A hospital worker walks along a corridor.

Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.

Hospital acquired infections (nosocomial infections) are significant because of the effect on the health of patients and staff, and the risk of transmission between patients and staff.

Fear of contracting COVID-19 can deter people with healthcare needs from attending hospital. Healthcare staff who contract COVID-19 or are required to isolate can be absent from work for prolonged periods, often at a time of maximum strain on the workforce.

Reference event

We identified transmission of COVID-19 in hospitals as a priority for investigation, due to concerns raised which suggested that people were being admitted to hospital without signs of COVID-19 and by the time they were discharged, or soon after, they had contracted COVID-19.

Investigation summary

Our investigation aims to help the NHS understand how to reduce the risks of hospital transmission of COVID-19. We have reviewed all the structures and processes in place designed to reduce hospital transmission and identified ways that these might operate more effectively.

The investigation looks at:

  • How national guidance, aimed at reducing nosocomial transmission, reflects the accepted international scientific knowledge as stated by the Scientific Advisory Group for Emergencies (SAGE).
  • The use of national policies to develop local policies and procedures at NHS trust level.
  • The implementation of these procedures at an operational level in acute hospital medical wards.

Factors examined include the development and use of guidance, testing for COVID-19 status, personal protective equipment (PPE), infection prevention and control practices, hospital design, staff and organisational response.

As part of the investigation we interviewed:

  • Frontline NHS healthcare workers on hospital wards
  • Patients and relatives who experienced hospital care over the last few months and believe they may have contracted COVID-19 whilst in hospital
  • NHS trust leaders
  • Senior national and regional healthcare leaders
  • Senior members of national bodies

As well as safety recommendations for national bodies, the investigation report also highlights key findings that may assist NHS trusts to immediately identify:

  • the factors influencing the risk of nosocomial transmission
  • considerations about what action may be taken to mitigate this risk
Investigation report