People with learning difficulties may have died needlessly from coronavirus, report finds
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Care workers looking after people with learning difficulties who had Covid-19 were not adequately trained or prepared, a report into coronavirus deaths has found.
“Untrained staff without the tools or knowledge required to monitor residents” with coronavirus could not “recognise signs of deterioration and act appropriately when needed” and relied heavily on GPs and out-of-hours support as a sufferer’s condition got worse.
Bristol, North Somerset and South Gloucestershire (BNSSG) CCG’s Learning Disability Mortality Reviews 2020/21 report highlights other factors likely to have contributed to deaths, such as an intolerance to oxygen masks in hospital and not enough done to help people overcome that.
It says that of the 100 people whose deaths were reviewed between January 2020 and March this year, over a third were related to pneumonia and about one in eight to Covid-19, although that figure is believed to be higher in reality because of under-reporting.
The report to the CCG’s governing body on June 1, said the learning disability population was six times more likely to die from coronavirus and the vast majority of deaths happened in the first couple of months of the pandemic.
It said 14 of the 16 Covid deaths reviewed occurred between March and May 2020.
“During this time there were difficulties with personal protective equipment (PPE) as well as a lack of guidance from the government regarding its usage,” the report states.
“This could provide some rationale as to why there were so few deaths reported beyond May to January 2021, as guidance was clearer and PPE readily available.”
It said eight out of 10 people with a learning disability in BNSSG received “satisfactory or better” care and no cases were identified where the care given contributed to death, although neither was any care deemed “outstanding”.
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The report’s findings from an in-depth review of those who died from Covid-19 said most would not have been able to follow the “hands, space, face” government guidance, including social distancing and wearing face masks in high-risk environments, without “significant support”.
“One person was noted to persistently follow [care home] staff around and would regularly go into other residents’ bedrooms,” it said.
“This was of particular concern when they contracted Covid-19.“Some of the restrictions caused great distress to residents.
“Across a number of care settings there was evidence of difficulty in isolating residents due to the design and layout of the buildings.
“They were designed to be sociable places with shared living spaces and open plan areas.
“Where this was not the case, outbreaks were easier to control.”
It said two people living in a residential service also required nursing care which was provided by district nursing rather than in-house staff.
“This could have been a likely source of infection as these were the only residents in the homes to receive district nursing care and to contract Covid-19,” the report said.
“Care providers acknowledged in the review that they were not trained in monitoring physical health or providing end-of-life care, both of which were expected during the pandemic.
“As a result, care staff relied heavily on GPs and out-of-hours support, often calling on a daily basis, and as health further deteriorated this would increase to multiple calls a day.”
It said there was no evidence any of the residential services used a recognised process for monitoring a resident’s health that includes spotting “early soft signs”, taking observations, responding and escalating.
“This led to untrained staff, without the tools or knowledge required to monitor residents with Covid-19,” the report said.
“There was further evidence of staff’s inability to recognise signs of deterioration and act appropriately when needed.
“In one case, staff contacted the GP surgery rather than emergency services when someone was showing clear signs of a stroke.
“Another person had fallen and was unable to move from the floor due to pain.
“The care team called the GP instead of an ambulance, prolonging the time taken for the person to receive the care they needed.
“Most homes had no training in providing end-of-life care even though they were supporting older adults, some of whom had experienced a decline in health, and the care staff did not have time to access additional training, especially during the pandemic.”
The review discovered that the people with learning difficulties who died had found it difficult to tolerate wearing oxygen masks when admitted to hospital.
“All were assessed as requiring oxygen but were unable to tolerate the masks or nasal cannula,” the report said.
“As a result they did not have oxygen treatment and it is possible that this may have contributed to death.
“There was no evidence of proactive support to enable tolerance of this through reasonable adjustments or desensitisation.”