19 May 2022 Spencer George BARR · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Lack of central points of contact for inter-agency referrals and information sharing View source Lack of a universal approach to inter-agency cooperation View source Failure of organisations to accept direct referrals from other agencies View source Failure to share relevant information adequately between agencies View source See 1 more concern
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Spencer George BARR · 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
Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.
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× 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 Young Adults Central Team, Birmingham; that does not assign responsibility.
PFD Monitor interpretation Lack of central points of contact for inter-agency referrals and information sharing
Wider context from the report “4. Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation . I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason . Consideration should be given to central points of contact being created within each agency, and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them.
” 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 Young Adults Central Team, Birmingham; that does not assign responsibility.
PFD Monitor interpretation Lack of a universal approach to inter-agency cooperation
Wider context from the report “3. I heard evidence that Birmingham Women's and Children's NHS Foundation Trust are now taking steps to improve intra-agency co-operation in an attempt to mitigate against the risk of further deaths in the future. However, I heard evidence that other agencies may not be aware of their own limitations when it comes to inter-agency co-operation. For instance, CGL gave evidence that they had no concerns regarding their co-operation with other services, but Birmingham Women's and Children's NHS Foundation Trust indicated that the connections between their respective agencies was poor. I am therefore concerned that there is no universal approach being taken by all agencies to improve inter-agency cooperation , and consideration should be given to the formation of a working group being set up between all agencies to ensure a coordinated approach is taken.
” 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 Young Adults Central Team, Birmingham; that does not assign responsibility.
PFD Monitor interpretation Failure of organisations to accept direct referrals from other agencies
Wider context from the report “5. Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies . Consideration therefore should be given as to whether there a better system of interagency referral is possible
” 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 Young Adults Central Team, Birmingham; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant information adequately between agencies
Wider context from the report “2. I heard evidence that full circumstances surrounding Spencer's deterioration and drug relapse in November 2021 - namely that he had received a significant back payment of benefits totalling over £5,000 from the DWP resulting in him purchasing drugs and overdosing - were not adequately conveyed between agencies , and as such agencies were unaware of the heightened risk of potential self harm and death that was posed by these circumstances. Inter-agency co-operation therefore appears to be inadequate , and consideration should be given to ensuring clinicians receive better training when it comes to the sharing of relevant information between agencies.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations