Poorly communicated guidance over PPE has the potential to put patients at risk across all healthcare settings, the Healthcare Safety Investigation Branch has warned.
It comes after an investigation was carried out into the case of a ‘clinically extremely vulnerable’ patient who was visited by care workers not wearing PPE and later died after contracting Covid-19.
The case was referred to the HSIB by a member of the public because district nurses used PPE when delivering homecare to the patient but other care workers did not and had been told it was not necessary.
The patient later died and their death was confirmed as being Covid-19 related, the report said. Neither the patient or any other household member were not showing any Covid-19 symptoms at the time of the care visits, the HSIB said.
In a report the HSIB said it had examined the documents available at the time and found that primary Covid-19 guidance for home care provision published on 6 April on the Public Health England website did not reference the PPE needed when caring for those within the most vulnerable groups.
There had been separate guidance published four days earlier on PPE use for those working in outpatient, community and social care settings but it was not linked to the PHE primary guidance and not easily accessible, the HSIB investigation found.
Newer guidance then published by Public Health England a few weeks later on the 27th April specifically for domiciliary care workers did include advice on PPE use when looking after the ‘clinically extremely vulnerable’ group, the HSIB said.
But the original (6 April) guidance was still live and available and did not refer to the updated version, the investigation found.
Public Health England withdrew the link to the primary guidance – which had been produced by the Department of Health but published on the PHE website – and provided a link to the newer updated guidance after being alerted to the incident by the HSIB.
Dr Kevin Stewart, HSIB’s Medical Director said the report had implications across healthcare settings.
‘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.’
He added: ‘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.’
Dr. Éamonn O’Moore, adult social care lead at PHE said: ‘We were very sorry to hear of what happened and lessons have been learnt.
‘We updated the links to the guidance clarifying the right one to use. We continue to update and revise UK guidance informed by the evolving evidence, as well as listening to feedback from the health and care sectors on its appropriateness and accessibility.’
RCGP honorary secretary Dr Jonathan Leach said: ‘It is crucial, that GPs, our teams and any other healthcare professionals working on the frontline during the COVID-19 pandemic feel safe when delivering care to patients.
‘This isn’t just a case of having adequate supply of PPE, but the appropriate guidance about how to use it – this is something the RCGP identified regarding PPE in general practice towards the start of the pandemic, and wrote to English Health and Social Care Secretary Matt Hancock asking for clarity about. It’s important that GPs and our teams continue to receive clear guidance around the use of PPE as we move into the next stages of the pandemic.’
