20 Oct 2025 Marc Daniel DAVIES · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Lack of staff training on conducting and documenting welfare checks View source Failure to reliably pass welfare information to others View source Inadequate documentation of welfare checks View source Inadequate welfare checks on residents View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marc Daniel DAVIES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Marc Daniel Davies was found unconscious at the Huntsman Hotel on 16 October 2024 after staff were alerted that he was unwell. He was not revived and died at the hotel; the inquest recorded the medical cause of death as the combined toxic effects of methadone, clonazepam and nitrazepam. The report raises concerns about inadequate welfare checks, insufficient documentation, and a lack of evidence that staff had been trained to conduct or document welfare checks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on conducting and documenting welfare checks
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably pass welfare information to others
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation of welfare checks
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate welfare checks on residents
Wider context from the report “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.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish guidance requiring welfare information in staff handovers to be acknowledged and acted upon, including when a person’s presentation changes.
Verbatim wording from the response “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).” Source location Response from Monmouthshire County Council & MJ Events
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt Welfare Response Bags and require Safe Guards to carry them during welfare checks.
Verbatim wording from the response “Having review procedures, MJ Events have adopted the use of Welfare Response Bags. Staff are required to carry the 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” Source location Response from Monmouthshire County Council & MJ Events
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and implement a prescriptive welfare-check form with recording and response guidance across all three temporary accommodation sites.
Verbatim wording from the response “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.” Source location Response from Monmouthshire County Council & MJ Events
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upgrade induction training with specific welfare-check guidance and place the protocol alongside welfare-check forms at all three sites.
Verbatim wording from the response “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.” Source location Response from Monmouthshire County Council & MJ Events
Open published response
21 Feb 2023 Andrew Mark STILL · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Failure to maintain visible chevron signage at bends View source Failure to take remedial action on a reported road-signage problem View source Failure to maintain complete bend marker provision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Mark STILL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Mark Still died at the scene after his motorcycle collided with a VW campervan on the A466 near Tintern on 3 June 2022. The concerns included an overgrown chevron sign, missing chevron markers and a lack of evidence that remedial action had been taken after the relevant authority was alerted.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain visible chevron signage at bends
Wider context from the report “There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend.
At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown . Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced.
I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take remedial action on a reported road-signage problem
Wider context from the report “There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend.
At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown. Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced.
I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete bend marker provision
Wider context from the report “There was a warning sign which alerted motorists to the forthcoming series of bends and the extended white road marking indicated a pending hazard. There was also a chevron marker closer to the bend.
At the inquest I found that Andrew had overtaken vehicles prior to the bends and would have seen the warning sign and the road markings. However, I found that the chevron sign near to the bend was overgrown. Moreover there was evidence that there had previously been 3 markers but two had been removed and not replaced .
I was informed that the relevant authority had been made aware of this problem by Gwent Police after Andrew’s death but there was no evidence at the inquest that any remedial action had been taken
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the chevron signs to improve visibility for motorists.
Verbatim wording from the response ““Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists.”” Source location Response from Monmouthshire County Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove foliage obstructing the remaining chevron marker.
Verbatim wording from the response ““Confirm that plans are in place for the chevron markers to be replaced and foliage removed from the remaining chevron marker to ensure it is visible to motorists.”” Source location Response from Monmouthshire County Council
Open published response
12 Nov 2019 Jamie Staley · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Lack of signage to alert pedestrians to the A40 and prevent entry onto the slip road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Staley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jamie Staley died immediately after being struck by a van when he accidentally wandered onto the A40 near Monmouth after drinking with friends. The inquest identified relatively easy pedestrian access to the A40 and a lack of signs warning pedestrians about or preventing entry onto the slip road as matters for consideration, although the lack of signage was not considered to have contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Monmouthshire County Council; that does not assign responsibility.
PFD Monitor interpretation Lack of signage to alert pedestrians to the A40 and prevent entry onto the slip road
Wider context from the report “The inquest determined that Jamie died after he accessed the A40 from Monmouth Town, near the Gibraltar tunnels. In considering Jamie’s movements on the night he died, the inquest determined that Jamie’s mistake had been caused by a combination of not knowing the area and being under the influence of alcohol, however access generally to the A40 in the area of was considered. Police Constable 217████████ gave evidence to the inquest and presented the findings of the Collision Investigation Report. He indicated that there is relatively easy access onto the A40 in this area and was surprised that there were no signs which could alert pedestrians to the A40, or to prevent them from entering onto the slip road .
Although lack of signage did not contribute to Jamie’s death I consider that this is a matter for consideration in preventing pedestrians from straying inadvertently onto this busy road in future .
The junction in question is the exit from the A40 travelling northbound immediately having travelled through the Gibraltar tunnels onto the B4233. The co-ordinates are 51.805620, -2.716463.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with SWTRA to identify additional safety measures for the junction.
Verbatim wording from the response “Whilst the report identifies that signage did not contribute to the accident we will continue to work with SWTRA to identify any additional measures that may improve safety on this junction.” Source location 2019-0463-Response-from-Monmouthshire-County-Council-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the A40 lies with the Welsh Government and South Wales Trunk Road Agency.
Verbatim wording from the response “The A40 is the responsibility of Welsh Government and South Wales Trunk Road Agency (SWTRA). I have copied SWTRA colleagues into this response should they wish to add any further comments.” Source location 2019-0463-Response-from-Monmouthshire-County-Council-Redacted
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations