Recipient

Air Liquide Healthcare Limited

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First report 23 Mar 2015•Latest report 23 Mar 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Air Liquide Healthcare Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Central Lincolnshire

    AI-generated summary

    Robert Spring · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Spring, who had chronic obstructive pulmonary disease and used home oxygen while smoking, died in a fire at his home on 14 March 2014. The fire was attributed to either a cigarette lighter or a dropped cigarette. The principal concerns were that relevant agencies were not fully informed of his smoking-related risk, so he was not assessed for available fire-safety equipment, and that more extensive communication between agencies was needed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Air Liquide Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS

    Wider context from the report

    “(I) 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. (II) 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 of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) 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. (IV) 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”. (V) The 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. (VII) Evidence was also given at Inquest that the availability of such safety 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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Air Liquide Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure by LFRS to assess high-risk Home Oxygen users for safety equipment

    Wider context from the report

    “(I) 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. (II) 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 of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) 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. (IV) 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”. (V) The 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. (VII) Evidence was also given at Inquest that the availability of such safety 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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Air Liquide Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS

    Wider context from the report

    “(I) 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. (II) 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 of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) 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. (IV) 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”. (V) The 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. (VII) Evidence was also given at Inquest that the availability of such safety 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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Air Liquide Healthcare Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness among relevant agencies of available safety equipment for high-risk patients

    Wider context from the report

    “(I) 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. (II) 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 of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) 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. (IV) 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”. (V) The 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. (VII) Evidence was also given at Inquest that the availability of such safety 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. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026