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

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23.33 I list below significant changes in arrangements at HMP Manchester that relate to specific problems in 1998 that have been identified in this report. In some cases Manchester’s arrangements reflect a national policy; in others a local initiative. It is outside the scope of the inquiry to evaluate how far current practice at Manchester prison achieves its aims. That is for those who are responsible for managing and monitoring the prison. Findings 23.34 From evidence given to the inquiry, I note the following significant changes in arrangements at Manchester relating to specific problems identified in this report: In accordance with Prison Service policy on segregation and adjudications, a risk assessment is now conducted before a prisoner is placed in cellular confinement There is a dedicated mental health nurse for the segregation unit at Manchester prison. This accords with good practice as recommended by the clinical adviser to the inquiry. Medical records are held electronically and accessible by authorised clinical staff from terminals, though not yet in the segregation unit. Manchester prison operates the ACCT arrangements which are a significant advance on the F2052SH system. The local policy includes, in particular, a Friends and Family Helpline, systems for responding to concerns about a prisoners, and questionnaires to prisoners after an ACCT plan is closed. The wing based disciplinary system was abolished in October 1999. Full statements of the circumstances are required and reviewed by managers whenever staff restrain a prisoner by force. Recommendation 22.35 I recommend that the Governor of Manchester and his colleagues: - examine each stage of the process of vetting Samaritan volunteers and selecting Listeners to identify and eliminate any avoidable delays - ensure that Listeners can be made available in all locations at any time of day or night - make provision for prisoners to use the Samaritans telephone in private. 175
PART FOUR FINDINGS, RECOMMENDATIONS AND OBSERVATIONS ABOUT INQUIRY PROCEDURE Findings are based on the balance of probabilities but, in weighing the evidence, I have also had regard to the principle that the more serious the allegation is, the more cogent must be the evidence to prove it. I have made some recommendations but have exercised restraint in doing so. Those who work in prisons are often best placed to draw lessons from past events and to devise operational solutions to deficiencies. I hope that the Prison Service and those who are responsible for healthcare in prisons will consider the findings and decide for themselves whether there are further lessons to be drawn. 176
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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
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Changes to assessing fitness 13.10
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13.20 One of the mental health nurs
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Chapter 14: SAFEGUARDS AGAINST SUIC
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Meeting the prisoner’s needs. Thi
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114 Prison culture The policy stat
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14.16 “Prisoners who are at risk
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Closing a Plan 14.25 The form says
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14.36 In oral evidence to the inqui
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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
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: prison. Many prisoners carry a host
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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