UK COVID-19 public inquiry needed to learn lessons and save lives
Authors: Jo Goodman, Kathryn de Prudhoe, Charlie Williams
Journal: The Lancet (2020)

With the UK's official COVID-19 death toll exceeding 60 000, and data from the Office for National Statistics indicating excess deaths of more than 70 000,1BBCMore than 70 000 excess deaths during the pandemic. BBC News.https://www.bbc.co.uk/news/health-54976362Date: Nov 17, 2020Date accessed: December 15, 2020Google Scholar the succession of grim milestones in 2020 has shown little sign of abating, despite optimism around COVID-19 vaccination. We know all too well that every single COVID-19 death is a family devastated by loss. We are members of the Covid-19 Bereaved Families for Justice, a group of over 2000 people who have lost a loved one to COVID-19 in the UK. The experiences of our group are as diverse as our members, and just a few of their stories are shared in the panel. There are loved ones lost from the front lines of the fight against COVID-19: medical staff and key workers who suffered from the authorities' poor pandemic preparation and inadequate personal protective equipment (PPE).2McCauley L Hayes R Taking responsibility for front-line health-care workers.Lancet Public Health. 2020; 5: e461-e466Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar There are those who contracted the coronavirus in the lost weeks before the UK's delayed national lockdown3BBCCoronavirus: Earlier lockdown would have halved death toll. BBC News.https://www.bbc.co.uk/news/health-52995064Date: June 10, 2020Date accessed: December 15, 2020Google Scholar in late March, 2020, or acquired COVID-19 in hospital, which remains a problem.4Heneghan C Howdon D Oke J Jefferson T The ongoing problem of UK hospital acquired infections. Centre for Evidence-Based Medicine.https://www.cebm.net/covid-19/the-ongoing-problem-of-hospital-acquired-infections-across-the-uk/Date: Oct 30, 2020Date accessed: December 15, 2020Google Scholar There are individuals whose deaths raise questions about advice from the online and telephone National Health Service (NHS) 111 services for urgent medical problems, which, alongside socioeconomic factors and structural racism, may have disproportionately impacted people of colour.5Kale S Blue lips and black skin: did a standard 111 question help cause Olufemi Akinnola's death from Covid-19?.The Guardian. Sept 23, 2020; https://www.theguardian.com/society/2020/sep/23/blue-lips-and-black-skin-did-a-standard-111-question-help-cause-olufemi-akinnolas-death-from-covid-19Date accessed: December 15, 2020Google Scholar And there are those whose family members were one of tens of thousands of potentially preventable deaths6Burki T England and Wales see 20 000 excess deaths in care homes.Lancet. 2020; 3951602Summary Full Text Full Text PDF Scopus (61) Google Scholar after many patients were released from hospitals to care homes without testing in the early stages of the pandemic.PanelFamily accounts of loved ones lost to COVID-19Jim RussellMy fiancé, Jim Russell, aged 51 years, had no underlying health issues—he was a fit and healthy man. Jim started showing symptoms around March 20, 2020—a slight cough, aching body, a slight temperature, but Jim kept assuming it was just the flu. By March 27, Jim was worse—he was getting really breathless when walking to and from the living room, and he had lost his appetite. I called 111. I took Jim to an assessment centre. He had his temperature and heart rate taken and was told he had all the symptoms of COVID-19, but they didn't have facilities to test his breathing. So he was given antibiotics and told to go home.On March 28, he collapsed in the toilet, although he didn't tell me about that at the time. On March 31, I woke at 0350 h to find Jim downstairs really struggling to breathe now. I called 111 and was told to take Jim to accident and emergency. They confirmed that Jim had COVID-19 and he was taken to intensive care. I video-called him—he was terrified and that was the last time we spoke. He was put on a ventilator on April 1. On April 4, I was asked if Jim could receive the trial drug dexamethasone and I said yes. Jim started to struggle and on April 7 he was transferred to another hospital to be put on extracorporeal membrane oxygenation for 28 days. On April 15, a video chat allowed me to see Jim for the first time in 16 days. On May 4, Jim's lungs were breaking down and there was nothing they could do. We drove to the hospital and I said to the nurse to switch off his machine thinking it would take a while; however, Jim died within a minute. I was sobbing. My whole world shattered.Connie McCreadyKatie HorneMy daughter, Katie Horne, aged 21 years, had her whole life ahead of her until COVID-19 hit. On March 18, 2020, after several weeks feeling tired, increasingly ill, and noticing that the whites of her eyes and skin were turning yellow she was admitted to