Investigation and inquest
On 8ᵗʰ February 2021 I commenced an investigation into the death of Clive Edward Rivers. The investigation concluded on the 28ᵗʰ May 2021 and the conclusion was one of Died from Covid-19 on a background whilst an inpatient at Tameside General Hospital and receiving immunomodulatory therapy prescribed for his skin condition. The medical cause of death was 1a Covid-19 on a background of immunomodulatory treatment; II Seborrheic eczema, Peripheral Vascular Disease
Circumstances of the death
Clive Edward Rivers was admitted to Tameside General Hospital having fallen at home. Whilst an inpatient the dermatologist put him on methotrexate for his skin condition and requested for him to be vaccinated against Covid-19 due to his increased risk of contracting Covid-19. This did not happen due to it not being policy to vaccinate inpatients. He contracted Covid-19 in hospital whilst awaiting discharge. He was discharged home to sheltered accommodation with a care package and a requirement to isolate. He deteriorated with Covid-19 on his return home. He died at his home address, ████████, Grange House, on 5th February 2021.
Coroner’s concerns
1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients. Therefore, Mr Rivers was not vaccinated.
2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19.
3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19.