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

13.20 One of the mental health nurses is responsible for work within the segregation
unit and is covered by another team member in her absence. Another nurse, who may
be a general nurse, attends the segregation unit at the weekend.
13.21 Ms Crowther comments in her statement that Dr Wright advised that a
therapeutic alliance between prisoner and health professionals should be adopted in the
segregation unit. Ms Crowther says:
“At Manchester, using the approach that we have, a rapport and trust is built up between
patients on the segregation unit and the nurse attending daily. This enables her to liaise
with the staff and the Listeners to identify problems. Her priority is the mental health of
the prisoner in the segregation unit. She has no discipline interest, and is there for
continued care when the prisoner leaves the segregation unit.”
13.22 In addition, Ms Crowther told the inquiry that since January 2007 the prison has
held medical records electronically. This means that they can be accessed by authorised
staff at computer terminals in all clinical areas and a business case had been put forward
to extend this to the segregation unit. Ms Crowther commented that everything was now
documented in one place, there had been no incidents of lost records or documents,
there was no problem interpreting handwriting and entries could be audited. Clinical staff
attending the segregation unit were no longer dependent on finding the hard copy
Inmate Medical Record. The record could be checked beforehand at any authorised
terminal or could be accessed by telephoning a member of staff with direct access.
Consideration
13.23 Current Prison Service requirements on prisoners’ fitness for adjudication and
cellular confinement provide that assessments should not now be made without
consulting information from records and that no prisoner should be placed in segregation
unless the segregation safety assessment has been completed. Both these new
measures, introduced since 1998, might have helped to protect Sonny Lodge.
Findings and recommendation
13.24 Drawing on Dr Wright’s advice,
I find that
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There was a systemic failure in the assessment of fitness for adjudication and
cellular confinement in that it was made without reference to any history or prior