Includes failures of controls specifically dedicated to oxygen humidifier safety, including operation and temperature checks, connection and engagement, flow verification, alarms, user instructions, handover checks and response to humidifier malfunction.
What is not included
Excludes general oxygen prescribing, supply, administration, supervision or clinical-monitoring failures where the oxygen humidifier is not the deficient control.
Excludes oxygen-concentrator, portable-cylinder and other oxygen-equipment failures unless they directly concern the oxygen humidifier safety process.
Excludes generic training, documentation or communication deficiencies unless they directly impair safe oxygen humidifier operation or monitoring.
Excludes failures occurring after oxygen flow has been reliably established when the remaining concern is clinical treatment or monitoring unrelated to the humidifier.
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.
Care Quality Commission1
Dolby Vivisol1
Fisher & Paykel Healthcare Limited1
HCA Healthcare UK1
Invacare Limited1
London Bridge Hospital1
Nursing and Midwifery Council1
Salter Labs1
Company1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Private limited company1
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
London Inner (South)
Concerns raised1
Failure to monitor humidifier operation and temperature
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
HCA Healthcare UK
London Bridge Hospital
Nursing and Midwifery Council
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
Nursing and Midwifery Council
Investigate the nursing-care concerns in accordance with statutory functions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
HCA Healthcare UK and London Bridge Hospital
Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
The completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised2
Failure to properly engage the humidifier screw cap, causing loss of oxygen flow to the nasal cannula
Failure of accompanying training and literature to explain the oxygen-flow implications of improper humidifier screw-cap engagement
This report raised 1 other concern. 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.12
Salter Labs
Complete a multidisciplinary technical review of the humidifier thread design and document its findings in the risk management file.
Salter Labs
Add multilingual labeling instructing users to check that the lid is properly sealed and explaining that leaks can reduce oxygen delivery.
Dolby Vivisol
Liaise with Invacare about revised instructions warning of oxygen-flow effects when humidifier caps are improperly fastened.
Dolby Vivisol
Modify humidifier literature to explain incorrect connection risks and emphasise confirming oxygen flow from the nasal cannula.
Dolby Vivisol
Review and update company instructions and training materials after receiving manufacturers’ finalized amendments.
Dolby Vivisol
Submit finalized literature amendments to NHS contract managers for approval.
Dolby Vivisol
Distribute approved updated literature to current and future equipment users, highlighting amendments for current humidifier patients.
Dolby Vivisol
Communicate literature amendments to relevant staff and reinforce them during future patient and carer installation training.
Invacare (UK) Limited
Provide guidance in current manuals on securely fastening humidifier bottle caps.
Invacare (UK) Limited
Update customer manuals with warnings that cross-threaded or improperly installed humidifier bottles and accessories can affect oxygen flow.
Invacare (UK) Limited
Phase the updated warning into all Invacare manuals over the next several months.
Salter Labs
Ensure updated equipment-provider literature includes reference to the humidifier safety valve.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Salter Labs
The current humidifier thread design is appropriate and has reduced cross-threading risk as far as possible.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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.
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
Humidifier bottles are supplied by others, so Salter Labs should directly address concerns about their design and operation.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Salter Labs
The equipment provider is responsible for updating training and literature about the implications of improperly engaging the humidifier cap.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Invacare (UK) Limited
Suppliers such as Dolby Vivisol are responsible for end-user training and literature, so Dolby Vivisol should lead this work.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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.