UK Covid Inquiry shortcomings makes case for Welsh Inquiry compelling, says bereaved group

Martin Shipton

A group representing families who lost loved ones during the pandemic has called on a Senedd committee to recommend the establishment of a dedicated Covid-19 inquiry for Wales.

In a written submission to the Public Accounts and Public Administration Committee, Covid Bereaved Families For Justice Cymru (CBFJC) argues that the UK Covid Inquiry hasn’t examined the handling of the pandemic by the Welsh Government in sufficient depth.

Referring to nosocomial (hospital acquired) deaths in hospitals and care homes, the group states: “This is an incredibly important and emotive issue for many CBFJC members. Many predominantly elderly and vulnerable family members were admitted to hospitals in Wales for essential medical treatment and due to poor infection prevention and control (IPC) and PPE they became infected with Covid-19 and died.

“Common themes include families seeking assurances that their family member would not be placed in a bed near to Covid-19 infected patients, only to find out later that such assurances were not kept and despite their vulnerabilities they had been accommodated on wards with Covid-19 infected patients and unnecessarily exposed to the virus. It is circumstances such as these that drive the group’s concerns at the wholly inadequate IPC, PPE, ventilation, and testing regimes in hospitals, particularly given the airborne nature of the virus (the risk of which was known from the outset of the pandemic but not acted upon).

“CBFJ Cymru campaigned extensively for an investigation into Covid-19 nosocomial infections in Wales, and we met with the former First Minister, Mark Drakeford in October and December 2021, and again in January 2022, around which time the National Nosocomial Covid-19 Programme was announced.”

The group says that promises made in a press release issued on behalf of then Health Minister, now First Minister, Eluned Morgan in January 2022 were not kept.

The group’s submission states: [The Welsh Government made the following claims:

* that Wales was the only UK nation to record every incident of a hospital acquired infection;

* that all incidents of Covid-19 caught in hospitals will be investigated;

* that the £4.5m investment (per year over two years, totalling £9m) was for the purpose of supporting Health Boards and the NHS Delivery Unit to take forward an important and complex programme of investigation work into cases of hospital-acquired Covid-19; and

* that the NHS in Wales did all it could to keep the virus out of hospitals.

“When the National Nosocomial Covid-19 Programme was announced, group members were overjoyed and some of us cried with relief. Deputy Chief Medical Officer Chris Jones told us in a meeting that he had advised the Welsh Government that all deaths from nosocomial infection needed to be recorded as Patient Safety Incidents, hence the need for individual responses.

“However, we quickly became frustrated at the lack of progress with the Programme, and our fears about the adequacy of the investigations have unfortunately been realised. Only those who had made a complaint got a report, and an investigation into every incident of a hospital-acquired infection has not taken place despite the ‘pledge’ to do so by the then Health Minister and now First Minister, Eluned Morgan.

“Many reports provided to bereaved families contradict the death certificate and/or medical notes, and fail to identify failures. Not a single cluster outbreak was investigated, despite there being hundreds.

“An End of Programme Learning Report was published in August 2024, and prior to this an Interim Learning Report was produced in March 2023. Despite the size of the budget and the importance of the undertaking, the Interim Learning Report (which at the date of publication in March 2023 purported to have assessed over 5,000 cases) is just 16 pages and the End of Programme Learning report (which claims to have assessed some 18,360 cases) is just 24 pages.

“At page 4 of the End of Programme report it is stated that 18,360 cases that met the definition of a patient safety incident were investigated. However, CBFJ Cymru is doubtful of these claims, and we know from our membership that not all cases of death resulting from a Covid-19 nosocomial hospital acquired infection were investigated.

“The inadequacies of the report and the absence of specific findings have shocked bereaved families in Wales, who had understood that the Programme would include a comprehensive investigation of the circumstances of individual deaths following a nosocomial Covid-19 infection, rather than what we now suspect to be a box ticking exercise to satisfy the legal obligation to record Patient Safety Incidents.

“ … Further, while we understand that the individual reports provided to bereaved families cannot be disclosed having regard to confidentiality and data protection issues, there has been no meaningful analysis of these individual reports to identify thematic issues (while maintaining confidentiality) so that health services in Wales can be improved in accordance with the publicly stated intention to ‘learn why it happened so we can do everything in our powers to prevent it from happening again’.

“For example: to determine how many hospital patients were infected and died following cluster outbreaks; how many patients were infected and died following exposure to Covid-19 positive patients on their ward; the dates on which routine testing of patients and staff were introduced at all hospitals across Wales (twice weekly testing of staff in Wales was required from mid December 2020 but was not implemented by most hospitals in Wales until much later) and the impact of these failures of compliance on infection levels; and how many of the 18,360 cases of hospital acquired Covid-19 were the subject of an investigation report .

