PFD report

Sandra Danks · Prevention of Future Deaths report

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Issued 3 Dec 2014•Teesside

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of backup oxygen provision during interruption of the main oxygen apparatus
    Part of recurring concern: Unsafe provision of oxygen therapy
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Supply backup oxygen cylinders and train home oxygen patients in equipment use and emergency procedures.

    Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Removed oxygen equipment was found in working order, and BOC was not contacted during the power failure.

    Stated by Boc LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of backup oxygen provision during interruption of the main oxygen apparatus

Wider context from the report

“(1) An interruption in the electricity supply to the main oxygen apparatus stopped the oxygen provision and there was no back up on the main oxygen apparatus to continue to provide oxygen, thus leaving Mrs Danks in a very vulnerable position. ”

Is this part of a recurring concern?

Yes — Unsafe provision of oxygen therapy.

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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

Supply backup oxygen cylinders and train home oxygen patients in equipment use and emergency procedures.

Verbatim wording from the response

“BOC delivers oxygen to home patients as part of its North East NHS contract. BOC has held the contract since 2011 following a public procurement tender process. BOC follows to the letter the requirements of such contract in terms of the specification given by North East NHS for the equipment and services provided and which are determined by the primary caregivers. As part of an oxygen concentrator installation - for long term oxygen therapy - the contract stipulates that BOC will deliver and train the patient on the use of a back-up oxygen cylinder in case of equipment malfunction or power failure. The back-up oxygen cylinder lasts 8 hours at the patient's prescribed flow rate and BOC will attend to the equipment reported fault within that period of time.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 1 · response
Published 3 December 2014

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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

Removed oxygen equipment was found in working order, and BOC was not contacted during the power failure.

Verbatim wording from the response

“In dealing with this patient, BOC has followed its robust processes and procedures, and is in compliance with the terms of its contract with North East NHS. The oxygen equipment was checked at the required regular intervals and all necessary risk assessments were carried out in line with BOC's contractual obligations. In the particular instance of this patient and the power failure, BOC was not contacted by the patient or a family member at the time of the power failure - had BOC been contacted, the advice given would have been for this patient to use the back-up oxygen cylinder supplied by BOC until power was reconnected. BOC would then have made a visit to replenish the back-up oxygen cylinder.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 3 · response
Published 3 December 2014

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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

Following its comprehensive review, BOC saw no reason at present to take further action, while continuing to monitor procedures.

Verbatim wording from the response

“Following BOC’s comprehensive review of its policies and procedures in respect of the supply of oxygen concentrators and BOC’s actions in respect of the current incident, BOC sees no reason at present to take any further action. BOC shall however continue to monitor its current procedures and make any adjustments and improvements as necessary.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 3 · response
Published 3 December 2014

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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

Existing policies, contractual requirements, backup oxygen provision, training, servicing and risk assessments were considered sufficient for patient safety.

Verbatim wording from the response

“BOC takes patient safety very seriously and has in place robust policies and procedures to ensure the safety of patients using BOC’s Oxygen Concentrators. BOC has conducted a full review of both its general policies and procedures in respect of the supply of oxygen concentrators and also a full review of BOC’s actions in respect of this specific patient since the initial supply of oxygen in July 2013.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 1 · response
Published 3 December 2014

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Continue monitoring current oxygen concentrator procedures.

    Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.
  2. 2

    Review policies, procedures and actions concerning oxygen concentrator supply and the incident.

    Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.
  3. 3

    Install fixed oxygen tubing to reduce trip and fall risks.

    Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.
  4. 4

    Service oxygen concentrators and complete associated risk assessments at regular intervals.

    Stated by Boc LimitedStated completedThe respondent said that this action was complete when they made their response on 3 December 2014.

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

Continue monitoring current oxygen concentrator procedures.

Verbatim wording from the response

“Following BOC’s comprehensive review of its policies and procedures in respect of the supply of oxygen concentrators and BOC’s actions in respect of the current incident, BOC sees no reason at present to take any further action. BOC shall however continue to monitor its current procedures and make any adjustments and improvements as necessary.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 3 · response
Published 3 December 2014

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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 policies, procedures and actions concerning oxygen concentrator supply and the incident.

Verbatim wording from the response

“BOC takes patient safety very seriously and has in place robust policies and procedures to ensure the safety of patients using BOC’s Oxygen Concentrators. BOC has conducted a full review of both its general policies and procedures in respect of the supply of oxygen concentrators and also a full review of BOC’s actions in respect of this specific patient since the initial supply of oxygen in July 2013.”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 1 · response
Published 3 December 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

Install fixed oxygen tubing to reduce trip and fall risks.

Verbatim wording from the response

“01.08.13 Fixed tubing installation completed to reduce risk of trips and falls”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 2 · response
Published 3 December 2014

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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

Service oxygen concentrators and complete associated risk assessments at regular intervals.

Verbatim wording from the response

“22.10.13 Machine serviced and RA (risk assessment) completed”

Source location

2014-0525-Response-by-BOC-Healthcare
Page 2 · response
Published 3 December 2014

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

Data last updated 7 September 2026