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.

Dear Ms Mutch, Thank you for your letter of 10 June 2021 to the Secretary of State for Health and Social Care about the death of Clive Edward Rivers. I am replying as Minister with responsibility for Covid-19 vaccine deployment and I am grateful for the additional time in which to do so. Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Rivers’ death. I can understand how deeply upsetting losing a loved one in such circumstances during the emergency period of the COVID-19 pandemic must be and I offer my most heartfelt condolences to Mr Rivers’ family and loved ones. In preparing this response, Departmental officials have made enquiries with NHS England and NHS Improvement (NHSEI), to which you also issued your report. I will address each matter of concern in turn. In relation to your concern about the availability of Covid-19 vaccinations for hospital inpatients’ with increased clinical risk factors, it may be helpful if I explain that in determining vaccine prioritisation, the Government takes advice from the Joint Committee on Vaccination and Immunisation (JCVI), which is the independent body made up of scientific and clinical experts who advise the Government on which vaccines the United Kingdom should use and provides advice on prioritisation at population level. The Government’s priority for the first phase of the COVID-19 vaccination programme was to reduce COVID-19 mortality and protect health and social care staff and systems. This position was informed by the JCVI’s advice on prioritisation, which the Government accepted. For the first phase, the JCVI advised1 that the vaccine be given to care home residents and staff, as well as frontline health and social care workers, followed by those aged 50 and 1 Priority groups for coronavirus (COVID-19) vaccination: advice from the JCVI, 30 December 2020 - GOV.UK (www.gov.uk)

above, in order of age and clinical risk factors. Included in this, were those with underlying health conditions, which put them at higher risk of serious disease and mortality.

Anyone in hospital and falling within the JCVI’s recommended groupings being invited for vaccination, would be eligible for the vaccine, subject to a clinical assessment of suitability on a case by case basis and local operational policies. While there is no national guidance preventing hospitals from vaccinating hospital inpatients, operational decisions on who to offer a vaccine to, and in what settings, are made locally, and in the context of the JCVI’s advice.

For individuals who are acutely unwell, the JCVI guidance, as stated in Chapter 14a of the Greenbook, advises against vaccination during acute illness. If an individual has been infected by COVID-19, then they should be clear of COVID-19 infection prior to vaccination. This guidance has been in place since November 2020 and has remained unchanged.

In relation to Mr Rivers’ discharge from hospital, I would like to assure you that it is our priority to ensure that everyone receives the right care, in the right place, at the right time. This includes ensuring that people are discharged safely from hospital to the most appropriate place, and that they receive the care and support they need.

Daily morning board rounds to review every person and make decisions, informed by the criteria to reside, are the foundation for avoiding delays and improving outcomes for individuals. Transfer from the ward to a dedicated discharge area should happen promptly.

The criteria to reside tool2 equips clinical teams to have discussions and make decisions about whether a person needs to stay in an acute bed to receive care. This should then lead to a plan concerning the resources and services required to support a safe and timely discharge of that person if they no longer need the support and services of an acute hospital.

When patients are discharged from hospital needing support to recover at home, rehabilitation or short term care, or care in a residential setting, our discharge guidance3 sets out that NHS organisations must work closely with adult social care colleagues, the care sector and the voluntary sector to arrange this care. Our guidance also sets out the importance of local authority and adult social care staff working closely with hospital staff to make arrangements to support safe and timely discharge. All patients (or their representative or advocate if they lack capacity) should be given information and advice when discharged, including who they can contact if their condition changes, how their needs will be assessed and the follow up support they will receive.

People should expect to receive high quality personalised care including regular updates and sharing of information about the next steps in their care and treatment. This should include joint decision-making processes and clarity on plans for the person’s post-discharge care.

2 Hospital discharge and community support: policy and operating model - GOV.UK (www.gov.uk)

3 Hospital discharge and community support: policy and operating model - GOV.UK (www.gov.uk)

At system level, a ‘transfer of care hub’ should be in place (physically or virtually) to ensure that all relevant services can be linked in order to provide appropriate care and support. Transfer of care hubs will ensure information essential to the continued delivery of care and support is communicated and transferred to the relevant heath and care partners on discharge (including the outcome of the last COVID-19 test for that person, where relevant).

Under the discharge pathways, all persons leaving hospital should receive a holistic welfare check to determine the level of support, including non-clinical factors like their physical, practical, social, psychological and financial needs. The recovery and support provided post-discharge (including rehabilitation and reablement services) aims to help people return to the quality of life they had prior to their most recent admission.

Every person who is discharged on pathways 1 to 3 should have an allocated case manager who will closely monitor and review progress to ensure the individual receives appropriate care without delay and that there is no delay in assessing and planning for any long-term support as soon as it is possible to form an accurate picture of likely need and options following a period of recovery after discharge.

It is vitally important that local organisations and system-level leaders reflect carefully on, and take learnings from, the circumstances of deaths related to the Covid-19 pandemic, such as that of Mr Rivers, and I am grateful to you for bringing these concerns to my attention. It is right that there is an active and continuous process of learning, adapting and responding to the challenges of the Covid-19 pandemic and you will know that the Prime Minister has announced that there will be a full statutory inquiry into the Government’s response to the Covid-19 pandemic, beginning in Spring 2022, to identify national learnings.

I am advised that the NHS in Greater Manchester has looked carefully at how Mr Rivers became infected with Covid-19 as well as the circumstances of his discharge from hospital, which I understand was explained in evidence to the inquest into his death.

Finally, you may wish to note that my officials have shared your report with the Care Quality Commission, the independent regulator for quality, and with the Healthcare Safety Investigation Branch (HSIB) to support its intelligence monitoring of patient safety risks.  The HSIB conducts national patient safety investigations where certain criteria are met. 

I hope this response is helpful.

MAGGIE THROUP