“Mr Spring was identified at the initial hospital assessment as being at high risk by…”

The coroner’s concerns

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— (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. (ill) | 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2015-0123

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0