live: UK COVID-19 inquiry

my lady may I deal with a plan for the hearing the plan for calling the evidence during the hearing will be to follow the patient Journey Through the healthare system in so far as practically possible hearing from those directly affected although may not always be possible given witness availability to follow strictly each and every stage of the journey running throughout that Journey will be the need to understand some of the basics of how covid-19 is transmitted and the infection prevention and control measures IPC needed to try and stop people becoming infected and inevitably when considering IPC measures we will need to be familiar with terminology such as PPE personal protective equipment that's clothing for examp example that is designed to protect the wearer and respiratory protective equipment normally a mask type of PPE designed to protect the wear from breathing in the harmful substance Professor begs an expert in the transmission of infectious diseases in hospitals will help us to understand the roots of transmission of covid-19 and the ways to prevent and control transmission of the virus now it should be noted that in relation to the transmission of covid as with many things in life there was and perhaps remains a lack of scientific consensus there are diverging views Each of which may be supported by a reasonable body of scientific evidence and so anything I say or more importantly anything of the module 3 experts say about infection transmission and consequential IPC measures cannot be taken as gospel it can't be considered to be the only view on those matters and importantly and perhaps unhelpfully you may think there does not always appear to be consistent and agreed terminology in addition to Professor begs the inquiry has instructed a trio of IPC experts to consider the guidance and IPC in practice Dr GN Shin Professor Dena gold and Dr Ben war will give evidence about topics and issues including IPC measures taken to protect both patients and indeed staff in NHS hospitals they will speak to the evolution of the covid-19 guidelines and to patient and staff testing and I anticipate that you will be assisted by other expert and indeed other witness evidence for example from the public health agencies the chief medical officers the chief nursing officers and others who will be able to assist on this topic I do however need to cover some background at the outset in relation to transmission and IPC the need for the inquiry to consider what was known about how covid was transmitted arises because the consequences for the types of infection and IPC measures which were needed to be adopted and the PPE that should be worn covid-19 as you know was a pathogen knows a SARS COV 2 it's an organism that causes the disease that became known as the wh uh named it in February of 2020 as covid-19 it's a respiratory disease transmitted through respiratory particles that contain the virus now for ease I'm going to refer to both the virus and indeed the disease as covid-19 and as to Transmission in very basic terms in order for a viral infection to be transmitted in humans viable virus particles must be transported from an infectious individual to a susceptible individual however when the virus particles eventually reach a susceptible individual they may not cause any infection simply because they might not come into contact with the receptors in the nose throat eyes and lungs that facilitate infection and so that means that in order for an infection to spread infectious individuals must shed virus particles into the environment in such numbers but eventually some of those reach the receptors of the susceptible person now there are various ways that a respiratory virus can be transmitted including and often in combination with each other and it may help us to have this simple diagram on screen thank you there are three main Roots firstly droplet trans particles from an infected person's respiratory tract which reaches the eyes nose and mouth of the person and on this diagram they're represented by the larger orange circles there is Airborne transmission I.E via the air and where the infection is spread by the dissemination of the smaller particles the smaller orange dots from the respiratory tract and there is contact transmission whether that's direct I.E from one person to another for example sneezing in someone's face or indirectly bya contact with a contaminated object or Surface such as the door handle is depicted here a light switch surgical equipment or instruments that haven't been cleaned properly where the uh surface is contaminated that is often known as fomite transmission now in the case of respiratory infections the size of the infected particle may be of significance when considering transmission the largest sized particles known as droplets are generally thought to fall to the ground or the surface within about one meter from The Source the smaller particles are known as Aerosoles and the reason the size is important is because whilst the larger droplets are considered to settle rapidly the smaller droplets the Aerosoles can remain in the air for longer travel longer distances and so are considered to be transmitted by the Airborne route when considering Airborne transmission Professor begs will provide you with a background to what he considers to be an historical confusion surrounding the size and behavior of respiratory particles that are exhaled in part the problem is said to arise from the terminology used by different scientific disciplines to describe these particles and the language used by the medical community is not always the same as that used by physicists and Engineers this he stes is not merely a question of semantics rather it has important implications for the IPC measures adopted including the PPE that is used when responding to a respiratory virus you will hear that because respiratory viruses such as covid have sa for when particular medical procedures are being carried out been deemed not to be transmitted via aerosols the result is that the IPC advice issued in the UK and and indeed overseas including that during 2020 and much of 2021 focused on prevention via the droplet and contact routs and the classification of covid as a droplet born virus also affected the ventilation requirements in health care facilities early in the pandemic it was thought by many that droplet transmission was the dominant route now that in part may have been due to the fact that the overarching strategy for South out in the UK pandemic influenza strategy from 2011 there is an initial infection prevention guidance adapted from that flu strategy and flu has historically been considered to be primarily a droplet born disease rather than an Airborne One you may hear that although a review in 2011 concluded that aerosols probably played more an important role in transmission than previously thought droplets were still considered to be the Principal route by which flu was transmitted and the epidemiological evidence in support of aerosol transmission was considered in uh inconclusive the medical community's understanding of SARS not to be confused with SARS COV 2 which became covid may have been equally influential in shaping early guidance given the similarity between the two