COVID-19 and Prevention of Future Deaths Reports: what are the effects (if any)?

In July 2021 we wrote about Prevention of Future Deaths Reports (PFDs) and what we could take away from the various PFDs issued by coroners in relation to patient care. We identified five themes from our review issued from January – June 2021 and these included:

• Failure to recognise/escalate patients who were becoming critically unwell;
• Investigations not being completed on time;
• Concerns over guidance and training for sepsis;
• Risk management and planning for discharge;
• Concerns of care and treatment provided in maternity wards.

Interestingly and rather surprisingly, there were no apparent themes in relation to the Covid-19 pandemic. This however has since changed.

Between June and September 2021 we reviewed 18 PFDs in a clinical setting that cited Covid-19 as the cause of death, or death due to complications because of Covid-19. 9 of the 18 PFD’s had Covid-19 cited as the direct cause of death or part of the cause of death. From these 18 PFDs we have identified three themes. Similarly to our previous review, we found that the area of Greater Manchester South produced the most PFD reports, with 10 of the 18 PFDs having been issued from that jurisdiction.

Communication and documentation

A large percentage of the PFDs we reviewed said that due to the pandemic and restrictions patients had been assessed over the phone, instead of in person. This then led to issues such as needs not being assessed well and patients not being referred to hospital earlier. This was applied in both an acute and mental health setting.

Another related issue is that patients were not being supported as they would usually have been at outpatient appointments. In one case the inquest heard that this impacted significantly on the quality of the history available to clinicians, support for a vulnerable patient and her decision-making.

A few PFDs said that Covid restrictions meant that communication had been difficult, and that written documentation did not cover the challenges this caused. We also found that the risks and management of patients in the community were not being conveyed clearly to community health professionals and to the patient’s family.

Policy and procedure

A further recurrent theme is that of policy and procedure, particularly in relation to the Covid-19 vaccine. In one case the patient had not been given the vaccine as the policy at the time was to give the vaccine to staff and not inpatients. This patient then contracted Covid-19.

We also saw cases where NICE guidance used by clinicians did not deal with the Covid-19 aspects/recognised risks. In one case the inquest heard that there will often be a raised D-Dimmer with Covid-19 and in addition that there is an increased risk of clots. The evidence before the inquest was that the existing NICE guidance used by clinicians did not deal with the Covid-19 aspects/ recognised risks. This meant that patients were at risk.

In another inquest, the trust were following PHE/NHS guidance in relation to regularity of swabbing of inpatients, but it was regularly taking in excess of 48 hours for swab results to be returned to the trust. The impact of the delay was that infectious asymptomatic patients were remaining on non-Covid wards for some days and spreading infection to other patients.

Engagement within a mental health setting

The pandemic put a huge strain on mental health services and many experienced delays due to operating under the constraints of Covid-19. This meant that some patients who did not engage properly with the service were not given more in-depth help. It also meant that there were delays in offering patients support which would have assisted them.

The existing challenges pre-Covid for mental health services had been exacerbated by Covid due to an increased need for their services. This was in part due to the impact on mental health due to isolation during lockdown.

Staffing levels were also referred to as a recurrent issue in mental health services. Levels were often inadequate due to higher dependency of patients with Covid-19.

What can be learnt?

The pandemic brought about additional issues for healthcare providers as well as exacerbating previous ones. Coroners will be alive to this fact and keeping a watch on how NHS providers demonstrate that any potential failings in systems/care connected with a death are properly investigated and that actions taken/improvements made can be properly evidenced. It could be said that they have been fairly tolerant so far, recognising that NHS Providers are operating in incredibly challenging circumstances and having to adapt to new risks. The concern may be that the tolerance wears off and coroners will be less understanding if NHS providers have failed to update policies and procedures adequately to take account of what appears to be the new norm.