Report of the Inquiry into the circumstances of the Death of Bernard ...
Report of the Inquiry into the circumstances of the Death of Bernard ... Report of the Inquiry into the circumstances of the Death of Bernard ...
Discharge report This is to be completed by a doctor when a prisoner is discharged from healthcare and returned to a residential unit. Daily supervision and support record This says that the purpose is to report on the prisoner’s mood and behaviour and all ongoing action taken to help the prisoner. It includes reporting on the implementation of the support plan decided at a case review and involvement by outside agencies and family. 14.9 When an F2052SH form was closed, the residential unit manager was to sign the form off and the file was placed in the prisoner’s personal record. The personal record is held in the prison’s central administration unit not on the residential wing. The system now: Assessment, Care in Custody and Teamwork (ACCT) 14.10 The F2052SH system has been replaced since the events detailed in this report. Implementation of the new policy was phased over 2005-2008. The new system drew on the experience of operating the F2052SH procedure and research on suicidal and selfharming behaviours, including a four-year project (the Safer Locals Programme) about the particular problems in Local Prisons (like Manchester), where large numbers of remand and sentenced prisoners spend short periods of time. PSO 2700 Suicide Prevention and Self-Harm Management, as revised and reissued in October 2007, set out the national policy. References below are to the current edition of PSO 2700. 14.11 Certain features of the new policies are of particular relevance to the case of Sonny Lodge. Statement of purpose The policy gives instructions on identifying prisoners at risk of suicide and selfharm and caring for them but it also places “considerable emphasis on reducing risk by ensuring all prisoners (whether identified at risk or not) receive individual support in managing any problems” (PSO 2700 Statement of Purpose, page 8). Among the goals of the policy is “reduction in distress and improved quality of life for all who live and work in prisons” (PSO 2700 Desired Outcome, page 8). 113
114 Prison culture The policy states that research evaluating the Safer Locals Programme found that suicide prevention was most effective when prison culture had the following characteristics: “staff felt valued, communication was good, prisoners felt safe and there were good staff relationships with senior managers, who were approachable and supportive. In contrast, some prisoners had a ‘traditional’ or negative culture, where staff relied on overuse of authority, distanced themselves from prisoners, and expressed distrust between uniformed and specialist staff groups. The quality of care for prisoners in these prisons was reduced.” (PSO 2700, paragraph 2.1.1) Staff-prisoner relationships Staff are advised that prisoners emphasised the value of having a member of staff listen to them and take their problems seriously. Interviews with suicidal prisoners confirmed that staff who took time to help them were appreciated. Several prisoners who had attempted suicide talked about how they wanted staff to “talk to them and engage with them, not just to observe them” (PSO 2700, paragraph 2.2.1). Change of status prisoners Reception staff are required to ensure that they talk with prisoners who have had a change of status. Local procedures must make provision for prisoners who have had a change of status without leaving the prison to undergo the equivalent of a ‘reception screen’ to assess risk of suicide or self-harm (PSO 2700, paragraph 4.8). Positive regimes and purposeful activity Positive regimes are defined as: “…those which enable prisoners to engage in activities which reduce distress and potentially reduce rates of suicide and self-harm, for example through improving mood and increasing coping skills and self-esteem. Potentially helpful activities include work, education, structured programmes, art and exercise.” (PSO 2700, paragraph 5.1.1)
- 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: Meeting the prisoner’s needs. Thi
- 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
Discharge report<br />
This is to be completed by a doctor when a prisoner is discharged from<br />
healthcare and returned to a residential unit.<br />
Daily supervision and support record<br />
This says that <strong>the</strong> purpose is to report on <strong>the</strong> prisoner’s mood and behaviour and<br />
all ongoing action taken to help <strong>the</strong> prisoner. It includes reporting on <strong>the</strong><br />
implementation <strong>of</strong> <strong>the</strong> support plan decided at a case review and involvement by<br />
outside agencies and family.<br />
14.9 When an F2052SH form was closed, <strong>the</strong> residential unit manager was to sign <strong>the</strong><br />
form <strong>of</strong>f and <strong>the</strong> file was placed in <strong>the</strong> prisoner’s personal record. The personal record is<br />
held in <strong>the</strong> prison’s central administration unit not on <strong>the</strong> residential wing.<br />
The system now: Assessment, Care in Custody and Teamwork (ACCT)<br />
14.10 The F2052SH system has been replaced since <strong>the</strong> events detailed in this report.<br />
Implementation <strong>of</strong> <strong>the</strong> new policy was phased over 2005-2008. The new system drew on<br />
<strong>the</strong> experience <strong>of</strong> operating <strong>the</strong> F2052SH procedure and research on suicidal and selfharming<br />
behaviours, including a four-year project (<strong>the</strong> Safer Locals Programme) about<br />
<strong>the</strong> particular problems in Local Prisons (like Manchester), where large numbers <strong>of</strong><br />
remand and sentenced prisoners spend short periods <strong>of</strong> time. PSO 2700 Suicide<br />
Prevention and Self-Harm Management, as revised and reissued in October 2007, set<br />
out <strong>the</strong> national policy. References below are to <strong>the</strong> current edition <strong>of</strong> PSO 2700.<br />
14.11 Certain features <strong>of</strong> <strong>the</strong> new policies are <strong>of</strong> particular relevance to <strong>the</strong> case <strong>of</strong><br />
Sonny Lodge.<br />
Statement <strong>of</strong> purpose<br />
The policy gives instructions on identifying prisoners at risk <strong>of</strong> suicide and selfharm<br />
and caring for <strong>the</strong>m but it also places “considerable emphasis on reducing<br />
risk by ensuring all prisoners (whe<strong>the</strong>r identified at risk or not) receive individual<br />
support in managing any problems” (PSO 2700 Statement <strong>of</strong> Purpose, page 8).<br />
Among <strong>the</strong> goals <strong>of</strong> <strong>the</strong> policy is<br />
“reduction in distress and improved quality <strong>of</strong> life for all who live and work in<br />
prisons” (PSO 2700 Desired Outcome, page 8).<br />
113