Recipient

Invacare Limited

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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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Surrey

    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 Invacare Limited; 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 Invacare Limited; 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 Invacare Limited; 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
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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