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

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hearing) whether the prisoner is in a fit state of health to attend the hearing and, if necessary, to undergo a punishment of cellular confinement (PDM 1995, paragraph 2.15). The final decision as to whether an accused is fit to face the hearing rests with the adjudicator (PDM 1995, paragraph 2.17). Prisoners serving a punishment of cellular confinement will be observed by an officer at least once an hour and will be visited daily by the chaplain. The 1995 manual states that the medical officer will visit daily to assess the physical, emotional and mental well-being of the prisoner and will note on the prisoner’s medical record whether or not s/he remains fit to continue undergoing the punishment (PDM 1995, paragraph 7.24). An accused may be guilty of an assault if, without applying unlawful force, s/he intentionally or recklessly causes another person to fear the application of immediate unlawful force (PDM 1995, paragraphs 6.4 and 6.5). The test for an attempted offence is that the accused did an act which was more than merely preparatory to the commission of the intended offence and intended to commit the full offence (PDM 1995, paragraph 6.74). Charges under the Prison Rules must be proved beyond reasonable doubt (PDM 1995, paragraph 7.1). The adjudicator must ensure that a record of proceedings is taken down on form F256, which may be required for a formal review of the hearing. It need not be a verbatim transcript but it must record the essence of the case and indicate how the adjudicator pursued the inquiry. If the person is found guilty it should be clear from the record why the adjudicator rejected any defence put forward (PDM 1995, paragraph 4.23). Changes to the system for adjudications since 1998 21.3 Since 1998 the jurisdiction of governors to determine offences under the Prison Rules has been reduced, following the case of Ezeh and Connors v UK (European Court of Human Rights; 2003 Application Nos. 39665/98 and 40086/98). The Court found that the applicants’ right to a fair trial under Article 6 of the European Convention was breached in adjudications in which governors imposed added days in prison of 40 and 7 days respectively. 157
21.4 PSO 2000, which came into effect in January 2006, has replaced the Prison Discipline Manual. In any case in which the adjudicating governor considers that a charge if proved could warrant punishments of additional days in prison they must adjourn the hearing and refer the case to an Independent Adjudicator appointed by the Lord Chancellor. Changes to assessing fitness for adjudication and cellular confinement 21.5 There have also been changes to the system of assessing fitness. These are described above in paragraphs 13.10 to 13.16. Consideration 21.6 It was clear to the inquiry that, even though many years have now passed, Governor McColm is still painfully aware that it was his decision to place Sonny Lodge in segregation. He has not sought to minimise his involvement and it was evident from his oral evidence that he has searched memory and conscience to consider whether he might have acted differently. In his opening statement to the inquiry, Counsel for the family said: “From the written evidence, it seems clear that Governor McColm had Sonny’s best interests in mind and was concerned about allowing him to return to the normal wing….” I agree. In relating how he made his decision to impose cellular confinement rather than another punishment, Governor McColm has repeatedly said that Sonny Lodge’s well-being was at the forefront of his mind. I recognise that Governor McColm was motivated by his judgment of where Sonny Lodge would obtain the best care. However cellular confinement is a punishment and the Prison Service now recognises that isolation increases vulnerability. I welcome the additional risk assessments that are now required before cellular confinement is imposed at adjudication. The investigation of the charge against Sonny Lodge 21.7 Representations have been made that I should consider the adjudication in the context of the approach and standards at the time. I have been reminded that the F256 record of hearing does not claim to be verbatim and that it was unusual for an adjudication to last as long as 20 minutes. I have been told that the length of time and the volume of paperwork generated are unusual, even by today’s standards and that this underlines the level of consideration that Governor McColm gave to the case. I recognise that Governor McColm was an experienced governor who approached the 158
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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
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11.6 Back in the chaplains’ offic
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take his clothes off for a search a
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Subsequent statements to the Prison
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Evidence to the inquiry SO Knight 1
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going to happen to him. She was als
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11.53 In his final letter to his gi
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Chapter 12: ISSUES RAISED IN THE CL
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should not routinely be used. But i
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impulsivity; difficulty forming rel
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any underlying paranoid illness as
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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 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: Chapter 21: THE ADJUDICATION AND PU
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
Page 197 and 198: LIST OF OBSERVATIONS ABOUT INQUIRY
Page 199 and 200: ANNEX 1 TERMS OF REFERENCE 1 1. To
Page 201 and 202: 9. Communications and record-keepin
Page 203 and 204: helpful. The chronology will not fo
Page 205 and 206: Notice of matters requiring explana
Page 207 and 208: ANNEX 3 LIST OF LEGAL REPRESENTATIV
Page 209 and 210: PSI Prison Service Instruction PSI
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