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 ...
There was an entry in the G wing observation book for 25 August about Ms A’s telephone call. No one followed it up to see whether Sonny Lodge was still feeling all right. SO Nuttall did not read the observation book when coming on duty but relied on the outgoing senior officer to tell him anything of note. There was no entry in Sonny Lodge’s history sheets about Ms A’s concern so once he left the wing the staff on his new unit had no record of it. The chaplain who visited Sonny Lodge on Wednesday did not share her concern for Sonny with wing staff and did not record the nature of Ms A’s concern; there was no plan for the chaplains to continue to support Sonny Lodge after Thursday morning. 22.15 In a large prison with a changing population, care for prisoners means that consistent use of records is a crucial proxy for consistent relationships. Protecting prisoners from suicide and self-harm cannot rely on one-off judgments made in isolation. It is a process. Judgments may need revising in response to changing circumstances or new information. 22.16 The Prison Service says there is no overarching prison policy document about record-keeping and communications but within each policy there are relevant requirements, for example, the completion of Use of Force Forms and in ACCT. Findings and recommendation 22.17 I find that: Use of Force and Injury to Inmate forms should have been completed on two occasions and were not. On 27 August 1998, loss of association and search records were not completed in accordance with the required procedures. 22.18 I repeat in part the finding in Chapter 15 Information was not always recorded so that it was available to others. Where information was available in the IMR, the escort records, the observation book and the history sheets it was either not referred to when, reasonably, it should have been, or it was not taken into account, when, reasonably it ought to have 165
prompted special protection. Consequently, judgments were made not to open an F2052SH in ignorance of material facts that ought to have been known. 22.19 I recommend that: 166 the Prison Service considers whether specific guidance might usefully be issued on the appropriate use of prisoners’ history sheets, in particular so that: - information affecting a prisoner’s custody and care is reliably recorded in his or her personal record; and - it is referred to when prisoners change locations or other significant events occur; the Prison Service considers issuing specific advice about recording information received from family, friends or outside agencies that a prisoner may be at risk of suicide or self-harm.
- 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: opportunity when the senior officer
- 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
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- Page 193 and 194: 41 Governor McColm did not explore
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- Page 209 and 210: PSI Prison Service Instruction PSI
prompted special protection. Consequently, judgments were made not to open an<br />
F2052SH in ignorance <strong>of</strong> material facts that ought to have been known.<br />
22.19 I recommend that:<br />
166<br />
<strong>the</strong> Prison Service considers whe<strong>the</strong>r specific guidance might usefully be<br />
issued on <strong>the</strong> appropriate use <strong>of</strong> prisoners’ history sheets, in particular so<br />
that:<br />
- information affecting a prisoner’s custody and care is reliably<br />
recorded in his or her personal record; and<br />
- it is referred to when prisoners change locations or o<strong>the</strong>r<br />
significant events occur;<br />
<strong>the</strong> Prison Service considers issuing specific advice about recording<br />
information received from family, friends or outside agencies that a<br />
prisoner may be at risk <strong>of</strong> suicide or self-harm.
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