“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. 2. 3. I am concerned that the current clinical and public health guidelines do not identify Healthcare professionals as a group at heightened risk of TB exposure. I am concerned that the current definition of ‘close contact’, thus triggering a contact trace or warn and inform letter, sets the bar too high for notifying NHS staff of the risk of exposure to TB. I am concerned that there are insufficient education measures in place to inform NHS staff of the TB symptoms to looks out for, and the need to inform any assessing clinician of their possible exposure to the condition in order to facilitate early diagnostic testing. Carrianne was exposed to a very aggressive form of TB from what seemed to be a rather transient exposure to the index patient during her occupation as a Nurse. Of course, not each and every contact with a patient will be logged within the medical records, especially in relation to an ambulatory patient such as the index patient in this case, and so it is possible that Carrianne had greater exposure to the patient while on the ward than interrogation of the medical records would suggest. But at its height, she had only been at work on the unit at the same time as the index patient over 23 and 24 November. The index patient was cared for in a side room with infection prevention measures in place but Carrianne may well have been unaware that the infectious disease in question was TB as she was not the “named nurse” for this patient and lots of patients had increased infection prevention measures in place during the pandemic. Indeed, Carrianne had denied any known TB exposure when asked by doctors during her respiratory illness. Carrianne’s case highlights the increased transmissibility of smear positive TB in the context of limited exposure to the index patient. I heard evidence from an expert who told me of cases of medical professionals contracting the condition despite no known direct contact with the patient but having spent time in a corridor containing an air vent leading from the infected patient’s room. The warn and inform parameters did not alter (as in broaden) to reflect the fact that the index case was smear positive and highly transmissible, and the patient was known to be ambulatory on the ward. I cannot see a good reason for restricting the warn and inform letter process, rather than applying the same broadly to all staff who worked on the unit at the relevant time. Carrianne’s case highlights the importance of warning all staff of TB cases on their wards, so that if they do become symptomatic in the coming months, and it may be many months later, they will be equipped with the necessary information to share with their treating clinicians. I heard evidence that the NHS hospital’s Occupational Health team will issue contact tracing or warn and inform letters to staff, but this may not include Agency workers, and, in this case, Nurses seconded from the RAF. This is a missed opportunity to ensure that the relevant OH team or GP is aware of the potential exposure to add to the clinical picture should the patient develop atypical respiratory symptoms. 6 I understand that your agency has input into the UK’s TB Action Plan, and I hope that the above concerns can be considered in your drive to reduce the incidence of TB nationally, but also specifically with regard to healthcare professionals to ensure they are given the greatest possible protection from TB related harm and death.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0032

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0