Covid-19: The visitor that shouldn’t have come to Irish nursing homes

WHILE HEALTH AUTHORITIES PREPARED HOSPITALS AND OTHER SECTORS FOR COVID-19, THE VIRUS WAS SILENTLY SPREADING THROUGH NURSING HOMES. HOW WAS IRELAND ‘CAUGHT OFF GUARD’?

Sitting in her bedroom in St Mary’s Hospital nursing home in the Phoenix Park in Dublin, Rose Hegarty was listening to Taoiseach Leo Varadkar’s March 12th speech announcing the closure of schools and restrictions on public gatherings. This was the Government’s first sweeping attempt to stem the coronavirus outbreak since the first case had been confirmed in the State 13 days earlier.

For the previous week, Hegarty had been taking protective steps of her own. The 84-year-old had been avoiding the home’s communal dining area, taking meals in her room and regularly using hand sanitiser. She knew that her underlying kidney condition meant danger if coronavirus came to her.

In the end, she was powerless to stop it. This week, Hegarty became one of 23 residents at the nursing home to die from Covid-19, the disease caused by the virus that has killed more than 230,000 globally.

Irish nursing homes, where 25,000 people live and 30,000 staff work, have become ground zero for the coronavirus pandemic in Ireland. The Phoenix Park nursing home is one of the worst affected.

By Thursday April 30th, some 735 people in community residential settings had died, accounting for 60 per cent of all 1,232 Covid-19 deaths in the State. Nursing homes accounted for 630 deaths or half the people who have died in the State since the first coronavirus-related death on March 11th – 52 days ago.

The elderly are among the most vulnerable to the deadly virus. One in every six nursing home residents who contracted Covid-19 have died, Department of Health figures show. This is more than three times the overall mortality rate among more than 20,000 people infected by the virus in the State.

The vast majority of the deaths from the virus of nursing home residents have taken place in those homes. Just 16 per cent have died in acute hospitals. Of those infected in nursing homes – 3,679 as of Thursday – just 5 per cent were hospitalised. Most residents infected recover from the virus.

We have an entire industry where we have a lot of people who are compromised due to age and previous conditions in a single area. All it takes essentially is one person and one sneeze or cough for the virus to spread

Nursing homes were advised by the HSE on March 25th that Covid-19 patients should be managed in their facilities and that transfer to hospital was “only appropriate where this will confer additional benefit”. The HSE says transfers to hospitals are based on case-by-case clinical decisions.

“We have an entire industry where we have a lot of people who are compromised due to age and previous conditions in a single area. All it takes essentially is one person and one sneeze or cough for the virus to spread,” says UCD researcher Karl Conyard, a public health adviser for HCA and Carers Ireland, a support network for health care assistants and carers. Conyard worked as a healthcare assistant in nursing homes for three years.

The scale of death to befall nursing homes in just seven weeks has left a sector that has suffered from years of funding and staffing challenges struggling to cope.

At St Mary’s, there are 150 nursing home beds and a separate 48-bed hospital.

As of this week, just under half of the 149 residents between the nursing home and hospital have contracted the virus or are suspected of having Covid-19, the HSE has said.

ON MARCH 6TH, St Mary’s, a publicly run facility, banned all visitors, taking its lead from the Nursing Homes Ireland (NHI), the representative body for the country’s private nursing home operators. About 75 per cent of the country’s 540 nursing homes are privately owned and operated.

Four days later, the State’s chief medical officer Dr Tony Holohan questioned the closure of nursing homes to visitors and the social impact of such restrictions “before they are really necessary”.

“It wasn’t too soon,” says Dr Jack Lambert, an infectious diseases specialist at the Mater Hospital in Dublin, who has treated nursing home patients infected with Covid-19 on his wards.

“That was absolutely the wrong decision, in hindsight,” he says of Dr Holohan’s querying the decision. “We didn’t close the nursing homes in a timely fashion. That was an opportunity.”

“This is a fast and hugely infectious disease. I see people come in to the hospital, and in 12 hours they go from zero to dead right in front of my eyes. It is a really scary disease. You can die very quickly if the right things are not done,” he says.

Dr Holohan later explained his comments, saying that introducing restrictions “too early” or “keeping them for too long” could weaken “public buy-in and understanding” and “greatly increase the risk of those measures not being effective”.

The National Public Health Emergency Team (NPHET) has since produced a graph showing that the steepest rise in nursing home cases came later than the 14-day incubation period after Dr Holohan’s statement.

