Includes failures in alarms dedicated to monitoring oxygen therapy, including missing or incorrectly configured upper or lower limits, failure to distinguish minor from critical oxygen-delivery problems, inadequate alarm prioritisation, and unreliable reactivation or escalation when an oxygen-related alarm occurs.
What is not included
Excludes general patient-monitoring alarm failures where oxygen therapy is not the material safety concern.
Excludes failures to measure or monitor oxygen saturation where no oxygen-therapy alarm deficiency is identified.
Excludes oxygen prescribing, administration, supply or equipment failures that do not concern the alarm control itself.
Excludes failures to respond after an oxygen-therapy alarm has operated reliably and clearly.
Trends
Reports over time
Reports mentioning this concern, 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.
Betsi Cadwaladr University LHB1
Dolby Vivisol1
Invacare Limited1
Medicines and Healthcare products Regulatory Agency1
NHS England1
Salter Labs1
the Shrewsbury and Telford Hospital NHS Trust1
Company1
Executive non-departmental public body1
Local health board1
Medicines and medical devices regulator1
NHS trust1
Reports and published responses 4 reports
See individual reports that have raised this concern, and the actions taken in response
Shropshire, Telford and Wrekin
Concerns raised3
Failure to establish routine practice of setting upper alarms on bedside oxygen meters
Uncertainty over whether bedside oxygen meters can be set with an upper alarm
Failure to set an upper alarm on bedside oxygen meters
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
the Shrewsbury and Telford Hospital NHS Trust
Upper oxygen alarms are not used because lower alarms with regular monitoring better address the greater risk of low oxygen levels.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised2
Difficulty determining the cause of low oxygen saturations amid simultaneous CPAP alarms in medical wards
Failure of CPAP alarms to distinguish minor mask leaks from total cessation of oxygen supply
Linked responses
Medicines and Healthcare products Regulatory Agency
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Medicines and Healthcare products Regulatory Agency
Review the designated medical-equipment alarm standard and its application to alarm severity and prioritisation.
Medicines and Healthcare products Regulatory Agency
Engage respiratory and anaesthesia professional bodies to explore training and healthcare-system measures addressing audible alarm prioritisation.
NHS England
Engage with the Faculty for Intensive Care Medicine to include disconnection-alarm guidance addressing alarm indications and response urgency.
Medicines and Healthcare products Regulatory Agency
Search the MHRA adverse-incident and corrective-action database for comparable ventilator alarm events.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Medicines and Healthcare products Regulatory Agency
The available evidence does not indicate a wider safety concern involving inability to identify ventilator faults from audible alarm tones.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Medicines and Healthcare products Regulatory Agency
Existing internationally recognised alarm standards, user training and manufacturer guidance sufficiently mitigate residual risks, so wholesale audible alarm redesign is not justified.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
NHS England
Changes to CPAP alarm design fall within the Medicines and Healthcare products Regulatory Agency’s remit.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Failure to set pulse oximeter alarm levels to reflect individual patients’ baseline oxygen saturations
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Betsi Cadwaladr University LHB
Check pulse oximeter alarm settings across approximately 1,200 devices.
Betsi Cadwaladr University LHB
Scope an action plan addressing pulse oximeter alarm-level safety.
Betsi Cadwaladr University LHB
Raise pulse oximeter alarm-setting issues at Welsh and UK level through the MHRA.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Betsi Cadwaladr University LHB
Some pulse oximetry alarm-setting issues concern manufacturers and should be addressed through Wales- and UK-level channels, including the MHRA.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Absence of a visual or audible alarm indicating 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.
Linked responses
Dolby Vivisol
Invacare (UK) Limited
Salter Labs
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Invacare (UK) Limited
Assess whether an alarm can detect oxygen-flow loss caused by an improperly engaged humidifier cap.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Salter Labs
The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Salter Labs
The concentrator manufacturer is responsible for addressing the absence of a visual or audible alarm for lost oxygen flow.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Dolby Vivisol
Equipment manufacture and design concerns fall outside the company’s functions, so it cannot respond to them.
Outside remitThe respondent said that this matter was outside its role or authority.
Dolby Vivisol
Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Invacare (UK) Limited
Existing alarms detect relevant concentrator faults, comply with applicable standards, and are considered sufficient without additional alarms.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Invacare (UK) Limited
An alarm detecting oxygen loss at the humidifier would be technically complex and introduce unacceptable risks and inconvenience without sufficient benefit.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.