Robert Spring
23 Mar 2015 · Coroner Paul Smith · Lincolnshire (Central)
The coroner's concerns
1. use of Home Oxygen and smoking habit
“Mr [name redacted] 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 [name redacted] had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide”
2. notification of smoking status to LFRS
“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 [name redacted] was a user of Home Oxygen”
3. lack of safety equipment distribution to at-risk individuals
“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”
4. lack of safety equipment assessment for Mr Spring
“The absence of full notification to LFRS meant that the extent of the risk to which Mr [name redacted] was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above”
5. lack of awareness of safety equipment availability
“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”