Recurring concern

Unreliable documentation and communication of patients’ oxygen requirements

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First reported 4 Feb 2015•Latest report 19 Mar 2025

Definition

What this concern includes

Includes failures in the dedicated process for recording, preserving, transferring or communicating patient-specific oxygen saturations, oxygen prescriptions, ambulatory-oxygen requirements and related oxygen-treatment information when the failure can leave receiving or treating staff without information needed for safe oxygen provision.

Not included

Excludes generic clinical-record deficiencies where oxygen-related information is not the material object.
Excludes failures of oxygen prescribing, administration, supply, equipment serviceability or monitoring where the oxygen-information documentation or communication process is not deficient.
Excludes general clinical handover or information-transfer failures without a material patient-specific oxygen requirement.
Excludes failures to act on complete and accessible oxygen information when the information process itself operated reliably.

Reports: 4
Individual concerns: 5
Date range: 2015–2025
Stated actions: 3

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.

NHS England2

Department of Health and Social Care1

East Suffolk and North Essex NHS Foundation Trust1

Royal Bolton Hospital1

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.

19 Mar2025
Manchester South
Concerns raised1
1. Failure of discharge letters to communicate clinically significant sedation and oxygen requirements
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.
Respondent positions 2
1. Position
  Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
1. Position
  Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Winnie Harrop · 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

Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.

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
Failure of discharge letters to communicate clinically significant sedation and oxygen requirements
Wider context from the report
“(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. ”
Source location
Winnie Harrop · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Clear health and social care discharge guidance and discharge documentation concerns fall outside NHS England’s remit.

Verbatim wording from the response
“Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.”

Source location
Response from NHSE
Page 1 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Further information about discharge guidance and documentation should be sought locally from Tameside and Glossop Integrated Care NHS Foundation Trust.

Verbatim wording from the response
“Your Report raised a concern around there being no clear guidance between health and social care as to the circumstances in which it is appropriate to send a patient back to a care home following a hospital admission. You also raised that Winnie’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. This particular concern falls outside of NHS England’s remit and should be raised locally with Tameside and Glossop Integrated Care NHS Foundation Trust, should the Coroner require any further information beyond what is set out in this response.”

Source location
Response from NHSE
Page 1 · response
Published 26 March 2025
Open published response
19 Jun2024
Essex
Concerns raised1
1. Failure to document low oxygen saturation and oxygen prescription
This report raised 9 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 3
1. Action
  Circulate learning requiring oxygen saturations to be recorded before oxygen administration.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated completed
2. Action
  Conduct monthly external peer audits of randomly selected ward notes against quality standards to identify and share documentation learning.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated completed
3. Action
  Transition all Trust patient records to the EPIC electronic records system by 2025.
  Stated by East Suffolk and North Essex NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
1. Position
  East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Chloe HUNT · 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

Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.

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
Failure to document low oxygen saturation and oxygen prescription
Wider context from the report
“f. Chloe’s low oxygen saturation level and the prescription of Oxygen was not documented on 14 March. ”
Source location
Chloe HUNT · Prevention of Future Deaths report
Page 3 · 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
Circulate learning requiring oxygen saturations to be recorded before oxygen administration.

Verbatim wording from the response
“The Trust has however acknowledged that the low saturations were not recorded in the notes. This learning point has been circulated to staff members, through the daily ward huddle, reiterating the need for oxygen saturations to be recorded prior to the administration of oxygen.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 4 · response
Published 26 June 2024
Open published response
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
Conduct monthly external peer audits of randomly selected ward notes against quality standards to identify and share documentation learning.

Verbatim wording from the response
“In addition to the steps above, the ward notes are subject to a clinical audit, which are peer reviewed (excluding Acute Kidney Injury and Sepsis which are done at ward level) from an external team, who visit the ward monthly and carry out a review of a randomly selected 10 patient notes, reviewing these against the quality standards. This enables the ward to obtain an external view on note keeping and promote learning established from outside the ward.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 4 · response
Published 26 June 2024
Open published response
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
Transition all Trust patient records to the EPIC electronic records system by 2025.

Verbatim wording from the response
“The Trust has recently signed a contract with EPIC to transition its patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.”

Source location
Response from East Suffolk and North Essex NHS Foundation Trust
Page 4 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.

Verbatim wording from the response
“Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

Source location
Response from NHS England
Page 1 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.

Verbatim wording from the response
“Your Report raises concerns with the care provided to Chloe whilst she was a patient at Colchester General Hospital. It is appropriate that East Suffolk & North Essex NHS Foundation Trust respond to your concerns, which do not fall under NHS England’s remit.”

Source location
Response from NHS England
Page 1 · response
Published 26 June 2024
Open published response
26 Jun2015
Manchester West
Concerns raised2
1. Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments
2. Failure of ward staff to know and identify patients’ continuing oxygen requirements
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.

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

Brian Anthony Gillard · 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

Brian Anthony Gillard, who had asbestosis and required ambulatory oxygen, died at Royal Bolton Hospital on 20 March 2015 after collapsing and suffering a cardiac arrest while using the toilet. The concerns included a lack of handover about his oxygen requirement, transfer to the toilet without oxygen, and leaving him unsupervised in a toilet without an emergency pull-cord.

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
Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments
Wider context from the report
“iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia. iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward. ”
Source location
Brian Anthony Gillard · Prevention of Future Deaths report
Page 3 · 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 of ward staff to know and identify patients’ continuing oxygen requirements
Wider context from the report
“iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia. iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward. ”
Source location
Brian Anthony Gillard · Prevention of Future Deaths report
Page 3 · concerns
Open source report
4 Feb2015
Manchester South
Concerns raised1
1. Unavailability of records of previous oxygen levels on readmission
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

Paul Moroney · 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

Paul Moroney attended Tameside Hospital by ambulance on 27 August 2014 with worsening breathing and concern about a blood clot, was discharged with arrangements to return the following day, and later required a second emergency ambulance. Concerns included the lack of monitoring or recording of his oxygen saturations, discontinuation of oxygen before discharge without monitoring, and the absence of previous oxygen-level records when he was readmitted.

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
Unavailability of records of previous oxygen levels on readmission
Wider context from the report
“3. When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels. ”
Source location
Paul Moroney · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of discharge letters to communicate clinically significant sedation and oxygen requirements

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to document low oxygen saturation and oxygen prescription

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments

Failure of ward staff to know and identify patients’ continuing oxygen requirements

Concerns raised1

Unavailability of records of previous oxygen levels on readmission

Respondent positions 2

Actions described in response 3

Respondent positions 2