Confusion over PPE guidance poses a patient safety risk


  • 27th August 2020

Today the Healthcare Safety Investigation Branch (HSIB) have published a new national intelligence report, Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response.[1] This looks at inconsistencies in the guidance on PPE requirements for care workers visiting ‘clinically extremely vulnerable’ individuals at home.

The report is in response to a member of the public raising concerns when visiting a patient at home in the ‘clinically extremely vulnerable’ category. They noted that while they were visited by district nurses in PPE, their care workers did not wear this, advising that this was not required. The patient later died, and their death was confirmed as Covid-19 related.

HSIB found that during April the guidance made available by Public Health England for care staff in this regard was inconsistent. While the primary guidance did not refer to the need to wear PPE when visiting ‘clinically extremely vulnerable’ individuals, other guidance issued in the same month did set out these additional safety provisions. As a result of this, multiple versions of the guidance were available to care workers, who would not be aware of the PPE requirements if they referred to the earlier version of this.

Speed of the response

HSIB state that they brought this to the attention of Public Health England on the 28 April 2020. They subsequently replaced the primary guidance with a link to a version with the additional PPE provisions on the 13 May.

Given the importance of clarity on infection control and PPE, it is very concerning that the conflicting guidance remained live on the website for a further two weeks after the issue was identified.

A wider system issue

The report acknowledges the complexity of providing and keeping up to date such a wide range of guidance, particularly in a crisis scenario, noting that this creates “a risk that patient safety issues may be missed”.[2] When considering the learning potential of this case, HSIB suggest that “there is an opportunity to introduce a document management system for guidelines to ensure that the latest information is available”.[3]

While this specific issue is now resolved, it is disappointing that there is no wider recommendation relating to the systems risks above identified by HSIB. Patient Safety Learning believes that there should be an additional recommendation on this that clearly identifies the relevant healthcare bodies responsible for looking into this.

There are also questions about how updated guidance is published and shared. Commenting on this in The Independent, Jane Townson, Chief Executive of the UK Homecare Association, mentioned problems with guidance being updated late at night with little notice.[4] She also stated that “there was a very high risk that care providers were not alerted to the changes unless they belonged to a membership association”.[5]

Who can lead this change?

While we have noted Public Health England's specific role in this case, formulating this type of guidance can involve a number of bodies across the UK, such as:

  • Department of Health and Social Care
  • NHS England and NHS Improvement
  • Public Health England
  • Public Health Wales
  • Public Health Agency Northern Ireland
  • Health Protection Scotland

When system-wide patient safety issues arise all these organisations have a role to play. We know that when it comes to implementing changes the system is“confused and complex, with no clear understanding of how it is organised and who is responsible for what”.[6]

Patient Safety learning believes it is vital that there is a clear approach to addressing such underlying safety issues. We need to ensure that learning and recommendations for change are prioritised and implemented widely across the health and social care system.

[1] Healthcare Safety Investigation Branch, National Intelligence Report: Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response, August 2020.

[2] Ibid.

[3] Ibid.

[4] The Independent, Coronavirus: ‘Confusing’ advice from Public Health England put patients at risk, watchdog says, 26 August 2020.

[5] Ibid.

[6] Care Quality Commission, Opening the door to change: NHS safety culture and the need for transformation, 2018.

HSIB PPE Report Image


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