Recipient

Dolby Vivisol

First report 24 Nov 2014•Latest report 24 Nov 2014

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Dolby Vivisol linked to the concerns in each report. Select any concern, action or position to view the source wording.

24 Nov2014
Surrey
Concerns raised3
1. Failure to properly engage the humidifier screw cap, causing loss of oxygen flow to the nasal cannula
2. Absence of a visual or audible alarm indicating loss of oxygen flow to the nasal cannula
3. Failure of accompanying training and literature to explain the oxygen-flow implications of improper humidifier screw-cap engagement
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Communicate literature amendments to relevant staff and reinforce them during future patient and carer installation training.
  Stated planned
2. Action
  Submit finalized literature amendments to NHS contract managers for approval.
  Stated planned
3. Action
  Review and update company instructions and training materials after receiving manufacturers’ finalized amendments.
  Stated planned
1. Action
  Liaise with Invacare about revised instructions warning of oxygen-flow effects when humidifier caps are improperly fastened.
  Stated in progress
2. Action
  Modify humidifier literature to explain incorrect connection risks and emphasise confirming oxygen flow from the nasal cannula.
  Stated planned
3. Action
  Distribute approved updated literature to current and future equipment users, highlighting amendments for current humidifier patients.
  Stated planned
Respondent positions 2
1. Position
  Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.
  Redirects responsibility
1. Position
  Equipment manufacture and design concerns fall outside the company’s functions, so it cannot respond to them.
  Outside remit
AI-generated summary

Gaenor Moore · 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

Gaenor Moore, who had chronic obstructive pulmonary disease and required an oxygen concentrator with humidifier, became breathless, deteriorated and died at her residential care home after the humidifier cap was not properly engaged, preventing oxygen flow to her nasal cannula. Concerns included the absence of a visual or audible alarm to indicate loss of oxygen flow and training and literature that did not explain the implications of failing to properly engage the humidifier cap.

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. The report was sent to Dolby Vivisol; that does not assign responsibility.
PFD Monitor interpretation
Failure to properly engage the humidifier screw cap, causing loss of oxygen flow to the nasal cannula
Wider context from the report
“• The lack of oxygen flow to the nasal cannula as a result of the screw cap to the humidifier not being properly engaged. • Absence of a visual or audible alarm on concentrator machine (product number INV-IRC5PO2AWN) to indicate the loss of oxygen flow to the nasal cannula when the screw cap to the humidifier (manufactured by Salter Labs) was tightened and cross threaded. • Accompanying training and literature did not reference the implications to oxygen flow in the event of failing to properly engage the screw cap to the humidifier. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dolby Vivisol; that does not assign responsibility.
PFD Monitor interpretation
Absence of a visual or audible alarm indicating loss of oxygen flow to the nasal cannula
Wider context from the report
“• The lack of oxygen flow to the nasal cannula as a result of the screw cap to the humidifier not being properly engaged. • Absence of a visual or audible alarm on concentrator machine (product number INV-IRC5PO2AWN) to indicate the loss of oxygen flow to the nasal cannula when the screw cap to the humidifier (manufactured by Salter Labs) was tightened and cross threaded. • Accompanying training and literature did not reference the implications to oxygen flow in the event of failing to properly engage the screw cap to the humidifier. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dolby Vivisol; that does not assign responsibility.
PFD Monitor interpretation
Failure of accompanying training and literature to explain the oxygen-flow implications of improper humidifier screw-cap engagement
Wider context from the report
“• The lack of oxygen flow to the nasal cannula as a result of the screw cap to the humidifier not being properly engaged. • Absence of a visual or audible alarm on concentrator machine (product number INV-IRC5PO2AWN) to indicate the loss of oxygen flow to the nasal cannula when the screw cap to the humidifier (manufactured by Salter Labs) was tightened and cross threaded. • Accompanying training and literature did not reference the implications to oxygen flow in the event of failing to properly engage the screw cap to the humidifier. ”
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
Communicate literature amendments to relevant staff and reinforce them during future patient and carer installation training.

