Strongest criticism yet of Welsh Government’s handling of the Covid crisis

Martin Shipton

The Welsh Government’s management of the pandemic has received its most damning denunciation yet at the UK Covid Inquiry.

Barrister Nia Gowman, representing the campaign group Covid-19 Bereaved Families for Justice Cymru, clinically demolished the handling of the crisis by senior politicians and top health officials, accusing them of endangering the lives of patients and healthcare workers through bad decision making and incompetence.

Failure

Ms Gowman told the Inquiry: “The Cymru group is disappointed that there has yet again been a failure by the Welsh Government to account for what went wrong in Wales. Whether this be the failure to complete comprehensive lookback exercises, a failure to provide key documents to the Inquiry, or the failure of Welsh witnesses to meaningfully reflect or show contrition, there has been a systemic failure in accountability.

“The Welsh Government and NHS Wales’ woeful approach to learning lessons is best demonstrated by its failure to conduct a national lessons learned review. In stark contrast to the approach of other UK nations, the lookback exercises in Wales have been piecemeal; a patchwork of reviews carried out by different bodies without cohesion or focus; all of them superficial, none of them getting to the heart of what went wrong.

“Staggeringly, some Welsh witnesses have staunchly stood by the lessons learned work done in Wales. Others, such as [First Minister and former Health Minister] Baroness Morgan, suggest that the Welsh Government is simply waiting for the Inquiry to report first. While the Inquiry is certainly an important process, it is deeply concerning that the Welsh Government wouldn’t want to understand for itself what went wrong in Wales, wouldn’t want to armour up as soon possible for the next pandemic.

“The lax approach to learning lessons in Wales is best illustrated by the, at best, cursory exploration of nosocomial infection [hospital-acquired infection by patients being treated for something else].

“Wales established a National Nosocomial Covid-19 Programme, purportedly to investigate individual patient safety incidents of nosocomial Covid-19. The Welsh Government, through Judith Paget [Director General for Health and Social Services and the NHS Wales Chief Executive] gave no meaningful assurance that all cases of nosocomial deaths had in fact been recorded as patient safety incidents. There has been no national oversight.

“Further, Eluned Morgan, Judith Paget and her predecessor Andrew Goodall, were somewhat nonchalant as to the absence of a national investigation into cluster outbreaks in Wales. The failure at national level to look at the root causes of clusters outbreaks, represents a clear missed opportunity to identify patterns and potentially life-saving interventions.”

Inadequacy

Ms Gowman added: “The Cymru group considers that the inadequacy of the Welsh Government’s approach to lessons learned is compounded by its continued failure to open itself up to detailed scrutiny by this Inquiry. The Cymru group has long highlighted concerns that the Welsh Government has cherry picked the disclosure it sends to the Inquiry. This concern has followed through to Module 3. When [former First Minister and Health Minister] Vaughan Gething gave evidence last week, he told the Inquiry that his discussions with Chief Executives of Health Boards, the CNO [Chief Nursing Officer], and CMO [Chief Medical Officer] were minuted, but for reasons that are not clear to the Cymru group, these minutes have not been disclosed to the Inquiry. This is unacceptable and a complete derogation of transparency.

“The Cymru group considers that the oral evidence given to this Module can be characterised by a reluctance in many quarters of the Welsh Government and NHS Wales to give open accounts of what went wrong and why, and to accept that mistakes were made – which they undoubtedly were.

“A feature of this Inquiry has been to highlight that the system in Wales is plagued by blurred lines of accountability which in turn allows for finger pointing instead of answered questions and pro-active action. “Notwithstanding that the Welsh Government accepted within its opening statement to the Inquiry that responsibility ultimately rested with them, Welsh Government witnesses have repeatedly deflected responsibility and criticism by deferring to the operational arrangements of the Health Boards who, in turn, appear to have been looking to a rudderless Welsh Government for clear guidance and national oversight which did not always materialise.

“While the Welsh Government and NHS Wales congratulate themselves for things that were done well, the Cymru group says this is because they have not looked closely enough at what went wrong and there remains a wide gulf within which nobody is willing to take responsibility in Wales.

“Within its oral closing, the Welsh Government has teased a potential acceptance that not all decisions taken in Wales worked, noting vaguely that issues have emerged or crystallised in respect of NHS capacity; critical care capacity; availability and distribution of PPE; field hospitals; nosocomial transmissions and services available to treat Long Covid. Frustratingly, the Welsh Government elaborated no further. The Cymru group looks forward with intrigue and scepticism to receiving the detail within the Welsh Government’s Written Closing.

