John Allison was getting weaker by the day. He hadn't eaten or drank for nearly two days. He was struggling to breathe.  

Care home staff were worried.

"He's frail," senior carer Anne Clarke said. "We'll keep trying to get him to eat and drink if we can."

John - a husband, a father, a grandfather - had been admitted to hospital in March after a fall.

As coronavirus spread around the country, the 76-year-old was discharged to a nursing home in Sheffield for rehabilitation.

While in the home, he tested positive for COVID-19.

"He was absolutely petrified of COVID," his daughter-in-law Lyndsey said. "He just kept saying: 'I'm really scared I'm going to get it.'"

Three weeks after going into the home, John died with the virus in April at the age of 76 – one of more than 30,000 coronavirus deaths in care homes in England and Wales.

COVID-19 restrictions prevented John's family from being at his bedside when he took his final breath.

"I'd promised I wouldn't leave him on his own and that I'd be there for him," Lyndsey said.

"It's just heart-breaking not being there for him."

In April, coronavirus was ripping through care homes across the UK. An overwhelmed care sector struggled to protect the elderly and most vulnerable people in society.

At the height of the crisis, more than 400 care home residents were dying every day with coronavirus.

Worryingly, the number of COVID-19 deaths of care home residents has been rising again in recent weeks as the UK battles a second wave of the virus.

A month after John's death last year, Matt Hancock tried to reassure the public about the impact of the virus on care homes as he addressed a Downing Street news conference.

"Right from the start we've tried to throw a protective ring around our care homes," the health secretary said.

But many in the care sector and families of COVID-19 victims have questioned that claim.

So why were the UK's care homes so badly hit by the virus? Did the government's initial guidance to carers cost lives? Or did too many care homes fail to "follow the procedures", as the prime minister claimed? And did we learn anything that could help to save lives in the future?

"Right from the start we've tried to throw a protective ring around our care homes"

Matt Hancock, 15 May

The first coronavirus infections in the UK were confirmed on 31 January.

On 25 February, while many of us were still crowding onto rush-hour trains and buses, the number of confirmed cases in the UK had risen to 13 and the government was publishing guidance for carers on COVID-19.

In hindsight, this guidance is astonishing.

The advice stated it was "intended for the current position in the UK where there is currently no transmission of COVID-19 in the community".

A critical line adds:

"It is therefore very unlikely that anyone receiving care in a care home or the community will become infected."

Three days later, the UK had its first community transmission of coronavirus confirmed.

The guidance issued to care homes remained in place until 13 March.

At this time, there were 798 confirmed coronavirus cases in the UK and 11 people were known to have died with the virus across the country.

Behind the scenes, the government had been warned that coronavirus cases were spreading rapidly.

On 10 March, the Scientific Advisory Group for Emergencies (SAGE) told ministers that "the UK likely has thousands of cases – as many as 5,000 to 10,000 – which are geographically spread nationally".

"Asking us to take COVID-19 positive patients is asking us to basically make out a suicide note for people in care"

Care home owner, 7 April

As coronavirus infections surged across the UK in early March, Mr Johnson laid bare the threat to the country in a sombre Downing Street news conference.

"Many more families are going to lose loved ones before their time," the prime minister said on 12 March.

A week later, the Department of Health and Social Care (DHSC) authorised thousands of patients to be discharged from hospitals into care homes.

Guidance issued on 19 March urged NHS trusts to discharge patients from hospitals as soon as clinically possible. The idea was to free up 15,000 beds.

"Unless required to be in hospital… patients must not remain in an NHS bed," the guidance stated.

The trusts were told they could do this without testing the patients to see if they had coronavirus. Further guidance on 2 April said:

"Negative [coronavirus] tests are not required prior to transfers/admissions into the care home."

But Sky News also learned at this time that care homes were being asked to take in people who had tested positive for coronavirus. The guidance added:

"Residents may also be admitted to a care home from a home setting. Some of these patients may have COVID-19 whether symptomatic or asymptomatic. All of these patients can be safely cared for in a care home if this guidance is followed."

People working in the system were not convinced.

Care homes quickly expressed grave concerns over the policy. Many were already desperately overstretched and struggling with staff and equipment shortages.

Warberries Care Home in Devon was asked to take in coronavirus patients in April

Warberries Care Home in Devon was asked to take in coronavirus patients in April

"Asking us to take COVID-19 positive patients is asking us to basically make out a suicide note for people in care," said Graham Greenway, the owner of one care home in Torquay.

Several councils threatened to withhold funding to help care homes deal with the coronavirus outbreak if they did not agree to take in COVID-19 patients.

Between mid-March and mid-April, about 25,000 patients were discharged from hospitals into care homes in England, the National Audit Office reported.

The House of Commons' own spending watchdog, the Public Accounts Committee (PAC), would later describe the policy as "an appalling error".

It was not until 15 April that the government said all patients discharged from hospitals would be tested for coronavirus.

Many families of care home residents who died with COVID-19 believe the discharge policy cost lives.

Dr Cathy Gardner has launched a High Court challenge against the DHSC and NHS England. She alleges that the failure to introduce adequate measures to protect care home residents from coronavirus was "one of the most egregious and devastating policy failures of recent times".

