The text came through at 3.02am on 25 October last year. “They put me in Covid ward because my temp was high,” wrote Carl Dillon, then 84, a retired mechanical engineer from Chorley, Lancashire. Carl, who had type 2 diabetes and chronic obstructive pulmonary disease (COPD) and had been shielding since March, had been taken to hospital the previous evening with stomach pain. Immediately, his daughter Christine Cherry, a 57-year-old potter from Preston, Lancashire, was concerned. She called him. “He sounded really anxious,” she says now. “Like he wanted me to help him.”
Christine phoned the Royal Preston hospital (RPH), a 700-bed, 70s-era hospital on the outskirts of Preston, to see if her dad could be moved. A doctor confirmed that Carl was in an assessment area of A&E with other suspected Covid cases, but told Christine not to worry. “He said: ‘He’s not near anybody. We have them in different bays.’ But it did concern me. It was a bay, not a room. A virus doesn’t stop at the top of a curtain.” She thinks the doctor sounded uneasy. “It felt like he was trying to reassure me, but also reassure himself at the same time that what he had done was OK,” she says.
Christine was not appeased, but there was nothing she could do. “I knew it was a disaster, even then,” she says. “Which is why I was up at three in the morning, trying to chase it up.” Carl was moved to a different ward around midnight the following day. He texted Christine to let her know. By then, it may well have been too late. Carl had been exposed to the virus for nearly 24 hours.
Carl was born in Guy’s Hill, Jamaica. His was an idyllic boyhood: “Swimming in rivers. Picking mangoes,” Christine says. He kept a faint Jamaican accent throughout his life, which thickened when he was talking with friends back home.
As a boy, he had dreamed of being a police officer, but when he came to the UK at 22 he could find work only in a factory in Preston. “That was a bugbear for him,” Christine says. “He was the top student in his class back in Jamaica.” He had been taught that Britain was the mother country. But when Carl arrived, he was surprised to find that people did not welcome Caribbean immigrants with open arms. “He suffered a lot of racism,” Christine says. “But he would never dwell on it. He just said that was how it was.” Eventually, Carl found better-paying work, as a mechanical engineer at a small local firm – the owner saw potential in him and trained him up.
Carl met Christine’s mum, Barbara, in 1958. He saw her on the street and was smitten. The feeling was mutual. But Barbara’s parents did not approve of their daughter dating a black man and spirited her to Yorkshire, to keep her away from him. To escape, Barbara told her parents she had a job interview. By the time they tracked her down, Barbara and Carl were married. “It was weird, because Dad eventually grew to like my grandparents,” says Christine. “The first time I saw my dad cry was at my grandmother’s funeral. He had a lot of respect for her.”
Barbara and Carl had eight children. Money was tight, but they would save all year to ensure their kids had a good Christmas. “Dad would make us queue up on the stairs, from youngest to eldest, and the presents would be at the bottom,” says his daughter Frankie Dillon-Salisbury, 53, an administrator from Penwortham, near Preston. Barbara was the nurturing parent, Carl the disciplinarian. “That was the Jamaican in him,” Christine says. “He wanted us to behave impeccably.”
Carl was a record collector – by the time he died, he had more than 4,000 vinyls – and there was always music on in the family home, mostly soul, funk and R&B. “Music was his life,” says Christine. He would spend hours on Sunday cooking West Indian dishes; the food always took ages to prepare, as he was a perfectionist. “You would be starving by the time he was finished,” says Christine. “But it would be amazing.” Another annoying habit: Carl would commandeer the family TV to watch cricket. “Urgh, it was so boring,” says Frankie. “And we had to be quiet, too. Cricket days were the worst.”
In 1977, Carl and Barbara divorced. Carl remarried a woman called Dorothy and the children grew distant from him. “I held a grudge against my dad, because I missed him terribly,” says Frankie. Both daughters reconnected with their father as they got older. “I saw it from an adult point of view, rather than just thinking: my dad left my mum,” says Christine.
