After thousands of positive Covid cases were reported as negative, public health experts estimated that at least 23 deaths might have been caused by a blunder at a private lab.
There was an error at the Immensa Health Clinic's lab in Wolverhampton that resulted in about 39,000 tests returning negative results when they should have been positive in the south west of England.
Two months after a Covid pandemic was declared by UK authorities, the owner of a DNA testing company incorporated a health clinic.
Immensa was awarded a contract by the government in October of 2020 to develop a volume of testing for Covid.
Under the rules, the contract did not go to tender.
The UK Health Security Agency estimates that the oversight resulted in about 55,000 additional infections, about 700 additional hospital admissions and 23 additional deaths.
Some people would have continued to take precautions to reduce the spread of infections even if they had received a false negative result.
There were reports of inaccurate results that led to the suspension of test and trace operations.
Staff at the lab set the threshold levels for reporting positive and negative results that led to the error.
Richard Gleave, the UKHSA director and lead investigator, said that they looked carefully at the arrangements in place for overseeing contracts of private labs.
There were staff errors within Immensa's laboratory that caused the incorrect reporting of test results.
There was no single action that the National Health Service could have taken to prevent this error.
Our report makes clear recommendations to reduce the risk of incidents like this happening again and to ensure that concerns are addressed and investigated quickly.
Jenny Harries, the UKHSA chief executive, said: "UKHSA is committed to being a transparent, learning organization and this means investigating where things have gone wrong and working out how things can be improved."
As soon as the UKHSA discovered the incident, many of the recommendations were implemented.
We will be able to spot problems sooner where they occur. As rapid incidents like this unfold, we want to improve how we work with our partners.