Safety warning over oxygen cylinder deaths

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HSIB launches national investigation into the design and use of portable oxygen cylinders
More than 400 incidents reported by NHS staff over a three year period including six deaths
HSIB says there are “persistent” incidents that mean lessons have yet to be learned at a national level

A “persistent” problem with the design and use of oxygen cylinders could be behind hundreds of patient safety incidents, including six deaths, the Healthcare Safety Investigation Branch has found.

The safety watchdog has launched a national investigation into the regulation and use of oxygen cylinders after the death of an 83-year-old patient, who did not receive oxygen because staff were unable to tell whether the cylinder was full or empty.

HSIB said the design of the cylinder was a causal factor.

During a three year period, more than 400 incidents of incorrect operation of oxygen cylinders were reported by NHS staff.

This included six patient deaths, five respiratory or cardiac arrests and four patients becoming unconscious. Other incidents including patients having difficulty breathing and suffering low oxygen saturation needing urgent medical attention.

HSIB said the issue was a national safety risk. The regulator warned: “Portable oxygen delivery systems are used in a variety of care settings and organisations across the NHS.

“The case referred to HSIB happened within an acute setting; however, similar systems are used within the ambulance service, general practices, mental health units, care homes and in patients’ own homes.”

The statement said there were similar incidents in several trusts around the country. “Evidence also suggests that issues relating to the safe delivery of oxygen through portable systems are persistent, with multiple instances occurring in single trusts; this indicates that safety issues associated with portable oxygen systems are yet to be resolved at a national level.”

HSIB has identified specific safety issues that it will now investigate. These include:

The differences between using a portable oxygen supply and the main supply built into hospital walls;
Some portable systems do not have a visual indication that the valve is open, and do not provide an indication of the amount of oxygen remaining;
Some systems do not provide a visual indication that oxygen is flowing to the patient.

HSIB said its investigation will review the regulation and use of portable oxygen systems within the NHS in England and will also consider the system wide influences on the design and safe use of oxygen systems – including cylinders, manifolds, tubing and masks.

In its interim report HSIB said the 83-year-old patient’s death was reported to the coroner but the local medical examiner determined the lack of oxygen during resuscitation would not have made a difference due to the man’s comorbidities and lack of response.

HSIB will produce a full report and could make national recommendations for changes to improve safety. The regulator was established in April 2017 to investigate systemic safety risks in the NHS.