Robert Spring
PFD Report
All Responded
Ref: 2015-0123
All 1 response received
· Deadline: 18 May 2015
Coroner's Concerns (AI summary)
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.
View full coroner's concerns
_ Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit: There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide_ The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation f the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014_ Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen. Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents_ Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable "misting systems' absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above_ (Vi) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust; there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity. (Vi) Evidence was also given at Inquest that the availability of such equipment is not well known; and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives_
Responses
Action Taken
United Lincolnshire Hospitals NHS Trust has met with Lincolnshire Fire & Rescue and Air Liquide to agree a process for sharing information, formalized the discharge process, and included a documented risk assessment in their standard operating procedure. The operating procedure also outlines a clear and agreed communication process between all parties. (AI summary)
United Lincolnshire Hospitals NHS Trust has met with Lincolnshire Fire & Rescue and Air Liquide to agree a process for sharing information, formalized the discharge process, and included a documented risk assessment in their standard operating procedure. The operating procedure also outlines a clear and agreed communication process between all parties. (AI summary)
View full response
Dear Mr Smith; refer to the Regulation 28 Report issued by yourself following the inquest into the death of Mr Robert Spring The matters of concern you have raised have been addressed by United Lincolnshire Hospitals NHS Trust (ULHT) taking the following action: ULHT have met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a process for sharing information: This is described in a new document which has been incorporated into Trust policy (see Attachment A): 2 ULHT have formalised the discharge process for this group of patients. These steps are also detailed in the same document and is now in place across the Trust 3_ As part of our standard operating procedure we have included a documented risk assessment designed by LF&R to identify patients who are at increased risk Of fire (see Appendix within the above attachment): The standard operating procedure also outlines a clear and agreed communication process between'all parties_ This will provide LFRR an opportunity to conduct a home assessment; and instali any required safety equipment There is now increased clarity detailed within the standard operating procedure for when it is appropriate to withdraw oxygen from patients due to unacceptable and unmitigated risks of Shope you find the above provides the reassurance you are seeking following the issue of a Regulation 28 Report, and covers all the points i) ~ vi) raise in the report
Sent To
- Lincolnshire County Council
- NHS Lincolnshire West Clinical Commissioning Group
- United Lincolnshire Hospitals NHS Trust
Response Status
Linked responses
1 of 4
56-Day Deadline
18 May 2015
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 4th April 2014, an investigation was commenced into the death of Robert Spring, aged 65 years. The investigation concluded at the end of the inquest on 6 March 2015. The conclusion of the inquest was that Mr Spring died as a result of an accident; the medical cause of death being: 1a Severe degree of burns Excess of alcohol consumption
Circumstances of the Death
Mr Spring had a long history of Chronic Obstructive Pulmonary Disease. He was a smoker. In February 2013 he was treated within the Emergency Department of Lincoln County Hospital for a head injury sustained after drinking alcohol: On 3rd March 2013 he was admitted as an inpatient to Lincoln County Hospital where he received treatment for bronchopneumonia.
3. On 25 March 2013, prior to discharge from hospital; he was assessed as meeting the criteria for the provision of Home Oxygen. He was discharged from hospital on March 28th He remained in receipt of Home Oxygen up until his death On 14 March 2014 Mr Spring died in a fire at his home, a flat forming part of a complex providing independent sheltered living_ An investigation by Lincolnshire Fire and Rescue Service (LFRS) concluded that the cause of the fire was either the use of a cigarette lighter , Or a dropped cigarette. Mr Spring died in his armchair. At the time of his death he was smoking whilst using an oxygen concentrator
5_
3. On 25 March 2013, prior to discharge from hospital; he was assessed as meeting the criteria for the provision of Home Oxygen. He was discharged from hospital on March 28th He remained in receipt of Home Oxygen up until his death On 14 March 2014 Mr Spring died in a fire at his home, a flat forming part of a complex providing independent sheltered living_ An investigation by Lincolnshire Fire and Rescue Service (LFRS) concluded that the cause of the fire was either the use of a cigarette lighter , Or a dropped cigarette. Mr Spring died in his armchair. At the time of his death he was smoking whilst using an oxygen concentrator
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Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you ANDIOR your organisation has the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.