viruses belief that SARS was predom predominantly drop this based not withstanding evidence that suggest Ed it was potentially or Airborne may also have influenced a view that covid would behave in the same way now my lady that's not to say that the Airborne route was not recognized as a possible route of transmission for covid the inquiry is in possession of numerous statements and documents that show that the scientists expert and advisers were aware that covid could be spread by aerosols but those uh Witnesses suggest that what was not clear was the extent to which aerosols transmitted the disease the circumstances in which this occurred and the relative contribution of droplet aerosol and contract contact transmission the extent to which the World Health Organization who guidance on this subject may have informed or colored the UK's position on transmission at the start of the pandemic the who stated cator torically that covid was not Airborne by July of 2021 wh partially accepted the airboard transmission occurred and it was not until December of 2021 the who changed its stance and acknowledged that covid could be transmitted by air assault particles that could remain suspended in the air that is a very brief overview of the issues that arise in relation transmission and underpinning what PPE needs to be worn is reference to health and safety requirements and the legal framework uh employers as I think my lady knows are under various legal duties to provide and maintain a safe working environment in so far is as reasonably practicable that includes preventing and controlling employees exposure to hadous subst hazardous substances including infection at work there is a framework known as the hierarchy of controls which should be considered by employers to help eliminate the risk and can I call up page 10 please there's the hierarchy of controls which the most effective at the top down to the least effective elimination in reality was always going to be difficult for covid-19 to be eliminated entirely although clearly there was efforts made to reduce the number of people attending hospitals GPS and the like you will see that PPE personal protective equipment is the final measure in the hierarchy and it's obvious that given that the risk of covid could not be entirely eliminated from Health Care settings and the need to provide Close Quarter care to patients PPE was always going to play a significant part in preventing the spread of the virus it's likely to be uncontroversial therefore to state that PP is one of the most important IPC measures that can be put in place to help people prevent people coming infected and so module three will be looking at what kinds of pp were recommended the G legalities the practicalities of this guidance and in particular the role of surgical face masks and respirators in protecting health care workers my lady is going to hear much about fluid resistant surgical pH masks I'm holding one up but they are the blue masks that many of us wore at various times frsm to give them their acronym uh provide a barrier to splashes and droplets impacting on the wearer's nose mouth and respiratory tract and you'll see that they are not designed to closely fit the wearer's face and the poor fit means the aerosols can be inhaled passing through the gap between the mask and the face because FSM are not only warn to protect the wearer but to prevent the wearer infecting someone else you may hear them also Rec recur referred to as Source control now protection against aerosol particles requires the use of respirators which remove the contaminant from the air before they breathed in there are different types many uh different types of respirators used in healthcare settings one that your lady ship will hear about most is ffp3 the filtering face piece I have one example here ffp3 offers the highest level of protection and is ordinarily by which I mean in non-pandemic times the only ffp class acceptable to the health and safety executive for use against infectious aerosols in the UK it's of a different quality of material and it fits the face with a much closer fit the health and safety regulations require that those required to use respirators are fit tested by a competent person results are satisfactory and those results are recorded and available for inspection now the IPC Trio of experts will note that for many NHS staff this was their first experience of using respirators and of fit testing because prior to the pandemics hospitals would not have tended to fit test workers who are unlikely to use ffp3 masks in their day-to-day roles so at the outset of the pandemic there were staff trained to perform fit testing they were few and far between and more NHS staff had to be rapidly trained this resonates with evidence from some of the spotlight hospitals from whom the inquiry obtained evidence some of those Spotlight hospitals told us they abandoned fit testing in favor of what's called fit checking with one Hospital stating it moved at one point to fit checking to avoid quote being overwhelmed a fit test is not the same as a fit check the latter of which is simply regarded as good practice to ensure the mask is being correctly worn and fit fit checking is not a regul regulatory requirement it is not a substitute for fit testing the British Medical Association notes for example that across range of their surveys female respondents consistently reported slightly higher rates of failing fit tests compared to males other research also suggests that failure rates of f fit testing are higher in stum ethnic minority backgrounds when compared with staff of white ethnicity including particular those with beards one of the core participants in this module F mhwg report that where fit tests were failed this did not necessarily result in more suitable PPE being provided so my lady I just want to Briefly summarize what PPE was recommended for healthcare workers and when this is by no means a reference to all of the guidance that was issued but it's to give you an indication of some of the issues that will arise in the evidence and may I start with a position as at January 2020 as you heard in module two in January of 2020 Co 19 was designated as a high consequence infectious disease or hsid H SIDS are highly transmissible infections are defined according to a set criteria which includes the fact that they typically have a high case fatality rate CFR the case fatality rate is the proportion of those with symptoms and an infection who die you will hear that because of the mode of transmission for an H is often unknown at the early stage ages and because certain procedures that generate aerosols are often required to be performed on hsid patients H SIDS require a high level of PPE to be worn but it should be noted that the mode of transmission does not determine whether a disease is an HD or Not by the 13th of March so two and a half months on covid-19 was Declassified as an agid by the advisory committee on dangerous pathogen and indeed nerve tag and that advice was accepted by the government a few days later therefore Co was subsequently to be managed like other contagious diseases now that decision was based on the evidence that about Co that had merged between January and March and in particular the fact that