Dear Ms Mutch,

Re: Regulation 28 Report to Prevent Future Deaths – Mr Leslie Harris (died 21 May 2020)

Thank you for your Regulation 28 Report dated 9th December 2020 concerning the death of Leslie Harris on 21st May 2020. Firstly, I would like to express my deep condolences to Mr Harris’s family.

The regulation 28 report concludes Leslie Harris’s death was a result of COVID 19 pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall.

Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding there is a risk that future deaths will occur unless action is taken. The inquest heard that Mr Harris was moved to a ward where other patients were in isolation from COVID-19 due to the interpretation of the Public Health England guidance about management in these circumstances. As a result of reflection and concerns, the trust have changed their policy and such movement no longer takes place.

Your report states that the guidance from PHE has not been amended and it was unknown how other trusts were choosing to interpret the guidance and as such putting potentially vulnerable patients at risk of developing COVID-19 whilst an inpatient.

The national IPC guidance (COVID-19: Guidance for the remobilisation of services within health and care settings Infection prevention and control recommendations), is published by Public Health England (PHE). NHS England and NHS Improvement are a contributor to the guidance development in accordance with their role as a

Ms Alison Mutch HM Senior Coroner for Manchester South Coroner’s Court, 1 Mount Tabor Street, Stockport SK1 3AG

National Medical Director Skipton House 80 London Road SE1 6LH

9th February 2021

NHS England and NHS Improvement commissioner with a duty to promote a comprehensive health service under the NHS Act 2006.

The national IPC guidance is updated regularly as and when new scientific evidence emerges. An updated version was published on 20 August 2020 providing examples of how organisations can safely manage patients/individuals’ treatment and care and reduce COVID-19 risks by the use of 3 specific COVID-19 risk pathways (high, medium and low risk) depending on whether the patient/individual has tested positive for COVID or is likely to have COVID, has not yet been tested or is awaiting the result of a COVID test or has tested negative for COVID.

The latest version, published on 21 January 2021, adds to the August guidance by taking into account evidence on new variant strains and amendments have been made to strengthen existing messaging and provide further clarity where needed, including updates to the care pathways to recognise testing and exposure.

The IPC measures recommended within the guidance are underpinned by the National Infection Prevention and Control Manual (NIPCM) practice guide and associated literature reviews National Infection Prevention and Control Manual: Home (scot.nhs.uk) The content is consistent with the administrative measures outlined in WHO IPC during healthcare when coronavirus disease (COVID-19) is suspected or confirmed: Interim Guidance, June 2020.

The principles in the guidance apply to all health and care settings. Its implementation should be underpinned at provider level by risk assessments that take into consideration the patient, environment, procedure and task being undertaken by any member of health care staff, and through safe systems of working: administrative, environmental and engineering measures/controls that need to be adopted to reduce the risk of transmission, including: personal protective equipment, hand hygiene, social distancing, cleanliness/decontamination of the environment and equipment, ventilation and separation and segregation of patient and staff within the high, medium and low risk pathways.

Further updates may be made to this guidance as new evidence on COVID-19 emerges and as the pandemic phases/levels change.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Alison Mutch

Re: Inquest into the death of Leslie Harris on 21st May 2020

Thank you for sending the attached report for Public Health England’s (PHE) consideration.

Under the Coroners and Justice Act 2009, please find below PHE’s response in relation to the investigation of the death of Leslie Harris

Concern raised

This report states that Mr Harris died of COVID-19 pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall. It outlines that the inquest heard that he was moved to a ward where other patients were in isolation from COVID-19 due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way, the trust has changed their policy and such movement no longer takes place. It also states that the Public Health England guidance has not been amended and it was unknown how other trusts were choosing to interpret the guidance as such putting potentially vulnerable patients at risk of developing COVID-19 whilst an in-patient.

Action taken

From the details within the report it is difficult to determine exactly which piece of guidance the trust was using in relation to the care of Mr Harris.

PHE publishes guidance on management of staff and exposed patients or residents in health and social care settings, which contains clear advice on segregation of patients who have been exposed to a patient with COVID-19 infection from patients who have not been exposed to the infection.

2 National Infection, Prevention and Control guidance is issued jointly by the four nations. PHE publishes this guidance. Guidance at the time contained information on infection control precautions, including cohorting of patients. This guidance was updated after the sad passing of Mr Harris. Updated versions of the guidance, with most recent updates on 20th August 2020 and 21st January 2021, provide advice on reducing the risk of COVID-19 transmission through use of high, medium and low risk COVID-19 risk pathways determined by risk assessment of individuals based on information including test status.

The report states that Mr Harris was put on a bay where patients had been exposed to a COVID-19 patient.

PHE has reviewed and updated this guidance several times as the pandemic has evolved. Guidance published on 4th April 2020 stated that in-patients who are known to have been exposed to a confirmed COVID-19 patient should be isolated or cohorted until their hospital admission ends, or until 14 days after last exposure (the recommended isolation period at the time).

The wording was further strengthened on 15th May 2020: In-patients who are known to have been exposed to a confirmed COVID-19 patient while on the ward (an exposure similar to a household setting), should be isolated or cohorted (grouped together) with other similarly exposed patients who do not have COVID-19 symptoms, until their hospital admission ends or until 14 days after last exposure.

In the current version of this guidance, a further clarification has been added: This also applies to in-patients who have previously recovered from COVID-19 and have been exposed to a confirmed COVID-19 case during their hospital stay.

PHE will be further reviewing this guidance to ensure that wording is tightened to prevent any misinterpretation of the advice.

I would like once again to convey my condolences to the family of Mr Harris and thank you for raising your concerns.