Delay in isolating Lanarkshire Covid patient led to hospital outbreaks

When a test was eventually carried out on day 10 of his hospital stay, by which time he had been transferred onto a second ward, the positive result was missed for a further three days because it was reported at 6.30pm on a Friday when infection prevention and control (IPC) staff had finished for the weekend.

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During the week, the IPC team would be notified of any positive results between 8.30am and 4.30pm Monday to Friday, and alert the relevant ward, but investigators found that there was “no clear process for communicating positive Covid swab results after [4.30pm] on a Friday”.

The man had been placed on two wards - C and D - at the unnamed NHS Lanarkshire hospital by the time medical and nursing staff became aware of his infection, and he is “considered to be the index [first] case of a cluster of Covid-19 cases in both wards C and D”.

The report notes that the delay in isolating him “likely impacted on the extent of the subsequent cluster of cases” on ward D and “contributed to increased contact exposure to the patient’s family”.

The patient’s next of kin - who had been visiting him in hospital - tested positive for Covid days after their relative’s positive swab was taken, but only learned of the delays in identifying and acting on the positive result “by accident” during a conversation with a junior doctor.

This was “inappropriate” and “there should have been conscious efforts to be open and transparent about this error as soon as it was realised by the staff responsible for this patient’s care”, said the SAER report.

The patient, who has not been identified at the request of his family, was admitted to hospital in Lanarkshire at a time when the Omicron wave was driving an increase in hospital admissions

However, it acknowledged that the staff themselves had “not immediately realised” the reporting delay, or its potential impact on virus spread, and that a “robust pathway” has now been established to ensure that positive Covid swabs reported out of hours at the weekend can be reviewed and patients isolated appropriately.

The patient survived and was discharged home, but the severity of the associated ward outbreaks is unclear.

Between March 2020 and December 2021, nearly 2000 Covid deaths in Scotland were reported in patients who were probably or definitely infected in hospital.

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The man’s family - whose complaint to NHS Lanarkshire triggered the SAER - did not want to be identified, but Elizabeth Rose, the solicitor representing them, said clarity is needed.

Ms Rose, founder of L&M MediLaw - the specialist medical negligence service within law firm, Levy & McRae - said: “The findings within the Significant Adverse Event Report make for grim reading.

“Investigations must be carried out to determine whether these avoidable failings have led to death or serious harm for those affected.

“Patient safety should be at the heart of any infection control policy and it is hoped that more robust measures will now be implemented.”

The highly infectious Omicron strain, and its BA.2 offshoot, have led to record numbers of patients contracting Covid in hospital.

In mid-March, an estimated 30 per cent of "Covid hospital admissions" in Scotland were patients exposed to the virus in hospital despite strict protocols around PPE, physical distancing, and isolation.

The percentage of probable/definite hospital-onset Covid cases in Lanarkshire matches the Scotland average (Source: Public Health Scotland)

As of April 17, according to the latest report from Public Health Scotland published yesterday, there have been 11,648 cases of patients probably or definitely infected in hospital - based on the timing of their positive swab.

This includes around 1,500 in Lanarkshire, in line with the national average. Ayrshire and Arran's rates have been highest.

An infection is considered "probable" hospital-onset where a positive swab is taken eight to 14 days after admission, and "definite" if it is taken after 14 days.

The SAER report said it was "likely" that the Lanarkshire patient had contracted Covid in hospital, noting that he had become "less well and more confused" from day 10 onwards. Delirium can be a symptom of Covid in the elderly.

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However, investigators said it was unclear, retrospectively, what difference the failure test the patient for Covid on day five made since it is impossible to know whether he would have tested positive at that point.

Workload and staffing pressures were also blamed for the infection subsequently being missed.

The man's positive swab was taken at 10.30pm on Thursday January 6, processed by the lab on Friday, and uploaded onto the electronic database at 6.30pm on January 7.

The report notes that on January 8, when a locum doctor providing weekend out-of-hours junior medical cover had reviewed the patient's bloods, "an opportunity to review the patient's Covid swab result was missed as this would have been visible under the 'microbiology' section of the lab results".

Ward staff were eventually made aware of the positive test result on January 10, when IPC staff returned, and the man was then isolated in a Covid ward.

Earlier on January 10, the man's next of kin had also telephoned nursing staff to let them know that they had tested positive for Covid using a lateral flow.

However, the SAER report notes that when a locum junior doctor phoned on January 12 "it [became] apparent that that patient's next of kin was unaware" that their relative's positive swab actually dated from January 6.

It highlights "concerns about Covid exposure to family members providing care to [this] patient in the intervening period", but says that "workload was high on ward D at the time of the incident which added to the pressure on both medical and nursing staff".

It added: "This patient had several ward moves and they were reviewed by a number of senior doctors within the medicine for the elderly team.

"This may also have contributed to the communication difficulties on 10 January 2022. Lack of continuity in senior level cover for patients on the Covid ward also then compounded the communication difficulties."

The review, led by Hairmyres-based Dr Laura Peacock, a consultant in medicine for the elderly, sets out a number of recommendations including guidance to include "worsening confusion or delirium" in older patients as a trigger for Covid screening, and that "ward moves for patients at risk of delirium should be minimised".

Lise Axford, chief of nursing services at University Hospital Hairmyres, said: “An internal review was initiated as soon as this incident was reported and we have been in contact with the family throughout this process.

"The lessons learned have been shared to help avoid similar occurrences. This also included introducing an enhanced process for reporting Covid-19 results during the out-of-hours period.”