Coronavirus: ‘Confusing’ advice from Public Health England put patients at risk, watchdog says

One vulnerable patient died after care workers visiting their home were told they did not need to wear PPE

Confusing guidance on protective clothing against coronavirus is a safety risk, HSIB has warned (Getty)

A vulnerable patient may have contracted coronavirus and died after care workers visiting their home did not wear protective clothing because of confusion over official Public Health England (PHE) advice, it has emerged.

The Healthcare Safety Investigation Branch (HSIB) has said it is concerned that patients could be at risk because of multiple versions of guidance that was produced by PHE on personal protective equipment (PPE).

During April, there were two different versions of advice to home care services on the government’s official website. One did not mention PPE requirements for staff visiting patients in their own homes, while another published a few weeks later said they did need to wear masks and other protective clothes.

In a new report, HSIB revealed that a patient who was classed as clinically extremely vulnerable to Covid-19 was visited by district nurses and care workers.

While the nurses wore PPE, the care workers did not and had been told this was not necessary. The patient later died and their death was confirmed as being linked to Covid-19. They had not previously displayed any symptoms.

HSIB examined guidance available at the time and found that Public Health England’s main Covid-19 guidance for home care services, published on 6 April, made no mention of PPE being needed when caring for those in the most vulnerable groups.

On 27 April, Public Health England published new protocols for home care services that did include a requirement for PPE, but the original 6 April advice was still live on the government website and had no reference to the subsequent changes.

In its report, HSIB warned: “There is a risk that service providers will operate on the basis of older guidelines and might be unaware of newer considerations.

“When responding to a crisis scenario where the evidence base is being rapidly developed, there is a fundamental challenge of ensuring that guidance is kept updated and easily accessible. While it is desirable to have a central repository, for example the gov.uk website, problems can still occur. This is an emerging safety risk.”

On 28 April, HSIB raised concerns with Public Health England, which then removed the link to the old guidance on 13 May.

Dr Kevin Stewart, HSIB’s medical director, 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.”

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. 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.”

During the height of the crisis in April and May – as hospitals ran out of masks and gowns, and social care providers struggled to source enough PPE of their own – PHE repeatedly changed its guidance for staff.

It was accused by some doctors of changing guidelines to suit the shortages of equipment.

Studies have shown that up to 20 per cent of hospital staff could have caught the virus in hospital, with research earlier this week showing that up to an eighth of hospital patients who had the coronavirus may have contracted it within the hospital.

Jane Townson, chief executive of the United Kingdom Homecare Association, told The Independent that of home care services were in an impossible position at the start of the pandemic.

She said: “HSIB is 100 per cent right. What was going on at the time was unsafe.

“The production of official guidance on personal protective equipment has been a shambles throughout the coronavirus pandemic. Guidance designed for different care settings has been consistently confusing for the organisations who needed to put it into practice.

“In the early stages, an absence of clarity led to inconsistent local interpretations being made by public health, local councils and community health organisations, all with different views about what was required.

“Even once guidance was published, dissemination was woefully inadequate. Guidance was published on the gov.uk website with little notice, frequently late on a Friday night, and provider associations received minimal notice to prepare briefings. There was a very high risk that care providers were not alerted to the changes unless they belonged to a membership association.”

She added: “In terms of the process going forward, what would be good would be to involve those who know about the service in the drafting stage, before the guidance is published when it possibly ends up causing extra work and is dangerous.”

Dr Eamonn O’Moore, adult social care lead at Public Health England, 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.”