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

and between staff and prisoners) in supporting prisoners. This was supported by the
research report, which the Guide said found, among other things, that the risk of suicide
and self-harm
“...could be reduced by a range of ‘protecting agents’ including supportive and helpful
staff, constructive activities, family contact, action against bullying and involvement of
outside agencies such as Samaritans”
and that
“Above all the vulnerable prisoner needed listening and understanding.”
14.5 Key features of the guidance were the F2052SH procedure and the Suicide
Awareness Team. The F2052SH procedure is named from the reference number of the
Self Harm at Risk Form in use at the time. IG 1/1994 says that:
“A Self Harm At Risk Form (F2052SH) will be raised in any case where a prisoner is
identified by any member of staff as requiring special care due to possible risk of suicide
or self-harm.” (IG 1/1004, Part 3, paragraph 2.2(a))
A Suicide Awareness Team was to be formed in every prison to lead and monitor care
for prisoners at risk.
14.6 There have been changes since 1998. The Guide was replaced in 2002 by
Prison Service Order (PSO) 2700 Suicide and Self-Harm Prevention. The system was
changed again in 2005, building on lessons drawn from experience and research. The
F2052SH has been replaced by a new procedure which is called ACCT (Assessment,
Care in Custody and Teamwork) and is described below. The current edition of PSO
2700 dates from October 2007 and is called Suicide Prevention and Self-Harm
Management.
The system in 1998: F2052SH
14.7 The F2052SH form was an orange booklet. Its distinctive colour made it clearly
visible among the other papers in a prisoner’s personal record. The front cover states
prominently, “This form may be raised by any member of staff who is concerned about a
prisoner.” Guidance for staff covers:
Identifying the prisoner’s needs by listening to the prisoner and showing concern.
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