Lincolnshire Community Health Services NHS Trust

Health and care · NHS trust

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First report 14 Jan 2014•Latest report 16 May 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
3

Naming this recipient

Published responses
33%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
18

Described in responses

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.

  1. Lincolnshire

    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

  2. South Lincolnshire

    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

  3. South Lincolnshire

    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
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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