Handle with care: mistakes and near-misses at UK Covid labs | Coronavirus


A week earlier than the UK’s first coronavirus lockdown, a lab employee at Aneurin Bevan College Well being Board in Newport was screening nostril and throat swabs from an intensive care affected person. The paperwork carried no medical particulars and the swabs weren’t double-bagged to point excessive threat. As such, the work was performed on an open bench. However the swabs had been extra harmful than thought. It later emerged that they got here from a affected person who was preventing for his or her life with Covid.

The incident in March 2020 was among the many first of dozens of mishaps, blunders and failures involving Covid that the Well being and Security Government (HSE) investigated over the course of the pandemic. With so many labs, hospitals, universities and take a look at centres dealing with the virus, such incidents got here as no shock.

Two blunders on the Royal Wolverhampton hospitals NHS belief in April 2020 had been typical of incidents early within the pandemic. Covid samples from contaminated sufferers had been knocked off racks into lab areas the place workers had been working. “While no precise hurt occurred, the implications of the incidents may doubtlessly have been extra severe,” the HSE discovered.

A month later, a scientist at Public Well being England’s Porton Down laboratory was bitten on the forearm whereas scooping a Covid-infected ferret from its cage. On eradicating their PPE and protecting go well with, the researcher seen the chunk had drawn blood. They showered to scrub the wound and on recommendation from the on-call medic, went house to self-isolate and monitor the wound.

The HSE met with Public Well being England in April 2021, 11 months after the ferret incident, and reported “important progress” at Porton Down, however managers on the web site acknowledged “a considerable quantity of labor that continues to be excellent”. The identical day, the lab acquired an enforcement letter from the HSE a couple of January 2021 mix-up over Covid samples, which led to scientists pipetting reside virus on the lab bench, believing it had been killed.

PHE was not the one authorities company introduced up on security considerations. One Sunday morning in November 2020, a workers member on the Nationwide Institute for Organic Requirements and Management, operated by the UK’s Medicines and Healthcare merchandise Regulatory Company, discovered {that a} room housing Covid-infected marmosets and hamsters had flooded. The water, pouring from a hose left on in a sink, was a couple of inches deep however had not entered the animals’ cages. A few of the water was collected and poured down the sink, with out being disinfected first.

Based on HSE studies, the flood unfold to the neighbouring hall and leaked into the workplace beneath. There, workers in full PPE and respiration gear shortly coated electrical gear and bagged up broken ceiling tiles. The remaining wastewater was disinfected and poured down the drain. “While it can’t be totally concluded whether or not or not reside virus may need [been] current within the leaked water, the chance seems to be minimal,” the HSE concluded.

To fulfill the large demand for Covid assessments, the federal government swiftly created and staffed its Lighthouse laboratories, which ran tens of millions of PCR assessments every week. The HSE studies spotlight quite a few instances when samples had been spilled on technicians or discovered to have leaked, with complete trays of take a look at samples typically dropped or knocked over.

Per week earlier than Christmas in 2020, because the Alpha variant was fuelling the UK’s deadliest wave of Covid, the Milton Keynes lab was ordered, on the final minute, to divert greater than 3,000 samples to the Alderley Park Lighthouse lab in Cheshire. With out correct “mediboxes” to bundle them in, workers secured the samples in waterproof wrap and despatched them off in a transport cage.

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“The choice was made in an effort to salvage specimens for testing, quite than discarding and never testing 3,000 plus sufferers,” the HSE report notes. However workers at Alderley Park weren’t impressed and thought of it a breach of transport laws. “Fortunately no leaked or broken samples had been detected,” they informed the investigation.

Additional incidents highlighted issues with house take a look at kits. Some swabs did not snap in the fitting place, which means folks needed to drive them into pattern tubes earlier than closing the lids. On being opened at Lighthouse labs, these sprang out and typically splattered PPE-clad technicians. Robots had their moments too. On the Leamington Spa Lighthouse lab in July 2021, a robotic flicked a swab out of a containment cupboard and on to the ground, prompting a swift evacuation till a spillage workforce arrived.

In spring 2021, the Division of Well being was rolling out an alternative choice to PCR often known as the Lamp take a look at. A lab run by the UK Well being Safety Company and Manchester College NHS basis belief was having issues with the take a look at and hosted an professional from the College of Central Lancashire to assist troubleshoot. After operating assessments on what had been regarded as innocent management samples, it emerged that two had been Covid-positive saliva. As a result of the work had been performed with out applicable precautions, all 5 folks within the room, together with a member of the Division of Well being’s “Tiger Crew” had been despatched house to self-isolate.

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