IN THE darkest hour of the pandemic of 2020, Matt Hancock, then Health Secretary, was challenged by a reporter over concerns that high numbers of elderly residents were dying in nursing homes from Covid-19 amid reports that they were being discharged from hospitals without being tested or without the results of their tests being known.
Hancock robustly denied the allegations during that live televised press conference of April 28. ‘The proportion of deaths in care homes is around one sixth of the total, which is just below what it is in normal times,’ he said. ‘I am determined to do everything I can to protect the vulnerable.’
Such a glib assurance might have served in the short term to defuse public anxieties. But, for all its denials, the Government has never been able to shift the perception that it threw the elderly under a bus to save the NHS.
In part this is thanks to Dominic Cummings, former chief adviser to the Prime Minister, who, a year on, declared that official rhetoric about putting a shield around care homes was ‘complete nonsense’ and that in reality ‘many people were left to die in horrific circumstances’.
Indeed, data from the Office of National Statistics is now available to show that in the week that Mr Hancock faced down hostile questioning from the media on this point, care-home residents were dying at the highest rate of the crisis.
There were only two weeks in which the death rate in care homes surpassed 8,000 fatalities – both of them were in April 2020 and the worst was the closing week of the month when there were almost 10,000 deaths.
The five-year average for April is about 2,500 care-home deaths a week. So at the moment Mr Hancock said the death rate in care homes was ‘below what it is in normal times’ it was in fact nearly four times higher.
Yet by then many NHS hospitals were past the peak and emptying their intensive care units of Covid patients, with big inner-city hospitals such as St George’s in South London seldom filling more than 40 of its 120 ventilator beds in the weeks and months that followed.
Seven purpose-built Nightingale hospitals, with a collective capacity of 11,000 beds, were also standing empty – but that was because the NHS was not ‘admitting anyone from nursing homes’, according to Professor Patrick Pullicino, a neurologist who came out of retirement to volunteer at the one in London.
He was angry about it. ‘If somebody in a nursing home gets Covid you don’t leave them there,’ he said at the time. ‘You have to monitor them and if they get to a certain point you bring them into hospital. You don’t leave them to die with hypoxia and pneumonia and put them on palliative care in a nursing home. That’s not the way to deal with it but that is what they are doing.
‘Get the elderly out of the nursing homes and put them in the Nightingale. There is plenty of room, there are plenty of people who are sick. Just look after them. What’s the idea of an age cut-off? It’s wrong.’
So was there a ‘cut-off’? Certainly, the initial lack of ventilators and PPE seemed to have inspired the National Institute for Health and Care Excellence (Nice) to propose new triage tests, such as the Clinical Frailty Scale, the previous month. Under this algorithm, patients were given a rating out of nine; if they scored below five they might qualify for life-saving treatment, but any higher and they might not.
The BMA actively supported this kind of discrimination and some GPs wrote to cancer sufferers and other seriously sick or disabled patients in the community, advising them not to go to hospital if they contracted Covid-19 because they would not qualify for a ventilator.
Such patients were sometimes told, quite candidly, that it would be better if they stayed at home and died there.
Elderly and critically ill people were even encouraged by doctors to sign forms to say they did not wish to be either resuscitated or taken to hospital if their conditions deteriorated, and told their self-sacrificial actions would protect the NHS.
Guidance published in April 2020 by the Department of Health eventually advised the NHS to transfer elderly people from their own homes into nursing homes, even if they had Covid, and to treat them there.
Together with the discharges from hospitals into care homes, it meant that people infected with Covid were sometimes cast among vulnerable and elderly residents who contracted the virus. They sometimes gave the disease to staff who inadvertently spread it among multiple sites where they worked.
Still, the policy looked more like a cack-handed response to a desperate situation rather than anything cynical until Dr Moosa Qureshi used the Freedom of Information Act to obtain government documents which revealed such merciless triaging was planned as early as 2016 in the event of a pandemic which threatened to overwhelm the NHS.
It is now commonly held that many of the estimated 42,000 care-home deaths in the first wave of the pandemic involved elderly people abandoned to the ravages of Covid-19. This would be a scandal in its own right yet it is unlikely to be the full story.
