Recurring concern
Unreliable monitoring of oxygen saturation during clinical care
- Reports that mention this concern
- 5
- Times this concern has been raised
- 7
- Stated actions linked to this concern
- 6
What this concern includes
Includes failures to initiate, perform, maintain or reliably use oxygen-saturation monitoring during clinical care, including paediatric oxygen blood monitoring and omitted or absent monitoring during hospital care.
What is not included
- Excludes failures of oxygen prescribing, supply, delivery or administration where oxygen-saturation monitoring is not the deficient control.
- Excludes generic physiological-observation or clinical-record deficiencies unless they directly concern oxygen-saturation monitoring.
- Excludes failures to act on an oxygen-saturation result after monitoring was reliably completed.
- Excludes oxygen-equipment alarms or technical failures unless they directly prevent reliable oxygen-saturation monitoring.
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.
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Medway NHS Foundation Trust
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
-
Medway NHS Foundation Trust
Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NICE considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.
-
Concerns raised1
Failure to routinely use oxygen blood monitoring in paediatric medicine
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
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Betsi Cadwaladr University LHB
Scope an action plan addressing pulse oximeter alarm-level safety.
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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.
-
Concerns raised1
Failure to adequately record and monitor blood oxygen levels
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- BMI The Alexandra Hospital
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
BMI The Alexandra Hospital
Maintain and use a hospital-wide documentation standards audit, recording variances and sharing results through peer review.
-
BMI The Alexandra Hospital
Notify relevant nursing staff that notes must record observations taken after patients are removed from oxygen.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
BMI The Alexandra Hospital
Oxygen saturation readings of 90–92% were generally considered adequate for a patient who smoked, although the 89% reading was not adequately documented.
-
Concerns raised3
Failure to monitor oxygen saturations before discharge after oxygen therapy
Failure to record oxygen saturations during hospital care
Failure to monitor oxygen saturations during hospital care
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Oxygen saturations were monitored and recorded during the hospital attendance, contrary to the concern that they were not.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026