“In terms of recommendations, the Welsh Government suggests that ‘less is more’. With respect, given its poor track record for reflection and learning lessons to date, the Cymru group considers that for the Welsh Government ‘less would in fact just mean less’ and there is clearly a need for a suite of substantive recommendations which go beyond the Welsh Government’s current proposals if there is to be meaningful change in Wales.”

Issues of concern

Ms Gowman went on to refer to some of the principal issues of concern for the Cymru Bereaved group.

She said: “First, the Infection Prevention and Control Guidance simply did not address the risk posed by Covid-19; an airborne virus. The Guidance was grounded in the flawed scientific view held by those such as Dr [Lisa] Ritchie [National Deputy Director of Infection Prevention and Control at NHS England] that Covid was transmitted via droplet and contact.

“The Guidance demonstrated an erroneous and quite frankly dangerous lack of appreciation of the likelihood of aerosol transmission as well as the potential for asymptomatic transmission. As a result, insufficient consideration was given to appropriate risk mitigation measures.

“In particular, there was insufficient consideration given to ventilation beyond the opening of windows. What was needed was mechanical ventilation, UV lights, and thought given to portable HEPA filters, which were low cost and portable.

“Baroness Morgan flippantly joked that a HEPA filter had been her most disappointing Christmas present. On the contrary, for the Cymru group, HEPA filters are a valuable piece of equipment which could have reduced nosocomial transmission rates and potentially saved lives.

“The IPC Cell, though not a decision-making body, became a de facto decision-making body because their recommendations were not challenged. As a consequence, the fundamentally flawed IPC Guidance was simply adopted by all, including decision-makers in Wales without question.

“The Cymru group finds this particularly concerning given that Sir Frank Atherton [the Chief Medical Officer for Wales] and the Welsh Nosocomial Transmission Group took a completely different view on the science regarding transmission. For example, in evidence, Sir Frank Atherton suggested that it was understood from a fairly early stage that there was a continuum of droplets to small particles to tiny particles. Despite this, not once did Frank Atherton or the Nosocomial Transmission Group challenge the IPC Guidance or describe it as inadequate.

“Further, Public Health Wales were represented on the IPC Cell and indeed Dr Eleri Davies of Public Health Wales was the Chair from March 31 2021. We have not heard evidence from Dr Eleri Davies, nor was a rule 9 request [asking for a statement or potentially relevant documents] sent to her.

“However, we know that no significant changes were made to the IPC Guidance to address aerosol transmission following her appointment as Chair. This suggests that either Dr Davies agreed with Dr Ritchie’s view that the mode of transmission, contrary to the views of others in Wales, or she understood the part played by aerosol transmission but somehow concluded that the Guidance was sufficient despite the absence of sufficient measures to address the risk.

“Was the lack of challenge indicative of the cultural problem in scientific advice groups in the UK whereby advice becomes mired in groupthink? Or was it because the wrong people were making the decisions about IPC? Laura Imrie [of the Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland] suggested that she did not think that it was the role of IPC guidance to look at ventilation as no member of the group felt that they were qualified to comment on ventilation. This in itself is quite remarkable.

“A further key issue with the guidance was the way in which changes were and conversely were not made to it. There were many iterations of the IPC guidance causing mass confusion, mistrust and likely contributed to non-compliance by healthcare workers. Many of the changes were minor and likely of little consequence. At the same time, changes which should have been made to reflect the evolving scientific knowledge surrounding aerosol and asymptomatic transmission, were not made in a timely manner or at all.

“Further, there was a lack of openness and honesty about the way in which the changes were communicated, particularly in relation to decisions to downgrade the requirement for all healthcare workers treating Covid-19 patients or suspected Covid-19 patients to wear FFP3 masks to FRSMs [a lower grade of mask]. Professor [Dinah] Gould stressed the importance of transparent communication in this regard.

“Dr Barry Jones [Chair of the Covid-19 Airborne Transmission Alliance] added that healthcare workers would have understood if those in charge had said ‘Look, it’s tough, there’s a world shortage of PPE’. Instead, there was a continued insistence by Dr Richie, including up and until she gave evidence to this inquiry, that Covid-19 was predominantly spread by droplet and contact transmission and that the Guidance was fine.

“As a consequence there is evidence that healthcare workers didn’t accept the Guidance intellectually because it was intellectually dishonest as to how decisions were arrived at. This was made particularly stark in the evidence of Ms [Tracy] Nicholls [Chief Executive, College of Paramedics] who said: ‘It felt like a big echo chamber and what our members were telling us in huge volume is that it didn’t feel right on the ground’.

