Recipient

Salter Labs

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: 5

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

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Salter Labs 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 3
1. Action
  Ensure updated equipment-provider literature includes reference to the humidifier safety valve.
  Stated planned
2. Action
  Add multilingual labeling instructing users to check that the lid is properly sealed and explaining that leaks can reduce oxygen delivery.
  Stated planned
3. Action
  Complete a multidisciplinary technical review of the humidifier thread design and document its findings in the risk management file.
  Stated completed
Respondent positions 4
1. Position
  The equipment provider is responsible for updating training and literature about the implications of improperly engaging the humidifier cap.
  Redirects responsibility
1. Position
  The current humidifier thread design is appropriate and has reduced cross-threading risk as far as possible.
  Existing arrangements considered sufficient
2. Position
  The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.
  Existing arrangements considered sufficient
3. Position
  The concentrator manufacturer is responsible for addressing the absence of a visual or audible alarm for lost oxygen flow.
  Redirects responsibility
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 Salter Labs; 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 Salter Labs; 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 Salter Labs; 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
Ensure updated equipment-provider literature includes reference to the humidifier safety valve.

Verbatim wording from the response
“3. 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.”

Source location
2014-0512-Response-by-Salter-Labs
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
Add multilingual labeling instructing users to check that the lid is properly sealed and explaining that leaks can reduce oxygen delivery.

Verbatim wording from the response
“Product Labeling – Corrective Action Pending”

Source location
2014-0512-Response-by-Salter-Labs
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
Complete a multidisciplinary technical review of the humidifier thread design and document its findings in the risk management file.

Verbatim wording from the response
“As a result of this incident and in light of the Coroner’s recommendation, Salter convened an internal multi-disciplinary technical design review in December 2014 to evaluate the thread design on several commercially available bubble humidifiers, including the Salter Bals 7600 series bubble humidifier. The design review team determined that:”

Source location
2014-0512-Response-by-Salter-Labs
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
The equipment provider is responsible for updating training and literature about the implications of improperly engaging the humidifier cap.

Verbatim wording from the response
“3. 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.”

Source location
2014-0512-Response-by-Salter-Labs
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
The current humidifier thread design is appropriate and has reduced cross-threading risk as far as possible.

Verbatim wording from the response
“humidifier required less rotation to secure the lid than any of the other humidifiers evaluated. This is an important design consideration for the typical humidifier user or carer.”

Source location
2014-0512-Response-by-Salter-Labs
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
The humidifier’s existing safety valve and leak-test instructions provide warnings for blockages and leaks, including cross-threading-related leaks.

Verbatim wording from the response
“2. Absence of a visual or audible alarm on concentrator machine (product number INV-IRCSPO2AWN) 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.”

Source location
2014-0512-Response-by-Salter-Labs
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
The concentrator manufacturer is responsible for addressing the absence of a visual or audible alarm for lost oxygen flow.

Verbatim wording from the response
“2. Absence of a visual or audible alarm on concentrator machine (product number INV-IRCSPO2AWN) 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.”

Source location
2014-0512-Response-by-Salter-Labs
Page 3 · 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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.4

Actions described in response 3

Respondent positions 4