After being made redundant from his job as an engineer, Carl worked as a DJ in local pubs and clubs. “He was cool,” says Frankie. “I was proud of him. He never looked or acted his age.” Carl had a show on a local radio station, Chorley FM, and his kids would text in song requests. He and Dorothy started a fruit and vegetable shop, which thrived for a time, until a supermarket moved in. “My dad was a grafter,” says Frankie. “He was always trying something new.”
When Carl was diagnosed with prostate cancer in 2012, Frankie would take him to his chemotherapy appointments. Carl told Christine stories about his childhood in Jamaica and the scrapes he would get into, like the time he fell off the back of a milk float and woke up in hospital. They made plans for what he would do with the land he still owned back home.
Looking back, Christine is thankful she grew closer to her father in later life. “That was a big thing for me,” she says. “I found out about his Caribbean heritage and who he was. The man, as opposed to my father. We connected.”
In the first wave of the pandemic, people avoided hospitals for fear of becoming infected. A&E departments were hushed and eerie. The government had to remind the public to use the NHS if they felt unwell.
It now seems that avoiding hospitals unless absolutely necessary was the right idea. More than 39,000 people are believed to have been infected with Covid in English hospitals during the second wave of the pandemic, with about one in four patients being treated for Covid in English hospitals in early December likely to have caught the virus while hospitalised for an unrelated condition. (In the first wave, non-urgent care in UK hospitals was cancelled; in the second wave, hospitals carried on as normal.)
According to data collected under the Freedom of Information Act by the Telegraph, 3,264 died of Covid acquired in English hospitals in the year to April 2021. A study from King’s College London estimates that at least 12.5% of all Covid patients in UK hospitals during the first wave contracted the virus in hospital. The true figure is almost certainly much higher, because not all cases are reported by hospital trusts. The criterion for a hospital-acquired infection – someone testing positive eight days after admission – necessarily excludes those who have shorter stays, those who are discharged and readmitted and those who become symptomatic before seven days have elapsed. “I predict it’s more like 25%,” says Dr Ben Carter, who co-authored the King’s research.
To make matters worse, systematic underfunding of the NHS in the decade since the financial crash had starved hospitals of investment. “The rationale was that we needed to prioritise paying salaries and getting medicine,” says Siva Anandaciva of the health policy thinktank The King’s Fund. “You can let a building run down for a bit – how bad can it get? Well, it got pretty bad.” Even pre-pandemic, wards were overflowing with patients. Among developed countries, the UK had among the lowest number of hospital beds per 1,000 people. “The focus of health policy has long been reducing the NHS estate and trying to run the system as red hot as you can, with as few beds and staff as you can get through,” says Anandaciva. It seemed that the NHS was plunged into crisis every flu season.
But NHS buildings were not the only problem. UK government guidance was – and continues to be – inadequate to prevent the spread of Covid in hospitals. It is an error that continues to mystify and alarm frontline medics to this day.
When Sars-CoV-2 emerged in 2019, scientists knew that it was a coronavirus and, therefore, that it was reasonable to expect that the disease it caused was transmitted through droplets and aerosols. This was why, when the first harrowing images emerged from Wuhan, China, in January 2020, medics wore hazmat suits, including FFP2 or FFP3 masks, which provide 90% to 95% protection against airborne diseases. In 2013, Jonathan Van-Tam, now England’s deputy chief medical officer, had co-authored a paper stating that medical staff should wear FFP3 masks when tending to patients infected with coronaviruses.
Accordingly, when the government’s New and Emerging Respiratory Virus Threats Advisory Group (Nervtag) first met to discuss Covid in January 2020, it designated it an airborne high-consequence infectious disease (HCID), which would require the highest level of PPE for healthcare staff. But, in March 2020, Nervtag declassified Covid as a HCID, meaning that health workers would not be given FFP3 masks when treating infected patients, but rather fluid-resistant surgical masks, which provide 56% protection against Covid. (An exemption was made for staff performing aerosol-generating procedures, such as intubating or extubating a ventilated patient.)
In February, an anonymous member of the Advisory Committee on Dangerous Pathogens told the BBC that the decision was pragmatic. “We couldn’t have given everybody an FFP3 anyway – there was no question of getting that quantity of them,” the source said. (The BBC also reported that health officials denied that PPE requirements had been downgraded due to shortages.) The UK did not have the FFP3 masks that Van-Tam had specified were necessary in 2013. We now know that coughing can generate more Covid airborne particles than the use of a continuous positive airway pressure (Cpap) machine, used to support patients’ breathing, which is categorised as a high-risk aerosol-generating procedure (AGP).
