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

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improving social skills and skills for employment. It does not mean isolation, idleness and hostile authority. Nor does it mean “keeping your head down”, as prisoners are often urged to do, if that means not drawing attention to yourself and not bothering the staff. Prison officers who know how to talk to prisoners appropriately can have a profound influence. Constructive engagement between staff and prisoners can save lives. By contrast, lack of fairness and respect increases prisoners’ distress. Much has changed for the better since 1998 in the policies and procedures of Manchester prison and the Prison Service generally. It is beyond the scope of the inquiry to say how successfully these changes operate in practice, but there is no doubt that the Prison Service has shown a strong commitment to learning from past tragedies. It has invested substantial resources in new strategies for preventing suicide and self-harm. The current policy seeks to reduce risk by “ensuring all prisoners (whether identified at risk or not) receive individual support in managing any problems”. Among the goals of the policy is “reduction in distress and improved quality of life for all who live and work in prisons”. From the evidence to this inquiry, that was not the ethos in significant parts of Manchester prison in 1998. What is the benefit of an inquiry of this kind, over a decade after Mr Lodge’s death? I am conscious of the costs, the time and energy diverted from present services, and the emotional demands placed upon everyone who had some personal involvement. Counsel for the family told the inquiry their aims were uncovering the truth, securing accountability for Mr Lodge’s death, and preventing future tragedies where possible. Through Sonny Lodge’s letters, and the evidence of those the inquiry spoke to, we have seen something of what it felt like for a troubled young man to be a prisoner at Manchester in 1998. We have learned how the face he put on for people he did not know or trust did not tell the whole story, how he responded differently to people according to how they treated him, and how casual mistreatment – by systems or people – can breed despair. Looking back over more than ten years, I must not present a sentimental view of Sonny Lodge because of the tragic manner of his death. But recounting his personal experience shows – if it were not already clear – that the basis of decent prisons is the principle that prisoners are complex individuals who deserve to be treated with humanity and respect. iii
The report makes 48 findings but only 9 specific recommendations. Those who work in prisons are best placed to devise operational responses. Much has changed since 1998 but I hope that prison managers will still find many lessons in the report. The main one is that a healthy prison culture, in which staff engage with prisoners as individuals and have the will and the resources to help them with problems, is the best defence against prisoners’ desperation and despair. Barbara Stow Chair of the Inquiry iv
Page 1 and 2: Report of the Inquiry into the circ
Page 3 and 4: Crown Copyright 2009 The text in th
Page 5: Reports from HM Prisons Inspectorat
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 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
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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
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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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