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Nosocomial COVID-19 reviews

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Learning from hospital-acquired COVID-19 infections in Wales

The COVID-19 pandemic has had a significant impact on population health and healthcare systems worldwide. NHS Wales rapidly adapted and altered its operational focus to minimise harm as far as possible. NHS staff worked tirelessly to maintain healthcare services for those most in need. However, COVID-19 was a new and unpredictable infection which made it extremely difficult to manage.

Due to the scale and severity of the pandemic, patients who required care in hospitals and other in-patient settings faced an inevitable increased risk of acquiring COVID-19. Managing the spread of COVID-19 in healthcare settings was challenging, particularly when prevalence was so high in the community, and in hospitals, there were higher levels of seriously unwell patients, longer lengths of stay and more people in hospital beds.

The nature of the pandemic has meant that unusually high numbers of patient safety incidents of nosocomial (hospital-acquired) COVID-19 have been recorded, affecting approximately 18,000 service users/families across Wales.


The National Nosocomial COVID-19 Programme

In April 2022, the National Nosocomial COVID-19 Programme was established to support NHS Wales organisations in their duty to conduct investigations into patient safety incidents of nosocomial COVID-19 which occurred between March 2020 and April 2022. Healthcare-acquired infections are sometimes considered a patient safety incident, depending on how and when the infection was acquired.

The National Nosocomial COVID-19 Programme has worked with Health Boards and Trusts to create a framework to ensure NHS Wales organisations adopt as consistent an approach as possible to the investigation process, ensuring investigations are done once and done well. The programme has supported NHS Wales organisations to investigate cases, providing some answers to loved ones, as well as capturing learning and experience.

Acknowledging the impact of COVID-19 on service users, families, carers and NHS Wales staff, the programme has adopted a learning approach that seeks not to place blame, but maximise the opportunity for learning and improvement.

In March 2023, NHS Wales published its National Nosocomial COVID-19 Programme Interim Learning Report, providing an overview of the programme and identifying some of the early learning themes emerging through the programme. A final learning report is due to be published during summer 2024.

Go to the NHS Wales website for more on the National Nosocomial COVID-19 Programme Interim Learning Report, including access to an easy-read version of the report.


Our progress

Swansea Bay University Health Board's dedicated Nosocomial COVID-19 Review Team has worked hard to progress patient safety investigations at pace. The programme extends its sincere thanks to patients, families, carers and staff for engaging in the investigation process which has provided an opportunity for reflection, learning and improvement.

As the National Nosocomial COVID-19 Programme came to an end on 31.03.2024, the mailbox through which the Swansea Bay Nosocomial COVID-19 Review Team could previously be contacted is no longer in use. Any queries and communication relating to the Programme may now be submitted via the Let’s Talk mailbox and helpline:


Telephone: 01639 684440


Useful information


Rydym yn croesawu gohebiaeth a galwadau ffôn yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. Mae’r dudalen hon ar gael yn Gymraeg drwy bwyso’r botwm ar y dde ar frig y dudalen.

We welcome correspondence and telephone calls in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. This page is available in Welsh by clicking ‘Cymraeg’ at the top right of this page.