Verbatim wording from the response
“3.2 The Company is actively liaising with Invacare (UK) Limited in relation to amendments proposed to their current instructions, which will warn about the potential effect of a failure to properly fasten a humidifier cap to its oxygen concentrator. The correspondence with Invacare is currently on-going, although I am told that Invacare proposes to update its instructions within the coming months. Upon receiving the final update from Invacare we will correspondingly review and/or update our instructions and training material.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
Open published response
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
Submit finalized literature amendments to NHS contract managers for approval.

Verbatim wording from the response
“3.3 Once all draft amendments to current literature have been finalised, the proposed amendments will be sent as soon as possible to NHS contract managers for approval.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
Open published response
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
Review and update company instructions and training materials after receiving manufacturers’ finalized amendments.

Verbatim wording from the response
“3.1 The Company is actively liaising with Salter Labs which manufactures the humidifier. Salter Labs has proposed additional wording on the product instructions in order to avoid leaks, and warn about the potential effect of a leak on the oxygen supply. The Company’s correspondence with Salter Labs is currently on-going, although I am informed by Salter Labs that updated labels will be attached to relevant products manufactured after 15 February 2015. Upon receiving the update from Salter Labs we will correspondingly review and/or update our instructions and training material.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
Open published response
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
Liaise with Invacare about revised instructions warning of oxygen-flow effects when humidifier caps are improperly fastened.

Verbatim wording from the response
“3.2 The Company is actively liaising with Invacare (UK) Limited in relation to amendments proposed to their current instructions, which will warn about the potential effect of a failure to properly fasten a humidifier cap to its oxygen concentrator. The correspondence with Invacare is currently on-going, although I am told that Invacare proposes to update its instructions within the coming months. Upon receiving the final update from Invacare we will correspondingly review and/or update our instructions and training material.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
Open published response
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
Modify humidifier literature to explain incorrect connection risks and emphasise confirming oxygen flow from the nasal cannula.

Verbatim wording from the response
“It is proposed that the humidifier leaflet will be modified to provide increased awareness of the impact caused by failure to connect the humidifier bottle correctly. Also there will be greater emphasis on the need to confirm the flow of oxygen from the nasal cannula. These enhancements will be reinforced during the patient/carer training provided by the Dolby Vivisol technicians.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
Open published response
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
Distribute approved updated literature to current and future equipment users, highlighting amendments for current humidifier patients.

Verbatim wording from the response
“3.4 When approval is obtained from the NHS contract managers, the updated literature will be sent to all current and future Equipment users. The amendments will be specifically highlighted to current humidifier patients.”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 3 · response
Published 24 November 2014
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
Equipment manufacture and design concerns should be addressed by the relevant manufacturers, Invacare and Salter Labs.

Verbatim wording from the response
“As stated above, the Company cannot respond on points relating to the manufacture or design of the Equipment. Concerns about these issues should properly be addressed by the manufacturer of the oxygen concentrator and/or humidifier (Invacare (UK) Limited and Salter Labs respectively).”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 2 · response
Published 24 November 2014
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
Equipment manufacture and design concerns fall outside the company’s functions, so it cannot respond to them.

Verbatim wording from the response
“As stated above, the Company cannot respond on points relating to the manufacture or design of the Equipment. Concerns about these issues should properly be addressed by the manufacturer of the oxygen concentrator and/or humidifier (Invacare (UK) Limited and Salter Labs respectively).”

Source location
2014-0512-Response-by-Dolby-Vivsol
Page 2 · response
Published 24 November 2014
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to properly engage the humidifier screw cap, causing loss of oxygen flow to the nasal cannula

Absence of a visual or audible alarm indicating loss of oxygen flow to the nasal cannula

Failure of accompanying training and literature to explain the oxygen-flow implications of improper humidifier screw-cap engagement

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 6

Respondent positions 2