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

In the coming months, it is anticipated that coronavirus will continue to impact the NHS at all levels of service provision. It’s likely that this impact will be felt more keenly in the autumn and winter.

Our investigation looks at hospital transmission of COVID-19 during spring and summer 2020, so that we can make safety recommendations to support the healthcare system to reduce the risk of transmission in hospitals during any potential escalation of the infection.

Reference event

We have identified several incidents where people go into hospital without signs of COVID-19 and by the time they are discharged, or soon after, have developed symptoms.

Investigation summary

Our investigation aims to help the NHS understand how to reduce the risks of hospital transmission of coronavirus. We will review all the structures and processes in place designed to reduce hospital transmission and identify if there are ways that these might operate more effectively. We will use accepted safety science tools to help inform our investigation.

We have developed a new multi-site model of safety investigation. This involves reviewing national structures and leadership, representative NHS trusts across the country, and understanding the challenges the virus presents to the whole healthcare system.

The investigation will look at:

  • How national guidance, aimed at reducing intra-hospital 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.

We will interview:

  • Frontline NHS healthcare workers on hospital wards
  • Patients 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

We will complete this investigation and publish our final report in a shorter timeframe than our standard national investigations, approximately four months. The final report will be published by November 2020 to help the NHS prepare for any re-escalation of the virus.

Safety recommendations

As part of our final investigation report we will make safety recommendations to the appropriate national bodies in order to improve patient safety.

We also aim to develop practical advice that NHS trusts may use to understand and manage the risk of hospital transmission of coronavirus.

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