Benjamin Nelson-Roux: Prevention of future deaths report

Child Death (from 2015)Other related deaths

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Date of report: 23/03/2023

Ref: 2023-0103

Deceased name: Benjamin Nelson-Roux

Coroner name: Jon Heath

Coroner Area: North Yorkshire and York

Category: Other related deaths | Child Death (from 2015)

This report is being sent to: Harrogate Borough council, North Yorkshire County Council and Department for Health and Social Care

[REDACTED], Chief Executive Harrogate Borough Council,
[REDACTED], Chief Executive North Yorkshire County Council
Rt Hon Steve BARCLAY MP, Secretary of State for Health and Social Care
I am Jon HEATH, Senior Coroner for the coroner area of North Yorkshire and York
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 14 April 2020 I commenced an investigation into the death of Benjamin NELSON-ROUX aged 16. The investigation concluded at the end of the inquest on 13 March 2023. The conclusion of the inquest was a narrative:  

On 8 April 2020 Benjamin Nelson Roux, aged 16 and a Child in Need, was found unresponsive at 23 Robert Street, Harrogate, a hostel for homeless adults in which he had been temporarily placed due to there being no more suitable accommodation available. His death was confirmed there at 16.50 hours that day. The cause of his death is unascertained. He had taken multiple drugs of abuse prior to death, the impact of which cannot be determined with any degree of confidence. It cannot be concluded that his accommodation has contributed to his death.
Ben Nelson Roux was 16 years of age and a Child in Need. He was a regular user of alcohol and drugs of abuse which impacted on his relationship with his family, his offending behaviour (he was a victim of child criminal exploitation) and his physical and mental health. He became homeless and was placed in an adult hostel as there was no other suitable accommodation in the County he lived in at the time. He was found deceased on the 8 April 2020. He had taken multiple drugs of abuse prior to his death the impact of which could not be determined with any degree of confidence.
During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.  

The MATTERS OF CONCERN are as follows:  
The search for suitable accommodation (in this instance for a homeless 16 year old Child in Need) did not extend beyond the County boundary.The lack of any residential substance misuse treatment facilities for children and young persons under the age of 18.
In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by May 18, 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
North Yorkshire Police
Tees Esk and Wear Valley NHS Trust Harrogate and District NHS foundation trust
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.
923/03/2023 Jon HEATH, Senior Coroner for North Yorkshire and York