I enjoyed, as always, Anthony Seaton's
recent contribution on COVID-19. We had quotations from Dylan Thomas, John Donne and Julius Caesar. However, I am a little concerned that some of his remarks could be taken to minimise the impact COVID-19 has had on care homes, though I am sure this was not his intention.
He makes the point that for some of the deaths, coronavirus pneumonia was just the last straw at the end of life. Undoubtedly, there will have been some for whom, and for their families, the virus may even have been a blessed release. He also distinguishes death directly due to the infection from that due to failure of different organs from the stress of it, perhaps the rapid pulse of fever with which a failing heart could not cope. I would submit that in all cases in which the virus was implicated, it is most likely to have been the underlying cause of death and the impact on the number of lives lost from it should not in any way be diminished.
The accuracy of those numbers depends entirely on the accuracy of death certification, something not done uniformly well by doctors. The Office for National Statistics (ONS) found over 20% of death certificates inaccurate. I am surprised the figure was not higher. The certificate itself is in two parts. In Part one, line 1a, the top line, the doctor enters the immediate direct cause of death. He should then, in the following lines below, go back through the sequence of conditions or events that led to death until the condition that started the fatal sequence is reached – the bottom line. This initiating condition is usually selected as the underlying cause of death.
So, in whatever circumstances coronavirus triggered the train of morbid events leading to death, last straw, organ failure or otherwise, it, the virus, was the underlying cause. Who knows for how long the person would otherwise have lived. The recent report of a nine-year-old who lost three grandparents to COVID-19 in the course of one week makes one's heart ache for her, whatever the nature of their underlying health.
In Part two of the death certificate, any other diseases, injuries, conditions or events considered to have contributed to the death, but not part of the direct sequence leading to it, are entered. Here one might, for example, put co-existing diabetes, dementia or frailty.
UK Governments need no help in stonewalling criticism about the care home debacle. Their response that it is easy to be wise after the event is hollow. The only retrospective thing is, perhaps, the magnitude of the number of care home deaths. Yet a medical student could have told them there would be lots of deaths in cheek-by-jowl institutions. It's rudimentary public health. The attempt the other day by the Deputy Chief Medical Officer at the Downing Street briefing to try to split hairs as to the relative contribution of the virus to care home deaths where it figured in death certificates was shameful. She can't advise people with certain pre-existing conditions to isolate or even shield, then seek to minimise the role of the virus by blaming those conditions.
Governments should do the decent thing and concede that their initial focus on the NHS, including transferring potentially COVID-19-infected patients out of hospital to care homes to free-up beds, was at least partly responsible for the subsequent care home tragedy. None of us would have found these decisions easy. The focus on the NHS in the face of panicked unpreparedness for a pandemic was, to a degree, understandable. Governmental credibility is weakened by constant denial.
Let me end with my own quotation from old Omar's Rubáiyát
Ah, Love! could thou and I with Fate conspire
To grasp this sorry Scheme of Things entire,
Would not we shatter it to bits and then
Re-mould it nearer to the Heart's Desire!
Dr Stefan Slater is a retired Consultant Physician