Jamie Lee Bennett died on May 2, 2020, just one day after being released from a 32-week sentence in jail for theft and willfully obstructing a police officer.
During a four-day inquest held this week, several prison staff spoke of the 33-year-old’s commitment to quit drugs so he could live with his son and family, remarking he was “full of life”, “excited” and “happy” on the day he left prison.
But he was found dead of a suspected overdose in his room at Norfolk Park Probation Hostel.
HIs sister said in a statement at the inquest: “He was so happy when he walked out of prison. He was so excited to see his son. He had hopes and dreams to find somewhere for him and his son to live together.
"He loved his son and he loved being a father. When I see his son they are an absolute double. He reminds me of him every time I see him.
"Jamie had the best sense of humour which often had us laughing for hours on end.”
However, at the conclusion of his inquest on April 29, assistant coroner Tanyka Rawden heard evidence of multiple failings in the care that Jamie received, both whilst in prison and in the short time that he was at the hostel where he was required to reside under the terms of his licence.
She concluded that the prison healthcare service did not formally consider retoxification or fully follow its policy in relation to see that Jamie was sent away with a ‘Naloxone kit’, an emergency drug made to reverse the effects of overdoses.
Crucially, she found there was a failure to provide information about Jamie, and that he had reduced support at the hostel in the key 48 hours after his release from prison.
She concluded that if that additional support had been put in place during that period, he might not have taken drugs or died.
She also found that there was a lack of training of staff including first aid training and how to conduct crucial welfare checks on residents and that there was a gap in staff’s knowledge in making an emergency response.
The family were supported following Jamie’s death by the charity INQUEST, which helps families following state related deaths.
Following the inquest, Ms Rawden said she intended to make two Prevention of Future Death reports to the Practice Plus Group (responsible for prison healthcare) and the Ministry of Justice, voicing her various concerns about the identified failings.
Speaking following the hearing, the family’s lawyer, Aimee Brackfield of Simpson Millar said it was ‘imperative’ that lessons were learnt to prevent further tragedy.
Laura Bennett, Jamie’s sister, said: “Jamie was a devoted and thoughtful soul who will be dearly missed. He was a loving son, father, brother, nephew, cousin and friend.
“While this Inquest has given us some answers to the questions we have had for so long, it is extremely upsetting to hear that more could, and should, have been done to help him with his recovery. Especially at a time of transition when he really needed that support.
“I hope that no one has to go through what my family has been through, and I hope that all of the findings that have come to light mean action is taken so that no one has to suffer as we have in the future.”
Aimee Brackfield from Simpson Millar added: “Today’s narrative verdict shines a light on a number of fundamental failings in the care that Jamie received. The bail hostel was a place where he should have felt safe and looked after.
“The Coroner heard evidence that information about Jamie’s substance misuse and his low tolerance to drugs as a result of his abstinence was not passed on to the bail hostel before Jamie’s release.
“Sadly, Jamie left prison without Naloxone, a potentially life-saving treatment for drug overdose, and the reasons for this were not recorded.
“The Coroner also identified that there was no plan in relation to supporting Jamie, particularly in relation to his substance misuse, when he was released to the bail hostel.”
Throughout the hearing the Coroner heard evidence from a number of witnesses, who confirmed that on May 2 Jamie was seen by a member of staff at 7am, but that member of staff did not rouse Jamie and could not confirm whether or not he was breathing.
That morning, the family became concerned having not heard from Jamie and asked another resident to check on him.
That resident raised concerns with staff, who had missed the mandatory 12 noon welfare checks.
Staff checked on Jamie as a result of the concerns raised by the family, at 1.35pm and sadly he was found unresponsive and soon after pronounced dead.
The Coroner heard that many staff did not have first aid training, they did not carry radios or first aid kits with them when checking on residents, and they were not aware of their responsibilities in relation to carrying out mandatory checks and how those checks should be carried out.
Aimee Brackfield said: “The family are truly devastated to learn that Jamie’s death could have been prevented, and it is now imperative that the coroner’s findings are acted upon, and changes made, so that others do not need to suffer in the same way that they have moving forward.”
Speaking following the hearing, the family said they were keen to raise awareness about substance misuse and how individuals can get help, having recently become aware of the service neverusealone.com which is available for individuals in need of support.