Source · Prevention of Future Deaths

Thomas Lear

Date: 11 Oct 2018 Coroner: Margaret Jones Area: Stoke-on-Trent and North Staffordshire Responses identified: 0 / 2 View PDF

A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.

Date 11 Oct 2018

56-day deadline 6 Dec 2018 est.

Responses identified 0 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.

View full coroner's concerns

(1) The deceased had been released from prison on the 29"" December 2018. He was homeless and lapsed quickly back into drug An ex-partner offered him some temporary gov,uk Rory The being him taking: accommodation. On the 6 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.

(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 his 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 Upthe_urgent nature of the text messages

Report sections

Investigation and inquest

On 17/01/2018 commenced an investigation into the death of Thomas Philip Lear_ investigation concluded at the end of the inquest 1Oth October 2018. The conclusion of the inquest was suicide

Circumstances of the death

The deceased was a 39 year old single male who had no permanent address after released from prison and was currently staying with his ex-partner at His medical history included drug misuse, anxiety, depression and previous suicide attempts. He was last seen by his ex-partner at 8.20 pm on the 6th January 2018 when she asked him to leave the address as he had returned under the influence of drugs He returned to the address and after being asked to leave again made a threat to hang himself At 10.40 pm a friend found hanging from a fence post in the back garden of his partner's property. Paramedics and police attended and death was confirmed at 11.16 pm on 6th January 2018. Toxicology confirmed he had used a number of illicit drugs. There was no third party involvement_ The cause of death given was: 1a Asphyxia_ 1b Hanging:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe that you or your organisation has the power to take such action.

Copies sent to

Trent & North Staffordshire

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Shared signals

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Report details

Date of report: 11 October 2018
Coroner: Margaret Jones
Coroner area: Stoke-on-Trent and North Staffordshire

Responses identified

Responses identified 0 of 2

2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Dec 2018 (estimated).

Sent to

Staffordshire Police

Ministry of Justice

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.