PFD report

Marc Daniel DAVIES · Prevention of Future Deaths report

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Issued 20 Oct 2025•Gwent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Lack of staff training on conducting and documenting welfare checks
  2. Failure to reliably pass welfare information to others
  3. Inadequate documentation of welfare checks
    Part of recurring concern: Unreliable welfare-check processes for people whose health is of concern
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Establish guidance requiring welfare information in staff handovers to be acknowledged and acted upon, including when a person’s presentation changes.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.
  2. Action

    Adopt Welfare Response Bags and require Safe Guards to carry them during welfare checks.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.
  3. Action

    Issue and implement a prescriptive welfare-check form with recording and response guidance across all three temporary accommodation sites.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable welfare-check processes for people whose health is of concern.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to conduct required welfare checks on people in distress; Unreliable welfare-check processes for people whose health is of concern.

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
Page 4 · response
Published 23 October 2025

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
Page 4 · response
Published 23 October 2025

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
Page 4 · response
Published 23 October 2025

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
Page 4 · response
Published 23 October 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Maintain and produce training data and verify that Safe Guards meet their job criteria.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.
  2. 2

    Use a simulated thigh muscle to support naloxone training.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.
  3. 3

    Maintain digital training records and an employee training matrix for completed staff training.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.
  4. 4

    Implement a mandatory staff training programme with completion required by 20 October 2025.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 23 October 2025.
  5. 5

    Provide monthly toolbox talks with training updates and reminders for Safe Guards.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 23 October 2025.
  6. 6

    Provide regular management and managing-director visits to temporary accommodation sites to support staff wellbeing.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.
  7. 7

    Record staff debriefs following major incidents.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 23 October 2025.
  8. 8

    Conduct monthly Council–MJ Events meetings to review contract implementation and share good practice.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 23 October 2025.
  9. 9

    Continue developing Tier 2 training through an appointed provider and pursue Highfield accreditation.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.
  10. 10

    Provide a three-tier training programme for sheltered-housing staff covering online, accredited provider-led, and CCTV/PSS training.

    Stated by MJ Events Support Ltd and Monmouthshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.

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

Maintain and produce training data and verify that Safe Guards meet their job criteria.

Verbatim wording from the response

“MJ Events will maintain and produce training data (as mentioned in Paragraph 4 above) for all Safe Guards and ensure that all staff engaged in shifts within the Council’s temporary accommodation are meeting their job criteria.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 6 · response
Published 23 October 2025

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

Use a simulated thigh muscle to support naloxone training.

Verbatim wording from the response

“In addition, using monthly Tool-Box talks, MJ Events will provide updates and reminders to Safe Guards. This has included the purchase of a simulated thigh muscle to support naloxone training.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 5 · response
Published 23 October 2025

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

Maintain digital training records and an employee training matrix for completed staff training.

Verbatim wording from the response

“For recording and evidencing purposes, MJ Events maintain a digital folder to store certificates of all completed staff training. The detail per employee is maintained in a training matrix which is continually updated.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 4 · response
Published 23 October 2025

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

Implement a mandatory staff training programme with completion required by 20 October 2025.

Verbatim wording from the response

“In addition, MJ Events have implemented a programme of mandatory training that their staff were required to complete by 20th October 2025.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 4 · response
Published 23 October 2025

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

Provide monthly toolbox talks with training updates and reminders for Safe Guards.

Verbatim wording from the response

“In addition, using monthly Tool-Box talks, MJ Events will provide updates and reminders to Safe Guards. This has included the purchase of a simulated thigh muscle to support naloxone training.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 5 · response
Published 23 October 2025

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

Provide regular management and managing-director visits to temporary accommodation sites to support staff wellbeing.

Verbatim wording from the response

“In the event of a major incident, such as a person’s death, MJ Events already make available counselling support to their members of staff and did offer this to Safe Guards on shift on the night of Marc’s death. MJ Events are committed to ensuring the wellbeing of their staff, with regular visits by their management team and managing director to all temporary accommodation to support their staff on the ground. 24 hr Access to a manager remains in place if needed and debriefs will be recorded going forward.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 5 · response
Published 23 October 2025

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

Record staff debriefs following major incidents.

Verbatim wording from the response

“In the event of a major incident, such as a person’s death, MJ Events already make available counselling support to their members of staff and did offer this to Safe Guards on shift on the night of Marc’s death. MJ Events are committed to ensuring the wellbeing of their staff, with regular visits by their management team and managing director to all temporary accommodation to support their staff on the ground. 24 hr Access to a manager remains in place if needed and debriefs will be recorded going forward.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 5 · response
Published 23 October 2025

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

Conduct monthly Council–MJ Events meetings to review contract implementation and share good practice.

Verbatim wording from the response

“To ensure that MJ Events continue to work to the Council’s Service Specification and remain committed to monitoring and upskilling of their staff in an ever-changing environment of homelessness, the Council and MJ Events will meet on a monthly basis to review the implementation of the contract specification, share good practice, and continue with joint training of both MCC and MJ Events staff where appropriate.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 6 · response
Published 23 October 2025

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

Continue developing Tier 2 training through an appointed provider and pursue Highfield accreditation.

Verbatim wording from the response

“Furthermore, MJ Events are continuing to develop their mandatory ‘Tier 2’ training and have appointed Secure 1, Ebbw Vale, as their training provider to further enhance the quality of their training provision. This includes accreditation by ‘Highfields.’ A process that is currently ongoing and is expected to be completed in the new year.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 4 · response
Published 23 October 2025

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

Provide a three-tier training programme for sheltered-housing staff covering online, accredited provider-led, and CCTV/PSS training.

Verbatim wording from the response

“Action Taken: All MJ Events Support staff hold Security Industry Authority DS security licenses and carry out First Aid at Work training as part of the licensing process, additional to this we are now providing all staff working within the sheltered housing accommodation sector the following 3 tier training programme.”

Source location

Response from Monmouthshire County Council & MJ Events
Page 5 · response
Published 23 October 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026