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

search, then the rules being put on the wall, Dr Wright said it gave a sense of how
somebody could feel that there was no way they would be able to fight. He commented
that it might well be that some individuals were more sensitive to these kind of factors
but, according to modern healthcare thinking, the way that that could be distinguished
was through ongoing assessment and multi stakeholder involvement.
Findings
12.33 Drawing on Dr Wright’s advice,
I find that:
Clinical care for Sonny Lodge’s physical health was appropriate and consistent
with practice at the time.
Clinical record-keeping was generally good except for an apparent practice of
recording on medication charts only when patients did not receive medication
and not when they did. That is not reliable or satisfactory.
The Prison Service did not deliver the psychiatric reassessment, counselling and
support to stay off drugs which doctors advised that Sonny Lodge needed.
There is no evidence that Sonny Lodge’s feelings of victimisation were the
consequence of any psychotic illness.
A sense of victimisation in the prison environment could have left Mr Lodge
feeling increasingly powerless and hopeless, as reflected in his letters, and
ultimately such feelings could have contributed to a state of mental ill-health and
a desire to end his life.
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