Virus in Welsh care homes – the disaster which didn’t have to happen
Our research clearly details the warnings senior officials gave and were given about the risks weeks before vital actions were taken to protect elderly people in care homes from coronavirus. Acting political editor Will Hayward and head of news David Jame
BY ANY measure, the situation in Welsh care homes during the coronavirus crisis has been a disaster.
Up until June 19, a total of 717 of the most vulnerable people in our society had died with the virus after it got inside our care homes.
You may think that these deaths were inevitable during a pandemic.
But across the world other countries have demonstrated that it didn’t have to be this way.
Political decisions – or the lack of them – resulted in the virus being able to infiltrate our care homes. These are places which were identified as the most at risk before coronavirus even arrived on our shores.
Our research has shown that medical leaders and politicians did nothing to stop patients from hospitals being discharged into care homes without a test – even when the risk that people showing no symptoms could pose was being discussed.
As early as March 31, papers were being circulated on the UK’s core scientific advisory body Sage expressly recognising the contribution asymptomatic people posed to coronavirus’ spread within hospitals.
Yet it was not until April 29 in Wales that people being sent from hospitals into care homes started to be routinely tested – two weeks after England. In that time, 1,097 patients potentially carrying the deadly virus were discharged into the most vulnerable of communities without a test.
A Senedd committee last week was told patients being discharged into care homes in Wales are now tested twice, just in case the first test gives a bad result – emphasising the huge risk they pose.
It raises so many questions – why were our leaders so slow to act? Why did their scientific advisers not realise the risks to care homes?
There are scores of papers in the now-published minutes of the Sage committee on the effectiveness of social distancing measures, on face masks, on transmission to and by children, on the conditions that make people susceptible to coronavirus, on gender, on ethnicity and so much more – yet none in March or April on how to protect the tens of thousands of our most vulnerable people in care homes.
Did our leaders not ask the question – even as care home owners and their representatives were begging them to stop and think about what they were doing?
And what role did the lack of testing capacity really play? Health Minister Vaughan Gething has insisted it did not play a part in his thinking – yet our research paints a different picture.
The Cynon Valley Leader has spoken to leading experts and care home owners as well as going through the data and scientific advice at the time to see whether Wales’ care home catastrophe could have been averted.
How does the loss of life in care homes in Wales compare?
When it comes to international comparisons, Wales did not do well.
There are more than 23,000 registered beds in Welsh care homes and the occupancy was about 92% going into the crisis. With the latest ONS figures showing 717 people have died with Covid-19 out of a care home population of 21,160, Wales lost 3.4% of all its care home residents.
This is far higher than New Zealand (0.04%), Germany (0.4%), Canada (1.5%) and Denmark (0.5%). Even Italy, whose health service was overwhelmed by the virus, performed better (3.1%).
Wales did manage to perform better than the UK as a whole, which lost an awful 5.3% of its care home population.
But this is perhaps something of which can be proud. not we
In a recent press conference Mr Gething identified only three ways the virus could enter Welsh care settings: 1. Visitors 2. Staff 3. Residents Visitors were stopped from entering homes early on in the crisis, so the only way for the virus to get in was through staff or residents. Residents being discharged from hospital posed a particular danger because in March and April our hospitals were full of Covid-19.
The best way to stop people bringing the virus in is to test them. Charles Musselwhite, co-director of the Centre for Ageing and Dementia Research at Swansea University, says this is something Germany did very well.
He told the Cynon Valley Leader that “introducing tests early on” was particularly effective and “especially Germany” did this well.
When asked if it was advisable to test all patients coming from hospital into a care home, he said: “Yes, 100% yes! There have undoubtedly been people with symptoms placed back in care homes who have been unable to isolate them. We have seen breaches of older people’s rights in being able to choose where to reside and having input into their care plans go out the window.
“It is certainly my opinion that care homes have been ignored in the planning of patient healthcare.
This needs urgently addressing. Testing should be happening regularly for every resident and for every member of staff and people who come into care homes.”
But the Welsh Government did not do this early on. It was not until April 29 that Mr Gething changed the policy to allow all residents coming into homes to be tested. Until that point, only those with symptoms were allowed to have a test. By April 29 it was too late to save many. The largest losses of life in care homes took place before the policy was brought in.
Compared to other places, Mr Gething was slow to change his policy. Even England was weeks ahead of him, with its Health Secretary Matt Hancock announcing on April 14 that everyone going into care homes could be tested. This meant that for weeks the virus was able to be seeded into the heart of Welsh care homes, with some seeing as many 15 deaths – many of which were never attributed to Covid-19.
“The people I have got in my care home are very frail and if they get coronavirus it is a death sentence,” Brian Rosenberg, owner of Tregwilym care home in Newport, told the Cynon Valley Leader. Mr Rosenberg lost almost 20 residents from his home, 12 of whom died in a matter of days.
So why was Vaughan Gething so slow to change the policy?
