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

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Chapter 20 The search and the incident in the cell (2): further consideration and findings Chapter 21 The adjudication and punishment 156 Chapter 22 Communications and record-keeping 162 Chapter 23 What has changed at Manchester Prison 167 PART FOUR: FINDINGS, RECOMMENDATIONS AND OBSERVATIONS ABOUT INQUIRY PROCEDURE 152 176 List of findings 177 List of recommendations 184 List of observations about inquiry procedure 186 ANNEXES 187 1 Terms of Reference 188 2 Note on procedure 191 3 List of legal representatives 196 4 Acronyms and references 197 vii
viii
Page 1 and 2: Report of the Inquiry into the circ
Page 3 and 4: Crown Copyright 2009 The text in th
Page 5 and 6: Reports from HM Prisons Inspectorat
Page 7 and 8: The report makes 48 findings but on
Page 9: CONTENTS PART ONE: WHAT LED TO THE
Page 13 and 14: Chapter 1 SONNY LODGE AND AN OUTLIN
Page 15 and 16: denied the charge. He admitted push
Page 17 and 18: and to Sonny’s wing. A health car
Page 19 and 20: was not aware of Sonny’s history
Page 21 and 22: The Court said that any failure to
Page 23 and 24: structure the inquiry’s considera
Page 25 and 26: 2.25 At the hearings, the solicitor
Page 27 and 28: or recognition. Their actions may b
Page 29 and 30: 18 In inquiries of this kind it ma
Page 31 and 32: Chapter 3: RISLEY: 15 TO 26 JUNE 19
Page 33 and 34: 0820 Appeared to be OK when unlocke
Page 35 and 36: Chapter 4: THE INCIDENT AT WHISTON
Page 37 and 38: admitted pushing the officer and ga
Page 39 and 40: Officer Brownley’s injury 4.20 Dr
Page 41 and 42: was required to resume wing duties
Page 43 and 44: would not be a problem. He said he
Page 45 and 46: Chapter 5: 27 JUNE TO 9 JULY 1998:
Page 47 and 48: continued assessment and recording
Page 49 and 50: 4 July 0630 1650 1930 5 July 0630 1
Page 51 and 52: Table 3 40 9 July 1335 1400 1609 17
Page 53 and 54: point on the history sheets kept on
Page 55 and 56: working prison occupied mainly by c
Page 57 and 58: privileges over and above the facil
Page 59 and 60: the actual memory of many of its st
Page 61 and 62:
with officers in the kitchen for go
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H wing: 25 July to 1 August 7.37 In
Page 65 and 66:
7.48 On Sunday 16 August, an entry
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Chapter 8: SUNDAY 23 AUGUST TO THE
Page 69 and 70:
Wing officer 8.8 Officer Sanderson
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chaplains to see him. Ms Lorimer to
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Thursday morning 8.21 Captain Palme
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9.5 Officer Downs told the inquiry
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visit before time and that there wa
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ecollection of the incident and mus
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9.34 Mr Bowcock was asked about the
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Chapter 10: AFTER THE SEARCH: THE I
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and now they’re doing three years
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Mr Lodge’s account of the inciden
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HCOs advised staff to loosen their
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punishment for the altercation in t
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82 The diagnosis of dissocial pers
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11.6 Back in the chaplains’ offic
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take his clothes off for a search a
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Subsequent statements to the Prison
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Evidence to the inquiry SO Knight 1
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going to happen to him. She was als
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11.53 In his final letter to his gi
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Chapter 12: ISSUES RAISED IN THE CL
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should not routinely be used. But i
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impulsivity; difficulty forming rel
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any underlying paranoid illness as
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Chapter 13: ISSUES RAISED IN THE CL
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Changes to assessing fitness 13.10
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13.20 One of the mental health nurs
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Chapter 14: SAFEGUARDS AGAINST SUIC
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Meeting the prisoner’s needs. Thi
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114 Prison culture The policy stat
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14.16 “Prisoners who are at risk
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Closing a Plan 14.25 The form says
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14.36 In oral evidence to the inqui
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CHAPTER 15: PREVENTING SUICIDE AND
Page 135 and 136:
mind in the last week of his life i
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colleague to see Sonny Lodge on Thu
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15.21 ACCT also requires a risk ass
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Chapter 16: THE INQUIRY’S CONSIDE
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Despite these findings, there is in
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16.17 The inquiry was told that pri
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Chapter 17: TRANSFERS, WING AND CEL
Page 149 and 150:
punishment, there is no evidence th
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held safely; Respect - prisoners ar
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Chapter 18: WAS SONNY LODGE VICTIMI
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surgeon at Whiston Hospital found S
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fact that, as he sees it, injustice
Page 159 and 160:
that it was made at all. However, i
Page 161 and 162:
forcefully, but for prison staff, i
Page 163 and 164:
Chapter 20: THE SEARCH AND THE INCI
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However, like the various reports o
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Chapter 21: THE ADJUDICATION AND PU
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21.4 PSO 2000, which came into effe
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21.13 In order to find the charge a
Page 173 and 174:
Chapter 22: COMMUNICATIONS AND RECO
Page 175 and 176:
opportunity when the senior officer
Page 177 and 178:
prompted special protection. Conseq
Page 179 and 180:
Manchester prison now 23.4 In evide
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Safety 23.13 I have described in pa
Page 183 and 184:
ehaviour, achievements, interaction
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prison. Many prisoners carry a host
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PART FOUR FINDINGS, RECOMMENDATIONS
Page 189 and 190:
Information was not always recorded
Page 191 and 192:
opportunities for social interactio
Page 193 and 194:
41 Governor McColm did not explore
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LIST OF RECOMMENDATIONS I have exer
Page 197 and 198:
LIST OF OBSERVATIONS ABOUT INQUIRY
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ANNEX 1 TERMS OF REFERENCE 1 1. To
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9. Communications and record-keepin
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helpful. The chronology will not fo
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Notice of matters requiring explana
Page 207 and 208:
ANNEX 3 LIST OF LEGAL REPRESENTATIV
Page 209 and 210:
PSI Prison Service Instruction PSI
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