A man lays on a hospital bed breathing through an oxygen mask strapped to his face.

Oxygen issues during the Covid-19 pandemic

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

There has been an increased demand for oxygen gas in hospital wards during the coronavirus (COVID-19) pandemic. COVID-19 can cause severe inflammation of the lungs, affecting a patient’s ability to breathe. As a result, an increased number of patients have required oxygen therapy within hospitals. Insufficient oxygen supply to seriously ill patients can have very severe consequences, including death.

Reference event

The investigation explored a reference event where an acute hospital trust (the Trust) declared a major incident when demands on its oxygen supply led to patients being diverted to different hospitals and a need to transfer patients between clinical environments.

The Trust had sufficient supplies of liquid oxygen available but its piped oxygen system was unable to deliver the volume of oxygen gas required to meet all patient needs.

Investigation summary

During the investigation, we:

  • Urgently investigated the reference event to better understand issues highlighted about limitations in piped oxygen supply to hospitals.
  • Explored the role of engineering specialists and medical gasses committees in piped oxygen supply.
  • Identified any safety action or learning that can assist in mitigating the risk to piped oxygen supplies, including urgently highlighting any actions that may assist NHS organisations in manging this risk.