Preventing Future Deaths reports arising from COVID-related deaths

It has been reported that approximately 100,000 people have now died from COVID-19 in the UK. Vulnerable adults are at the greatest risk of the disease and it is understood that close to 20,000 care home residents died in the first wave last year. Recent reports from the Guardian show the deaths in care homes in England have increased by 46%, the highest level since mid-May last year.

The Chief Coroner’s guidance in March 2020 confirmed that COVID-19 is a naturally occurring disease and therefore is capable of being a natural cause of death. This clarified the position that a death arising from COVID would not ordinarily be referred to the coroner, however, such a referral would be considered justified if there were additional factors which meant that a report of death to the coroner would be necessary.

Despite the alarming number of deaths, only a very limited number of inquests have resulted in a cause of death related to COVID, thus being an incredibly rare event. Recent reports in the Guardian have found that Preventing Future Deaths reports have arisen following only two inquests relating to COVID.

The Senior Coroner for Greater Manchester South, Alison Mutch, inquired into the deaths of Anthony Slack and Leslie Harris, both of whom were found to have died from COVID. A series of failures were identified in relation to both deaths.

Mr Slack died on 13 April 2020 after being infected at his care home and after a fall he waited four hours for an ambulance to arrive. Aside from a sparsity of documentation in the care home, concerns were raised in respect of the fact that residents had become infected with COVID and it was unclear whether this had been brought in by staff or new residents; staff were unclear as to the requirements for wearing PPE; and the shortage of ambulances arising from staff needing to self-isolate (and the need for increased cleaning). The Preventing Future Deaths report was sent to Public Health England, NHS England, Greater Manchester Health and Social Care Partnership, the Care Quality Commission and the relevant care home, all of which are required to respond by 26 January 2021.

Mr Harris believed to have become infected whilst in hospital for surgery following a fall. During his recovery, he tested positive and died of COVID-related pneumonia. The Preventing Future Deaths report was directed at Public Health England and NHS England and both are expected to respond no later than 3 February 2021 to the management of patients in hospitals.

The responses to these Preventing Future Deaths reports will be a seminal moment in the pandemic. It will be the first time the relevant public bodies will formally respond to concerns arising from the public response, particularly in respect of care home protection, PPE guidance and stretched healthcare resources.

Many millions of people in the UK have been affected by the pandemic, no more so than the families who have lost loved ones. A collective of families are lobbying the government to commission a rapid public inquiry into the government’s handling of the crisis and to direct that there should be an increased number of inquests relating to COVID, so that circumstances of COVID-related deaths can be better understood and to provide a mechanism to learn lessons from the first wave. The Prime Minister refused to commission a rapid public inquiry in the summer but has committed to looking back and reflecting on the government’s handling of the crisis in due course, which may include the timing of lockdowns, public guidance, equipment and PPE shortages, and the efficacy of the “protective ring” around care homes – although the precise terms of reference will no doubt be a matter of debate and heavily politicised.

With the increasing and unrelenting demands placed on the NHS, the distribution of limited resources, the desperate need for more healthcare staff to care for those who are seriously unwell and, of course, the significantly higher number of fatalities compared to the first wave, it may be that we find many more deaths being reported to the Coroner with a growing number of Preventing Future Deaths reports.

The concern now is that the rising numbers of deaths in care homes is not limited to the “first wave” with last week’s figures rising to 1,260 from 824 and 661 in the preceding weeks, demonstrating that the impact of the national roll-out of the vaccine to the most vulnerable groups has yet to be felt. Latest figures suggest that an alarming third of all deaths from the pandemic relate to adults in care homes.

In such circumstances, it is difficult to see how the government can resist calls for a comprehensive public inquiry into the handling of the pandemic.

Lee Biddle, Associate, BLM

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