That is a very good question. There were suggestions that the reluctance stemmed from Wales’ very limited test capacity in April, with Mr Gething being forced to abandon a target of 9,000 tests a day by the end of the month.
When we questioned the Health Minister in a recent press conference, he replied furiously “you are wrong” and that testing had nothing to do with it.
He went as far as to say that even if he’d “had treble the amount of testing capacity” he would still have not allowed testing of people without symptoms in care homes.
He said the reason for the delay was that they “based our decisions on advice and evidence. The advice and the evidence changes”.
So Mr Gething says he was advised that there would be no point in testing people without symptoms, and that he changed this on April 29 because the advice changed.
However the Health Minister’s version of events was totally contradicted by the First Minister a week later when Mr Drakeford said in Plenary: “The reason why we changed the guidance was not because the clinical advice had changed, but because we recognised the need to give confidence to people in the sector.”
What Mr Gething says is also hard to reconcile with a close reading of the papers published with the minutes of the UK’s core scientific advisory body Sage.
On this group, and its subcommittees, sit the most eminent public health scientists in the UK from the top institutions and public health bodies. All the UK’s devolved administrations are represented. The research done by Sage informs the advice which Wales’ technical advisory cell and Scotland’s own Covid-19 advisory group tailor to the situations in their respective countries and give to their ministers.
The Sage minutes of March 31 include an NHS England paper written by
Professor Stephen Powis dated March 31 which looked specifically at the risk of “nosocomial transmission” – the extent to which transmission within hospitals from patients to healthcare workers and vice versa had become one of the key sources of the UK outbreak.
He was absolutely clear about the risk that people in hospital with no symptoms posed, saying: “A key additional risk is transmission of coronavirus from non-diagnosed Covid-19 positive patients or staff, ie those who are asymptomatic or paucisymptomatic.”
He was also absolutely clear about why these patients were not being tested.
“We must consider public perception and workforce expectations of testing,” wrote Prof Powis.
“In most Trusts there remains insufficient testing capacity to test NHS and other critical staff away on sickness absence with suspect Covid-19 or self-isolating, and all sectors are under significant pressure. With the current pressure on the NHS and social care it could be perceived as inappropriate to prioritise those apparently well.”
People with no symptoms in hospital were not being tested because there was not enough capacity to test all the doctors and nurses and care workers self-isolating at home – and health bosses thought it would be inappropriate. Lack of testing capacity was clearly at the heart of this issue.
This is an NHS England document. But it was seen by the advisors of all the devolved administrations on the Sage committee. And on March 31, significant divergences in lockdown policies between England, Wales, Scotland and Northern Ireland had not yet emerged – and would not for several weeks. The four nations had gone into lockdown together just a week earlier. The chief medical officers and top NHS officials were acting in concert as they tried to prepare their hospitals for the huge demands they knew were days away from almost overwhelming the healthcare system in early April.
Even if we accept Mr Gething’s version of events, there are still enormous questions for him to answer.
“He might think he has done the right thing but I don’t think he has,” said care home owner Brian Rosenberg. “And I don’t think a lot of other people think he has either.”
According to Mr Rosenberg, the decision not to test directly led to the death of many of his residents.
“What [Mr Gething] is saying is clearly against the evidence. Obviously my home as well as many others have suffered a catastrophic amount of deaths.
“The people that were discharged from hospital were not tested because they only displayed the symptoms once they got to us. By the time they are in the care home, it is too late, it has spread.
“It is always easy to be wise after the event, but it is pretty fundamental to test people before they leave hospital.”
Throughout the crisis politicians from across the political spectrum have said they are “following the advice”. But science, especially on new and developing diseases, is not exact. There are judgement calls to be made and these are political decisions to be taken by elected politicians.
There was plenty of advice from early on that suggested that everyone going into care homes should be tested – regardless of symptoms. This was advice many care homes had seen and taken on board. In many ways, they were miles ahead of the Welsh Government.
Glyn Williams owns Gwyddfor care home in Bodedern, near Holyhead on Anglesey. In February he read an article on coronavirus that guided his entire attitude towards the virus.
“In February when I read the Lancet medical journal I came across some evidence about protecting healthcare workers. It actually stopped me dead in my tracks,” he told the Cynon Valley Leader. “I thought, ‘Jesus, this is a biological threat’. We have to treat this like biological warfare.
“The evidence in the article cited an example of a pre-op patient who within hours managed to infect 14 healthcare professionals before the onset of symptoms.
“It was at that point I thought that this was a very dangerous virus because it could be transmitted during the incubation phase, which was so unusual.”
That article in the Lancet and the study was by no means the of evidence.
There was a lot of advice from the World Health Organisation around testing in care homes. This guidance talks about prioritising testing for care homes.
Mr Williams added: “The scary thing is the government must have seen this advice, because I had seen it. In February the doctors and the researchers were suggesting that basic PPE was not good enough against Covid-19. I am sure that the government would have seen that but wouldn’t have had the levels of PPE they needed.
