This week, hundreds of pages of emails, correspondence and reports emerged, detailing what happened, and didn't happen, in the nursing homes sector during the Covid-19 crisis.
They shed new light on what went on in the background as the virus was looming, and silently slipping into Ireland, across February and March.
900 nursing home residents have died due to Covid-19 in Ireland. They make up more than half of all deaths attributed to the disease here.
Is there anything more that should have been done to stop the virus sweeping through one of the most vulnerable parts of society? Families are looking for answers, and politicians calling for inquiries. To try to understand the decisions made, Prime Time has gone back through minutes, documents, correspondence and press conferences over the key two months of February and March, which led up to Ireland’s nursing home crisis.
Two months: How Covid-19 hit Ireland's nursing homes
On 29 February, Ireland had its first confirmed positive case of Covid-19. "We've been preparing for this eventuality for months ... and a case arising here is not unexpected," said Dr Tony Holohan, chair of the National Public Health Emergency Team (NPHET) at a press conference that evening. He wasn't wrong.
In late January, while details were still emerging from China about an as-yet-unnamed pneumonia-like disease, the HSE's High Consequences Infectious Diseases Group had been meeting. They were developing an initial communication plan and procedures for certain sectors in the event of a major outbreak.
By the time NPHET took the reins on 27 January, potential stumbling blocks had been identified - personal protective equipment (PPE) was one.
There was enough stock for "coming weeks" minutes of NPHET's first meeting say, but it appears not enough for the medium-term. Three days later, NPHET asked the Department of Health to raise the issue of PPE procurement at the EU Health Security Committee, a group of public health experts which coordinates across Europe, through the European Commission.
By the time Dr Tony Holohan was telling the media about our first case, the Health Service Executive (HSE) was a month into the process of finding additional sources of personal protective equipment. It still wouldn't be enough.
That early preparation in February was wide-ranging, but focused on increasing the surge capacity within the acute health system - the ability of hospitals to deal with a wave of cases coming through the door at once.
In mid-February, the "key immediate priorities" for the health system, according to NPHET minutes, were "preparedness planning, including containment, self isolation, mass gatherings, home testing, planning assumptions" and importantly "capacity of acute services and testing capacity".
By then, having been largely-focused on the general election for the previous month, the Irish media was starting to look towards the virus.
Prime Time broadcast its first item on coronavirus on 20 February, looking at the impact on hospitals in China and how it was spreading across the world.
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Stories and footage from there had showed hospitals struggling to cope with the number of people seeking help, 'rescue' flights were landing in Europe carrying passengers from a cruise which had been moored off Japan. Those on board had been quarantined for two weeks.
The word 'coronavirus' was growing larger in the public conscience. Preventing what was happening elsewhere from occurring here was the main mission for Irish health officials. Ireland must be prepared "across short, medium and long term horizons ... should there be a similar scenario to Italy," say the minutes of NPHET for 23 February.
A growing global crisis
At that time, Covid-19 was "a public health emergency of international concern", according to the World Health Organization (WHO), but not yet a pandemic. 90% of cases were still in just four countries: China, Iran, Italy and South Korea. Medical science was learning more about the disease every day.
On 24 February, an international team of scientists was preparing to leave Wuhan, China. They'd been there as part of a World Health Organization mission to learn about the characteristics of this new disease.
A key thing the WHO scientists had been trying to understand was about the number of people who were getting the virus but not the symptoms of the disease - ie: 'how big a deal was asymptomatic transmission?'
Their report was released four days after their return, on 28 February, the day before Ireland confirmed its first case.
The WHO team called for countries to "immediately activate the highest level of emergency response mechanisms". But on asymptomatic transmission they concluded: "The majority of the relatively rare cases who are asymptomatic on the date of identification/report went on to develop disease. The proportion of truly asymptomatic infections is unclear but appears to be relatively rare and does not appear to be a major driver of transmission."
The models in use now estimate around 50% of all cases are asymptomatic, though the new cases caused by asymptomatic people are thought to account for a lower percentage.
As their report was being published, at home, Nursing Homes Ireland (NHI) was writing to the Department of Health asking about personal protective equipment.
In one of the earliest of what would soon become almost-daily emails, NHI CEO Tadhg Daly wrote: "I note the HSE has confirmed in the media there is 'adequate stock'. This is not the case for our member nursing homes, who require stocks of PPE. We require confirmation of procedures in place to provide nursing homes with stocks of PPE".