It did not help that the UK had prepared for the wrong kind of pandemic. As part of its 2016 Operation Cygnus exercise, the government had war-gamed a mass outbreak of influenza, which is transmitted through droplets.
An obsession with droplet transmission was evident from the start. Boris Johnson talked repeatedly about washing hands, advice that was echoed by government infographics that urged people to stay 2 metres away from each other and wash their hands often; all the better if they sang Happy Birthday while doing it. Officials allowed PPE stockpiles to run down, leading to a mad scramble in the early days of the crisis. Even when it became apparent that Covid was an airborne virus, the government did not change its PPE requirements. To this day, UK healthcare staff working on Covid wards are given only surgical masks for protection, unless performing AGPs.
Prof Lidia Morawska of Queensland University of Technology, an expert in the transmission of airborne diseases, believes this is wrong. “Healthcare staff should be wearing FFP3 masks all the time when attending to Covid cases or suspected Covid cases,” Morawska says. The danger is not just to staff, but also to patients. “Infected healthcare staff will in turn infect others. They will act as vectors of disease,” Morawska says. Staff in intensive care units are 50% less likely to become infected with Covid than their colleagues on general wards, because they have access to better PPE and the air is cleaned more regularly.
It is very hard, when the huge and unwieldy ship of the British state has been set in motion, to correct its course. Did these decisions prove catastrophic, putting at risk the most vulnerable people in our society?
On 24 October, Carl had terrible stomach pains. Christine called an ambulance, which took him first to the A&E department of Chorley and South Ribble hospital, 11 miles south of Preston, where he was assessed. But the A&E closed at 8pm, so Carl was sent to RPH, where initially he was left in a corridor.
Because Carl had a temperature – a symptom of Covid, but also of many other illnesses – a doctor put him with suspected Covid cases in an assessment area of the A&E department. Carl ought to have been kept in an isolation room, away from Covid patients, while awaiting his test results. (His Covid test came back negative.) Public Health England (PHE) guidance states: “If the patient/individual has symptoms or a history of contact/exposure with a case, they should be prioritised for single room isolation.” But it adds that, if single rooms are not free, patients can be cohorted – put together in the same ward – with suspected and confirmed Covid patients. “Use privacy curtains between bed spaces to minimise opportunities for close contact between patients,” the guidance suggests.
In better-resourced healthcare systems, such as Singapore’s, hospitals do not cohort suspected or confirmed Covid cases, instead putting them in negative pressure isolation rooms (which are designed so that air does not leak out) or, at a minimum, in single-occupancy rooms with private toilets. Staff in attendance wear full PPE, including high-quality N95 respirators.
When the pandemic started, the team at Singapore General hospital built an additional 50 isolation rooms in 50 days. “We managed Sars in Singapore, so our institutions already had the memory of how to manage outbreaks of novel respiratory pathogens,” says Dr Ian Wee, a doctor at the hospital. As a result, only four patients were detected with Covid on general wards in the hospital in a six-month period. None of these patients infected the people in the beds around them.
In the UK, when doctors had multiple possible Covid cases and not enough private rooms to isolate them, they ended up being put in the same ward, all coughing and spluttering the same air. In an October 2020 report on hospital-acquired infections in the first wave, investigators from the watchdog Healthcare Safety Investigation Branch heard that suspected Covid patients were being put in wards alongside confirmed Covid cases while awaiting test results. Disturbed relatives would beg staff to place their relatives in private rooms, only to be told that none were available.
In many respects, Carl may simply have been unlucky. There are large national disparities in rates of hospital-acquired Covid. Lancashire has seen more hospital-acquired infections than anywhere else in England throughout the second wave, with 1,640 cases in the period August 2020-February 2021, nearly 30% of total infections. (By comparison, fewer than 2% of total Covid cases in the Whittington Health NHS trust, in north London, were acquired in hospital.) In November 2020, researchers examined infection control measures in 23 hospitals in the north-west and found “substantial deficiencies”. Patients were allocated to beds before Covid test results were available. Doctors moved freely between high-risk and low-risk pathways. In one hospital, staff were not being regularly tested for Covid.
