SAFER HOSPITALS
the stakeholders to ensure a successful outcome which is acceptable to everyone is provided in the NHS Estates technical bulletin on Mycobacterium abscessus.7
George McCraken
George has worked as a healthcare engineer for over 30 years. He has a particular interest in the impact of the built environment on occupant safety and has provided his experience and expertise to assist with the creation of guidance and standards for many years.
All the essential elements of good governance Infection risks may be introduced at any stage of a building project, including design, construction, installation, and commissioning. While the infection prevention and control (IPC) team plays a key role in ensuring that the built environment is safe, they cannot deliver a safe environment on their own.
It took considerable time for infection prevention and
control to become recognised as everyone’s responsibility within already constructed and operational hospitals. Similarly, everyone involved in a new-build project has a role to play – whether they realise it or not – in protecting the future occupants of a building from infection. No one intentionally wishes to harm a patient entering a
new hospital. However, what may appear to be ‘innocent’ mistakes can result in patients becoming unwell or, in some cases, losing their lives. The further individuals are removed from direct patient care, the more difficult it becomes to recognise how their actions may affect patient outcomes. Furthermore, such actions may not impact a single patient but could affect several patients – or even everyone – within a hospital or across multiple healthcare facilities. Importantly, many of these risks are not prevented
Dr Manjula Meda
Dr Manjula Meda is a clinical microbiologist and infection control doctor at Frimley Health NHS Foundation Trust, Surrey. She has a special interest in prevention of hospital infections through built environment design especially around water and wastewater safety in healthcare. She has introduced water and wastewater safe concepts in patient care in the U.K for the first time. She currently holds the position of Chair of the Healthcare Infection Society (HIS). In this role she has led the development of a HIS water and wastewater safety course and the formation of BEIPI (Built Environment Infection Prevention Initiative) bringing together all those involved in building hospitals from architects to IPC teams together with the aim to build safer hospitals.
through traditional infection control practices or by the infection prevention and control team alone. For example, applying excessive sealant during the installation of a sink drain can lead to biofilm accumulation, which may subsequently result in the transmission of infection to patients. Similarly, poor installation of waterproof lining in a wet room can allow water ingress, leading to mould growth and potentially severe infections among patients. Inadequate room design can also create infection risks.
For instance, failing to ensure a clear workflow from ‘dirty’ to ‘clean’ in areas where decontamination takes place – such as where drug administration trays are cleaned before being returned to the drug preparation area – can make effective decontamination difficult and increase the risk of infection transmission. Even seemingly minor design choices, such as the unnecessary installation of a sink in a room, can introduce additional risks. In reality, the number of potential hazards is too great to list exhaustively. A major factor allowing such risks to remain unaddressed is the lack of effective governance. For example, many individuals working on construction projects are aware that water pipes should be capped to prevent the ingress of dirt and microorganisms, and such requirements are often included in method statements. However, in practice this is rarely implemented on construction sites. This should not be surprising. Often, no one is specifically responsible for ensuring the process takes place. There is typically little or no training provided to on- site workers explaining why such measures are important, and there is rarely any auditing to confirm that they are being followed. As a result, these important practices are frequently overlooked. Another example is the wetting of water systems and commissioning that are particularly high risk stages in the life of the water system and yet poor control of these processes still remains a frequent cause of major failure in their safety. A publication looking at outbreaks of waterborne infection in newly opened buildings between the mid-1970s and 2018 found inadequate commissioning to be a major cause. What is of concern is that over this time span inadequate commissioning still remained a
40 Health Estate Journal April 2026
major cause. Commissioning plans need to completed at inception of a project (see NHS Estates technical bulletin on Mycobacterium abscessus). When those involved in design, construction, installation, and commissioning are working on a new hospital, the stakes are significantly higher. The future occupants of these buildings are often among the most vulnerable members of society. In this sense, they act as a ‘canary in the cage’ but unfortunately by the time they become unwell it is too late. Practices that have become accepted in construction outside the healthcare sector may therefore pose serious risks when applied in hospitals. Consequently, stronger governance, clearer accountability, and greater awareness of infection risks are essential to ensure that new healthcare facilities provide a safe environment for patients. Processes need to be put in place – before installation team starts on any work, they need to be trained on what the risks are of getting installation wrong, what the critical control points are to ensure safe operation of what they are installing and the work needs to be audited and importantly who is responsible and accountable for overseeing this process.
Conclusion In summary, this article highlights how the built environment profoundly influences infection risk, antimicrobial resistance, and ultimately patient safety in new healthcare facilities. Persistent failures in design, installation, commissioning, and governance – many long recognised but not systematically addressed – continue to place vulnerable patients at risk. The evidence demonstrates that early identification of hazards, true multidisciplinary competence, mature use of guidance, and robust governance are essential to preventing costly late stage failures. By adopting a risk based approach, front loading projects with the right expertise, learning systematically from past incidents, and engaging with manufacturers and innovators, England has the opportunity to build hospitals that are not only safer but also more cost effective throughout their lifecycle.
References 1 Tackling drug-resistant infections globally: final report and recommendations.
https://amr-review.org/sites/default/ files/160525_Final%20paper_with%20cover.pdf
2 ECDC. Rapid risk assessment – Carbapenem-resistant Enterobacterales – third update. Last accessed 02 October 2025.
3 Browne K, White N, Tehan P, Russo PL, Amin M, Stewardson AJ, Cheng AC, Graham K, O’Kane G, King J, Kiernan M, Brain D, Mitchell BG. A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study. Trials. 2023 Feb 22;24(1):133. doi: 10.1186/s13063-023-07144-z. PMID: 36814314; PMCID: PMC9944767.
4 An organisation with a memory.
https://qi.elft.nhs.uk/wp- content/uploads/2014/08/r_02-an-organisation-with-a- memory-l-donaldson.pdf
5 Building a safer future.
https://assets.publishing.service.gov. uk/media/5afc50c840f0b622e4844ab4/Building_a_Safer_ Future_-_web.pdf
6 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
https://www.gov.uk/government/publications/ report-of-the-mid-staffordshire-nhs-foundation-trust-public- inquiry
7 NHS Estates Technical Bulletin (NETB) No.2024/3. https://
www.england.nhs.uk/wp-content/uploads/2024/08/ prn01343-nhs-estates-technical-bulletin-2024-3.pdf.pdf
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