Recurring concern

Unreliable PAT testing and safety assurance for electrical equipment

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First reported 5 May 2022•Latest report 17 Nov 2025

Definition

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.

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.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2022–2025

First to latest report issue date

Stated actions
0

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.

NHS England1
P31
Princess Alexandra 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.

  1. Essex

    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

  2. Black Country

    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
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Data last updated 7 September 2026