In a report which recognises the unprecedented response the NHS has been required to deliver due to the COVID-19 pandemic, HSIB has today published a prospective safety “Investigation into COVID-19 transmission in hospitals”. The intention is to help the NHS as it prepares itself for the coming autumn/ winter period and beyond.

Hospital acquired infections (nosocomial infections) are significant given the impact on the health of patients and staff alike and the risk of onward transmission. The concern of contracting COVID-19 appears to be deterring people with healthcare needs from hospital attendance, whilst staff who contract COVID-19 or need to isolate can be absent from work for prolonged periods, at a time of immense pressure on the work force. 

The investigation teams visited six acute NHS trusts to carry out observations and interviews and the resulting report examines a number of factors: development and use of guidance, testing, personal protective equipment, infection prevention and control practices, hospital design, staff and organisational response.

As well interviewing senior leaders, family and patient views were sought through two online focus groups. The focus group attendees 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 addition to a number of safety observations, HSIB makes the following recommendations:

R/2020/095: It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19.

R/2020/096: It is recommended that NHS England and NHS Improvement:

  • supports additional capacity for testing for NHS patients and staff (Pillar 1 testing)
  • facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies becomes available.

R/2020/097: It is recommended that NHS England and NHS Improvement:

  • develops a national intensive infection prevention and control (IPC) safety support programme for COVID-19 which focuses on leadership, IPC technical support, education, practice, guidance and assurance
  • develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England

R/2020/098: It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital estate to reduce the risk of nosocomial transmission.

R/2020/099: It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission

R/2020/100: It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19

R/2020/101: It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach to national leadership models at times of crisis and under normal conditions.

R/2020/102: It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to:

  • the use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information
  • the increased use and availability of personal computing devices and electronic health record systems.

The report acknowledges that the safety recommendations identified by the investigation may require action over the short, medium and longer term.


If you have any questions about the report or the implementation of its recommendations please contact Joanna Lloyd, Alastair Currie or James Atkins.

For further support and advice relating to the impact of COVID-19, please view our COVID-19 Advisory Service page.

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