The previous day, 27 February, HSE CEO Paul Reid had given a 'situation update' to the media in Dublin. The global crisis was ballooning, but, he said, Ireland was in a containment phase.
"We've acted very early in terms of purchase of protective equipment," he said, referring to work started in late January. "We've 700,000 gowns purchased already, four million gloves, 2.7 millions masks, 1.5 million surgical masks".
That equipment would mainly be distributed to hospitals and GPs. Both were expected to make up the first line of defence against the virus, and both needed PPE.
The Department of Health responded to the email from Nursing Homes Ireland: "We are following the advice of the Chief Medical Officer and NPHET and will follow-up with them regarding your query."
Private nursing homes like those represented by NHI make up 80% of the sector, providing care services for 24,000 people. Eight in ten nursing home residents have their care funded in part through the State's Fair Deal scheme, many in large part. In 2019, the State budgeted €1 billion for the payments under Fair Deal.
The State requires nursing homes to comply with infection control standards set out by the regulator, HIQA. That includes having stocks of PPE. However, few nursing homes had stocked up for a pandemic.
The emergence of Ireland's crisis
The next day after Tadhg Daly's email about PPE, Chief Medical Officer Dr Tony Holohan, who chairs NPHET, was telling the country that someone in Ireland had tested positive for Covid-19, for the first time.
The crisis had truly begun.
Health authorities were soon asking pupils and staff at a school in the east of the country to isolate. That was 1 March, come 2 March the European Centre for Disease Control was publishing a new rapid risk assessment.
It said the risk of widespread sustained disease spread in Europe was "moderate to high", and that national authorities should prepare a pandemic-level response, advising countries:
"Priority response measures should focus on healthcare systems and healthcare workers in order to ensure rapid detection and diagnosis of cases… Measures to ensure appropriate functioning of the healthcare system with increasing numbers of cases should be planned and implemented."
On the question of the existence of asymptomatic cases, it said evidence from tests of passengers on one cruise ship where an outbreak occurred showed 51% of people who carried the virus had no symptoms. However, on whether those passengers could pass the disease to others, it said: "there remains no strong evidence of transmission preceding symptom onset".
By the next morning, 3 March, Ireland still had just one confirmed case of Covid-19. Germany had 188 cases, France was about to report its fourth death, while in the UK there were 51 confirmed cases.
That evening, NPHET began the first of what became daily press conferences, to update the media and wider public about Covid-19. There Dr Tony Holohan said we had our second case, also linked to travel. The Department of Foreign Affairs was advising against going to northern Italy, where the initial outbreak had spread to four provinces, 2,500 confirmed cases, and resulted in 79 deaths.
The fear across Europe, and reflected in the European Centre for Disease Prevention and Control (ECDC) advice, was that healthcare systems would be overwhelmed, ventilators could need to be rationed, and doctors forced to make choices between patients.
By now, the HSE was concluding the purchase of additional ventilators. Updating the media on PPE stocks, CEO Paul Reid would say "we're continuously making sure we've a supply, and we've a good steady supply committed".
By the evening of 4 March, we had and our first cluster - believed to be a family in the west of the country. On that day, two schools linked to cases decided to close. Reports from the time say one school made the decision "pending advice from the HSE".
The Department of Education and NPHET released a statement saying: "It is essential that any decisions regarding responses to Covid-19 are proportionate, necessary and based on specific public health advice. No other response is appropriate".
When asked more recently about the timing of advice provided on visiting restrictions to nursing homes, Dr Holohan often refers back to this time period, and this concept outlined there: that measures needed to be taken in line with national-level advice - not individually, or by certain sectors, or certain bodies.
"If I can take you back to that week," he told Today with Sean O'Rourke, "we'd a number of unilateral actions taking place across society. There was school closures happening. There was sporting organisations making decisions. There were other organisations making decisions. And there were certain decisions being made in relation to nursing homes. All of which were not, let's say, emanating from the public health advice that we were giving.
"We wanted to have the country move in step with the advice, and have people follow the advice as we issued it. We didn't want to see a measure like restricting visitation to nursing homes - which is cutting people off from their loved ones - being introduced any earlier [than necessary]."
The week before visiting restrictions
The "decisions being taken in relation to nursing homes" that Dr Holohan was talking about was advice given by Nursing Homes Ireland. On Friday 6 March, NHI issued a statement saying "visiting restrictions are now in place in nursing homes nationwide. No non-essential visiting, children, or groups will be allowed".
