Why did so many people die in care homes? That may be the most urgent question of the likely public inquiry into the UK’s Covid-19 response. The NHS wasn’t overwhelmed, but 16,000 residents of care and nursing homes have died so far, compared with fewer than 3,000 in Germany and none in Hong Kong. The health secretary, Matt Hancock, claims the government “threw a protective ring” around care homes. So, what went wrong? Controlling the infection In late January, as the Covid-19 death toll ticked up in Wuhan, China, care operators in Britain grew nervous. The Care Providers Association asked contacts at the Department of Health and Social Care (DHSC) if there was any specific action they needed to take. Word came back: there was nothing to advise. A week later, the industry group tried again. How should it isolate infected residents and restrict visits, and who would supply personal protective equipment (PPE)? Government guidance that finally came on 25 February bore a relaxed tone. Face masks “do not need to be worn by staff”, there was no block on visits and there was “no need to do anything differently in any care setting at present”. It said: “It remains very unlikely that people receiving care in a care home ... will become infected.” Over the following three months, care homes across the UK have been devastated by Covid-19. Forty per cent of homes have been hit in England, more in Scotland, and at least a dozen care workers are dead. The advice, officials stress now, was “related to what we knew at the time”. “We should have been focusing on care homes from the start,” said Prof Martin Green, chief executive of the industry association Care England. “What we saw … was a focus on the NHS and that meant that care homes often had their medical support from the NHS withdrawn.” There were warning signs that care homes would suffer. In early February, the government’s own Scientific Pandemic Influenza Group on Modelling reported that infections were doubling at least every five days in China. There was probably already sustained transmission in the UK and “severe cases are more common in older age groups”. But there was no rush, continued the message. On 3 March, England’s chief medical officer, Chris Whitty, defended a lack of specific measures to protect care homes, saying: “One of the things we are keen to avoid is doing things too early.” It was already too late for many. The following week, as the NHS pushed to discharge patients into care homes, came the first care home outbreaks in London, Nottingham, Stockport and Tameside. Green is angry. “In every crisis [the DHSC] go into overdrive about the NHS and forget social care. They should take it off their name,” he said. Thirty-three outbreaks in the first week of March turned into 793 by the end of the month. Data tracking the spread was not made public by Public Health England (PHE) until 29 April. Neither was the government stopping visits to care homes by family and friends, which “surprised” the former Conservative health secretary, Jeremy Hunt. PHE guidance on 13 March asked homes only to keep out unwell visitors and those with suspected Covid-19. This was right for the time, insists the DHSC, which says it “followed a science-led action plan”. When an outbreak hit Wren Hall nursing home in Nottinghamshire, Anita Astle, the manager tried to handle it using DHSC guidance to separate symptomatic residents “in a single room with a separate bathroom, where possible”. “We did that for 10 days and it was still spreading,” she said. “I decided I’m not doing this anymore. If you followed their advice, you could have someone in a bedroom with symptoms, someone next door without symptoms.” Dementia sufferers often like to walk around their homes, and as the homes don’t lock residents in, the virus spreads. Wren Hall created an isolation unit and a “red team” of dedicated care workers, but the virus killed 10 residents in three weeks. “If [the government] were an employee of mine,” Astle said. “I would have sacked them for gross negligence.” DHSC says it took the right steps at the right time, guided by the best scientific advice. In early April, Adelina Comas, a London School of Economics academic scouring international evidence, warned that the policy of only isolating symptomatic residents “will not be effective in preventing the spread of infection”. By then, Hong Kong had locked down homes and was quarantining infected cases in hospital, not in homes. Spain responded to care home deaths in late March by isolating “possible and probable” cases as well as symptomatic residents. Germany kept its care home outbreaks to a minimum by saying that no one was allowed into care homes from hospitals without a negative Covid-19 test, or having undergone quarantine in designated centres or repurposed hotels for at least 14 days. DHSC says it is “not advisable” to draw international comparisons and that since 2 April it urged the use of PPE with all patients, symptomatic or not. Hospital discharges To protect the NHS from the devastating situation that emerged in Italy – with the near collapse of hospitals – UK ministers ordered 15,000 hospital beds to be vacated by 27 March. Making beds available was part of the “national effort” and “will help to save thousands of lives” they told care homes. Guidelines said there was no need to test discharged patients because Covid-19 sufferers “can be safely cared for in a care home”. Whether Covid-19 sufferers could be safely treated in care homes lacking clinical expertise and medical equipment was arguable. More certain was that their presence put others at risk in residential homes designed for communal activity, not isolation. With staffing stretched by absences and a chronic lack of protective equipment, infections spiralled upwards. Some homes have now alleged that hospitals covered up infections of discharged patients. The Care Quality Commission is investigating claims that “a patient’s positive Covid-19 status was known to the hospital but not disclosed at the point of discharge” – a potential breach of the Health and Social Care Act. Another risk was Covid-19-negative patients being discharged into infected homes, and subsequently catching coronavirus. “At the peak of the outbreak we had admissions from hospital,” said a nurse at a residential home where eight people died. The same staff treated everyone so infection spread was inevitable, she said on condition of anonymity, adding that two of the discharged people died from Covid-19. “Imagine if that was your relative,” she said. “I don’t think people know what is happening.” It wasn’t until 16 April that the government announced NHS patients being discharged into care homes would be first tested