17 May 2024 Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 3 Failure of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors View source Failure of NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors View source Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jonathan Paul SZCZEPANSKI · 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
Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.
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× 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital discharge documentation to provide warnings on NSAID prescribing considerations and risk factors
Wider context from the report “(3) Where repeat prescriptions were issued on discharge of a patient from hospital back
to community primary care, there was no warning on the discharge documentation
to alert the prescriber to the considerations and risk factors in the prescription of
NSAIDs (including the use of PPI).
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors
Wider context from the report “(2) The software being used to prescribe NSAIDs did not automatically generate a
specific warning flag to alert the prescriber to the considerations and risk factors in
the prescription of NSAIDs (including the use of PPI).
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation
Wider context from the report “(1) There is a lack of local practitioner guidance on the practical implementation of the
NICE NSAIDs - prescribing issues documentation.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resend a reminder about co-prescribing PPIs with NSAIDs through the discharge prescribing safety work.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Trust and safety lead to develop systems promoting safer NSAID prescribing after hospital discharge.
Verbatim wording from the response “3. Where repeat prescriptions were issued on discharge of a patient from hospital back to community primary care, there was no warning on the discharge documentation to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with all practices to highlight the importance of using OptimiseRx and Eclipse prescribing safety tools.
Verbatim wording from the response “2. The software being used to prescribe NSAIDs did not automatically generate a specific warning flag to alert the prescriber to the considerations and risk factors in the prescription of NSAIDs (including the use of PPI).” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a reminder about co-prescribing PPIs with NSAIDs to the Lincolnshire Formulary.
Verbatim wording from the response “ICB response
It is long-standing accepted practice, as per NICE guidelines, that PPIs should be considered as a co-prescription with NSAIDs for at risk patients.” Source location 2024-0271 Response from Lincolnshire Integrated Care Board
Open published response
Concerns raised 14 Lack of assertive outreach and organised welfare checks after community discharge View source Failure to seek immediate family views on accommodation and treatment and care pathways View source Failure to communicate immediate family concerns to relevant care agencies View source Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis View source Lack of an adequate Care Programme Approach View source Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures View source Unavailability of specialist Dual Diagnosis workers for complex cases View source Unavailability of a dedicated or commissioned drug and alcohol recovery service View source Lack of interface between senior or experienced providers for complex cases View source Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis View source Failure to recognise and adequately manage complex Dual Diagnosis View source Failure to appoint a care coordinator to monitor care under an appropriate care plan View source Lack of coordination between mental health and addiction services View source Absence of a Dual Diagnosis protocol defining provider roles View source See 11 more concerns
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.
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AI-generated summary
Toby Peter Edward Nieland · 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
Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.
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× 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of assertive outreach and organised welfare checks after community discharge
Wider context from the report “6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies ) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to seek immediate family views on accommodation and treatment and care pathways
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate immediate family concerns to relevant care agencies
Wider context from the report “1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased , nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate guidance and training for mental health practitioners on substance misuse and Dual Diagnosis
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training , in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an adequate Care Programme Approach
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
Wider context from the report “5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist Dual Diagnosis workers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases ;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a dedicated or commissioned drug and alcohol recovery service
Wider context from the report “7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of interface between senior or experienced providers for complex cases
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases ;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
Wider context from the report “8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and adequately manage complex Dual Diagnosis
Wider context from the report “2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint a care coordinator to monitor care under an appropriate care plan
Wider context from the report “4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination between mental health and addiction services
Wider context from the report “3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services ;
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a Dual Diagnosis protocol defining provider roles
Wider context from the report “9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time ) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:
a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases;
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;
” Open source report
Concerns raised 4 Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS View source Failure by LFRS to assess high-risk Home Oxygen users for safety equipment View source Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS View source Lack of awareness among relevant agencies of available safety equipment for high-risk patients View source See 1 more concern
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
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.
