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Originator: National Patient Safety Alert - NHS England Patient Safety

Issue date: 11-Dec-2025 15:07:29

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
  • Social Care Providers (registered with CAS)
  • Special Health Authorities
  • Territorial CMOs in Northern Ireland, Scotland & Wales
  • GP - Locum
  • GP Practices
  • Integrated Care Boards
  • Primary Care Networks
  • GP Practices 1

Action category: Action

Title: Risk associated with adult breathing circuits lacking a patent exhalation route

Broadcast content:

This joint National Patient Safety Alert has been issued by the NHS England National Patient Safety Team, in collaboration with the Faculty of Intensive Care Medicine, regarding the risk of harm from incorrectly assembled breathing circuits lacking proper exhalation routes for patients receiving invasive or non-invasive ventilatory support. Organisations caring for patients on invasive and non-invasive breathing circuits are required to develop local guidance and visual aids for circuit assembly, implement training on specific safety checks, and establish clear communication processes.

All actions must be completed within 6 months.



Additional information: This is being sent to GP Practices for information as you may have patients who use these breathing circuits.

Alert reference: NatPSA/2025/008/NHSPS

Action underway deadline: 15-Dec-2025

Action complete deadline: 12-Jun-2026

Attachments:

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Email: safetyalerts@mhra.gov.uk

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