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 report references data presented to SAGE in mid-May that suggested around 20% of patients were reporting symptoms seven days after admission.
The aim of our 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 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 measures include eight national safety recommendations, safety observations and a tool that NHS trusts can use straight away to review their approach.
Kathryn Whitehill, HSIB Principal National Investigator, says: “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.”
- Factors examined in the investigation: development and use of guidance, testing, personal protective equipment, infection prevention and control practices, hospital design, staff and organisational response.
- The investigation teams visited six acute NHS trusts to carry out observations and interviews. The six sites represented a range of geographical locations, socioeconomic conditions, building and environmental conditions and local population ethnicity.
- Interviews were conducted with senior leaders from across the healthcare system.
- Family and patient views were garnered through two online focus groups with 12 attending in total. All had a relative that had died from COVID-19, with the overwhelming majority believing their relative had contracted COVID-19 in a hospital setting.
- In response to the report consultation this month (Appendix B in the report), NHS England and NHS Improvement confirmed they would begin to publish nosocomial transmission rates from trusts on a weekly basis.
Read the report
For more information, download and read the COVID-19 transmission in hospitals report.