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

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Recommendations 16.21 I recommend that: the Prison Service considers issuing further guidance on disclosure in cases where the police are investigating allegations of assault involving prisoners and prison staff. In particular, where the Prison Service declines to investigate possible misconduct by staff because of a related police investigation, I recommend that there is a presumption that information that would have been material to a conduct investigation should be disclosed to the police. I recommend that the Prison Service ensures that reports into the circumstances of a death in prison are brought to the attention of all the establishments mentioned in the report’s findings or conclusions so that any appropriate action can be taken and any lessons learned. 135
Chapter 17: TRANSFERS, WING AND CELL MOVES, AND THE WING BASED DISCIPLINARY SYSTEM Introduction 17.1 The inquiry examined: the reasons that Sonny Lodge was frequently moved, the regimes he experienced and whether these may have contributed to his vulnerability to suicide and/or self-harm; the impact of the wing-based disciplinary system on Sonny Lodge and whether this may have contributed to his vulnerability to suicide and/or self-harm. Consideration 17.2 After induction, Sonny Lodge was based in E, H, K and G wings during his period at Manchester. After the alleged assault on G wing on 27 August he spent the night in the segregation unit. 17.3 Dr Wright, the clinical adviser to the inquiry, suggested that cell moves might have contributed to instability for Sonny Lodge. Referring to the theory that attachment to a social setting and a place contributes to mental health and a sense of well-being, Dr Wright said that removal from a setting that has become familiar can present a challenge to psychological health. 17.4 SO Nuttall and the Governor of Manchester indicated that the number of moves experienced by Sonny Lodge was not unusual for a short-term prisoner in a local prison where the establishment is juggling high turnover of prisoners to and from the courts. In their view, short-term prisoners do not become attached to their cells in the way longterm prisoners do. That may well be so, as a matter of degree, but cell moves, especially to share a space designed for one prisoner and with an unscreened toilet, with yet another, usually unchosen, cellmate must be one of the unpleasant experiences of prison. According to Sonny Lodge’s cellmate on G wing, he asked for Sonny to share his cell because they were friends outside. If that is the case, the arrangement suggests a kindness by a member of staff. Moving from E wing 17.5 The inquiry has found no evidence that the moves were malicious. The move from E wing resulted from an adjudication in which Sonny Lodge was given a severe 136
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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
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Thursday morning 8.21 Captain Palme
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9.5 Officer Downs told the inquiry
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visit before time and that there wa
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ecollection of the incident and mus
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9.34 Mr Bowcock was asked about the
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Chapter 10: AFTER THE SEARCH: THE I
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and now they’re doing three years
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Mr Lodge’s account of the inciden
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HCOs advised staff to loosen their
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punishment for the altercation in t
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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 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: 16.17 The inquiry was told that pri
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
Page 175 and 176: opportunity when the senior officer
Page 177 and 178: prompted special protection. Conseq
Page 179 and 180: Manchester prison now 23.4 In evide
Page 181 and 182: Safety 23.13 I have described in pa
Page 183 and 184: ehaviour, achievements, interaction
Page 185 and 186: prison. Many prisoners carry a host
Page 187 and 188: PART FOUR FINDINGS, RECOMMENDATIONS
Page 189 and 190: Information was not always recorded
Page 191 and 192: opportunities for social interactio
Page 193 and 194: 41 Governor McColm did not explore
Page 195 and 196: 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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