hospital. She was diagnosed with autoimmune hepatitis with treatment commencing on March 20. Unfortunately, Katie did not respond to treatment and needed a liver transplant. Katie was first tested for COVID-19 around March 23, before being transferred to another hospital. Katie was tested again, as she was advised that two nurses who had treated her on the ward had themselves tested positive. This time Katie's test was positive—she could not therefore have a liver transplant while infected. Given that Katie was immunosuppressed and due to the progression of liver damage and COVID-19, on April 9, Katie was deemed to no longer be able to have a transplant. She died on April 11.Lessons must be learned. It is incomprehensible to us that PPE was not prioritised for health-care staff caring for immune-compromised patients like Katie, especially when it was known how dangerous COVID-19 was. The virus not only prevented her from having the life-saving transplant she needed, she was particularly vulnerable to the virus due to her weakened immune system. The hospital's response to us, when this was put to them, was "The Government and NHS England Policy at this time was not to routinely wear PPE, except in the setting of known Covid-19 infection". This advice was clearly disastrously wrong. PPE should have been prioritised from the outset of the pandemic, especially for staff caring for the most vulnerable patients. I believe this massive failure cost Katie her life.Samantha HorneMatt PearsOn Feb 14, 2020, my brother, Matt Pears, was diagnosed with stage 4 non-Hodgkin lymphoma. Matt was just 48 years old. He had been fit and healthy until then and was determined to beat his cancer and recover. His haematologist initially started him on chemotherapy as an outpatient, but then because the cancer was more aggressive than originally thought Matt was told he would need 3 months of intensive chemotherapy as an inpatient. Half way through this treatment, the hospital locked down in anticipation of the first spike of COVID-19 cases. Then the hospital began freeing up ward space for the expected influx of patients with COVID-19, and Matt was moved from a single room to an open ward with oncology and haematology patients. He was so angry and very frightened. The chemo had knocked out his immune system and he thought that if he caught COVID-19 he would have little chance.Despite the presence of COVID-19 patients in the hospital by then, Matt told me that staff on his ward did not wear PPE. Inevitably, he became infected with the coronavirus and was moved to a COVID-19 ward. Gradually, he became more breathless and was eventually moved to a respiratory unit. He was given continuous positive airway pressure but couldn't tolerate it and his condition worsened. He was ultimately transferred to the intensive care unit and ventilated.My brave brother, his immune system obliterated, battled on for almost another 3 weeks. His lungs collapsed twice but he held on. Then on May 17 at 0700 h, we got the call we were all dreading—to tell us that Matt had taken a turn for the worse. At around 0830 h he died, with his beloved wife by his side. Matt had been beating his cancer and we were so proud of him. His cancer wasn't a death sentence, but COVID-19 was. We have been left in utter devastation, disbelief, and shock. Now I need answers. Why didn't the UK go into lockdown sooner, when we had seen the impact in other countries? Why wasn't the NHS provided with enough PPE? Why was the majority of that PPE inadequate? Why was the NHS pushed to breaking point by this government?Kathy EdmundsOlufemi AkinnolaOn April 26, 2020, I lost my father, Olufemi Akinnola, to COVID-19. He died a month before his 61st birthday. My father was a kind, loving, nurturing man who doted on his friends and family. He was our support, our cheerleader, our comfort. Losing him has been the worst thing to happen in my life. My father was a key worker, he took care of people with learning difficulties for a UK charity. He took the virus very seriously, using gloves and a scarf to try and protect himself at work and asking all of us to be as safe as possible. When he caught the virus, he followed government guidelines to stay at home. He isolated himself in the living room to protect the rest of the family. When things did not improve, he called the 111 service as well as a GP. He was prescribed antibiotics and was reassured to stay home and that he would be fine. This turned out not to be the case as, despite a few days of feeling better, my family awoke to find he had passed away in the night.My dad was an active man who enjoyed his allotment and the gym. I fear my dad died because of an arrogant government that did not take this threat to the population seriously enough. I believe the reliance on the 111, though a good service, is improper for this pandemic. I believe that my dad, as a Black man, had symptoms ignored