What should a hospital's medical gas policy contain?

HTM 02-01 Part B (2026 edition) splits the paperwork in two: an operational policy (OP) with the high-level arrangements, signed off by several stakeholders including the Medical Gas Safety Group (MGSG), and standard operating procedures (SOP) with the site detail, which need not follow the same approval route. Both should be based on the compliance audit and risk assessment (CARA) of the pipeline system, repeated in full every three years, and both are treated as dynamic documents. HTM 02-01 notes that many of the difficulties that follow a failure of medical gas supplies can be avoided if these protocols are in place before an emergency.

Who owns it

• The Executive Manager is responsible for the operational policy and gives it final approval and sign-off; preparation is usually delegated to the MGSG, specifically the Authorised Person (MGPS) and the Chief Pharmacist.
• The policy should contain a defined protocol for periodic review through the MGSG, which should meet quarterly and review the policy annually, with a way to make immediate updates such as new contact details.
• An organisation with several sites should have one overarching OP and a separate SOP for each site.

What it covers

• Scope and roles: what the policy applies to and who holds each role. The sample policy in Appendix A of Part B, which HTM calls one approach of many, uses the terminal units as the limit of the estates department's responsibility and places ultimate management responsibility with the Executive Manager.
• System limits: users should know the capacity of the system and its limitations, and the SOP should name the people who need to be consulted before new medical equipment is connected to the pipeline.
• Use of gases: medical gases should not be used for non-medical purposes except as a test gas for medical equipment, and medical air rather than oxygen should power equipment such as ventilators.
• Control of work: all work on the system should have detailed risk assessments and method statements and run under the permit to work managed by the Authorised Person (MGPS); key management should follow the SOP.
• Gas quality: the Chief Pharmacist oversees the quarterly quality control test results.
• Record drawings: the OP should state the current status and availability of the as-fitted drawings.
• Contractors: compliance with the organisation's policy, and the responsibilities for monitoring contractors' work.
• Training: only staff who have completed the required safety training should carry out tasks involving medical gases; the sample policy says no one should operate or work on any part of the system unless adequately trained or supervised.
• Emergencies: the SOP should set out the procedures to follow in an emergency, with a section for each gas system covering, among other items, the capability and limitations of its primary, secondary and tertiary supplies (see emergency plan).

Keeping it usable

HTM 02-01 asks for a small A3 or A4 site plan showing, among other things, the liquid oxygen vacuum-insulated evaporators (VIEs), plantrooms, manifolds, cylinder stores and emergency backfeed kits, and for personnel and contact details to sit in a single, easily accessible section. It sees little point in the policy repeating guidance from other departments, such as fire practice, which should be referenced where appropriate. All staff working with the pipeline system should be aware of and familiar with the OP and SOP.