Recurring concern

Failure to ensure staff competence to administer oxygen therapy

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First reported 17 Nov 2014•Latest report 25 Nov 2020

Definition

What this concern includes

Includes failures of training, induction, authorisation, competence assessment, refresher provision or competence records specifically intended to ensure staff can safely administer oxygen therapy, including standard, high-flow and portable-cylinder oxygen.

Not included

Excludes the general availability, prescribing, supply or clinical appropriateness of oxygen therapy where staff competence is not the deficient control.
Excludes oxygen-related fire or ignition risks unless the assertion specifically concerns staff competence to administer oxygen.
Excludes generic clinical training or first-aid competence deficiencies without a direct oxygen-therapy administration component.
Excludes equipment malfunction, maintenance or alarm failures where staff competence is not the shared unsafe condition.

Reports: 4
Individual concerns: 6
Date range: 2014–2020
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Acorn Lodge Care Centre1

Cwm Taf Morgannwg University Local Health Board1

Department of Health and Social Care1

Lodge Care Home1

Tameside and Glossop Integrated Care NHS Foundation Trust1

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.

25 Nov2020
South Wales Central
Concerns raised1
1. Incomplete training in oxygen administration
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.
AI-generated summary

Thomas William Browne · 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

Thomas William Browne, a highly vulnerable patient dependent on non-invasive oxygen ventilation, was found collapsed in a hospital toilet on 17 July 2018 after being left there unaccompanied. His oxygen cylinder was exhausted when he was found, and the inquest concluded that he died from natural causes. Concerns included the absence of systems to monitor patients dependent on finite oxygen supplies, deficiencies in the root cause analysis, incomplete oxygen-administration training, and the lack of formal procedures for recording when oxygen supplies would expire.

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.
PFD Monitor interpretation
Incomplete training in oxygen administration
Wider context from the report
“(3) Training in the administration of Oxygen remains incomplete. ”
Source location
Thomas William Browne · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Nov2016
South Yorkshire (Western)
Concerns raised3
1. Lack of audit of the appropriateness of on-the-job portable oxygen cylinder training
2. Failure to document portable oxygen cylinder training and trained personnel
3. Failure to provide formal training on the use of portable oxygen cylinders for patients
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Simon Timothy Harper · 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

Mr Simon Timothy Harper was admitted to hospital with jaundice and abdominal distention and later developed multiple organ failure. During his transfer to intensive care, his portable oxygen cylinder was not turned on; he suffered a cardiorespiratory arrest, was resuscitated, and died after treatment was withdrawn. Concerns included inadequate documented training and lack of a suitable transfer policy for using portable oxygen cylinders.

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.
PFD Monitor interpretation
Lack of audit of the appropriateness of on-the-job portable oxygen cylinder training
Wider context from the report
“Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training. The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this. The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue. ”
Source location
Mr Simon Timothy Harper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to document portable oxygen cylinder training and trained personnel
Wider context from the report
“Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training. The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this. The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue. ”
Source location
Mr Simon Timothy Harper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide formal training on the use of portable oxygen cylinders for patients
Wider context from the report
“Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training. The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this. The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue. ”
Source location
Mr Simon Timothy Harper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Apr2016
Inner North London
Concerns raised1
1. Lack of training of the Clinical Manager to administer oxygen
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.
AI-generated summary

Doreen Mattinson · 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

Doreen Mattinson, an 80-year-old resident of Acorn Care Home with dementia and other comorbidities, deteriorated rapidly with laboured breathing on 12 November 2015. Concerns were raised about the administration of oxygen, including the flow rate, her supine position, and the absence of evidence of training for the registered nurse who administered it.

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.
PFD Monitor interpretation
Lack of training of the Clinical Manager to administer oxygen
Wider context from the report
“(3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen. ”
Source location
Doreen Mattinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Nov2014
Manchester South
Concerns raised1
1. Lack of staff training to use high flow oxygen equipment
This report raised 7 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 1
1. Action
  Provide high-flow oxygen training for Ward 41 staff through scheduled equipment-trainer sessions and interim physiotherapist support.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
AI-generated summary

Elsie Mallalie u · 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

Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.

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.
PFD Monitor interpretation
Lack of staff training to use high flow oxygen equipment
Wider context from the report
“2. She was entirely dependent on high flow oxygen, but none of the staff on ward 41 was trained to use this equipment. ”
Source location
Elsie Mallalie u · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Provide high-flow oxygen training for Ward 41 staff through scheduled equipment-trainer sessions and interim physiotherapist support.

Verbatim wording from the response
“We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Incomplete training in oxygen administration

Concerns raised3

Lack of audit of the appropriateness of on-the-job portable oxygen cylinder training

Failure to document portable oxygen cylinder training and trained personnel

Failure to provide formal training on the use of portable oxygen cylinders for patients

Concerns raised1

Lack of training of the Clinical Manager to administer oxygen

Concerns raised1

Lack of staff training to use high flow oxygen equipment

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

Actions described in response 1