Oliver Walter John Stephen BARNETT · Prevention of Future Deaths report

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Issued 8 May 2024•Cheshire

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in responses

Recipients and published 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.

Concerns raised1

  1. Lack of residential substance misuse treatment facilities for children under 18

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. Department of Health and Social Care

    Keep evidence, good practice, and effective service models for children’s and young people’s treatment under review.

  2. Department of Health and Social Care

    Improve treatment pathways for care leavers, young people outside mainstream education, those involved with criminal justice, and those with co-occurring mental health problems.

  3. Department of Health and Social Care

    Share good practice to support quality improvements in children’s and young people’s alcohol and drug treatment.

  4. Department of Health and Social Care

    Support local authorities through targeted assistance to improve children’s and young people’s alcohol and drug treatment.

  5. Department of Health and Social Care

    Provide £532 million in additional funding to local authorities to improve drug and alcohol treatment quality and capacity.

  6. NHS England

    Discuss all Regulation 28 reports through the national Regulation 28 Working Group.

  7. NHS England

    Share learning and insights from Regulation 28 reports across NHS national and regional teams.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Department of Health and Social Care

    Concerns about inadequate support should be addressed through the treatment service’s complaints procedure or the local authority.

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

    Community-based treatment and existing alternative residential placements are generally considered more appropriate than dedicated residential rehabilitation for young people.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Department of Health and Social Care

    Community treatment with clinical and psychosocial support is generally considered appropriate for children requiring detoxification.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. NHS England

    Residential substance misuse treatment for children and young people is outside NHS England’s remit.

    Outside remitThe respondent said that this matter was outside its role or authority.
  5. NHS England

    The Department of Health and Social Care is responsible for responding to the concerns about residential substance misuse treatment.

    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 children under 18

Wider context from the report

“There are no residential substance misuse treatment facilities for children and young persons under the age of 18 in England. If a child is acutely unwell through substance misuse, they will be treated in hospital and then discharged home to receive treatment in the community. Parents/guardians must manage the detoxification programme, and the risk of relapse, supported by substance misuse agencies. There is a disparity between the treatment offered to adults and children, and the absence of residential substance misuse facilities places children at greater risk of relapse and death by overdose. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Keep evidence, good practice, and effective service models for children’s and young people’s treatment under review.

Verbatim wording from the response

“Alongside investment in service delivery, my department is supporting Local Authorities, providing targeted support to areas which need it, sharing good practice and working to improve treatment pathways for care leavers, and young people not in mainstream education, involved with the criminal justice system or experiencing cooccurring mental health problems. As we support quality improvements in children and young people’s alcohol and drug treatment we will keep the evidence, good practice and the question of the most effective service models under review.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Improve treatment pathways for care leavers, young people outside mainstream education, those involved with criminal justice, and those with co-occurring mental health problems.

Verbatim wording from the response

“Alongside investment in service delivery, my department is supporting Local Authorities, providing targeted support to areas which need it, sharing good practice and working to improve treatment pathways for care leavers, and young people not in mainstream education, involved with the criminal justice system or experiencing cooccurring mental health problems. As we support quality improvements in children and young people’s alcohol and drug treatment we will keep the evidence, good practice and the question of the most effective service models under review.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Share good practice to support quality improvements in children’s and young people’s alcohol and drug treatment.

Verbatim wording from the response

“Alongside investment in service delivery, my department is supporting Local Authorities, providing targeted support to areas which need it, sharing good practice and working to improve treatment pathways for care leavers, and young people not in mainstream education, involved with the criminal justice system or experiencing cooccurring mental health problems. As we support quality improvements in children and young people’s alcohol and drug treatment we will keep the evidence, good practice and the question of the most effective service models under review.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Support local authorities through targeted assistance to improve children’s and young people’s alcohol and drug treatment.

Verbatim wording from the response

“Alongside investment in service delivery, my department is supporting Local Authorities, providing targeted support to areas which need it, sharing good practice and working to improve treatment pathways for care leavers, and young people not in mainstream education, involved with the criminal justice system or experiencing cooccurring mental health problems. As we support quality improvements in children and young people’s alcohol and drug treatment we will keep the evidence, good practice and the question of the most effective service models under review.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Provide £532 million in additional funding to local authorities to improve drug and alcohol treatment quality and capacity.

Verbatim wording from the response

“Additional funding of £532 million over three years from 2022/23 to 2024/25 has been given to local authorities to improve the quality and capacity of drug and alcohol treatment.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Discuss all Regulation 28 reports through the national Regulation 28 Working Group.

Verbatim wording from the response

“Although NHS England is not able to respond to the specific issues set out within your Report, I would like to provide an assurance on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 1 · response
Published 28 June 2024

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

Share learning and insights from Regulation 28 reports across NHS national and regional teams.

Verbatim wording from the response

“Although NHS England is not able to respond to the specific issues set out within your Report, I would like to provide an assurance on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 1 · response
Published 28 June 2024

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

Concerns about inadequate support should be addressed through the treatment service’s complaints procedure or the local authority.

Verbatim wording from the response

“Relapse prevention support should be provided for as long as it is needed. Throughout this process, it is important that parents feel supported by the drug and alcohol treatment service managing their child’s care and appropriately involved in the intervention – parents should not be left to feel they are managing the process on their own. Any parent who feels they are not receiving an adequate service should use the treatment service’s complaints procedures or contact their local authority if they feel their concerns are not being addressed.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Community-based treatment and existing alternative residential placements are generally considered more appropriate than dedicated residential rehabilitation for young people.

Verbatim wording from the response

“Substance misuse among children and young people typically cooccurs with and compounds other problems and vulnerabilities. Therefore, it is important that links are maintained with their family and positive social networks, as well as other sources of support including child social workers, schools, youth offending teams and mental health services. Differences in emotional and cognitive development, problem awareness and readiness for change, as well as consent and safeguarding issues, all require a different approach and mean that residential rehabilitation is not one that easily translates from adult to young peoples’ service provision.”

Source location

Response from DHSC
Page 2 · response
Published 28 June 2024

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

Community treatment with clinical and psychosocial support is generally considered appropriate for children requiring detoxification.

Verbatim wording from the response

“Having taken advice from my officials, my understanding is that it is rare for detoxification to be clinically appropriate for a child under 18. In instances where it is judged appropriate, as in the case of Oliver, then in line with national clinical guidelines, most cases can be managed in the community with appropriate clinical and psychosocial support provided by community drug and alcohol treatment service in partnership with a local NHS hospital or mental health trust.”

Source location

Response from DHSC
Page 1 · response
Published 28 June 2024

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 for children and young people is outside NHS England’s remit.

Verbatim wording from the response

“Treatment for substance misuse is not something that comes under NHS England’s remit, although my colleagues from our national Mental Health, Prevention and Children and Young People Teams have been sighted on your Report.”

Source location

Response from NHS England
Page 1 · response
Published 28 June 2024

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

The Department of Health and Social Care is responsible for responding to the concerns about residential substance misuse treatment.

Verbatim wording from the response

“I note that you have also addressed your Report to the former Secretary of State for Health and Social Care, Victoria Atkins MP. The Department of Health and Social Care is the appropriate organisation to respond to your concerns.”

Source location

Response from NHS England
Page 1 · response
Published 28 June 2024

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

Data last updated 7 September 2026