Benjamin NELSON-ROUX · Prevention of Future Deaths report

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Issued 23 Mar 2023•North Yorkshire and York

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Lack of residential substance misuse treatment facilities for under-18s
  2. Failure to search beyond the county boundary for suitable accommodation

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. North Yorkshire Council

    Review Young People’s Pathway accommodation capacity, including whether acceptable supported accommodation levels and emergency provision remain available.

  2. North Yorkshire Council

    Train operational staff responsible for the Joint Working Protocol and provide ongoing updates after its revisions are completed.

  3. North Yorkshire Council

    Explore relationships with neighbouring housing authorities بشأن suitable accommodation for under-18s, potentially including signposting to registered social landlords.

  4. North Yorkshire Council

    Review and update the Joint Working Protocol to reflect North Yorkshire Council’s unitary authority arrangements.

  5. North Yorkshire Council

    Amend the accommodation pathway to assess the possibility and suitability of out-of-area placements when local accommodation is unavailable.

  6. North Yorkshire Council

    Review and update the escalation process for cases lacking suitable local accommodation, including its incorporation into the Joint Working Protocol.

  7. Department of Health and Social Care

    Invest £532 million in delivering the drug strategy, including support for substance misuse services.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. North Yorkshire Council

    Residential substance-misuse treatment provision for under-18s will be addressed by the Coroner directly with the Secretary of State.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Department of Health and Social Care

    Residential substance-misuse treatment is not best practice for most young people because community-based, coordinated interventions are generally as effective.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. Department of Health and Social Care

    Local partners, led by Children’s Services, are responsible for planning suitable residential arrangements for young people with complex needs.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of residential substance misuse treatment facilities for under-18s

Wider context from the report

“2. The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to search beyond the county boundary for suitable accommodation

Wider context from the report

“1. The search for suitable accommodation (in this instance for a homeless 16 year old Child in Need) did not extend beyond the County boundary. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Review Young People’s Pathway accommodation capacity, including whether acceptable supported accommodation levels and emergency provision remain available.

Verbatim wording from the response

“The number of units of accommodation available is reviewed under the Young People’s Pathway via quarterly contract meetings with the providers.”

Source location

Response from North Yorkshire Council
Page 3 · response
Published 27 March 2023

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

Train operational staff responsible for the Joint Working Protocol and provide ongoing updates after its revisions are completed.

Verbatim wording from the response

“All operational staff who have responsibility for using the Joint Working Protocol will receive training and ongoing updates once revisions are completed.”

Source location

Response from North Yorkshire Council
Page 4 · response
Published 27 March 2023

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

Explore relationships with neighbouring housing authorities بشأن suitable accommodation for under-18s, potentially including signposting to registered social landlords.

Verbatim wording from the response

“The Council will explore the possibilities of establishing relationships with neighbouring local housing authorities regarding potential suitable housing accommodation for persons under 18. This would possibly signpost to registered social landlords.”

Source location

Response from North Yorkshire Council
Page 3 · response
Published 27 March 2023

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

Review and update the Joint Working Protocol to reflect North Yorkshire Council’s unitary authority arrangements.

Verbatim wording from the response

“The proposal is to review and update the Joint Working Protocol “Provision of accommodation for 16 and 17 year olds who are Homeless or threatened with Homelessness in North Yorkshire – Joint Working Protocol V8” as a consequence of the new unitary status. This document outlines the Young People’s Pathway for 16 and 17 year olds.”

Source location

Response from North Yorkshire Council
Page 3 · response
Published 27 March 2023

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

Amend the accommodation pathway to assess the possibility and suitability of out-of-area placements when local accommodation is unavailable.

Verbatim wording from the response

“The accommodation pathway will be amended to review the possibility and suitability of any out of area placement, in the cases of a young person where accommodation is not available within the local authority area.”

Source location

Response from North Yorkshire Council
Page 3 · response
Published 27 March 2023

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

Review and update the escalation process for cases lacking suitable local accommodation, including its incorporation into the Joint Working Protocol.

Verbatim wording from the response

“Any case where there is lack of suitable accommodation for a young person in the North Yorkshire area will be raised with a senior manager. The escalation process will be reviewed to reflect changes to North Yorkshire Council and included in the joint working protocol.”

Source location

Response from North Yorkshire Council
Page 3 · response
Published 27 March 2023

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

Invest £532 million in delivering the drug strategy, including support for substance misuse services.

Verbatim wording from the response

“The government recognises that there is a need to improve specialist community drug and alcohol services for children and young people. We hope that the £532million of supplemental funding that we are investing in the delivery of the drug strategy will allow local authorities to meet the needs of residents that have substance misuse needs – including children and young people.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 March 2023

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

Residential substance-misuse treatment provision for under-18s will be addressed by the Coroner directly with the Secretary of State.

Verbatim wording from the response

“2. The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18.”

Source location

Response from North Yorkshire Council
Page 1 · response
Published 27 March 2023

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

Residential substance-misuse treatment is not best practice for most young people because community-based, coordinated interventions are generally as effective.

Verbatim wording from the response

“The provision of inpatient or residential substance misuse interventions for young people away from home is only appropriate in a few, complex case and there is limited demand for residential rehabilitation – which provides an adult-oriented addiction model – for children and young people.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 27 March 2023

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

Local partners, led by Children’s Services, are responsible for planning suitable residential arrangements for young people with complex needs.

Verbatim wording from the response

“Where inpatient or residential support is assessed as required for young people with complex needs, local partners should come together to plan the most suitable arrangement. This may involve the young person being accommodated in temporary fostering arrangements or a child and adolescent mental health inpatient unit with support provided from the local young people’s specialist substance misuse service.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 March 2023

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

Official responses located
2/2

Data last updated 7 September 2026