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

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practicable, Dr Wright said that he understood that current thinking favoured a system that was a compromise between logistics and clinician independence, namely multidisciplinary assessment with input from healthcare and discipline professionals. 13.6 In his oral evidence, Dr Wright enlarged on the role of healthcare in reviewing prisoners held in the segregation unit. He considered that going round a segregation unit spending a few moments at each door, without even a clinical area for further examination was a poor instrument for assessing mental health. Doctors were ”deferred to and defaulted to” but felt vulnerable to unrealistic expectations where they were expected to take clinical responsibility in a setting that was not conducive to making satisfactory judgments. Dr Wright considered this a systemic failure. Dr Wright’s favoured model 13.7 The model Dr Wright preferred was for a dedicated registered mental health nurse to have the segregation unit as part of their responsibility and for that person to be actively care planning, building up therapeutic alliances with prisoners in the segregation unit and working in close collaboration with discipline staff. Dr Wright felt this model had been slow to be adopted, partly because of historic resistance in primary care to considering personality disorder as a treatable condition. Dr Wright stressed the importance of dedicated staff working in the segregation unit, not a rotation of a large number of staff primarily based elsewhere. 13.8 Dr Wright advised that new IT systems meant that it was now possible. in at least some prisons. for healthcare staff in the segregation unit to have access online to medical records. He did not think it was possible to make an accurate assessment of risk without access to records, but reference to records was not a sufficient condition, as the doctor was being asked to make a one-off screening judgment rather than engaging in ongoing assessment through a therapeutic alliance over a period of time. 13.9 In oral evidence to the inquiry, Dr Wright said: “Modern clinical practice in both the drug misuse and mental health fields…is around a strong therapeutic alliance which is based…on an ongoing relationship with an individual in which unconditional positive regard is expressed, and also an environment in which they feel free to disclose their health and social need.” This was the best way to identify risk, to reduce it and treat it. .Dr Wright considered it was achievable in prison but required culture change. 105
Changes to assessing fitness 13.10 There have been changes to the system of assessing fitness for adjudication and segregation since 1998. 13.11 Prison Service Order (PSO) 2000 on Adjudications (in force from January 2006) states that “a list of all those appearing before the adjudicator must be passed to the Healthcare Unit in sufficient time to enable any relevant concerns about individual prisoners to be given to the adjudicator before the start of the prisoner’s adjudication.” (PSO 2000, paragraph 2.25) 13.12 The PSO also stated that the adjudicator “may also wish to take into account” information in any F2052SH or ACCT (PSO 2000, paragraph 2.25). 13.13 PSO 2000 was subsequently amended. The current guidance states: “before any punishment of cellular confinement…is imposed…a medical practitioner or registered nurse must first complete an Initial Segregation Safety Screen and the adjudicator must take account of any medical advice that the punishment is not suitable when making his or her decision.” (PSO 2000, paragraph 7.27A) Among other questions, the Segregation Safety Screen asks: “Has the person selfharmed in this period of custody/are they on an open ACCT OR is the person currently taking any anti-psychotic medicine?” 13.14 Notes on the form say that the screen should be completed after: a discussion with the prisoner reference to the clinical record and any other relevant documentation gathering information from other members of the care team/discipline staff reviewing the nature of the incident which led to segregation being necessary to check for indicators of mental distress. 13.15 PSO 1700 gives instructions on the use of Segregation. PSO 2000 (on Adjudications) advises that a prisoner serving a punishment of cellular confinement is subject to the observational requirements applying when segregated under the provisions of PSO 1700. PSO 1700 says that the segregation screening form should be completed for any prisoner placed in segregation to await adjudication for longer than four hours. 106
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Report of the Inquiry into the circ
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Crown Copyright 2009 The text in th
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Reports from HM Prisons Inspectorat
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The report makes 48 findings but on
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CONTENTS PART ONE: WHAT LED TO THE
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viii
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Chapter 1 SONNY LODGE AND AN OUTLIN
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denied the charge. He admitted push
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and to Sonny’s wing. A health car
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was not aware of Sonny’s history
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The Court said that any failure to
