Intended for healthcare professionals


Covid-19: Neglect was one of biggest killers in care homes during pandemic, report finds

BMJ 2021; 375 doi: (Published 22 December 2021) Cite this as: BMJ 2021;375:n3132
  1. Elisabeth Mahase
  1. The BMJ

The pandemic has disproportionately affected people living in care homes, who accounted for an estimated 30% of all deaths from covid-19 across 25 countries despite making up only 1% of the world’s population, a report has estimated.1

The analysis was carried out by Collateral Global, a research group that says it is dedicated to reporting on the effects of governments’ mandatory covid-19 mitigation measures. The report said the pandemic had exacerbated long running problems in the care sector, such as chronic underfunding, poor structural organisation, staff undertraining, underskilling, and underequipping, and a “lack of humanity in dealing with the most vulnerable members of society.”

“Neglect, thirst, and hunger were—and possibly still are—the biggest killers,” the group said. They also said that care home residents faced barriers in access to emergency treatments during the pandemic.

To carry out the analysis the group used national datasets on mortality from 25 countries, 17 cohort studies comparing deaths with a previous period, and 16 cohort studies reporting interventions or factors associated with excess mortality. The countries they looked at included the UK, US, Australia, Belgium, France, Canada, Israel, and France, but they emphasised that the quality of the evidence was limited and country comparisons should be treated with caution.

The report also looked at excess deaths, defined as the number of reported deaths from all causes during the crisis above what would be expected under non-crisis conditions. It said that all 17 cohort studies examined pointed to excess mortality worsening during the pandemic. However, the authors said that, despite the studies involving vast numbers of care homes around the world, the quality of the evidence was not good.

In England and Wales a study analysed the national death registry of all deaths of adults between March and June 2020 and compared these with historical data from January 2014 up to March 2020. A total of 57 860 excess deaths were reported, 44% of which (25 611) were in care homes or hospices. Of the 25 611 excess deaths in care homes and hospices, 61% (15 623) were due to covid-19, while 6267 were from dementia and 2358 from ill defined conditions. There were also 1495 fewer deaths from cancer than expected, and 1211 excess deaths from cardiac disease.

The study authors suggested that undiagnosed covid-19, poor testing, and inadequate staffing and infection control were the likely factors contributing to the excess deaths in care homes.2

Crowding and poor care

The report found that care homes with fewer beds were less likely to report covid deaths among residents. In the US, covid-19 cases and deaths were found to be at significantly lower rates in “Green House” homes, which usually have fewer than 12 beds, than in traditional homes that had either less than or more than 50 beds. As well as being less crowded, Green House residents also receive significantly more hours a day of care from certified nursing assistants than residents in traditional nursing homes.

The effects of chronic understaffing, whether this was due to pre-existing staffing shortages or workers becoming sick or leaving because of the pandemic, were also suggested as a contributing factor towards care home mortality. In some areas, such as in France and Spain, there were reports of long term care residents being confined to their rooms for days without assistance with eating and drinking and nursing home residents being found in a “state of complete abandonment” by armed forces brought in to help.

Looking at where care was good, the report pointed to US research that found that nursing homes with a five star inspection rating had 24% lower numbers of deaths from covid than those with a one star rating. Meanwhile, a French study found that mortality among covid patients decreased substantially if they had daily clinical examination or vital signs measurement.

To reduce mortality among care home residents and improve the care they get, the report authors recommended increasing staffing levels, reducing the number of beds in facilities, employing staff confinement strategies with residents, and implementing clinical changes such as daily examinations.

Nadra Ahmed, chair of the National Care Association, said, “In preparation for the impact [of covid-19] governments across the world focused on making sure that their hospitals were ready for the inevitable support they would need and set about creating capacity by discharging people out of the acute settings into support services. What followed was a seeding of the virus into support settings, like care homes, at a time when there was little or no testing available.

“Clearly, care settings had not been adequately prepared, by any of the governments’ strategies to manage the crisis that followed, and we lost residents who already had complex healthcare conditions, which was why they were in a care setting in the first place. The reality is that in the absence of a plan to support and protect older people in care settings we saw the consequences unfold in a way that potentially saw people losing their lives prematurely.”

Martin Green, chief executive officer of Care England, said, “Adult social care and the NHS are two sides of the same coin and need to be treated as such. The government shouldn’t have placed such a myopic focus on the NHS without due consideration for social care too.”

He said that he was “phenomenally” proud of the care workforce and wanted to ensure that they were recognised as professionals with proper career pathways and commensurate funding.

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