because the health service is systemically ill equipped to recognise warning signs in darker skin. My father was a great man who deserved better. I hope that in writing this, others will be spared this pain.Lobby AkinnolaElizabeth LewisMy nana, Elizabeth Lewis, was gentle, kind, and caring. She was also resilient and strong. She had an unrelenting love for her family. She was a feminist, a progressive thinker, and she shaped and influenced every member of our large family, all of whom adored her. My nana was 95 years old. She had heart failure, hypertension, and a history of stroke. She contracted coronavirus in a nursing home full of vulnerable residents no longer able to access the care they needed due to COVID-19, as well as untested patients discharged from hospital. My understanding is that the resident nurse of the home did not wear PPE while caring for Nana. COVID-19 cases and untested patients should never have been discharged from hospital into care homes full of vulnerable people. The UK Government must be transparent and be held accountable for the mismanagement of nursing homes—statistics on COVID-19 cases in every home should be published. We were also unhappy with the end-of-life palliative care that my nana received. The system is a jigsaw of private and public agencies that does not function as a whole and lacks accountability.Ageing is inevitable and we have an ageing population. Government ministers and policy makers must reconsider their attitudes towards the care of the elderly. I think Atul Gawande's book Being Mortal: Medicine and What Matters in the End should be required reading. I want the government to empathise and put themselves in the shoes of my nana and our family to imagine our pain and suffering due to their apathetic response to this pandemic.Anouchka Montague-LewisDilys BrewerDilys Brewer, my mother, was still very active at the age of 88 years. Although she was beginning to slow down, she still drove and was not dependent on anyone for help with daily living activities or personal care. Her diary was full and she was looking forward to outings with friends and family. Mother had a great sense of fun, she had a warm and generous heart, she was compassionate, caring, and was loved by many. On March 10, she visited the GP feeling very ill with a dry cough and lost appetite, although she had no temperature, headache, or muscle pain. She was prescribed antibiotics and sent me a relieved e-mail in the evening saying "I have not got coronavirus!" I called the GP on March 16 to say that my mother had not improved at all and requested a home visit. We were asked to contact 111 first and the GP prescribed different antibiotics. I tried calling 111 many times without success, assuming that the lines were overloaded and someone would answer in due course. I later discovered that there was supposed to be an option in her area to choose between COVID-19 queries and non-COVID-19 queries, but due to a "technical fault" that option did not actually exist then.By March 23, my mother was weak and very breathless. Finally, the GP visited and arranged for immediate admission to hospital. There, two lung x-rays showed a pattern of lung damage related to COVID-19, although two swab tests were negative. Mother passed away after 10 distressing days alone in hospital. The death certificate showed the primary cause of death was clinical COVID-19 pneumonia. I am left with a feeling of valuable time lost, public health systems failing us, and confusion about testing and diagnosis of COVID-19. It was like sleepwalking through a nightmare.Helen Brewer Jim Russell My fiancé, Jim Russell, aged 51 years, had no underlying health issues—he was a fit and healthy man. Jim started showing symptoms around March 20, 2020—a slight cough, aching body, a slight temperature, but Jim kept assuming it was just the flu. By March 27, Jim was worse—he was getting really breathless when walking to and from the living room, and he had lost his appetite. I called 111. I took Jim to an assessment centre. He had his temperature and heart rate taken and was told he had all the symptoms of COVID-19, but they didn't have facilities to test his breathing. So he was given antibiotics and told to go home. On March 28, he collapsed in the toilet, although he didn't tell me about that at the time. On March 31, I woke at 0350 h to find Jim downstairs really struggling to breathe now. I called 111 and was told to take Jim to accident and emergency. They confirmed that Jim had COVID-19 and he was taken to intensive care. I video-called him—he was terrified and that was the last time we spoke. He was put on a ventilator on April 1. On April 4, I was asked if Jim could receive the trial drug dexamethasone and I said yes. Jim started to struggle and on April 7 he was transferred to another hospital to be put on extracorporeal membrane oxygenation for 28 days. On April 15, a video chat allowed