Fit testing investigation completed

A serious incident investigation into the delays in fit testing of FFP3 masks during the COVID-19 pandemic has been completed.

The investigation took place after we became aware that there was a delay for some teams in getting fit tested and has highlighted learning that we need to take forward as a trust as well as highlighting areas of good practice.

In summary the investigation finds that:

  • This was an unprecedented situation in which guidance and supply of FFP3 masks was changing rapidly.
  • Decisions were made with the best intentions based on the difficulties in understanding the supply chain to the hospital. However the investigation highlights some processes that could have been followed were not.
  • There is no evidence of physical harm to staff as part of this issue however we accept that there has been distress and anxiety caused.  We are reiterating our apology to staff and our commitment to support the health and wellbeing of all of our staff seriously.
  • The investigation provides us with information and learning that we can embed across the organisation including improving how information reaches our teams on the ground.
  • Routine processes are now in place to ensure fit testing is provided to those staff who need it and there are systems in the place to review this regularly as the supply of FFP3 masks continues to be a challenge.

The Trust made the decision to move to fit checking rather than fit testing because we were extremely concerned that we would run out of FFP3 masks due to difficulties in the national supply chain.

The investigation found that while this decision was made with the best of intentions external guidance should have been considered further.  It also found that incidents raised by staff should have alerted the organisation to staff concerns earlier.

There were clear communication difficulties that were exacerbated by the fact that the Trust’s management structures were going through significant change and a number of vacancies did not help the flow of information or the understanding of the escalation of issues for staff.

The report did highlight good practice, specifically the way in which our clinical teams responded to the challenge through redeployment and working collaboratively. It noted that when fit testing was re-established the health and safety teams went over and above what is expected to ensure fit testing was available and provided to all staff who required it.

The Trust is focussing on learning from the investigation and steps have already been taken to do this.

Fit testing is now embedded across services and regular audits are taking place across clinical patient facing teams to give assurance that staff are fit tested who need to be.

The report is now being shared with our regulators, unions and the health and safety executive.