St Mary’s nursing home reversed its decision after Dr Holohan’s comments and, for a seven-day period, allowed visitors in and out.

While staff were appealing for PPE on social media the virus was already silently spreading through the care home

It changed its rules again on March 18th in an internal memo to staff stating “a no visiting approach will be reintroduced for all residents”.

At this stage, there were reported Covid-19 outbreaks – each defined as two cases or more – in just three nursing homes, official figures show.

Staff at St Mary’s were beginning to express concerns over a shortage of personal protective equipment (PPE), with some even making appeals for PPE donations on social media. At this stage the virus was already silently spreading through the care home.

In a March 26th email, staff were instructed on the “prudent” rationing of PPE. “The unnecessary use of PPE will deplete stocks which will be needed as the number of people with the virus increases,” the email said.

A HSE spokeswoman said St Mary’s first requested additional PPE on March 19th, with a consignment delivered the next day, and it currently had “adequate” supply.

Staff were reminded that HSE guidelines did not recommend the use of face masks when treating confirmed or suspected Covid-19 cases “in situations other than close contact”.

At the time, PPE shortages were being felt across other nursing homes.

Tadhg Daly, the chief executive of Nursing Homes Ireland, said the organisation had been looking for PPE for nursing homes from late February and early March. “Beg, borrow and steal – we were trying to source it where we could,” he recalls.

Paul Reid, HSE chief executive, reported to the organisation’s board on February 21st that 11,500 PPE “packs” had been issued to GPs, out-of-hours services, primary care centres, public health doctors, occupational health workers and even to the Defence Forces and university GP services. There was no mention of nursing homes in his report, seen by The Irish Times.

Given the large number of people in the nursing home sector, it beggars belief that Simon Harris, the Minister for Health, has not even picked up the phone to ring us 

Daly had, from late February, unsuccessfully sought help for the sector on the supply of PPE and staff as well as guidance from the Government. Frustrated, on March 25th he complained publicly about the failure of Minister for Health Simon Harris to meet his group and at least five unanswered letters or emails.

“Given the large cohort of people in the nursing home sector, it beggars belief that he has not even picked up the phone to ring us,” Daly said that day.

The nursing homes group eventually met Harris on Monday, March 30th. A package of State supports for nursing homes was announced the following weekend.

The group, representing more than 400 nursing homes, is still not represented on the National Public Health Emergency Team or its sub-groups.

The Department of Health says the regulator of the nursing homes sector, the Health Information and Quality Authority (Hiqa), is “very familiar” with the sector, including “the challenges that may exist”, and is “the appropriate body” to inform the NPHET.

The department says it has been in “ongoing, extensive communication” with the nursing homes body and the HSE has been “regularly engaging” with it since January.

ON MARCH 29TH – the day before the Minister first met the nursing homes group – Rose Hegarty’s family were informed there had been a confirmed case at St Mary’s.

At this stage, the number of Covid-19 clusters in nursing homes, mostly in the east of the country, had surged to 24, a six-fold increase in just one week, and the death toll had risen to 46.

“They contacted my sister, to say that there was a case, not in her ward,” Jane Carrigan says, recalling the news of the case at her aunt’s nursing home. “It was the other side of the building; we were hoping against hope it wouldn’t reach her,” she says.

Hegarty was moved into St Mary’s Oisín ward from hospital last July after a severe kidney infection. From Finglas in north Dublin, Hegarty was widowed in her 40s and never had children, but was very close to her nieces and nephews.

“She loved St Mary’s and it had given her a new lease on life,” her niece says. A nature lover, Hegarty enjoyed the home’s gardening activities. The window of her ground floor room gave her regular sight of the deer roaming in the Phoenix Park.

On April 2nd, the first resident in St Mary’s died from Covid-19.

Two days later, it emerged that there was a positive case in Rose Hegarty’s ward. Relatives recalled her premonitions after hearing the news.

“She had said it will come for her,” says Carrigan. “She could be stoic and always planning for the worst possible outcome.”

The penny was dropping that we had so many sick. Covid was in the building

The day the virus arrived on Hegarty’s ward, Margo Hannon, a health care assistant on the ward for three years, walked outside a secluded area and cried.

“The penny was dropping that we had so many sick. Covid was in the building,” Hannon says.

