Our response to UK Covid-19 Inquiry Module 2 Report findings that delayed decision-making led to avoidable loss of life

Our response to UK Covid-19 Inquiry Module 2 Report findings that delayed decision-making led to avoidable loss of life.

The publication of the UK Covid-19 Inquiry’s Module 2 Report is a watershed moment for the intensive care community. It provides a post-mortem of a Government that failed when the stakes were highest. For the Intensive Care Society, this report is not just a political critique, it is the record of a national tragedy.

The report lays bare the “toxic” and “chaotic” culture at the heart of the Government at the time. Our members were faced with the direct, long-lasting, irreparable and devastating consequences of delayed decision-making. We are deeply concerned by the level of ignorance shown by the political officers, and to some extent, civil servants regarding how the NHS actually operates. The people with the most relevant expertise were left out of the process at the very moment their knowledge was needed most. This exclusion of frontline expertise must never happen again.

As a community who were engaged in this crisis from the very outset, the Report's primary conclusion of 'repeatedly, too little, too late' is a difficult thing to read. We agree with Baroness Hallett's assertion: it is both the failure to act and the repeating of this failure in July 2020, that made it inexcusable. While this represents acknowledgement of a reality we had long known, reading the assessment that a 'lock-down' just one week earlier may have saved 23,000 lives, precludes any sense of validation. We think only of those who might not have died and those who may not have grieved. 

The Intensive Care Society has long advocated for robust, real-time data on critical care capacity. Yet, the Inquiry once again confirms that the Government was essentially "flying blind" while we scrambled for resources. By excluding the frontline expertise our members could offer, decision-makers transferred the risk from the political sphere directly onto the shoulders of healthcare professionals, causing a profound moral and psychological injury that persists today.

The Inquiry’s finding that decision-makers had little understanding of the impact of their decisions on people from socially deprived communities and of minority ethnic backgrounds aligns with our clinical observations. We strongly endorse the recommendation to improve the routine consideration of health inequalities in emergency planning.

Looking forward

The Inquiry has confirmed that the catastrophic delays in decision-making were the result of a systemic disconnect between the political centre and the clinical frontline. To honour all lives lost, we must move beyond a culture of retrospective blame and toward a proactive model of health service resilience.

The Intensive Care Society maintains that a resilient critical care system is not a luxury, but the fundamental infrastructure upon which both national health and economic stability depend. 

We call for:

• The permanent appointment of a National Critical Care Consultant Lead, to work within the Cabinet Office’s Resilience Directorate. This person must have current clinical experience providing NHS critical care and will work to make sure that both clinical parameters and real-time ICU capacity are integrated into the Government's "National Risk Register".
• Investment in a UK wide, real-time ICU dashboard that provides a "single source of truth" for bed occupancy, staffing ratios and patient outcomes l to move away from the fragmented, manual reporting systems that hindered the initial response to the COVID19 pandemic. 
• Implementation of a mandatory Health Equity Impact Assessment to ensure that shielding and resource allocation strategies recognise and protect the most vulnerable members of society from the outset.
• An ‘Intensive Care Workforce Covenant’,  a long-term funding and retention strategy that recognises the unique psychological and physical demands of the intensive care environment. 

The Society is ready to work with the Government to support the transition from a reactive “crisis” footing to a sophisticated, data-driven, and expert-led model of national health security. The cost of inaction has been laid bare; the time for structural reform is now.