now be submitted. The police

officers' misconduct concerning the events of

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22nd May 2009 at the police station should be

enquired into and appropriately dealt with, at

least departmentally.

(15) The· Senior Administrators of the Department of

Correctional Services are largely to blame for the

\/ tragedy at Armadale. The "apparent" lack of

knowledge of Mrs. Spence-Jarrett, Mr. Hesson and

Mrs. Johnson of the accommodation, is less thar /

believable and displays an inexcusable breach of

duty. How can Mrs. Johnson explain her visits to

Armadale on 21 st April 2009 when she "did not go

into the dormitory ... went to the doorway" and on ,

7th May 2009 when she "did not go into the

dormitory [she] stand at the entrance?"

There should be a review of the senior posts of

the Department - some may well be superfluous

and unnecessary.

(:~§:)······ e:>;~e~t~W~l~g,·}~tf~~~l';tl~~~.1.e1:;:W~s·~;1f:i;p~jor:;p['Qblem ,/

-Ymeirna~Irnt:Jm·petniissible:.pg'Ji>Ut~tronwas tts ·girls; .

The, , C1Gtu9t p~cupat1g~6 .. Cit:i:tl01~$,,;;; .. was,. ]Q;~,girls.';

Serious consideration should be given to restrict

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the population to the permitted maximum. In that

regard, the Commissioner of Corrections, must

advise herself and be aware, at all times,

whenever the maximum occupancy of a juvenile

institution is attained. The Children's Court should Q_ f.-{) 0'- f --~--~ Cl:

be so advised, and no further correctional orders 1 v s. c- "'' ' , ... , ( • ,~ :/

should be made, to receive a child into the

institution, until a vacancy exists. Legislation is

required to implement this. It will require close

monitoring of all such institutions islandwide and

strict enforcement. '.Note,· ,for· ·example1t> by;'

aA,9logy, ur;ider.,the Criminal Justice. (Reform) Act, "

section 10, a "court shalLnotrnake a cOmmuniqt

service order" unless; ·inter ana, arrangements can;

be made, in a particular -area, for p~rforming work;

and for its proper supervision of a convicted .

offender.

The debacle of Armadale created by some of those persons most

intimately concerned with it, displayed "a hardening of their hearts and a

coarsening of their consciences." Disadvantaged children in an institution,

primarily due at times to errant parents, give us the opportunity, with

compassion, understanding, love, sincerity and genuine humility to rescue

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and help this segment of our youth in the society. Most of us as parents,

have experienced the "rebellion" of our teenage children but our response

is not to abandon them to institution-life, but with controlled caring to

recognize it probably, as an assertion of their emerging individuality. One

solution to our problems in Jamaica, is to commence to build a conscience

- the differentiation between good and bad, right and wrong - in our

children - from the early infant stage. Our children, from early infancy

are the prime nucleus for change to a more mature, caring, humane and

just society, based on good morals. Some persons concerned with

Armadale failed to grasp the opportunity. Undoubtedly, financial

resources were at times unavailable to the Department of Correctional

Services. That should not be a deterrent to humane treatment.

Importantly, "Armadale" must never again occur.

I extend my gratitude to all counsel who appeared, both from the Solicitor

General's Office who marshaled the evidence and counsel who appeared

on behalf of interested persons. They all assisted in this Enquiry. I thank

also the members of the Secretariat, the staff of the Ministry, stenotypists,

the police officers and all persons who submitted statements for use at

the Enquiry. I am grateful also to the personnel at the National Volunteer

Centre who warmly accommodated us during the several days of the

hearing. They all contributed to the smooth progress of the proceedings.

