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.

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

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.

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.