Samuel Stewart
12 Nov 2025 · Coroner Lydia Brown · West London
The coroner's concerns
1. lack of action after positive drug test
“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. unclear pathways after positive drug test
“pathways after a positive test result were either not followed or unclear”
3. missed opportunity for support after positive drug test
“An opportunity was missed to support [name redacted] and discuss this with him”