“They wrote their guidance around what they could provide.”
This perception that guidance on PPE and testing was written to fit around available resources was echoed by all the care providers contacted by the Cynon Valley Leader.
The theme of care providers being ahead of the Welsh Government when it came to the virus also comes up again and again. One letter seen by the Cynon Valley Leader from Public Health Wales to a south Wales care home owner summed this up.
When asked about whether they should be testing all people coming into their homes, the PHW expert said: “There is no test to see if the patient is ‘incubating’ Covid after exposure until they develop symptoms, which may be up to 14 days postexposure”.
Whereas many care homes took it upon themselves to try to isolate all patients coming in, the PHW official said: “I wouldn’t advocate this as routine practice for any patient coming out of hospital.”
Homes were under real pressure to take people from hospital. One Port Talbot care home owner told the Cynon Valley Leader he was pushed by the local authority to take in residents without a test. A demand he refused.
Care home owners are furious they were not protected by testing until, in many cases, it was too late.
Mr Rosenberg said: “We had to do the very best we could but my staff were on their knees. For the Health Minister then to turn around and glibly say that he was acting on advice, I think that is absolutely outrageous.
“If somebody advises me something, I want to test that advice against the evidence that I have got in front of me as to whether that is a rational approach. All of this was completely irrational.
“The only way the virus could come into my home was through staff and residents being moved in. only piece
Staff couldn’t be tested either until they were symptomatic. Once someone develops a symptom, it is too late and they have probably spread it.”
The results were catastrophic for Mr Rosenberg. “The undertakers was so overwhelmed that they were slow to clear the deceased from our homes, so we had dead bodies in the home for longer than we ought to have.”
This is not just about tests
It wasn’t just the lack of testing that left care homes feeling abandoned. There was also chronic problems with sourcing the right PPE for staff so they could both stay safe and avoid passing the virus to other residents.
On April 10, the Cynon Valley Leader published a leaked letter from Royal College of Nursing Wales director Helen Whyley to Mark Drakeford in which she described the chaotic situation in Welsh care homes.
She wrote: “Our members are telling us of their increasing frustration in not receiving any information on the testing process. It is critical that we act together to provide reassurance.
“Personal Protective Equipment (PPE) provision is directly affected by the lack of testing, as with asymptomatic patients or staff it is unclear whether the individual nurse or HCSW [healthcare support worker] should be wearing PPE or not – and this uncertainty leads to stress.
“Our members in care homes are under particular pressure because in homes with a small number of staff, having several staff off work has a negative impact on the care that can be provided to vulnerable older people.”
All the providers we spoke to confirmed this situation. Mr Rosenberg said that he had managed to get by because he sourced PPE from another of his care homes in England.
Even now, with the virus more under control, many care homes are well ahead of the Welsh Government when it comes to protecting their residents.
“If you look at the European Centre for Disease Control recommendations for recovering Covid patients, it clearly states that at least two negative tests are required within 48 hours of discharge,” said care home owner Mr Williams.
“So we have implemented that policy ourselves. We are implementing a higher standard. We have said to Betsi Cadwaladr Health Board that they must provide us with two negative tests within 48 hours of discharge and they must have been isolated during that period or we simply won’t take them.
“What we have found is that they have now complied with that because they have no choice. They are so desperate for beds. We are actually driving the policy based on real safety as opposed to the government, which is driving policy based on what they can do.
“It is being driven by Care Forum Wales, not by the Welsh Government. That is the only way we have managed to weather the storm.”
Mario Kreft MBE, who has eight care homes in north Wales and is also chair of Care Forum Wales, criticised the UK and Welsh governments’ lack of engagement with the care sector.
He said: “At the earliest stage, if only the governments of the UK had brought in the nations’ representatives in early February we would have had a much better result than we had. But because homes have acted so well, got ahead of the game and being so protective of their residents and staff, we have had far less than would otherwise have been the case. But as you know, we have still had absolute carnage in some places.”
Speaking to care home owners and staff, it is clear the virus has exposed an already underfunded and creaking system.
Some local authorities pay as little as £80 a day for people in residential homes. As one home owner said: “You would struggle to get a hotel for that, let alone care.”
On top of that there is a fragmented and disjointed system, with 22 local authorities, seven health boards, Public Health Wales, the Older Persons Commissioner and Care Inspectorate Wales.
Ultimately the people who suffer are the residents of these care homes. Even those who did not get the virus were subject to lower standards of care, as staff were forced to selfisolate for lack of testing.
It didn’t have to be this way – the international comparisons bear this up. Politicians are not just elected to follow advice. They are elected to interrogate it, to test it, to question everything that doesn’t make sense. Saying “that was the advice at the time” when everyone working in the sector at the time could see the catastrophe coming, does not look good on them.
There are still serious questions to answer – and very probably a lot of lawsuits.