Recipient

Lincolnshire Community Health Services NHS Trust

First report 14 Jan 2014•Latest report 16 May 2017

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 33%
Concerns addressed: 1
Stated actions: 18

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.

33%published responses found

18stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Lincolnshire Community Health Services NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 May2017
Lincolnshire
Concerns raised2
1. Lack of continuity in medical staff dispatched by the GP's practice
2. Failure to ensure the appropriateness of medical staff dispatched by the GP's practice
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Lower limb training is not mandatory because workplace training, competency assessment and tissue viability nurse sign-off provide alternative safeguards.
  Existing arrangements considered sufficient
AI-generated summary

Ruth Milne · 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

Ruth Milne was admitted with severe sepsis affecting both legs and died within 24 hours from multi-organ failure and septic shock. The report raised concerns about continuity of care, the appropriateness and expertise of staff attending before admission, and whether safeguarding action plans and recommendations had been implemented.

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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of continuity in medical staff dispatched by the GP's practice
Wider context from the report
“(1) The lack of continuity and the appropriateness of the medical staff dispatched by the GP's ████████ at Hawthorn Medical Practice, Skegness. The Safeguarding report by ████████ Unstone Head of Safeguarding dated November 2015 identified this. ”
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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure the appropriateness of medical staff dispatched by the GP's practice
Wider context from the report
“(1) The lack of continuity and the appropriateness of the medical staff dispatched by the GP's ████████ at Hawthorn Medical Practice, Skegness. The Safeguarding report by ████████ Unstone Head of Safeguarding dated November 2015 identified this. ”
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Lower limb training is not mandatory because workplace training, competency assessment and tissue viability nurse sign-off provide alternative safeguards.

Verbatim wording from the response
“Staff can access a “lower limb course” and whilst this is highly recommended it is not mandated. All training needs are fed into a centralised training needs analysis, this then informs a competency matrix which identifies which staff require training in a specific area. If staff do not attend the “lower limb course” then training is provided within the workplace and sign off is supported by the tissue viability associate nurse. Staff within the Skegness team have received bespoke training of this nature.”

Source location
Ruth-Milne-Response
Page 3 · response
Published 16 August 2017
Open published response
23 Jul2015
South Lincolnshire
Concerns raised2
1. Insufficient guidance on care and caution when co-prescribing ACEI drugs and Spironolactone
2. Insufficient guidance to take a holistic view of patients' best interests when co-prescribing ACEI drugs and Spironolactone
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Lynn POYSER · 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

Lynn POYSER had impaired kidney function and was prescribed Lisinopril while already taking Spironolactone. She was admitted to hospital with severe hyperkalaemia and suffered a cardiac arrest from which she could not be resuscitated. The principal concern was whether guidance on co-prescribing these medicines sufficiently emphasised caution, review, and monitoring of renal function and electrolytes.

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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient guidance on care and caution when co-prescribing ACEI drugs and Spironolactone
Wider context from the report
“1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 – 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia. Those to whom I make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for care and caution and the need to take a holistic view of the best interests of the patient. ”
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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient guidance to take a holistic view of patients' best interests when co-prescribing ACEI drugs and Spironolactone
Wider context from the report
“1: Evidence was presented at the inquest to the effect that the interaction between Lisinopril and Spironolactone is well known, and that Lisinopril can precipitate deterioration in a patient's renal function. NICE published guidelines on initiation of Angiotensin converting enzyme inhibitor therapy indicates that patients should be reviewed one to two weeks after initiation of therapy and have their renal function and electrolyte status checked 10 – 14 days after initiation of ACEI therapy. This is re-iterated in LCHS guidance. The expert evidence at the inquest pointed out that, following a report of a trial in 1999 "The Randomised Aldactone Evaluation Study", there was an increase in the co-prescription of Spironolactone and Lisinopril in heart failure, immediately followed by an increase in hospital admissions and subsequent deaths associated with hyperkalaemia. Those to whom I make this report may wish to consider whether or not the current guidance relating to the co-prescription of ACEI drugs, such as Lisinopril, and Spironolactone draws sufficient attention to the need for care and caution and the need to take a holistic view of the best interests of the patient. ”
Open source report
14 Jan2014
South Lincolnshire
Concerns raised4
1. Failure to provide continuing patient education about Infliximab treatment risks
2. Delays in initiating treatment when tuberculous meningitis is suspected
3. Lack of protocols for pre-Infliximab tuberculosis screening
1. Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Craig Adam White · 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

Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.

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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide continuing patient education about Infliximab treatment risks
Wider context from the report
“3 The need for continuing patient education about the risks of Infliximab treatment ”
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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Delays in initiating treatment when tuberculous meningitis is suspected
Wider context from the report
“4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected ”
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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of protocols for pre-Infliximab tuberculosis screening
Wider context from the report
“1 Protocols for pre-Infliximab treatment screening for tuberculosis ”
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 Lincolnshire Community Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Wider context from the report
“2 Awareness of Health Care Professionals, in particular prescribers of the increased risk of TB inherent Infliximab treatment ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of continuity in medical staff dispatched by the GP's practice

Failure to ensure the appropriateness of medical staff dispatched by the GP's practice

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised2

Insufficient guidance on care and caution when co-prescribing ACEI drugs and Spironolactone

Insufficient guidance to take a holistic view of patients' best interests when co-prescribing ACEI drugs and Spironolactone

Concerns raised4

Failure to provide continuing patient education about Infliximab treatment risks

Delays in initiating treatment when tuberculous meningitis is suspected

Lack of protocols for pre-Infliximab tuberculosis screening

Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment

Respondent positions 1