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

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ANNEX 4 ACRONYMS AND REFERENCES ACCT Assessment, Care in Custody and Teamwork. This is the name of the current Prison Service policy to protect prisoners against suicide and self-harm. AG Advice to Governors F2052A Record of Events. Part of an individual prisoner’s record. Commonly known as ‘history sheets’. It is held on the residential unit where the prisoner is based. F2052SH Self harm at risk form F213 Injury to Inmate record form HMP Her Majesty’s Prison HMCIP Her Majesty’s Chief Inspector of Prisons HMCIP 1996 HMP Manchester: Report of a Full Announced Inspection by HM Chief Inspector of Prisons, Home Office, London HMCIP 1998 HMP Manchester: Report of an Unannounced Short Inspection, Home Office, London HMCIP 2002 Report on a Full Announced Inspection of HM Prison Manchester 11-21 November 2001 by HM Chief inspector of Prisons IEP(S) Incentives and Earned Privileges (Scheme) IG Instruction to Governors IG 1/1994 Caring for the Suicidal in Custody IG 79/1994 Caring for the Suicidal in Custody (additional guidance) IMR Inmate Medical Record PDM 1995 The Prison Discipline Manual that was issued in 1995. It was replaced in 2006 by PSO 2000 (see below), in force from January 2006 PO Principal Officer 197
PSI Prison Service Instruction PSI 18/2005 Introducing Assessment, Care in Custody and teamwork – the replacement for the F2052SH PSO Prison Service Order PSO 1700 Prison Service Order on Segregation PSO 2000 Prison Service Order on Adjudications PSO 2700 Suicide Prevention and Self-Harm Prevention (2002 edition) 198 Suicide Prevention and Self Harm Management (2007 edition) PSO 4000 Prison Service Order on Incentives and Earned Privileges Scheme RMN Registered Mental Health Nurse SO Senior Officer Standing Order 4 Prison Service Standing Order on Facilities
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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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Despite these findings, there is in
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16.17 The inquiry was told that pri
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Chapter 17: TRANSFERS, WING AND CEL
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punishment, there is no evidence th
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held safely; Respect - prisoners ar
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Chapter 18: WAS SONNY LODGE VICTIMI
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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 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: ANNEX 3 LIST OF LEGAL REPRESENTATIV
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