for Covid-19 – by which time almost 1,000 homes in England had suffered outbreaks. The guidance still allows discharges pending test results. By the end of April, 6,500 care home residents in England were dead from Covid-19. Testing On 12 March, around the time the pandemic took off, the government decided to reduce testing for Covid-19 in the community. Care homes desperate to know more about infection felt they suddenly knew less. They were spotting puzzling symptoms like loss of appetite and sudden confusion, which differed from the standard advice to watch for coughs and a fever. Testing, though, was limited. After someone in a home tested positive, no more tests would be offered, managers reported. US research was already showing the importance of testing widely in care homes. Research into an outbreak near Seattle, in Washington state, found that only judging by symptoms may miss half of infected residents. It was highlighted by Comas, who by now was attracting national attention for her work. She also observed that South Korea and Singapore, which had successfully protected care homes, tested anyone who may have had contact with carriers, regardless of symptoms. Research published in April by Nicholas Grassly, a member of the government’s Scientific Pandemic Influenza Group on Modelling and a professor at Imperial College, also found weekly screening of healthcare workers, irrespective of symptoms, reduces their contribution to transmission by between a quarter and a third. Yet the current government policy, announced by Matt Hancock on 28 April, is to test care home staff and residents only once unless the person subsequently develops symptoms. Sam Monaghan, chief executive of MHA, the largest charitable provider of care homes, which has lost hundreds of residents to Covid-19, said the current policy was “outrageous in the face of the evidence that is now available”. “One single asymptomatic staff member or resident through no fault of their own can cost lives,” Monaghan said. Last week, MHA reported that tests of nearly 2,700 staff and residents found at least one asymptomatic carrier in every location tested. Sir David Behan, chief executive of the largest provider of care homes in the UK, HC-One, which has lost more than 900 residents, also said testing “would have reduced the transmission of the virus and would have reduced the death toll”. The early weeks of the new testing regime were mired in “a complete system failure”, care operators complained. “At one point we got the results after 24 hours, some we never get back and some we get back a week later,” said Astle, the manager at Wren Hall. “That’s not helpful when they come back positive. In that week they have been happily spreading the virus around.” “The testing arrangements remain chaotic,” said Vic Rayner, director of the National Care Forum last week. The DHSC said at the weekend that it has sent tests to at least 6,000 care homes, which means tests have not yet been dispatched to about 9,000 homes. All homes for looking after over-65s will be offered tests by “early June”, it said. The National Care Forum, which represents charitable providers, reckons at least 200,000 tests are needed daily to properly track infections, not the 30,000 promised by the DHSC. Staff and protective equipment “Colleagues have been asked to wear bags over their faces for lack of surgical masks,” one care worker told their trade union helpline in early April. “It’s getting to the point where I want to quit my job. I feel I’m endangering my own life.” As headlines screamed about shortages of masks, gowns and visors, the NHS became the top priority for PPE. Care homes were left scrambling for supplies. “The issue we hear most is: ‘I am desperate for masks. Has anyone got any gloves?’” said Nadra Ahmed, executive chair of the National Care Association in early April. “Once you run out, it is a question of being down to Marigolds and bin liners.” Care workers were engaged in similarly close-contact nursing as their NHS colleagues, but rarely had the most protective FFP3 masks. PPE deliveries from the national stockpile often consisted of a box of 300 masks. At Wren Hall, staff were using more than 400 per day. During its worst outbreak from 24 March to 13 April, when 10 residents died, the home had no FFP3 masks, no gowns and no visors, Astle said. Forty-eight members of staff contracted the virus. The home has been buying masks through a camping gear company with a contact in China. Infection rates have meant staff absences of up to 20% and, in at least a dozen cases, death. On 1 April, Carol Jamabo, 56, a care worker in Bury, became the first known to have died from the virus. Official data this month showed care workers have been dying from Covid-19 at twice the rate of their NHS colleagues. Absence rates have been high too – running between 10% and 20%. Sir David Behan said that on several occasions HC-One has come close to breaching its “critical staffing level”. “We had to use staff from other homes and we now know that’s a route of transmission,” he said. An unpublished PHE study, conducted at Easter and revealed by the Guardian, found temporary staff had spread the virus between London care homes. On 14 May, the government finally produced new guidelines stipulating that staff and agency workers should work in only one care home “wherever possible”. Conclusion Matt Hancock’s claim to have thrown “a protective ring around care homes” was rhetoric intended to calm a nation shocked by deaths among some of society’s most vulnerable. But a public inquiry is likely to hear claims that government policies lagged behind warnings from care operators and international evidence. It is sure to ask whether slowness to lock down the most vulnerable, to test them and protect their care workers with better PPE, cost lives. Care homes in the UK remain the engine of the epidemic – accounting for almost as many deaths as in hospitals. While homes in other countries like Hong Kong and Germany edge back to normality, the crisis continues in Britain. A spokesperson for DHSC stressed that officials have been dealing with an “unprecedented global outbreak, the worst pandemic for a hundred years”. “We have been working tirelessly with the care sector to reduce transmission and save lives, and have based all our decisions on the latest scientific and clinical advice – as a result nearly two thirds of care homes have had no outbreak at all.” They highlighted a £600m fund to help limit staff movement between care homes and £1.3bn for accommodation to isolate residents. “We are also testing all care workers and residents, regardless of symptoms, and ensuring millions of items of PPE are delivered to the frontline.”