Her 88-year-old father Michael Gibson died from "probable COVID-19" in an Oxfordshire care home on 3 April. The home had readmitted a former resident who had been in hospital and had not been tested for coronavirus.

"To know that this might have played a factor and the government might have contributed directly to my father's death is almost unbelievable," Dr Gardner said.

"It's so difficult to get my head around it. It makes me extremely angry."

Sir James Eadie QC, representing the government, told a High Court hearing in November that the aim of the "discharge requirement" introduced in March was "to ensure those who were medically fit to be discharged were being discharged to avoid that overwhelming" the NHS.

"It is wrong to suggest it was being done without a care for the risk in care homes," he said.

"These risks were being subjected to continuing care and consideration."

Kathleen Keenan, 84, died with COVID-19 after she went back to her care home following a positive test in hospital.

Her daughter Helen said: "They were like fodder on the infantry line - 'just get rid of all of those, we're not saving them because we haven't got enough resources or time'.

"I can't do anything for my mum except honour her memory and ask for an apology for what happened to her, because she deserved far better than she got, and I don't want any other family to be in the same situation as we are and other families are. It's atrocious."

A spokesperson for the NHS trust which runs Walsall Manor Hospital, where Ms Keenan had been discharged from, said it had contacted the care home to advise of her COVID-19 positive status "and the home was happy for her to return, supporting her self-isolation".

"At the time of Mrs Keenan's treatment there were no bed capacity issues within the trust,” the spokesperson added.

"Our care homes were effectively thrown to the wolves"

Meg Hillier, chair of the Public Accounts Committee

To understand how care homes policy affected the course of the pandemic in the early months, we need also to look at the equipment the sector had – or rather didn't have – to deal with COVID-19.

In late March, Britons gathered on their doorsteps to clap for carers for the first time in a show of appreciation for those on the frontline of the coronavirus pandemic.

At that very moment, inside care homes across the UK, there was real fear among staff who were dangerously short of personal protective equipment (PPE).

At the start of the outbreak, the only central stockpile of PPE – held by Public Health England - was designed for a flu pandemic.

It lacked items - such as gowns and visors - which had been recommended by an independent committee advising the Department of Health on stockpile contents in 2019.

"We have to be using aprons and gloves, bin bags and all sorts of things because there are suspected cases of COVID-19 in our home," one care worker told Sky News in April.

"None of the staff that work with these people have protective gear."

Central PPE stocks distributed to social care accounted for 15% or less of the modelled requirement for a reasonable worst-case scenario from mid-March to mid-May, with the exception of face masks, according to a National Audit Office report.

And again, government guidance looks painfully inadequate in hindsight.

On 13 March, the sector was advised that when caring for "residents with symptoms", staff should use PPE for activities with "close personal contact" including "washing and bathing, personal hygiene and contact with bodily fluids".

The use of PPE was not required where residents were not showing symptoms.

By late March and early April, organisations such as Unison and the Royal College of Nursing, and care homes themselves, were raising concerns.

One care home owner in Nottingham told Sky News that her suppliers had been told to redirect PPE to NHS trusts.

A nurse looks through a window of a closed door leading to the red zone at the Wren Hall care home in Nottingham in April 2020

A nurse looks through a window of a closed door leading to the red zone at the Wren Hall care home in Nottingham in April 2020

A survey of more than 2,600 care workers by the University of Kent in April found PPE was "often unavailable or unsuitable".

"No communication, no PPE, no respect," one care worker said in the report.

Meg Hillier, chair of the Public Accounts Committee, said: "The failure to provide adequate PPE or testing to the millions of staff and volunteers who risked their lives to help us through the first peak of the crisis is a sad, low moment in our national response.

"Our care homes were effectively thrown to the wolves, and the virus has ravaged some of them."

The government has insisted that no PPE supplier was asked to prioritise the NHS over the care sector.

A DHSC spokesperson said in April that PPE had been provided to more than 26,000 care homes, hospices and home carers across the country.

"The full weight of the government is behind this effort and we are working closely with industry and social care providers to make sure care staff have the protection they need to continue to deliver care safely," the spokesperson said.

"The testing arrangements remain chaotic"

The National Care Forum, 19 May

Seventy-six days after he had celebrated Brexit on 31 January, Boris Johnson was back in Downing Street - but in very different circumstances.

In April, the prime minister had been in intensive care after falling seriously ill with coronavirus. Contingency plans had been drawn up in case he died.

But on the 16th of that month, Mr Johnson was recovering at home after being discharged from hospital.

That day, Foreign Secretary Dominic Raab, standing in for the PM, confirmed the first national lockdown was being extended for another three weeks.

"We are now beginning to see that our efforts are paying off," he said.

"There is light at the end of the tunnel, but we are at a delicate and dangerous stage of this pandemic."

The next day 490 care home residents died with COVID-19. It was the UK's deadliest day for care home deaths during the pandemic.

Behind the scenes, SAGE had issued a warning to the government.

On 14 April it said that care homes "remain a concern" and advised that "increased testing in these settings… is important".

