Source · HSSIB Patient Safety Investigation
Oxygen issues during the COVID-19 pandemic
HSSIB’s introductionThere 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. This investigation looks at the provision of piped oxygen gas supplies to hospitals.
Published 19 May 2021
Launched 15 January 2021
Published
HSIB Legacy
Medical devices
Coronavirus (COVID-19)
Indexed content
4 recommendations
4 observations
3 actions
4 of 4 responded
Safety Recommendations
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.
AI-generated response summary NHS England will explore specifying key roles, responsibilities, competencies, and support for designated officers within the ongoing revision of the Health Technical Memorandum (HTM) for medical gas pipeline systems.
Response received 17 September 2021
The current version of “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” includes the identification of key personnel in relation to medical gas systems e.g. Authorising Engineer (MGPS). The revision of this document will explore this area further including identifying how the appointment and training of designated officers may be supported. Response received on 17 September 2021 ------------------------------------------------------- Updated response received on 21 August 2026 NHS England has now updated HTM02-01: Medical gas pipeline systems. This was published on 19th August 2026 and is available here NHS England » Health Technical Memorandum 02-01: Medical gas pipeline systems . In updating the document we sought to address the concerns raised in your recommendations and you will see your recommendations both referenced and addressed in the revised document. NHS England has also reviewed your recommendations around improving the assurance process for people working on these systems, specifically around Authorising Engineers. In response, a new national register has been established and is being implemented over the next 3 years (starting April 2026). This will ensure a standard and consistent approach to assuring our AEs hold the relevant training, knowledge and skills and demonstrate the correct behaviours. A copy of the letter which has been sent to all Directors of Estates in England can be found here NHS England » Authorising engineers – national register and certification .
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.
AI-generated response summary NHS England is developing an assured and certified central register of qualified and experienced MGPS Authorising Engineers, which will launch alongside the updated HTM.
Response received 17 September 2021
This issue is being explored partly through the updating of the HTM, but also more widely. The approach of creating an assured and certified central register of appropriately qualified and experienced MGPS Authorising Engineers is being developed and will be launched in parallel with the publication of the HTM. Response received on 17 September 2021 ------------------------------------------------------- Updated response received on 21 August 2026 NHS England has now updated HTM02-01: Medical gas pipeline systems. This was published on 19th August 2026 and is available here NHS England » Health Technical Memorandum 02-01: Medical gas pipeline systems . In updating the document we sought to address the concerns raised in your recommendations and you will see your recommendations both referenced and addressed in the revised document. NHS England has also reviewed your recommendations around improving the assurance process for people working on these systems, specifically around Authorising Engineers. In response, a new national register has been established and is being implemented over the next 3 years (starting April 2026). This will ensure a standard and consistent approach to assuring our AEs hold the relevant training, knowledge and skills and demonstrate the correct behaviours. A copy of the letter which has been sent to all Directors of Estates in England can be found here NHS England » Authorising engineers – national register and certification .
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). ------------------------------------------------------- Updated response received on 21 August 2026 NHS England has now updated HTM02-01: Medical gas pipeline systems. This was published on 19th August 2026 and is available here NHS England » Health Technical Memorandum 02-01: Medical gas pipeline systems . In updating the document we sought to address the concerns raised in your recommendations and you will see your recommendations both referenced and addressed in the revised document. NHS England has also reviewed your recommendations around improving the assurance process for people working on these systems, specifically around Authorising Engineers. In response, a new national register has been established and is being implemented over the next 3 years (starting April 2026). This will ensure a standard and consistent approach to assuring our AEs hold the relevant training, knowledge and skills and demonstrate the correct behaviours. A copy of the letter which has been sent to all Directors of Estates in England can be found here NHS England » Authorising engineers – national register and certification .
AI-generated response summary NHS England and NHS Improvement confirmed that the update of Health Technical Memorandum (HTM) 02-01 has started and will incorporate all relevant HSIB recommendations. No timeline for completing and reissuing the HTM was provided.
Response received 17 September 2021
The update of the “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” has started and it will include consideration of all the recommendations raised by the HSIB in this report. Response received on 17 September 2021 ------------------------------------------------------- Updated response received on 21 August 2026 NHS England has now updated HTM02-01: Medical gas pipeline systems. This was published on 19th August 2026 and is available here NHS England » Health Technical Memorandum 02-01: Medical gas pipeline systems . In updating the document we sought to address the concerns raised in your recommendations and you will see your recommendations both referenced and addressed in the revised document. NHS England has also reviewed your recommendations around improving the assurance process for people working on these systems, specifically around Authorising Engineers. In response, a new national register has been established and is being implemented over the next 3 years (starting April 2026). This will ensure a standard and consistent approach to assuring our AEs hold the relevant training, knowledge and skills and demonstrate the correct behaviours. A copy of the letter which has been sent to all Directors of Estates in England can be found here NHS England » Authorising engineers – national register and certification .
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.
AI-generated response summary CQC will reflect estates issues in its new regulatory model's well-led framework, exploring how to use NHS Premises Assurance Model data and collaborate with NHS Estates by December 2022. Contact with NHS Estates was established by September 2021.
Response received 17 September 2021
We welcome this report, which shines a light on an estates issue that can have a significant impact on patient safety. We are committed to working with partners, including NHS Estates, to ensure that where there are concerns about the management and governance of estates issues, we can act upon these in a timely and effective manner. As we develop our new regulatory model, we will ensure that the management and governance of estates issues is reflected in our trust level well-led framework. We will explore ways of working with NHS Estates (and other relevant partners such as the Health and Safety Executive) that enable them to raise with us any assurance concerns they have, and provide the technical expertise to help us respond to such risks appropriately. Establish contact with the NHS Estates team with regards to the recommendations made to our respective organisations in this report . Timeline: September 2021 complete. Develop options with NHS Estates for how the data and assurance gained through the NHS Premises Assurance Model (PAM) can be utilised in our new regulatory approach. This will focus on: How the analysis NHS Estates carries out on the PAM can be shared with us, so that there is clear and early identification of possible risks What specialist support and advice NHS estates can provide inspection teams in responding to these risks. Timeline: December 2022. Response received on 17 September 2021.
Safety Observations
It may be beneficial if national NHS recruitment and training programmes for engineering and estates professionals were developed to address existing challenges with the estates and facilities workforce.
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.
It may be beneficial if the NHS Premises Assurance Model contained further specific questions to support the identification of MGPS concerns at trust level.
It may be beneficial if the principles of user-centred design were adopted to help ensure that updates to the Central Alerting System assist users to interpret information.
Safety Actions
The Trust procured pipeline flow meters and electronic telemetry to allow active monitoring of flow rates across the hospital estate.
The NHS Premises Assurance Model will be transitioned to a mandatory online reporting system in summer 2021.
All national Central Alerting System issuing organisations and teams will be accredited to issue national patient safety alerts from mid-2021.