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.
What is 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.
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
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
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked responses
Department of Health and Social Care
North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
North East London NHS Foundation Trust
Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Redirects 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.
Linked responses
Birmingham South Central CCG
NHS England
Wychall Lane Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
NHS England
Ask the CQC to ensure inspections check that primary care services have equipment and skills to address respiratory emergencies.
Wychall Lane Surgery
Provide defibrillator, oxygen, oximeter and recommended CPR equipment for managing medical emergencies in the practice.
Birmingham South Central CCG
Assist the practice involved in the incident to identify and address issues highlighted by the incident.
Birmingham South Central CCG
Circulate learning from the incident to all commissioned GP practices.
Birmingham South Central CCG
Circulate incident learning to surrounding clinical commissioning groups for dissemination to their practices.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Except in remote or inaccessible locations, practices may rely on rapid access to emergency services when determining appropriate equipment and training.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
NHS England
The CQC is responsible for using its inspection regime to ensure primary care services carry necessary equipment and skills for respiratory emergencies.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Wychall Lane Surgery
General practice is not an emergency service and is not contracted, equipped or organised to deliver team-based emergency care.
Outside 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.