First reported 24 Nov 2014•Latest report 3 Feb 2017
Definition
What this concern includes
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.
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.
Reports
2
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2014–2017
First to latest report issue date
Stated actions
13
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.
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
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.
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.
Responses linked to these concerns
Each 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
Action
Investigate the nursing-care concerns in accordance with statutory functions.
Stated by Nursing and Midwifery CouncilStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Action on concern 1 is assigned to the NMC; LBH considers itself not required to act because it is not responsible.
Stated by HCA Healthcare UK and London Bridge HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The completed RCA action plan was considered sufficient to mitigate recurrence risk, with the planned actions carried out.
Stated by Care Quality CommissionExisting 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.
Responses linked to these concerns
Each 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.12
Action
Complete a multidisciplinary technical review of the humidifier thread design and document its findings in the risk management file.
Stated by Salter LabsStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Add multilingual labeling instructing users to check that the lid is properly sealed and explaining that leaks can reduce oxygen delivery.
Stated by Salter LabsStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Liaise with Invacare about revised instructions warning of oxygen-flow effects when humidifier caps are improperly fastened.
Stated by Dolby VivisolStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Action
Modify humidifier literature to explain incorrect connection risks and emphasise confirming oxygen flow from the nasal cannula.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Review and update company instructions and training materials after receiving manufacturers’ finalized amendments.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Submit finalized literature amendments to NHS contract managers for approval.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Distribute approved updated literature to current and future equipment users, highlighting amendments for current humidifier patients.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Communicate literature amendments to relevant staff and reinforce them during future patient and carer installation training.
Stated by Dolby VivisolStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Provide guidance in current manuals on securely fastening humidifier bottle caps.
Stated by Invacare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Update customer manuals with warnings that cross-threaded or improperly installed humidifier bottles and accessories can affect oxygen flow.
Stated by Invacare (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Phase the updated warning into all Invacare manuals over the next several months.
Stated by Invacare (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Action
Ensure updated equipment-provider literature includes reference to the humidifier safety valve.
Stated by Salter LabsStated plannedThe respondent said that this action was planned when they made their response on 24 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The current humidifier thread design is appropriate and has reduced cross-threading risk as far as possible.
Stated by Salter LabsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.
Stated by Salter LabsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.
Stated by Dolby VivisolRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Humidifier bottles are supplied by others, so Salter Labs should directly address concerns about their design and operation.
Stated by Invacare (UK) LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The equipment provider is responsible for updating training and literature about the implications of improperly engaging the humidifier cap.
Stated by Salter LabsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Suppliers such as Dolby Vivisol are responsible for end-user training and literature, so Dolby Vivisol should lead this work.
Stated by Invacare (UK) LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
