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 ...
should be located in shared accommodation, and should be observed frequently at irregular intervals (the frequency was not specified). 3.6 The continuous medical record shows an entry for the next day but only about Sonny’s physical health. 3.7 Sonny was housed in normal location on A wing. The page for initial action by the residential unit manager was not completed. 3.8 A case review was held on 22 June, attended by a senior officer and two officers. Sonny said he had spoken with Probation, who had tried to help him. It was decided that the form should be kept open at least until the next review. The support plan was: to remain in shared accommodation to contact Probation. to attend full-time education classes. The daily supervision and support record 3.9 During the 11 days that the F2052SH file was open there are 54 entries in the daily supervision and support record as shown in the table below. I have abbreviated or clarified some entries. It is not always possible to tell from the entries whether they were based on passive observation or active interaction. I have highlighted in bold type the seven entries that clearly indicate some conversation. Nowhere on the form is the frequency of required observation specified. Table 1 16June 0600 Appears to have slept all night. No problems 0700 Appears asleep at roll check 1430 Seen on induction…; states does not feel suicidal but concerned about sentence, warrant and date of release. Advised…Seems cheerful and happy enough 1730 Appeared to be OK when unlocked for teatime meal 1745 Appeared to be OK at tea up 2100 Seen at start of duty. Seems OK. 17June 0600 Appeared to have slept all night. No problems 0700 Appears asleep 21
0820 Appeared to be OK when unlocked for breakfast 1215 Lying on bed. Seemed OK 1120 Nurse called to a fit. Care given. …Calmed down and an inmate who knows him put in his cell over dinner 2100 Spoke to inmate. Seems to be alright 2135 Called by cellmate. Having a fit. Initial care then nurse attended 2140 Nurse’s entry. Attended to Lodge. Appeared to recover normally from fit. Observations satisfactory. Mattress placed on floor. Windows opened. 2205 Got back into bunk by himself 2300 Sitting on bed eating 18 June 0010 Seems to be asleep 0530 Appears to have slept alright 0650 Seems OK at commencement of shift 1150 Seen by probation officer, chaplain and PO on a Review Board: [detailed entry about place on education and clarification of release date.] 1700 Collected tea. Seems fine. 1955 In bed at bang-up 2100 Seen at start of duty. No problems 19 June 0600 Appears asleep. No problems through the night 0640 Inmate appears asleep. No problems 1540 Sat on bed. Appears OK. 2045 Called by cellmate. Having a fit. Nurse [and senior staff] attended. 20 June 0600 Rang bell at 0145 asking for medication. Night Orderly Officer attended. Medication refused as had had all his entitlement. Slept well after this. 0700 Asleep at roll check 1600 No problems on…[illegible] 2100 Seen. OK 21 June 0600 Slept most of the night. No problems. 0700 Appeared to be asleep. 2000 Appeared to be OK at lock up. 22 June 0600 Appears to be asleep at roll check 22 0645 Appears asleep 1215 Checked. No problems
- Page 1 and 2: Report of the Inquiry into the circ
- Page 3 and 4: Crown Copyright 2009 The text in th
- Page 5 and 6: Reports from HM Prisons Inspectorat
- Page 7 and 8: The report makes 48 findings but on
- 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: Chapter 3: RISLEY: 15 TO 26 JUNE 19
- 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
- Page 57 and 58: privileges over and above the facil
- Page 59 and 60: the actual memory of many of its st
- Page 61 and 62: with officers in the kitchen for go
- Page 63 and 64: H wing: 25 July to 1 August 7.37 In
- Page 65 and 66: 7.48 On Sunday 16 August, an entry
- Page 67 and 68: Chapter 8: SUNDAY 23 AUGUST TO THE
- Page 69 and 70: Wing officer 8.8 Officer Sanderson
- Page 71 and 72: chaplains to see him. Ms Lorimer to
- 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
0820 Appeared to be OK when unlocked for breakfast<br />
1215 Lying on bed. Seemed OK<br />
1120 Nurse called to a fit. Care given. …Calmed down<br />
and an inmate who knows him put in his cell over<br />
dinner<br />
2100 Spoke to inmate. Seems to be alright<br />
2135 Called by cellmate. Having a fit. Initial care <strong>the</strong>n nurse<br />
attended<br />
2140 Nurse’s entry. Attended to Lodge. Appeared to<br />
recover normally from fit. Observations<br />
satisfactory. Mattress placed on floor. Windows<br />
opened.<br />
2205 Got back <strong>into</strong> bunk by himself<br />
2300 Sitting on bed eating<br />
18 June 0010 Seems to be asleep<br />
0530 Appears to have slept alright<br />
0650 Seems OK at commencement <strong>of</strong> shift<br />
1150 Seen by probation <strong>of</strong>ficer, chaplain and PO on a<br />
Review Board: [detailed entry about place on<br />
education and clarification <strong>of</strong> release date.]<br />
1700 Collected tea. Seems fine.<br />
1955 In bed at bang-up<br />
2100 Seen at start <strong>of</strong> duty. No problems<br />
19 June 0600 Appears asleep. No problems through <strong>the</strong> night<br />
0640 Inmate appears asleep. No problems<br />
1540 Sat on bed. Appears OK.<br />
2045 Called by cellmate. Having a fit. Nurse [and senior staff]<br />
attended.<br />
20 June 0600 Rang bell at 0145 asking for medication. Night Orderly<br />
Officer attended. Medication refused as had had all his<br />
entitlement. Slept well after this.<br />
0700 Asleep at roll check<br />
1600 No problems on…[illegible]<br />
2100 Seen. OK<br />
21 June 0600 Slept most <strong>of</strong> <strong>the</strong> night. No problems.<br />
0700 Appeared to be asleep.<br />
2000 Appeared to be OK at lock up.<br />
22 June 0600 Appears to be asleep at roll check<br />
22<br />
0645 Appears asleep<br />
1215 Checked. No problems
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