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Estates, Facilities and Capital Services
Pharmacy Technician Team Leader, Pharmacy Governance, Fife Pharmacy
NHS Fife Medical Gas Committee
Director of Estates, Facilities & Capital Services
01 May 2013
01 November 2019
01 November 2022




To ensure that medical gases used through pipeline systems are handled, stored, administered, and maintained safely within all hospitals and departments of NHS Fife.


Medical Gas Pipeline Systems (MGPS) are installed in the following hospitals within NHS Fife:

  • Victoria Hospital Kirkcaldy  - Phase 1 & 2

  • Victoria Hospital, Kirkcaldy – Phase 3
  • Victoria Hospital, Kirkcaldy – Hospice
  • Queen Margaret Hospital, Dunfermline
  • St Andrews Community Hospital , St Andrews




The Chief Executive


The NHS Fife Chief Executive has ultimate responsibility for medical gases and liquid nitrogen, including the allocation of resources and the appointment of personnel and will appoint a sufficient number of Authorised Persons - Medical Gas Pipeline System (AP(MGPS)) in writing, necessary to manage the MGPS safely and effectively. The appointments of AP(MGPS) are undertaken via the concession manager for the Phase 3 building (Victoria Hospital) following completion of approved training and assessment and recommendation of suitability via the Authorising Engineer.


The appointment of AP(MGPS) will be on the recommendation of the Authorising Engineer (MGPS) with specialist knowledge of MGPS.


Pharmacy Responsibility


The NHS Fife Director of Pharmacy has the delegated overall responsibility for medical gases within NHS Fife and medical gases will be subject to the same quality control requirements as other medicines.


In addition to the Quality Control requirements the Director of Pharmacy holds ultimate responsibility for maintaining a register of Certificates of Analysis for medical liquid oxygen delivered


By retention of Certificates of Conformity, the pharmacy department must ensure that cylinder gases comply with Ph.Eur requirements and that all other gases and gas mixtures comply with the manufacturers ‘product licences and that medical gases manufactured on site meet quality control requirements.


Pharmacy is responsible for the purchasing function of medical gases.  Responsibility for placing orders with pharmacy is delegated to Estates/Hotel services.


Authorising Engineer (MGPS)


The Authorising Engineer (MGPS) must be appointed in writing by the Chief Executive and must be suitably qualified in accordance with Scottish Health and Technical Memorandum (SHTM ) 02-01.


The duties and responsibilities of the Authorising Engineer (MGPS) include:-

Recommending to the Chief Executive those persons who, through individual assessment, are suitable to be Authorised Persons(MGPS);


Ensuring that all Authorised Persons( MGPS) have satisfactorily completed an appropriate training course before appointment and are re-assessed every three years and have attended a refresher, or other training course, prior to such re-assessment.


Carry out an annual audit of documentation, plant and distribution system and provide this to the senior executive with assigned MGPS responsibilities.


As required, provide professional, technical and contractual advice to NHS Fife in accordance with SHTM 02-01.


To monitor the implementation of operational policies and procedures


Authorised Person (MGPS) (AP(MGPS))



An Authorised Person (MGPS) is a person who has sufficient technical knowledge, training and experience in order to understand fully the hazards and risks posed by a medical gas pipeline system and who is appointed in writing by the executive manager on the recommendation of an authorised engineer with specialist knowledge of MGPS.  The certificate of appointment must state the class of work which the person is authorised to initiate and the extent of his/her authority to issue and cancel permits-to-work.

They are responsible for the day to day management of the MGPS and for ensuring that NHS Fife MGPS maintenance specification and schedule of equipment (including all plant, manifolds, pipe work, valves, terminal units and alarm systems) are kept up to date, and for ensuring it is operated safely and efficiently in accordance with statutory requirements and guidelines.


The AP(MGPS) must have read, understood and be able to apply the guidance in SHTM 02-01, especially in relation to validation and verification, and must also be completely familiar with the medical gases pipe routes, their means of isolation and the central plant.  He/she must ensure that the work described in any permit-to-work is carried out to the necessary standards. They must ensure all documentation is kept in accordance with SHTM 02-01


It is the duty of the AP(MGPS) to liaise with the Designated Nursing Officer (DNO) on any limits of involvement in the isolation of sections of the MGPS during an emergency.  Liaising with DNO, the Quality Controller (MGPS) and others, who need to be informed of any interruption or testing of the MGPS as a result of any work carried out.


The AP(MGPS) supervises work carried out by Competent Persons (MGPS) and ensures the standard of that work, including obtaining method statements and risk assessments from contractors.


 The AP(MGPS) must organise training of Estates staff and other staff as required and /or transfer of MGPS information as is needed for the efficient and safe operation of the MGPS.



