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

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and additional expense might have been avoided if I had asked the Minister to consider converting the inquiry as soon as there were indications that a key witness was reluctant to cooperate. 2.38 The note on investigation procedure that I adopted after consultation with the interested parties is at Annex 2 to the report. In devising procedures that would serve the purposes of the terms of reference and be fair to all concerned, I found that the Inquiries Act 2005 and the Inquiry Rules 2006 provided a helpful guide. However, at that point, I had not contemplated that the investigation might be converted to a statutory inquiry and there were some respects in which the investigation procedure I adopted differed from the statutory rules. For example, the procedure did not specify that witnesses who might be subject to criticism would necessarily be sent confidential warning letters, nor that there was a presumption that documentary evidence would be available to members of the public as well as the interested parties. These inconsistencies caused some complications in the final stages of the inquiry. Those who conduct future ad hoc inquiries might find it helpful to have regard to the possibility of conversion to a statutory footing when devising procedures. 2.39 An independent investigator requires discretion to pursue inquiries in the way that he or she finds appropriate to the particular case. I have therefore decided not to make recommendations about procedure but rather certain observations about lessons I learned during the inquiry: 2.40 Observations about inquiry procedure The need to compel a key witness to give evidence caused additional delay and expense. Those who conduct similar investigations in future may wish to seek conversion to a statutory inquiry at an early stage if there are indications of a lack of cooperation from witnesses such that compulsive powers may be required. The Inquiries Act 2005 and the Inquiry Rules 2006 provide a helpful guide to procedures that are fair to all parties. Those who conduct similar investigations in future may wish to refer to them in devising procedures. Where there is a possibility that an investigation may be converted to a statutory inquiry, it is desirable to avoid disparities between the procedures applying to the nonstatutory stage and those that apply in the event of conversion. 17
18 In inquiries of this kind it may be appropriate for the bereaved family to be offered an opportunity to speak briefly in person as part of the closing procedures immediately before the final legal submissions, provided that it is understood that new allegations and evidence cannot be introduced at that stage.
Page 1 and 2: Report of the Inquiry into the circ
Page 3 and 4: Crown Copyright 2009 The text in th
Page 5 and 6: Reports from HM Prisons Inspectorat
Page 7 and 8: The report makes 48 findings but on
Page 9 and 10: CONTENTS PART ONE: WHAT LED TO THE
Page 11 and 12: viii
Page 13 and 14: Chapter 1 SONNY LODGE AND AN OUTLIN
Page 15 and 16: denied the charge. He admitted push
Page 17 and 18: and to Sonny’s wing. A health car
Page 19 and 20: was not aware of Sonny’s history
Page 21 and 22: The Court said that any failure to
Page 23 and 24: structure the inquiry’s considera
Page 25 and 26: 2.25 At the hearings, the solicitor
Page 27: or recognition. Their actions may b
Page 31 and 32: Chapter 3: RISLEY: 15 TO 26 JUNE 19
Page 33 and 34: 0820 Appeared to be OK when unlocke
Page 35 and 36: Chapter 4: THE INCIDENT AT WHISTON
Page 37 and 38: admitted pushing the officer and ga
Page 39 and 40: Officer Brownley’s injury 4.20 Dr
Page 41 and 42: was required to resume wing duties
Page 43 and 44: would not be a problem. He said he
Page 45 and 46: Chapter 5: 27 JUNE TO 9 JULY 1998:
Page 47 and 48: continued assessment and recording
Page 49 and 50: 4 July 0630 1650 1930 5 July 0630 1
Page 51 and 52: Table 3 40 9 July 1335 1400 1609 17
Page 53 and 54: point on the history sheets kept on
Page 55 and 56: working prison occupied mainly by c
Page 57 and 58: privileges over and above the facil
Page 59 and 60: the actual memory of many of its st
Page 61 and 62: with officers in the kitchen for go
Page 63 and 64: H wing: 25 July to 1 August 7.37 In
Page 65 and 66: 7.48 On Sunday 16 August, an entry
Page 67 and 68: Chapter 8: SUNDAY 23 AUGUST TO THE
Page 69 and 70: Wing officer 8.8 Officer Sanderson
Page 71 and 72: chaplains to see him. Ms Lorimer to
Page 73 and 74: Thursday morning 8.21 Captain Palme
Page 75 and 76: 9.5 Officer Downs told the inquiry
Page 77 and 78: visit before time and that there wa
Page 79 and 80:
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
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fact that, as he sees it, injustice
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that it was made at all. However, i
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forcefully, but for prison staff, i
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Chapter 20: THE SEARCH AND THE INCI
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However, like the various reports o
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Chapter 21: THE ADJUDICATION AND PU
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21.4 PSO 2000, which came into effe
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21.13 In order to find the charge a
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Chapter 22: COMMUNICATIONS AND RECO
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opportunity when the senior officer
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prompted special protection. Conseq
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Manchester prison now 23.4 In evide
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Safety 23.13 I have described in pa
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ehaviour, achievements, interaction
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prison. Many prisoners carry a host
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PART FOUR FINDINGS, RECOMMENDATIONS
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Information was not always recorded
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opportunities for social interactio
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41 Governor McColm did not explore
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LIST OF RECOMMENDATIONS I have exer
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LIST OF OBSERVATIONS ABOUT INQUIRY
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ANNEX 1 TERMS OF REFERENCE 1 1. To
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9. Communications and record-keepin
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helpful. The chronology will not fo
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Notice of matters requiring explana
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ANNEX 3 LIST OF LEGAL REPRESENTATIV
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PSI Prison Service Instruction PSI
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