Coroner rules failings at Newbury’s Two Saints hostel contributed to Jamie Lee Ralph’s death
Multiple failings at a homeless hostel contributed to a resident’s death, a coroner has ruled.
Shortcomings at Two Saints in Newtown Road were highlighted in damning testimony by a whistleblower who said: “This is not a safe place to work.”
The evidence was heard at an inquest in Reading Town Hall on Monday (July 15), into the death of Jamie Lee ‘Ralphie’ Ralph last July 6.
Mr Ralph had fallen, unobserved, and struck his head while suffering shakes triggered by severe alcohol withdrawal, leading to a fatal bleed on the brain.
Staff put him on regular monitoring but discontinued it so he could sleep.
The next day, a fellow resident and friend named Ben reported that Mr Ralph was experiencing full-body shakes and so he went to get him alcohol to relieve the withdrawal symptoms.
But when he returned, he found his friend slumped, unconscious, on the bed.
Staff and then paramedics tried in vain to resuscitate him.
A member of staff at the time, Nazia Silentium, said in a statement that she felt colleagues did not have the “appropriate knowledge, training or facilities” for dealing with high risk clients.
She said: “I wasn’t given training in how to deal with alcohol issues…medical emergencies and withdrawals had become far too normalised.
“It was not a safe place to work, and now that I have worked in other facilities I can see how dangerous it is.
“The lack of support and lack of staff gave me concern but whenever I challenged this, I was told I had an issue following authority.”
The hostel was “extensively understaffed, often relying on untrained agency staff,” she added.
Another staff member, Cassandra Chavlet, said that, when Mr Ralph was discovered unconscious, emergency services asked her to get a defibrillator.
However, she believed the one on site was broken and so she drove to a nearby Tesco to get one.
Hostel support manager Donna Ind said she was upset by Ms Silentium’s testimony.
The coroner asked: “Why are you upset?
“This is someone who worked there who formed the opinion that it wasn’t a suitable or safe place to work; leaving aside personal issues, help me understand why that isn’t a fair assessment of how it was in July last year.
“Just from your own evidence I’ve identified a number of issues: monitoring wasn’t properly undertaken; medical assistance wasn’t sought, documentation wasn’t properly prepared and members of staff not knowing there was a working defibrillator on site.
“It doesn’t paint a picture of an organisation that was particularly well run or knew what was happening…help me if I’ve got that wrong.”
An emotional Ms Ind said: “I think we did everything we could.”
She said there had, indeed, been problems recruiting staff at the time, and a senior staff member had been on long term sick leave.
Ms Ind told Mr Ralph’s family who attended the inquest: “We’re very sorry for what happened to Jamie - he was really well loved at Two Saints, by both staff and clients.”
And she outlined a number of lessons learned and improvements made since Mr Ralph’s death.
Summing up, assistant Berkshire coroner Priya Malhotra said a subdural haemorrhage was the direct cause of death but noted that “no medical attention or advice was sought following the fall” and that proper monitoring did not take place.
In addition staff had insufficient knowledge of the on-site defibrillator.
Ms Malhotra said these and other failings were “causative of death more than minimally, negligibly or trivially” and concluded death was due to an unwitnessed fall “contributed to by service delivery issues”.
She went on to praise Ms Ind and Two Saints for the improvements made but asked to see future audits in September because of “niggling concerns” that remained.
Ms Malhotra said she would then advise, in writing, whether she would make recommendations to prevent future deaths.
