First reported 23 Mar 2015•Latest report 5 Jun 2025
Definition
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.
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
3
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
8
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.
Air Liquide Healthcare Limited1
Care Quality Commission1
Civil Aviation Authority1
Department for Transport1
European Union Aviation Safety Agency1
Health and Safety Executive1
Lincolnshire County Council1
Medicines and Healthcare products Regulatory Agency1
NHS Lincolnshire Integrated Care Board1
Recipient name withheld1
Stewarts Law LLP1
United Lincolnshire Teaching Hospitals NHS Trust1
West Midlands Ambulance Service University NHS Foundation Trust1
NHS trust2
Aviation regulator1
Company1
English county council1
Health and social care service regulator1
Integrated care board1
Medicines and medical devices regulator1
Ministerial department1
Private limited company1
Workplace safety regulator1
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.
Carmarthenshire and Pembrokeshire
Concerns raised2
Failure to recognise oxygen fires and immediately cut off the oxygen supply
Unavailability of protective equipment for cockpit fires
This report raised 5 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
Action
Continue monitoring safety data and future aviation safety investigation recommendations relating to fire risks.
Stated by Civil Aviation AuthorityStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing airworthiness, operational, certification and safety-management safeguards provide adequate mitigation, so no aviation safety regulatory changes are currently required.
Stated by Civil Aviation AuthorityExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
CAA safety data does not indicate that onboard fire risks or flight-deck fire consequences require changes to existing rules.
Stated by Civil Aviation AuthorityDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing airworthiness, operational, certification and safety-management controls provide adequate mitigation, so no regulatory framework change is currently required.
Stated by Civil Aviation AuthorityExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Failure to follow the safe valve-opening sequence for oxygen regulators
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.
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.4
Action
Consider whether HSE should take further action, including updating oxygen-cylinder safety guidance to reflect new MHRA information or guidance.
Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Action
Make all frontline staff aware of medical-gas-cylinder assembly and disassembly requirements, adiabatic compression, and particle-impact risks.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Action
Continue engaging the Association of Anaesthetists and Royal College of Anaesthetists on oxygen-cylinder ignition and fire-safety messaging.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Engage additional professional, healthcare and emergency-service organisations to shape and disseminate oxygen-cylinder ignition and fire-safety messaging.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 18 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Issuing or changing formal guidance or policies on oxygen use and safety is outside the regulator’s remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The regulator cannot issue oxygen safety guidance because it lacks clinical expertise and access to necessary specialist expertise.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Responsibility for issuing oxygen safety guidance lies with the MHRA and HSE.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
MHRA is the lead authority and regulator for the equipment involved, so it leads the relevant investigation and regulatory action.
Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
It is premature for HSE to consider action before MHRA’s investigative and regulatory work is completed.
Stated by Health and Safety ExecutiveUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Issuing guidance on oxygen-cylinder operation and use is outside the respondent’s remit.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Central Lincolnshire
Concerns raised2
Failure by LFRS to assess high-risk Home Oxygen users for safety equipment
Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS
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.
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.3
Action
Include a documented fire-risk assessment in the standard operating procedure to identify patients at increased risk.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Incorporate a process for sharing information with Lincolnshire Fire & Rescue and Air Liquide into Trust policy.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
Action
Define an agreed communication process between the relevant parties in the standard operating procedure.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2015.
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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.