me to see Jim for the first time in 16 days. On May 4, Jim's lungs were breaking down and there was nothing they could do. We drove to the hospital and I said to the nurse to switch off his machine thinking it would take a while; however, Jim died within a minute. I was sobbing. My whole world shattered. Connie McCready Katie Horne My daughter, Katie Horne, aged 21 years, had her whole life ahead of her until COVID-19 hit. On March 18, 2020, after several weeks feeling tired, increasingly ill, and noticing that the whites of her eyes and skin were turning yellow she was admitted to hospital. She was diagnosed with autoimmune hepatitis with treatment commencing on March 20. Unfortunately, Katie did not respond to treatment and needed a liver transplant. Katie was first tested for COVID-19 around March 23, before being transferred to another hospital. Katie was tested again, as she was advised that two nurses who had treated her on the ward had themselves tested positive. This time Katie's test was positive—she could not therefore have a liver transplant while infected. Given that Katie was immunosuppressed and due to the progression of liver damage and COVID-19, on April 9, Katie was deemed to no longer be able to have a transplant. She died on April 11. Lessons must be learned. It is incomprehensible to us that PPE was not prioritised for health-care staff caring for immune-compromised patients like Katie, especially when it was known how dangerous COVID-19 was. The virus not only prevented her from having the life-saving transplant she needed, she was particularly vulnerable to the virus due to her weakened immune system. The hospital's response to us, when this was put to them, was "The Government and NHS England Policy at this time was not to routinely wear PPE, except in the setting of known Covid-19 infection". This advice was clearly disastrously wrong. PPE should have been prioritised from the outset of the pandemic, especially for staff caring for the most vulnerable patients. I believe this massive failure cost Katie her life. Samantha Horne Matt Pears On Feb 14, 2020, my brother, Matt Pears, was diagnosed with stage 4 non-Hodgkin lymphoma. Matt was just 48 years old. He had been fit and healthy until then and was determined to beat his cancer and recover. His haematologist initially started him on chemotherapy as an outpatient, but then because the cancer was more aggressive than originally thought Matt was told he would need 3 months of intensive chemotherapy as an inpatient. Half way through this treatment, the hospital locked down in anticipation of the first spike of COVID-19 cases. Then the hospital began freeing up ward space for the expected influx of patients with COVID-19, and Matt was moved from a single room to an open ward with oncology and haematology patients. He was so angry and very frightened. The chemo had knocked out his immune system and he thought that if he caught COVID-19 he would have little chance. Despite the presence of COVID-19 patients in the hospital by then, Matt told me that staff on his ward did not wear PPE. Inevitably, he became infected with the coronavirus and was moved to a COVID-19 ward. Gradually, he became more breathless and was eventually moved to a respiratory unit. He was given continuous positive airway pressure but couldn't tolerate it and his condition worsened. He was ultimately transferred to the intensive care unit and ventilated. My brave brother, his immune system obliterated, battled on for almost another 3 weeks. His lungs collapsed twice but he held on. Then on May 17 at 0700 h, we got the call we were all dreading—to tell us that Matt had taken a turn for the worse. At around 0830 h he died, with his beloved wife by his side. Matt had been beating his cancer and we were so proud of him. His cancer wasn't a death sentence, but COVID-19 was. We have been left in utter devastation, disbelief, and shock. Now I need answers. Why didn't the UK go into lockdown sooner, when we had seen the impact in other countries? Why wasn't the NHS provided with enough PPE? Why was the majority of that PPE inadequate? Why was the NHS pushed to breaking point by this government? Kathy Edmunds Olufemi Akinnola On April 26, 2020, I lost my father, Olufemi Akinnola, to COVID-19. He died a month before his 61st birthday. My father was a kind, loving, nurturing man who doted on his friends and family. He was our support, our cheerleader, our comfort. Losing him has been the worst thing to happen in my life. My father was a key worker, he took care of people with learning difficulties for a UK charity. He took the virus very seriously, using gloves and a scarf to try and protect himself at work and asking all of us to be as safe as possible. When he caught the virus, he followed government guidelines to stay at home. He isolated himself in the living room to protect the rest of the family. When things did not