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

colleague to see Sonny Lodge on Thursday and Father McCann drew in Mr Johnson on
Friday. Each knew only part of the picture.
15.15 In the absence of the consistent relationships that Dr Wright considers the best
defence, information sharing becomes critical. In a local prison with a rapidly changing
population, consistent use of records has to act to some extent as a proxy for consistent
relationships. It needs to be systematic so that essential information is not lost along the
way. Information that is recorded needs to be used.
15.16 There were numerous occasions in the last week of Sonny Lodge’s life when
information was not recorded, or not recorded in all the right places or not referred to:
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The prisoner escort records that accompanied Sonny Lodge to and from
Liverpool referred to a risk of suicide and self-harm but no cognisance
seems to have been taken of them in reception when he returned to
Manchester on Tuesday evening despite Ms A’s telephone call. HCO Stell
did not see the records and he did not know that Sonny Lodge had selfharmed
in prison.
Ms Lorimer decided to keep her concerns within the chaplain’s team but it
appears that no record was made and there was no plan for further support
after Captain Palmer’s visit.
Officer Sanderson is to be commended for his notes in the wing
observation book on Tuesday evening but he did not make a note in Sonny
Lodge’s history sheets. The notes contained significant information that
should have been recorded in the history sheets as well as the observation
book even though Officer Sanderson judged there was no immediate cause
for concern.
SO Nuttall did not read the observation book when he came on duty on
Thursday evening. It appears to have been customary at Manchester at the
time to rely on oral handovers.
An entry was made in the Inmate Medical Record (IMR) in the evening of
Thursday 27 th when Sonny was examined after the incident in the cell
before transfer to the segregation unit. The entry immediately above was
about Ms A’s warning that Sonny might harm himself. It is extraordinary that