Spencer Barr

Birmingham Children’s Hospital 
Steelhouse Lane 
Birmingham 
B4 6NH 

Tel: 

PFD7715 
30th June 2022 

HM Senior Coroner for Birmingham and Solihull 
50 Newton Street  
Birmingham  
B4 6NE 

Dear Coroner for Birmingham and Solihull, 

Re: Response to Regulation 28 Report to Prevent Future Deaths 

We are writing in response to the Regulation 28 Report to Prevent Future Deaths report following 
the inquest into the tragic death of Spencer Barr. We would like to express our condolences to the 
family and friends of Spencer, who have clearly lost a very special person.  

The Regulation 28 report highlighted a number of concerns and was sent to other key mental 
health partners. Colleagues from Birmingham Women's and Children's NHS Foundation Trust 
(responsible for Forward Thinking Birmingham, FTB) and Change Grow Live - CGL (Birmingham city 
council public health commissioned service) recognised the need for close collaboration, and we 
have met to discuss the raised concerns and work on a joint response and plan of action.  

We hope that it fully addresses the concerns raised in the report and emphasises the important 
developments taking place across Birmingham.  

Your matters of concern were 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1)  In the months prior to his death, Spencer had been under the care of multiple agencies, 

including Referral Management Team (RMC) (part of Birmingham Women's and Children's 
NHS Foundation Trust), as well as the addiction service Change Grow Live (CGL); the Young 
Adults Central Team of the Probation Service; and Birmingham and Solihull Mental Health 
NHS Foundation Trust. 

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. 

Response to 1 & 2 above  
It is important to clarify that no current process exists nationally or in policy that would have 
enabled or required the DWP to seek out information about a person’s mental health or substance 
misuse risk from healthcare providers. 

If such a process is to be developed this must be in the context of the DWP policy as it would not 
be legal for healthcare providers to proactively offer confidential Health information to the DWP. 
As you will appreciate there are also a number of issues of confidentiality that would need to be 
addressed in order to allow such a process to function, such as patient consent to share 
information.  

As stated, once the services were made aware by the family of the payment to Spencer, this 
information relating to the potential for an increase in risk was shared between FTB and CLG and 
the risk assessments and multi-disciplinary team revised Spencer’s risk assessment quickly. There 
was no mechanism for services to have oversight of benefits or monies provided to Spencer.  

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. 

Response to matter of concern 3 
Forward Thinking Birmingham have set up a multi-agency working party to ensure the dual 
diagnosis pathways between organisations providing mental health services and substance misuse 
services are reviewed and strengthened. The task group includes representatives invited from 
CGL, FTB, BSOL CCG, BCC and BSMHFT.  

CGL have direct access to referring into FTB and can directly refer young people where there are 
mental health concerns and substance misuse concerns this has been strengthened further with 
the agreement of the development of a fast-track pathway and expediting referrals for mental 
health assessment from CGL via a trusted assessment model. We believe this will support patients 
at the earliest opportunity addressing risk. The oversight of the task group and progress will be 
monitored through the Birmingham Joint Strategic Operational forum where all system partners 
are represented.  

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. 

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 and feasible. 

Response to matters of concern 4 & 5 
In FTB both the service user’s named Core Worker and Lead Professional act as central point of 
contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts 
as a point of contact if the service user’s named Core Worker or lead professional is not available 
this ensures that there is always a specific allocated point of contact in the working day to share 
essential information. FTB is committed to ensuring information is shared across agencies to 
support patient safety and we have agreed to grant licences to CGL that will enable them to access 
important clinical patient details. 

When the Core Worker or lead professional is not available the out of office message will include 
the telephone number for colleagues who can redirect queries and make arrangements to make 
contact with patients in a crisis.  

We would like to reassure you that CGL have an established central point of contact and have 
accepted referrals from any individual and agency since March 2015 when the service was 
commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the 
following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals. 

In the last 12 months CGL have received referrals from various sources including self-referrals 
individuals wanting to access support for themselves, family and friends, GPs, mental health 
services, housing, probation, the police, hospitals, and children services. We hope this provides 
you with assurance that interagency referral systems are in place and operating.  

We hope that you can see that FTB/CGL have taken their roles very seriously and that learning has 
taken place. As well as addressing the points of concern outlined in the Regulation 28 report, the 
system is looking at recently announced funding opportunities for substance misuse services and 
investment into a 16-25 youth substance misuse and mental health pathway, this would further 
improve care for young adult patients with substance and mental health issues and align with the 
0-25 services in Forward Thinking Birmingham.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Finally, if helpful we would very much welcome the opportunity to talk further with you about the 
mental health system in Birmingham both in terms of the challenges and the improvements being 
made for the patients and families we serve.  

Yours sincerely, 

Director of Nursing 

Birmingham Women & Childrens 
Forward Thinking Birmingham 

           Director 

            CGL

Birmingham Coroner’s Court 

FAO Mr Adam Hodson, 
Assistant Coroner for Birmingham and Solihull 

Young Adults Central Team Birmingham 
11-15 Lower Essex Street 
Birmingham 
B5 6SN 

Date: 11th November 2022 

Response to Regulation 28 Report 
following the Inquest Touching the Death 
of Mr Spencer Barr (DOB: 24/10/1997) 

Dear Sir, 

I am writing on behalf of the Probation Young Adults Central Team Birmingham in response 
to the Regulation 28 Report issued following the Inquest into the very sad death of Spencer 
Barr. 

I know that you will share a copy of this response with the family and I would first like to 
express my sincere condolences for their loss.  Every death in such circumstances is a 
tragedy and the implementation of learning from this is therefore very important. 

I respond to the areas of concern you raised as follows:-

Matter of concern – inter agency co operation appears to be inadequate regarding the 
sharing of relevant information between agencies 

Response – Probation is committed to having in place relevant and up to date Information 
Sharing Agreements to cover all areas of its work which provide a legal framework within 
which information can be passed to and from partner agencies.  Probation is reviewing the 
position in this regard with the other IP organisations to ensure there are no barriers to 
sound and effective inter agency co-operation and sharing of information. 

Matter of concern – 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 

Response – It is noted that Forward Thinking Birmingham has set up a multi-agency 
working group in response to this recommendation and Probation is very willing to be a 
party to this working group and contribute to improvements in inter-agency cooperation and 
sharing of information. 

Matter of concern – that there appear to be no central points of contact for agencies to 
facilitate that co-operation. Consideration should be given to central points of contact being 

Open Letter (Other - Not to SU) 

07/2018 

 
 
                   
 
 
 
 
 
   
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 created within each agency and ensuring that those points of contact are shared between 
agencies to ensure information can flow freely between them. 

Response – Probation now has a central point of contact e-mail 
wmps.birminghamsctransfers@justice.gov.uk .  Probation is taking steps to raise 
awareness of this SPOC with partner agencies to ensure this central point of contact 
facilitates information to be shared at all times. 

Matter of concern – Consideration should be given as to whether a better system of inter 
agency referral is possible and feasible. 

Response – insofar as this relates to Probation, the commissioning of rehabilitative services 
and the making of referrals is subject to regular review as part of the commissioning 
processes and Probation is committed to continuous improvement and will continue to work 
with partner agencies to refine and improve referral processes. 

Thank you for bringing these matters of concern to our attention.  Please be assured that 
learning from the circumstances of this untimely death will also be shared more widely with 
colleagues across the Probation Service. 

Yours sincerely 

Head of Legacy / Litigation & Inquests 
Probation Business Strategy & Change 
HMPPS 

Open Letter (Other - Not to SU) 

07/2018