Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0029, written 23 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Jan 2024 |
|---|---|
| Reference | 2024-0029 |
| Deceased | Thomas Langley |
| Coroner | Sabyta Kaushal |
| Coroner area | Derby and Derbyshire |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Travel Lodge 1 CORONER I am Sabyta KAUSHAL, Assistant Coroner for the coroner area of Derby and Derbyshire 2 CORONER’S LEGAL POWERS I 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 22 May 2019 I commenced an investigation into the death of Thomas Roy LANGLEY aged 24. The investigation concluded at the end of the inquest on 18 January 2024. The conclusion of the inquest was that: Thomas Roy Langley, date of birth 12th July 1994, of , had a history of mental illness to include depression, schizophrenia, learning difficulties, alcohol and drug misuse; there had been several drug overdoses. On the evening of 21st May 2019, he arrived at the Travel Lodge Hotel, County Ground Derby. During the early hours of 22nd May 2019, he took toxic levels of MDMA , which sadly resulted in his death on 22nd May 2019 at the hotel. 4 CIRCUMSTANCES OF THE DEATH Found collapsed in hotel room. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. There is no fully trained First aid trained employee on site at a Travel Lodge hotel premises for 24 hours of the day; at present there is a fully trained first aid employee on site from only 7am to 7pm. Emergency medical situations could present themselves between after 7pm and 7am and when there is only 1 Travel Lodge employee on the premises. 2. All staff employees do not presently have basic first aid training with regular follow up refresher courses. i.e. they do not have both online AND face to face practical training to assess and handle emergency medical situations that may present themselves day or night - situations that may cause an employee and residents staying at a Travel Lodge to panic. It may be the case that they have a lack of understanding of the present first aid training. This training is key at night when there is only 1 member of staff on site at a Travel Lodge hotel premises. CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 March 19, 2024. I, 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to the following – parents of the deceased Derbyshire County Council Staffordshire County Council South Derbyshire District Council Derbyshire Healthcare NHST Trust North Staffordshire Combined Healthcare Trust / Harplands Hospital Queen’s Hospital Burton who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Coroner. 9 Dated: 23/01/2024 Sabyta KAUSHAL Assistant Coroner for Derby and Derbyshire CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
11th March 2024 Ms Sabyta Kaushal Derby & Derbyshire Coroners Office Saint Katherines House Saint Mary's Wharf Mansfield Road Derby DE1 3TQ Dear Ms Kaushal Thank you for your Regulation 28 report dated 23 January 2024, concerning the circumstances relating to the passing of Mr Thomas Roy Langley, which your report confirms was sadly caused as a result of Mr Langley taking a toxic level of a number of substances at some point during his stay at the Derby Cricket Ground Travelodge on the 21st - 22nd May 2019. I have read your report in detail, and as a result I reviewed our existing first aid arrangements, paying particular reference to this incident. This review has included discussions with other departments across the wider business, as well as a review of all the incidents reported as requiring the provision of first aid assistance during 2023, which confirms, as with the review of incidents reported during 2019 which was undertaken following notification of the inquest, that the majority of the incidents that require first aid assistance still occur during the day, with only circa 9% of incidents occurring between the hours of 00:00 and 06:00. It should also be noted that the first aid provisions in place at the Derby Cricket Ground Travelodge at the time this tragic incident occurred complied with the legal obligations placed upon Travelodge by the Health & Safety (First Aid) at Work Regulations 1981 (“The Regulations”). The first aid risk assessment was undertaken as required by The Regulations, and follows the guidance set out with the Health & Safety Executive’s (“HSE”) guidance document ‘First aid at work: Guidance on regulations’, which advises that for low hazard environments, such as offices and shops, which would include Travelodge hotels, with fewer than 25 employees on duty, only 1 first aid Appointed Person is required. The guidance also states that under The Regulations, employers have no legal duty to provide first aid for non-employees / members of the public, but recommends that we consider them when undertaking our assessments, which Travelodge had done and as a result had provided the hotel management teams with basic first aid training, above what was required for a first aid Appointed Person. Travelodge reviews its safety and security policies and risk assessments on an annual basis, or more frequently if an incident occurs indicating that a review of a current policy, procedure or risk assessment is required. Prior to the incident involving Mr Langley occurring in May 2019, this risk assessment was reviewed in January 2019, and confirmed to continue to be adequate and appropriate. Additionally, it should also be noted that the pathologist specifically stated that due to the level of toxins taken by Mr Langley, no amount of first aid provision that could have been provided at the hotel would have altered the subsequently tragic fatal outcome. Having reviewed our existing arrangements, taking into account the number of incidents reported, types of injuries reported that require first aid assistance, the times of day when incidents tend to occur and the specific circumstances relating to the passing of Mr Langley, I have concluded that our existing first aid arrangements of providing basic first aid training to the members of our hotel management teams, who are generally on site at hotels during the day when the majority of incidents requiring the provision of first aid occur, continues to be adequate and appropriate. However, in light of your concerns, we have decided to extend the level of training given to all reception team members, including those who cover the night shift, to include the basic level of first aid training currently provided to our management teams. This will result in over 3,500 extra Travelodge team members being provided with basic first aid training, and will ensure that there will always be a team member on duty that has had a basic level of first aid training 24hrs a day. We are currently working through the logistics of providing this additional training to such a large number of team members, which will be implemented at the earliest opportunity this year. All other hotel team members will continue to be provided with adequate and appropriate first aid information and instruction to enable them to undertake the duties of a first aid appointed person should the need arise. Thank you for bringing your concerns to my attention. Yours sincerely Head of Safety & Security
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