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

flagging special risk may be too high. What are staff to do? If they are too ready to label,
then the resource available for the most vulnerable is spread more thinly. Staff have to
make judgements from limited evidence. They must also pay attention to what a prisoner
says of himself. It seems Sonny Lodge told the officers on Tuesday that his girlfriend
was mistaken.
15.12 Physical surroundings may militate against prisoners’ disclosing distress.
Consider the circumstances of the conversations with the two officers on Tuesday and
also with Captain Palmer on Thursday morning: called out of the holding room into
reception; at the wing office, “on a light note”, when Sonny came to collect his canteen;
out of the cell on to the landing in order to talk more privately. Despite the staff members’
best efforts to provide a degree of privacy, the conversations were all held with Sonny in
relatively public places and probably standing up. The officers and Captain Palmer said
there was nothing in Sonny’s demeanour to indicate a need for a more secluded
interview. But can that really be a reliable way of finding out whether someone who is a
stranger to you is battling with despair sufficient to end their life?
15.13 The chaplains offered support and concern but were more or less strangers to
Sonny Lodge. Hindsight shows they did not judge the risk correctly. That does not mean
their judgments were wrong at the time or from what they knew. But there was relevant
information they did not know about; and I question whether they sufficiently shared
what they knew. On Wednesday, Ms Lorimer knew Sonny’s history of self-harm, that he
sometimes had thoughts of suicide and that Ms A was concerned for his welfare. Ms
Lorimer was clearly an experienced and caring counsellor but the logistics of the prison
were not conducive to a continuing counselling relationship. Captain Palmer’s
conversation with Mr Lodge next day was supportive but of a different order. Mr Johnson
told the inquiry that on Friday he did not know that Sonny had self-harmed in the past or
that, earlier in the week, Ms A had specifically said she was concerned Sonny might do
himself harm.
The importance of sharing information
15.14 Risk assessment is not an exact science or a one-off event. It is a process in
which information may accumulate. The chaplains did not know that two officers had
spoken to Sonny on Tuesday evening after Ms A telephoned to say she feared he might
self-harm. The discipline staff did not know that she telephoned again or of the
chaplains’ involvement on Wednesday and Thursday. Ms Lorimer arranged for her
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