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

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30 cigarettes a day. His medical records show various attempts to overcome addiction to heroin and amphetamines but his attendance at clinics was unreliable and his treatment programmes lapsed. 1.6 Sonny’s sisters knew him as a beloved brother and affectionate uncle who adopted a happy go lucky front and acted younger than his years, whose life was blighted by his addiction and who needed help more than punishment. 1.7 Sylvia O’Reilly said of her brother: “Sonny wasn’t a violent person. He was never violent. … he would get very upset and very low but it was basically because of himself and the person he was and he was never aggressive. He would never pick a fight with anybody. He wasn’t like that. … his disappointments in life were his own disappointments in life … he’d get upset about it… he’d cry, and we’d discuss it but he never got aggressive. “He wasn’t an aggressive, violent person… He was a 28-year-old supposedly ‘man’, who was more like a child, in a lot of ways… that had drug problems. “He had two children that he really loved but he couldn’t get his head round looking after his children properly. …it hurts me to think that there could be anyone out there just imagining him to be something that he wasn’t. … He was a massive Disney fan. He needed help, that’s all he needed - help, not punishment; help. “Sonny wasn’t a bad person. He was a petty criminal with a drug habit who needed help more than anything.” Risley prison 1.8 Sonny Lodge was admitted to Risley prison on 15 June 1998. He was given medication for withdrawal from drugs. A health care officer opened a self-harm prevention plan (called a form F2052SH) because Sonny had self-harmed at Risley a year earlier and told the officer he might harm himself. 1.9 The F2052SH was closed at Risley on 25 June. On 26 June Sonny cut his arms with a razor blade and was taken to hospital. He spent the night in Warrington Hospital and was then taken to Whiston Hospital for treatment. An incident occurred there and Sonny Lodge was later charged with inflicting grievous bodily harm on one of the escorting officers. This was why he was in prison on the day he died. The circumstances of the incident are contentious and the inquiry has examined it in detail. Sonny Lodge 3
denied the charge. He admitted pushing the officer, but claimed it was in response to an assault upon him. The evidence was not tested in court because of Sonny Lodge’s death. Information came to light in the inquiry about the disciplinary history of the officer involved. Garth prison 1.10 Sonny Lodge was assessed by a psychiatrist at Warrington hospital who recommended further psychiatric assessment and medication. 1.11 From hospital, Sonny was discharged to the healthcare wing at Garth prison. An officer in the healthcare centre opened a new F2052SH. A nursing care plan was devised aiming to relieve depression and risk of self harm. Sonny saw the prison medical officer, who recommended that he needed counselling but not medication. 1.12 Sonny was charged under the Prison Rules with assaulting an officer at Whiston Hospital. A governor’s adjudication was opened at Garth. The record indicates that Sonny pleaded guilty. The adjudication was adjourned as the incident was in the hands of the police. Sonny spoke privately to a governor at Garth who thought his actions might be considered self-defence. The governor was sufficiently concerned about Sonny’s account to write to the Head of Residential Services at Risley. 1.13 Sonny stayed in the healthcare centre at Garth until 9 July. The medical officer’s discharge report recommended that Sonny needed ongoing support and that long-term issues about drug abuse needed addressing. On 9 July Sonny attended a hospital outpatient appointment and from there was transferred to Manchester prison. Manchester Prison 1.14 When Sonny arrived in Manchester, the F2052SH remained open. There were frequent entries in the daily supervision and support records but appeared to be no support plan. Records by a senior officer, a health care officer and the medical officer indicate that Sonny claimed to be coping well, no longer felt suicidal and wanted the file to be closed. After two days in the induction unit, Sonny was transferred to E wing on 11 July. The F2052SH file was closed at a case review on 20 July 1998. 1.15 For the rest of his time at Manchester prison, Sonny was not on an F2052SH suicide prevention plan. The inquiry has examined the operation of the measures 4
Page 1 and 2: Report of the Inquiry into the circ
Page 3 and 4: Crown Copyright 2009 The text in th
Page 5 and 6: Reports from HM Prisons Inspectorat
Page 7 and 8: The report makes 48 findings but on
Page 9 and 10: CONTENTS PART ONE: WHAT LED TO THE
Page 11 and 12: viii
Page 13: Chapter 1 SONNY LODGE AND AN OUTLIN
Page 17 and 18: and to Sonny’s wing. A health car
Page 19 and 20: was not aware of Sonny’s history
Page 21 and 22: The Court said that any failure to
Page 23 and 24: structure the inquiry’s considera
Page 25 and 26: 2.25 At the hearings, the solicitor
Page 27 and 28: or recognition. Their actions may b
Page 29 and 30: 18 In inquiries of this kind it ma
Page 31 and 32: Chapter 3: RISLEY: 15 TO 26 JUNE 19
Page 33 and 34: 0820 Appeared to be OK when unlocke
Page 35 and 36: Chapter 4: THE INCIDENT AT WHISTON
Page 37 and 38: admitted pushing the officer and ga
Page 39 and 40: Officer Brownley’s injury 4.20 Dr
Page 41 and 42: was required to resume wing duties
Page 43 and 44: would not be a problem. He said he
Page 45 and 46: Chapter 5: 27 JUNE TO 9 JULY 1998:
Page 47 and 48: continued assessment and recording
Page 49 and 50: 4 July 0630 1650 1930 5 July 0630 1
Page 51 and 52: Table 3 40 9 July 1335 1400 1609 17
Page 53 and 54: point on the history sheets kept on
Page 55 and 56: working prison occupied mainly by c
Page 57 and 58: privileges over and above the facil
Page 59 and 60: the actual memory of many of its st
Page 61 and 62: with officers in the kitchen for go
Page 63 and 64: H wing: 25 July to 1 August 7.37 In
Page 65 and 66:
7.48 On Sunday 16 August, an entry
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Chapter 8: SUNDAY 23 AUGUST TO THE
Page 69 and 70:
