Free the Way

Private and voluntary organisations · Registered charity

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First report 10 Nov 2021•Latest report 10 Nov 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
7

Described in responses

Concerns and recipient responses

Statements from Free the Way linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. County Durham and Darlington

    AI-generated summary

    Philip Anthony ELLIS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Anthony Ellis died on 28 May 2021 at a drugs rehabilitation service after self-administering drugs that he had obtained while leaving the premises unsupervised. The principal concerns were that he was able to leave the service in breach of its rules to obtain drugs, and that Free the Way had not undertaken a serious incident review into the supervision failures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Free the Way; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake serious incident reviews of supervision failures

    Wider context from the report

    “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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Free the Way; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to supervise service users to prevent unsupervised departure from service premises

    Wider context from the report

    “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. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Restrict clients from spending time away from the project until achieving at least three months' abstinence.

    Verbatim wording from the response

    “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:”

    Source location

    2021-0380-Response-from-Free-the-Way_Published
    Page 1 · response
    Published 16 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require staff or suitably established recovering residents to escort clients leaving the project.

    Verbatim wording from the response

    “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:”

    Source location

    2021-0380-Response-from-Free-the-Way_Published
    Page 1 · response
    Published 16 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Closely monitor treatment entrants and house clients at higher overdose risk in continuously staffed accommodation.

    Verbatim wording from the response

    “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:”

    Source location

    2021-0380-Response-from-Free-the-Way_Published
    Page 1 · response
    Published 16 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Escort relapsed clients to their homes to collect property before re-entering treatment.

    Verbatim wording from the response

    “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:”

    Source location

    2021-0380-Response-from-Free-the-Way_Published
    Page 1 · response
    Published 16 November 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Because clients live in community accommodation, they remain free to leave, and such departures cannot be mitigated.

    Verbatim wording from the response

    “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”

    Source location

    2021-0380-Response-from-Free-the-Way_Published
    Page 1 · response
    Published 16 November 2021

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026