Marc Davies
PFD Report
Partially Responded
Ref: 2025-0525
Coroner's Concerns (AI summary)
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
View full coroner's concerns
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.
Responses
Action Taken
Monmouthshire County Council and MJ Events have implemented a 3-tier training program for staff working in sheltered housing, including online certifications, industry-accredited first aid and awareness training, and CCTV/PSS training and licensing. (AI summary)
Monmouthshire County Council and MJ Events have implemented a 3-tier training program for staff working in sheltered housing, including online certifications, industry-accredited first aid and awareness training, and CCTV/PSS training and licensing. (AI summary)
View full response
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.
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.
Sent To
- Monmouthshire County Council
Response Status
Linked responses
1 of 2
56-Day Deadline
15 Dec 2025
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.