Multiple failures by the NHS 111 telephone advice service early in the pandemic left Covid patients struggling to get care and led directly to some people dying, an investigation has found. The Healthcare Safety Investigation Branch (HSIB) looked into the help that NHS 111 gave people with Covid in the weeks before and after the UK entered its first lockdown on 23 March 2020. It identified a series of weaknesses with the helpline, including misjudgment of how seriously ill some people with Covid were, a failure to tell some people to seek urgent help, and a lack of capacity to deal with a sudden spike in calls. It also raised concerns that the government’s advice to citizens to “stay at home” to protect NHS services deterred people who needed immediate medical attention from seeking it from GPs and hospitals, sometimes with fatal consequences. HSIB’s investigation was prompted by a series of reports in the Guardian in 2020 about inadequacies in 111 operations in the initial weeks of the pandemic, and claims by the Covid-19 Bereaved Families for Justice that many callers with Covid received inadequate advice and died after being wrongly told to stay at home. HSIB’s 15-month investigation uncovered an array of failings, including some key flaws in the Coronavirus Response Service (CRS), a telephone triage service set up on 5 March 2020 to which 111 call handlers were to transfer queries from anyone concerned about the virus. Mistakes identified by HSIB included that: The CRS algorithm did not allow for the assessment of any life-threatening illness a caller had – such as obesity, cancer or lung disease – to establish whether they should undergo a clinical assessment. When many callers reached the core 111 service, there was no way to divert them as intended to the CRS, which was operationally independent of 111. Although patients who had Covid-19 symptoms as well as underlying health conditions, such as diabetes, were meant to be assessed when they spoke to the core 111 service, some were not. The number of extra calls to 111 in March 2020 meant that only half were answered. To illustrate its findings, HSIB published four short anonymised accounts provided to them by the families of deceased Covid patients’ families about their experience of 111 early in the pandemic. All four were advised to stay at home, did not receive in-person medical help until they were gravely ill, and later died. In one case, calls from a sick man and his relatives went unanswered. In another, a man – a 45-year-old doctor – was misdiagnosed as having a chest infection, prescribed an inhaler and antibiotics, and died 16 days after being admitted to hospital. Of the advice to stay at home and call 111, which was widely promoted at the time, HSIB concluded: “The decision to redirect the public to call NHS 111 rather than access healthcare advice in other ways, for example through their GP, shifted the immediate burden of managing patients with Covid-19 in the community. This increased capacity in the wider healthcare system, but risked disrupting continuity of care for patients with complex health needs.” The Department of Health and Social Care declined to comment on that advice. Rachel Power, chief executive of the Patients Association, said: “While we appreciate that NHS 111 was working under new and very challenging circumstances, and knowledge of the effects of Covid-19 was in its infancy, the report … supports our own calls for the NHS to improve and standardise the level of service provided by NHS 111 across the country.” Its own research in 2021 found that some 111 users “felt badly let down” by it, she added. NHS England highlighted the “vital role” NHS 111 had played in the response to Covid, fielding 2m calls in March 2020 alone and referring more than 500,000 people for assessment. A spokesperson said: “Call handlers followed guidance set out by Public Health England, which was regularly updated as the understanding of Covid-19 improved, and the NHS has captured learning throughout the last two years to contribute to the response to any future pandemics.”