By mid-April the situation in St Mary’s had rapidly deteriorated. An internal memo dated April 13th – seen by The Irish Times – says that a fifth of residents in all but one ward were confirmed or suspected Covid-19 cases.

“It is reasonable to assume transmission is generalised,” the memo says.

The same could have been said for the country at large at this point. By April 13th, the number of known cases had reached 10,647 and the number of deaths 365, with clusters in over a quarter of nursing homes.

On Tuesday April 14th, Margo Hannon was on leave at home watching online streams of two residents’ funerals. By that Friday the number of coronavirus deaths in St Mary’s had reached 11.

Grief is normal for healthcare workers. This is completely different. It doesn’t matter what age they are, they are all someone’s family. You feel wounded

“Grief is normal for healthcare workers. This is completely different. It doesn’t matter what age they are, they are all someone’s family. You feel wounded,” she told The Irish Times.

In an eight-day period, four of the 25 residents on the ward died.

“You build up a rapport and a relationship. I did feel trauma, I still do,” she says.

NURSING HOME STAFF across the country have felt the strain in other ways.

Homes have reported severe staff shortages due to nurses and healthcare workers taking sick leave because of Covid-19 or having to self-isolate due to exposure. Long delays in Covid-19 test results for staff and residents, the infectious nature of the disease and the reliance on agency staff in a poorly paid, under-resourced sector that has a long history of staff recruitment difficulties have all contributed to the growth in outbreaks.

“Many nursing homes rely on agency staff, which means you could have one carer in seven different nursing homes working seven days a week, so you can imagine the spread from A to B,” says Karl Conyard, the public health adviser for HCA and Carers Ireland.

“For a respiratory virus [that] has such a long, long incubation phase, it is very, very hard to stop outbreaks.”

By Wednesday, April 29th, the HSE had redeployed 217 members of staff to nursing homes. Surveys by Nursing Homes Ireland had reported homes losing considerably more than this. Some 85 HSE nurses had been deployed to nursing homes, just one for every five private nursing homes.

“It is a shameful response to an emerging tragedy,” says Dr Jack Lambert of the Mater.

One Co Tipperary nursing home operator, Ann Fitzpatrick, who owns St Theresa’s in Thurles says that the 72,000 applicants to the HSE’s “Be On Call for Ireland” initiative intended to draw staff back to the health service “has not been for Ireland but for the HSE” and this has affected much-needed recruitment into depleted nursing homes.

The department says that the HSE will work with nursing homes “through the critical stages of outbreaks” but that the HSE “must also maintain its own services at safe staffing levels”.

If there was a war tomorrow, you could ask who wants to be in the Army, and the next day you would have people lined up. You would have them going off to war the day after. But this is a total failure of a dysfunctional system

Dr Lambert believes HSE staff should be redeployed from “superfluous” Covid community hubs and that even the publicly requisitioned and under-used private hospitals could be used as “step-up” facilities to move infected residents out of nursing homes to keep them free of Covid-19.

“If there was a war tomorrow, you put out a call and say who wants to be recruited to be enlisted in the Army. Then the next day you would have people lined up; you would have them going off to war the day after. This is a total failure of a dysfunctional system,” he says.

One Dublin nursing home battling a cluster says Covid-19 has left them short of essential cleaners, catering staff and other low-paid workers “who are fearful of coming to work”.

“We and my colleagues around the country need boots on the ground,” says a manager.

IN MID-APRIL, PROF DERMOT POWER, a consultant geriatrician at the Mater Hospital, was brought in to help tackle the cluster at St Mary’s.

The lack of rapid testing was driving the outbreak, he says. There were delays of up to a week getting results, and residents were moved into “cohorts” within the 25-bed wards – of confirmed cases, suspected cases and those without symptoms.

“You are trying to isolate patients as best you can. People were being moved around a lot,” he says.

At the same time, high numbers of staff were “beginning to drop off”, he says.

The testing delays meant staff with a cold were unnecessarily out awaiting results, while asymptomatic staff who had the virus continued to work. It was the “perfect storm,” says Power.

Despite the number of deaths, the home was still living hand-to-mouth when it came to PPE. “There was always a perception that there was only enough for today, we were surviving on the ‘just in time’ principle, and by some miracle some would arrive from somewhere,” says Power.

Staff in other nursing homes talk about being feeling isolated and unsupported by the HSE, or lost in the system, and questioning how the State values lives in nursing homes, given the response to their crisis

Now all staff were wearing surgical masks, and heavier duty “FFP”, or filtering facepiece, masks when caring for residents.

