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

There was an entry in the G wing observation book for 25 August about Ms A’s
telephone call. No one followed it up to see whether Sonny Lodge was still
feeling all right.
SO Nuttall did not read the observation book when coming on duty but relied on
the outgoing senior officer to tell him anything of note.
There was no entry in Sonny Lodge’s history sheets about Ms A’s concern so
once he left the wing the staff on his new unit had no record of it.
The chaplain who visited Sonny Lodge on Wednesday did not share her concern
for Sonny with wing staff and did not record the nature of Ms A’s concern; there
was no plan for the chaplains to continue to support Sonny Lodge after Thursday
morning.
22.15 In a large prison with a changing population, care for prisoners means that
consistent use of records is a crucial proxy for consistent relationships. Protecting
prisoners from suicide and self-harm cannot rely on one-off judgments made in isolation.
It is a process. Judgments may need revising in response to changing circumstances or
new information.
22.16 The Prison Service says there is no overarching prison policy document about
record-keeping and communications but within each policy there are relevant
requirements, for example, the completion of Use of Force Forms and in ACCT.
Findings and recommendation
22.17 I find that:
Use of Force and Injury to Inmate forms should have been completed on two
occasions and were not.
On 27 August 1998, loss of association and search records were not completed
in accordance with the required procedures.
22.18 I repeat in part the finding in Chapter 15
Information was not always recorded so that it was available to others. Where
information was available in the IMR, the escort records, the observation book
and the history sheets it was either not referred to when, reasonably, it should
have been, or it was not taken into account, when, reasonably it ought to have
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