Lynn Hadley

“Evidence emerged during the inquest from two destructive examinations of the damaged regulator indicated that ignition happened following either adiabatic compression or particle impact. Either of these two events occurred within the on/off shuttle cartridge assembly of the brass regulator which was attached to an oxygen cylinder used to treat Mrs. [name redacted].”

“Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition.”

“Evidence from the Fire Investigation Officer, confirmed that there was little if any knowledge of either adiabatic compression or particle impact and the ramifications of such an event when opening a cylinder incorrectly by those responsible for using the equipment.”

“Evidence from the MHRA confirmed that they are aware of four cases of ignition within valve components of oxygen cylinders leading to fire since 2011 including this incident. The valve manufacturer VTI, Germany has subsequently reported nine cases of ignition. VTI are also examining a further 20 regulators. At present no defects have been found.”