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

F2052SH: Garth 29 June to 9 July
5.5 Garth prison provided inpatient healthcare for Risley. On arrival at Garth on 29
June, Sonny was admitted to the hospital wing and a healthcare officer opened a fresh
F2052SH. The reason he gave was that Sonny had been admitted from hospital
following repair of self-inflicted injuries. The healthcare officer completed the nursing
assessment on the form. He said that Sonny’s mood on arrival was pleasant and
cooperative. He was placed in a gated cell in the prison hospital with maximum
supervision and staff were to observe his physical condition in case of any complications
after the surgery to his arms.
5.6 Next morning, the medical officer conducted a lengthy examination recorded in
the Inmate Medical Record (IMR) and summarised in the Health Care Assessment in the
F2052SH. He found Sonny emotional at present, with no evidence of mental illness and
no intention of self harm on arrival at Garth. He described him as seeming a quiet,
pleasant individual. He concluded that he needed counselling.
5.7 The medical officer prepared a healthcare discharge report for the F2052SH on 1
July in anticipation that Sonny would be transferred from the healthcare centre to a
residential unit. He noted that he had been very settled since admission and no
concerns were raised. He had long standing drug abuse problems and “recent
bereavements”. The recommendation on management within the residential unit was
that Sonny “needs ongoing support” and his “long-term drug abuse issues needed
addressing.” In fact, Sonny Lodge was not discharged but remained in the healthcare
centre throughout his time at Garth. The IMR says he was being kept at Garth because
an investigation was pending at Risley.
5.8 No support plan or case reviews are recorded in the F2052SH but the Inmate
Medical Record contains a nursing care plan which recorded the patient’s
problems/needs, the aim of care/goal, nursing action and provision for review dates and
a daily record of nursing care.
Nursing care plan
5.9 The goal indicated in the plan was to relieve depression and thus possible risk of
self-harm. The planned actions were:
to give medication and monitor the results;
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