Recurring concern

Unreliable oxygen administration and clinical oversight

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First reported 18 Apr 2016•Latest report 18 Jul 2023

Definition

What this concern includes

Includes failures in the clinical process for administering oxygen and overseeing the decision, including unclear staff understanding, inadequate documentation of the indication or rationale, failure to record clinician discussion, and failure to communicate or review the basis for oxygen treatment.

Not included

  • Excludes failures limited to oxygen supply, prescribed flow or target range where administration and clinical oversight are otherwise reliable.
  • Excludes oxygen-concentrator, humidifier, alarm and other equipment-specific failures unless they directly impair the oxygen-administration and oversight process.
  • Excludes oxygen-related fire risks unless they are part of the clinical administration and oversight failure.
  • Excludes generic documentation, training or communication deficiencies that are not specifically connected to oxygen administration.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2016–2023

First to latest report issue date

Stated actions
2

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
Betsi Cadwaladr University LHB1
County Durham and Darlington NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
Lodge Care Home1
Medicines and Healthcare products Regulatory Agency1
North East London NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Welsh Ambulance Services NHS Trust1

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. North Wales (East and Central)

    AI-generated summary

    Philip Hawkins · 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

    Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.

    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 document the rationale for oxygen administration and clinician discussion

    Wider context from the report

    “Care Concerns in the ED 4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas. 5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians. 6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician. 7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23. 8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him. ”

    Source location

    Philip Hawkins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

    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

    Delays in administering oxygen during emergencies

    Wider context from the report

    “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”

    Source location

    Winbourne Gregory Charles · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.

    Verbatim wording from the response

    “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 4 · response
    Published 5 May 2023

    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

    Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.

    Verbatim wording from the response

    “e. Oxygen administration was delayed.”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 6 · response
    Published 5 May 2023

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  3. South Wales Central

    AI-generated summary

    Thomas William Browne · 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

    Thomas William Browne, a highly vulnerable patient dependent on non-invasive oxygen ventilation, was found collapsed in a hospital toilet on 17 July 2018 after being left there unaccompanied. His oxygen cylinder was exhausted when he was found, and the inquest concluded that he died from natural causes. Concerns included the absence of systems to monitor patients dependent on finite oxygen supplies, deficiencies in the root cause analysis, incomplete oxygen-administration training, and the lack of formal procedures for recording when oxygen supplies would expire.

    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

    Incomplete training in oxygen administration

    Wider context from the report

    “(3) Training in the administration of Oxygen remains incomplete. ”

    Source location

    Thomas William Browne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    ALLAN WILLIAM CUNLIFFE · 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

    Allan Cunliffe, who had bowel problems and mental health issues, became ill on Summers Ward on 17 July 2018 and died in A&E on 18 July 2018 after deterioration associated with a perforated bowel and sepsis. The substantive concerns included poor communication, inadequate recording and calculation of NEWS scores, failures to follow observation protocols, and confusion about oxygen administration, with the jury stating that insufficient record keeping and communication probably led to an avoidable death.

    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

    Confusion regarding oxygen administration

    Wider context from the report

    “(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training. ”

    Source location

    ALLAN WILLIAM CUNLIFFE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide Acute Illness Management training for registered and unregistered nursing staff on assessing and responding to deteriorating patients, including oxygen therapy.

    Verbatim wording from the response

    “More recently Pennine Care now also provides Acute Illness Management training for both registered and unregistered nursing staff. A workshop covering the systematic approach to assessing a deteriorating patient is delivered. During this airways and breathing are discussed and includes how to assess, and take action (inclusive of oxygen), in the event of an emergency. A demonstration/simulation is also delivered. The course details why a person needs oxygen to survive and the consequences of our body not receiving enough whilst also detailing normal and abnormal signs relating to the airway and breathing.”

    Source location

    2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
    Page 3 · response
    Published 18 May 2020

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Mr Matthews · 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 Matthews, who had pneumoconiosis and COPD, was admitted to hospital after being found collapsed and later suffered further cardiac arrests before dying on 19 February 2016. The principal concerns were that oxygen was not prescribed or recorded at the required rate, and that there was no system to ensure the oxygen concentrator was working correctly or that damage to it was promptly reported and investigated.

    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 ensure administration of oxygen at the prescribed rate

    Wider context from the report

    “(2) Notwithstanding the conclusion of the manufactuer that the oxygen was still being delivered by the device in the right concentration, I am concerned that there was no system in place to ensure that the oxygen was being administered at the prescribed rate. An oxygen concentrator had been set up for use by the patient and the flow rate had been set at 2 litres per minute. The Trust's policy states that all oxygen must be prescribed and the prescribed rate should be recorded on the drug chart. The oxygen was not prescribed on the drug chart and the flow rate was not recorded. This meant that staff were unaware of the prescribed rate and there was no means of checking that the concentrator was delivering the prescribed flow rate. (3) The Trust's policy for oxygen states that oxygen must be prescribed and that the prescribed rate should be recorded on the drug chart. However, no such prescription was made in the drug chart and no record was made of the flow rate. ”

    Source location

    Mr Matthews · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Doreen Mattinson · 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

    Doreen Mattinson, an 80-year-old resident of Acorn Care Home with dementia and other comorbidities, deteriorated rapidly with laboured breathing on 12 November 2015. Concerns were raised about the administration of oxygen, including the flow rate, her supine position, and the absence of evidence of training for the registered nurse who administered it.

    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

    Lack of training of the Clinical Manager to administer oxygen

    Wider context from the report

    “(3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen. ”

    Source location

    Doreen Mattinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026