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

this was either not read or prompted no concern, even though Sonny was
going into segregation.
The inquiry has not established who completed the conduct report for the
adjudication. It refers to the entries for infringements on the wing but not to
the entry from 27 July about a serious act of self-harm, even though the
history sheets were only four pages long.
15.17 Staff who were responsible for Sonny Lodge in the segregation unit and at the
adjudication did not know of his history of self-harm nor his girlfriend’s fears for his life.
Sonny showed distress during the adjudication, but we are told this was not to an
unusual degree. It says something about the environment and its impact on prisoners if
tearfulness among grown men in adjudications was not unusual.
What if an F2052SH had been opened?
15.18 What if an F2052SH had been opened on Tuesday or Wednesday? Sonny would
have come to the attention of the senior officer coming on duty at the start of a shift. It
seems unlikely that he would have been singled out for loss of association and
searching in the way that happened. Or, if he had been, staff would have been alert to
the need to check his welfare. Officer Bowcock would surely not have berated Sonny
Lodge about the rules if he had known that he was identified as at risk of suicide. It
seems unlikely that there would have been cause for Sonny to be placed in segregation
or charged under the Prison Rules but, if there had been, those who were charged with
his care would have taken special precautions.
15.19 If an F2052SH had been opened in the healthcare centre on Thursday as a result
of the entry in the medical record, segregation staff and the medical officer would have
been aware of it, and it is unlikely Governor McColm would have placed Sonny in cellular
confinement.
Would the current system make a difference?
15.20 It is instructive that Sonny Lodge committed a serious act of self-injury the day
after the first F2052SH was closed, and seemingly a dangerous offence with a staple
gun only four days after the closure of the plan at Manchester. Both demonstrate the
value of the period of further review after the closure of a care plan – what the Governor
of Manchester called a ‘parachute period’. The ACCT system has introduced this.
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