Competent Person (MGPS) (CP(MGPS))
The Competent Person is the person who carries out the installation and/or maintenance. They must have received appropriate training and must be registered to BS EN ISO 9001/BS EN ISO 13458 in accordance with SHTM 02-01.


The duties and responsibilities of a (CP(MGPS)) as NHS employees or appointed specialist contractors are:-


Performing repairs (planned and emergency), alterations or extensions, as directed by the AP(MGPS), in accordance with the Permit to Work System and SHTM02-01.


Performing repairs (planned and emergency), alterations or extensions, as directed by the AP(MGPS), in accordance with the Permit to Work System and SHTM02-01.


Performing engineering tests appropriate to all work carried out and informing the AP(MGPS) and provide copies of all test results and update of drawings to include system modifications.


Carrying out all work in accordance within the relevant national legislation / guidance and NHS Fife policies.


Providing appropriate method statements and risk assessments to NHS Fife Estates Department and /or VHK  Phase 3, Engie helpdesk (ext. 29292, option 2).


Quality Controller(MGPS)


The Quality Controller (MCPS) (QC(MGPS)) is an appropriately trained person appointed by the Chief Executive on the recommendation of a Chief Pharmacist.  Appropriately trained Pharmacy staff may carry out some tasks designated by the QC(MGPS).


The duties and responsibilities of the QC(MGPS) are:-


Assuming responsibility of the quality control of the medical gases at the terminal units and plant.


Liaising with the AP(MGPS), in order to carry out specific quality and identity tests on the MGPS (including quarterly checks on medical air) in accordance with the Permit to Work System and relevant quality/European Pharmacopoeia (Ph.Eur.) standards.


To organise MGPS training for pharmacy staff who may deputise for the QC(MGPS)


Designated Nursing Officer DNO (MGPS)


The DNO is a Senior Nurse Manager / Senior Manager or the Senior (night) Nurse in charge of a ward / department with whom the AP(MGPS) liaises on any matters affecting the MGPS.


For the purposes of MGPS work at ward level, the Senior Nurse Manager / Senior Manager will have jurisdiction over most MGPS work to be carried out and sign the relevant Permit to Work issued by the AP(MGPS).  This will include all planned and emergency local work in normal working hours.


In the event of a planned interruption involving more than one ward, e.g. for a major shutdown, the DNO will be consulted.  The person assuming this responsibility will liaise with other clinical staff as necessary.


DNO(MGPS) must have undertaken appropriate training as required by this policy.


Senior Nurse Managers must ensure appropriate DNO cover and arrangements are in place 24 hours a day in areas where there are Medical Gas pipelines.  For example in the out of hours period this may be delegated to the on-call manager with the responsibility to delegate to the Senior Nurse on-duty or clinical co-ordinator should a clinician be required.


Designated Porters (MGPS)


Designated Porter (DP(MGPS)) is the Porter in charge, having particular responsibilities for medical gases.


He/she will have undergone specialist training in medical gas safety, cylinder identification and safe handling and storage of medical gas cylinders, including relevant manual handling training (cylinders).


DP(MGPS) are not subject to the MGPS permit to Work System and must, therefore, NEVER PERFORM UNCONTROLLED ISOLATION OF A MGPS.  Their training must reflect this requirement.  All training must be documented and records kept by departmental line managers.


It is essential that DP(MGPS) work safely at all times, using the appropriate Personal Protective and Manual Handling Equipment.  The non-wearing of safety/PPE could invalidate any claims for any personal injuries received while performing medical gas duties.


Personal protective or manual handling equipment will be supplied by the Hotel Services Department and any found to be missing, or defective in any way, must be reported immediately to a Line Manager by the Designated Person.


For the purposes of this Policy, Line Managers may allocate DP(MGPS) to Pharmacy, Theatres and General areas respectively.  In these instances, specific training in departmental techniques may be necessary.


DPs assist in the delivery of medical gas cylinders in all areas of NHS Fife – providing full gas cylinders and returning empty gas cylinders the medical gas store in accordance with NHS Fife Procedure for  Medical Gas Cylinders


Appropriately trained DPs attach and remove cylinders from medical equipment regulators and manifold tailpipes.


DPs perform a minimum of a weekly check on cylinders and inform pharmacy of any deficiencies or stock orders required.



Health Care Professionals who administer Medical Gases/Oxygen.


It is the responsibility of all health care professionals administering medical gases to ensure they have had suitable training (see section 4 –Training) and are competent in all appropriate aspects of handling and administration of medical gases.


Medical gases should be considered as medicines and must be prescribed.  It is the responsibility of all healthcare staff administering medical gases to ensure that it is prescribed on the Kardex or other prescription document before it is administered. See Safe Use of Medicines Policy and Procedure for details about administering Oxygen in an emergency.


