This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.

Hospital acquired infections (nosocomial infections) are significant because of the effect on the health of patients and staff, and the risk of transmission between patients and staff.

Fear of contracting COVID-19 can deter people with healthcare needs from attending hospital. Healthcare staff who contract COVID-19 or are required to isolate can be absent from work for prolonged periods, often at a time of maximum strain on the workforce.

Trigger for investigation

We identified transmission of COVID-19 in hospitals as a priority for investigation, due to concerns raised which suggested that people were being admitted to hospital without signs of COVID-19 and by the time they were discharged, or soon after, they had contracted COVID-19.

Investigation summary

Our investigation aims to help the NHS understand how to reduce the risks of hospital transmission of COVID-19. We have reviewed all the structures and processes in place designed to reduce hospital transmission and identified ways that these might operate more effectively.

The investigation looks at:

  • How national guidance, aimed at reducing nosocomial transmission, reflects the accepted international scientific knowledge as stated by the Scientific Advisory Group for Emergencies (SAGE).
  • The use of national policies to develop local policies and procedures at NHS trust level.
  • The implementation of these procedures at an operational level in acute hospital medical wards.

Factors examined include the development and use of guidance, testing for COVID-19 status, personal protective equipment (PPE), infection prevention and control practices, hospital design, staff and organisational response.

As part of the investigation we interviewed:

  • Frontline NHS healthcare workers on hospital wards
  • Patients and relatives who experienced hospital care over the last few months and believe they may have contracted COVID-19 whilst in hospital
  • NHS trust leaders
  • Senior national and regional healthcare leaders
  • Senior members of national bodies

As well as safety recommendations for national bodies, the investigation report also highlights key findings that may assist NHS trusts to immediately identify:

  • the factors influencing the risk of nosocomial transmission
  • considerations about what action may be taken to mitigate this risk

Download and read the full report.

Safety recommendations

We’ve made eight safety recommendations as a result of this investigation. Safety recommendations have been made to the Department of Health and Social Care, NHS England and NHS Improvement, and NHSX.

We expect a response to our safety recommendations within 90 days of publication of the investigation report. The responses will be shared here when they’re available.

Department of Health and Social Care

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.

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 conditions.

NHS England and NHS Improvement

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.

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
  • develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England.

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.

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.

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.


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 systems.


You can tell us what you think about our healthcare safety investigations and your experience of HSIB by filling out our online feedback form.