Risk of confusion
In April we identified an emerging safety risk of confusion over guidance on PPE requirements after a case was referred to us by a member of the public. Care workers had visited the home of a ‘clinically extremely vulnerable’ patient and did not wear PPE. The patient later died and the death was confirmed as COVID-19 related. The report emphasises that the patient was not showing symptoms of the virus when the care visits took place.
Examining the guidance
We examined guidance available at the time and found that Public Health England’s primary COVID-19 guidance for home care provision, published on 6 April, did not reference the PPE needed when caring for those within the most vulnerable groups. On 2 April, separate Official UK Guidance* on PPE had been published for those working in outpatient, community and social care settings but was not linked to the PHE primary guidance and not easily accessible. Public Health England then issued newer guidance on 27 April (how to work safely in domiciliary care in England) which did include PPE provisions for the ‘clinically extremely vulnerable’ group. However, the original (6 April) guidance was still live and available and did not reference the new update.
After we highlighted the case and the associated safety concerns to Public Health England, they withdrew the link to the primary guidance and provided a link to the newer guidance.
Our Medical Director, Dr Kevin Stewart said: “Guidance that protects frontline workers and vulnerable patients needs to be as clear and accessible as possible and this is even more important in times of crisis. However, there are multiple guidelines for different care sectors and it is easy to see where confusion can occur as new updates overlap with older versions. Our report recognises the challenges in implementing national guidance and that further work is needed to understand the most effective systems that would enable better version control.
“Whilst our analysis focused on PPE guidance for carers working in homes, the risk to patient safety because of poorly communicated guidance is applicable across all healthcare settings. Our aim is to identify specific safety risks for COVID-19 and share that insight as widely as possible to aid the decision-making process and ensure consistent care for all.”