mortality rates were considered to be low may I just pause there to make this observation though about a relatively low mortality rate compared to other AGD because whilst the prop portion of those infected who die of covid was known to be about approximately 1% Which is higher than seasonal flu but lower than for example SARS covid is highly transmissible so if lots of people get infected even if the fatality rate is relatively low you will still get high numbers of deaths and indeed as you know from the on statistics a number of people did get infected leading to that over 18 6,000 deaths that I referred you to at the beginning when considering the evidence relating hsid it's important not to alide issues of what PPE was recommended whilst covid was classified as an hsid with what PPE should have been recommended once it was Declassified they are two separate issues and two points may arise for your lady ship's consideration whilst it may be that the declassification of Co as an HD was a reasonable decision this did not signify that covid-19 was not transmitted bya Airborne route and equally just because a higher level of PPE was used whilst covid was classified that doesn't automatically mean that the higher level of PPE for healthcare workers was no longer appropriate once the disease had been Declassified by March 2020 on the the 13th of that month the IPC guidance stated that the following PPE should be worn ffp3 mass and disposable eye protection should be worn at all times in high-risk areas where agps and I'll come back to those in a moment are being conducted that included intensive care units high dependency units where they were managing the covid-19 patients the blue mask F frsm to be worn by General Ward staff community staff ambulance social Care staff the close patient contact andless an AGP was being performed agps another acronym aerosol generating procedures are procedures that are thought to have a high risk of aerosol generation and an increased risk of transmission from patients with a known or suspected infection so during agps healthcare workers should wear the ffp3 respirator they have eye prot protection disposable long sleeve gown gloves you will hear that there are issues relating to what procedures were designated as agps and in particular concern that cardiopulmonary resuscitation CPR was not listed as an AGP that led to a Divergence in approach from some bodies including the resuscitation Council in the UK and the College of paramedics and ambulance trust who recommended that ffp3 was worn when conducting CPR in contrast to the UK IPC guidance which didn't make that recommendation a month on in April 2020 the IPC guidance recommended reuse and sessional use of PPE in effect prolonged use of specific PP items during a single period of time when working in a specific setting so to give you an example wearing the same mask and goggles throughout a wardr but still changing apron and gloves every time physical contact was made with a patient and that guidance was brought in because there were concerns about supplies of gowns in particular which resulted in specific guidance being issued recommending that sessional use and reuse where there were severe shortages of Supply I jump forward to June of 2021 on the 1st of June by this stage IPC guidance recommended an enhanced role for local risk assessments the guidance stated that if an acceptable sorry an an unacceptable risk of transmission remains following the risk assessment it may be necessary to consider the extended use of rpe for patient care the risk assessment should include Val evaluation of the ventilation in the area and the prevalence of infections or new variants of concern in a local area and by March 2022 the guidance now stated that ffp3 should be used for agps and when dealing with cases of suspected or confirmed infection spread predominantly via the Airborne route now my lady you will hear the other iterations of the IPC guidance use phrases such as spread wholly spread predominantly by the Airborne route not only were they considered confusing but you may want to consider how practically useful words such as wholly and predominantly were to those who had to at this guidance at short notice and disseminate it accurately to healthcare workers on the front line you may hear evidence from some witnesses that the changes in 2022 to which I've just alluded were to paraphrase too little too late because it appears that for much of the pandemic and certainly up to the end of 2021 the position was that if a healthcare worker was working in an ICU or an hdu or a covid hotspot or they were performing agps they had a higher level of PPE throughout but for the remaining healthc care workers who made up the vast majority of the workforce it was simply the blue F frsm masks that were recommended you will hear that there was concern amongst the medical community that the IPC guidance did not sufficiently protect healthcare workers particularly before vaccinations became available and they belief that the ffp3 masks were not being recommended say for the hotpots and the agps because they were insufficient supplies of those respirators it is argued by some that the IPC guidance was influenced by Supply rather than safety it failed to adopt what is called the precautionary principle now there may also be disagreements about the precise definition of the precautionary principle but in short the pr aary principle describes an approach that should be adopted for addressing hazards subject to high scientific uncertainty and rules out lack of scientific certainty as a reason for not taking preventative action during the course of the evidence my lady will doubtless hear the phrase the absence of evidence is not evidence of absence and you will need to consider whether the government agencies and those that advised them were more pragmatic than precautionary when it came to the IPC guidance that was issued can I deal with um symptoms and asymptomatic infection once a person becomes infected with covid it takes several days normally before symptoms start to appear and it is during this pre-symptomatic period which could be hours it could be days where a person becomes infectious before symptoms appear this is when the virus is incubating and individuals are most contagious there may therefore be a period of time where an individual is infected with the virus capable of spreading the virus without them feeling ill or realizing that they are infected and infectious that's some of the terminology that you're likely to hear about will be resonate from earlier modules asymptomatic in particular the person never develops any symptoms and you will want to draw a distinction between asymptomatic infection where the person has the virus does not have the symptoms an asymptomatic transmission where the person has the virus and passes it on you can be asymptomatically infectious and not necessarily pass the virus on put another way just because you have it doesn't mean you transmit it now you've already heard in earlier modules some evidence about what was and was not known about the extent to which covid-19 was transmitted asymptomatically but it appears to be accepted in the UK the possibility of asymptomatic transmission was acknowledged early on in the pandemic by the end of January 2020 the fact and degree of asymptomatic transmission however was challenging for the health care system's response to the pandemic for example it caused difficulties in accurately ascertaining the number of people infected with covid because asymptomatic people often went untested because they didn't realize they had the virus therefore were undiagnosed the relatively long incubation period of the virus which for the Wuhan variant the first variant was four to six days and so high rates of asymptomatic infection meant that it was difficult to identify infected patients and staff and understand the networks of transmission I just referred to testing and so it may have to set the scene for consideration of this by summarizing the roll out and some of the matters that will need to be examined during this module testing is uh obviously important and initially focused on testing symptomatic in patients to determine whether they had the disease and if so what treatment they should be given but it wasn't just important for that testing has an important IPC function as for example it Ena enables covid-19 positive patients to be isolated the testing of healthcare workers was rolled out on various dates across the UK from the end of March 2020 thereby enabling infected healthcare workers to be isolated and those who had a negative test returned to work the dates when asymptom matting testing uh of Staff also varied across the UK and do war will explain the challenges in determining where and how covid-19 was acquired as this too can affect IPC measures in particular it can be important to determine whether covid-19 was acquired in hospital and if so the extent to which it was patients infecting healthcare workers and vice versa patients infecting other patients healthcare workers infecting other healthcare workers there are challenges in determining all of those things but not withstanding those challenges Dr War considers it likely that the number of patients across the UK who cont trct a hospital acquired infection or nomial infection as it is called to be well over a 100,000 people the age of the hospital estate is also important when considering IPC it affects the ability of the hospital to implement IPC measures it also affects for example oxygen provision and that is a matter that did come to the fall during the pandemic can I deal firstly with ventilation in England alone the NHS estate encompasses some 177,000 buildings and whilst not all of those are Hospital 12% of the total estate predates the founding of the NHS that was in 1948 around 177% is over 60 years old and about 44% is 30 to 60 years old if one thinks about it in relation to implementing IPC measures the number of single occupancy patient rooms the ability to socially distance in Wards to open the windows to separate covid and non-co patients are all important and in this regard good ventilation is key can I put up on screen please 474 319 on page 11 thank you I just want to say one thing a couple things about ventilation that's the process where clean outside air is introduced into a room space to flush out any virus other the pollutants it doesn't completely remove all infectious aerosols in the room its aim is to dilute and reduce the concentration of aerosols to a safe level and so generally speaking the better the ventilation the lower the concentration of covid in the room and if one looks at this diagram that Professor begs will speak to one can see there that um it's set out the position the virus is the blue dots but clearly an infectious person has left the room at 2:30 looking at the top uh brown row at 2:30 when they've left in a poorly ventilated room there is a large concentration of the virus and even one hour later continuing to the top right side of the page there is still a fair concentration of the virus in that room contrast that if your lady ship will with the good ventilation at the bottom includes there the ceiling fan a window that could be opened a portable air cleaner in this case there is less of it even just shortly after the infected person has left and by 3:30 significantly different picture painted now my lady that is obviously a simplistic diagram but if one pauses to think about an old hospital Ward with multiple beds and windows that don't open and aging ventilation systems one can see how important ventilation is in healthcare system settings and Professor begs will tell you that ventilation in English healthc Care Systems is governed by Health technical memoranda those memoranda give advice and guidance on the design installation and operation of specialized building and engineering technology for use in healthc Care Systems there are similar htms in Scotland and the htms were written before the covid-19 pandemic and Professor begs will tell you that ordinarily they prioritize Comfort odor Energy Efficiency over infection he considers the htms to be outdated based on the current understanding of Airborne transmission and in urgent need of updating thank you can take the um diagram down thank you I mentioned oxygen supply issues the impact of the Aging NHS estate on pandemic response was also seen in the capacity of the piped oxygen supply system in many hospitals and that was a matter about which a number of the spotlight hospitals were asked by way of example you may recall seeing reports in the news about oxygen supply issues in Watford General that was one of the inquiry Spotlight Hospitals now back on the 4th of April of 2020 the hospital declared a critical incident due to oxygen supply issues in short the previous month they'd wanted to undertake an urgent upgrade of the their ability to supply oxygen but unbeknownst to the hospital's trust the Department of Health had instructed that work is stopped on bulk oxygen systems that had not been prior approved a few days before the critical incident there were warning signs when on the morning of the 1st of April the alarm panels at Watford General were triggered indicating there was high pressure in the oxygen delivery system that matter was raised over the course of the next few days with various bodies who tried to assist in having for example a mobile unit delivered to Watford hospital but come the fourth as a result of the critical incident being declared approximately 60 ambulances were diverted and seven inpatients when transferred to other hospitals out from Watford General now I should add that by the end of the day oxygen capacity had been increased and 7 Days Later new evaporators were delivered but that is a snapshot of the types of um problems caused by an aging state that couldn't Supply the requisite amount of oxygen to the hospitals may I turn now to some of the other matters set out in module 3's scope and firstly the position in relation to GPS for many of us the GP is the first Port of Call and at the onset of the pandemic there were approximately 35,000 full-time equivalent GPS in the UK but as Dr Michael molland the honorary Secretary of the rcgp will tell you there were concerns pre pandemic that there were simply not enough GPS to meet the level of demand pre pandemic the rcgp also called for investment to increase and enhance digital infrastructure and you may increase in remote console ations module 3 has