PFD report

Thomas Philip Lear · Prevention of Future Deaths report

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Issued 11 Oct 2018•Stoke-on-Trent and North Staffordshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear 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
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

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 raised2

  1. Failure to provide out-of-hours access to urgent Integrated Offender Manager communications
  2. Lack of post-release accommodation assistance
    Part of recurring concern: Failure to secure suitable accommodation for people released from prison
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 provide out-of-hours access to urgent Integrated Offender Manager communications

Wider context from the report

“(2) On Saturday 6th January 2018 he threatened to hang himself. At 3.37pm and at 5.03pm that day the mother of the deceased sent two text messages to the mobile phone of ████████is allocated Integrated Offender Manager (IOM) indicating that he had threatened to hang himself. The IOM phone number is only available Monday-Friday and there was no apparent divert to any other number which might have picked up the urgent nature of the text messages. ”

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

Lack of post-release accommodation assistance

Wider context from the report

“(1) The deceased had been released from prison on the 29th December 2018. He was homeless and lapsed quickly back into drug taking. An ex-partner offered him some temporary accommodation. On the 6th January she refused him admission to her house because he was clearly under the influence of drugs. Shortly after he hung himself in the rear garden at her address. It was not apparent at the inquest that any help had been offered to the deceased with regards to accommodation following his release from prison. ”

Is this part of a recurring concern?

Yes — Failure to secure suitable accommodation for people released from prison.

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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