Recurring concern
Failure to ensure clear and followed instructions for safe equipment use
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Request correctionFirst reported 15 Dec 2015•Latest report 31 Mar 2026
What this concern includes
Includes failures of controls specifically dedicated to safe equipment-use instructions, including provision, availability, clarity, completeness, identification of defect or hazard indications, user understanding, and monitoring or assurance of compliance, across clinical, industrial, recreational and other operational equipment.
Not included
- Excludes generic training, supervision, documentation or compliance deficiencies that are not specifically tied to safe equipment-use instructions.
- Excludes equipment defects, maintenance or certification failures where no instruction or instruction-compliance control is deficient.
- Excludes clinical, referral, care or operational protocols that do not govern the safe use of equipment.
- Excludes failures concerning the operation of a particular piece of equipment when the report does not identify an equipment-use instruction or compliance-control deficiency.
- Reports
- 22
- Individual concerns
- 26
- Date range
- 2015–2026
- Stated actions
- 53
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to provide clear, available instructions for equipment use
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 concernsEach 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.3
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Action
Maintain explicit carbon monoxide checks within safe premises audits and related safety controls.
Stated by The Scout Association -
Action
Strengthen point-of-use safety information through equipment-check guidance, warning requirements and replacement carbon monoxide labels and resources.
Stated by The Scout Association -
Action
Promote the safe premises audit tool, Nights Away permit review and carbon monoxide stove-safety guidance through the annual communications plan.
Stated by The Scout Association
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Concerns raised1
Failure to provide guidance on professional supervision or fitting of lap belts
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 concernsEach 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.4
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Action
Review wider intelligence on wheelchair and armchair support belts, including incidents, standards and product instructions and warnings.
Stated by Office for Product Safety and Standards -
Action
Write to the Office of Product Safety and Standards expressing concerns about the lap belt product.
Stated by Department of Health and Social Care -
Action
Review the relevant safety standard and ORTONES belt instructions for warnings concerning prescription, fitting, skin injury and strangulation risks.
Stated by Medicines and Healthcare products Regulatory Agency
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Action
Inform OPSS about the ongoing investigation and include it in manufacturer communications to assess proposed corrective actions.
Stated by Medicines and Healthcare products Regulatory Agency
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Addressing missing warnings for belts not classified as medical devices or accessories is outside the regulator’s remit.
Stated by Medicines and Healthcare products Regulatory Agency
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Concerns raised1
Instructions for Use failing to identify SP5 and ERC defect indications
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 concernsEach 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
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Action
Investigate the reported heart-lung machine safety concerns and determine appropriate follow-up action.
Stated by Medicines and Healthcare products Regulatory Agency
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The separate CP5 System Panel’s “Arterial clamp is defective” error message adequately indicates the issue.
Stated by Medicines and Healthcare products Regulatory Agency
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Position
The incident resulted from perfusionists failing to follow clear warnings and training, not from missing IFU wording.
Stated by LivaNova -
Position
Existing error messages, icon removal and perfusionist training adequately identify ERC clamp problems, so additional IFU instructions are unnecessary.
Stated by LivaNova
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Concerns raised1
Failure to use the Rotanda for transfers between sitting and standing
Responses linked to these concernsEach 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.4
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Action
Train all staff to follow care plans and use prescribed equipment, with signed declarations confirming understanding and commitment.
Stated by Lifeway Care Ltd -
Action
Provide care-plan and prescribed-equipment training to all new staff.
Stated by Lifeway Care Ltd -
Action
Display an app banner reminding carers to follow care plans and use prescribed equipment during every care visit.
Stated by Lifeway Care Ltd
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Action
Provide regular refresher training in the future.
Stated by Lifeway Care Ltd
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Concerns raised1
Lack of overtly clear operating instructions on CD oxygen cylinders in heightened situations
Responses linked to these concernsEach 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.5
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Action
Provide illustrated online instructions covering safe VIPR operation, cylinder handling and oxygen administration.
