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

mind in the last week of his life is very different from what he wrote in letters. Moreover,
suicidal behaviour may be impulsive. Dr Wright advised that assessment by a clinician of
fitness for cellular confinement or other prison procedure on the basis of a brief
conversation is of dubious value. He argues the need for a continuous therapeutic
relationship. The best defence against suicide in prison is supportive interaction through
consistent relationships.
The response to Ms A’s warnings
15.9 Dr Wright concluded that opportunities to prevent Sonny Lodge’s suicide were
missed in the final days of his life, in particular in response to the telephone calls from
his girlfriend. I agree. In the final week of Sonny Lodge’s life, Ms A did what she could to
protect Sonny. Yet no F2052SH was opened; individuals who did not know him made
judgements in ignorance of information known to others; information was not sufficiently
shared or always recorded in the place where it would be read when needed; some
information that was recorded - in the IMR and history sheets - was not taken into
account.
15.10 HCO Stell, Officer Sanderson, Ms Lorimer, Mr Johnson and Captain Palmer all
spoke with Sonny Lodge in the last days of his life because of concerns about his
welfare. On Tuesday 25 August, after Sonny Lodge was refused bail by the magistrates,
Officer Sanderson’s record in the observation book says, in terms, that his girlfriend said
Mr Lodge had a history of self-harm. Officer Stell’s entry in the medical record says Ms A
was worried Sonny might harm himself. Ms Lorimer was aware that Sonny Lodge was
depressed, that his girlfriend was concerned and that there had been at least one
previous incident of serious self-harm. Captain Palmer saw Mr Lodge at Ms Lorimer’s
request but did not recall that he had been alerted to any risk of self-harm. Mr Johnson
says that on Friday Ms A did not refer to self-harm but he and the staff in the segregation
unit spoke about whether Sonny Lodge might be at risk of suicide.
15.11 People knew that Sonny’s girlfriend was worried about him but, in each case, the
staff member decided not to open an F2052SH. Each showed concern for Sonny and
was experienced in the prison environment. No-one identified Sonny’s vulnerability. That
is not to condemn the individual staff concerned. Unfortunately, it is not uncommon for
prison staff to be working with prisoners who have a history of self-harm. I have also
been told that it is not an uncommon occurrence for families to register concerns. In a
place where so many needy, damaged people are concentrated, the threshold for
124