“The abject failure of the Programme is a glaring example of the failure of the Welsh Government to live up to their lofty rhetoric and promises, and it has prolonged our bereavement.

“We seek a Welsh public inquiry that will be able to access the investigation records of the National Nosocomial Covid-19 Programme, and shine a light on the extent of the failures to protect patients in Welsh hospitals. This is all the more important as no investigation through inquests has taken place to date, even in the circumstances of cluster outbreaks and deaths.”

Care home investigation

The submission goes on to make the point that the group was promised a care home investigation by Mark Drakeford during a face to face meeting with him at Welsh Government buildings on August 30 2022. He agreed that ‘just because it is difficult, it doesn’t mean it shouldn’t happen’. To date nothing has been delivered. We sent 18 chaser emails following the meeting, and all that was done was that the Welsh Government issued a form to advise care homes on how to deal with complaints.”

The group states that testing decisions and policy in Wales were “slow, dysfunctional, reactionary, and false statements were made to justify not implementing testing sooner.

“These failings are most clearly demonstrated in connection with care homes, with hospital patients discharged into care homes with Covid-19 without testing – thus seeding the deadly infection into the most vulnerable communities in Wales – and in connection with the failure to implement asymptomatic testing in care homes until it was too late,” says the group.

“ In both cases the reason for the failure to test was because there was no testing capacity in Wales (another glaring failure of resilience and preparedness). However, the Welsh Government blamed: “the science” because otherwise they would have had to admit their failure.

“This is a complicated issue, but the evidence is now publicly available. In short, the former First Minister, Mark Drakeford, made false statements in the Senedd when claiming on April 29 and May 6 2020 that there was no clinical value in routine asymptomatic testing in care homes. Whereas it was well known from mid-April that Covid-19 was transmitting at high levels asymptomatically and that asymptomatic testing was required to protect care home residents.

“The absurd views expressed by Mr Drakeford caused serious concerns within the scientific community in Wales, and in response Peter Halligan, the Chief Scientific Adviser for Wales, caused an email to be sent to Dr Rob Orford and Fliss Bennee on April 30 2020 upon hearing them, which reads: ‘Dear Rob, Fliss, Peter Halligan is keen to understand the rationale, evidence and advice behind the First Minister’s comments last night on the telly that there is no value to testing for Cov-19 in care homes. Please can you enlighten us.’

“Mr Drakeford was not alone in making such false statements. During a question-and-answer session on June 23 2020 (publicly available on video1) Mr Gething was asked the question: ‘The Welsh Government has said that the scientific advice was it would not be a good use of testing capacity to test asymptomatic patients until the end of April. If it was the case that there was a lack of testing capacity that caused this advice, was it the fact that there weren’t enough tests that meant you made the decision to not test people who were going into care homes until the end of April?’ To which Mr Gething responded: ‘No…we based our decisions on advice and evidence’.

“The journalist continued: ‘Surely if you’d had enough tests to have been able to test everyone, you should have been testing everybody who went from a hospital into a care home. And it was the fact that you didn’t have enough tests that made that advice the advice that it was at the time’. Which elicited a similar response from Mr Gething: ‘No…you’re just wrong…if we had treble the amount of testing capacity…then that was still the evidence and advice that we had…we didn’t get advice that said, ‘you really should do this but you can’t because you don’t have testing capacity’.

“What so incenses the members of CBFJC is the continued false claims of the Welsh Government that their policy was based on science and not a lack of capacity to learn from past mistakes. If the truth is acknowledged, it will be clear that better preparation could have avoided the severity of the impacts of the pandemic, but unless this is done, we are destined to repeat the same mistakes in Wales.

“The tragedy of the approach of Welsh Government is that it puts the reputations of a small number of Welsh politicians above the wider public Interest. CBFJ Cymru considers that the misrepresentation of scientific issues in this way is a matter of very grave concern and is a key aspect of core decision making in Wales that requires careful scrutiny.”

Anger

The submission concludes: “The anger felt by bereaved families in Wales is not just rooted in the loss of their loved ones, but in the Welsh Government’s refusal to accept their mistakes, and in the ineffectiveness of the Welsh organisations tasked to protect the people of Wales, particularly the elderly and vulnerable.

“There needs to be urgent Welsh specific scrutiny in Wales so that there can be learning and improvement.

“The Welsh Government also needs to take responsibility for what went wrong (which it has yet to do) so that the many thousands of bereaved families can begin to move on.”

The submission will be discussed by members of the committee on Wednesday December 10.