Skip to main content

Early learning from hospital-acquired COVID-19 patient safety investigations published

NHS Wales has published a new report detailing the good progress being made to investigate and learn from hospital-acquired COVID-19 in Wales.

Established in April 2022, the National Nosocomial COVID-19 Programme is supporting NHS Wales organisations to carry out a review of nosocomial (hospital acquired) COVID-19 patient safety incidents that occurred between March 2020 and April 2022. The programme has prioritised the investigation of the most complex cases, with an aim to provide as many answers as possible for service users, families, carers and staff impacted by nosocomial COVID-19. The programme also aims to maximise learning opportunities across NHS Wales, to drive quality and safety improvements.

Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospital and other in-patient settings faced an increased risk of hospital acquired COVID-19.

In its first year, the programme has supported NHS Wales organisations to assess and investigate over 5,000 cases of nosocomial COVID-19, where they meet the definition of a patient safety incident and is on track to have successfully investigated all cases of hospital-acquired COVID-19 by March 2024.

Findings in the report include;

  • The value of bereavement support and care-after-death services have for people experiencing grief and signposting to support at the earliest opportunity.
  • The benefits of a single point of contact and support for people navigating the concerns process.
  • The impact of visiting restrictions and visiting considerations should continue to be carefully balanced with risk.
  • Inequities in the concerns process for people who receive healthcare via independent providers.
  • Inconsistent approaches to the management and reporting of health care acquired infections across Wales.
  • The need for improved application and improvement of DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation.
  • The need for improvement in how Infection prevention and control (IP&C) guidance, is reviewed and communicated to staff.
  • Better communication with families and carers around ward movements.

The Deputy Chief Medical Officer for Wales, Chris Jones said: “The National Nosocomial COVID-19 Programme and Welsh Government extend sincere condolences to those who lost loved ones after acquiring COVID-19 in healthcare settings. COVID-19 was a new and unpredictable infection which made it extremely difficult to manage and the impact of the COVID-19 pandemic on service users, families, carers, NHS staff and the wider public cannot be underestimated. I want to thank NHS colleagues and everyone who has engaged with the programme so far. These findings provide an extremely valuable national insights that will improve the quality and safety of healthcare services in Wales.”

Claire Roche, Executive Director of Nursing and Midwifery for Powys Teaching Health Board said: “The NHS in Wales rapidly learned and adapted throughout the pandemic to minimise the harmful impact of COVID-19, with health and care staff working tirelessly through the most challenging period in the 75-year history of the NHS. Despite our best efforts, COVID-19 had a major impact on patients and services. March 2023 marks three years since the start of the pandemic so this is a poignant opportunity to reflect on how COVID-19 has affected all our lives, and to remember those we have lost.

“Here in Powys we have made sure that we have learned throughout the pandemic, and we continue to learn for the future. This interim report has important lessons that are already being put into practice, but a significant amount of work still lies ahead over the second year of the National Nosocomial COVID-19 Programme and we look forward to continuing to participate in this vital work.”

The National Nosocomial COVID-19 Programme will be working with NHS Wales organisations to further identify, share and embed learning in the second year of the programme. Patient safety incidents of nosocomial (hospital acquired) COVID-19 that took place after April 2022 will continue to be investigated by NHS Wales organisations as part of their duties.

Read more about the programme and its Interim Learning Report.

More information about Investigating and Learning from Cases of Healthcare Acquired Covid-19 in Powys is available from our website at

Published: 29/03/23