Security of medical gas cylinders
Part 1:
General checklist and instructions for completion
1. Introduction
NHS Protect1 is the organisation with policy and operational responsibility for tackling
crime affecting the NHS. This remit includes the provision of a safe and secure
environment for the delivery of patient care. Some NHS organisations have been the
victim of medical gas cylinder theft. These cylinders are targeted mainly for their scrap
metal value and/or for their contents.
NHS Protect has developed the Guidance on the security and secure storage of medical
gas cylinders document to support NHS organisations providing acute and community
based hospital services in the secure management of these items. The guidance aims to
raise awareness of the security issues around medical gas cylinders and highlight good
practice and preventative measures to secure these items from theft. This is to assist
NHS organisations and professionals responsible for various stages of procurement,
management and use at NHS sites, to assess the risks and vulnerabilities that exist, and
to develop a proportionate approach to protecting medical gas cylinders from theft and
loss.
2. About the checklists
In addition to the guidance, two checklists has been developed to assist organisations to
review their existing security arrangements for medical gas cylinders.
The checklists should be used in conjunction with the medical gas cylinders guidance as
well as with the Guidance on the security and management of NHS assets. The
checklists can be used to identify areas where further action may be required to ensure
the security and secure storage of medical gas cylinders.
This checklist (Part 1) focuses on the policies, standard operating procedures (SOPs),
security management arrangements, and reporting and audit processes relating to the life
cycle of medical gas cylinders. This is from point of receipt through to their use, and
finally to the return of empty cylinders to the supplier for replenishment.
The other checklist (Part 2) focuses on the physical security and storage arrangements in
place.
3. Completing the checklist
Responsibility for the security and secure storage of medical gas cylinders lies with all
staff involved in the management and use of medical gas supplies. Completion of this
checklist should be a multi-disciplinary exercise, however overall responsibility and
assurance for medical gases lies with the NHS organisation’s Chief Pharmacist. This is
because the gases contained in the cylinders are classed as a medicine. As a
result, overall responsibility for using the checklist lies with the Chief Pharmacist. It is
advisable, because of their expertise in security matters, to involve the organisation’s
Local Security Management Specialist (LSMS), or nominated equivalent, in the
completion of this checklist.
Local risk assessment(s) should inform the frequency at which the checklist is used to
review security arrangements for medical gas cylinders, medical gas pipeline systems
1
NHS Protect is the operating name of the NHS Counter Fraud and Security Management Service.
2
(MGPSs) and vacuum-insulated evaporators (VIEs) facilities. It is recommended that the
checklist is used at least annually.
Action plan
Completion of an action plan template is the next step once the checklists have been
completed. A template is available on the Medicine security page of the NHS Protect
website. The template should be used to develop a plan of action on how areas identified
as lacking or needing improvement will be addressed, the timescale for this action and
the person(s) responsible. The outcomes should assist organisations in identifying areas
for further development and improvement.
Next steps
The findings of this review and action plan should be presented at the Medical Gas
Committee.
A periodic review of progress should be undertaken against the action plan until it has
been signed off as completed. It is recommended that this occurs on a quarterly basis.
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Section 1: Policies and SOPs for security of medical gas
cylinders
Yes
No
N/A
Yes
No
N/A
1. Are there policies in place for the management and security of
medical gas cylinder stock?
2. Is there an SOP outlining procedures for escalating concerns,
dealing with security breaches or incidents such as intruders, and
discovery of evidence of loss or theft of medical gas cylinders?
3. Are the overarching policies and SOPs for the security of medical
gas cylinders harmonised across all sites/locations?
4. How is information on security of medical gas cylinders
disseminated to staff (tick all that apply)
 induction
 training
 awareness materials
 policies and SOPs
 intranet.
5. Is there an SOP in place to monitor staff compliance with
organisational policies, SOPs and security measures for
managing and accessing the medical gas cylinder storage/supply
areas and reporting incidents when they occur?