“On the issue of FFP3 masks, the Cymru group submits that the IPC Cell became too tied to the need for a high level of evidence to prove that FFP3 masks were more effective. What was needed was a common sense approach. When people’s lives are at risk, it is better to be safe than sorry. The extent to which the availability (or otherwise) of FFP3 masks was driving policy decisions remains a real concern to the Cymru group.”

IPC Guidance

Ms Gorman then moved on to concerns surrounding the implementation of IPC Guidance, stating: “First, the Welsh Government had long been aware that the NHS estate in Wales was a barrier in the implementation of effective IPC measures more generally. These difficulties were brought into sharp focus when the pandemic struck. Notwithstanding this, little was done by NHS Wales to mitigate the concerns relating to the NHS estate to ensure effective implementation of the IPC Guidance, and little was done by the Welsh Government to ensure national oversight on the issue. This represented a missed opportunity.

“Second, many of our members witnessed healthcare workers failing to adhere to IPC guidance, most notably failing to wear the correct PPE appropriately or at all. A concerning discrepancy has emerged between healthcare workers and operational leads as to the availability of PPE in the early stages of the pandemic. Policy and operational leads swear blind that there were no supply issues on the one hand and healthcare workers report that they felt unsafe in work due to non-availability of PPE on the other.

“Where PPE was available, what was being done to mitigate compliance and complacency fatigue? What was being done to ensure that staff wore PPE correctly, to combat the chin wearers? Ultimately, non-compliance with Guidance was not acceptable and placed vulnerable patients at avoidable risk and more should have been to prevent it.

“Third, the Cymru group is concerned by the lack of proper segregation of patients in Welsh hospitals. Though there was supposed to be a Traffic Light system in place, those we represent witnessed non-Covid patients placed on Covid wards, Covid patients placed on non-Covid wards, people in corridors, an inconsistent utilisation of those categories.

“Members intervened to ask for their loved ones not to be placed on a Covid ward, including one family member who was immunosuppressed. They were still placed on a Covid ward, where they contracted Covid and died. Suspected Covid patients were also kept on wards until they tested positive. A total failure of common sense.

“A Welsh Government report disclosed to the Inquiry states that ‘Nosocomial transmission of Covid-19 is unfortunately widespread in health boards/ Velindre Trust across Wales. Hospital transmission of Covid-19 has been a major safety and quality concern for all NHS organisations since the start of the pandemic. Actions to address this need to take account of the multiple factors that influence hospital transmission and the particular nature of the virus itself. In the week ending 14/2/21, a Wales total of 211 hospital onset cases (definite or probable) were reported. This represents 8% of all confirmed Covid-19 cases and 53% of total Covid cases within Welsh hospitals.’

“What is particularly distressing for those we represent is that nosocomial transmission was worse in the second waves, despite there being a period in the Summer of 2020 where lessons should have been learned from the first wave. Instead, no lessons were learned. The rates of nosocomial transmission in hospitals increased and more people died as a result.

“The evidence betrayed a belief that nosocomial transmission was an inevitability, and underlined the concern of the Cymru group that the Guidance was merely a sticking plaster covering a festering wound.”

Testing

Turning to concerns about testing, Ms Gorman said: “We have heard from many witnesses, including Dame Ruth May [former Chief Nursing Officer for England], that testing played a vital role in reducing nosocomial transmission.

“Despite this, Wales was later than England in introducing PCR testing of asymptomatic healthcare workers and were also later in introducing routine testing of healthcare staff when Lateral Flow Tests became available. On the latter, it wasn’t until December 2020 that the Welsh Government’s policy requiring routine testing of all healthcare workers was announced.

“The evidence before this Inquiry is that Sir Frank Atherton knew about the importance of regular testing as early as May 4 2020. In particular, there is a note made during the call of the senior clinicians group, of which Sir Frank was a member stating: ‘Need to be really clear why we will not test all HCWs [healthcare workers]’.

“When asked about the Welsh Government’s delay in introducing testing, we have been given different excuses. Sir Frank Atherton took little responsibility and instead blamed the UK Government, stating that policy leads at UK level didn’t communicate rapidly with their counterparts in Wales. A different excuse was suggested by Andrew Goodall and Vaughan Gething grounded in the absence of LAMP technology [a simple, fast, and affordable method that can be used to detect viral pathogens] in Wales, but this does not explain the delay in implementing regular testing with LFDs [Lateral Flow Devices] which were available to all four nations from the same date. The reason for the delay therefore remains unclear and is inexcusable.