Stated by Boc Limited -
Action
Modify the cylinder valve handwheel tamper-evident cover with black raised-letter printing to clarify removal before use.
Stated by Boc Limited -
Action
Make IOD medical oxygen cylinders with electronic setup and flow alarms available to healthcare facilities.
Stated by Boc Limited
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Action
Develop a single-operation medical gas VIPR with two manufacturers and test the valves for compliance with the relevant ISO standard.
Stated by Boc Limited -
Action
Continue product-evaluation and improvement projects addressing valve operation and patient safety.
Stated by Boc Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Responsibility for ensuring healthcare staff receive appropriate cylinder training and retraining rests with the healthcare facility.
Stated by Boc Limited
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Position
Nurse awareness training was not provided because the hospital declined the offered training session.
Stated by Boc Limited
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Concerns raised2
Failure to provide jet ski hirers with emergency engine cut-off instructions
Failure to provide jet ski hirers with instructions on areas to avoid
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to use sensory mats in accordance with manufacturers instructions
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 concernsEach 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.4
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Action
Test sensor mats and establish daily care-plan checks plus manager walkaround checks of their operation and placement.
Stated by Bupa Care Services UK -
Action
Remind Bupa Care Homes to order equipment through the Clinical Equipment Guide.
Stated by Bupa Care Services UK -
Action
Record sensor-mat need, type and required position in every high-fall-risk resident’s additional care plan.
Stated by Bupa Care Services UK
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Action
Complete one-to-one sessions with all staff on sensor-mat equipment and correct use.
Stated by Bupa Care Services UK
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Concerns raised1
Lack of user and carer awareness of positional asphyxia risks during hoisting
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Develop and establish a self-hoisting policy and checklist covering risk warnings, equipment checks, emergency plans, fault reporting and competency confirmation.
Stated by London Borough of Southwark
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Concerns raised1
Lack of instructions for inserting and confirming placement of nasogastric decompression tubes
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 concernsEach 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.4
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Action
Review manufacturers’ instructions for use for nasogastric feeding and decompression tube placement.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Work with manufacturers to update instructions for use where the review identifies applicable changes.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Share the report with the topic selection and prioritisation team for consideration of guidance on nasogastric decompression.
Stated by National Institute for Health and Care Excellence
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Action
Share the HSIB and coroner reports with the guideline surveillance team to assess whether the nasogastric tube recommendation requires updating.
Stated by National Institute for Health and Care Excellence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing Royal Marsden Manual guidance is considered sufficient, so NHS England would not routinely provide national guidance on nasogastric tube insertion.
Stated by NHS England
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Position
NICE is the statutory body responsible for developing and disseminating clinical guidance on nasogastric tube placement and confirmation.
Stated by NHS England -
Position
The MHRA is best placed to consider instructions for nasogastric decompression tubes as the UK regulator of medical devices.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Lack of clear practical guidance for managing high-risk electrical devices in specialist housing
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Action
Work with the Home Office on guidance review and revision to address risks concerning high-risk electrical devices and digital keypad locks.
Stated by National Fire Chiefs Council -
Action
Review LFB guidance on portable electric fan heaters in specialist housing.
Stated by London Fire Commissioner
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Existing statutory care-home guidance and the specialised housing guide satisfactorily address risks from high-risk electrical devices.
Stated by National Fire Chiefs Council
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Position
National fire safety guidance matters under the Fire Safety Order should be raised with the Home Office, which has the statutory guidance duty.
Stated by London Fire Commissioner -
Position
LFB cannot enforce controls on tenants’ portable heaters where lease or tenancy terms limit providers’ options and officers lack enforcement powers.
Stated by London Fire Commissioner -
Position
Fire precaution issues should be examined by technical committee FSH/14, which is responsible for relevant building fire-safety standards.
Stated by British Standards Institution
Data last updated 7 September 2026