Recurring concern

Inadequate controls for oxygen-related fire risks

First to latest report 23 Mar 2015 — 5 Jun 2025

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
8

What this concern includes

Includes failures of controls specifically intended to prevent, detect or respond to fires or ignition risks involving medical or aircraft oxygen, including recognising oxygen fires, isolating oxygen supplies, controlling ignition sources, assessing heightened oxygen-related fire risk, providing dedicated protective equipment and reviewing relevant fire safeguards.

What is not included
  • Excludes generic fire-safety deficiencies where oxygen is not materially involved.
  • Excludes ordinary oxygen prescribing, flow-rate, supply or monitoring failures where no oxygen-related fire or ignition risk is identified.
  • Excludes generic equipment, emergency-response or risk-assessment deficiencies not specifically dedicated to oxygen-related fire safety.
  • Excludes unrelated fires, smoke alarms and fire-detection failures that do not involve an oxygen-related ignition or fire risk.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Richard Mohamed Fekry Osman · 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

    Richard Mohamed Fekry Osman was a passenger on flight MS804, which crashed into the Mediterranean Sea on 19 May 2016 after a fire broke out on the flight deck; there were no survivors. The inquest stated that the fire was caused by an ignition source of unknown origin, most likely associated with the first officer’s oxygen supply system. The substantive concerns included cockpit fire and smoke procedures, oxygen-system risks, fire-protection equipment and extinguishers, smoking regulations, and arrangements for participation in or transfer of aircraft accident investigations.

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    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 recognise oxygen fires and immediately cut off the oxygen supply

    Wider context from the report

    “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

    Source location

    Richard Mohamed Fekry Osman · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of protective equipment for cockpit fires

    Wider context from the report

    “(1) That a full review of cockpit fire/smoke procedures be undertaken to include, but not limited to: - the recognition of an oxygen fire (identifiable by a characteristic noise comparable to that of a blowtorch) and the immediate cutting off this oxygen supply. - the installation or carrying of protective equipment to deal with any cockpit fires. - a review of the effectiveness of Halon fire extinguishers to deal with onboard fires. - a review of regulations (if required) to prevent the use of cigarettes in the cockpit and related flammable items and materials. - the additional risk analyses to take into account the hypothesis of an overpressure in the oxygen distribution system. ”

    Source location

    Richard Mohamed Fekry Osman · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Continue monitoring safety data and future aviation safety investigation recommendations relating to fire risks.

    Verbatim wording from the response

    “However, given the specific concerns identified by the Assistant Coroner, the CAA will continue to carefully monitor safety data and future aviation safety investigation recommendations related to fire risks with a view to taking appropriate action where necessary.”

    Source location

    Response from Civil Aviation Authority
    Page 5 · response
    Published 3 July 2025

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    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

    Existing airworthiness, operational, certification and safety-management safeguards provide adequate mitigation, so no aviation safety regulatory changes are currently required.

    Verbatim wording from the response

    “No new fires have been identified by the CAA as a result of this audit programme and the CAA remains satisfied that all known risks fall within existing design, certification and operational controls.”

    Source location

    Response from Civil Aviation Authority
    Page 4 · response
    Published 3 July 2025

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    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

    CAA safety data does not indicate that onboard fire risks or flight-deck fire consequences require changes to existing rules.

    Verbatim wording from the response

    “The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.”

    Source location

    Response from Civil Aviation Authority
    Page 5 · response
    Published 3 July 2025

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    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

    Existing airworthiness, operational, certification and safety-management controls provide adequate mitigation, so no regulatory framework change is currently required.

    Verbatim wording from the response

    “The CAA’s review of the Assistant Coroner’s recommendations has concluded that no change to the existing aviation safety regulatory framework is currently required. The CAA remains satisfied that the safeguards in place, which are underpinned by airworthiness and operational regulations, design and certification requirements and operator safety management systems provide adequate risk mitigation. As part of this review, subject matter experts have examined relevant safety data held by the CAA under the Mandatory Occurrence Reporting Scheme, which does not indicate there is a risk of fire onboard large commercial aircraft - or the consequences of a flight deck fire - necessitate changes to existing rules. The CAA is also mindful of international requirements directed by ICAO which do not support change to existing fire safety controls at the present time.”

