Notification of investigation 

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case has highlighted several issues related to the safe delivery of oxygen from portable systems.

The investigation will focus on the design of portable oxygen delivery systems, supply and storage of oxygen cylinders to clinical areas and the design and delivery of training.

The HSIB acknowledges NHS Improvement’s Patient Safety Alert ‘Risk of death and severe harm from failure to obtain flow from oxygen cylinders’ published today Tuesday 9th January 2018. 

Completion of investigation 

The full report and summary including the recommendations are available below

The news release is available here 

A commentary on working with HSIB from Dr Matthew Matusik, one of the experts involved in the investigation is available here