6. Is the LSMS consulted for security input during the development,
review and sign off of any security related medical gas cylinder
policies and SOPs?
Section 2: Security management arrangements
7. Is the medical gas supplier consulted for their input into security
issues around the management, delivery and receipt of medical
gas cylinders?
8. Is responsibility for the security of medical gas cylinders assigned
to a member of staff at the appropriate grade or level of
responsibility?
9. Is the LSMS consulted on security issues in relation to medical
gas cylinders?
10. Is security a standing agenda item at the medical gas committee?
11. Is the LSMS a member of the medical gas committee?
12. Is responsibility for the security of medical gas cylinders in
wards/departments/satellite areas assigned to a member of staff
in that area?
13. Are access control systems (where they are used to restrict
access to medical gas cylinder storage facilities):
 linked to human resources processes, enabling starters’ and
leavers’ information to be reconciled with access permissions?
 monitored and reviewed on a regular basis to ensure
compliance and modifications are made when necessary?
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Section 3: Ordering, receipt and central stock management
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
14. Has an agreed minimum cylinder stock level been set?
15. Has an agreed maximum cylinder stock level been set?
16. Is a dedicated stock management system used to record the
requisition of medical gas cylinders?
17. Is there a process in place for the ordering of medical gas cylinder
stock from suppliers?
18. Does the stock management system have safeguards which
ensure that only authorised individuals order medical gas
cylinders?
19. Is there a record of all staff who are authorised to order medical
gas cylinder stock?
20. Is the receipt of cylinder stock from suppliers witnessed and
supervised by an appropriate member of staff?
21. Are received cylinders checked against the delivery note and the
original requisition form to verify that the correct (medical gas)
type, cylinder size, and quantity have been received?
22. Where it is not possible for deliveries to be signed for and
witnessed by an appropriate member of staff (e.g. out of hours
deliveries), are the cylinders left in an agreed secure location?
23. Is there a process in place for dealing with discrepancies in
medical gas cylinder stock received?
Section 4: Internal orders
24. Is there an SOP for internal ordering of medical gas cylinders from
central stores to wards/departments/satellite areas?
25. Does the SOP for medical gas cylinders define what stock levels
should be maintained outside of the central or main cylinder
stores?
26. Are fully auditable records kept from delivery to receipt of cylinder
stock (i.e. stock maintained outside of central or main stores)?
Section 5: Stock checks and tracking systems
27. Are stock checks carried out at the main stores?
28. Are stock checks carried out at the local stores?
29. Are stock checks carried out at a sufficient frequency determined
by a local risk assessment?
30. Where a stock management system is in use, does it provide
information on what has been received and returned by the NHS
organisation to the supplier?
31. Are audits undertaken of medical gas cylinder stock (i.e.
independently of the annual audit undertaken by the supplier)?
32. Where an independent audit of medical gas cylinder stock is
undertaken, is the frequency of the audit determined by a local
risk assessment?
33. Where an independent audit of medical gas cylinder stock is undertaken, does it take
account of cylinders:
 in main stores
 in local stores
 in the possession of healthcare professionals (if applicable)
 in the possession of paramedics (if applicable)
 stored in vehicles such as patient transport service
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 stored in smaller satellite services
Section 6: Reporting and audit
Yes
No
N/A
34. Is there a process in place for staff to follow when unaccounted for
losses in medical gas cylinder stock are identified?
35. Are all security-related incidents, such as theft or robbery (real or
attempted), reported to the police and LSMS?
36. Are all security-related incidents, such as theft or robbery (real or
attempted), recorded on the NHS Protect’s Security Incident
Reporting System (SIRS)?
37. Are records of medical gas cylinder stock maintained for auditing
and reconciliation purposes?
General:
Use this area to report on any other areas of security risk and to provide further
information on any of the numbered responses.
Assessment carried out by
Job title
Date of assessment
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