Public Health England (PHE) had to be pushed into making its coronavirus guidance clearer following the death of a vulnerable Brit who was visited by carers who were not wearing PPE.
Official guidance about when to wear personal protective equipment (PPE) were ‘confusing’ and ‘not visible’ during the peak of the UK’s outbreak, investigators say.
Independent watchdog the Healthcare Safety Investigation Branch has published a report revealing how it told PHE to make its advice clearer.
A member of the public complained to the HSIB after seeing someone who was shielding in April – during the depth of Britain’s crisis – die after they were visited by carers who didn’t wear protective equipment.
It emerged that the carers had not been told to wear PPE and Government guidance was so unclear at the time that they had been told they didn’t need to.
The report implies the patient got coronavirus from one of the carers, emphasising that they were not ill before the visit, but says ‘there is no way of knowing how the patient contracted Covid-19’.
The HSIB said there were multiple versions of advice about PPE online at the same time and PHE hadn’t made it clear enough which one to follow.
After being told about the patient’s death, PHE later changed its online advice to make it clearer which was the latest version.
Both PPE and PHE’s handling of the coronavirus crisis have been heavily scrutinised in recent months, with the Government slammed for not making protective equipment available for carers and PHE under fire for stopping swab tests in March.
‘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,’ said Dr Kevin Stewart, medical director at the HSIB.
‘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.’
PHE has come under scrutiny in this investigation for not having clear enough rules on what protective equipment carers should wear when around vulnerable people.
It now has a 28-page document on the gov.uk website outlining how home carers can protect themselves and their patients from coronavirus.
But in April, when the virus was killing hundreds of people per day, there were two versions of the guidance, the HSIB said.
And one of them, published on April 6, did not spell out what protective equipment should be worn when treating extremely vulnerable people who were shielding.
An update from April 27 says that carers should wear ‘a fluid repellent surgical mask, gloves and an apron’ in this scenario.
The previous version of the guidance did not offer specific advice, and the carers who visited the patient in the report did not wear PPE because they didn’t know they should.
Both versions were online at the same time and the older one did not contain a note to say it had been updated.
The HSIB report said: ‘There was no straightforward way of navigating the gov.uk website. The guidance was not visible.’
As a result of this, the HSIB said, healthcare workers did not know what they should have been doing.
‘In the reported case,’ it said, ‘district nurses used PPE when delivering homecare.
‘However, other care workers did not use PPE and had been told this was not necessary.
‘The patient later died, and their death was confirmed as being Covid-19 related. The care visits occurred when the patient and other household member were not showing any Covid-19 symptoms.’
After the HSIB told Public Health England its guidance was confusing the government body took down the April 6 link.
Protective equipment for care staff was a contentious issue for months at the start of, and through the peak of, Britain’s coronavirus crisis.
Obsessed with protecting the NHS, Government officials were accused of overlooking the care sector and leaving it in the lurch while the virus spread wildly through homes and killed thousands of vulnerable elderly people.
A letter sent from the Association of Directors of Adult Social Services (Adass) to the Department of Health in April saw the care chiefs accuse a senior figure at the Department of overseeing a ‘shambolic response’.
It raised concerns about testing in care homes, funding for the sector, and inadequate amounts of personal protective equipment (PPE) for staff, the BBC reported at the time.
Adass said it was facing ‘confusion’ and having to do extra work as a result of mixed messaging put out by the Government.
It said the situation around PPE, which was by then mandatory for all healthcare workers, was ‘shambolic’ and that deliveries had been ‘paltry’ or ‘haphazard’.
The care sector, which looks after around 400,000 of Britain’s most vulnerable people, was being overlooked while officials focused on the NHS, Adass said.
They raised fears of a ‘significant imbalance’ between hospital patients and people relying on care in nursing homes or their own houses.
The bosses added that they welcomed coronavirus swab testing for people working in social care but said it looked as it if it would be ‘rolled out without being given thought to who is going to be tested and what we are going to do with the result’.
Dr Eamonn O’Moore, chief of adult social care 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.’