James Aran Spencer · Prevention of Future Deaths report

On 31 March 2016 I 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

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

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 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 user's 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.