Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0140, written 2 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jan 2025 |
|---|---|
| Reference | 2025-0140 |
| Deceased | James Keen |
| Coroner | Lydia Brown |
| Coroner area | West London |
| 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.
West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA Date: 2 January 2025 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Revon Healthcare CORONER I am Lydia Brown Senior Coroner for West London 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 18 December 2023 I commenced an investigation into the death of James Stephen KEEN. The investigation concluded at the end of the inquest . The conclusion of the inquest was Drug related death 1a Cardiotoxic Effects of Methamphetamine and Sildenafil 1b 1c II CIRCUMSTANCES OF THE DEATH James was found deceased in his room at December 2023. He had a history of severe mental ill-health and substance abuse, together with diagnoses of autism and ADHD. He was living in supported accommodation and had input from community mental health services and seemed to be making progress with independent living, with a number of negative drug tests conducted prior to his death. CORONER'S CONCERNS Surbiton Surrey on 8 During the course of the inquest the evidence revealed matters giving rise to concern. In my 1 2 3 4 5 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. - [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 February 2025. I, the coroner, may extend the period. 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [NAMES] . 8 I 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 Coroner. 2 January 2025 9 Signature Lydia Brown Senior Coroner for West London
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.
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) During the inquest the court was advised that the untrained support workers at the supported accommodation would conduct physical health checks including taking a temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion regarding what readings were being obtained, whether or not the readings were within normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. I can confirm that there is no expectation for healthcare assistants [HCAs] that work in supported living services to be qualified nurses and all our healthcare assistants have completed all the mandatory training that is required to work in social care settings. However, all our support workers have been additionally provided with adequate training specific to physical health monitoring to enable them to conduct physical health checks and our staff can independently raise concerns when readings appear abnormal by calling paramedics or booking urgent GP appointments including calling GP out of hours. I can confirm that vital signs equipment within the placement are all fully functional. See updated Physical Health training our staff have additionally undertaken attached. (2) There seemed to be a real risk that the observations could give either falsely reassuring information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the support workers and lack of documentation. Following the above valid statement, all staff have undergone additional physical Health Training. Staff have good understanding of the normal ranges and are able to raise concerns where readings appear abnormal and document accordingly to ensure residents are safely supported with any physical health challenges.[ see attached training certificates ] We have also stepped up engagement with community teams to ensure they are aware that residents with physical health concerns due to ongoing class A substance misuse have now been given eviction notices to terminate the placement as these residents are unable to guarantee their own safety in the community.[ See a sample of attached relevant incident report and eviction letters to this effect] (3) There was no evidence of induction or annual training or checking support workers understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest. I can confirm that all new support workers are indeed provided with 2-week induction period and have annual mandatory training to effectively work in their role [ see attached staff training matrix]
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