Health investigators launched an examination of guidance on personal protective equipment (PPE) for health and care staff after the death of a person who was shielding.

The Healthcare Safety Investigation Branch (HSIB) said an “emerging safety risk of confusion over guidance on PPE” was identified after a member of the public expressed concerns about a shielding patient who had died from Covid-19.

The referral said that some care workers did not use PPE when doing home visits.

Made in April, the referral highlighted “confusion around PPE use requirements when visiting a patient at home who was in the ‘clinically extremely vulnerable’ category”, according to the HSIB report.

The patient, who was deemed to be “clinically extremely vulnerable”, was visited by district nurses who used PPE.

But other care workers did not use PPE and had been told this was not necessary, according to the referral.

The care visits occurred when the patient and other household member were not showing any Covid-19 symptoms.

But the patient later died from Covid-19.

While HSIB investigators said that there is no way of knowing how the patient contracted Covid-19, they reiterated the importance of clear PPE guidance to reduce the risk of Covid-19 transmission when delivering care in people’s homes.

Investigators examined guidance available at the time and found that Public Health England’s primary Covid-19 guidance for home care provision, published on April 6, did not reference the PPE needed when caring for those within the most vulnerable groups.

On April 2, separate official guidance on PPE had been published for those working in outpatient, community and social care settings, but was not linked to the PHE primary guidance and not easily accessible, HSIB said.

HSIB said that newer PHE guidance on how to work in domiciliary care was issued on April 27 by PHE, which included information on PPE provisions for the “clinically extremely vulnerable” group.

But investigators said that the original guidance was still live and available and did not reference the new update.

Public Health England withdrew the link to the primary guidance and provided a link to the newer guidance after HSIB investigators raised safety concerns.

There are multiple guidelines for different care sectors and it is easy to see where confusion can occur as new updates overlap with older versions.

Dr Kevin Stewart, HSIB’s medical director, said: “Guidance that protects frontline workers and vulnerable patients needs to be as clear and accessible as possible and this is even more important in times of crisis.

“However, there are multiple guidelines for different care sectors and it is easy to see where confusion can occur as new updates overlap with older versions.

“Our report recognises the challenges in implementing national guidance and that further work is needed to understand the most effective systems that would enable better version control.

“Whilst our analysis focused on PPE guidance for carers working in homes, the risk to patient safety because of poorly communicated guidance is applicable across all healthcare settings.

“Our aim is to identify specific safety risks for Covid-19 and share that insight as widely as possible to aid the decision-making process and ensure consistent care for all.”

Dr Eamonn O’Moore, adult social care lead at Public Health England, said: “We were very sorry to hear of what happened and lessons have been learnt.

“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.”