The next day, Health Secretary Matt Hancock announced all care home residents and staff with COVID-19 symptoms would be tested for the virus. But this did not include all asymptomatic residents or staff.

Figures released by the National Care Forum the following week showed only a quarter of care workers eligible for coronavirus tests had managed to access them.

One carer who was off work with coronavirus symptoms told Sky News she faced a 140-mile trip to get to her nearest test centre.

It was only on 28 April that testing was extended to all care staff and residents, regardless of whether they had symptoms.

Despite the government's pledge, the National Care Forum - which represents 120 of the UK's social care charities - said on 19 May that testing arrangements "remain chaotic, there is no reliable timescale for getting the test results and there are simply not enough tests prioritised for social care".

"We discovered too many care homes didn't really follow the procedures in the way that they could have but we're learning the lessons"

Boris Johnson, 6 July

Everything you've just read helps to explain why care home bosses were so angry when Mr Johnson commented on their response to the coronavirus crisis in July.

"Too many care homes didn't really follow the procedures in the way that they could have but we're learning lessons the whole time," the prime minister said.

What then are the lessons? Those in charge of social care say the advice needed to be clearer.

"Government guidance has come to the sector in stops and starts - with organisations grappling with over 100 pieces of additional guidance in the same number of days," said Vic Rayner, executive director of the National Care Forum.

But did Mr Johnson also have a point?

A study by the University of Kent in April found eight in 10 care workers believed they would not be paid if they had to self-isolate.

Fear of not being able to support themselves meant some were not self-isolating, causing virus transmission risks, the researchers found.

Many care workers reported being confused about their rights to statutory sick pay.

Some staff thought that they would be subject to disciplinary proceedings if they were forced to self-isolate, according to the survey of 2,600 care workers.

England's chief medical officer Chris Whitty said in July that "major risks" in care settings had not been considered early on, such as staff working in multiple homes and not being paid sick leave.

The DHSC's social care plan, published on 15 April, mentioned nothing about restricting staff movements between homes in its section on "controlling the spread of infection in care homes".

Carl Heneghan, professor of evidence-based medicine at the University of Oxford, said staff movement could have been of "huge" significance in allowing COVID-19 to spread in care homes.

"The government should have advised that agency staff, if used, should be employed in a single care home and not travel between multiple care homes. That advice should have been given in the middle of March," he added.

What lessons have been learned?

It took time but changes were brought in that should have helped better protect care home residents and staff.

After the first wave of coronavirus, care home staff were told in September to stop "all but essential" movement between care homes to protect residents.

The government has since moved to ban care workers moving between care homes in England during the pandemic.

It was also announced in September that care home residents and workers would get free PPE as part of the government's social care action plan.

Care home staff are now advised to wear PPE when providing personal care to residents - whether they are showing symptoms or not.

But as coronavirus infections have surged in the latest wave, care homes have once again been badly hit.

Figures from the Care Quality Commission show that the week ending 22 January saw the highest number of COVID-19 deaths of care home residents since early May with 1,705 fatalities - up 32% on the previous week.

The NHS confirmed on 1 February that every care home resident in England had been offered a COVID-19 jab.

But the National Care Association has raised concerns about the number of carers taking up the vaccine.

One care home owner in west London told Sky News half of his staff had refused the jab and called on the government to do more to combat misinformation.

Care homes are again being asked to take COVID patients straight from hospitals without having had a recent test for the virus.

Under guidance issued in January, the NHS advises that patients can be moved from a hospital directly to a care home within 90 days of a positive COVID test or the onset of symptoms.

Patients are not required to have a further COVID-19 test in the 48 hours prior to their discharge but they have to complete a 14-day isolation period. They also must not have shown any new coronavirus symptoms or had any new COVID-19 exposure.

Previously, COVID patients who were discharged from hospital to a care home were required to have first been transferred to a care home specifically designated for the purpose of caring for them while they complete a 14-day isolation period.

With the country still battling to contain COVID-19, John Allison's daughter-in-law Lyndsey is in no doubt that the government failed to throw a protective ring around care homes, as the health secretary promised.

"Did they heck," she said.

"All this talk about the over-70s being the most vulnerable, being in the shielding group - 'we need to shield our elderly, we need to protect the NHS' – and then they go and send elderly people, without testing other elderly people, all together so they end up contracting it.

"They did not shield the elderly."

A DHSC spokesperson said: "Throughout the pandemic we have taken the advice of scientific and medical experts, and as new evidence has emerged we have taken swift action to try and limit the spread of the virus.

"We have been doing everything we can to protect care homes - providing billions of pounds of additional funding, free PPE, infection control guidance, increased staff testing and providing priority vaccines.

"Almost 10 million of the most vulnerable people in the UK have now been vaccinated and every elderly care home resident in the country has now been offered the vaccine."


Credits:

Research and reporting: David Mercer, news reporter

Additional reporting: Ganesh Rao, Nick Martin, Lisa Holland, Laura Bundock

Digital design: Nathan Griffiths and Pippa Oakley, digital designers

Sub-editor: Connor Sephton

Editor: Matthew Price

Pictures: PA/AP/Reuters