Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0574, written 12 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Nov 2025 |
|---|---|
| Reference | 2025-0574 |
| Deceased | Samuel Stewart |
| Coroner | Lydia Brown |
| Coroner area | West London |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | North London NHS Foundation Trust · Barnet, Enfield and Haringey Mental Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 28 May 2025 THIS REPORT IS BEING SENT TO: Governor Plus Group, BEH, MOJ, Family . CORONER I am Lydia Brown for West London CORONER'S LEGAL POWERS of HMP Wormwood Scrubs, Practise I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 20 July 2023 I commenced an investigation into the death of Samuel Anthony Donald STEWART. The investigation concluded at the end of the inquest . The conclusion of the inquest was Drug related death 1a Myocardial fibrosis 1b 1c II Morbid obesity (caused by Olanzapine) CIRCUMSTANCES OF THE DEATH 1 2 3 4 Samuel Stewart was on remand in HMP Wormwood Scrubs. He was resident in a single cell on the Incentivised Substance Free Living environment "ISFL", which is a wing meant to be free from drugs and residents sign a "contract" of behaviour which includes undertaking regular drug testing, most of which were negative. One test, however, undertaken 6 March 2023 was positive but no steps were taken to discuss this with Sam, to support him or to arrange a multi-disciplinary team meeting with prison and healthcare staff to consider this further. Sam was found deceased in his cell on 15 July 2023 and there was some drugs paraphenalia within the cell. HIs cause of death was due to drugs in combination with long term cardiac damage, probably caused by previous drug taking behaviour. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. 5 6 The MATTERS OF CONCERN are as follows. - Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 July 2025. I, the coroner, may extend the period. 7 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons family of Sam 8 I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 28 May 2025 9 Signature Lydia Brown Senior Coroner for
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 16 July 2025 Dear Ms Brown, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR SAMUEL STEWART Thank you for your Regulation 28 report of 28 May 2025, addressed to the Governor of HMP Wormwood Scrubs and the Ministry of Justice (MOJ), as well as to the healthcare providers at the prison, Practice Plus Group (PPG) and Barnet, Enfield and Haringey (BEH) Mental Health Trust. I am responding on behalf of the first two recipients. I know that you will share a copy of this response with Mr Stewart’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed concerns regarding a lack of clarity about the actions that should be taken when a prisoner who is residing on an Incentivised Substance Free Living (ISFL) wing produces a positive result in a drug test. Our Prison Drugs Strategy, published in 2019, expresses our commitment to respond effectively when an individual fails a drug test, by offering support and treatment to those who want to abstain, and clear guidance about sanctions for repeat offenders who will not engage with support. At HMP Wormwood Scrubs there is a local policy, agreed between the prison and the Forward Trust, who are subcontracted by their healthcare provider Practice Plus Group, with regards to the actions that should be taken by both prison and healthcare staff if a prisoner tests positive for illicit substances whilst residing on the ISFL wing. Following a positive test prison staff are required to complete a referral to the Forward Trust. It is then the responsibility of healthcare staff to take the subsequent actions, such as discussing the positive result with the prisoner. I have received assurances from the Governor of HMP Wormwood Scrubs that she has reminded all managers on the IFSL wing, in writing, of the requirements following a positive test. The managers have and will continue to remind staff working in the ISFL of their duties during briefings. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely, Interim Director General of Operations
Practice Plus Group Building 1330, Arlington Business Park, Theale, Reading, RG7 4SA practiceplusgroup.com Ms Lydia Brown H.M. Senior Coroner For West London 25 Bagleys Lane Fulham London SW6 2QA 17 July 2025 Dear Madam, Regulation 28: Prevention of Future Deaths Report – Samuel Stewart I write in response to your Regulation 28 Prevention of Future Deaths Report issued to all IPs, including Practice Plus Group, on 28 May 2025 following the inquest touching upon the death of Samuel Stewart at HMP Wormwood Scrubs. Practice Plus Group would like to express its sincere condolences to Sam’s family and friends. This response addresses the matters of concern in so far as they relate to Practice Plus Group only. Matter of Concern: Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him. Response: We consider it is important to outline at the outset that in this case healthcare was unfortunately not made aware of the positive test and therefore were not in a position to take Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW action. The drugs test in question is a prison process and as heard at the inquest, this positive result was not communicated to anyone in healthcare. However, Practice Plus Group, and the wider healthcare team at HMP Wormwood Scrubs, do have a process in place when positive results are communicated to us. For context, whilst Practice Plus Group provide the primary healthcare services and clinical substance misuse services, Forward Trust provide non-clinical substance misuse (Psychosocial) services and North London NHS Foundation Trust (formally Barnet, Enfield and Haringey NHS Trust) provide secondary mental health services. We have outlined the steps which would be taken below: Practice Plus Group, Primary Services and Clinical SMS: - On the Independent Substance Free Living after a positive drug test result the prison staff will liaise with the healthcare staff in the treatment room to confirm what medication the patient is taking. - If the patient has tested positive to a medication they are not prescribed, healthcare staff working on the wing will refer the patient to the clinical SMS team via a task within SystmOne - The Clinical SMS team will then review the patient and carry out their own urine drug screen. - If this comes back as positive the patient will be referred to the Substance Misuse Non- Medical Prescriber for an assessment. A Datix will be submitted at this point and this links into the multi-agency meeting with other stakeholders noted below. - A clinical plan will then be put in place and added to the patients care plan on SystmOne. - Communication processes are in place between Forward Trust, the prison and healthcare. This is led by the Modern Matron and all parties meet weekly to discuss the three different incident reporting systems used (Ulysses, Datix and incident reporting). The aim of this meeting is to ensure all areas have shared the relevant information and all patients are captured. Forward Trust also have a process which responds to the patient’s needs and works alongside the PPG processes. As noted above, communication processes are in place to ensure multi- agency working. Page 2 of 3 I hope that the above response provides assurance that Practice Plus Group are committed to providing a high-quality healthcare service at HMP Wormwood Scrubs and trust this response addresses the concerns you had. Yours sincerely, National Medical Director, Health in Justice Practice Plus Group Page 3 of 3
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