improve, he called the 111 service as well as a GP. He was prescribed antibiotics and was reassured to stay home and that he would be fine. This turned out not to be the case as, despite a few days of feeling better, my family awoke to find he had passed away in the night. My dad was an active man who enjoyed his allotment and the gym. I fear my dad died because of an arrogant government that did not take this threat to the population seriously enough. I believe the reliance on the 111, though a good service, is improper for this pandemic. I believe that my dad, as a Black man, had symptoms ignored because the health service is systemically ill equipped to recognise warning signs in darker skin. My father was a great man who deserved better. I hope that in writing this, others will be spared this pain. Lobby Akinnola Elizabeth Lewis My nana, Elizabeth Lewis, was gentle, kind, and caring. She was also resilient and strong. She had an unrelenting love for her family. She was a feminist, a progressive thinker, and she shaped and influenced every member of our large family, all of whom adored her. My nana was 95 years old. She had heart failure, hypertension, and a history of stroke. She contracted coronavirus in a nursing home full of vulnerable residents no longer able to access the care they needed due to COVID-19, as well as untested patients discharged from hospital. My understanding is that the resident nurse of the home did not wear PPE while caring for Nana. COVID-19 cases and untested patients should never have been discharged from hospital into care homes full of vulnerable people. The UK Government must be transparent and be held accountable for the mismanagement of nursing homes—statistics on COVID-19 cases in every home should be published. We were also unhappy with the end-of-life palliative care that my nana received. The system is a jigsaw of private and public agencies that does not function as a whole and lacks accountability. Ageing is inevitable and we have an ageing population. Government ministers and policy makers must reconsider their attitudes towards the care of the elderly. I think Atul Gawande's book Being Mortal: Medicine and What Matters in the End should be required reading. I want the government to empathise and put themselves in the shoes of my nana and our family to imagine our pain and suffering due to their apathetic response to this pandemic. Anouchka Montague-Lewis Dilys Brewer Dilys Brewer, my mother, was still very active at the age of 88 years. Although she was beginning to slow down, she still drove and was not dependent on anyone for help with daily living activities or personal care. Her diary was full and she was looking forward to outings with friends and family. Mother had a great sense of fun, she had a warm and generous heart, she was compassionate, caring, and was loved by many. On March 10, she visited the GP feeling very ill with a dry cough and lost appetite, although she had no temperature, headache, or muscle pain. She was prescribed antibiotics and sent me a relieved e-mail in the evening saying "I have not got coronavirus!" I called the GP on March 16 to say that my mother had not improved at all and requested a home visit. We were asked to contact 111 first and the GP prescribed different antibiotics. I tried calling 111 many times without success, assuming that the lines were overloaded and someone would answer in due course. I later discovered that there was supposed to be an option in her area to choose between COVID-19 queries and non-COVID-19 queries, but due to a "technical fault" that option did not actually exist then. By March 23, my mother was weak and very breathless. Finally, the GP visited and arranged for immediate admission to hospital. There, two lung x-rays showed a pattern of lung damage related to COVID-19, although two swab tests were negative. Mother passed away after 10 distressing days alone in hospital. The death certificate showed the primary cause of death was clinical COVID-19 pneumonia. I am left with a feeling of valuable time lost, public health systems failing us, and confusion about testing and diagnosis of COVID-19. It was like sleepwalking through a nightmare. Helen Brewer As a group going through the pain of that loss, we are determined to prevent others from enduring the same experiences. So we are campaigning for lessons to be learned as quickly as possible to save lives as the pandemic continues and ahead of the wide-scale roll-out of COVID-19 vaccines across the UK. We call for an immediate public inquiry with a rapid review phase. The UK Prime Minister Boris Johnson has previously suggested that an immediate public inquiry into the government's handling of COVID-19 would be a distraction7The Financial TimesThe UK needs a two-stage inquiry into the handling of coronavirus.The Financial Times. July 20, 2020; https://www.ft.com/content/154ab79c-ca81-11ea-9f2a-f28f919e3c0eDate