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Incidents of Nosocomial COVID-19

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. So far, the programme has supported NHS Wales organisations to investigate over 12,000 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 in March 2024.

Our progress 


Our dedicated nosocomial COVID-19 review team has now concluded its patient safety investigations included in the National Nosocomial COVID-19 Programme. The programme extends its sincere thanks to patients, families, carers and staff for engaging in the investigation process which is providing an opportunity for reflection, learning and improvement. The team continues to review learning themes, engaging with colleagues to share findings and support improvement. The organisation continues to investigate nosocomial COVID-19 patient safety incidents outside of the programme dates as part of typical review processes.

Impacted patients, families and carers who have been contacted as part of the programme can still reach us if they wish to discuss any queries or concerns, using the below details:


We have now started to write to patients, or the next of kin of patients who have died, that caught COVID-19 in our hospitals during the pandemic to tell them about the findings of our investigations into the care provided at that time. This is part of the process to investigate all such cases as part of the National Nosocomial COVID-19 Programme.

The letter will provide information about the outcome of any investigation into potential or actual harm, as well as an apology and acknowledgement of what happened, what was known at the time and the next steps.

In 2023, letters were sent to 1,594 people to tell them a review would be conducted of all patients who may have caught COVID-19 in hospital. To support people at this difficult time they were invited to contact us through our Healthcare Associated Infection COVID-19 telephone service. As well as providing support, this allowed us identify and collate themes to help drive improvement in our services. It is only through reflecting on their experience that the organisation can learn. We also offered bereavement support information.

The Health Board will now write to those people again to tell them about the outcome of that review and what action can be taken if they are not satisfied with the outcome. We understand that receiving this letter some time after their experience of the impact of Covid-19 could be upsetting and we are sorry for the additional distress this may have caused. Once again, we will invite those people with questions or concerns to contact us through our Healthcare Associated Infection COVID-19 telephone service so that we can capture their experiences and offer the necessary support.

Our contact details

Health Care Acquired Infection (HCAI) COVID-19 Helpline telephone number: - 03000 846 992

Email address:

Links and resources