Source · Prevention of Future Deaths

Robert Spring

Ref: 2015-0123 Date: 23 Mar 2015 Coroner: Paul Smith Area: Lincolnshire (Central) 1 response identified · 4 indexed addressees View PDF

AI-generated concerns summaryThere was no direct mechanism for the hospital to notify the fire service of high-risk home oxygen users who smoke, as the oxygen supplier's system prevented full disclosure of the smoking risk. This meant the patient was not assessed for specialist safety equipment, highlighting a need for improved inter-agency communication.

Date 23 Mar 2015

56-day deadline 18 May 2015 stated in the report

Responses identified 1 of 4

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

There was no direct mechanism for the hospital to notify the fire service of high-risk home oxygen users who smoke, as the oxygen supplier's system prevented full disclosure of the smoking risk. This meant the patient was not assessed for specialist safety equipment, highlighting a need for improved inter-agency communication.

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

1 respondent

United Lincolnshire Hospitals NHS Trust

NHS Trust

PDF

AI-classified response stance Action Taken

AI-generated response summary

• United Lincolnshire Hospitals NHS Trust (ULHT) met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a new information-sharing process, which has been incorporated into Trust policy. • ULHT has formalised the discharge process for high-risk home oxygen patients, and this is now in place across the Trust. • A documented risk assessment designed by LF&R has been included in the standard operating procedure to identify patients at increased fire risk, alongside a clear communication process.

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

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

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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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Shared signals

Report details

Reference: 2015-0123
Date of report: 23 March 2015
Coroner: Paul Smith
Coroner area: Lincolnshire (Central)

Responses identified

Responses identified 1 of 4

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 18 May 2015 (stated in the report).

Sent to

Air Liquide

Lincolnshire County Council

NHS Lincolnshire West Clinical Commissioning Group

United Lincolnshire Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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