PFD report

Darrell Spear · Prevention of Future Deaths report

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Issued 8 Jun 2021•Manchester South

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

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

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Report evidence summary

Concerns raised3

  1. Lack of a clear strategy to address identified risks
    Part of recurring concern: Failure to establish effective plans to address identified safety concerns
  2. Poor inter-agency information sharing
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
  3. Delays in addressing identified self-neglect and hoarding risks
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

Lack of a clear strategy to address identified risks

Wider context from the report

“2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

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

Poor inter-agency information sharing

Wider context from the report

“2. The evidence before the inquest suggested that communication between agencies was poor in relation to information sharing and that there was no clear strategy to address the risk presented to both Mr Spear and his wife. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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

Delays in addressing identified self-neglect and hoarding risks

Wider context from the report

“1. The inquest heard that Mr Spear and his wife were known to agencies and that it was recognised that self-neglect and hoarding were significant issues. Their lifestyle meant that there was a significant risk to them both including from fire. Although these issues had been identified in the months preceding Mr Spear’s death it was only on 22nd September that steps were taken to arrange to clear the property later that week. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
0/1

Data last updated 7 September 2026

No official response is included in the current published snapshot.