Rare inquests into UK Covid deaths raise concerns over care failings

Exclusive: only two inquests are known have led to ‘prevention of future deaths’ reports to agencies

A series of healthcare failures that could lead to more people dying from Covid-19 were highlighted by a coroner during rare inquests into deaths in the first wave of the pandemic.

The senior coroner for Greater Manchester South, Alison Mutch, sent reports to NHS England, Public Health England and other authorities as part of her duty to identify action required where there is “a risk that future deaths will occur”.

More than 100,000 people have now died from Covid-19 in Britain, but a Guardian analysis has found only two such “prevention of future deaths” reports from inquests into coronavirus fatalities.

In March the then chief coroner for England and Wales, Mark Lucraft QC, issued guidance stating that inquests would not normally be necessary after a death from Covid-19. Many bereaved families argue they should be held and are still seeking answers about the circumstances in which their relatives died.

Mutch’s reports concerned the cases of Anthony Slack, 85, who died on 13 April after he became infected with coronavirus at his care home, and Leslie Harris, who died on 21 May after appearing to have contracted the virus while in hospital.

Slack, a married father of three, grandfather and great-grandfather, died after he and other residents contracted Covid-19 at The Vicarage in Greater Manchester. At the time his daughter, Sharon Slack, told the Manchester Evening News she was angry with the government for failing to protect vulnerable people in care homes.

Mutch’s report stated that Slack died from Covid-19, and that after a fall at the care home he had waited four hours for an ambulance to arrive. Mutch highlighted as “matters of concern”:

  • Residents in the care home had been infected with Covid-19, and the care home was unclear whether the virus had been brought in by staff or new residents.

  • Care home staff were unclear about requirements for wearing personal protective equipment because the guidance was changing.

  • There was a shortage of ambulances because ambulance staff were self-isolating awaiting Covid-19 tests, and because of the need for increased cleaning.

  • There was limited documentation at the care home about Anthony Slack’s state of health and how it was being observed.

Almost 20,000 care home residents died from Covid-19 in the first wave. The health secretary, Matt Hancock, claimed in May that the government had “tried to throw a protective ring” around care homes.

Mutch sent her report in December to Public Health England, NHS England, Greater Manchester Health and Social Care Partnership (GMHSC), the Care Quality Commission and the care home itself. They have until 26 January to respond officially.

A CQC spokesperson said inspectors had made “a targeted inspection” of the care home in July, “partly in response to concerns about infection prevention and control measures. Inspectors continue to monitor the service closely and are in the process of responding to the coroner’s report.”

A spokesperson for North West ambulance service said they were “very sorry that we were unable to get to Mr Slack more quickly” and offered condolences to his family. “We were experiencing an extremely high volume of calls in the early stages of the pandemic and while we do all we can to prioritise patients, this does on occasion sadly leave some waiting longer than we would like,” they said.

“Since then we have made changes to increase the number of ambulances available to respond when demand spikes, including enhancing our procedures to support deep cleaning, recruiting more staff and continuing to work with other healthcare providers.”

Public Health England said it would not comment publicly before responding formally to the coroner. GMHSC Partnership said it would provide a public response, but not before it had responded formally to the coroner. The Vicarage care home did not respond to a request for comment.

Mutch’s second report said Harris was admitted to Stepping Hill hospital in Stockport for surgery on a fractured hip after a fall at home. He was recovering but was then put on a bay where a patient had tested positive for the virus. He died from Covid-19 pneumonia.

In her prevention of future deaths report, Mutch raised concern about PHE guidance regarding management of patients in hospitals, although she noted that the hospital trust had changed its policy.

PHE and NHS England have until 3 February to respond to that report. NHS England did not respond to the Guardian with a comment on either case.

Additional reporting: Sam Cutler


David Conn

The GuardianTramp

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