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

Chapter 12:
ISSUES RAISED IN THE CLINICAL REVIEW (1): CLINICAL CARE; IDENTIFYING
RISK OF SUICIDE; THE EFFECT OF A SENSE OF VICTIMISATION,
Introduction
12.1 The inquiry undertook to examine whether the medical care of Sonny Lodge was
appropriate, including the assessment that Sonny Lodge was fit for adjudication and
cellular confinement on 28 August 1998.
12.2 Dr Nat Wright prepared a clinical review of Sonny Lodge’s medical care in prison,
based on the documentary evidence and written statements obtained by the inquiry. He
also gave oral evidence at the public hearing, and provided a written summary from
Sonny Lodge’s GP records prior to his admission to prison.
12.3 I asked Dr Wright:
to examine whether the healthcare provided to Sonny Lodge was appropriate,
applying the principle of equivalence with treatment provided by the NHS.
In addition to his review of the clinical care of Sonny Lodge, I asked Dr Wright to advise
me about:
any factors that might have contributed to Mr Lodge’s state of mind at the time of
his death; and
any lessons that might help to prevent future such tragedies.
12.4 I have referred to Dr Wright’s advice where relevant in other parts of the report
but it is set out in this chapter and the next one in more extended form. This chapter
deals with clinical care, the significance of a sense of victimisation, and issues in
identifying risk of suicide. The next chapter deals with the particular issue of assessing
prisoners’ fitness for adjudication and cellular confinement.
Summary of Dr Wright’s advice
12.5 In respect of Sonny Lodge’s clinical care, Dr Wright advised that, with a few
minor exceptions, he was impressed by both the standard of note keeping in the clinical
record and clear references to how healthcare provision for Sonny Lodge would be
planned. There also appeared to be timely reviews of the healthcare he was receiving.
However, he argues that there was a systems failure in the process of assessment for
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