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Nursing homes timeline: Early predictions of problems with PPE, hospital discharges and poaching of staff in letters

Hundreds of pages of correspondence between Nursing Homes Ireland and the Department of Health were released yesterday.

ON 6 MARCH details of visitor restrictions in nursing homes across the country were announced as the Covid-19 pandemic reached Irish shores.

At the time, 13 people had been diagnosed with the disease in the Republic of Ireland, and three in Northern Ireland.

Nursing Homes Ireland (NHI), the representative group for voluntary and private nursing homes, said the decision was made for the protection of residents.

It was the first major public point of disagreement between the organisation and public health authorities as, four days later, the Chief Medical Officer Dr Tony Holohan said such a measure was premature and should be lifted. 

Three days on, however, a strict ban on visitors was recommended by the National Public Health Emergency Team (NPHET), led by Holohan.

The disharmony didn’t end there though – in fact, it didn’t even start there, as documents released yesterday by the Department of Health clearly set out.

Included in 140 pieces of correspondence between its officials and NHI from 28 February to end-April, were early predictions of how many of the difficulties – shortages of personal protective equipment (PPE), recruitment problems and hospital discharges – would ravage the sector.

As of 25 May, there were 254 clusters of coronavirus in nursing homes, and of the 1,606 people who have died from Covid-19 in Ireland, 878 (54%) lived in such settings. 

As the crisis continues, a narrative that such outbreaks were not just predictable but inevitable has developed across many countries in Europe.

A lack of proper equipment such as face masks and gowns, the movement of staff around different healthcare facilities and a lack of guidance and testing for hospital discharges have all now been identified as possible contributory factors for the devastating death toll in Ireland’s 580 nursing homes.  

The prospect of all of them happening was raised with authorities.  

With the release of correspondence between the group and the department, we can see exactly what was being asked for and when. 

The alarm bells about the possibility of the catastrophe had been ringing in Ireland since 28 February when NHI began raising its concerns with ministers and department officials. It wanted help on how to keep the virus out of care homes entirely.

On that day, Tadhg Daly, the chief executive of NHI wrote to Junior Minister for Older People, Fine Gael’s Jim Daly, thanking him for his phone call during which they discussed the HSE and HSPC guidance in relation to the coronavirus outbreak.

In that early letter, Tadhg Daly raised concerns about a possible shortage of PPE – which became one of the key problems for Ireland’s nursing homes. It was the first time the sector documented how some nursing homes did not have adequate stocks.

Leading up to that date, nursing home members said they had been unable to acquire the equipment and the NHI boss outlined that he had asked the HSE about the provision of items such as face masks. 

letter 1

It later emerged – in April – that the PPE issue had escalated to such an extent that some nursing homes were forced to use painters’ overalls and supplies from a local school and vet as PPE.

PastedImage-75712 NHI's Tadgh Daly in the Dáil yesterday

In that first letter, NHI also told department officials that the first Covid-19 case had been confirmed and urgent guidance was needed for the sector (the public announcement of the first case only came on 29 February). Daly attached a leaflet provided to Scotland’s nursing home owners and asked for the HSE and HPSC to review it so they could provide similar “dedicated guidance”. 

Officials responded to Daly saying that they were following the advice of the Chief Medical Officer Dr Tony Holohan and NPHET.

The letter committed to “follow up” with NPHET about the queries raised. There were 69 pieces of correspondence between the Department of Health and NHI throughout March.

The emails and letters show that the tone taken between NHI and the department in those early stages was relatively friendly, with open lines of communication evident from both sides. 

On 2 March, there was reference to guidance being issued to nursing homes on how to deal with the virus in the congregated care setting, with reference also to a HSE conference call which was described as “very positive”.

On 3 March, a department official confirmed that a subgroup on vulnerable people was set up under NPHET. Tadgh Daly asked for a commitment that nursing homes would be included in planning.

On 5 March, nursing homes took part in a conference call with the HSE. Somewhere in the next few hours, the atmosphere changed. 

Daly raised the issue of visitor restrictions with a department official, proposing that the NHI issue guidance to its members immediately due to the vulnerability of residences. The official passed the queries on with a note that the NHI had been “very responsible and helpful” with regard to its communications with its members. 

She also said that she had “advised Tadgh to await our response before issuing a communication to his membership”. 

A ban on non-essential visiting was announced by NHI the following day – 6 March. There was no further email or letter about the issue released as part of yesterday’s document dump so it’s unclear if the department or the HSE knew before it happened. 

Daly, on that day, also raised another issue that was to become a major controversy – the discharging of patients from hospitals to nursing homes, without testing taking place.

In a message, written to the HSE and forwarded to the department, he said he was getting “increasing queries from members re safe and appropriate discharges from acute hospitals to nursing homes”. 

“There is an immediate requirement on the HSE to outline the procedures for discharge,” he wrote, including a message to the department official that it was important “to work together” in order to maximise available capacity.

The NHI boss asked whether all patients would be swab-tested, and what reassurances and information could be provided to protect nursing home staff and residents.

He warned that matters may get “out of control” without correct communication by the HSE.

letter 2

On 9 March, Daly asked for a response, stating that collective communication to nursing homes on the matter was essential. 

On the same day, after the department asked the HSE for guidance, a HSE official said that draft guidance on patient discharges was in production, but not yet ready for circulation.

Again on 9 March, the NHI sent a letter to the Secretary General of the Department of Health Jim Breslin, to raise another issue that nursing homes have since said hindered their chances of fighting Covid-19: the recruitment of healthcare workers by the HSE from the sector.

The letter was also sent to Minister Harris.

The correspondence warned that hiring staff from the nursing home sector would have a detrimental impact on care homes and could even “endanger older people”.

The NHI asked for the restrictions on the recruitment of healthcare assistants from outside the EU to be lifted. 

“The potential recruitment of staff from our sector will be to the severe detriment of people in nursing home care who present with severe underlying conditions,” he wrote.

It will threaten the capacity of nursing homes to meet their care needs during a period of a health emergency and will endanger older people.

“It will also prove counter-productive as any reduction in the capacity of the nursing home sector will have an immediate impact on the timely and appropriate discharge of patients to nursing homes.”

An email to a number of TDs, including Health Minister Simon Harris, also on 9 March shows Daly highlighted the “considerable anxiety” among private and voluntary homes regarding their capacity to access PPE. 

“Your assistance with this will be vital to keep private and voluntary nursing homes open as the crisis deepens. Timely provision of such equipment is paramount for the protection of our frontline workers and in turn residents.

“Suppliers have confirmed to NHI and members that they are not in a position to supply as they state that they are supplying all such products exclusively to HSE at this time,” he said. 

We appreciate there is unprecedented requirements for such equipment but seek assurance of immediate access to supply for private and voluntary nursing homes and there will not be discrimination applied in providing such essential equipment.” 

Breslin responded to say officials will “look at the issues raised”.

On 10 March, NHI again told the department that immediate communication was required on hospital discharges. The group asked that risk assessments be carried out on a patient if they are going to be sent to a nursing home.

Daly again said that nursing homes wanted assurances that if a patient had been in contact with a Covid-19 patient that they not be discharged into a nursing home.

On 12 March, NHI asked the department for urgent guidance as to what nursing homes should do if a staff member or resident is suspected of having Covid-19.

The correspondence recalls that advice to date had been on prevention and PPE. New protocols should be circulated as a priority, the department was told.

Guidance was issued two days later to advise that residents with suspected Covid-19  should be isolated while awaiting results, while confirmed cases should be managed by acute hospital services.

NHI also told the HSE that it was its members’ view that no patient should be transferred unless that person tested negative for the virus.

The group said it was trying to strike the balance of not exposing residents to the virus, while also responding to the national crisis by freeing up capacity in the acute hospitals.

letter 2

That day – 12 March – Taoiseach Leo Varadkar took to a podium in Washington DC to tell the nation he ‘needed to speak about the coronavirus’.

With his announcement about immediate school and college closures came increased fears about maintaining safe staffing levels in nursing homes.

There were 70 confirmed cases of coronavirus in Ireland at this time, and one death had been recorded. A woman in the east of the country was confirmed to have died after being diagnosed with Covid-19 on the same day the World Health Organisation declared a pandemic, and its chief Tedros Adhanom Ghebreyesus said he was worried about “alarming levels of inaction” in some parts of the world. 

Two days later, nursing homes asked about getting all of their residents tested. They also asked about PPE, again. 

On 15 March, the day the pubs shuttered, the NHI again raised issues around nursing homes securing PPE, with the additional concern that much of the current stock was largely “inadequate”.

St Patrick’s Day, and a letter was sent to the Minister Simon Harris from the nursing home group to tell him its members were under severe staffing pressure. The minister was also told that the HSE was targeting particular nursing homes in a bid to attract staff.

On 18 March – as a reminder of the friendly relations – Daly thanked a department official for their round-the-clock availability, but added that securing PPE had been “challenging to say the least”.

He said that he had received communications from nursing homes that the HSE has been “inconsistent” and “not supportive” when they have inquired about obtaining PPE. 

A commitment that the HSE would provide PPE to nursing homes was sought, with NHI asking that it be addressed as a matter of urgency.

PastedImage-50468 The nightly Department of Health briefing

As has been previously well-aired, NHI requested an urgent meeting with Minister Harris on 19 March. The next day, the group confirmed to the department it was dealing with a nursing home outbreak – listed among the 557 cases confirmed that day, which marked a huge increase of 52% on the previous day’s total. A conference call between officials and NHI then took place.

On 24 March, the nursing homes groups made a submission to the health minister for additional funding, something it said was necessary to ensure the continuation of its services.

Minister Harris met with NHI on 30 March – two days after the Taoiseach issued the stay-at-home order – and committed to providing those extra supports. It was also a day after the first Aer Lingus flight carrying PPE from China landed. 

Out of the NPHET meeting on 31 March, it was agreed that those living in long-term residential care are very vulnerable and six healthcare actions were agreed, which included infection control specialist teams and the priority of healthcare staff testing.

The number of clusters in nursing homes was becoming apparent – as of midnight 1 April, there were 40 across the country, most of which were located in the east. 

At this juncture, Harris said that Hiqa should undertake a risk assessment to see which nursing homes required extra supports. 

Then, in early April, NHI conducted a survey of its members which was forwarded to Minister Harris. Some 44% of nursing homes said they were waiting more than 10 days for testing.

One operator commented that they were “still waiting 20 days later” while another said that “one resident died while awaiting testing”. One nursing home said it was  “simply a disaster”.

The survey showed that 12% of nursing homes said they were still “waiting indefinitely” for PPE to be supplied.

Another provider said they were using “painters overalls, painters goggles, surgical masks that cost €1.50 each”.

“We have spent over €12,000,” it said.

We have received eye protection from a local school, overalls from local vet, face masks purchased from dressmakers.”

On 14 April, Daly writes to the department ahead of a video conference and mentions contingency planning in relation to depleted staffing levels.

“Consider mobilisation of resources for example from the Red Cross, St John’s Ambulance, FCA, Army, first responders Order of Malta to help nursing homes with staffing,” he said.

On 15 April, trade unions and health authorities agreed on a scheme that could see HSE staff redeployed to badly affected private nursing homes on a voluntary basis. 

The stories of those individual nursing homes ravaged by Covid-19 started to emerge in the press within days. St Mary’s Hospital in the Phoenix Park lost 11 of its residents between 2 and 17 April. (That number, sadly, has since increased.)

Also on 17 April, NHI raised its objection with the minister about nursing homes not having a seat on NPHET, stating that it is “like Hamlet without the prince”.

On 20 April, RTE’s north-east correspondent Sinéad Hussey reported that a County Louth nursing hope was taken over by a HSE hospital group because of how it was suffering through the pandemic. Dealgan House in Dundalk had seen 10 deaths up to that point. That figure has since grown to 23.

On 23 April, the Department of Health confirmed that there were 191 clusters of the virus in nursing homes, composed of 2,231 cases. That day, Dominic McGrath reported in that many operators were privately criticising the Health Information and Quality Authority (HIQA) for its slow response to the crisis. There were questions raised about why it took until 21 April for the watchdog to issue an assessment framework to help prepare nursing homes for a Covid-19 outbreak. 

A spokesperson for Hiqa, which is represented on NPHET, said at the time: “Since early March, HIQA has been in frequent contact with the providers of nursing homes, the Department of Health and the HSE to ensure that residents are protected and continue to receive safe care during the Covid-19 outbreak.” 

Around that time, concerns were also raised about the financial support scheme for nursing homes not being finalised some two weeks after its announcement.

The department then went ahead and published the details, much to the “shock and disappointment” of NHI which said it was under the impression there would be further engagement before such an action was taken.

After considerable correspondence on the Draft Outbreak Assistance payments for nursing homes, the group began to look at how visitor restrictions might be lifted in the future. 

As the peak passed and other issues around PPE and discharges also subsided, Hiqa was hearing from residents about feelings of isolation and loneliness. 

On 12 May, a briefing document for a video conference with the health minister outlined some suggestions. It suggested that initial visits be kept to 15 to 30 minutes to allow more people access. It also said any changes should be reviewed on a weekly basis.

That same day, Daly wrote to Hiqa chief executive Phelim Quinn, a NPHET member, to say he was disappointed to read the Irish Times article that stated “prison-type visiting scenarios” are envisaged when visitation is reopened.

He said the linking of nursing homes to prisons is “offensive, upsetting and irresponsible”. He said those working in nursing homes are only interested in protecting residents and their well-being.

Last night, there was some light for residents and their families. At the evening Department of Health briefing, Holohan said officials – who he described as “very sensitive” – are trying to be “creative” about how visiting in some form may be able to begin again from the end-June.

“It’s one of the reasons why, if I go back to the beginning, we were reluctant to see a blanket restriction on visiting into facilities, particularly nursing home facilities, which is essentially cutting people off from their loved ones who live in these facilities,” he said. 

The cache of documents was characterised yesterday by Sinn Féin’s Louise O’Reilly as healthcare providers “begging” for assistance, while Fine Gael’s Fergus O’Dowd said it “is not a fact” that nursing homes were isolated. During the Oireachtas committee hearing on Covid-19 in nursing homes, he said that the State provided funding to the private nursing homes and now wealthy companies were complaining that the State did not do enough for them.

“We need to stop this game of blaming everyone… we are not doing enough, we never did enough,” he said, adding, “It is a scandal that this happened.”

Meanwhile, Mervyn Taylor from Sage Advocacy, a group which advocates for vulnerable people such as the elderly, said he still does not believe the voices of older people are being heard in this country. 

-With reporting by Sinéad O’Carroll

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