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Accountability Accomplished: Samuel Howes inquest findings of multiple failings

It was 11:12 on Thursday 30th March when we got the knock on the door. The court usher popped her head into the room, the jury was returning with their findings, and we were needed back in court.


The jury had retired at 11 am the previous day following the 2 ½ week inquest into my son Samuel Howes death on 2nd September 2020. They had an unenviable task having listened to in excess of 30 witnesses in a hugely complex case. No wonder it took a whole day for them to reach their conclusion.


We’d sat with our legal team in our allocated family room for the past day keen to unpick their thoughts. The jury had been hugely engaged in the courtroom. They had posed insightful questions to witnesses. They had even asked the Coroner whether they could consider additional factors in their deliberation. Sadly, one member had dropped out early. She asked to be released after I read my statement on the first day, too triggered to continue.




We walked into the courtroom for the final time. Other family members joined online. I took my place next to our legal team and my daughter Daisy. The jury entered and the microphone was placed in front of the foreperson. My heart was hammering. Did they get it? Did they understand? Did they care about my boy? Please validate him and our experiences were my silent pleas.


The head juror started to read the findings. I heard the opening lines, ‘Samuel suffered from ongoing mental health issues including anxiety and depression. Samuel’s mental health led to his use of drugs and dependency on alcohol which exacerbated his poor mental health’.

I reached for the tissues. They totally got it! They understood. The language and tone were respectful, no judgement. I could feel the empathy in their words.


The juror went on to detail a catalogue of failings and inadequate responses across the board. They described in huge detail the lack of care and rigour. By now I was sobbing. Two and a half years I'd waited for his day. To hold these organisations to account and have the truth be told.


The Coroner then addressed our family and thanked us for our drive to get the inquest heard and our dedication to Samuel. He stated that no one couldn't have done more to save Samuel in the last months of his life than me, his mum. I knew deep down this was true but hearing it at the end of his horrendous process was incredible. I looked across at the jury and mouthed 'thank you’.


We’d sat through horrific evidence. Police officers who’d judged, ignored and vilified my child in custody. Not one bad apple but multiple people who just didn’t care. The ease with which they justified their neglect was unbearable.


The last days of evidence had focused on Samuel’s missing person investigation. He had gone missing and had rung an ambulance from a friend’s house, in crisis, saying he was suicidal. This was the first time he had ever reached out for help. He left before the ambulance arrived.


There followed a botched investigation. The Coroner had actually requested that it wasn’t called an investigation because no actions to look for Samuel were ever undertaken. No photograph was shared, no phone calls to me, no CCTV was checked. No one was ever looking for a highly vulnerable 17-year-old suicidal child. The only action taken by the police was to close the case nine hours after he died.


I sat across from the Croydon police inspector that should have led the investigation. No one rang him was his defence. He didn’t pick it up on his IT system, neither did any of his team. ‘Not my fault’ he declared. He’s been given informal performance management I’ve since heard. He didn’t do his job. He didn’t care. I passed him in the corridor a short while after his evidence. He kept his head down. I could have ripped it off. Instead, I kept my dignity. We both knew he’d failed my child.


The jury was a random group of people from across South London. Boy, did they do an amazing job. They came through for us and more importantly for Samuel. They renewed my faith in humanity.


There followed lots of family and legal team hugging. We had worked closely for the past few months, and I couldn’t have hoped for a better outcome. I was stunned. The speed of the findings being read and trying to take in what I’d just heard blew my mind.


People outside of our close circuit suggested we had an ending, closure, justice? These are not words I would choose. Samuel is still dead. He was hugely failed by those who should have protected him. Accountability is my preferred word. The senior representatives of both the Metropolitan and British Transport Police admitted failings. They knew the evidence was damning.


Croydon Council took a shameful legal stance. They declined to release Samuel’s social care records in the lead-up to the inquest, apart from the bare minimum.

It’s too difficult and time-consuming they declared. I appealed to the Chief Executive and Director of Children’s Services two weeks before the inquest. I hoped approaching them as the bereaved mother might appeal to their sense of fairness. They kept to the party line. We must leave it to the lawyers, they said. At the same time, they hoped for an open and honest inquest in their email. Their patronising tone and refusal to even speak to me left me devastated.


This was one of my lowest pre-inquest points. We could fight this battle, but it would delay the inquest for maybe another year. I couldn’t allow this to happen. I’d built my life around this date for a whole year. Instead, we had to use the vast number of emails and paperwork I had. We were hugely disadvantaged, and I was advised to manage my expectations by my barrister.


Our legal team at Bhatt Murphy were incredible. Michael Oswald, our lawyer, gave me a pep talk days before the inquest. He described how I had advocated for Samuel and that was obviously from the huge amount of evidence we had. It was now time for me to put my trust in them. Trusting others when you have been so badly let down doesn’t come easy. It also meant relinquishing some control.


I put my faith in the Coroner’s court system and my amazing legal team. We fought 4 powerful state organisations and their mighty legal teams, all funded by the taxpayer. I listened to police officers squirm as they gave damning evidence and witnessed their discomfort. I heard admissions of failures from their leadership, obviously mortified at the neglect Samuel suffered. It was hugely re-traumatising, but I needed my day/s in court.


The most important outcome is knowing Samuel would be truly proud of all the efforts to get out accountability in his name. I hope sharing our story publicly will help build a legacy of change in his name.




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