We have now completed a national investigation into the provision of piped oxygen gas supplies to hospitals.

There has been an increased demand for oxygen gas in hospital wards during the COVID-19 pandemic. COVID-19 can cause severe inflammation of the lungs affecting a patient’s ability to breathe.

As a result, an increased number of patients have required oxygen therapy within hospitals. Insufficient oxygen supply to seriously ill patients can have very severe consequences, including death.

Reference event

The investigation explores a reference event where an acute hospital trust (the Trust) declared a major incident when demands on its oxygen supply led to patients being diverted to different hospitals and a need to transfer patients between clinical environments.

The Trust had sufficient supplies of liquid oxygen available but its piped oxygen system was unable to deliver the volume of oxygen gas required to meet all patient needs.

Investigation summary

During the investigation, we:

  • Urgently investigated the reference event to better understand issues highlighted about limitations in piped oxygen supply to hospitals.
  • Explored the role of engineering specialists and medical gasses committees in piped oxygen supply.
  • Identified any safety action or learning that can assist in mitigating the risk to piped oxygen supplies, including urgently highlighting any actions that may assist NHS organisations in manging this risk.

Safety recommendations

As part of our final investigation report we have made four safety recommendations to the appropriate national bodies in order to improve patient safety. They are requested to respond within 90 days and their responses will be published here when they’re available.

NHS England and NHS Improvement

HSIB recommends that NHS England and NHS Improvement review and further specify the key roles, responsibilities and competencies of individuals identified in the health technical memorandum (HTM) for medical gas pipeline systems, including identifying how the appointment and training of designated officers may be supported.

NHS England and NHS Improvement

HSIB recommends that NHS England and NHS Improvement implement a process to provide ongoing assurance on the qualifications and experience of individuals identified in the health technical memorandum (HTM) for medical gas pipeline systems (MGPS), including how MGPS Authorising Engineers, or their subcontractors, are appointed by NHS trusts.

NHS England and NHS Improvement

HSIB recommends that NHS England and NHS Improvement completes ongoing work to review, revise and reissue the health technical memorandum (HTM) for medical gas pipeline systems (MGPS). An updated HTM should reinforce multidisciplinary team working and include:

  • Updated advice on the type and design of MGPS infrastructure recommended for NHS trusts.
  • Enhanced processes to encourage shared working between clinical and nonclinical teams on MGPS issues.
  • Specifications for the relevant levels of competence and training for NHS staff on MGPS.
  • Any updated processes or guidance generated in response to the other safety recommendations specified in this report (R/2021/120, R/2021/132, R/2021/133).

Care Quality Commission (CQC)

HSIB recommends that the Care Quality Commission reviews and adapts its assessment model for NHS hospital estates to ensure greater scrutiny of estates related safety concerns.

In addition, HSIB made the following safety recommendation in an interim bulletin in March 2021:

HSIB recommends that NHS England and NHS Improvement urgently issues definitive guidance on the role, function, and key attendees of the medical gas committee. This guidance should identify and encourage key multidisciplinary relationships and board-level reporting of medical gas issues.

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Reports

Final report: Oxygen issues during the COVID-19 pandemic
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Final report
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Second interim bulletin: Oxygen issues during the Covid-19 pandemic
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Interim bulletin: oxygen issues during COVID-19 pandemic
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