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

41 Governor McColm did not explore the circumstances of the incident sufficiently to
dispose of Sonny Lodge’s counter-allegation against Officer Bowcock (paragraph
21.16).
42 Governor McColm did not explore the circumstances of the incident sufficiently to
find that the charge against Sonny Lodge was proved beyond reasonable doubt
(paragraph 21.16).
.
43 The assessment of Sonny Lodge’s fitness for adjudication and cellular
confinement before the hearing complied with Prison Service policy at the time
but the system of assessing fitness without regard to any history or prior
knowledge was not satisfactory. Current Prison Service policy now requires a risk
assessment, including reference to medical records, before a punishment of
cellular confinement is imposed (paragraph 21.16).
44 After 4.40 in the afternoon on 28 August, when Sonny Lodge was in segregation,
he was not observed at least once an hour as required by the Prison Discipline
Manual (paragraph 21.16).
Communications and record-keeping
45 Use of Force and Injury to Inmate forms should have been completed on two
occasions and were not (paragraph 22.17).
46 On 27 August, loss of association and search records were not completed in
accordance with the required procedures (paragraph 22.17).
47 Information was not always recorded so that it was available to others. Where
information was available in the IMR, the escort records 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 prompted special
protection. Consequently, judgments were made not to open an F2052SH in
ignorance of material facts that ought to have been known (paragraph 22.18).
What has changed at HMP Manchester
48 From evidence given to the inquiry, I note the following significant changes in
arrangements at Manchester relating to specific problems identified in this report:
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