    Source location

    Response from Civil Aviation Authority
    Page 5 · response
    Published 3 July 2025

    Open published response

  2. Black Country

    AI-generated summary

    Mrs Lynn Hadley · 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

    On 13 April 2020, paramedics attended Mrs Lynn Hadley at home for COVID-19-type symptoms and began administering oxygen. The oxygen cylinder sparked and caught fire, and despite efforts by family members and paramedics, Mrs Hadley could not be removed from the house and died from fatal burn injuries. The concerns included possible ignition caused by adiabatic compression or particle impact when the oxygen regulator was opened, limited awareness of these risks among equipment users, and other reported cases of ignition involving oxygen-cylinder valve components.

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    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 follow the safe valve-opening sequence for oxygen regulators

    Wider context from the report

    “2. Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition. 3. Evidence from the paramedic confirmed that she opened the patient valve first before opening the on/off valve, thus increasing the chance of the reported phenomena occurring. ”

    Source location

    Mrs Lynn Hadley · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Consider whether HSE should take further action, including updating oxygen-cylinder safety guidance to reflect new MHRA information or guidance.

    Verbatim wording from the response

    “Once completed, we will:”

    Source location

    2021-0346-Response-from-Health-and-Safety-Executive_Published
    Page 1 · response
    Published 18 October 2021

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    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

    Make all frontline staff aware of medical-gas-cylinder assembly and disassembly requirements, adiabatic compression, and particle-impact risks.

    Verbatim wording from the response

    “Response: WMAS took immediate action as detailed during the Inquest. All frontline WMAS staff were swiftly made aware of the specific requirements for assembly/disassembly of all medical gas cylinders, awareness of adiabatic compression and particle impact, and furthermore a great deal of input went into sharing lessons learned widely throughout partner organisations. The table below provides a summary/timeline of action taken.”

    Source location

    2021-0346-Response-from-West-Midlands-Ambulance-Service_Published
    Page 1 · response
    Published 18 October 2021

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    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

    Continue engaging the Association of Anaesthetists and Royal College of Anaesthetists on oxygen-cylinder ignition and fire-safety messaging.

    Verbatim wording from the response

    “We believe the MHRA is best placed to take specific leadership action in relation to the risk of incidents which can lead to ignition and fire in the context of oxygen cylinders. We will firstly engage with all the professional organisations who are the most likely to be involved in the administration of oxygen. Their members will be involved in the key stages of setting up of oxygen cylinders and accessory devices (required for the administration to a patient) and the monitoring of the progress of the patient when this has begun. It is hoped, in their professional leadership roles, they will be able to understand and shape the final messages needed to effect culture change amongst their membership, with our assistance where it is within our remit.”

    Source location

    2021-0346-Response-from-MHRA_Published
    Page 2 · response
    Published 18 October 2021

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    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

    Engage additional professional, healthcare and emergency-service organisations to shape and disseminate oxygen-cylinder ignition and fire-safety messaging.

    Verbatim wording from the response

    “We believe the MHRA is best placed to take specific leadership action in relation to the risk of incidents which can lead to ignition and fire in the context of oxygen cylinders. We will firstly engage with all the professional organisations who are the most likely to be involved in the administration of oxygen. Their members will be involved in the key stages of setting up of oxygen cylinders and accessory devices (required for the administration to a patient) and the monitoring of the progress of the patient when this has begun. It is hoped, in their professional leadership roles, they will be able to understand and shape the final messages needed to effect culture change amongst their membership, with our assistance where it is within our remit.”

    Source location

    2021-0346-Response-from-MHRA_Published
    Page 2 · response
    Published 18 October 2021

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    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

    Issuing or changing formal guidance or policies on oxygen use and safety is outside the regulator’s remit.

    Verbatim wording from the response

    “1. ‘All agencies involved may wish to consider reviewing and issuing guidance for the operation and use of oxygen cylinders.”

    Source location

    2021-0346-Response-from-CQC_Published
    Page 3 · response
    Published 18 October 2021

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    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

    The regulator cannot issue oxygen safety guidance because it lacks clinical expertise and access to necessary specialist expertise.

    Verbatim wording from the response

    “As a regulator it is unfortunately outside of the CQC's remit to issue or change formal guidance or policies around oxygen usage or safety. We are not clinical experts on oxygen cylinders or have access to the expertise which would be necessary in order to issue safety guidance. This role is more suited to the MHRA and HSE from whom I am aware separate responses will be sent to you.”