“To compound the delays, despite the Welsh Government’s announcement in December 2020, the roll-out of routine testing of all healthcare workers in Wales did not in fact commence until January 2021 and was not implemented on the ground until as late as July 2021 in some cases.

“Again, there has been no clear explanation for this delay either. Senior witnesses such as Vaughan Gething did not appear to be aware of the delay in rolling out routine testing until this Inquiry, which begs the question as to why the Welsh Government wasn’t taking proactive steps to monitor the rollout of the testing programme, and ensuring that Welsh Government policy was being implemented.

“Wales was also later than other UK nations in introducing regular testing for patients. It was only in January 2021 that the Welsh Government first recommended testing of all patients on admission (with further testing of asymptomatic in-patients at day 5) and it was only in March 2021 that the Welsh Government recommended a regime of re-testing at five day intervals.

“A further area of concern for the Cymru group relates to escalation of care. The powerful impact evidence of [Cymru group member] Paul Jones, and the distress he and his wife Karen suffered when their daughter Lauren was not escalated until her oxygen levels became dangerously low will, no doubt, still be with the Inquiry.

“Key Welsh witnesses have been at pains to stress that critical care capacity was never breached in Wales and that decisions as to which patients should be prioritised for escalation were never required. However it is unlikely that this is correct.

“Andrew Goodall was questioned at length regarding the adequacy of Welsh data. Put bluntly, the data was completely deficient.

“The Inquiry heard important evidence from [expert witnesses] Professor [Charlotte] Summers and Dr [Ganesh] Suntharalingham who opined that variations in decision making and conscious or subconscious application of clinical thresholds are likely to have occurred and that ICU admission changed via local informal processes meaning those who might ordinarily be admitted to Intensive Care Units were not.

“Vaughan Gething accepted in his evidence that the Welsh Government’s assurances regarding not reaching critical care capacity did not necessarily mean that all patients in Wales were escalated at the right time and received the treatment they needed.

“Indeed, accounts given by the bereaved and those working on the frontline in Wales point toward healthcare workers feeling pressured to make decisions about escalation and access to critical care, patients being turned away from critical care who would otherwise have been admitted to critical care, dilution of nursing ratios and gatekeeping access to treatment.

“This evidence plays on the minds of those I represent, many of whom had loved ones who died outside of the intensive care unit or respiratory wards. The torturous thought of what might have happened if only their loved one had been ventilated sooner or at all, and the wondering of whether their loved ones would have been able to celebrate this Christmas with them, if only they’d had access to care they would otherwise have received in peace time.

“Rather than congratulate themselves for never breaching critical care capacity, the Cymru group asks the Welsh Government to look behind the data toward the material reality of what hospital looked like for those patients who desperately needed care. The data does not tell the whole story. It doesn’t show the conscious and subconscious decisions made by doctors, it doesn’t show the diluted nursing ratios, it doesn’t show whether there was sufficient capacity for ventilators, medication, equipment and consumables in the hospital where it was needed at the time it was needed.

“In a similar vein, the Cymru group continues to hold concerns regarding inappropriate DNACPRs [Do Not Attempt Cardiopulmonary Resuscitation] being placed on their loved ones without consultation with patients and family members. The evidence of [Covid Bereaved Cymru co-lead]Anna-Louise Marsh-Rees was particularly illuminating as she explained that on the one hand her father’s Treatment Escalation Plan suggested that he was for CPR whilst the DNACPR document suggested he was not. The lack of digitisation of DNACPRs and Treatment Escalation Plans in Wales renders wholescale audit virtually impossible and this itself is unacceptable and should be rectified.”

‘Quiet deaths’

Concluding, Ms Gorman said: “I close by drawing upon the words of Anna-Louise Marsh-Rees, who said in respect of the Cymru group:

‘most of our loved ones…were older. They led very silent, quiet deaths…it’s almost death by indifference … nobody communicated to them, nobody told them what was happening, they didn’t have communication with their loved ones. And I really do think we need to ponder on … that element of it. It’s those quiet silent deaths that are the real tragedy.’

“The Cymru group is grateful to the Inquiry for supporting its ongoing participation in the Inquiry and looks forward to developing its position on the evidence and advancing constructive and measurable recommendations across the range of issues within the written closing.”

Inquiry Chair Baroness Heather Hallett thanked Ms Gorman for her contribution, saying: “Thank you very much indeed. As persuasive as ever.”