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

Information was not always recorded so that it was available to others.
Where information was available, in the Inmate Medical Record, 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 it ought to have prompted special
protection (paragraph 15.24).
8 If information had been shared properly, an F2052SH would have been opened.
This would have altered the course of events and would probably have prevented
Sonny Lodge taking his life when he did (paragraph 15.24).
9 The current arrangements for safeguarding prisoners against suicide and self
harm represent a significant advance on the F2052SH system. I note in
particular: the care planning approach, the emphasis on interaction, not
observation, and on identifying and responding to specific individual need; the
tapering of special support after a plan is closed; the requirement that concerns
expressed by people outside the prison are systematically assessed (paragraph
15.24).
10 The best defence against suicide in prison is a positive prison culture which
values prisoners as complex individuals, pays heed to the concerns of prisoners’
family and friends, offers practical support with prisoners’ problems and
recognises that what a prisoner says to a stranger is not a sufficient way of
assessing prisoners’ distress (paragraph 15.24).
The incident at Whiston Hospital
11 At the time of the incident at Whiston Hospital, there was in existence a rumour
that Officer Brownley would engineer an assault by a prisoner and Governor
Williams spoke to Officer Brownley about it (paragraph 16.8).
12 At the time of the incident at Whiston Hospital, Officer Brownley had a pending
appeal against refusal of an application for a transfer to Manchester prison
(paragraph 16.8).
13 Despite these findings, there is insufficient evidence to conclude, on the balance
of probabilities, that the incident in the toilet cubicle was premeditated or
contrived (paragraph 16.8).
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