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structure the inquiry’s considera
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2.25 At the hearings, the solicitor
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or recognition. Their actions may b
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18 In inquiries of this kind it ma
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Chapter 3: RISLEY: 15 TO 26 JUNE 19
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0820 Appeared to be OK when unlocke
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Chapter 4: THE INCIDENT AT WHISTON
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admitted pushing the officer and ga
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Officer Brownley’s injury 4.20 Dr
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was required to resume wing duties
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would not be a problem. He said he
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Chapter 5: 27 JUNE TO 9 JULY 1998:
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continued assessment and recording
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4 July 0630 1650 1930 5 July 0630 1
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Table 3 40 9 July 1335 1400 1609 17
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point on the history sheets kept on
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working prison occupied mainly by c
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privileges over and above the facil
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the actual memory of many of its st
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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
Page 67 and 68: Chapter 8: SUNDAY 23 AUGUST TO THE
Page 69 and 70: Wing officer 8.8 Officer Sanderson
Page 71 and 72: chaplains to see him. Ms Lorimer to
Page 73 and 74: Thursday morning 8.21 Captain Palme
Page 75 and 76: 9.5 Officer Downs told the inquiry
Page 77 and 78: visit before time and that there wa
Page 79 and 80: ecollection of the incident and mus
Page 81 and 82: 9.34 Mr Bowcock was asked about the
Page 83 and 84: Chapter 10: AFTER THE SEARCH: THE I
Page 85 and 86: and now they’re doing three years
Page 87 and 88: Mr Lodge’s account of the inciden
Page 89 and 90: HCOs advised staff to loosen their
Page 91 and 92: punishment for the altercation in t
Page 93 and 94: 82 The diagnosis of dissocial pers
Page 95 and 96: 11.6 Back in the chaplains’ offic
Page 97 and 98: take his clothes off for a search a
Page 99 and 100: Subsequent statements to the Prison
Page 101 and 102: Evidence to the inquiry SO Knight 1
Page 103 and 104: going to happen to him. She was als
Page 105 and 106: 11.53 In his final letter to his gi
Page 107 and 108: Chapter 12: ISSUES RAISED IN THE CL
Page 109 and 110: should not routinely be used. But i
Page 111 and 112: impulsivity; difficulty forming rel
Page 113 and 114: any underlying paranoid illness as
Page 115: Chapter 13: ISSUES RAISED IN THE CL
Page 119 and 120: 13.20 One of the mental health nurs
Page 121 and 122: Chapter 14: SAFEGUARDS AGAINST SUIC
Page 123 and 124: Meeting the prisoner’s needs. Thi
Page 125 and 126: 114 Prison culture The policy stat
Page 127 and 128: 14.16 “Prisoners who are at risk
Page 129 and 130: Closing a Plan 14.25 The form says
Page 131 and 132: 14.36 In oral evidence to the inqui
Page 133 and 134: CHAPTER 15: PREVENTING SUICIDE AND
Page 135 and 136: mind in the last week of his life i
Page 137 and 138: colleague to see Sonny Lodge on Thu
Page 139 and 140: 15.21 ACCT also requires a risk ass
Page 141 and 142: Chapter 16: THE INQUIRY’S CONSIDE
Page 143 and 144: Despite these findings, there is in
Page 145 and 146: 16.17 The inquiry was told that pri
Page 147 and 148: Chapter 17: TRANSFERS, WING AND CEL
Page 149 and 150: punishment, there is no evidence th
Page 151 and 152: held safely; Respect - prisoners ar
Page 153 and 154: Chapter 18: WAS SONNY LODGE VICTIMI
Page 155 and 156: surgeon at Whiston Hospital found S
Page 157 and 158: 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
Page 165 and 166: 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
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Chapter 22: COMMUNICATIONS AND RECO
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opportunity when the senior officer
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prompted special protection. Conseq
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Manchester prison now 23.4 In evide
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Safety 23.13 I have described in pa
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ehaviour, achievements, interaction
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prison. Many prisoners carry a host
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PART FOUR FINDINGS, RECOMMENDATIONS
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Information was not always recorded
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opportunities for social interactio
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41 Governor McColm did not explore
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LIST OF RECOMMENDATIONS I have exer
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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
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ANNEX 3 LIST OF LEGAL REPRESENTATIV
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PSI Prison Service Instruction PSI
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