Sources across nursing homes criticise the slow reaction of the Government and State authorities in coming to the aid of nursing homes, many of which have had to source and buy their own PPE, often dealing with companies that are only supplying the HSE.

Staff in other nursing homes talk about being feeling “isolated” and unsupported by the HSE, “lost in the system” and questioning how the State values lives in nursing homes, given the response to their crisis.

Outlining its own response, the nursing homes regulator Hiqa says that it ensures the HSE and department are on “a daily basis fully aware of all identified risk” and any “services” required.

Hiqa says that on Thursday April 30th it “escalated” information on 360 nursing homes where there were infections or suspected Covid-19 cases, highlighting 12 “designated centres” that required “specific intervention and risk mitigation”.

The department says that the State is providing “an unprecedented level of support to private nursing homes”, and in the past seven days had delivered almost 3.6 million items of PPE to community residential facilities.

TONY MURTAGH’S 91-YEAR-OLD MOTHER, Carmel, has been in St Mary’s for four years with advanced dementia. Since late March, the family had been asking about the scale of the outbreak.

On April 20th, he read in the media that there were 15 Covid-19 deaths in the home. “That was how the relatives found out the extent of what was happening,” he says.

Given her dementia his mother has a tendency to wander. This week Tony Murtagh was told she had walked onto another ward, which gave him concerns over infection controls in the home.

“I have gone way beyond frustration; I just feel so let down,” he says.

His mother tested negative for coronavirus last week and will now be moved to a separate ward with other negative residents. Looking back, he says the care home “should never have opened back up” to visitors in March.

ON THE MORNING OF Sunday, April 19th, Rose Hegarty began to develop a cough. By mid-afternoon, she was breathing with an oxygen mask. The next day all residents and staff in St Mary’s were tested in an effort to map the extent of the home’s cluster.

At the same time, infectious disease consultants from the Mater were on-site to set up ongoing, rapid testing for the facility.

Prof Power says this testing in almost real-time was the “key” in getting to grips with the outbreak. It has allowed St Mary’s to segregate residents into positive and negative Covid-19 wards this week, and ensure working staff are not unknowingly carrying the virus.

“The rate of positive results coming back is falling. I would like to think we have turned it around,” he says, but warns that the possibility of patients becoming re-infected is “terrifying”.

On Sunday April 25th, Rose Hegarty tested positive for Covid-19.

That same day the number of nursing homes with clusters rose to 209, the national death toll reached 1,063 and the number of cases hit 18,561.

“She was so vulnerable with her kidneys, we couldn’t do anything – that was hard,” her niece Jane Carrigan says. “I’m not sure how conscious she was in the last week of her life, she was sleeping a lot,” she says.

In the days before Rose Hegarty died, her family were allowed see her from outside through the window of her ground floor room, the window from which she had watched the Phoenix Park deer.

Cathy Carrigan, another niece and goddaughter, was allowed into the bedroom in full PPE gear to hold her hand for a short few minutes.

Rose Hegarty died last Monday, April 27th.

THE SURGE THAT public health officials feared for the country’s hospitals hit the nursing homes.

Dr Jack Lambert believes the pandemic has exposed “two tiers of care” in Ireland and that the Covid-19 pandemic has “re-exposed the crisis” in the nursing home sector. He and others say that the State was too focused on ramping up capacity in the State’s hospitals, following the international experience of the outbreak, particularly in Italy. As a result, it missed that some of the most vulnerable people to the disease were in nursing homes.

“There was a focus on the acute services and little or no focus on residential services until it became apparent that that was where the main battlefield was. They were caught off guard,” says Co Clare GP Michael Harty.

Harty, a former TD and chairman of the Oireachtas health committee, believes that accountability will be sought over how the crisis in the nursing homes was handled. “There will be an inquiry. I think there will be a lot of questions to answer in how Government responded and did they respond in the right matter? Did the HSE have the capacity to respond and what were the tensions between the department and the HSE and the Government,” he says.

Rose Hegarty’s family believe that the failings lie at a political level. The frontline staff at St Mary’s in the Phoenix Park have been incredible, says her niece Jane Carrigan.

Her aunt tried to protect herself during the pandemic but there were things she could not control, like PPE for staff and testing. She had taken every precaution to avoid the virus but it was in vain.

“It didn’t make a difference,” says Carrigan.