Central Alerting System
View Alert


Originator: National Patient Safety Alert - MHRA

Issue date: 23-Sep-2020 15:27:15

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • Special Health Authorities
  • Territorial CMOs in Northern Ireland, Scotland & Wales

Action category: Action

Title: Philips Respironics V60 ventilator – actions to be taken to avoid potential unexpected shutdown leading to complete loss of ventilation.

Broadcast content: In March 2020 Philips Health Systems released an FSN concerning a number of V60 ventilators. This FSN concerned a hardware fault in the device, which can result in an unexpected shutdown. 

There are 2 ways in which this shutdown can occur: 
  • The first will sound a warning to alert the user that the machine is shutting down. This will let the user know they need to switch to an alternative source of ventilation. There is a risk that the patient will be unventilated while this second source of ventilation is prepared. 
  • The second failure mode will cause the device to shut down with no warning to the user. If a device fails in use and does not alarm, the patient will not be adequately ventilated and there is a potential risk of brain damage or death, depending on how long it takes clinicians to become aware of the situation and respond. 

There has been a significant delay of replacement parts arriving in the United Kingdom, resulting in an increased risk of this failure occurring. MHRA has decided to update the guidance issued in the Medical Device Alert published in June. MHRA will continue to work with the manufacturer to improve the delivery time for replacement components. 

See additional information in the attached alert for the complete list of affected device serial numbers.


Additional information: This alert is not relevant to Primary Care.

Alert reference: NatPSA/2020/007/MHRA

Action underway deadline: 25-Sep-2020

Action complete deadline: 07-Oct-2020

Attachments:

Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency