As we headed into week two of Samuel’s inquest we had a welcome three-day weekend. It gave us an extra day of processing and recovery. I went on a spa day with my daughters to decompress and build resilience for the week ahead. I didn’t realise how much we would need it.
We started with expert witnesses commissioned by the Coroner to provide specialist knowledge on the care afforded to Samuel.
The expert Social Worker challenged Samuel’s risk planning and the lack of rigour with his missing episodes. The risk assessment was outdated and inadequate. He needed a robust trigger plan when he went missing, she stated. Croydon Children’s Services should have been leading this vital work. I’d never even heard of a trigger plan before.
The expert psychiatrist praised Samuel’s dedicated CAMHS psychiatrist although an ADHD diagnosis may have been missed. He was, however, scathing of the crisis service he was referred to 3 months before his death. They withdrew Samuel’s care after 19 days citing a lack of engagement. They should have persevered, and Samuel should have received a review from the consultant he believed. It summed up the lacklustre approach from this service.
The police witnesses gave evidence from Wednesday to Friday. I was relieved that I had no emotional attachment to these people, I’d never met them and holding their grief was not part of the picture.
As we assembled before court started, I saw multiple police personnel gathered with their legal teams. Ceremonial uniforms brought an air of intimidation. The damning Casey report into the Metropolitan police had just been released, adding to the tension.
As we entered court there were ripples of conversation from the MET police legal team. ‘We think we’ve found the psychiatric nurse who saw Samuel whilst in custody’ they declared to the Coroner. I couldn’t believe what I was hearing. How could they pull this card as they were about to give evidence? I had been led to believe for over 2 years that he’d never been seen. Court was adjourned. But it was all a red herring. An hour later we were back in court, my nerves in tatters.
Over the next 2 days, we were to hear from a range of British Transport Police and Metropolitan Police officers. Nothing could have prepared me for their evidence.
The first BTP officer described Samuel banging his head repeatedly off hard surfaces and self-harming so badly his clothes were confiscated, and he was left naked on the cell floor. The officer described this behaviour as ‘attention seeking’ and ‘fairly normal’. He failed to complete vital safeguarding forms that would have alerted other agencies to Samuel’s state. He handed it over to a colleague on the next shift who also failed to do them and yet again the next officer too. They were never completed. No one was ever alerted to Samuel’s state.
Meanwhile, Samuel was due to see both a custody nurse and a psychiatric liaison nurse. Neither happened. Three officers mistakenly stated in notes that he had been seen when he wasn’t. The psych nurse was specifically told he was ‘well known and violent’ and didn’t need to be seen. His girlfriend, arrested at the same time and displaying similarly worrying behaviours, was given a 2-hour psychiatric assessment and emergency safety plan on release.
Samuel was released from custody after 20 hours with no assessment, no safeguarding alerts and no one outside of the station knew of his high-risk behaviour. He took his life less than 48 hours later.
Each police officer sat in front of me and gave condolences. They then went on to reveal errors, omissions and how the term ‘attention seeking’ was widely used in the Croydon custody suite to describe self-harming. It was not only shocking but gut-wrenchingly painful to hear. I didn’t need their condolences. I just needed them to do their job properly. Many proudly told of changes in their rank, promotions since Samuel’s death. Talk about rubbing salt in wounds.
One police safeguarding specialist documented at midday that Samuel was ‘still volatile’. The records showed that he’d been asleep for 3 hours. She conceded her mis-observation. How easily negative language flowed.
I could understand one error, one unkind judgement but this was seven people from two different forces. Their casual approach and culture of indifference to a vulnerable adolescent left me reeling.
We don’t receive any formal mental health or suicide prevention training they declared. I found that astonishing given their role in custody suites with vulnerable people.
I have found myself both aghast at what I have heard and angry at the lack of care and compassion that Samuel received. The hideous labelling and lack of basic safeguarding were truly awful. As a mum how do I even begin to process that?
The final days of evidence ahead are focused on Samuel’s missing person report and his death. The MET police are due to give evidence again and I brace myself for what I am about to hear.
We are looking to receive a conclusion from the jury mid-week. It is complex and multi-layered. It is out of our hands. I know that our legal team and us as a family have advocated for Samuel and no matter the result, Samuel would be super proud of our efforts.
We just pray for some accountability from organisations that should have better safeguarded our boy.