Investigation into hospital’s Covid oxygen shortages finds staff missed key safety meetings

Pipes in some NHS hospitals could not deliver the volume of oxygen needed by hundreds of Covid patients

Some hospitals struggled to supply enough oxygen to their wards during the Covid pandemic, sparking several major incidents (Getty/iStock)

Doctors and nurses were absent from crucial meetings about oxygen supplies to hospital wards in the run up to the coronavirus crisis, a safety watchdog has warned.

At one hospital trust, which was forced to declare a major incident during the second wave of the crisis, doctors had not attended the hospital’s medical gas committee (MGC) since 2014.

The Healthcare Safety Investigation Branch (HSIB) said it had discovered a similar lack of input at other NHS trusts and also warned that none of the urgent alerts and guidance from NHS England ahead of the Covid surge had been discussed at the committee.

HSIB has launched an investigation into the failure of oxygen piping systems during the Covid surge after a number of hospitals were forced to declare major incidents and divert patients to other hospitals.

The problem was not because of a lack of oxygen but because of a failure of the hospital pipes to deliver the volume of oxygen needed by all the Covid patients. At some hospitals, oxygen levels were reduced and wards were reconfigured to try to reduce the strain on the pipes.

HSIB has not named the NHS trust at the centre of its investigation, which was launched in January, but the Queen Elizabeth Hospital, in Woolwich, declared a major incident in December and diverted patients, while Queen’s Hospital in Romford, Essex, also declared an incident. St Helier Hospital, in Sutton, south London, also had to divert patients in January.

Read more:

• London hospital diverts patients amid fears over its oxygen supply
• London hospitals face ‘ticking time bomb’ over oxygen supplies
• London hospital declares major incident over oxygen supply fears

HSIB was set up in 2017 by former health secretary Jeremy Hunt to investigate systemic safety risks in the NHS, and has adopted a model similar to the Air Accident Investigation Branch and other similar bodies.

In an interim bulletin on Thursday, HSIB said the medical gas committees for every NHS trust should have had nursing and medical staff represented at every meeting to discuss oxygen supplies and give their view on what was needed to safeguard patients ahead of the second wave.

At the trust which triggered the investigation, HSIB said the committee met eight times between September 2018 and September 2020, adding: “A senior nursing representative and medical representative did not attend the MGC, although this [recommendation] was set out in the trust policy. There were 15 possible nursing attendees identified for the MGC. However, nursing representation had only been present at three of the eight meetings.

“The medical director had understood that medical representation was attending the MGC, but following the incident the trust identified that there had been no medical representation at the MGC since 2014.”

HSIB said the lack of attendance and difficulties in communication between professional groups “inhibited the trust’s ability to share clinical and non-clinical knowledge about the role of the medical gas pipeline system and its impact on patient safety during the Covid-19 pandemic.”

It added: “The trust also identified that none of the estates and facilities alerts, or associated guidance, issued by NHS England had been discussed at the MGC at the time they were issued.

“The investigation has now conducted visits and interviews with other NHS trusts to understand how their MGCs are organised. HSIB has identified similar concerns about a lack of multidisciplinary involvement in the MGC and misunderstandings about its role.”

HSIB recommended NHS England urgently issue new guidance to hospitals on the role of the MGC and how it should operate.

The body said its investigation would continue to look at the limitations on oxygen infrastructure, decision-making in the light of the pandemic, and specific roles within NHS trusts.