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Independent review announced into response to Llwynhendy TB outbreak

30 September 2021

Public Health Wales and Hywel Dda University Health Board (UHB) have announced that they have jointly commissioned an external review of the response to the Tuberculosis (TB) outbreak in the Llwynhendy area. 

The review is being commissioned because of the duration of the outbreak and the significant number of people who have been affected, to learn lessons from the Llwynhendy outbreak, and as part of both organisations’ commitment to being open and honest with the public and other organisations.

The review is independent, and will be chaired by Professor Mike Morgan, previously NHS England’s National Clinical Director for Respiratory Disease. The panel will include specialists in public health outbreak control, respiratory medicine, tuberculosis disease, and microbiology, as well as a layperson.

The review will examine whether the response to the outbreak since 2010 overall, and at each stage, was conducted in accordance with best practice guidance in place at the time of each phase of the outbreak. 

It will also review any reported cases of people identified over the course of the outbreak who have sadly died where the death certificate identified that TB contributed to or caused the death.  Additionally, individuals who have developed active TB will also be reviewed.

Dr Fu-Meng Khaw, National Director, Health Protection and Screening Services/Executive Medical Director at Public Health Wales, said: “We understand that the TB outbreak has been very concerning for the Llwynhendy community and for everyone involved, in particular for the family of the patient who very sadly died. Public Health Wales and Hywel Dda UHB have jointly commissioned this review in order to ensure that the response to the outbreak was as robust as possible, and to ensure that lessons are learned for any future outbreak of TB."

Dr Phil Kloer, Deputy Chief Executive and Executive Medical Director, Hywel Dda UHB, said: “This review will look back in detail at the decisions made by both organisations over the course of the Llwynhendy TB outbreak, and will take an independent view on the management of the response. Both Public Health Wales and Hywel Dda UHB are grateful to Professor Mike Morgan and his panel for accepting the invitation to review the outbreak. It is important to both organisation that key learnings are identified.”

The review should identify lessons learned and make recommendations to Public Health Wales and Hywel Dda UHB for improvement. There may also be recommendations for other key stakeholders.

A report on the findings of the review is expected around May 2022, with an interim report being made available in February 2022.

As part of Phases 1 and 2 of the screening exercise carried out in 2019, more than 2000 people were screened. This identified 31 active cases, and more than 250 cases of latent TB, and treatment was given as appropriate.

Very sadly, there was one death associated with this outbreak. The thoughts of those at Public Health Wales and at Hywel Dda UHB are with the family of the deceased.

The review is taking place independently of the ongoing active management of the outbreak, and there will be no impact on any clinical treatment or management that individual patients are receiving.

Public Health Wales and Hywel Dda UHB will make contact with people directly involved with the outbreak and further communication will be made in the next few weeks in relation to the review. 

More information can be found at