Source · Prevention of Future Deaths

James Spencer

Ref: 2017-0072 Date: 20 Mar 2017 Coroner: Lydia Brown Area: Exeter and Greater Devon Responses identified: 1 / 1 View PDF

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

Date 20 Mar 2017

56-day deadline 15 May 2017 est.

Responses identified 1 of 1

Other related deaths

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.

View full coroner's concerns

_ _ 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

1 respondent

James Spencer

20 Mar 2017 PDF

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)

View full response

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:

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

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0072
Date of report: 20 March 2017
Coroner: Lydia Brown
Coroner area: Exeter and Greater Devon

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 May 2017 (estimated).

Sent to

Stoneham Bass

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.