Hospitals in this part of England are badly in need of repair. Before Covid, NHS Digital data showed that Lancashire hospitals needed £40.2m in funding to address their repairs. At RPH alone, £3.6m was needed for urgent repairs to avoid serious injuries to patients or “catastrophic failure”, in addition to £32.8m in funding for building, refurbishing or maintaining the building itself. Inspectors from the Care Quality Commission (CQC) who visited in 2019 found that patients at risk of deteriorating in the A&E unit were not always spotted, while the facilities and premises in the critical care unit were unsafe. (RPH says that, in its most recent meeting with the CQC, in October 2020, no serious issues were highlighted; work started on a new critical care unit in June 2020 and it was completed last month.)
At RPH, most buildings date from 1975-84. Newer hospitals have side rooms with en suites, meaning that suspected Covid cases can be isolated while awaiting test results. Older hospitals, such as RPH, have bigger wards with shared toilets, bays without doors and ineffective ventilation systems. (At the beginning of the pandemic, RPH installed curtains in high-risk areas to create a physical barrier between patients. In the summer of 2020, these curtains were upgraded in Covid areas to disposable antimicrobial curtains.)
In addition, the NHS entered the pandemic with a workforce crisis. Anandaciva says there were 100,000 vacancies and there was a huge reliance on temporary workers. He points to the Nightingale hospitals. “These were purpose-built facilities that could have supported social distancing and infection control during the pandemic,” he says. “But they couldn’t be used because there weren’t enough staff.” It was no way to run a healthcare system at the best of times. For some patients, it may have been lethal.
Carl was discharged from RPH on 4 November, having turned 85 on 30 October. Doctors told Christine his stomach pain was most likely caused by gallstones and that Carl had probably passed them. She wore a mask while driving her dad home with all the windows open. “He was glad to be out of there,” Christine says. She left him with some food and told him to ring her if he needed anything. Because Carl was shielding – type 2 diabetes and COPD increase the risk of severe illness from Covid – he could not leave the house.
Carl lived alone – Dorothy died about six years ago – so it is hard for Christine to know exactly when he fell ill. On 10 November, Christine’s sister Monique went to drop off some shopping for him. Carl seemed unwell, although he did not have the most recognised Covid symptoms – a dry cough and a temperature. On 15 November, he was not answering phone calls, so Frankie took him for a Covid test, which came back positive the next day.
Frankie went to Carl’s house to stay with him. He seemed confused and weak. She could not bear to tell him the result. “I knew he would be scared to death,” Frankie says. “He looked so vulnerable.” At 10am, Frankie spoke to a GP, who said an ambulance would come to collect Carl; it did not show up until 8.30pm. She told Carl he had Covid only when the paramedics arrived. “He just nodded,” Frankie says. “Like he knew.”
Carl was taken back to RPH. Both sisters feel that the care Carl received there was substandard. He was not deemed a suitable candidate for a ventilator, although he was put on a Cpap machine in a side room on the ward. On 30 November, Christine received a distressing video call from her father. “It was horrendous,” she says. “I couldn’t see Dad, but I could hear someone struggling to breathe.”
Barely anyone left without picking up Covid in December or January if they hadn’t come in with it
Caroline, a hospital doctor
In the days that followed, when they were allowed to visit, Christine and Frankie would find Carl begging for water. “It felt like they put him in a side room and left him to die,” says Christine. On one occasion when Christine was visiting, no one came to check on her father for two and a half hours. “It seemed that the staff didn’t want to come to the end of the ward where my dad was,” she says. She complained; a doctor came to see her and apologised. “It felt like: he’s 85, he doesn’t stand a chance, just leave him,” Frankie says. At one point, Carl took off his oxygen mask and told his daughters: “I’ve had enough. I’m tired.”
On 4 December, Christine received a call from the hospital: Carl was dying. She and Frankie spent most of the day with him. Carl could not speak, but he would squeeze their hands in response to questions, so they knew he could hear them.