instructed Professor Adrian Edwards to prepare an expert report on the impact of the pandemic on General Medical Practice one of the matters he lights is the he highlights is the rise in the number of telephone appointments during the pandemic to give one example in England in march 2020 there were 6.6 million telephone appointments one year on there are 11.4 million it should be noted however that both Professor Edwards and indeed the rcgp consider that remote consultations are not appropriate for all patients this Echoes the sentiments of many contributors to every story matters who spoke of how difficult it was to assess patients without seeing them in person they described remote consultations as risky and worrying the contributors said they lost valuable insights they would usually gain from in-person appointments there were significant fluctuations in gp's workloads during the onset of the different waves of the infection and across different parts of the country during later stages of the pandemic there was a need for GP staff to support the vaccination effort alongside their usual care and there was a significant impact on GPS in relation to shielding staff in every general practice had to go through their systems identifying patients who should be advised to Shield those systems were imperfect not all illnesses were recorded that would have correctly coded in a patient records medications again which would have influenced the assessment weren't necessarily recorded in the records and you may hear concerns that from the outset it was unclear who should be in the shielding group and who should not practices report receiving a significant significant number of calls from patients asking for advice on this Professor Edwards considers the evidence suggests that overall people's experience of accessing a GP is deteriorating the pandemic exacerbated the problems with access he considers there to have been a lack of pre-pandemic planning for Primary Care and points to a start contrast between the lack of plans pre pandemic what with what he describes as a deluge of guidance which was then issued I think a matter that was referred to in the video that we saw this morning that Deluge was described by one GP nurse who told every story matters I have probably on average about 20 different guidelines to read on a daily basis at work at the end of the day we were focusing more on reading these guidelines than we were on actually actioning for our patients it took away a lot of precious clinical time and patient experience and Professor Edwards will also explain some of the data relating to face Toof face versus virtual appointments but as he points out it is not all about about statistics but the potential effect on patient care to quote him if I may general practice care is not transactional in nature it is relational pharmacists are a matter that module 3 will consider data suggests that in 2022 there were over 14,000 registered pharmacies and Community pharmacies across the UK and you will hear that those figures are are lower than when compared with Pharmacy data published in 2019 in August whether that decrease is as a direct result of the pressures brought to bear on pharmacies by the pandemic may be difficult to establish but the pandemic undoubtedly had a number of impacts on pharmacies and pharmacists the reduced access to GPS led to a surge in demand for Community Pharmacy Services it included a substantial increase in the number of patients seeking advice for more serious conditions or mental health issues and it led to a rise in the number of prescriptions being issued there were demands placed on pharmacists when the vaccine was rolled out alongside the sector's own struggles with pharmacists becoming ill with covid-19 and self-isolating an indication of some of those pressures on pharmacists may be gleaned from every story matters where one Community pharmacist said this because doctors shut down oh my God it became hysteria we had days where there was 80 or 90 people queuing outside the pharmacy you will hear there is concern amongst pharmacists that they were overlooked and the Community Pharmacy was not considered alongside other NHS service providers it led Community Pharmacy to not having the support it needed throughout the pandemic and to just give you two examples Pharmacy teams were initially excluded from the life of Insurance scheme announced in England in April 2020 which guaranteed a £60,000 life Assurance payout to families of I quote eligible Frontline Health and Care staff in England who died from the virus as originally planned the scheme would only extend to pharmacist in exceptional circumstances however the government soon changed its mind and included pharmacists in the scheme and it is worth noting for example that a similar scheme in Wales included pharmacists from the outset pharmacists consider they were overlooked in relation to PPE where Community Pharmacy initially had to Source its own PPE and in May 2020 when the Department of Health launched a portal to provide access to PPE it was only made available to GP surgeries and small Care Homes it took many months until the late summer of 2020 pharmacies to be finally allowed access to the portal and you will hear by contrast the different arrangements for supply of PP to pharmacies in Scotland for example led to fewer problems accessing [Music] PPE my lady the feasibility of implementing IPC guidance and far Pharmacy settings is likely to be another feature of the evidence along with that issue of PPE in April so just a month into the pandemic 34% of Pharmacists responding to a ryal pharmaceutical Society survey said they were unable to Source continuous supplies of PPE 94% of respondents said they were unable to maintain 2 m social distancing from other staff and 40% of respondents said they were unable to maintain social distancing from patients risk assessments appear to be an issue in the pharmacy sector there are results from a survey from the RPS and the UK black pharmacist Association in June 20120 that found that more than 2third of Pharmacists and pre-registration pharmacists from ethnic minority across primary and secondary care had not yet had access to a covid-19 risk assessment that was nearly 2 months after the NHS that they should take place can I turn to 99111 and ambulances across the UK there are 10 ambulance trusts in England a Welsh ambulance trust a Northern Ireland ambulance uh Social Service health and social care trust and there's a Scottish Ambulance Service all the ambulance trusts are responsible for provision of 9999 services in England and Wales they also responsible for 111 services in Scotland it's called nhs24 that covers the 111 service and in Northern Ireland although they don't usually operate 111 they did have that service during the pandemic the inquiry has statements from all these organizations in which a number of issues emerge first there was the obvious increase in calls to 111 and 999 and an inevitable impact on response times to calls and an ambulance arriving to take just one example the London Ambulance Service took 214,000 calls in March 2020 which was an increase on the previous month the average time to answer Rose from 4 seconds in January 2020 to 200 seconds that's 3 minutes 