A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found.
The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April.
The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks.
The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
The HSIB report said the care worker in question “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.”
“We were very sorry to hear of what happened and lessons have been learnt,” said Dr Éamonn O’Moore, PHE’s head of adult social care. “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.”
Angel said: “It has been consistently confusing for people who had to put it into practice … It has relied heavily on cross-referencing between different online documents, they were using unfamiliar and ambiguous expressions and the information we needed was dotted across the gov.uk website.
“Because the guidance wasn’t clear, in the early stages, local councils, community health services and providers were having to interpret what they thought were the right answers. We have been worried throughout coronavirus that both people receiving care and the workforce would not be adequately protected by the correct use of PPE.”
PHE and other public bodies issued general guidance on 2 April that included PPE provisions for home care workers working with people in the “clinically extremely vulnerable” group, but separate primary guidance for home care provision issued four days later did not include this information.
PHE then issued guidance on 27 April on how to work safely in domiciliary care in England which did include PPE provisions needed for people in the “clinically extremely vulnerable” group.
The primary guidance, however, was not updated and remained live on the gov.uk website until 13 May. In between, the investigators looking into the Covid-19 death of the home care client alerted PHE to the safety risk.