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Jury finds “catalogue of errors” by staff contributed to death of prisoner in HMP Lewes

5 December 2023
Media Release

Inquest proceedings touching upon the death of Stephen Coster
Before HM Assistant Coroner Rachel Redman
Hastings Coroner’s Court
28 November 2023 – 4 December 2023

A jury has found that a “catalogue of errors” from prison and healthcare staff at HMP Lewes possibly contributed to the death of inmate Stephen Coster.

Stephen, 43, died while on remand at HMP Lewes on 5 May 2022. An inquest hearing before a jury took place at Hastings Coroner’s Court from 28 November 2023 – 4 December 2023.

Stephen was found on his cell floor naked, shaking and unable to respond verbally to staff between 5 – 5.30am on the morning of 3 May 2022.

The jury found that healthcare failed to escalate Stephen’s treatment to a more thorough assessment. Both healthcare and prison staff assumed he was under the influence of illicit substances, namely spice. The nurse who attended Stephen told the jury that he “did not present as physically unwell,” and that it would have been easier for her to call an ambulance “if I could have been bothered.”

The jury concluded that healthcare staff failed to provide Stephen with an appropriate care plan, and inadequate communications resulted in a lack of coordinated check on Stephen’s condition.

The jury, having heard from officers that they were not trained to recognise the signs and symptoms of a spice attack, damningly concluded that “a lack of knowledge of processes and procedures lead to a catalogue of errors.”

Stephen was checked later at around 8.30am, and continued to present with similar symptoms. This time an ambulance was called. The jury concluded that delays to completing paperwork resulted in the ambulance being unable to leave prison grounds for over 40 minutes, despite a paramedic clearly stating that Stephen should be taken to hospital immediately with life threatening conditions. They stated that “inadequate leadership” resulted in an “unacceptable” delay.

Stephen died two days later in hospital from meningitis. He was not using illicit substances at the time of his death.

The jury found that there was a realistic possibility that the above failures more than minimally, negligibly and trivially contributed to his death.

This reflected the evidence of Dr James Whitehorn, an expert consultant in infectious diseases at Guy’s and St Thomas’ Hospitals, who opined that the healthcare staff’s assessment of Stephen at 5 – 5.30am was “not adequate”, and that it was a “realistic possibility” that the delays in getting Stephen to hospital contributed to his death.

Stephen was from Croydon. A father of one, he worked as a hod-carrier. Like any young person, he loved music, film and television.

Stephen’s mother, Wendy Newton, commented: “Going into this Inquest I wanted to know the truth about what happened to my son on the morning of 3rd May 2022. I have since learnt that prison officers and healthcare staff failed to give Stephen the treatment he needed. They did not care if he lived or died. I am pleased that the jury have found that the prison and healthcare staff’s errors were unacceptable, and possibly contributed to Stephen’s death. The thought of me never being able to see Stephen’s face again absolutely breaks my heart. I love him and miss him every day.”

Daniel Cooper of Imran Khan and Partners, solicitor for Ms Newton, commented: “If an inmate was found collapsed on their cell floor tomorrow morning in HMP Lewes, the evidence heard in this Inquest indicates that they would be assumed to be under the influence, that they would not be regularly checked on, and that if an ambulance was called, it would have to wait for over 40 minutes to leave the prison while officers completed paperwork. As the jury have found, this is unacceptable, and can lead to death. We hope this Inquest leads to changes in the prison service, which result in prisoners at HMP Lewes being provided appropriate emergency medical care moving forward.”

NOTES TO EDITORS For further information, please contact Patrick Dunne on and Lucy McKay on

The family is represented by INQUEST Lawyers Group Members Daniel Lemberger Cooper and Patrick Dunne of Imran Khan and Partners solicitors and Taimour Lay of Garden Court Chambers.

Other interested persons represented at the inquest are the Ministry of Justice (HMP Lewes) and Practice Plus Group, healthcare providers at the prison.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

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