Lee Davies
PFD Report
All Responded
Ref: 2016-0239
All 1 response received
· Deadline: 23 Aug 2016
Coroner's Concerns (AI summary)
Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The evidence revealed that staff, including night staff at the hostel, have no direct training or guidance on what steps should be taken when a resident is found in circumstances which suggest that they may have _injected or otherwise take illicit drugs aged Drug groin.
The training which they are given, known as a Harm Reduction Course, has some focus on recognising the signs of an overdose and, in appropriate cases, administering opiate antidoles, but does not give any guidance or training on monitoring and safeguarding a resident in this situation: Given that many of the residents in this hostel are likely to have alcohol or drug issues, a lack of guidance or training is likely to lead to future deaths in circumstances in which residents are simply put to bed and left without any form of ongoing monitoring:
The training which they are given, known as a Harm Reduction Course, has some focus on recognising the signs of an overdose and, in appropriate cases, administering opiate antidoles, but does not give any guidance or training on monitoring and safeguarding a resident in this situation: Given that many of the residents in this hostel are likely to have alcohol or drug issues, a lack of guidance or training is likely to lead to future deaths in circumstances in which residents are simply put to bed and left without any form of ongoing monitoring:
Responses
Action Planned
The Wallich will present a PowerPoint on 'Dealing with Drug Overdose' to staff by the end of August 2016, revise their policy to include Cymorth Cymru's guidance by August 2016, and revise their e-learning module by September 2016. (AI summary)
The Wallich will present a PowerPoint on 'Dealing with Drug Overdose' to staff by the end of August 2016, revise their policy to include Cymorth Cymru's guidance by August 2016, and revise their e-learning module by September 2016. (AI summary)
View full response
Dear Mr Barkley Following your report under Regulation 28 Report to Prevent Future Deaths, write to advise on the action proposed to be taken by The Wallich and action taken to date to prevent future deaths_ The Wallich is a Welsh charity working with homeless and vulnerably housed people. Following the death of Lee Colin Davies Wallich completed a review of its policy and guidance for working with users. Action: Frontline hostel staff to receive instruction and guidance by hostel management via team meetings and one to one instruction: PowerPoint point presentation 'Dealing with Overdose' to be presented and discussed with all staff members by the end of August 2016_ Risk of overdose to be monitored via team meetings and organisational wide health & Safety Committee to take on a monitoring role immediate_ The Wallich policy to be revised to include guidance from Cymorth Cymru' s specifically designed for support workers working with users. Completion August 2016_ The Wallich e-learning module to be revised to include updated guidance and rolled out across the organisation September onwards Should you require further information or clarity please do not hesitate to contact me_
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
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2020-0261
Sent to: Midlands Partnership NHS Foundation TrustAll responded
This report (2016-0239) is shown above.
Sent To
- Wallich Centre
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Aug 2016
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 14h April 2016 commenced an investigation into the death of Lee Colin DAVIES 36_ The investigation concluded at the end of the inquest on 15th June 2016. The conclusion of the inquest was a "Drug Related" and the medical cause of death was 1a Combined Toxicity and Bronchopneumonia
Circumstances of the Death
Lee Colin DAVIES was residing at a resettlement hostel for the homeless as from 1st April 2016 as an emergency placement: He was known to have been an intravenous user of illicit drugs for some years. In the early hours of the morning, around 0145hrs, on gth April 2016, he was found on the floor in a toilet cubical with his trousers down and a needle in his He was later assisted to his feet and taken back to his room by a fellow resident When checked the following morning around 10am, he was discovered unresponsive lying on his bed and declared deceased shortly afterwards by the attending paramedics_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.