Christine talked to him about a day from her childhood, before her mum and dad separated, when they moved house. Instead of unpacking the boxes, the family went for a walk past a river, through a farm. The farmer came out with a shire horse. Instead of being angry, he put the children on the horse and took them for turns around the farmyard.
From the hospital window, Christine could see snow on the hills. Snow was a big thing for Carl; he saw it for the first time when he came to the UK. She described the view. Frankie played calming music from her phone.
A priest came to administer the last rites. Carl mouthed the words to the prayers. He passed away to the sound of Christine reciting his favourite, Psalm 23. “The lord is my shepherd; I shall not want. He maketh me to lie down in green pastures: he leadeth me beside the still waters.”
Frankie sobs at the memory. “While I am grateful we got to be with him, it still hurts,” she says.
Frontline NHS staff have been desperately lobbying the government for the equipment and systems to prevent future hospital-acquired Covid cases. Despite their best efforts, they have not got very far.
Before Covid hit, Dr Eilir Hughes, a GP in the small town of Nefyn in north-west Wales, spent most of his time dealing with stoical farmers who should have come to see him months earlier or anxious retirees who were not sick. Hughes now runs the Fresh Air NHS campaign, a national coalition of health professionals and scientists calling for the government to recognise that Covid is airborne and that any serious attempt to prevent the spread of viruses in hospitals must recognise the importance of ventilation and adequate PPE.
Hughes attended Ysgol Bro Plenydd primary school in the village of Y Ffôr, not far from Nefyn. The building dated back to the 30s, when tuberculosis – also an airborne disease – was rife. To minimise the spread of TB, architects designed an open-air school, with plenty of windows to let in fresh air. “The whole wall was pretty much glass,” Hughes says. “That stays with you.” Hughes’ parents operated a dairy farm and knew that ventilation is central to good animal husbandry.
Hughes was horrified by PHE’s insistence that surgical masks were adequate protection against Covid. “We have wards in hospitals with patients who are Covid cases. Often, they’re coughing and spluttering. But because they are not considered aerosol-generating, they don’t require the higher specification of PPE. Can someone please explain that one to me? No one has so far.”
In January 2021, Hughes coordinated an open letter, signed by 1,654 clinicians and scientists, that called on the government to make FFP3 masks available to all staff working with confirmed or suspected Covid patients and improve the ventilation in all hospitals. The letter, which was endorsed by the British Medical Association and the Royal College of Nursing, decried UK guidance as “inadequate”. But despite these high-profile backers, Hughes and his colleagues confronted deep inertia from PHE. “Hospital infection control officers are just fixated on droplet transmission and hand-washing,” Hughes says.
Individual staff who tried to challenge the guidance have been met with threats or gaslighting. “I am public enemy No 1 in my hospital … I’ve recorded conversations and done everything I can to protect myself,” says one NHS consultant, speaking anonymously. He forwards me emails sent to his chief executive, begging them to improve the ventilation on wards and provide FFP3 masks for staff. He believes that the existing guidance is tantamount to “corporate manslaughter”.
The Department of Health and Social Care (DHSC) insists that there is no proved link between the deaths of frontline health workers and the supply of PPE – and that its guidance around safe working includes the need for good ventilation. “Throughout this global pandemic, the safety of NHS and social care staff has been our top priority and we continue to work tirelessly to deliver PPE to protect them,” says a DHSC spokesperson. “In response to the new Covid-19 variants, the UK Infection Prevention Control cell conducted a comprehensive review of evidence and concluded current guidance and PPE recommendations remain appropriate.”
Caroline (not her real name) is a hospital doctor who works on an elderly care ward that admits Covid and non-Covid patients. The ward is split into red and green bays, depending on the Covid status of the patients in them. The bays are next to each other. Staff treat Covid and non-Covid patients and mix in the same communal areas. Patients use the same bathrooms. “Just saying that out loud still sounds surreal,” she says. “We infected so many patients – barely anyone left without picking up Covid in December or January if they hadn’t come in with it.” Early in 2021, Caroline emailed the chief executive of her hospital, pleading for FFP3 masks and improved ventilation.