    Source location

    2021-0346-Response-from-CQC_Published
    Page 3 · response
    Published 18 October 2021

    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

    Responsibility for issuing oxygen safety guidance lies with the MHRA and HSE.

    Verbatim wording from the response

    “As a regulator it is unfortunately outside of the CQC's remit to issue or change formal guidance or policies around oxygen usage or safety. We are not clinical experts on oxygen cylinders or have access to the expertise which would be necessary in order to issue safety guidance. This role is more suited to the MHRA and HSE from whom I am aware separate responses will be sent to you.”

    Source location

    2021-0346-Response-from-CQC_Published
    Page 3 · response
    Published 18 October 2021

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    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

    MHRA is the lead authority and regulator for the equipment involved, so it leads the relevant investigation and regulatory action.

    Verbatim wording from the response

    “MHRA are the lead authority, as they are the regulator for the equipment involved in this incident. However, during the investigation a Multidisciplinary Team (MDT), comprising the Care Quality Commission, West Midlands Ambulance Service, West Midlands Fire Service, MHRA, Medical Gas Solutions and HSE, was established to:”

    Source location

    2021-0346-Response-from-Health-and-Safety-Executive_Published
    Page 1 · response
    Published 18 October 2021

    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

    It is premature for HSE to consider action before MHRA’s investigative and regulatory work is completed.

    Verbatim wording from the response

    “HSE continues to support MHRA and we believe it would be premature for us to consider taking any action before their work is completed.”

    Source location

    2021-0346-Response-from-Health-and-Safety-Executive_Published
    Page 1 · response
    Published 18 October 2021

    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

    Issuing guidance on oxygen-cylinder operation and use is outside the respondent’s remit.

    Verbatim wording from the response

    “The issuing of guidance is not within the remit of the MHRA, however, we are able to provide a degree of leadership as the Agency which had primacy in the latter stages of the investigation of this incident.”

    Source location

    2021-0346-Response-from-MHRA_Published
    Page 1 · response
    Published 18 October 2021

    Open published response

  3. Central Lincolnshire

    AI-generated summary

    Robert Spring · 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

    Robert Spring, who had chronic obstructive pulmonary disease and used home oxygen while smoking, died in a fire at his home on 14 March 2014. The fire was attributed to either a cigarette lighter or a dropped cigarette. The principal concerns were that relevant agencies were not fully informed of his smoking-related risk, so he was not assessed for available fire-safety equipment, and that more extensive communication between agencies was needed.

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    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 by LFRS to assess high-risk Home Oxygen users for safety equipment

    Wider context from the report

    “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide. (II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen. (IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”. (V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above. (VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity. (VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives. ”

    Source location

    Robert Spring · Prevention of Future Deaths report
    Page 2 · concerns

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    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 direct notification of heightened Home Oxygen and smoking risks to LFRS

    Wider context from the report

    “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide. (II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014. (III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen. (IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”. (V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above. (VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity. (VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives. ”

    Source location

    Robert Spring · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Include a documented fire-risk assessment in the standard operating procedure to identify patients at increased risk.

    Verbatim wording from the response

    “3. As part of our standard operating procedure we have included a documented risk assessment designed by LF&R to identify patients who are at increased risk of fire (see Appendix 1 within the above attachment). The standard operating procedure also outlines a clear and agreed communication process between all parties. This will provide LF&R an opportunity to conduct a home assessment, and install any required safety equipment.”

    Source location

    2015-0123-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    Open published response

    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

    Incorporate a process for sharing information with Lincolnshire Fire & Rescue and Air Liquide into Trust policy.

    Verbatim wording from the response

    “1. ULHT have met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a process for sharing information. This is described in a new document which has been incorporated into Trust policy (see Attachment A).”

    Source location

    2015-0123-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    Open published response

    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

    Define an agreed communication process between the relevant parties in the standard operating procedure.

    Verbatim wording from the response

    “3. As part of our standard operating procedure we have included a documented risk assessment designed by LF&R to identify patients who are at increased risk of fire (see Appendix 1 within the above attachment). The standard operating procedure also outlines a clear and agreed communication process between all parties. This will provide LF&R an opportunity to conduct a home assessment, and install any required safety equipment.”

    Source location

    2015-0123-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
    Page 1 · response
    Published 23 March 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026