First reported 18 Apr 2016•Latest report 28 Apr 2023
Definition
What this concern includes
Includes failures in recognising the need for emergency oxygen, selecting or understanding the required emergency oxygen level, initiating or administering oxygen promptly, and applying the relevant emergency oxygen procedure during an acute event.
Not included
Excludes general oxygen prescribing, routine oxygen supply or non-emergency oxygen therapy where emergency administration is not the identified unsafe condition.
Excludes oxygen equipment malfunction, concentrator alarms and oxygen-related fire risks unless they directly concern emergency oxygen administration.
Excludes generic staff training, communication or documentation deficiencies unless they directly impair administration of oxygen during an emergency.
Excludes failures to monitor oxygen saturation or supervise oxygen-dependent patients where emergency oxygen administration is not the shared unsafe condition.
Reports
3
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2016–2023
First to latest report issue date
Stated actions
6
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.
Acorn Lodge Care Centre1
Department of Health and Social Care1
Lodge Care Home1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
North East London NHS Foundation Trust1
Wychall Lane Surgery1
Executive non-departmental public body1
Integrated care board1
Ministerial department1
NHS trust1
Nursing home1
Type not available1
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.
East London
Concerns raised1
Delays in administering oxygen during emergencies
This report raised 14 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
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.
Stated by North East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to provide oxygen during resuscitation in GP practices
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
Action
Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.
Stated by Wychall Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
Action
Assist the practice involved in the incident to identify and address issues highlighted by the incident.
Stated by Birmingham South Central CCGStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.
Action
Circulate learning from the incident to all commissioned GP practices.
Stated by Birmingham South Central CCGStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
Action
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
Stated by Birmingham South Central CCGStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
Stated by Wychall Lane SurgeryOutside remitThe respondent said that this matter was outside its role or authority.
Inner North London
Concerns raised2
Failure to administer the required oxygen flow
Lack of recognition of the oxygen level required in an emergency situation
This report raised 2 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.
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Includes failures in recognising the need for emergency oxygen, selecting or understanding the required emergency oxygen level, initiating or administering oxygen promptly, and applying the relevant emergency oxygen procedure during an acute event.