“I had a call from the head of our infection control saying: ‘If you want to make a difference, spend more time cleaning communal touch areas with alcohol wipes,’” she says. The windows on Caroline’s ward open 5cm (2in). She asked management if they could be opened further. “I was told no, because of patient safety, even though the theoretical risk of the patients climbing out of the window was far lower than the risk of them dying of Covid,” she says.
Caroline has been tracking hospital-acquired cases on her ward and believes that at least 13 patients meet the criterion. “The most distressing thing is that we are killing our patients,” Caroline says. “This goes against the principle of ‘first do no harm’. We are actively doing harm.”
Earlier generations of clinicians stressed the life-saving importance of fresh air. Florence Nightingale championed well-ventilated wards with high ceilings. But, somehow, this knowledge has been forgotten. “It’s amazing,” says the intensive care doctor Tom Lawton, who is part of the Fresh Air NHS campaign. “We’ve gone the other way. We’ve forgotten the importance of fresh air and are obsessed with washing our hands and singing Happy Birthday.”
Despite the best efforts of the Fresh Air NHS campaign, the guidance has not changed. On 8 December, William Shakespeare, an 81-year-old man from Warwickshire, became the second person to receive the Covid vaccine in the UK. His image was beamed around the world. Many commented on the unusual coincidence of Shakespeare’s name, but few noticed the laminated sign affixed to a window behind Shakespeare’s head. It read: “PLEASE LEAVE WINDOWS CLOSED.” All three windows were shut.
What stings most for Christine is that all those months of careful shielding were for nothing. “I never thought I’d be in this position,” she says. “I thought we kept him safe.” Christine does not blame individual staff, but she is angry with the hospital authorities. “He didn’t deserve to die the way he did,” she says.
Lancashire Teaching Hospitals NHS foundation trust has denied that Carl was infected with Covid in hospital. “We offer our sincere condolences to Mr Dillon’s family and have discussed their concerns about his treatment with them,” says a spokesperson. “From our review of Mr Dillon’s case, the evidence doesn’t suggest that he caught Covid-19 while an inpatient in our hospital, and our hard-working staff have followed robust infection control measures in line with guidance from Public Health England throughout the pandemic.” They point out that Carl was treated in a side room after his initial admission, where he tested negative, and state that there were no Covid outbreaks on the ward in question during the period in which he was hospitalised. In January 2021, RPH brought in protective shields between beds to reduce the risk of airborne transmission.
Belatedly, it appears that the government has realised that safe hospitals require investment. Last October, the government allocated £3.7bn for the construction of 40 new hospitals, including four in the north-west. Announcing the funding, Johnson pledged that RPH would be replaced. But, in his March budget, the chancellor, Rishi Sunak, cut NHS England’s budget from £148bn in 2020-21 to £139bn in 2021-22.
In March 2021, the Fresh Air NHS campaign chalked up a small victory: the government published guidance acknowledging the risks of airborne transmission, along with a new slogan: hands, face, space and fresh air. The Health and Safety Executive mandated that employers assess workplaces for ventilation and prohibited people from working in poorly ventilated indoor settings.
But the government has not changed the guidance on PPE in hospitals, which was followed by staff at RPH, even though the Royal College of Nursing published a damning report in March, stating that the government’s infection control protocols were “fundamentally flawed and need replacing”, because they do not recognise the risk of airborne transmission. The BMA has also called for better PPE to protect against airborne transmission.
Estimates for the total number of English hospital-acquired Covid deaths in the second wave of the pandemic range from 4,000 to 10,000. A survey of 349 bereaved family members from the campaign Covid-19 Bereaved Families for Justice found that more than 40% of respondents believed their loved one contracted Covid in hospital. The family of the late Captain Sir Tom Moore have stated that he, too, contracted Covid in hospital. “No one comes to hospitals in a pandemic for fun,” says Lawton. “We owed it to them not to give them Covid.”
We told patients it was safe and sent them to underfunded, run-down hospitals. We clapped for NHS staff in the streets, then asked them to work in wards wearing inadequate PPE. At least 850 NHS staff died of Covid in the first and second waves of the pandemic. Perhaps worst of all, we exposed the most vulnerable people in our society to a deadly virus in a place that was meant to heal them.