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Dated this 15th day of January 2010

Paul Harrison, OJ., C.D., Commissioner

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List of ~lii6its

Exhibit 1 Diagrammatic plan of Armadale Juvenile Correctional Youth Centre Compound with buildings (DVD disc attached)

Exhibit 2

Exhibit 3

Operational reports re Armadale - period 3oth June 2008 to 2oth February 2009

Letter dated 18th November 2008 from Claudeth Hamilton re fire extinguishers

Exhibit 5 Letter dated 11 th March 2009 from Faydene Ferreira re fire drill

Exhibit 6 List of infractions and sanctions re Armadale

Exhibit 7 Letter dated 20th May 2009 from Faydene Ferreira re absconding wards

Exhibit 8 Memorandum dated lSth November 2006 - rededication of Cottage dormitory

Exhibit 9 Syllabus of training course at Carl Rattray College for Correctional Officers

Exhibit 10 Photographs (81 prints) on DVD disc - Armadale facility after fire on 22nd May 2009 (DVD disc attached)

Exhibit 11 Minutes of meeting - 24th November 2007 - Department of Correctional Services

Exhibit 12 Statement of Kerry-Ann Wilson - detainee

Exhibit 13 Memorandum dated 26th May 2007 from Neilson Anderson re condition of buildings at Armadale

Exhibit 14 Engineer's report from Michael Clarke re condition of buildings at Armada le

Exhibit 15 Extract from National Building Code (Jamaica) 1983 edition

Exhibit lSA Extract from National Building Code (Jamaica) 1992 2nd Edition

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Page 131: Teh Full 2010 Armadale Report

it 16 Extract from National Building Code (Jamaica) 1983 edition - re sanitary facilities

·it 17 Extract from National Building Code (Jamaica) 1983 edition re escape and exits

1it 18 Diary entries numbers 26 - 31 dated 22nd May 2009 and numbers 1 - 10 dated 23rd May 2009 - Alexandria police station

>it 19 Two (2) detonated CS teargas grenade han-ball-experiment 14th August 2009 (with police)

)it 20 One (1) detonated C N teargas canister - experiment 26th August 2009 (with police)

:>it 21 One (1) detonated C N teargas canister - experiment 26th August 2009 (with police)

bit 22 Chart by analyst Coates of Office dormitory after fire

bit 23 C D disc - pictures of Armadale - taken 23rd May 2009 (DVD disc attached)

ibit 24 Letter dated 12th June 2009 re inspection at Armadale by Jamaica Fire Brigade, St. Ann

ibit 25 Diagram of office building and Office dormitory by Assistant Supt. Rowe

ibit 26 Minutes of meeting dated 31 st January 2007 between Children's Advocate and Department of Correctional Services officials

1ibit 27 Minutes of meeting dated 24th September 2007

1ibit 28 Minutes of meeting dated 23rd October 2007 at Medallion Hall Hotel

1ibit 29 Letter dated 28th March 2008 from Children's Advocate re draft Cabinet submission

libit 30 Letter dated 1 st April 2008 from Commissioner of Corrections re draft Cabinet submission

1ibit 31 Minutes of meeting dated 31st March 2009 - discussions re children

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Exhibit 32 One (1) detonated CS teargas canister - experiment on 28th August 2009 (with police)

Exhibit 33 Memorandum dated 1 ih June 2005 from Commissioner of Corrections and reporting of incidents

Exhibit 34 Extracts from 2007 Department of Correctional Services Report -tables 25, 26 and 27

Exhibit 35 Book of rules - wards code of conduct - Juvenile Correctional Centres

Exhibit 36 Memorandum dated 24th July 2006 from Deputy Commissioner Custodial Services

Exhibit 37 Minutes of meetings - Population Reduction - held in 2008

Exhibit 38 List of girls at Armadale on 22nd May 2009, and particulars.

Exhibit 39 Letter dated 29th May 2009 from Director of Medical Services

Exhibit 40 DVD disc of Han-ball demonstration on 14th August 2009 (DVD disc attached)

Exhibit 41 DVD disc of C N teargas canister demonstration on 28th August 2009 (DVD disc attached)

Exhibit 42 DVD disc of C S teargas canister demonstration on 28th August 2009 (DVD disc attached)

Exhibit 43 Postmortem examination report of Rochelle King

Exhibit 44 Postmortem examination report of Shaunna-lee Kerr

Exhibit 45 Postmortem examination report of Nerisa Gooden

Exhibit 46 Postmortem examination report of Ann Marie Samuels

Exhibit 47 Postmortem examination report of Kaychelle Nelson

Exhibit 48 Postmortem examination report of Stephanie Smith

Exhibit 49 Postmortem examination report of Georgiana Saunders

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