First reported 24 Nov 2014•Latest report 17 Nov 2025
Definition
What this concern includes
Includes failures in prescribing, recording, supplying or delivering oxygen where they prevent provision of the required oxygen flow or target range.
Not included
Oxygen-related fire controls
Oxygen-concentrator equipment alarms or fault procedures
Monitoring or discharge documentation that does not affect required oxygen provision
Reports
9
Distinct published reports
Individual concerns
10
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
13
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Acorn Lodge Care Centre1
Boc Limited1
Central and North West London NHS Foundation Trust1
Circle Health Group Limited1
County Durham and Darlington NHS Foundation Trust1
Department of Health and Social Care1
Dolby Vivisol1
gtd healthcare1
Invacare Limited1
Lodge Care Home1
Medicines and Healthcare products Regulatory Agency1
NHS England1
Philips Respironics1
Princess Alexandra Hospital1
Royal Bolton Hospital1
Healthcare site2
NHS trust2
Private limited company2
Company1
Executive non-departmental public body1
Independent healthcare provider1
Medicines and medical devices regulator1
Ministerial department1
Multi-service care provider1
Nursing home1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Essex
Concerns raised1
Failure to provide oxygen flow meeting patient requirements at discharge
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The prescribed home oxygen level was appropriate because it reflected an evidence-based respiratory assessment at discharge.
Stated by the Princess Alexandra Hospital NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
Concerns raised1
Unavailability of oxygen from a resuscitation oxygen bottle
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Require trained nurses to conduct daily oxygen-supply checks and induct temporary and new staff on oxygen availability before care begins.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Campbell Centre always has an ample, accessible oxygen supply, disputing that the resuscitation oxygen bottle ran out.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Lack of valid prescriptions for supplementary oxygen including target ranges
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised2
Failure to prescribe and record oxygen flow rates on the drug chart
Failure to ensure administration of oxygen at the prescribed rate
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to administer the required oxygen flow
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to prevent unsafe disconnection of oxygen supply and departure from the ward
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised1
Failure to provide required oxygen during patient transfers within a ward
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Teesside
Concerns raised1
Lack of backup oxygen provision during interruption of the main oxygen apparatus
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Supply backup oxygen cylinders and train home oxygen patients in equipment use and emergency procedures.
Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing policies, contractual requirements, backup oxygen provision, training, servicing and risk assessments were considered sufficient for patient safety.
Stated by Boc LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Removed oxygen equipment was found in working order, and BOC was not contacted during the power failure.
Stated by Boc LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Following its comprehensive review, BOC saw no reason at present to take further action, while continuing to monitor procedures.
Stated by Boc LimitedNo action considered necessaryThe respondent said that no further action was needed.
Surrey
Concerns raised1
Failure to properly engage the humidifier screw cap, causing loss of oxygen flow to the nasal cannula
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Complete a multidisciplinary technical review of the humidifier thread design and document its findings in the risk management file.
Stated by Salter LabsStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Add multilingual labeling instructing users to check that the lid is properly sealed and explaining that leaks can reduce oxygen delivery.
Stated by Salter LabsStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Liaise with Invacare about revised instructions warning of oxygen-flow effects when humidifier caps are improperly fastened.
Stated by Dolby VivisolStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Action
Modify humidifier literature to explain incorrect connection risks and emphasise confirming oxygen flow from the nasal cannula.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Review and update company instructions and training materials after receiving manufacturers’ finalized amendments.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Submit finalized literature amendments to NHS contract managers for approval.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Distribute approved updated literature to current and future equipment users, highlighting amendments for current humidifier patients.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Communicate literature amendments to relevant staff and reinforce them during future patient and carer installation training.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Provide guidance in current manuals on securely fastening humidifier bottle caps.
Stated by Invacare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Update customer manuals with warnings that cross-threaded or improperly installed humidifier bottles and accessories can affect oxygen flow.
Stated by Invacare (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Phase the updated warning into all Invacare manuals over the next several months.
Stated by Invacare (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The current humidifier thread design is appropriate and has reduced cross-threading risk as far as possible.
Stated by Salter LabsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.
Stated by Salter LabsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.
Stated by Dolby VivisolRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Humidifier bottles are supplied by others, so Salter Labs should directly address concerns about their design and operation.
Stated by Invacare (UK) LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in prescribing, recording, supplying or delivering oxygen where they prevent provision of the required oxygen flow or target range.
