Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0072, written 20 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2017 |
|---|---|
| Reference | 2017-0072 |
| Deceased | James Spencer |
| Coroner | Lydia Brown |
| Coroner area | Exeter and Greater Devon |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Stonham Bass Stoneham 2 Gosforth Parkway Gosforth Business Park Newcastle NE12 8ET 4 CORONER | am Lydia Brown assistant coroner, for the coroner area of Exeter and Greater Devon 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 31 March 2016 | commenced an investigation into the death of James Aran Spencer. The investigation concluded at the end of the inquest on 28 November 2016. The conclusion of the inquest was misadventure. The cause of death was multiple drug toxicity 4 | CIRCUMSTANCES OF THE DEATH The deceased died due to the use of illegal “street drugs” that he self injected following a prolonged period of abstinence from drug use. At the time he was living in a Bail Hostel in accordance with the terms of his license. His previous history of drug use was documented and recognised, although he had claimed to be clean from drug use while in prison and immediately following release. He was seen in his bedroom by the employed support officer the day before he was found deceased, “snoring” and lying partially clothed on his bedroom floor. Drugs paraphernalia was in clear view within the bedroom. The support officer had very little first aid knowledge or training and very little drug awareness and so did not act on these signs and left the deceased alone without requesting immediate emergency medical assistance. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — The deceased was found in a classic posture of drug-related collapse, but no action was taken due to inadequate training — “mandatory training” had not been given at the time of induction. Support officers working in this role will be likely to encounter this type of situation in a vulnerable population of recently released prisoners, and it is well recognised that the user's tolerance will have decreased after a period of withdrawal and therefore the risk of death significantly increases. The induction policy, the quality of induction of staff and ongoing training updates should all be considered to ensure better awareness of officers, and better safety for residents. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken fo prevent future deaths and | believe you have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15" May 2017. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — The family of James. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief . 9 PATE] 9 g het “pf isieneo BY CORONER] VW
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Your Ref! Date: 12" May 2017 hy Stonham HM Senior Coroner for County of Devon Exeter and Devon Coroner's Office ro U Room 226 Devon County Hall 2 Gosforth Parkway Topsham Road Gosforth Business Park Exeter Newcastle upon Tyne EX2 4QD NE12 8ET T: 0845 155 1234 F: 0845 155 0394 DX: 742490 Gosforth Park Dear Sirs, Re: James Spencer Deceased — Regulation 28 Report dated 20 March 2017 In respect of the Regulation 28 Report, we now provide our response as required. Prior to Mr Spencer's death, the organisation offered training to support officers on drug awareness. This training was a one day course covering a range of topics. This training was not mandatory for operational colleagues working on the BASS contract but was delivered subject to, and dependant on, the experience, knowledge and professional background of the colleague. Since this unfortunate incident, and due to the concerns identified within the Regulation 28 report, the drug training delivered to colleagues working on the BASS contract has been fully reviewed. Drug awareness training is now delivered to all new operational colleagues working on the BASS contract as part of their mandatory training programme. Furthermore we have also rolled this training out to existing operational colleagues by way of "refresher" training, ensuring that all colleagues will receive this training. Yours sincerely Director of Partnerships - New Models of Care OFFICIAL-SENSITIVE
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