Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0380, written 10 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2021 |
|---|---|
| Reference | 2021-0380 |
| Deceased | Philip Ellis |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 CORONER 1 , Manager, Free the Way, 37 Church Street, Seaham, County Durham, SR7 7EJ I am Crispin OLIVER, Assistant Coroner for the area of County Durham and Darlington 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 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 II 4 CIRCUMSTANCES OF THE DEATH Died on 28 May 2021 at 13 Glebe Terrace, Easington, at 20:41. Phil had been admitted to a drugs rehabilitation service on 26 May 2021. In breach of the supervision rules for service users he was able to leave the service premises unsupervised and obtain drugs, which he brought into the service premises. He self administered them on the premises, where he died. Specifically, the evidence heard at the Inquest confirmed that Phil Ellis had been able to access his home unsupervised whilst collecting clothing on 28th May. Furthermore, on a separate occasion he had been able to leave the service premises unsupervised to go into the community and meet people. On either or both occasions he could have, and probably did, obtain the drugs and drug paraphernalia implicated in his death. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 05 January 2022. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Crispin OLIVER Assistant Coroner for County Durham and Darlington Dated: 10 November 2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Free the Way 37 Church Street Seaham County Durham SR7 7EJ www.freetheway.com Regulation 28 Report (Re. Phillip Anthony Ellis) To whom it may concern: Free the Way 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 Step) where individuals who are further on in the program, support newer arrivals who may be struggling to adapt and understand the philosophy of 12 Step treatment protocols. Phillip has been resident at our project on several occasions and on this occasion, he had moved on into living 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 to his well-being. While Phillip was allowed to return to his home to collect clothing, prior 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 drugs and paraphernalia and another issue of concern for the future. Based on this evidence Free the Way will be introducing the following measures, with immediate effect, to ensure that any re-occurrence of such an incident is significantly reduced: 1. 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 a 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. 4. 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 they 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 they are still free to leave at any Registered Charity No 1107435 Company Limited by Guarantee Registered in England and Wales No. 5024637 Free the Way 37 Church Street Seaham County Durham SR7 7EJ www.freetheway.com time and we are unable to mitigate such events. However, should clients leave the project without the approval of staff they will not be allowed to return to the project and their tendencies and license agreements will be terminated with immediate effect. If you 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. Yours sincerely, B ly ~ AL AT Y Project Manager} Registered Charity No 1107435 Company Limited by Guarantce Registered in England and Wales No. 5024637
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