Multiple failures at a Newbury hostel contributed to the tragic death of a 34-year-old resident, a coroner has ruled.

Jamie Lee Ralph, also known as Ralphie, passed away at Two Saints in Newbury on July 6, 2023, after experiencing an unwitnessed fall just hours before.

The 34 year old had been residing at the West Berkshire Council-approved service for several months, where he was tackling alcohol dependency and Type 2 diabetes.

In an inquest held today (15/7), assistant coroner Priya Malhotra ruled that his death was partly due to several failings at the centre, located in Newtown Road.

Tragic shortcomings included failing to contact medical services following Mr Ralph's fall, a lack of staff knowledge of the nearest defibrillator, and the fact monitoring was not undertaken despite a fall and withdrawal symptoms being previously reported.

After the inclusion of 14 witness statements, Reading Coroner’s Court heard that the coroner had concerns about observations and basic welfare checks despite the facility putting policies in place to prevent such an incident from occurring.

Recording her verdict, assistant coroner Priya Malhotra said: “In conclusion, I believe that after hearing the evidence and seeking the advice of medical professionals around this case, that the failings at Two Saints were causative of his death.

“This is on the evidence given that he had not been observed in over an hour. Earlier assistance and advice could have been taken to prevent Ralphie’s death. This is on the balance of probabilities that his death was due to a fall on July 5.”

The court heard how Ralphie was seen to be going to through withdrawal symptoms from alcohol dependency prior to his death. It is believed that the resident had an unwitnessed fall in his room between 5:30pm and 6pm on July 5 and was put on monitoring every 30 minutes, before being taken off it a few hours later to allow for sleep.

The next day, fellow resident and friend Benjamin entered his room and reported that Ralphie was experiencing full-body shakes and went to get him alcohol to relieve the withdrawal symptoms. Upon returning, it was reported that the 34-year-old was slumped over on his bed and unresponsive.

After calling paramedics at 12:04pm, staff at the facility started CPR as advised by 999 medical staff. Paramedics arrived at 12:14pm and took over. Despite 30 minutes of life-saving care, Ralphie was tragically pronounced dead at 12:46pm.

During the inquest, evidence was taken from Nazin Silentium, who was at the time working within the hostel.

When asked about the service, she said: “Medical situations in Two Saints had become far too normalised when ever I was working there. 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.”

Two Saints confirmed that at the time many of their staff were agency workers and were unaware of some policies and necessary information.

Following the Mr Ralph's death, the support manager for Two Saints Donna Ind said that brand-new protocols to avoid future incidents have been adopted and future training has been implemented.

She added: “We don’t use the agency that we were using during the incident anymore and it is very rare that we use agency staff. It is mostly full-time staff and relief workers.

“We now have 34 policies which everyone is required to read before working.”

Prior to his death, Ralphie was reportedly making steps to transfer to a rehabilitation facility with the hope of recovering from his alcohol addiction.