Comment piece – by Diane Peacock

As a relative of someone living in a care home, I was dreading the news that a resident or staff member had tested positive for Covid-19. It was obvious that nursing and/or residential care homes contained the largest enclosed communities of extremely vulnerable people in any healthcare setting outside acute hospital wards and hospices.

Weekly death registrations in care homes from week ending 13th March to week ending 27th March 2020 produced by the ONS/NRS published on the BBC website show overall death rates in care homes were below the five year national average, with no Covid related deaths reported on death certificates at that stage.

On 19th March 2020 the Government and the NHS had produced a directive that stated “unless required to be in hospital, patients must not remain in a NHS bed.” Acute and community hospitals were told they “must discharge all patients as soon as they are clinically safe to do so.” Patients would be discharged home with or without healthcare support depending on need or to a suitable community bed.

Discharge from hospital, it was stated, should happen as soon as possible and was “expected to free up at least 15,000 beds by Friday 27th March 2020, with discharge flows maintained after that.”

On the 23rd March as the death toll in UK hospitals reached 335, the Prime Minister announced a national emergency. He said we needed to stay at home, protect our NHS and save lives. The same day an already operational ‘Capacity Tracker’ was extended to become a ‘system wide’ directive requiring all residential care homes, nursing/care homes and hospices to be fully using a Capacity Tracker by Wednesday 1st April 2020.

Since then care homes have been required, on a daily basis, to input bed occupancy and vacancies and staffing shortages, and confirm whether they were open or closed to admissions, including the number of Covid-19 residents.

Accelerate discharge

One primary aim of this single, centralised ‘system’ was to enable Clinical Commissioning Groups (CCGs) and local authorities (LAs) to accelerate the discharge from hospitals to care homes of those patients deemed suitable, and to deploy agency staff where care home workforce capacity was diminished by staff self-isolating or testing positive for Covid-19.

On 2nd April, in tandem with the above, the Government issued “Admission and Care of Residents during COVID-19 Incident in a Care Home” that stated:

“As part of the national effort, the care sector also plays a vital role in accepting patients as they are discharged from hospital – both because recuperation is better in non-acute settings, and because hospitals need to have enough beds to treat acutely sick patients. Residents may also be admitted to a care home from a home setting. Some of these patients may have COVID-19, whether symptomatic or asymptomatic. All of these patients can be safely cared for in a care home if this guidance is followed.”

By the week ending 3rd April deaths in care homes, including those with Covid on death certificates, had risen to be over 1000 above average weekly death numbers.  Two weeks later on week ending 17th April 2020 ONS figures for deaths of care homes residents in England notified to CQC involving Covid-19 reached their peak with 845 care home residents dying in hospital, 2,473 residents dying in care homes, 49 dying elsewhere and 260 where the place of occurrence of death was not stated.

Peak mortality

On 28th April ‘Community Care’ UK reported that the CQC stated that there had been over 4,000 deaths involving Covid-19 in care homes in England in the past two weeks and that this was over four times the number recorded in residential and nursing homes up to that point. Since 10th April an estimated 42% of total Covid deaths in my locality have been in care homes, this does not include care home residents that have also died of Covid in local hospitals or in undisclosed locations.

Given that by the week beginning 17th April the wider community had already been in lockdown for 26 days and some care homes’ relatives and friends had been barred from visiting seven days or more earlier, Covid, although undiagnosed, must have already been in some care homes.

The exponential rise in care home deaths was likely seeded by one or more of the following:

  • residents discharged from hospital with confirmed Covid and those untested but with Covid;
  • new residents admitted from home some either with Covid symptoms or asymptomatic;
  • by unprotected, untested staff exposed to the virus from asymptomatic family members or when on public transport or doing essential shopping;
  • or by agency staff, similarly exposed, but also moving from care home to care home for work where they could have contacted Covid.

All care home staff, including BAME staff at high risk of more serious infection should have been provided with enough appropriate PPE and routine testing to protect those they care for and themselves from Covid.  While the Government has now been pressured into taking action on PPE and testing in care homes, care home residents are still contracting – and dying disproportionately from Covid-19.

Even as late as 8th June not all residents and staff in care homes had been tested.

With the cessation of local Joint Overview and Scrutiny Committees to oversee the impact of healthcare strategies at local levels, how can the best interests of the most vulnerable people in care homes be assured?

Too serious to trust to CCGs

The dreadful loss of life through Covid or suspected Covid is far too serious a matter to be consigned to CCG Boards or LA Cabinets that meet every other month or to a Public Inquiry that could take months, if not years, to report.

No amount of questioning can bring back the thousands that have died in care homes but the more we know now, the better prepared we will be for a second surge or for another pandemic that may well emerge in the months and years to come.

Below are some of questions that need to be addressed at local and national levels.

  • How many patients in total have been discharged from the hospital into care homes since 19th March 2020?
  • How many care home residents were admitted to hospital for another condition and died in hospital of Covid since 1st April?
  • How many residents from care homes were admitted to hospital on or after 1st April with suspected or confirmed Covid, then died in hospital?
  • How many people who tested Covid-positive in hospital since 1st April were discharged to a care home?
  • How many asymptomatic patients were discharged untested from hospital for Covid into care homes and later developed symptoms of Covid since 1st April?
  • How many care home staff members, in what roles, were absent from work because of their own or a family member’s suspected or confirmed Covid since 1st April?
  • How many staff, when tested in care homes, were found to have Covid?
  • How many agency staff have been deployed to cover for staff absence since 1st April?
  • How many of these agency staff were tested before entering a new care home?
  • What additional face-to-face, clinical support have care homes with suspected or confirmed Covid received during this period?
  • What is the justification for CCGs and local authorities continuing to transfer Covid-positive or suspected Covid patients to care homes?
  • To what extent did the differences in scale and financial status of care home provision locally and nationally impact on the equality of access to appropriate staffing, PPE and testing?

Failures to minimise harm

The Government is ultimately responsible for failing to identify and prioritise the acute needs of this highly vulnerable sector in time to minimise avoidable harm.  Both the timing and huge numbers of excess deaths of care home residents in care homes and in hospitals graphically reveals and discredits the Government’s claim that “right from the start” they “tried to throw a protective ring around care homes”.

It is not acceptable for CCGs and local authorities to relinquish responsibility by saying that they were following government guidelines. The Government, NHS bodies and local authorities, have a moral – if not legal – duty of care for vulnerable citizens.

 

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