Recurring concern

Unreliable PAT testing and safety assurance for electrical equipment

First to latest report 5 May 2022 — 17 Nov 2025

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 0

What this concern includes

Includes failures in the PAT testing and associated safety-assurance process for electrical equipment, including overdue or absent testing, failure to identify and manage equipment whose testing is unavailable, and contingency arrangements needed to maintain safe equipment use during testing disruption.

What is not included

Excludes general electrical-equipment faults, maintenance or inspection failures where PAT testing or its continuity is not the identified concern.
Excludes generic contingency planning deficiencies unrelated to PAT testing or electrical-equipment safety assurance.
Excludes clinical equipment serviceability or oxygen-therapy provision failures where PAT testing is not materially involved.
Excludes broader workplace electrical-safety or equipment-certification concerns that do not specifically concern the PAT testing process.

Trends

Reports over time

Reports mentioning this concern, 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.

NHS England1

P31

Princess Alexandra Hospital1

Reports and published responses 2 reports

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

17 Nov2025
Essex
Concerns raised1
1. Out-of-date PAT testing for oxygen equipment
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

NHS England
the Princess Alexandra Hospital NHS Trust
Respondent positions 2
1. NHS England
  The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
  Redirects responsibility
1. the Princess Alexandra Hospital NHS Trust
  The oxygen concentrators did not require portable appliance testing because there was no legal requirement for supplier testing.
  Disputes the concern
AI-generated summary

Paolino AMICO · 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

Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

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
Out-of-date PAT testing for oxygen equipment
Wider context from the report
“(1) The consultant required a discharge plan for oxygen therapy to be in place before Mr Amico could go home. The hospital discharge plan and medications were confusing and the referral for oxygen therapy requirement was unclear, and the PAT testing for the machine was out of date. Paramedics advised the family that the oxygen provided on Mr Amico’s discharge was low flow and was not meeting his oxygen requirements with his oxygen saturations at 68% and this immediately improved on ambulance crew equipment. ”
Source location
Paolino AMICO · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.

Verbatim wording from the response
“The Princess Alexandra Hospital NHS Trust will be providing their own response to this Report, however, the Hertfordshire & West Essex ICB have advised NHS England of the Trust’s governance arrangements and actions being taken to address the concerns raised. It is understood that the Trust’s Patient Safety Group (PSG) has active oversight of several of the areas highlighted in the Report, particularly medicines safety, recognition of deterioration, and incident learning.”

Source location
Response from NHS England
Page 4 · response
Published 19 November 2025
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
The oxygen concentrators did not require portable appliance testing because there was no legal requirement for supplier testing.

Verbatim wording from the response
“Portable Appliance Testing (PAT) is a process used to ensure the safety of electrical appliances and equipment. The head of patient services at BOC has informed our operations team that they do not PAT test concentrators as there is no legal requirement for them to be PAT tested.”

Source location
Response from Princess Alexandra Hospital
Page 2 · response
Published 19 November 2025
Open published response
5 May2022
Black Country
Concerns raised2
1. Failure to reassess risks from non-testing of electrical appliances
2. Lack of a contingency plan for risks from absent PAT testing
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Keith Holmes · 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 Keith Holmes was found unresponsive and later confirmed deceased in his room at McHugh House after a fire in the early hours of 30 December 2021. The fire investigation could not determine whether the fire was caused by an electrical fault involving a fridge or by smoking materials igniting clothing or bedding. The principal concerns were the increased fire or accident risk from unmaintained electrical equipment during the Covid-19 pandemic, the failure to reassess that risk, and the absence of a contingency plan for a similar lockdown situation.

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 reassess risks from non-testing of electrical appliances
Wider context from the report
“(2) P3 failed to carry out a reassessment of the increased risks posed by the non-testing of electrical appliances in McHugh House during the Covid 19 Pandemic. This was during a time when it was expected that residents would spend significant periods of each day in their room; ”
Source location
Mr Keith Holmes · Prevention of Future Deaths report
Page 3 · 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
Lack of a contingency plan for risks from absent PAT testing
Wider context from the report
“(3) I was told in evidence that P3 do not have a contingency plan on managing the increased risks posed by the absence of PAT testing in the event the UK is placed into a similar lockdown situation as experienced during 2020/2021. ”
Source location
Mr Keith Holmes · Prevention of Future Deaths report
Page 3 · concerns
Open source report