Almost immediately, it hit RTÉ's Liveline. Relatives were concerned about the impact on their loved ones, who they worried would be isolated or lonely. At the same time, they understood why the decision was being made, and there was an understanding that the elderly were at high-risk from the virus.
A nursing home owner came on the air: "It's a scary time for people in nursing homes," he said, "if that virus gets into the nursing home, it could wipe us out."
In the wake of the NHI decision, NPHET released another statement. In it Dr Holohan said: "We ask that no organisation, school or health service provider acts unilaterally. We need to respond to the threat of Covid-19 in unison, following the advice of Public Health."
In short, the NPHET view was, there was no need for visiting restrictions ... yet.
That was what was happening in public. In the background, calls were being made, and correspondence sent. Over the previous 24 hours, the first case of community transmission had been confirmed; someone had the disease in Cork, but no one knew how they got it. Authorities were trying to trace possible contacts among patients and staff in Cork University Hospital.
In the Cork area, nursing homes were concerned about taking in people being transferred from hospitals. That meant patients who would in normal circumstances have been moved to nursing homes were remaining in hospital beds, and on wards. This was happening as fears grew about our hospitals' ability to handle a looming surge.
In an attempt to assuage fears, on the 6th, HSE South sent a "letter of assurance" to local nursing homes.
"We wish to stress that any patient discharged from CUH will have undergone a full risk assessment and full medical assessment and will be deemed low risk and suitable for discharge into the community," the letter read.
This didn't mean that all patients were being tested before being transferred, but they were being assessed.
We were still less than seven full days on from our first confirmed case, but heading into the weekend. There were a total of 18 cases nationally.
The concern in the media, and the health system, was focused mainly on intensive care capacity. "We're looking in the first instance to avoid a surge into our hospitals and acute settings but we acknowledge that at some point that that's a possibility we have to prepare for", the HSE's Paul Reid told Pat Kenny.
The NPHET view that visiting restrictions for nursing homes were not yet required remained unchanged over that weekend. That Sunday, the 8th, The Business Post said senior health officials believed up to 1.9m Irish people could get Covid-19. Health officials said they could not dispute the number when they appeared on radio.
Through the following Monday the advice on nursing home visiting restrictions stayed the same. It didn't change after a meeting at 2pm on the Tuesday, 10 March. The NPHET minutes from that day say "unilateral/widespread restriction of visiting to nursing homes, hospitals and healthcare facilities is not required at this time".
Yet 36 hours later, the NPHET advice would be to stop nursing home visits, and the Taoiseach was addressing the nation live on TV.
Implementing visiting restrictions
'What happened in those hours? And would it have been better to have stopped restrictions earlier?'
They have been the two questions most frequently asked by politicians and journalists around the timing of the advice on visiting restrictions in recent weeks.
In global terms, the answer to the first question is that the WHO declared a pandemic.
In Irish terms, Dr Holohan said recently, the answer is that the advice changed because the information changed. "We did, over the course of the 11th, if I remember correctly, see a change in the disease pattern", he said.
After the press conference on 11 March, he says he went back upstairs in the Department of Health, to the private offices. There, Dr Cillian De Gascun, who leads the testing regime, had new data on cases.
"Cillian already knew that there had been a significant number of cases identified during the course of the afternoon of that day", Dr Holohan said. "We were looking at a potential doubling in case numbers in about a 48-hour period. We took the decision to hold a meeting of NPHET that evening.
"We convened that meeting at 9pm on the evening of the 11th, it concluded at 1am in the morning, and the announcements were made the following morning by the Taoiseach."
The Taoiseach spoke from outside the Irish embassy in Washington. Ireland was moving from the "containment" to the "delay" phase of the response.
Visiting restrictions were to be place in nursing homes from the morning of 13 March - the next day. Schools, colleges and creches were to be closed. Shops could stay open, but people were asked to stay at home. Indoor mass gatherings of more than 100 people were banned, outdoors the limit was 500.
Ireland was on the road to lockdown. "We know that older people and those with chronic diseases are at real risk." Leo Vardakar said: "We have a duty as a society to protect ourselves and above all to protect others - our parents and grandparents, our family and friends, co-workers and neighbours."
The answer to the second question often put to Dr Holohan - about the timing of the advice on visiting restrictions in nursing homes - is something politicians on the Oireachtas Committee have also been trying to get at in recent weeks.
Dr Holohan says the epidemiological data available now proves that the decision was taken at the right time, and not before. He bases this on a graph which, he says, shows there was a two-week-plus interval between when the visiting restrictions were imposed, and when widespread clusters began to emerge in nursing homes. Nursing homes make up many of the State's long term residential facilities, shown in green on the graph.
Essentially, he says, the gap between the last visitors being allowed in and the clusters emerging is too long. He says it shows there isn't a link between the clusters and visitors.
When it comes to Covid-19, it's hard to be definitive about how the disease spreads. We now know about asymptomatic transmission, and that elderly people don't necessarily display or spread the disease in the same way as others.
According to data based on testing at the time, three weeks on from the restrictions being implemented, 40 clusters had emerged in nursing homes. That's a small number in more recent terms, more than 200 others developed since. If visitors can't be linked to the vast majority of clusters, how did the virus get in? Is it possible to say?
What happened with hospital transfers and PPE?
Rewind to 10 March and the HSE was reacting at a national level to the concerns raised regionally four days prior, about transfers to nursing homes from hospitals. At the time, the position of the ECDC was that people could have the virus and not have symptoms, but there was no strong evidence that they spread the virus.
That day, the HSE issued guidance to hospitals and nursing homes, telling them the steps to take when moving people between the two. Nursing Homes Ireland had been asking the HSE for something, to try to assure their members. "Will the HSE swab all discharges? What reassurance will be provided to nursing homes to protect residents and staff?" NHI's Tadhg Daly had asked over the previous days.
The guidance covered the process for moving people who'd had confirmed Covid-19, people who had symptoms of Covid-19, and asymptomatic people who were candidates to be transferred.
In short, it said, anyone confirmed to have had Covid-19 needed to test negative twice before being moved. It said people without symptoms could move to nursing homes if there was somewhere to isolate them for 14 days. While it said they could also move if they did have symptoms, once they had received a negative test result, and they could be isolated on arrival.
Specifically, on the transfer of patients with symptoms who were contacts of a confirmed case, but had not been tested themselves, it said: "Transfers to RCF (Residential Care Facilities) should proceed provided that the resident has had a sample reported as not-detected."
In other words, if someone was being considered for transfer to a nursing home and they had symptoms of Covid-19, they should be tested, and only if the result was negative, should they be moved.
That guidance was issued on 10 March. On 30 March, new advice was issued in its place.
New guidance on hospital transfers
This was a far more comprehensive document covering everything from staffing processes to the process of declaring an outbreak over. But on transfer of people with symptoms, the requirement that they be tested before being transferred was removed.
The 30 March document says: "All transfers or admissions with current fever or symptoms of acute respiratory tract infection should be accommodated in their own room with bathing and toilet facilities and encouraged to stay in their own room and avoid contact with other residents. If not already done they should ask their doctor for advice on testing for Covid-19. Subsequent management is determined by the outcome of the assessment."
On the broader concern some nursing homes had about accepting people being transferred from hospital, the updated guidance said: "Although accepting admission or transfer of residents poses a risk of introducing Covid-19 to a [Residential Care Facility], this is considered a necessary risk in the context of maintaining access to a critical service and the risk can be mitigated by rigorously following this guidance."
The words "necessary risk" are in bold in the document.
Essentially, the guidance changed from 'test people with symptoms before moving them to nursing homes', to 'consider testing people with symptoms after they've been moved, but isolate them whether they've symptoms or not'.
Some nursing home owners are convinced clusters were caused by people being transferred from hospitals into their facilities. They say both versions of the guidance around moving people should have been stricter, and people should have been tested beforehand.
Prime Time asked the HSE why the protocols were changed, the HSE said it changed the policy to one which assumed every patient being transferred might be infected with the virus.
"The requirement for testing was replaced by a requirement to isolate all people transferred to nursing homes in a single room for a monitoring period of 14 days," it said in a statement.
"This was done on the basis that a single test that failed to detect the virus did not give sufficient assurance that the person was not infected. It was decided to manage the transfer of patients without testing because testing would not change the requirement for isolation. This is because everyone transferred would be treated as if they might be incubating infection and testing might delay transfer, contrary to the patients' interests."
Figures provided by Nursing Homes Ireland indicate around 1,000 people were transferred into nursing homes from acute hospitals during February and March.
The HSE's Paul Reid recently told the Oireachtas Committee on Covid-19 that "there's no evidence" to link the transfer of patients to clusters in nursing homes.
A Department of Health report released in recent days comments on the 10 March guidance, saying: "If the protocols set out in the guidance were adhered to, along with the appropriate use of infection prevention control processes within the facilities, the risk of transfer to and subsequent spread of Covid-19 to Long Term Residential Care Facilities would have been low."
It doesn't comment on later guidance.
On how the virus got in, it says "an emerging picture from the accounts from other jurisdictions are that the virus is likely to have [been] carried unwittingly into facilities by asymptomatic or very mildly symptomatic patients or staff, through no fault of either".
The battle to get PPE
A key part of the 'infection prevention control processes' mentioned there is the use of personal protective equipment. As the 10 March transfer guidance was being issued, PPE was a significant issue in a growing number of nursing homes, according to the correspondence sent by NHI.
Two days later, the Taoiseach was speaking in Washington. 'Social distancing' was becoming the dominant phrase on the airwaves, 'asymptomatic' would soon be added, later 'reproduction number'. In the meantime, the correspondence continued about PPE and transfers.
"No information was provided with regard to accessing PPE equipment which is a critical requirement to support nursing homes." NHI CEO Tadhg Daly wrote again to the Department of Health on 13 March. "Nursing homes are reporting they're being inundated with calls from hospitals/HSE facilities enquiring about capacity to facilitate discharges/transfers".
A further ECDC rapid risk assessment had just been published, making it clear that transmission of the virus by people without symptoms was a growing concern: "Potential transmission from an asymptomatic person has been reported in a familial cluster of five Covid-19 patients," it said.
At this point, the health authorities in Ireland were projecting the surge would come in late March or early April, and preparing for that.
Nursing Homes Ireland weren't the only ones writing to the department. The Health Information and Quality Authority (HIQA), the State body which inspects and regulates nursing homes, was growing concerned. It also contacted departmental officials on 13 March, with a list of HSE-run homes it considered "at risk". HIQA says the correspondence received "an acknowledgement" on the same day.
Staff in the department were working through the weekend, and late in the evening, on issues across the health system. On Saturday 14 March, a leading official in the Older Services section responded to NHI saying work around transfers was "on-going".
Concern among the public around Covid-19 was spiking. That weekend 124,000 calls were made to a HSE helpline which normally deals with 500 calls daily.
Come Monday, the Government was ready to publish the National Action Plan on Covid-19. The 50-page document set a course for a "multi-agency public health-led" response to the coronavirus pandemic. It set the course for how State bodies would try to manage the crisis.
The only specific mention of nursing homes in the document is in the part about acute services. The plan was to "on an ongoing basis, accelerate appropriate discharge of patients [from acute services] to appropriate facilities, or with homecare support".
There were 169 cases confirmed in Ireland by then, and two deaths. Italy's problem was national, Spain had 5,700 cases, and was about to report 100 deaths a day. Borders were being closed across Europe, which was the epicentre of a global pandemic.
Morning Ireland's top interviewee that day was Dr Catherine Motherway, President of the Intensive Care Society of Ireland. She expressed her sympathies to colleagues in Italy, where the virus had forced horrendous choices on doctors around prioritising ventilators. "Have you got enough respiratory equipment across our hospitals to deal with this expected surge?" was one of the first questions from presenter, Audrey Carville. It was the question everyone wanted answers to.
A lot was going on that Monday, 16 March. The criteria for getting a test was changed too. Before, anyone who had returned from an 'at-risk' area, or was linked to outbreaks, was considered for testing. Now, if you had flu-like symptoms you were asked to phone your GP who could refer you for a swab.
GPs were quickly flooded with calls, resulting in a massive backlog. Extra laboratories, testing kits, and swabbing capacity was soon needed, and results were taking days - many more than a week.
That same day, HSE Outbreak Control Teams working in two separate nursing homes identified clusters, and informed the relevant bodies. They were the first clusters confirmed in nursing homes. The process would be repeated more than 250 times through the crisis.
At the press conference that evening, the NPHET team said their modelling was estimating Ireland could have 10,000 cases by 29 March, less than two weeks later.
Nursing Homes Ireland was still writing to the Department of Health in the meantime. "There is a critical issue with challenges of securing PPE for the nursing home sector", Tadhg Daly had written on 15 March. "Members are reporting that suppliers are not in a position to supply as they state they are supplying all such products exclusively to the HSE at this time."
The health authorities were struggling to get enough PPE for their own staff and hospitals. At the same time, nursing homes were trying to buy PPE for their workers, and finding all of it had been bought up by the HSE.
The HSE would eventually have to source PPE from China, while still dealing with Irish suppliers, to access sufficient stocks. This PPE would begin arriving in the first week of April, by which point it had agreed to provide equipment and other services to private nursing homes, to help them deal with the crisis.
Something somewhat similar was happening with staff. By St Patrick’s Day, the HSE was undertaking a massive recruitment campaign to shore up the health system for the surge, while Nursing Homes Ireland was running a recruitment drive of its own, trying to get staff to replace people who are unavailable, sick, or in some cases, going to work for the HSE.
The Taoiseach addressed the nation: "We all need to take steps to reduce close human contact. That is how the virus is spread… I know these choices won't be easy, but they are necessary."
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Swathes of the economy had been shut down, there was masses of people losing their jobs, and suddenly requiring income support from the State.
The shutters stayed down on nearly all pubs and bars, on the national holiday.
'Issues on multiple fronts'
From the documents available, it appears the senior staff in the Department of Health and HSE were dealing with issues on multiple fronts at this stage. Staffing, PPE, clusters, surge capacity, testing backlogs, access to swabbing … the list goes on. They were taking calls from Nursing Homes Ireland, but NHI weren't the only ones calling.
"We're very appreciative of your round-the-clock availability", NHI CEO Tadhg Daly wrote to senior managers in the Department of Health and HSE on 18 March, but, he said, the situation had grown especially urgent "in the past 24/48 hours".
Requesting an immediate conference call, he said "the provision of PPE, oxygen and other required supplies is challenging to say the least, with many nursing homes exhausting their stock... An increasing number of nursing homes residents and staff are awaiting testing. Delays occurring can present cataclysmic consequences."
It appears the requested call happened that night. The next day NHI sent a communication to members, quoting a letter sent to HSE offices by a senior HSE official. The letter said HSE offices around the country were to immediately provide names of specific local staff members to nursing homes in their areas, to communicate with in relation to outbreaks. On PPE in nursing homes, it said HSE offices had been told to contact two national-level staff members "in the event there is a need for an urgent initial level of PPE to be provided to a centre with an outbreak".
From the correspondence and documents available, it appears officials were beginning to recognise nursing homes needed more attention.
Around the time that conference call was happening on the 18th, NPHET was meeting, and the NPHET Subgroup on Vulnerable People had been discussing nursing homes. The testing backlog was discussed, with the supply of reagents being highlighted as a significant problem when it came to getting results to tens of thousands of people.
At the subgroup, it was decided there was a need to examine issues "arising in the (nursing home) sector". And "to develop proposed measures, including temporary financial support to respond to those issues, where necessary".
A 'short-life working group' was set up. It would meet for the first time the following day.
That night on Prime Time, David McCullagh was trying to get an update about surge capacity from Dr Catherine Motherway, of the Intensive Care Society of Ireland, who was leading an ICU team in Limerick.
"How well provided are we [with intensive care beds] in comparison to other countries in Europe?" he asked. "We've roughly about half the European norm, and we have half the beds that Italy would have," she responded. Her comments would go viral: "If we don't control surge, we will have a major problem coping."
Dr Catherine Motherway, Intensive care physician at UH Limerick discusses how well provided with ICU beds Irish hospitals are, and steps the community might take to prevent the spread of Covid 19 #RTEPT | #COVID19 | #coronavirus | @mcculld pic.twitter.com/mJNUip7jnZ— RTÉ Prime Time (@RTE_PrimeTime) March 19, 2020
The Nursing Homes Working Group
The members of the new short-life working group came from the Department of Health, HSE, National Treatment Purchase Fund and HIQA, all of which are government bodies.
During this crisis, HIQA has been considered to be the representative of nursing home residents on NPHET by government and officials. In normal times, they’re the regulator and body which inspects the homes.
On the day the working group was set up, 18 March, HIQA had made what it calls "a formal offer" to assist the HSE in liaising with nursing homes. It says this was done "in recognition of the fact that there was no established relationship between the HSE and the private sector".
When they heard about the working group, Nursing Homes Ireland wanted to be on it. Tadhg Daly wanted to know why he wasn't invited, by this point he was requesting an urgent meeting with Minister for Health Simon Harris about the crisis.
At 1.31am on 20 March, a senior Department of Health official wrote to Mr Daly, explaining the terms of reference of the working group and the urgency required in setting it up. He asked NHI to help with lining up a conference call between the group and a home hit by the virus. This was agreed, and the call took place at 3.30pm that day.
HSE managers assisting the working group began immediately trying to get to grips with the problems which NHI had been raising. They were soon asking Nursing Homes Ireland for help and information about supply chain issues, if they had done "forecasting exercises" in relation to PPE, oxygen, or medicines, and "details of any direct engagement with HSE procurement to date".
At its core, Nursing Homes Ireland represents the interests of nursing home owners, but it does not control them, manage them, or oversee them. "As an organisation with a broad membership of individual providers, we don't collect the detailed data outlined", Tadhg Daly wrote back on 21 March, while giving his general overview in response to the questions asked.
That was Saturday. By the Sunday, we had almost 1,000 cases of Covid-19 in the country. Six people had died. Covid-19 had spread to 190 countries worldwide.
The next day, NPHET met again. It decided to tighten the criteria under which people could access a test. A massive backlog had arisen, and the testing process needed to be more focused, the minutes indicate.
In the meantime, Minister for Finance Paschal Donohoe announced new measures, in an attempt to keep money in people's pockets and the economy moving through the crisis. There had been unprecedented job losses, ministers were estimating 400,000 people could be let go due to the crisis. The €3.7bn Covid-19 income support scheme would see the State cover 70% of people's pay if businesses kept them on the books, while people who had lost their jobs during the pandemic were entitled to €350 a week income support, up from €203.
NHI writes to the minister directly
Tadhg Daly had begun writing directly to Minister Harris also by now, asking for emergency help for nursing homes, PPE, and a 50% increase in the State funding provided per person under the Fair Deal scheme.
The next day, he wrote to officials about staffing problems. "As you are aware there are significant recruitment challenges in the sector. Members are reporting applications now withdrawn."
He attached correspondence given to him from one nursing home, sent in by potential hire: "Due to developments with the government yesterday… It does not make sense for us financially, I have to put my family first in this situation."
The staffing issue was now putting homes "at grave risk", Daly wrote on 25 March. Officials from the Department of Health responded almost immediately, saying colleagues in the Department of Employment Affairs and Social Protection were looking at the issue.
The nursing homes working group was having its third and final meeting by now, and examining a submission from Nursing Homes Ireland, detailing all their concerns about the sector. These now ranged from staffing to oxygen supply. On 26 March, the working group completed its work, and prepared to report upwards within NPHET.
In public, the surge was still a huge concern. On the morning of the 27th, Taoiseach Leo Varadkar said Ireland's ICUs were expected to reach capacity within days.
Later that day, following advice from NPHET, he announced Ireland was moving into the most stringent phase of social restrictions. Cocooning: people over the age of 70 were asked not to leave their homes for 14 days.
"The number of confirmed cases in Ireland exceed 2,100. Sadly, the number of deaths is 22," the Taoiseach said. "There is a day-on-day increase in the number of admissions to intensive care units, and the number has doubled since Monday."
Minister Simon Harris was on Morning Ireland that Saturday, 28 March. The level of community transmission was too high, he said, the plan was push the virus from the community, to a household level.
The next day, Sunday 29 March, a meeting was lined up between Nursing Homes Ireland, senior health officials, and the minister, to be held in the Department of Health. It took place at 2.30pm on the Monday.
By then the first batch of PPE was on the way from China. "Fifteen years worth" of equipment had been ordered by the HSE. 24 clusters had been identified in nursing homes. A month later there was 219.
The day after meeting the minister, 31 March, Tadhg Daly wrote to officials. "I acknowledge the commitment of the minister and department to enhanced measures..."
It would be the last email he sent to the department in March.
That same day, NPHET was meeting, and considering a paper from its subgroup on vulnerable people. The minutes say: "It was agreed that the growing number of clusters of Covid-19 infections in nursing homes and residential healthcare settings ... requires an immediate and targeted focus on implementation of specific and enhanced public health measures for long term residential care centres."The HSE was asked to deploy "an integrated outbreak crisis management response across all long term residential care settings".
Four days later, the minister publicly announced a €72m support scheme for nursing homes. It was Saturday 4 April, the week when many had expected the surge to swamp our acute hospitals.
The surge there never materialised.
Ireland's hospitals didn't get hit like Italy's, but we did get hit.