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Covid-19: Protect health and social care workers and refer their deaths to the coroner

It is imperative that there is no further delay in providing every healthcare worker with effective PPE

Amid a mounting death toll of healthcare workers and ongoing alarm over the inadequate provision of effective personal protective equipment (PPE), the government’s limp response has continued. On 10 April, the health secretary Matt Hancock suggested that healthcare workers may be using PPE inappropriately, and that these deaths should not be assumed to be occupationally related. [1] This following weekend, the government were unable to say whether PPE will soon run out amid a critical shortage of supplies. A BMA survey has revealed that many doctors are still working without adequate PPE. This all contributes to a growing feeling that political leaders have neither the gravitas nor mettle to lead in a crisis of this magnitude. We are left wondering who can be trusted to independently investigate causality with deaths occurring in such a heated climate?

Doctors have specific responsibilities with regard to the reporting of deaths. If it is thought that a death could be due to an injury or disease attributable to any employment held by the person during the person’s lifetime, and/or through exposure to a toxic substance, we are obliged to inform the coroner. [2] As this pandemic unfolds and we witness the deaths of our fellow healthcare professionals during active service and under controversial occupational conditions, there arises the inevitable question of whether the coroner should be involved?

Survey data show that half of doctors working in high risk areas did not have adequate supplies of long sleeve disposable gowns, goggles, or full-face visors. [3] Almost half the GPs surveyed did not have adequate supplies of fluid resistant masks and almost two thirds did not have adequate supplies of eye protection. [3] Operating staff were only being fitted with full protective clothing more recently. This included FFP3 masks, goggles or visor, protective hood and double gowning and double gloves for all patients undergoing surgery (i.e. known SARS-C0V-2 virus positive, suspected, and also unknown). What is the human price of this delay?

The UK government’s revised guidelines perhaps suggested a willingness to relook at this issue in the light of the severe disquiet of frontline health and social care workers (HSCWs). [4,5,6] However the government is advocating a risk adapted strategy, the logical extension of which is that a HSCW who sees a known covid-19 patient should get better PPE than a HSCW who sees an asymptomatic covid-19 patient (e.g. attending Primary (GP) or Secondary (Hospital) Care or receiving community care) for other health conditions. Risk adaptation is only required when supplies are inadequate.

The efficacy of the PPE currently provided is also brought into question. In addition to being able to spread through contaminated surfaces and droplets, there are emerging data which indicate SARS-CoV-2 may also be transmitted through aerosol particles and aerosol (as well as droplet) transmission has also been reported for other coronaviruses. [7-15] But the new guidelines do not appear to have acknowledged this issue. On the contrary, a systematic review on the use of surgical masks in influenza (a non coronavirus) concluded: “There is little evidence to support the effectiveness of face masks to reduce the risk of infection.” [16] Equally, the new guidelines state that there is no evidence respirators add value over fluid-resistant surgical masks except in the context of aerosol generating procedures—but the statement is unreferenced, and is also contrary to a randomised trial which concluded that continuous use of “N95 [FFP3] respirators have superior clinical efficacy to medical masks.” [17] The relative contribution of aerosols in terms of infectivity for covid-19 is not known. So, until this is clear, surgical masks—which the Government, Public Health England and NHS(E) state as standard for the vast majority of HSCWs—should not be considered effective protection if a person breathes or coughs over you. 

It is imperative that there is no further delay in providing every healthcare worker with effective PPE. Frontline HSCWs should be receiving the best protection. An insufficient supply of FFP3 masks and goggles will expose HSCWs to unjustifiable risk and deaths will result—something the government are not currently prepared to admit. Failing to provide the best effective PPE and exercising appropriate candour during the pandemic is playing roulette with HSCWs. They all deserve better; we must maximally protect the living.

Ultimately, policy on this issue is inextricable from the uncomfortable moral question: to what level of added occupational risk is our government prepared to expose our healthcare workforce? Because without a dedicated, publically transparent, contemporaneously maintained account of the number of HSCWs hospitalized with, in ICU with, and/or deceased from covid-19, we can’t begin to quantify the true extent of serious harm to HSCWs that occurred during the pandemic. And without referring each HSCW death to the coroner, can we be confident that the circumstances of their employment have not resulted in these individuals paying the ultimate price through their daily work? 

The government have intimated that an investigation would be carried out into the extent to which health workers had caught the virus on the frontline, but there will be little trust in any investigation conducted behind heavy Whitehall doors. [18] If this administration is truly confident that HSCWs have been adequately protected, the prospect of a coroner’s inquest should be no cause for concern.

Find out more about our #properPPE campaign

John FR Robertson, Professor of Surgery & Consultant Surgeon, University of Nottingham. 

Marcia Stewart, Lay member, Social Care professional & emeritus academic BA(Hons).

Denise Kendrick, Professor of Primary Care Research and General Practitioner, University of Nottingham. 

Herb F Sewell, Emeritus Professor of Immunology & Consultant immunologist, University of Nottingham.

Competing interests: None declared

Acknowledgements: Professor Sheila M. Bird, Formerly Programme Leader at MRC Biostatistics Unit, Cambridge Institute of Public Health; for her critical reading and comments on our draft article. 

References:

  1. https://www.bbc.co.uk/news/uk-52252470
  2. http://www.legislation.gov.uk/uksi/2019/1112/made
  3. https://www.bma.org.uk/news-and-opinion/ppe-supply-remains-low
  4. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe
  5. https://actionnetwork.org/petitions/ppe-now
  6. https://www.thetimes.co.uk/article/nhs-staff-beg-boris-johnson-give-us-the-right-protective-coronavirus-gear-cs77576v6
  7. Bourouiba L. Turbulent Gas Clouds and Respiratory Pathogen Emissions Potential Implications for Reducing Transmission of COVID-19. March 26, 2020.doi:10.1001/jama.2020.4756
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  9. Juan Wang & Guoqiang Du COVID-19 may transmit through aerosol. Irish Journal of Medical Science https://doi.org/10.1007/s11845-020-02218-2
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  13. Hung L. The SARS epidemic in Hong Kong: what lessons have we learned?. JRSM. 2003; 96(8): 374-378.
  14. Kim S, Chang S, Sung M, Park J, Bin Kim H, Lee H et al. Extensive Viable Middle East Respiratory Syndrome (MERS) Coronavirus Contamination in Air and Surrounding Environment in MERS Isolation Wards. Clinical Infectious Diseases. 2016; 63(3): 363-369.
  15. Tellier R, Li Y, Cowling B, Tang J. Recognition of aerosol transmission of infectious agents: a commentary. BMC Infectious Diseases. 2019;19(1)
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  17. McIntyre et al A Randomized Clinical Trial of Three Options for N95 Respirators and Medical Masks in Health Workers. American Journal of Respiratory and Critical Care Medicine 2013; 187: 960-66
  18. https://www.theguardian.com/society/2020/apr/11/matt-hancock-reveals-deaths-of-19-nhs-workers-amid-ppe-row#maincontent