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

CHAPTER 15:
PREVENTING SUICIDE AND SELF HARM (2): CONSIDERATION AND FINDINGS
Consideration
15.1 The Prison Service has a duty to take reasonable care to protect the life and wellbeing
of prisoners in its custody. There are reasons why many people in prison are
especially vulnerable. They include mental ill-health and other medical problems, drug or
alcohol dependence, the experience of withdrawal from dependence, the experience of
confinement, things that happen in prison, being cut off from family and friends and other
kinds of support, problems prior to imprisonment, being unable to attend to personal
problems outside the prison.
15.2 During his time in prison Sonny Lodge was at times identified as being at risk of
suicide and self-harm and on one occasion he deliberately lacerated his arms. At the
time of his death he was not thought to be at risk and there were no special safeguards
to help or protect him. This chapter examines:
compliance with the F2052SH system in force at the time
the limitations of that system
problems in identifying risk
the response to Ms A’s warnings
the importance of sharing information
what would have been different if an F2052SH had been opened
how practice would have differed under the current ACCT system.
Compliance with the F2052SH procedures at the time
15.3 The inquiry examined whether the F2052SH procedure was operated in
accordance with Prison Service guidance and appropriately and whether there are
lessons to be drawn.
15.4 So long as Sonny Lodge was subject to an F2052SH staff maintained special
observation of him and the plans were operated seemingly conscientiously and broadly,
though not entirely, in accordance with guidance and the usual practice at the time. It
was to the credit of staff at Risley that a plan was opened when Sonny Lodge was
admitted and, at Manchester, that they kept the plan open initially despite Sonny’s
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