Lee Colin DAVIES · Prevention of Future Deaths report

On 14th April 2016 I commenced an investigation into the death of Lee Colin DAVIES aged 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 Drug Toxicity and Bronchopneumonia.

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 9th April 2016, he was found on the floor in a toilet cubical with his trousers down and a needle in his groin. 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.

[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.

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 drug antidotes, 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.