Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0525, written 20 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2025 |
|---|---|
| Reference | 2025-0525 |
| Deceased | Marc Davies |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| 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 Chief Executive Of Monmouthshire County Council 2 Managing Director Of Mj Events 1 CORONER I am Caroline SAUNDERS, Senior Coroner for the coroner area of Gwent 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 18 October 2024 I commenced an investigation into the death of Marc Daniel DAVIES aged 45. The investigation concluded at the end of the inquest on 10 October 2025. The conclusion of the inquest was recorded as: Drug Related death The medical cause of death was: 1a) The combined toxic effects of methadone, clonazepam and nitrazepam The conclusion of the inquest was that: Marc Daniel Davies died at the Huntsman Hotel in Shirenewton, Chepstow on 16/10/2024 from the toxic effects of prescribed and unprescribed drugs. 4 CIRCUMSTANCES OF THE DEATH Marc Daniel Davies resided at the Huntsman Hotel in Monmouthshire. The accommodation, for people who are vulnerable and homeless, was provided by Monmouthshire County Council (MCC). On 16/10/2024, the safe guards on duty were alerted to concerns raised by friends of Marc, that he was unwell. On checking Marc, the guards noted he was not conscious but thought he was sleeping and put him in the recovery position. They did not conduct routine welfare checks thereafter, did not record the findings of their checks and did not seek medical assistance. Marc was later discovered moribund by another resident. The safeguards performed CPR and called the emergency services. Marc could not be revived and died on 16/10/2024 at the Huntsman Hotel. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) MCC contracted with MJ Events to provide safe guards; officers to ensure the security of the premises and the welfare of the residents. The officers were expected to undertake welfare checks if they had concerns about residents, including if they were under the influence of drugs or alcohol. Managers from MCC and MJ Events who gave evidence to the inquest both agreed the welfare checks undertaken by the guards on duty on 16/10/2024, and documentation completed, were inadequate. There was no evidence that the staff had received training on how to conduct welfare checks or what should be documented. A failure to check on the welfare of staff and to reliably pass that information on to others could again result in a resident not receiving medical care in a timely manner. Kindly advise me as to the training that you intend to provide to staff to ensure that they are properly equipped with the skills to discharge their duties at work. 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 December 15, 2025. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family Members And Next Of Kin I have also sent it to Not Applicable . 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 9 Dated: 20/10/2025 Caroline SAUNDERS Senior Coroner for Gwent 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.
Joint Response from Monmouthshire County
Council and MJ Events Support Ltd. to the
Coroner’s Report on the Death of Marc
Davies (16 October 2024)
Author:
Position: Housing Options Team Manager
Date: 01.12.25
Content:
1. Coroner’s concerns in relation to Monmouthshire County Council and MJ Event
Support
2. Monmouthshire County Council’s response
3. Concern one and Action taken
4. Concern two and Action taken
5. Concern three and Action taken
6. Concern four and Action taken
7. Additional Information
1. Coroner’s Concerns in relation to Monmouthshire County Council and MJ Event
Support Ltd.
Monmouthshire County Council contracts with MJ Events to provide ‘Safe Guards’ –
officers, to support the Council with the delivery of temporary homeless
accommodation. The service commissioned operates on a concierge type basis. In
respect of the Huntsman, which is privately owned and managed, the main purpose of
the service is to support the private owner with their management of their property.
The service commissioned by the Council seeks to support the owner of the Huntsman
with the security and integrity of their property/premises, whilst also supporting the
welfare of the residents. In supporting the welfare of residents, the role of Safe Guards
includes undertaking welfare checks if they have concerns about residents, including
scenarios where they have concerns about residents being under the influence of drugs
or alcohol.
The Coroner’s concerns are listed in point format below together with Monmouthshire
Council and MJ Event’s responses and action points to those concerns.
2. Monmouthshire County Council’s response to the Coroner’s findings
The tragic death of Marc Davies made a huge impact on both the Council and MJ Event
staff at the time, and we continue to offer our condolences to both his family members
and associates.
Although the outcome of the Coroner’s report was that Marc’s death may not have been
preventable, the report has given the Housing Options Service and MJ Events time to
reflect on current practices and review the joint approach, with a view to identifying
opportunity to strengthen arrangements. The Council and MJ Events have worked
together to strengthen roles and procedures ensure that clearer guidance and
monitoring of staff is undertaken to guarantee that the safety and wellbeing of residents
remain paramount and central to service delivery
Having reviewed the recording and logging of welfare checks, the Council and MJ Events
agree that there was scope to improve the consistency of the recording undertaken, on
occasions was less clear and could be subjective depending on the member of staff on
shift. The Council and MJ Events concur that a consistent and more robust approach to
welfare checks must be implemented going forward.
3. Concern one:
Managers from MCC and MJ Events who gave evidence to the inquest both agreed the
welfare checks undertaken by the guards on duty on 16/10/2024, and documentation
completed, were inadequate.
Action Taken:
MJ Events have reviewed their Welfare Check form and developed and issued a new
template form for use throughout Monmouthshire Council’s three temporary
accommodation sites. The form is more prescriptive and for the benefit of Safe Guards,
the guidance explains what detail needs to be recorded, by whom, and what action
should be taken. (See Appendix 1). This revised template form is now in use.
4. Concern two:
There was no evidence that the staff had received training on how to conduct welfare
checks or what should be documented.
Action Taken:
MJ Events have reviewed their approach to staff training. MJ Events have upgraded their
Induction Training to include specific guidance in conducting welfare checks.
The guidance / protocol is now in-situ alongside the Welfare Check form in all three
temporary accommodation sites as a refresher for those asked to conduct welfare
checks as part of their shift. (See Appendix 2).
In addition, MJ Events have implemented a programme of mandatory training that their
staff were required to complete by 20th October 2025.
Furthermore, MJ Events are continuing to develop their mandatory ‘Tier 2’ training and
have appointed Secure 1, Ebbw Vale, as their training provider to further enhance the
quality of their training provision. This includes accreditation by ‘Highfields.’ A process
that is currently ongoing and is expected to be completed in the new year.
For recording and evidencing purposes, MJ Events maintain a digital folder to store
certificates of all completed staff training. The detail per employee is maintained in a
training matrix which is continually updated.
Having review procedures, MJ Events have adopted the use of Welfare Response Bags.
Staff are required to carry they Welfare Response Bags when undertaking welfare
checks to eliminate wasted time returning to the office to collect items to support a
resident. Safe Guards will also always carry radios and body cams to
5. Concern three:
A failure to check on the welfare of staff and to reliably pass that information on to
others could again result in a resident not receiving medical care in a timely manner.
Action Taken:
Clearer staff guidance in relation to welfare checks has been established that will
ensure that that information in staff handovers (typically twice daily) is acknowledged
and acted upon if necessary. This will ensure more accountability for Safe Guards on
shift. (See Appendix 1).
There is also clearer staff guidance of what to do in the event of a person’s presentation
changing throughout the course of a shift.
In the event of a major incident, such as a person’s death, MJ Events already make
available counselling support to their members of staff and did offer this to Safe Guards
on shift on the night of Marc’s death. MJ Events are committed to ensuring the wellbeing
of their staff, with regular visits by their management team and managing director to all
temporary accommodation to support their staff on the ground. 24 hr Access to a
manager remains in place if needed and debriefs will be recorded going forward.
6. Concern four:
Kindly advise me as to the training that you intend to provide to staff to ensure that they
are properly equipped with the skills to discharge their duties at work.
Action Taken:
All MJ Events Support staff hold Security Industry Authority DS security licenses and
carry out First Aid at Work training as part of the licensing process, additional to this we
are now providing all staff working within the sheltered housing accommodation sector
the following 3 tier training programme.
Tier 1- on-line training, certificated by pro-trainings UK (mandatory prior to deployment)
• Fire safety principles level 2
• First Aid for knife attacks level 2
• Naloxone for opioid overdose
• Martyn’s Law level 1
• Welfare and Vulnerability Engagement (Wave)
• Safeguarding (group A)
Tier 2 – designed and delivered by an approved industry training provider and accredited
by Highfield
• First Aid (including pulse rates/breathing rates)
• Principles of Safeguarding
• Drug and Alcohol Awareness
• Naloxone (with practical session)
• Mental Health Awareness
Tier 3 – delivered by approved industry training provider
• CCTV / PSS training and license
In addition, using monthly Tool-Box talks, MJ Events will provide updates and reminders
to Safe Guards. This has included the purchase of a simulated thigh muscle to support
naloxone training.
7. Additional Information
To ensure that MJ Events continue to work to the Council’s Service Specification and
remain committed to monitoring and upskilling of their staff in an ever-changing
environment of homelessness, the Council and MJ Events will meet on a monthly basis
to review the implementation of the contract specification, share good practice, and
continue with joint training of both MCC and MJ Events staff where appropriate.
MJ Events will maintain and produce training data (as mentioned in Paragraph 4
above) for all Safe Guards and ensure that all staff engaged in shifts within the Council’s
temporary accommodation are meeting their job criteria.
MJ Events will continue to inform MCC of any concerns they have with those placed in
temporary accommodation 24 hours a day and can expect a rapid response to these
concerns from senior officers in the Housing Options Service under the Council’s out of
hours arrangements.
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