James Keen

I am Lydia Brown Senior Coroner for West London

On 18 December 2023 I commenced an investigation into the death of James Stephen KEEN. The investigation concluded at the end of the inquest . The conclusion of the inquest was Drug related death 1a Cardiotoxic Effects of Methamphetamine and Sildenafil 1b 1c II

James was found deceased in his room at [REDACTED] Surbiton Surrey on 8 December 2023. He had a history of severe mental ill-health and substance abuse, together with diagnoses of autism and ADHD. He was living in supported accommodation and had  input from community mental health services and seemed to be making progress with  independent living, with a number of negative drug tests conducted prior to his death.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) During the inquest the court was advised that the untrained support workers at the  supported accommodation would conduct physical health checks including taking a  temperature, oxygen saturation readings and pulse. The evidence was unclear as to whether blood pressure readings were taken. It was apparent that there was considerable confusion  regarding what readings were being obtained, whether or not the readings were within  normal limits, and what (if anything) the staff did with the results. The court was advised the thermometer at the home was broken. (2) There seemed to be a real risk that the observations could give either falsely reassuring  information and miss evolving ill-health indicators or be needlessly alarming for residents, by suggesting normal results were in fact abnormal, given the paucity of understanding of the  support workers and lack of documentation. (3) There was no evidence of induction or annual training or checking support workers  understanding and ability to effectively carry out this quasi-nursing role, or that the qualified staff appreciated the lack of knowledge displayed in the evidence at inquest.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.