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× 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 NHS Lincolnshire Integrated Care Board; 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 NHS Lincolnshire Integrated Care Board; 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 NHS Lincolnshire Integrated Care Board; 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 NHS Lincolnshire Integrated Care Board; 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
Concerns raised 3 Failure to consider suicide-attempt history and antidepressant-associated risk together when assessing treatment risk View source Failure to make direct mental health referrals when self-referral is not appropriate View source Failure to arrange or record follow-up contact after clinical care View source
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
John William THORPE · 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
John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.
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× 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider suicide-attempt history and antidepressant-associated risk together when assessing treatment risk
Wider context from the report “3 That ████████ knowledge, elicited at the inquest, that "sometimes when anti-depressant is started it can give you more energy" and that Mr Thorpe had a history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants , viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk , where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed".
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct mental health referrals when self-referral is not appropriate
Wider context from the report “1. That the deceased was asked to "self-refer" himself to IAPT rather than a direct referral being made on his behalf to an appropriate mental health resource . His widow was particularly critical of this at the Inquest, commenting she attempted to fill the form in for him but it wasn't completed and she believed her husband would have responded if a direct referral had been made. I appreciate this may be 'standard practice' but the point is surely not in every case and Doctors should be encouraged to use their discretion more
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange or record follow-up contact after clinical care
Wider context from the report “2 That no intention to follow him up, with a definite appointment being given or by telephone contact, is recorded in the clinical records .
” Open source report
Concerns raised 5 Lack of awareness among seasonal agricultural workers of how to access GP services View source Failure to ensure that medicines are shown to A&E staff View source Access by seasonal workers to UK prescription-only medicines posted from home without prescription View source Lack of awareness among seasonal agricultural workers of 999 and 111 services View source Lack of awareness among seasonal agricultural workers of entitlement to free GP services for chronic conditions View source See 2 more concerns
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
Dimitar SHTYANOV · 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
Dimitar SHTYANOV, a Bulgarian seasonal agricultural worker with a history of asthma, became ill in August 2012 and attended hospital twice before arriving in cardiac arrest on 11 August; resuscitation was unsuccessful. The inquest recorded the medical cause of death as bilateral pneumothoraces due to acute asthma. Concerns included seasonal workers’ limited awareness of GP, 999 and 111 services, and uncertainty about whether Dimitar’s medicines from Bulgaria were shown to hospital staff.
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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among seasonal agricultural workers of how to access GP services
Wider context from the report “(1) Evidence was presented to the effect that the majority of seasonal agricultural workers do not know how to access General Practitioner Services and indeed are not aware of the service . They often access primary health care at need via the accident and emergency department
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that medicines are shown to A&E staff
Wider context from the report “(4) Dimitar obtained salbutamol inhalers (labelled in both English and Bulgarian – the latter in Cyrillic Script) and injectable long acting beclomethasone (labelled in Cyrillic script) by post from Bulgaria, with extra supplies being posted to him when he became ill. The evidence as to whether or not these medicines were shown to A&E staff was inconsistent . I was informed in Court that it is very common for seasonal workers with chronic conditions to have what would be prescription only medicines in the UK posted to them from home where such medicines can often be purchased freely without prescription.
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Access by seasonal workers to UK prescription-only medicines posted from home without prescription
Wider context from the report “(4) Dimitar obtained salbutamol inhalers (labelled in both English and Bulgarian – the latter in Cyrillic Script) and injectable long acting beclomethasone (labelled in Cyrillic script) by post from Bulgaria, with extra supplies being posted to him when he became ill. The evidence as to whether or not these medicines were shown to A&E staff was inconsistent. I was informed in Court that it is very common for seasonal workers with chronic conditions to have what would be prescription only medicines in the UK posted to them from home where such medicines can often be purchased freely without prescription .
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among seasonal agricultural workers of 999 and 111 services
Wider context from the report “(2) They are often not aware of either the 999 service or the 111 service
” 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 NHS Lincolnshire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among seasonal agricultural workers of entitlement to free GP services for chronic conditions
Wider context from the report “(3) They are often not aware that they are entitled to GP services in the UK, without charge, for the management of chronic medical conditions
” Open source report
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Addressed to NHS South Lincolnshire Clinical Commissioning Group, now represented here by NHS Lincolnshire Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations