NHS England
NHS / Health Body
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NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. (AI summary)
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Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Clive Rivers, died 5 February 2021 Thank you for your Regulation 28 Report to Prevent Future Deaths (“PFD Report”) dated 10 June 2021 concerning the death of Mr Clive Rivers on 5 February 2021. Firstly, I would like to express my deep condolences to Mr Rivers’s family. The inquest held on 8 February 2021 concluded that Mr Rivers’s death was a result of Covid-19 on a background of immunomodulatory treatment. Following the inquest, concerns were raised via a PFD Report to NHS England, specifically in relation to the following points:
1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients. Therefore, Mr Rivers was not vaccinated;
2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19;
3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19. Please see below answers to each individual point of concern raised: Point 1: On 30 December 2020 the Joint Committee on Vaccination and Immunisation issued the following guidance: National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 23rd September 2021
“Phase 1 – direct prevention of mortality and supporting the NHS and social care system
JCVI advises that the first priorities for the COVID-19 vaccination programme should be the prevention of mortality and the maintenance of the health and social care systems. As the risk of mortality from COVID-19 increases with age, prioritisation is primarily based on age. The order of priority for each group in the population corresponds with data on the number of individuals who would need to be vaccinated to prevent one death, estimated from UK data obtained from March to June 2020 (see reference 3):
1. residents in a care home for older adults and their carers
2. all those 80 years of age and over and frontline health and social care workers
3. all those 75 years of age and over
4. all those 70 years of age and over and clinically extremely vulnerable individuals[footnote 1]
5. all those 65 years of age and over
6. all individuals aged 16 years[footnote 2] to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality[footnote 3]
7. all those 60 years of age and over
8. all those 55 years of age and over
9. all those 50 years of age and over”
Full details of this guidance can be found here: Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination, 30 December 2020 - GOV.UK (www.gov.uk)
I am also aware that a letter went out to the wider healthcare sector on the 4th December 2020, prior to the vaccination programme commencing, indicating at that stage that vaccination of inpatients could occur in line with JCVI guidance for cohort one. There was no further correspondence regarding the vaccination of inpatients from the national Programme until May 2021 regarding the vaccination of people with Severe Mental Illness (SMI), learning disability and dementia.
The guidance C1399-Updated-JCVI-guidance-for-vaccinating-immunosuppressed- individuals-with-third-primary-dose.pdf (england.nhs.uk) states that: If the individual is receiving care within a hospital that operates as a hospital hub and there is available vaccine supply, we recommend the individual receives the vaccine on site in line with the consultant’s recommendation on timing. If it is not possible to offer the individual a vaccine on site, consultants should write clear advice to the individual’s GP specifying the optimal timing and any interaction with their current treatment. The individual should then receive their vaccination through a PCN grouping-led site.
Point 2:
The National Hospital Discharge policy (August 2020 version which was in place at the time) set out the Criteria to Reside in acute settings. In the policy, it is clear that once an individual no longer meets the Criteria to Reside, they should, where possible, be discharged on that day and ideally by 5pm. The Criteria to Reside is a framework for clinicians to use to guide decision-making. Clinical exceptions may occur but must be warranted and justified.
Point 3:
Public Health England’s guidance states that discharge of Covid-19 patients to their own home can be done when the patient’s clinical status is appropriate for discharge, for example, once assessed to have stable or recovering respiratory function, and any ongoing care needs can be met at home. The guidance states that people should be given clear safety-netting advice for what to do if their symptoms worsen. The complete guidance can be found here: Guidance for stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients - GOV.UK (www.gov.uk). The section ‘ Discharge of COVID-19 patient to own home’ is of most relevance.
The National Hospital Discharge policy states that community health, social care and acute care staff need to work in full synchronisation (include housing professionals where necessary) to ensure people are discharged in a safe and timely manner.
As part of the Short term rehabilitation/reablement-at-home review described in the August 2020 version of the national policy, a professional supervision/case management model should be used and the case manager must review all people on their caseloads daily including the question: can we safely discharge this person? Post discharge, the case managers, in conjunction with the single point of access, will need to work with partners to ensure the staff and infrastructure are available to meet immediate care needs.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients. Therefore, Mr Rivers was not vaccinated;
2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19;
3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19. Please see below answers to each individual point of concern raised: Point 1: On 30 December 2020 the Joint Committee on Vaccination and Immunisation issued the following guidance: National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 23rd September 2021
“Phase 1 – direct prevention of mortality and supporting the NHS and social care system
JCVI advises that the first priorities for the COVID-19 vaccination programme should be the prevention of mortality and the maintenance of the health and social care systems. As the risk of mortality from COVID-19 increases with age, prioritisation is primarily based on age. The order of priority for each group in the population corresponds with data on the number of individuals who would need to be vaccinated to prevent one death, estimated from UK data obtained from March to June 2020 (see reference 3):
1. residents in a care home for older adults and their carers
2. all those 80 years of age and over and frontline health and social care workers
3. all those 75 years of age and over
4. all those 70 years of age and over and clinically extremely vulnerable individuals[footnote 1]
5. all those 65 years of age and over
6. all individuals aged 16 years[footnote 2] to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality[footnote 3]
7. all those 60 years of age and over
8. all those 55 years of age and over
9. all those 50 years of age and over”
Full details of this guidance can be found here: Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination, 30 December 2020 - GOV.UK (www.gov.uk)
I am also aware that a letter went out to the wider healthcare sector on the 4th December 2020, prior to the vaccination programme commencing, indicating at that stage that vaccination of inpatients could occur in line with JCVI guidance for cohort one. There was no further correspondence regarding the vaccination of inpatients from the national Programme until May 2021 regarding the vaccination of people with Severe Mental Illness (SMI), learning disability and dementia.
The guidance C1399-Updated-JCVI-guidance-for-vaccinating-immunosuppressed- individuals-with-third-primary-dose.pdf (england.nhs.uk) states that: If the individual is receiving care within a hospital that operates as a hospital hub and there is available vaccine supply, we recommend the individual receives the vaccine on site in line with the consultant’s recommendation on timing. If it is not possible to offer the individual a vaccine on site, consultants should write clear advice to the individual’s GP specifying the optimal timing and any interaction with their current treatment. The individual should then receive their vaccination through a PCN grouping-led site.
Point 2:
The National Hospital Discharge policy (August 2020 version which was in place at the time) set out the Criteria to Reside in acute settings. In the policy, it is clear that once an individual no longer meets the Criteria to Reside, they should, where possible, be discharged on that day and ideally by 5pm. The Criteria to Reside is a framework for clinicians to use to guide decision-making. Clinical exceptions may occur but must be warranted and justified.
Point 3:
Public Health England’s guidance states that discharge of Covid-19 patients to their own home can be done when the patient’s clinical status is appropriate for discharge, for example, once assessed to have stable or recovering respiratory function, and any ongoing care needs can be met at home. The guidance states that people should be given clear safety-netting advice for what to do if their symptoms worsen. The complete guidance can be found here: Guidance for stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients - GOV.UK (www.gov.uk). The section ‘ Discharge of COVID-19 patient to own home’ is of most relevance.
The National Hospital Discharge policy states that community health, social care and acute care staff need to work in full synchronisation (include housing professionals where necessary) to ensure people are discharged in a safe and timely manner.
As part of the Short term rehabilitation/reablement-at-home review described in the August 2020 version of the national policy, a professional supervision/case management model should be used and the case manager must review all people on their caseloads daily including the question: can we safely discharge this person? Post discharge, the case managers, in conjunction with the single point of access, will need to work with partners to ensure the staff and infrastructure are available to meet immediate care needs.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.