20 in March 2022 and on one day in March 20 sorry 2020 and on the 26th of March in 2020 there was a peak where it took nearly 10 minutes to answer a call the increase in demand on London Ambulance Service uh coincided with a spike in sickness of their staff with up to 20% of their staff off sick in March of that [Music] year there was an increase in demand for ambulances and so the module will consider how patients were prioritized to receive an ambulance and for escalation by way of conveyance to hospital and the impact this had on the paranics and indeed the call handlers the prioritization of calls received by 999 ambulance Co handers is not specific to the pandemic there are as you will hear two triage systems used across the UK which categorize calls by color or number depending on the nation and that dictates the severity of the patient's condition and therefore the target response time in which they should receive an ambulance response if one is sent at all those targets vary between each Nation but during the pandemic temporary changes were made to the pathway pathway for a patient who contact the service with confirmed or suspected covid this was known as protocol 36 and in short if protocol 36 applied the patient was triaged into a lower category and had to wait longer for an ambulance response Professor Snooks the inquiries expert looked at prehospital care and will take you through the details of the changes and the impact in more detail nhs111 in England and Wales and Northern Ireland and NHS 24 provide initial assessment and triage for those needing urgent but not emergency advice and Care unsurprisingly Demand on those Services significantly and rapidly increased and again Professor Snooks consider the efficacy of the initiatives and the impact on the safety and quality of care provided for those bringing that service she found a high number of calls went unanswered and considers that in summary although there was some Merit in the use of triage tools they were not always accurate in identifying calls that did and did not need immediate care there are issues related to the appropriateness or otherwise of IPC guidance and in particular which type of mask was recommended for people working in on ambulances there are also concerns about access to and the suitability of PP and can I pause there and ask my lady to think about some of the realities faced by paramedics attending a patient's home and then taking them to hospital paramedics did not necessarily know whether the patient or indeed anyone else in the address had covid-19 it was not possible to socially distance in the back of an ambulance the patient's condition might mean it was not appropriate for the patient to wear a mask there were often long delays outside hospitals while waiting for the patient to be admitted as the College of paramedics told the inquiry in January 2021 they experienced Handover delays at hospitals of sometimes between 10 and 12 hours sometimes more and when you think about that time of year coupled with temperatures of minus 2° that was not an environment where a door for ventilation could be opened without compromising the environment for the patient there were the additional burdens caused by the need to clean and DEC uh decontaminate the vehicles and the College of paramedics and indeed a number of ambulance trust members reported that the Disposable aprons they were provided as PPE were completely impractical and that once outside any spillages or pathogens that might be on them were blown into the paramedics faced by gust of wind I touched there on the issue of Handover delays and your ladyship will hear from Katherine Henderson the president of the Royal College of emergency medicine who speaks about the impact of hand over delays on the emergency departments she notes the harmful effects on patient care that are caused by delays in the emergency department in assessing treating and then deciding to admit patients and that brings me on in the patient Journey to the hospital and it hardly needs saying that for some people Co took a devastating toll on their physical health attacking as it did vital organs the heart the lungs the kidneys such that there was a significant increase in the need for more intensive care beds and staff now you will hear about the attempts to increase intensive care capacity there is no doubt that it did increase but you will nonetheless need to consider whether there was still an inability to care for some patients in an ICU setting with the amount and type of care that they needed two experts Professor Charlotte Summers and Dr ganes the ringum have provided an expert report and the headlines from their reporter as follows the UK entered the pandemic with less ICU capacity by which I mean fewer staffed equipped I beds than other developed countries and Health Care Systems figures provided by the Intensive Care Society the UK indicate the UK entered the pandemic with just 7.3 Critical Care beds per 100,000 by contrast Germany had 28.2 beds per 100,000 and the Czech Republic had 43.2 Critical Care beds per 100,000 the experts will tell you patients were looked after in ways that were stretched and diluted compared to usual Critical Care sometimes in makeshift icus sometimes far from home for much of the time with no or limited access to their families think about the impact on ICU staff caring for the most seriously ill patients results of surveys indicate that many staff would meet the criteria for being diagnosed with a mental health disorder including post-traumatic stress disorder an indication of the strain that ICU was under can be seen through the lens of what is called interhospital Critical Care transfers now they Rose dramatically during the pandemic and that was not because ICU patients were being transferred to perhaps more Specialist Care or being moved nearer to home but as you will hear from the experts simply because there was not enough capacity they will tell you that the transfers are regarded as the last result and then if we look please though at um this graph on screen this is the mean daily interhospital transfers between critical care units across the UK and you have set out there the position as it was in the runup in the two years in the runup to the pandemic the dotted line roughly representing when the pandemic started and you can see there the rise particularly for example in early 2021 where the number of people being transferred out to a bed elsewhere Rose dramatically I just say one thing about uh the graph it is one of a suite of graphs prepared for the inquiry thanks to the Joint efforts of two organizations nnar and sag nnar is the Intensive Care National Audit and Research Center it collects data from intensive care units and high dependency units across England Wales and Northern Ireland and sag is the Scottish Intensive Care Society audit Group performing a similar role in Scotland at the inquiries request n and sag work together to produce a combined report of comparable ICU statistics which will be looked at and we are extremely grateful to both organizations for their considerable assistance during the pandemic there was great concern amongst the medical profession that Frontline doctors would be called upon to make ethically and legally challenging