Source · Prevention of Future Deaths

Philip Ellis

Ref: 2021-0380 Date: 10 Nov 2021 Coroner: Crispin Oliver Area: County Durham and Darlington Responses identified: 1 / 1 View PDF

The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.

Date 10 Nov 2021
56-day deadline 5 Jan 2022
Responses identified 1 of 1
Alcohol, drug and medication related deaths

Coroner's concerns

AI summary
The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
View full coroner's concerns
That the deceased was able to leave the service premises unsupervised and obtain drugs in breach of the services own rules. The evidence at the Inquest indicated that there had not been a serious incident review undertaken by Free the Way into the failures of supervision in this case.

Responses

1 respondent
Free the Way Other
PDF
Action Taken

Free the Way has introduced measures including escorting clients returning from relapse to collect belongings, searching all property, and restricting unaccompanied leave. Clients entering treatment will be monitored closely and subject to regular room checks and urine screening. (AI summary)

View full response
Free the 37 Church Street Seaham County Durham SR7 7EJ WwW: freetheway com Regulation 28 Report (RePhillip Anthony Ellis) To whom it may concem: Free the are a quasi-residential treatment project, supporting individuals to recover from substance misuse related issues. We work to a peer-support model of treatment ( 12 where individuals who are further on in the program, support newer arrivals who may be struggling to adapt and understand the philosophy of 12 treatment protocols Phillip has been resident at our project on several occasions and on this occasion; he had moved on into semi-independently in his own accommodation within the local area. Phillip continued to receive support from the project as and when requested. However; he had gotten into a relationship and was therefore spending a lot of his time in Darlington where his family also reside. Whenever he presented to the project either requesting support; or on a drop-in basis he always presented lucid and there were no concerns as t0 his well-being: While Phillip was allowed to return to his to collect clothing; to re-entering treatment with us, and this was unaccompanied this has certainly raised issues and something that needs to be addressed in the future. Phillip was also allowed to leave the project, in the company, of another resident and in accordance with our peer-support model of care, however; this could also have provided Phillip with the opportunity of purchasing and paraphemalia and another issue of concern for the future Based on this evidence Free the will be introducing the following measures, with immediate effect, to ensure that any re-occurrence of such an incident iS significantly reduced: Clients re-entering treatment at Free then Way following relapse, will be escorted to their own homes, if required; to collect their property and possessions 2 All property will be searched by & member of staff prior to their return to the client 3 _ No clients entering treatment will be allowed to leave the project unaccompanied, and any client who does leave the project will require an escort from a member of staff, or another resident who is established in their own recovery with over 6 months of abstinence. This is in accordance with our peer-support model of care Clients entering treatment will be monitored closely, with those more at risk of overdose residing at a property that is staffed 24/7
5. All clients will be subject to regular room checks and searches, as well as subject to regular urine screening: 6, No clients will be allowed to spend time away from the project until are 3 months Or more abstinent from all substances While we will adhere stringently to the above objectives, aS we are a quasi-residential treatment facility where clients reside in accommodation units within the community then are still free to leave at any Registered Charity No [107435 Company Limited by Guarantee Registered in England and Wales No5024637 Way Way Step) ` Step : living home prior drugs Way they they

Free the 37 Church Street Seaham County Durham SR7 7EJ WWw E reetheway com time and we are unable to mitigate such events. However; should clients leave the project without the approval of staff - will not be allowed to return to the project and their tendencies and license agreements will be terminated with Immediate effect Ifyou feel that you require any further information in respect of this issue, please don't hesitate in contacting us and we will happily oblige any further requests

Report sections

Investigation and inquest
On Third June 2021 I commenced an investigation into the death of Philip Anthony ELLIS aged 43. The investigation concluded at the end of the inquest on Tenth November 2021. The conclusion of the inquest was Narrative Conclusion - Accidental drugs related death.: I a Respiratory Failure I b Complications of Multiple Drug Toxicity I c

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2021-0380
Date of report
10 November 2021
Coroner
Crispin Oliver
Coroner area
County Durham and Darlington

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Jan 2022.

Sent to

Free the Way

Source links