Recipient

Free the Way

First report 10 Nov 2021•Latest report 10 Nov 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Registered charity. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

10 Nov2021
County Durham and Darlington
Concerns raised2
1. Failure to undertake serious incident reviews of supervision failures
2. Failure to supervise service users to prevent unsupervised departure from service premises
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Restrict clients from spending time away from the project until achieving at least three months' abstinence.
  Stated planned
2. Action
  Require staff or suitably established recovering residents to escort clients leaving the project.
  Stated planned
3. Action
  Closely monitor treatment entrants and house clients at higher overdose risk in continuously staffed accommodation.
  Stated planned
1. Action
  Escort relapsed clients to their homes to collect property before re-entering treatment.
  Stated planned
Respondent positions 1
1. Position
  Because clients live in community accommodation, they remain free to leave, and such departures cannot be mitigated.
  Unable to act
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

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to undertake serious incident reviews of supervision failures

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

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 4

Respondent positions 1