decisions about which patients should be escalated to Critical Care in the event there was no no more critical care capacity you'll hear that for a brief period of time the Department of Health convened a working group to consider and develop a clinical prioritization tool to be used in the event that saturation of critical care resources was reached one of the experts Dr singam was a member of that working group and he will explain its work and the tool itself in more detail in fact the tool was stopped uh very shortly after it was asked to be uh worked on because it was considered that Critical Care Resources would not in fact be so stretched that the tool was needed now irrespective of whether that assessment of Critical Care Resource was correct there are parts of the profession that felt a drift in the absence of any national guidance about how to prioritize patients in need of critical care to many the idea that the UK even needs to consider drafting such a tool will be unpalatable but as for example the British medical ass Association point out had workable guidance been available then in the bma's view this would have gone a considerable way to addressing doctor's concerns about personal or legal liability and would have helped manage moral distress moral distress occurs when you believe you know the ethically correct action to take but you're constrained from taking it it would have meant had there been such a tool that all healthc Care Professionals would have been following the same guidance and it is clear that in the absence of national decision-making tool some hospitals including for example one of the spotlights develop their own policies for level of care decisions where there were limited resources and my lady I referred to diluted care uh a moment ago and one aspect of diluted care is reduced Staffing ratios intensive care units are overseen by dedicated teams ordinarily icus have one nurse with specialist critical care training per patient during the pandemic in some places the ratios were stretched to one critical care nurse to four or even six patients with some additional support being provided by nurses and support workers who did not have Critical Care skills the chief nursing offices in the UK and other witnesses will provide evidence about the impact of those changes on the nursing profession and the impact of the pressures on ICU on patient care and outcomes whilst that may be difficult to ascertain and quantify there is evidence that suggests that the pandemic resulted in a rationing of care and or poor outcomes can I pick two examples You may wish to consider what nnar call ICU capacity strain that is a mismatch between supply and demand with availability of beds staff and or other resources and the need to admit and provide care for commit critically ill patients the demand pre pandemic nnar reported that higher strain was associated with higher Hospital mortality and so nnar sought to determine whether patients admitted to an ICU during times of strain uh experienced a higher risk of death the short answer is that they did the greater the mismatch between the supply and the demand the more likely it was that a patient who was admitted to intensive care would die as part of its work the inquiry commissioned a research company to conduct a survey of Health Care Professionals included GPS A&E staff General Hospital WS doctors and it was asking those healthcare workers about the decisions about escalation of care in waves 1 and two now I stress it was not intended to be a representative survey nor could it be but it was merely to hear directly from a large number of Frontline staff about the challenges they faced uh when dealing with escalation decisions and can I ask please that we call up the survey can I invite your lhip to publish the entire survey later today but if we go please to page three in the survey this is just from the executive summary but it sets out there that of the 1683 healthc Care Professionals from the mix of roles that were spoken to over half of those healthc Care Professionals reported some patients could not be escalated to the next level of care due to lack of resources during either wave and if you look A&E doctors and paramedics were more likely to have been unable to escalate care due to a lack of resources the primary reasons were lack of available beds lack of staff and finally in the bottom box there 4 fths 81% of healthc Care Professionals agreed that more patients were able to be escalated during the pandemic compared to before over 2third agreed that patients who were unable to be escalated were more severely ill that resonates you may think my lady ship with a paramedic on the video this morning who spoke about the difficult decisions that he had to make taking those pieces of evidence as a whole you may think there was a picture being painted not only of a healthc care system creaking at the seams but a sense of the scale of the hugely difficult decisions being repeat L made by healthcare workers which affected who was treated for treat escalated for treatment and who was [Music] not let me deal briefly please if I may with those efforts to increase Hospital capacity there were nearly 900,000 admissions of covid patients to hospital across the UK measures taken to increase capacity included suspending elective care that's planned surgery a decision that was taken in each of the four nations just before the UK went into lockdown it's an undoubted indirect harm you may think there was the discharge decisions of those medically fit there was the rearranging the layout of hospitals to increase the number of beds there was the building of The Nightingales and field hospitals increasing to Staffing capacity by redeploying others to work in acute and critical Wards by introducing the temporary register for returning healthcare workers by using traine doctors student nurses traine paramedics to help bolster the Staffing capacity and there was the use of private hospitals across the Health Care System those arrangements are not new but during the pandemic how private hospitals were used varied from Nation to Nation those measures will be examined in more detail throughout the hearing let me just say something about nighting girls please if I may and can I call up on screen please page 19 of 47 4319 during the pandemic there were the Nightingale hospitals in England and Northern Ireland the Louisa Jordan as it was known in Scotland and in Wales the use of planned and actual field hospitals often used as step down facilities they were all set up to provide extra capacity as modeling suggested that demand for hospital beds might be exceeded I'm lady I'm not going to take you through what can be seen on the map there are one in uh Scotland two hospitals in Northern Ireland a number of planned and actual hospitals in Wales and seven in England and we have uh obtained evidence from all of those who can speak to why they were set up how they were used it was not all that were used for covid patients they were not all Critical Care capacity they were used in a variety of ways to carry on elective surgery use as vaccination centers in due course and the evidence that we will consider look at that Staffing capacity is clearly a matter of concern there were high