UK nurse Pauline Cafferkey most likely contracted ebola by wearing a visor as part of her personal protective equipment instead of the standard goggles normally provided, an investigation has concluded.
The probe was carried out by Save the Children, the charity Ms Cafferkey was working for when she became infected.
It said it was not possible to identify the exact way in which she caught the virus while volunteering in Sierra Leone, but concluded it was probably due to her use of a visor in a context “geared to the use of goggles”.
While both headpieces are equally safe to use as part of personal protective equipment (PPE), visors require the health worker to wear an alternative set of clothes and adhere to protocols that are slightly different to those associated with goggles.
“At the time of this incident there were differences in the protocols and PPE that volunteers were trained on in the UK and those used in the different treatment facilities”
Save the Children
Ms Cafferkey, who has now recovered from the disease, could not get the goggles to fit her when arrived at the treatment centre in Kerry Town in December, so wore a visor instead.
She had previously worn a similar visor while volunteering with a different charity a few weeks earlier in Sierra Leone.
The investigation panel, which was chaired independently by a senior official from Public Health England, found training was of a “good standard”.
But it added that at the time of the incident “there were differences in the protocols and PPE that volunteers were trained on in the UK and those used in the different treatment facilities in Sierra Leone where the volunteer nurse worked”.
It said this had the potential to cause confusion for healthcare workers.
The panel was concerned that when workers had deviated from endorsed protocols or not used the prescribed equipment, it had not been picked up on immediately and so action may not have been taken quickly enough.
In its recommendations, the panel said there should be “good coordination” between the foundation training organisations and the treatment centres, so that equipment and protocols were aligned and volunteers are trained to use the same equipment used in the field.
Justin Forsyth, chief executive of Save the Children, said: “Lessons have already been learned and as a result of the findings we have further tightened our protocols and procedures.
“We maintain confidence in both our equipment and our protocols, as long as they are followed properly”
“These include refresher training of the use of PPE and working within ‘risk zones’, improved logging of potential incidents, all changes in PPE protocol must be signed off by the ebola treatment centre director,” he said.
He added: “We maintain confidence in both our equipment and our protocols, as long as they are followed properly. But we keep them under constant review. Staff safety is our number one priority.”
Ms Cafferkey worked in Sierra Leone from 7 to 28 December 2014. When she returned to the UK she was screened for the virus at Heathrow Airport and cleared for a connecting flight to Glasgow, despite her saying she felt unwell.
The government said it has now strengthened screening procedures and will isolate and re-asses ebola volunteers who report feeling ill, even if they do not show symptoms of the disease.