Recurring concern

Failure to safely supervise patients receiving oxygen therapy

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First reported 26 Jun 2015•Latest report 25 May 2022

Definition

What this concern includes

Includes failures of supervision specifically linked to patients receiving oxygen therapy, including reliance on family members, leaving patients without appropriate nursing oversight, and inadequate arrangements to detect or respond when a patient removes or cannot maintain an oxygen mask or supply.

Not included

Excludes general patient-supervision or welfare-check failures where oxygen therapy is not a material part of the unsafe condition.
Excludes failures of oxygen prescribing, supply, equipment serviceability or flow delivery where supervision of oxygen therapy is not deficient.
Excludes generic staff training or communication deficiencies unless they directly cause unsafe supervision of a patient receiving oxygen therapy.
Excludes documentation or monitoring failures that do not impair supervision or timely detection of oxygen-therapy problems.

Reports: 3
Individual concerns: 3
Date range: 2015–2022
Stated actions: 1

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.

Barking, Havering and Redbridge University Hospitals NHS Trust1

Circle Health Group Limited1

gtd healthcare1

Royal Bolton Hospital1

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.

25 May2022
East London
Concerns raised1
1. Reliance on a family member to maintain oxygen mask placement
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remind nursing staff of expectations for safely caring for patients receiving oxygen therapy.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated planned
Respondent positions 1
1. Position
  In acute deterioration, it may not be possible to provide additional staff to supervise a patient removing oxygen therapy.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustUnable to act
AI-generated summary

Elizabeth Margaret Mills · 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

Elizabeth Margaret Mills was admitted to hospital with abdominal pain on 25 March 2021, underwent surgery for a perforated pyloric ulcer, and later developed pneumonia requiring increasing oxygen therapy. She died after removing an oxygen mask while unattended in a side ward, when nasal cannulae were replaced but were no longer connected to an oxygen supply. Concerns included poor medical record-keeping about the do-not-attempt-CPR process, reliance on her husband to keep the mask in place, and the Trust’s failure to investigate unexpected events through a Serious Incident Investigation.

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
Reliance on a family member to maintain oxygen mask placement
Wider context from the report
“2. During the final hours of her life, Mrs Mills required increasing levels of oxygen therapy. Mrs Mills was agitated and repeatedly removed her venturi mask. Medical and nursing staff left Mrs Mills in a side ward in the care of her husband, relying upon him to ensure her mask remained in place. ”
Source location
Elizabeth Margaret Mills · 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
Remind nursing staff of expectations for safely caring for patients receiving oxygen therapy.

Verbatim wording from the response
“The expectation is that if a nurse leaves the patient, they will notify the patient/relative/visitor of where they are going, how long they will be and to call, if assistance is required. Nursing staff will be reminded of the expectations involved in nursing patients receiving oxygen therapy.”

Source location
Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022
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
In acute deterioration, it may not be possible to provide additional staff to supervise a patient removing oxygen therapy.

Verbatim wording from the response
“care to assist with giving oxygen therapy safely. However, in an acute situation, such as EM’s situation, where the patient deteriorates quickly, it may not be possible to facilitate extra staff and the focus would be on providing immediate treatment. It is expected that nursing staff would escalate the fact that a patient is agitated and removing their oxygen mask to the doctor/nurse in charge. It would be reasonable for a nurse to leave the patient for a short period in order to communicate with colleagues/escalate any concerns, if the patient was settled. Patients’ relatives can be very helpful in reassuring and calming patients to assist with giving therapies such as oxygen but there would not be an assumption that they would deal with administering the therapy.”

Source location
Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022
Open published response
8 Jul2015
Manchester South
Concerns raised1
1. Failure to prevent unsafe disconnection of oxygen supply and departure from the ward
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 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

Amanda Jane Ellams · 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

Amanda Jane Ellams died approximately four days after surgery to repair an incisional hernia in February 2015. The concerns included inadequate medical and nursing record-keeping, incomplete pre-operative medical information, discharge despite low oxygen saturations and inadequate oxygen monitoring, and three unanswered calls to the out-of-hours District Nursing telephone service during the night of her death.

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 prevent unsafe disconnection of oxygen supply and departure from the ward
Wider context from the report
“2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare) ”
Source location
Amanda Jane Ellams · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Jun2015
Manchester West
Concerns raised1
1. Failure to supervise patients requiring oxygen while they are in ward facilities
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

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 supervise patients requiring oxygen while they are in ward facilities
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Reliance on a family member to maintain oxygen mask placement

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to prevent unsafe disconnection of oxygen supply and departure from the ward

Concerns raised1

Failure to supervise patients requiring oxygen while they are in ward facilities

Actions described in response 1

Respondent positions 1