Staff must ensure that they have selected the correct medical gas and the correct equipment before administration of a medical gas.


It is the responsibility of the nurse in charge of each ward and department to ensure an adequate back up supply of medical gas in cylinder form is available for use in the event of an emergency.  This can be done in partnership with the pharmacy team.


Medical Gas Committee (MGC)


The Medical Gas Committee (which shall report to the NHS Fife Managed Service Drug and Therapeutics Committee) shall consist of  a minimum of :

  • Senior AP(MGPS)
  • Chief Pharmacist (or their representative),
  • A nominated Designated Nursing Officer / Senior Nurse Manager
  • Health and Safety Officer
  • Portering Manager or their deputy.
  • Authorising Engineer (MGPS)
  • Quality Controller or their deputy


The MGC will be responsible for reviewing the Medical Gas Policy and ensuring its implementation. It will also raise awareness of training issues and, where applicable, take decisions appertaining to the use of medical gases and any equipment that may require a medical gas supply taking full account of the risks involved.




Description of NHS Fife Medical Gas Plant and Systems

Plant and other systems available in NHS Fife Hospitals are fully described inAppendix A- Plant and Other Systems


Actions to be Taken In The Event of a Medical Gas System Alarm

All staff must be aware of the actions to take in the event of any medical gas system alarm. The alarm system and actions are laid out in

 Appendix B-  Actions to be Taken In The Event of a Medical Gas System Alarm


Isolation of Medical Gases by Senior Nurse in Charge/ Person in Charge of Ward / Department in the Event of Fire.

All staff must be aware of the actions that must be taken in relation to piped medical gases in the event of a fire.

These actions are fully described in:

 Appendix C-   Isolation of Medical Gases by Senior Nurse in Charge/ Person in Charge of Ward / Department in the Event of Fire


Actions to be taken in the Event of Total Failure of Medical Gas Systems to Ensure Continued Patient Supply

It is essential that staff in areas where patients are receiving any treatment with a medical gas supplied through a pipeline system know what actions to take in the event of a failure of the pipeline system in order to ensure continued supply to patients.

Information outlining actions required are described in

Appendix D-  Actions Required to Ensure Patient Supply in the Event of a Total or Partial Failure of Piped Medical Gas Supply


Permit To Work System

A permit to work is required before any work can be carried out on a medical gas pipeline system, including vacuum and scavenging systems. This system is explained in:

Appendix E-  Permit To Work System


Care And Management Of Pipeline Suction Equipment

It is essential that all staff using suction of any kind are familiar with the assembly operation and care of all components of suction equipment.

Requirements for care of suction equipment can be found at

Appendix F – Care and Management of Pipeline Suction Equipment




A local risk assessment of all areas where medical gases are used and stored must be carried out at least annually and when any significant changes are made to use or storage of medical gases in those areas.  This assessment must be carried out by the department user assisted by pharmacy and Estates, as required. A copy of the local risk assessment / audit must be stored in the ward / department. Any on-going issues / risks identified must be notified to Pharmacy and / or Estates department as appropriate.



All staff working in areas where Medical Gas Pipelines are in use must familiarise themselves with the emergency procedures outlined in appendices A, B, C, D, E & F related to this procedure.

In wards and departments where staff attach and use equipment on medical gas and suction pipelines, it is the responsibility of Senior Charge Nurse / Department Head to implement a routine for regular operational checks of medical gas flow meters and Suction Controllers.

  • For medical gas flow meters ensure the equipment is operating normally and that there are no leaks.
  • For suction flow meters ensure the suction is operating to at least 500 mg of mercury.

Visually check the pipeline protector to ensure it is not discoloured or pink – if so it must not be used.

Ensure all ancillary equipment is place, e.g. tubing, ,jars and liners – see appendix F for full information.




Appendix A –  Location & Configuration Of Piped Medical Gases & Piped Suction Systems in NHS Fife Hospitals


Appendix B - Actions in the Event of a Medical Gas Pipeline System Alarm


Appendix C - Isolation of Medical Gases by Senior Nurse in Charge/Duty Manager in the Event of Fire


Appendix D-  Actions Required to Ensure Patient Supply in the Event of a Total or Partial Failure of Piped Medical Gas Supply


Appendix E - Permit to Work System


Appendix F – Care and Management of Pipeline Suction Systems


NHS Fife policy GP/M1 – Manual Handling


GP/M3-2– Procedure for Cylinders


GP/M3 – Management of Medical Gas Policy


GP/M3-3 – Management Procedure for the Safe Use Storage and Transport of Liquid Nitrogen




The Medicines Act 1968


The Human Medicines Regulation 2012


Scottish Health and Technical Memorandum SHTM 02-01