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

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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 (paragraph 23.34). 183
LIST OF RECOMMENDATIONS I have exercised restraint in making recommendations. 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 of this inquiry and decide for themselves whether there are further lessons to be drawn. Mental health care in segregation units 1 I recommend that the Prison Service urges all prisons, in conjunction with their local primary care trust, to provide dedicated mental health care for segregation units (paragraph 13.25). Access to Electronic Medical Information System (EMIS) in segregation units 2 I recommend that Electronic Medical Information Systems (EMIS) in prisons incorporate provision for clinical staff to have confidential access to medical information at a terminal in the segregation unit (paragraph 13.25). Disclosure of information to the police 3 I recommend that the Prison Service considers issuing further guidance on disclosure in cases where the police are investigating allegations of assault involving prisoners and prison staff (paragraph 16.21). 4 In particular, I recommend that where the Prison Service declines to investigate possible misconduct by staff because of a related police investigation, there is a presumption that information that would have been material to a conduct investigation should be disclosed to the police (paragraph 16.21). Circulation of reports 5 I recommend that the Prison Service ensures that reports into the circumstances of a death in prison are brought to the attention of all the establishments mentioned in the report’s findings or conclusions so that any appropriate action can be taken and any lessons learned (paragraph 16.21). Adjudications and use of force 6 I recommend that the Prison Service advises adjudicators to consider examining use of force statements in any adjudication where force has been used following an incident of alleged assault (paragraph 21.17). 184
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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
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mind in the last week of his life i
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colleague to see Sonny Lodge on Thu
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15.21 ACCT also requires a risk ass
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Chapter 16: THE INQUIRY’S CONSIDE
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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 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: 41 Governor McColm did not explore
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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