Spread of coronavirus in hospitals a risk to patient safety


Helping the healthcare system reduce the spread of COVID-19 in hospitals is the focus of a comprehensive report by the Healthcare Safety Investigation Branch (HSIB).


The report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital.


The aim of HSIB’s investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further. The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured the experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.


The report concludes with short, medium and long term measures that support both immediate and future responses as the NHS continues to tackle the virus. The report makes eight safety recommendations, to the Department of Health and Social Care, NHS England and NHS Improvement and NHSX. The recommendations are as follows:


  1. It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID- 19.
  2. It is recommended that NHS England and NHS Improvement:
    • Supports additional capacity for testing for NHS patients and staff (Pillar 1 testing).
    • Facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies becomes available.
  3. It is recommended that NHS England and NHS Improvement develops a national intensive infection prevention and control (IPC) safety support programme for COVID-19 which focuses on leadership, IPC technical support, education, practice, guidance and assurance and also develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England.
  4. It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital estate to reduce the risk of nosocomial transmission.
  5. It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission.
  6. It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.
  7. It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach to national leadership models at times of crisis and under normal
  8. It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to:
    • The use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information
    • The increased use and availability of personal computing devices and electronic health record


Kathryn Whitehill, Principal National Investigator at HSIB commented:


“We were moved by stories shared and grateful for the input from families, staff and system leaders. We know the profound personal and organisational impact this virus has had; our intention is not to criticise the NHS response rather set out a prospective view of safety that supports their efforts as cases rise and we head into winter.


“The spread of coronavirus in hospitals presents a risk to patient safety. It also puts enormous strain on the workforce and the fear of contracting COVID-19 in hospital can deter patients from attending hospital who may need urgent treatment for other conditions.


“Our investigation sought to understand factors that helped or hindered efforts to manage the risk of transmission on hospital wards. We also examined the NHS response in the context of the ‘hierarchy of controls’ – a widely used approach that sets out measures to mitigate risk ranked by their effectiveness. Our report sets out 39 key findings that cover everything from hospital design and guidance to PPE and testing capacity. This detailed insight enabled us to develop safety recommendations that would aid short and long term planning and ensure that NHS trusts had measures they could implement immediately.”


You can read the full report here.