Report of the Inquiry into the circumstances of the Death of Bernard ...

PART THREE
THE ISSUES THE INQUIRY EXAMINED: CONSIDERATION, FINDINGS AND
RECOMMENDATIONS
This part of the report contains the inquiry’s consideration of the evidence, the findings
and some recommendations.
It contains some evidence that has not been set out in the narrative in earlier chapters.
This includes some of the advice the inquiry received from Dr Wright, information about
Prison Service policies and procedures and changes at Manchester Prison, reference to
research findings, and some observations that witnesses made in evidence to the
inquiry.
Findings are based on the balance of probabilities but, in weighing the evidence, I have
also had regard to the principle that the more serious the allegation is, the more cogent
must be the evidence to prove it.
I have made some recommendations but have exercised restraint in doing so. Those
who work in prisons are often best placed to draw lessons from past events and to
devise operational solutions to deficiencies. I hope that the Prison Service and those
who are responsible for healthcare in prisons will consider the findings and decide for
themselves whether there are further lessons to be drawn.
95