Recurring concern

Unsafe transfer and connection of portable oxygen supplies

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First reported 6 Mar 2015•Latest report 22 Mar 2019

Definition

What this concern includes

Includes failures of controls dedicated to safely transferring or connecting portable oxygen supplies, including connection checks, tug tests, confirmation of flow, alarms or equivalent verification that the oxygen supply reaches the patient.

Not included

  • Excludes generic oxygen equipment maintenance, supply availability, prescribing or clinical monitoring failures unless they directly concern the transfer or connection of portable oxygen supplies.
  • Excludes failures involving other clinical equipment connections where oxygen transfer or oxygen delivery is not the shared safety concern.
  • Excludes generic checklist, training or documentation deficiencies unless they directly undermine safe portable-oxygen transfer or connection.
  • Excludes failures occurring after oxygen delivery has been reliably connected when the concern is solely subsequent clinical treatment or monitoring.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2019

First to latest report issue date

Stated actions
1

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.

Department of Health and Social Care1
Leeds Teaching Hospitals NHS Trust1
Thames Valley and Wessex Adult Critical Care Operational Delivery Network1

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.

  1. Milton Keynes

    AI-generated summary

    Mark Stephen Anthony Simon KUBIAK · 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

    Mark Stephen Anthony Simon KUBIAK suffered a cardiac arrest and died during transfer from Critical Care at Milton Keynes Hospital to the John Radcliffe Hospital on 25 July 2018. The oxygen supply to his portable ventilator was not connected properly, and the principal concern was that the transfer checklist did not require the oxygen supply to be checked or a tug test to be completed.

    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 the transfer checklist to require oxygen supply checks

    Wider context from the report

    “That the Thames Valley Transfer Network Checklist does not require the oxygen supply to be checked, or for a tug test to be completed at the time that the oxygen is transferred from the ward supply in the hospital to the portable cylinder. If such a check and test had been carried out, the failure of the oxygen flow to the patient would immediately have been noticed and the situation rectified. ”

    Source location

    Mark Stephen Anthony Simon KUBIAK · Prevention of Future Deaths report
    Page 1 · 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 the transfer checklist to require tug tests

    Wider context from the report

    “That the Thames Valley Transfer Network Checklist does not require the oxygen supply to be checked, or for a tug test to be completed at the time that the oxygen is transferred from the ward supply in the hospital to the portable cylinder. If such a check and test had been carried out, the failure of the oxygen flow to the patient would immediately have been noticed and the situation rectified. ”

    Source location

    Mark Stephen Anthony Simon KUBIAK · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Mr Simon Timothy Harper · 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

    Mr Simon Timothy Harper was admitted to hospital with jaundice and abdominal distention and later developed multiple organ failure. During his transfer to intensive care, his portable oxygen cylinder was not turned on; he suffered a cardiorespiratory arrest, was resuscitated, and died after treatment was withdrawn. Concerns included inadequate documented training and lack of a suitable transfer policy for using portable oxygen cylinders.

    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

    Transfer of Patients Policy failing to cover portable oxygen cylinder transfers

    Wider context from the report

    “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training. The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this. The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue. ”

    Source location

    Mr Simon Timothy Harper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. West Yorkshire Eastern

    AI-generated summary

    Connor Adrian Turner · 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

    Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving hospital.

    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

    Lack of a system for instructing and training parents and carers to transfer oxygen supplies to portable cylinders

    Wider context from the report

    “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder. (2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so. (3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes. ”

    Source location

    Connor Adrian Turner · Prevention of Future Deaths report
    Page 2 · 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

    Implement a staff-parent oxygen-therapy risk assessment with education on prescribed use, equipment operation, flow-rate control, and fire, tubing, and product-related hazards.

    Verbatim wording from the response

    “Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are:”

    Source location

    2015-0082-Response-by-Leeds-Teaching-Hospitals
    Page 2 · response
    Published 6 March 2015

    Open published response
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Data last updated 7 September 2026