The Evidence-Based Medicine DataLab at the University of Oxford offers further insight into what might have really happened when it published figures showing huge leaps in community prescriptions (ie not hospital) of a powerful sedative called Midazolam.
It has identified two notable spikes over the last 18 months. The first was in April 2020 when 38,582 items were written compared with 21,310 in March and 17,991 in February of that year (a doubling in two months). The second surge came in January 2021, the peak deaths period of the second wave, when a second high of 27,636 items were prescribed.
Midazolam is used in a variety of clinical settings, including anaesthesia and for sedation in intubated patients (though in the community this would not be practicable). It is also used increasingly to make dying patients comfortable in end-of-life care.
In the view of Dr Ben Goldacre of the EBM DataLab the latter purpose explains the surge in prescriptions. ‘That’s good doctors doing good end of life care, in hard circumstances,’ he tweeted. ‘On a vast scale.’
Palliative care often represents medicine at its most compassionate and excellent but, as the abuses under the discredited Liverpool Care Pathway have revealed, the misapplication of sedatives and painkillers can sometimes be deadly.
The problem with Midazolam, as Nice acknowledges, is that when used with opiates it can trigger a ‘potentially fatal respiratory depression’.
It doesn’t take a huge leap of the imagination to see how dangerous a drug with the power to depress the respiratory system can be to patients with a virus which attacks their lungs. The likely consequence of a combination of Midazolam with an opiate in elderly patients who may require oxygen is death, particularly if the patients are additionally rendered unable to drink or denied hydration.
The massive use of Midazolam must therefore raise the question of how many of those nursing home deaths were either by Covid or the misuse of such medication. The numbers of deaths ‘with Covid’ or ‘from Covid’ will always remain a mystery.
Even so, Professor Pullicino says that ‘these patients, in the normal course of events, should have been admitted to hospital for treatment and not have been put on end-of-life care . . . it is likely many of these patients could have been saved’.
Perhaps there was no desire to save them. Perhaps they were considered as having passed their ‘sell-by’ date, so to speak.
At times, such attitudes appeared prominent in the pandemic, for instance when ‘blanket’ Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders were imposed across entire care homes or written out for people simply because they had learning disabilities of one kind or another.
Simultaneously, people with conditions such as Down’s syndrome and autism were pushed down the queue when it came to the distribution of vaccines.
Officially, a total of 508 people were given DNACPR notices without their consent but a study by the University of Sheffield discovered that they were served on a third of all patients admitted to hospital with the virus.
Following an outcry, the Care Quality Commission, the Department of Health and NHS England moved to halt such practices though there are reports of such policies remaining in force in some hospitals long after they were supposed to have ended.
Perhaps such institutions were confused given that the original instruction from the NHS had stated in black and white that ‘mental health needs, a learning disability or autism’ were vulnerabilities which counted against a person when providers have to make ‘difficult decisions in the context of reduced capacity and increasing demands’. (This document may have been amended since.)
Or maybe they were just reluctant to change course. Even today care staff supporting adults with such conditions are specifically directed by the NHS to Compassion in Dying, the sister charity to Dignity in Dying, the group formerly known as the Voluntary Euthanasia Society, for further information on care planning.
Dr Pia Matthews, governor of the Anscombe Bioethics Centre and a senior lecturer at St Mary’s University, Twickenham, has noted the apparent conflict of interest. ‘Implicit in some apparently benign approaches is the view that people are better off dead than disabled,’ she says.
The scale of the failure to protect the weakest and the most vulnerable in society during the pandemic warrants a public inquiry. Yet it would be a mistake to see such an exercise simply about learning from the lessons of the pandemic.
If anything, such abuses should represent a warning to society of future threats at a time when the Assisted Dying Bill of Baroness Meacher seeks to license doctors to prescribe lethal drugs to those they say are terminally ill and to oversee their deaths.
The pandemic has exposed deep and disturbing prejudices against the elderly, the gravely ill and people who are disabled. Any degradations of protections that guarantee equality before the law will only open the door to unforeseen horrors. They might make the scandals of the Covid pandemic look like a warm-up to the main act.