put on an anti-rip gown. She replies that she should not be there at all, as she does not intend to harm herself. One of the four officers who were party to the incident described in an incident report the chain of events as follows: “I instructed the prisoner again to remove her t-shirt and she refused. She continued to talk over me and was not listening to instructions. Staff used non-threatening physical contact to assist her [to change] but then she became physically resistant. Spontaneous use of force was applied to continue changing prisoner xx into a gown. I had the right arm. Officer xx had her left arm, and officer xx had control of the head. Prisoner xx continued to be non-compliant. Prisoner was offered another opportunity to remove her pants, but the prisoner did not reply. Officer xx assisted with the removal of her bottoms and was successful. Prisoner was escorted to her cell and was locked with no further issues.” It is hard to imagine how four officers restraining and forcibly undressing a distressed woman in order to dress her in a gown ‘for her own protection’ could possibly be seen to be conducive to the woman’s wellbeing or to the development of a healing relationship with staff. And yet, Incident Information Reports analysed by this review indicated that this was not a one-off occurrence. In another incident, involving a woman sent from the Receiving Office to the ISU as she was deemed to be at risk, a similar chain of events unravelled. On arrival at the ISU, the woman was placed in a strip cell and told to remove her clothes. One of the four officers involved described what happened next. “Upon arrival at the ISU she became non-compliant and refused to take her clothes off and change into a gown. She finally removed her top and bra and put on the gown but refused to remove her pants. Staff instructed xx to move from the strip room to her allocated cell. Once in the cell, I instructed xx to remove her pants and underwear. She did so after much abuse towards staff. Her behaviour became worse as she announced she had her period. When officer xx instructed her to remove her hair tie, she stood in front of her and then spat in her face. Spontaneous use of force was used, and the hair tie was removed. I took her right arm, officer xx had her left arm, officer xx took the head and officer xx had her legs as the prisoner was resisting. Staff exited the cell with no further issues.” This incident again involved four officers, struggling with one woman, in this case for the purpose of removing her hair-tie, aggravating what was clearly an already tense situation. 42