accessed: December 15, 2020Google Scholar or diversion of resources in the fight against COVID-19. We have long proposed that quite the opposite is true: an effective rapid review phase would be an essential element in combating COVID-19. An independent and judge-led statutory public inquiry with a swift interim review would yield lessons that can be applied immediately and help prevent deaths in this tough winter period in the UK. Such a rapid review would help to minimise further loss of life now and in the event of future pandemics. In the wake of the Hillsborough football stadium disaster on April 15, 1989, for example, the Inquiry of Lord Justice Taylor delivered interim findings within 11 weeks, allowing life-saving measures to be introduced in stadiums ahead of the next football season.8National ArchivesInquiry into Hillsborough Stadium Disaster (Taylor Inquiry): evidence, papers and report.https://discovery.nationalarchives.gov.uk/details/r/C9261Date: 1989–1990Date accessed: December 15, 2020Google Scholar Any government, particularly during an unprecedented public health crisis, should be guided by the evidence, and we have never been more in need of swift, evidence-based policy recommendations. Although it is not for us to determine the outcome of such an inquiry, there are certain areas that we believe should be addressed as a matter of priority. First, in line with WHO's principal recommendation to test, trace, and isolate,9WHOCOVID-19 press conference.https://www.who.int/docs/default-source/coronaviruse/transcripts/who-transcript-emergencies-coronavirus-press-conference-full-13mar2020848c48d2065143bd8d07a1647c863d6b.pdfDate: March 13, 2020Date accessed: December 15, 2020Google Scholar it is essential that we assess the robustness of the UK's test and trace programme, including steps that can be taken to improve its infrastructure and to build public confidence and compliance. Second, government policy making and communications must be reviewed, including how infection control measures are decided and how risk levels are communicated to the public. Third, with research showing the disproportionate impact of COVID-19 on Black and ethnic minority communities in the UK,10Shirley S Pan D Nevill C et al.Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-analysis.EClinicalMedicine. 2020; (published online Nov 12.)https://doi.org/10.1016/j.eclinm.2020.100630Google Scholar it is crucial that we identify actions to mitigate the impact of COVID-19 on these communities. Fourth, a rapid review phase of an inquiry should look at the functioning and capacity of the NHS to provide appropriate care to patients with COVID-19, how to ensure the provision of other routine NHS services during the pandemic, and the ability of the 111 services to accurately identify those in need of hospital care. Furthermore, a review should analyse what systems are in place to prevent the virus from being transmitted in hospitals to patients and NHS staff, such as supplies of PPE, risk assessments, case isolation processes, and testing of staff, and what support is available to staff. Finally, a review should deliver crucial lessons to be applied in care homes to prevent residents and health workers from contracting coronavirus, including supplies of PPE, hospital discharge procedures, case isolation processes, risk assessments, wellbeing support, access to treatment, staff turnover issues, and testing for staff. We call for a statutory public inquiry and urge the UK Government and public health professionals to adopt a new mantra: "Rapid review. Learn lessons. Save lives." We are all members of the Covid-19 Bereaved Families for Justice. We declare no other competing interests. Learning from crisesIn response to the Comment by Jo Goodman and colleagues of the Covid-19 Bereaved Families for Justice,1 we have every sympathy with the individuals for their loss and we too hope that lessons will be learned. However, we believe that they will not achieve their aim by calling for an independent and judge-led statutory public inquiry. Although such inquiries have their place, experience would suggest that they have proven to be particularly poor in their evaluation of operational matters. Full-Text PDF UK COVID-19 public inquiry and lessons from patient safetyThe family accounts of loved ones lost to COVID-19 make for tough reading.1 The Covid-19 Bereaved Families for Justice group are right to campaign for an immediate public inquiry so that lessons can be learned as quickly as possible to save lives as the pandemic continues. Any suggestions that this would be distracting are against the modern understanding of human factors and the science of crisis management. It is a well established principle of patient safety that, during a crisis, the team should promptly pause to consider a rapid review of whether or not the actions being taken are correct and effective. Full-Text PDF