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

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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
0820 Appeared to be OK when unlocked for breakfast 1215 Lying on bed. Seemed OK 1120 Nurse called to a fit. Care given. …Calmed down and an inmate who knows him put in his cell over dinner 2100 Spoke to inmate. Seems to be alright 2135 Called by cellmate. Having a fit. Initial care then nurse attended 2140 Nurse’s entry. Attended to Lodge. Appeared to recover normally from fit. Observations satisfactory. Mattress placed on floor. Windows opened. 2205 Got back into bunk by himself 2300 Sitting on bed eating 18 June 0010 Seems to be asleep 0530 Appears to have slept alright 0650 Seems OK at commencement of shift 1150 Seen by probation officer, chaplain and PO on a Review Board: [detailed entry about place on education and clarification of release date.] 1700 Collected tea. Seems fine. 1955 In bed at bang-up 2100 Seen at start of duty. No problems 19 June 0600 Appears asleep. No problems through the night 0640 Inmate appears asleep. No problems 1540 Sat on bed. Appears OK. 2045 Called by cellmate. Having a fit. Nurse [and senior staff] attended. 20 June 0600 Rang bell at 0145 asking for medication. Night Orderly Officer attended. Medication refused as had had all his entitlement. Slept well after this. 0700 Asleep at roll check 1600 No problems on…[illegible] 2100 Seen. OK 21 June 0600 Slept most of the night. No problems. 0700 Appeared to be asleep. 2000 Appeared to be OK at lock up. 22 June 0600 Appears to be asleep at roll check 22 0645 Appears asleep 1215 Checked. No problems
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 and 28: or recognition. Their actions may b
Page 29 and 30: 18 In inquiries of this kind it ma
Page 31: Chapter 3: RISLEY: 15 TO 26 JUNE 19
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
Page 81 and 82: 9.34 Mr Bowcock was asked about the
Page 83 and 84:
Chapter 10: AFTER THE SEARCH: THE I
Page 85 and 86:
and now they’re doing three years
Page 87 and 88:
Mr Lodge’s account of the inciden
Page 89 and 90:
HCOs advised staff to loosen their
Page 91 and 92:
punishment for the altercation in t
Page 93 and 94:
82 The diagnosis of dissocial pers
Page 95 and 96:
11.6 Back in the chaplains’ offic
Page 97 and 98:
take his clothes off for a search a
Page 99 and 100:
Subsequent statements to the Prison
Page 101 and 102:
Evidence to the inquiry SO Knight 1
Page 103 and 104:
going to happen to him. She was als
Page 105 and 106:
11.53 In his final letter to his gi
Page 107 and 108:
Chapter 12: ISSUES RAISED IN THE CL
Page 109 and 110:
should not routinely be used. But i
Page 111 and 112:
impulsivity; difficulty forming rel
Page 113 and 114:
any underlying paranoid illness as
Page 115 and 116:
Chapter 13: ISSUES RAISED IN THE CL
Page 117 and 118:
Changes to assessing fitness 13.10
Page 119 and 120:
13.20 One of the mental health nurs
Page 121 and 122:
Chapter 14: SAFEGUARDS AGAINST SUIC
Page 123 and 124:
Meeting the prisoner’s needs. Thi
Page 125 and 126:
114 Prison culture The policy stat
Page 127 and 128:
14.16 “Prisoners who are at risk
Page 129 and 130:
Closing a Plan 14.25 The form says
Page 131 and 132:
14.36 In oral evidence to the inqui
Page 133 and 134:
CHAPTER 15: PREVENTING SUICIDE AND
Page 135 and 136:
mind in the last week of his life i
Page 137 and 138:
colleague to see Sonny Lodge on Thu
Page 139 and 140:
15.21 ACCT also requires a risk ass
Page 141 and 142:
Chapter 16: THE INQUIRY’S CONSIDE
Page 143 and 144:
Despite these findings, there is in
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 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 and 208:
ANNEX 3 LIST OF LEGAL REPRESENTATIV
Page 209 and 210:
PSI Prison Service Instruction PSI
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