These are the conclusions set out in our latest report, charting our national investigation into the patient safety risks associated with oxygen delivered via medical gas pipeline systems (MGPS) during COVID-19.
Launched in January 2021, the investigation identified that the majority of hospital wards and departments had to accommodate patients with greater oxygen needs due to COVID-19. We were made aware of at least a dozen NHS trusts where concerns over oxygen were raised and emergency action had to be taken to mitigate the risk.
This issue was exemplified in the report with the case of a hospital that declared a major oxygen provision incident during the second wave of the pandemic.
Excessive demands on its MGPS led to major disruption, with patients being diverted to other hospitals and elective surgery being cancelled. The investigation reiterated that it was not an issue with the amount of liquid oxygen available rather the ability of the system to deliver the flow of oxygen required.
The investigation emphasises that the pandemic has highlighted just how safety critical hospital MGPS are in delivering safe care. It examined not only the current engineering and technology systems in place to ensure MGPS operate effectively, but also explored how well this crucial role is understood across hospital teams, and how MGPS safety is assured by regulators.
There were a number of findings, which highlighted some key areas for learning and improvement.
- Collaboration and communication: create systems and processes to bring together expertise (clinical and non-clinical) in a trust to map and plan the MGPS to ensure the most effective use. The investigation identified that teams that work across disciplines were ‘better able’ to respond to the demands created by COVID-19.
- Updated design: systems should be designed in line with recent developments in healthcare and key technical documents should be updated to reflect this – HSIB’s report noted that, for example, the last update to the MGPS health technical memorandum was 2006.
- Rethinking infrastructure investment: trusts reported that maintenance backlogs and the prioritisation of investment in estate may have created extra challenges for MGPS that were not identified prior to COVID-19. The report includes one safety observation suggesting it ‘may be beneficial if medical gas pipeline systems were prioritised for financial investment and ongoing management where they may not be effective for future anticipated clinical needs.’
The report concludes with four safety recommendations and four safety observations, all with the aim of improving management and understanding of MGPS across the NHS. Three safety actions completed since the investigation started have also been included.
Dr Stephen Drage, Director of Investigations at HSIB says: “ Our investigation highlighted just how critical the MGPS is and that if it fails the impact is significant.
"Any uneven demand in the pipework could mean that a concentration of oxygen in one area – for example to COVID-19 patients – could lead to a reduction elsewhere. Patient wellbeing can be at further risk as may have to make tough decisions about prioritisation of care to ensure that sufficient oxygen is distributed across the hospital.
“We recognise the speed at which the NHS had to adapt to this unprecedent demand. Our report is not aimed at criticising the response to oxygen issues, rather it is there to examine and understand why existing measures may not have been fully effective in addressing the risks to the MGPS.
The investigation findings and resulting safety recommendations can help to inform future responses to COVID-19 or other respiratory viruses, which continue to be recognised as a possible feature of future global pandemics.”
Key national findings in full
- The COVID-19 pandemic placed unprecedented demands on MGPS due to the number of patients requiring oxygen therapy and the different types of oxygen therapy equipment used.
- The MGPS is a critical system in the safe and effective operation of an acute NHS hospital.
- A lack of financial investment in updating MGPS infrastructure created challenges for NHS trusts in responding to the COVID-19 pandemic.
- There is a lack of shared ownership and knowledge of MGPS among hospital-based multidisciplinary teams; this limits trusts’ ability to effectively respond to MGPS patient safety concerns.
- Organisations that used a multidisciplinary approach to understanding and planning the MGPS involvement in the COVID-19 response, including the impact of ward moves and the choice oxygen therapy, were better able to respond to demands on the MGPS system.
- Current guidance on the design and management of MGPS contained within the relevant health technical memorandum is outdated and does not reflect developments in oxygen therapy and challenges in managing MGPS.
- Current assurance mechanisms for MGPS are not effective in ensuring that MGPS-related patient safety concerns are proactively identified and resolved.