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Safe zones compromised COVID-19 testing is being used to inform decisions around infection control. If there are people moving into or between health and social care settings (patients or staff), who have tested negatively and are not showing typical symptoms of COVID-19, they will likely be treated accordingly. For example, they may be placed in ‘green’ areas, dedicated for those who do not have the virus. These areas are designed to protect non COVID-19 patients but there is a risk that some patients could have had a false negative test result and slipped through the net, compromising safety measures. A danger of misdiagnosis If clinicians are relying on test results being accurate, people who are experiencing symptoms but are told they are COVID-19 negative may be dismissed or misdiagnosed. In a recent blog published on the hub, patient ‘Sarah’ explains how she was discharged from A&E, following a negative test result, and diagnosed with anxiety. A few days on she deteriorated, needing to be admitted to hospital again, this time by ambulance. She was told by paramedics that, according to her observations, she should have been in a coma. Doctors later confirmed that her initial test result had been falsely negative and that she did have COVID-19. Sarah also expressed concern for the paramedics who were not wearing adequate protection to treat someone with COVID-19, because they were wrongly reassured by the test that she was negative [4]. Impact in the community If members of the public test falsely negatively for COVID-19, there is the risk that they will not isolate and will spread the infection further as they access supermarkets, pharmacies and don’t distance from members of their household. There may also be cases where patients who had a false negative were incorrectly advised they were safe to return to work. For key workers in particular, this would increase the risk of spreading the virus to their colleagues and service users. Impact on mental health and recovery There is a risk that a patient’s mental health and wellbeing could deteriorate if they receive a negative test result but are in fact suffering from COVID-19. This is of particular concern in relation to the significant number who are experiencing a slow and debilitating recovery but have not necessarily needed hospital care [5][6]. We are hearing from COVID-19 support groups that these ‘moderate’ sufferers are often left feeling lonely, depressed and frustrated that they are unable to get back on their feet as quickly as they feel they should [7]. There seems to be little support for this group, particularly where they have tested negatively and their symptoms do not align with the official list of symptoms for coronavirus infection. Some people who were sure they had the virus but received a negative test result, have ended up doubting themselves. They pushed their bodies too hard too soon, causing relapses in symptoms and they have subsequently faced further mental health challenges. In an anonymous account shared on the hub, one patient explains how a false negative caused their mental health to deteriorate. “I thought that I should be physically active if I didn't have COVID-19, so I pushed myself and berated myself when I repeatedly became unable to breath with a pounding heart upon any exertion. I couldn't cope caring for my four children and was in a 'critical' dangerous mental state many times. I self-harmed to try and cut off from feeling so awful.” [8] Concluding thoughts Patient Safety Learning are concerned that false negative test results could present several risks to patient safety and we ask the following questions: How are the number of false negative tests being monitored and is this data being publicly reported? Is adequate research being undertaken to understand the cause/s behind the false negative results? What steps are being taken to reduce the testing problems commonly encountered by healthcare professionals that lead to false negatives? Do staff taking swabs feel adequately trained and supported? Is patient feedback around the ease of the self-testing process being captured and reported on? Is the current support and guidance for people who are home-testing fit-for-purpose and endorsed by human factors experts? What is the guidance for caring for patients in hospitals and care settings when they are experiencing symptoms of COVID-19 but have tested negatively? What support is available for patients who believe they have had COVID-19 and are experiencing debilitating symptoms weeks later, but may not have been tested or may have tested negatively? A highly accurate antibody test would help to address some of the concerns raised in this blog and provide a clearer picture of the rate of false negatives. When is that likely to be widely available? References UK Parliament, House of Commons Debate: COVID-19 Response, Volume 676, 18 May 2020. https://hansard.parliament.uk/commons/2020-05-18/debates/8FA78498-C990-4246-A745-AE0F36F7B948/Covid-19Response West, Colin. P, Montori, Victor. M and Sampathkumar, P, Covid-19 Testing: The Threat of False-Negative Results, Science Direct, 11 April 2020. https://www.sciencedirect.com/science/article/pii/S0025619620303657#! Department of Health and Social Care, Coronavirus (COVID-19): scaling up testing programmes, Last Updated 6 April 2020. https://www.gov.uk/government/publications/coronavirus-covid-19-scaling-up-testing-programmes Sarah, My ‘false negative’ COVID-19 test put others at risk, Patient Safety Learning’s the hub, 19 May 2020. The Guardian, ‘Weird as hell’: the Covid-19 patients who have symptoms for months, 15 May 2020. https://www.theguardian.com/world/2020/may/15/weird-hell-professor-advent-calendar-covid-19-symptoms-paul-garner; Sky News, Prof Tim Spector: There’s no such thing as a ‘classical’ COVID-19 case, Facebook, 18 May 2020. https://www.facebook.com/skynews/videos/3470045256358345 Facebook, Covid-19 Support Group, Last Accessed 22 May 2020. https://www.facebook.com/groups/625349464716052/?multi_permalinks=636948470222818 Anonymous, ‘False negative’ and the impact on my mental health, Patient Safety Learning’s the hub, 22 May 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/false-negative-and-the-impact-on-my-mental-health-r2297/

I was experiencing symptoms of Covid-19 and when I became unable to complete a sentence or walk to the bathroom, my GP advised me to go to hospital. I have mental health difficulties and one of the staff recognised me from when I had been admitted previously, following a suicide attempt. I felt that I was treated like a 'frequent flyer' of A&E and that my symptoms were taken less seriously than they would have been otherwise. I was sent home after my tests for Covid came back negative and was told that it was just anxiety. I got much worse over the coming days. If I had tested negative, why was I feeling desperately unwell with all the published symptoms of Covid? I thought that I should be physically active if I didn't have Covid-19, so I pushed myself and berated myself when I repeatedly became unable to breath with a pounding heart upon any exertion. I couldn't cope caring for my four children and was in a 'critical' dangerous mental state many times. I self-harmed to try and cut off from feeling so awful. My physical health deteriorated. The ambulance was called by the GP who had sent a nurse to assess my oxygen levels and the paramedic said I should be in a coma according to my obs. This made me feel less like I was making it up, but it was still in my head despite my husband telling me repeatedly that the results of the test are 30% wrong. The paramedic gave me oxygen and I protested strongly against going to hospital a second time. The paramedic insisted I went, put me on oxygen and reassured me he would ask the hospital staff to relate to me as a patient who was showing clear signs of Covid and that I did struggle with my mental health but that I was doing my best to recover. I also asked the paramedics to inform the hospital staff about my eating disorder so they could gently help me to manage my low blood sugar without judgements and causing me further shame. In the hospital I saw a Dr who confirmed that I did have Covid-19 and that my test must have been a 'false negative'. I had felt judged, dismissed and had doubted myself. The first thing anyone I spoke to asked was whether or not I had had a test and whether it was positive. The negative test result isolated me from calling family and greeting neighbours as I didn't have the energy to go into the false negative answer. I found that saying my test was 'negative' sparked a surge of invalidation of everything I was experiencing. The isolation caused me further significant harm to my mental health. Among other fleeting symptoms I have had overwhelming fatigue, breathlessness, sweats or chills, no smell or taste, a rash, headaches and low mood. After nearly four weeks I am slowly recovering. I am lucky to have a social worker, family support worker and psychologist available over the phone through this period, so I do feel my family and I are supported. But I am interested to know if anyone else has found their symptoms are being quickly dismissed as anxiety when they are sure they have the virus? Or if anyone else feels like they haven't had their symptoms taken as seriously because of their mental health difficulties?