Samuel Stewart

I am Lydia Brown for West London

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 [REDACTED] 1b 1c II       Morbid obesity (caused by Olanzapine)

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.

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. 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

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.