Wing officer 8.8 Officer Sanderson
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chaplains to see him. Ms Lorimer to
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Thursday morning 8.21 Captain Palme
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9.5 Officer Downs told the inquiry
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visit before time and that there wa
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ecollection of the incident and mus
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9.34 Mr Bowcock was asked about the
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Chapter 10: AFTER THE SEARCH: THE I
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and now they’re doing three years
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Mr Lodge’s account of the inciden
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HCOs advised staff to loosen their
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punishment for the altercation in t
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82 The diagnosis of dissocial pers
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11.6 Back in the chaplains’ offic
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take his clothes off for a search a
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Subsequent statements to the Prison
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Evidence to the inquiry SO Knight 1
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going to happen to him. She was als
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11.53 In his final letter to his gi
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Chapter 12: ISSUES RAISED IN THE CL
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should not routinely be used. But i
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impulsivity; difficulty forming rel
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any underlying paranoid illness as
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Chapter 13: ISSUES RAISED IN THE CL
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Changes to assessing fitness 13.10
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13.20 One of the mental health nurs
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Chapter 14: SAFEGUARDS AGAINST SUIC
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Meeting the prisoner’s needs. Thi
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114 Prison culture The policy stat
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14.16 “Prisoners who are at risk
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Closing a Plan 14.25 The form says
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14.36 In oral evidence to the inqui
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CHAPTER 15: PREVENTING SUICIDE AND
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mind in the last week of his life i
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colleague to see Sonny Lodge on Thu
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15.21 ACCT also requires a risk ass
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Chapter 16: THE INQUIRY’S CONSIDE
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Despite these findings, there is in
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16.17 The inquiry was told that pri
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Chapter 17: TRANSFERS, WING AND CEL
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punishment, there is no evidence th
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held safely; Respect - prisoners ar
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Chapter 18: WAS SONNY LODGE VICTIMI
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surgeon at Whiston Hospital found S
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fact that, as he sees it, injustice
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that it was made at all. However, i
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forcefully, but for prison staff, i
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Chapter 20: THE SEARCH AND THE INCI
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However, like the various reports o
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Chapter 21: THE ADJUDICATION AND PU
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21.4 PSO 2000, which came into effe
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21.13 In order to find the charge a
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Chapter 22: COMMUNICATIONS AND RECO
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opportunity when the senior officer
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prompted special protection. Conseq
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Manchester prison now 23.4 In evide
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Safety 23.13 I have described in pa
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ehaviour, achievements, interaction
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prison. Many prisoners carry a host
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PART FOUR FINDINGS, RECOMMENDATIONS
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Information was not always recorded
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opportunities for social interactio
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41 Governor McColm did not explore
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LIST OF RECOMMENDATIONS I have exer
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LIST OF OBSERVATIONS ABOUT INQUIRY
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ANNEX 1 TERMS OF REFERENCE 1 1. To
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9. Communications and record-keepin
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helpful. The chronology will not fo
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Notice of matters requiring explana
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ANNEX 3 LIST OF LEGAL REPRESENTATIV
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PSI Prison Service Instruction PSI
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