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

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Discharge report This is to be completed by a doctor when a prisoner is discharged from healthcare and returned to a residential unit. Daily supervision and support record This says that the purpose is to report on the prisoner’s mood and behaviour and all ongoing action taken to help the prisoner. It includes reporting on the implementation of the support plan decided at a case review and involvement by outside agencies and family. 14.9 When an F2052SH form was closed, the residential unit manager was to sign the form off and the file was placed in the prisoner’s personal record. The personal record is held in the prison’s central administration unit not on the residential wing. The system now: Assessment, Care in Custody and Teamwork (ACCT) 14.10 The F2052SH system has been replaced since the events detailed in this report. Implementation of the new policy was phased over 2005-2008. The new system drew on the experience of operating the F2052SH procedure and research on suicidal and selfharming behaviours, including a four-year project (the Safer Locals Programme) about the particular problems in Local Prisons (like Manchester), where large numbers of remand and sentenced prisoners spend short periods of time. PSO 2700 Suicide Prevention and Self-Harm Management, as revised and reissued in October 2007, set out the national policy. References below are to the current edition of PSO 2700. 14.11 Certain features of the new policies are of particular relevance to the case of Sonny Lodge. Statement of purpose The policy gives instructions on identifying prisoners at risk of suicide and selfharm and caring for them but it also places “considerable emphasis on reducing risk by ensuring all prisoners (whether identified at risk or not) receive individual support in managing any problems” (PSO 2700 Statement of Purpose, page 8). Among the goals of the policy is “reduction in distress and improved quality of life for all who live and work in prisons” (PSO 2700 Desired Outcome, page 8). 113
114 Prison culture The policy states that research evaluating the Safer Locals Programme found that suicide prevention was most effective when prison culture had the following characteristics: “staff felt valued, communication was good, prisoners felt safe and there were good staff relationships with senior managers, who were approachable and supportive. In contrast, some prisoners had a ‘traditional’ or negative culture, where staff relied on overuse of authority, distanced themselves from prisoners, and expressed distrust between uniformed and specialist staff groups. The quality of care for prisoners in these prisons was reduced.” (PSO 2700, paragraph 2.1.1) Staff-prisoner relationships Staff are advised that prisoners emphasised the value of having a member of staff listen to them and take their problems seriously. Interviews with suicidal prisoners confirmed that staff who took time to help them were appreciated. Several prisoners who had attempted suicide talked about how they wanted staff to “talk to them and engage with them, not just to observe them” (PSO 2700, paragraph 2.2.1). Change of status prisoners Reception staff are required to ensure that they talk with prisoners who have had a change of status. Local procedures must make provision for prisoners who have had a change of status without leaving the prison to undergo the equivalent of a ‘reception screen’ to assess risk of suicide or self-harm (PSO 2700, paragraph 4.8). Positive regimes and purposeful activity Positive regimes are defined as: “…those which enable prisoners to engage in activities which reduce distress and potentially reduce rates of suicide and self-harm, for example through improving mood and increasing coping skills and self-esteem. Potentially helpful activities include work, education, structured programmes, art and exercise.” (PSO 2700, paragraph 5.1.1)
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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
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7.48 On Sunday 16 August, an entry
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Chapter 8: SUNDAY 23 AUGUST TO THE
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Wing officer 8.8 Officer Sanderson
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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
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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 and 116: Chapter 13: ISSUES RAISED IN THE CL
Page 117 and 118: Changes to assessing fitness 13.10
Page 119 and 120: 13.20 One of the mental health nurs
Page 121 and 122: Chapter 14: SAFEGUARDS AGAINST SUIC
Page 123: Meeting the prisoner’s needs. Thi
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
Page 167 and 168: Chapter 21: THE ADJUDICATION AND PU
Page 169 and 170: 21.4 PSO 2000, which came into effe
Page 171 and 172: 21.13 In order to find the charge a
Page 173 and 174: 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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