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

should be located in shared accommodation, and
should be observed frequently at irregular intervals (the frequency was not
specified).
3.6 The continuous medical record shows an entry for the next day but only about
Sonny’s physical health.
3.7 Sonny was housed in normal location on A wing. The page for initial action by the
residential unit manager was not completed.
3.8 A case review was held on 22 June, attended by a senior officer and two officers.
Sonny said he had spoken with Probation, who had tried to help him. It was decided that
the form should be kept open at least until the next review. The support plan was:
to remain in shared accommodation
to contact Probation.
to attend full-time education classes.
The daily supervision and support record
3.9 During the 11 days that the F2052SH file was open there are 54 entries in the
daily supervision and support record as shown in the table below. I have abbreviated or
clarified some entries. It is not always possible to tell from the entries whether they were
based on passive observation or active interaction. I have highlighted in bold type the
seven entries that clearly indicate some conversation. Nowhere on the form is the
frequency of required observation specified.
Table 1
16June 0600 Appears to have slept all night. No problems
0700 Appears asleep at roll check
1430 Seen on induction…; states does not feel suicidal
but concerned about sentence, warrant and date of
release. Advised…Seems cheerful and happy
enough
1730 Appeared to be OK when unlocked for teatime meal
1745 Appeared to be OK at tea up
2100 Seen at start of duty. Seems OK.
17June 0600 Appeared to have slept all night. No problems
0700 Appears asleep
21