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

LIST OF FINDINGS
Clinical care
1 Clinical care for Sonny Lodge’s physical health was appropriate and consistent
with practice at the time (paragraph 12.33).
2 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 (paragraph 12.33).
3 The Prison Service did not deliver the psychiatric reassessment, counselling and
support to stay off drugs which doctors advised that Sonny Lodge needed
(paragraph 12.33).
Sonny Lodge’s mental health
4 There is no evidence that Sonny Lodge’s feelings of victimisation were the
consequence of any psychotic illness (paragraph 12.33).
5 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 (paragraph 12.33).
Assessing fitness
6 There was a systemic failure in the assessment of fitness for adjudication and
cellular confinement in that it was made without reference to any history or prior
knowledge of Sonny Lodge. That was not contrary to Prison Service policies in
1998 but it was unsatisfactory. Current Prison Service policy requires a risk
assessment, including reference to medical records, before a punishment of
cellular confinement is imposed. (paragraph 13.24).
Safeguards against suicide and self-harm
7 There was a systemic failure to protect Sonny Lodge in the last days of his life in
that:
Insufficient regard was paid to Ms A’s warnings.
Judgments were made not to open an F2052SH, in ignorance of
material facts that ought to have been known.
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