NHS Patient Safety Alert - Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders

The NHS has issued a Safety Alert for medical oxygen cylinders. Published Tuesday 9th January 2018. Website links included below.


A warning alert has been issued on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders. The design of oxygen cylinders has changed over recent years with the intention to make them safer to use.

Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

An unintended consequence of these changes is that patient safety incidents have occurred where staff believed oxygen was flowing when it was not, and/or they have been unable to turn on the oxygen flow in an emergency.

This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.

Different manufacturers and models of oxygen cylinders use different control designs. NHS Improvement and the Medicines and Healthcare products Regulatory Agency (MHRA) are supporting the distribution of training materials and resources for different manufacturers' designs of oxygen cylinder via the Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO) networks.


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.


11 January 2018

Following the initial Safety Alert, the HSIB issued an Interim Bulletin on the 29 March whilst they continue their investigations.


29 March 2018



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