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

apparent assurances that it was unnecessary. A nurse at Garth tried to arrange an early
visit by Sonny’s girlfriend or sister. That was sensible and kind.
15.5 However, there were departures from good practice. For example:
There is no entry at Risley for initial action by the residential unit manager.
The first case review at Risley was held after one week, not within 72 hours as
required. There was no support plan until the review.
There appears to have been no initial plan by the unit manager or a support plan
while the F2052SH was open at Manchester.
Case reviews at Risley and Manchester did not involve any specialist staff but
seemingly wing officers without particular knowledge of Sonny.
The frequency of observations was generally not specified and is not consistent.
A preponderance of the entries at Manchester record periodic observation
overnight when Sonny was asleep.
The limitations of the F2052SH system
15.6 Entries in the F2052SH form illustrate the limitations of the F2052SH system
which the new ACCT is meant to address. For the most part they give precious little
information and there is little evidence of engagement with Sonny Lodge and his
problems.
15.7 The F2052SH system had fine aspirations. It was ground-breaking. It provided a
structure for paying special attention to prisoners thought to be at risk and may have
saved many lives. The preamble to the policies was about supportive relationships and
sharing information but too often entries in the daily supervision and support records
indicated observation not interaction and provided no significant information for
colleagues. At Manchester and also at Risley it is not altogether clear what the support
amounted to. It fell well short of the individualised care plan addressing individual
problems that the ACCT system now aims to provide.
Problems in identifying risk
15.8 Dr Wright spoke of the difficulty of predicting suicidal intent from one-off
interactions. Stated intention to a stranger cannot be a reliable guide. What Sonny
Lodge reportedly told Healthcare Officer Stell and Officer Sanderson about his state of
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