On 21 May 2020 I commenced an investigation into the death of Lewis Martyn POWTER, who died on 10 May 2020 aged 36 years. The investigation concluded at the end of the inquest on 19 July 2022. Medical Cause of Death – overdose Conclusion – Drug related.

Mr Powter was an IPP offender who had been diagnosed with emotionally unstable personality disorder and had been addicted to drugs for over 10 years. When in the community, he, in common with a number of IPP offenders, suffered from continued anxiety over the issue of potential recall. On release in November 2019, Mr Powter was put on the Offender Personality Disorder (OPD) pathway - a community based service which is part of a joint national strategy shared between probation and health service providers which have access to a shared computer log system, nDelius, for these purposes. As a result of his substance misuse issues, Mr Powter was also under the care of Change Grow Live (“CGL”), a charitable organisation, and was prescribed Subutex. As a third sector organisation, CGL did not have access to nDelius. A multi-agency meeting in respect of Mr Powter took place between the local NHS Trust, probation and CGL in January 2020. There was no further such meeting about him, despite his ongoing vulnerabilities as described above and: (a) the potential impact of lockdown upon him; and (b) the fact that he reported that he had stopped taking his prescription for subutex and was abstaining from drugs. Having abstained from drug-taking for over a month, with the result that he had a reduced tolerance level, Mr Powter died of a self-administered overdose on 10 May 2020. At that time, he was experiencing increased anxiety because, as an IPP liable to recall to prison at any time he had, on 4 May 2020, been identified to the police as the perpetrator of an assault and was informed that he would be facing court proceedings in relation to it.