Philip Anthony ELLIS · Prevention of Future Deaths report

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

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.

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.