UK Inquiry Tracker

James Spencer

PFD Report All Responded Ref: 2017-0072

Date of Report 20 March 2017

Coroner Lydia Brown

Coroner Area Exeter and Greater Devon

Response Deadline est. 15 May 2017

Other related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 15 May 2017

Coroner's Concerns (AI summary)

Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.

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_ _ 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_ day Drugs and drug 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 users 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

Responses

James Spencer

20 Mar 2017

Action Taken
Drug awareness training is now mandatory for all new operational colleagues working on the BASS contract and has been rolled out as refresher training for existing colleagues. (AI summary)

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Dear Sirs , Re: James Spencer Deceased Regulation 28 Report dated 20th 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 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. 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:

Sent To

Stoneham Bass

Response Status

Linked responses 1 of 1

56-Day Deadline 15 May 2017

All responses received

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 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

Circumstances of the Death

The deceased died due to the use of illegal 'street drugs" that he self injected following 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 before he was found deceased, 'snoring" and lying partially clothed on his bedroom floor. paraphernalia was in clear view within the bedroom The support officer had very little first aid knowledge or training and very little awareness and so did not act on these signs left the deceased alone without requesting immediate emergency medical assistance.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action