Jury finds inadequacies as inquest into death of Caden Stewart at HMP/YOI Cookham Wood closes 10 August 2021 Before Patricia Harding, Senior Coroner for Mid Kent and MedwayShepway Centre, Oxford Road, ME15 8AWFinal hearing 2 - 10 August 2021 The inquest into the death of 16-year-old Caden Stewart concluded on 10 August 2021. Following a 7 day hearing, the jury found that Caden died of natural causes and that, at the time of Caden’s death, there were “inadequate reporting and recording procedures in place, coupled with insufficient communication between prison officers and healthcare staff combined, which led to healthcare failing to attend Caden Stewart’s requests to see him”. The jury could not conclude that these factors contributed to Caden’s death. Caden was a much loved son, brother and friend. He was described at the inquest as an outgoing and vivacious person with a great sense of humour. He had no previous medical concerns. On 26 June 2019, whilst detained at HMP/YOI Cookham Wood, Caden complained of a headache and chest pains, and appeared to be in pain and discomfort after playing football and attending the gym. The gym staff failed to pass on this information to healthcare, and other officers were not aware of his condition. He was taken back to his cell where he later rang his emergency cell bell and asked to see healthcare as he felt unwell. The prison officer who attended Caden’s cell stated that he passed this message to healthcare, but the nurses in healthcare deny receiving the message. Healthcare did not attend. Caden was found unresponsive in his cell over four hours after asking for medical help. He was taken to Medway hospital where he received a CT scan which showed that he had suffered from a brain haemorrhage. He was transferred by ambulance to Kings College Hospital and taken for urgent surgery. He was formally pronounced dead at Kings College Hospital on 27 June 2019. A post-mortem examination revealed the immediate cause of death was a haemorrhage caused by an arteriovenous malformation (AVM). The inquest heard evidence from: The Physical Education Instructors (PEI), one of whom was reading a magazine and not attending to Caden, despite Caden being clearly in the line of sight and in pain. PEI officers did not contact healthcare to say that Caden had become unwell whilst in the gym. The prison officer who was in charge on the cell block on the evening of Caden’s death. The jury heard that he responded to Caden’s emergency request to see healthcare, but did not follow up to ensure healthcare had met with Caden. He also did not communicate to other members of staff that Caden was feeling unwell. The nurse who was on site on the evening of Caden’s death. She told the jury that, had she received a request to see Caden, she would have seen him within 20 minutes of receiving the request. A consultant doctor who was of the view that, had Caden received the appropriate treatment at Kings College Hospital more quickly, it was more likely than not he would have survived. Caden’s family said: “We sincerely believe that if Caden had received treatment earlier, he would still be with us. These children are in the care of HMP/YOI Cookham Wood and their communication and observation skills are severely lacking. Caden was asking for help from the people who were meant to be looking after him. It breaks our hearts that we were not there to help him that day, and that the people who were trusted to look after him failed him and failed us. Although we are grateful for this inquest process, having to re-live Caden's death has been extremely hard. Caden’s death has been very hard on us, the family, and his friends. We are pleased with the outcome of the inquest. We hope that lessons are actually learned this time around, as it is obvious from previous inquests that not much had changed and not much had been learned. We hope that no other family have to go through the same thing. We also hope that Hackney Children’s Services will listen to families in the way they did not listen to us. We believe that if they had intervened earlier, Caden would not have been in HMP/YOI Cookham Wood. We would like to thank the charity INQUEST & the legal team for all their support. Thank you to Sophie Walker & Lois Clifton for all their help and support over the course of the last 2 years, and thank you to the Coroner's office & Coroner Patricia Harding for being thorough throughout the inquest. We would also like to say thank you to the only people from London Borough of Hackney Social Services who have supported us from the moment they met Caden till now: Nina (social worker), Gabriel, Paul & Kwame (former YOT workers), Christopher (YOT worker) from Brent Council, and Anita, Shaiann & Margaret". Lois Clifton of Simpson Millar solicitors said: “It has been a long journey for Caden’s family to get to this result and ensure that the tragic circumstances which led to Caden’s death were properly investigated. Caden was a child. The Young Offender Institution (“YOI”) staff should have properly communicated to ensure that Caden was monitored and assisted when he had asked for help. To hear from a clinician that there was a chance Caden would have survived had he received appropriate treatment confirms the family’s concerns that there were missed opportunities in the hours leading to his death which could possibly have saved him. HMYOI Cookham Wood has a responsibility to the children detained there, and the family hope that lessons will be learnt to ensure this does not happen again. Deaths of children whilst in the care of the state show, time and again, that YOIs are ill-equipped to protect detained children". Deborah Coles, director of INQUEST said: “Caden’s obvious distress and calls for help were ignored by staff and as a result a potentially preventable death might have been avoided. Yet again the health and welfare of children in the care of the state has been found wanting. This reinforces our concerns about the inherent risks of prisons for children”. ENDS NOTES TO EDITORS For further information, interview requests and to note your interest, please contact INQUEST on 020 7263 1111 or [email protected]. Caden’s family are represented by INQUEST Lawyers Group members Lois Clifton of Simpson Millar LLP and Sophie Walker of One Pump Court chambers. The family are supported by INQUEST Caseworker Eliza Lass. Other Interested Persons represented are the Ministry of Justice, Oxleas NHS Foundation Trust, and Hackney Council. INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people. Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.