vacancy rates across all sectors of the UK going into the pandemic nursing levels were low and nursing vacancy rates were high and clearly covid caused additional Staffing pressures for example in England in April 2020 figures provided by the BMA suggests that 30% of recorded NHS staff abanes were covid related in Scotland there was absences that were highest in April and June 2020 in Wales absences peaked in April 2020 and in Northern Ireland absence due to covid-19 was actually highest in January and March 2022 if one stands back it appears that the UK entered the pandemic with not enough staff was then compounded by staff absence through illness staff being absence through shielding staff lost because they had long covid and that's before one even considers the long-term impact on the morale and wellbeing of healthcare workers who were simply burnt out it is Little Wonder therefore as you stated in the module one report the inquiry also heard that there were severe staff shortages that a significant amount of the hospital infrastructure in England was not fit purpose you said this my lady this combination of factors had a directly negative impact on infection control measures and on the ability of the NHS and the care sector to Surge up capacity during a pandemic the Health and Social care services in Wales and Scotland confronted similar challenges to England my lady may I pause there and invite you to consider taking an early lunch I have a few matters I would like to address afterwards but if your lhip is content and indeed the stenographer is I'm happy to carry on for another few minutes I'm in your ladyship's hand um perhaps carry on just for a few more minutes [Music] certainly can I turn then to matters relating to death end of life and DNA cprs this is an undoubtedly distressing and painful topic when considering the numbers of people who died the first covid death in England was on the 5th of March it was a little bit later in Scotland on the 13th 3 days later in w Wales and 2 days after that in Northern Ireland you know at the outset I said there were 186,50 eight deaths involving covid-19 can I just look briefly please at page 20 of uh document thank you and can I ask your lady ship to look at the second column that refers to age standardized mortality rates per 100,000 it'll be appreciated that England has by far the largest population in the UK and so as you would expect it has a higher number of accorded deaths but the age standardized mortality rates allows comparisons to be made across the different population sizes different age distributions and you will see there that Scotland towards the bottom of the table in fact had the lowest rate of deaths per 100,000 at 1249 England has 145 Wales was slightly less than that at 144 and indeed Northern Ireland slightly less at 130 as is often the case when looking at statistics there needs to be a degree of caution as there are inevitably caveats and qualifications there were differences in the way that the Department of Health recorded deaths it was initially there had to be a positive test that was changed in due course again in August 2020 it was changed and deaths were counted as covid deaths of the patient died within 60 days of testing positive the availability of testing will also have an effect on how covid was recorded on a death certificate and of course there was limited testing capacity at the start of the pandemic which may mean that some patients died who may have had covid but were not tested and therefore not recorded as a covid death whether by any of the health authorities or statistical agencies ascertaining how many healthc care workers died of covid-19 and of that number those who caught the infection at work is not straightforward due to com repeating estimates and incomplete information figures from the statistics authorities across the UK indicate there have been 904 deaths involving covid-19 of health care workers now that figure only includes those between age between 20 and 64 and covers slightly varying time periods contrast that with data provided by NHS England who as at the 3rd of July 2023 had recorded 559 NHS staff as having died of covid-19 it will immediately be seen that the on has a higher count um than the figures provided by nhse and that is a matter of concern to some of the core participant groups in Scotland the health boards reported 97 staff to have died the Welsh government does not hold or publish official or verified data on the number of NHS staff who died and in Northern Ireland the Department of Health asked the trust to provide the daily number of deaths of Health and Social care workers but the department has told the inquiry does not hold any collated data thank you I'm told I misread and I said 97 Scottish staff died it's 27 forgive me thank you we have obtained evidence about the deaths of healthcare workers from the 22 spotlights six of whom reported no deaths some of those numbers vary because sometimes they've included the data from hospitals or trusts not always separating each and there are regulations which may be a good point to deal with just before lunch and then at least some other matters to just after there are regulations in place that may be a way of ascertaining the number of healthcare workers death they are called The Riddle regulations the reporting of injuries diseases and dangerous occurrence regulations 2013 riddle requires uh in this context employers to report specified workplace incidents to the health and safety executive in the context of healthcare workers in a health care setting the hsse considers that those reportable incidents includes cases of disease or deaths arising from covid only when the employee has been infected with the virus through deliberately working with it such as in a laboratory or being incidentally exposed to the virus incidental exposure can occur within the healthc care sitting where people have known to have covid known as occupational exposure now evidence from the hsse notes that riddall was drafted to capture single oneof unexpected events and was not intended to be used in a pandemic involving thousands of instances of infection where in employer may be required to make a judgment as to whether the worker caught it at work as a result of workplace exposure or from The Wider Community my lady will hear from a witness from the hsse who will go into this in more detail but the hsse itself uh looked at the data which was collected from the 10th of April 2020 riddle reporting indicates there were 12,330 nonfatal occupational disease reports and 170 fatal reports between their reporting in April 2020 and March 2022 the HSC unsurprisingly have noted there appeared to be both Under reporting and over reporting of covid-19 by employers and healthc Care settings now on any view the Fatal reports are lower than one might have expected given the on and indeed the NHS England figures that I outlined relating to healthcare worker deaths and you will hear from the uh Kevin Rowan the head of organization and services at the THC which sets out their concerns about the Under reporting of covid-19 that's a topic likely to be touched on by other witnesses as well thank you very much M car we'll take a the lunch and break now I shall return at 10: to 2 all rise