Robert Spring · Prevention of Future Deaths report

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
2 Excess of alcohol consumption.

1. 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.

2. 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.

4. On 14 March 2014 Mr Spring died in a fire at his home, a flat forming part of a complex providing independent sheltered living.

5. 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.

(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.