Restrictions on visitors and other factors related to the COVID 19 pandemic are being blamed for deaths and serious harm of several patients in Victorian hospitals whilst a hyper fixation on COVID 19 symptoms led to increased waiting times, misdiagnosis, and patient frustration.
At the beginning of the pandemic family members were refused permission to sit by the side of loved ones as they died. The restrictions were purportedly put in place to protect the “very sick” from the potentially deadly virus, as several outbreaks within hospitals allegedly cost some vulnerable patients their lives.
A new report has come out from Victoria’s health safety watchdog on sentinel events.
Sentinel events are the most severe adverse patient safety events in the Australian healthcare system. It is important that we do not ignore these, but rather that we learn from them.
The report outlines 22 cases between July 2020 and July 2021 linked to COVID 19, such as the visiting restrictions, staff shortages, and a more difficult working environment.
The report talked about medical professionals being hyper fixated on the COVID 19 symptoms, leading to incidents where patients were misdiagnosed, were neglected, or had increased waiting times for tests that would have proven the patients were suffering from something other than COVID.
A number of nurses have suggested that enforcing the visitor bans, which often had a negative impact on non-COVID positive patients, has been one of the most difficult elements of the pandemic. They were traumatised while having to hold up iPads to allow people to see the final breaths of their loved ones who were quarantined in their hospital beds. Some of these nurses were driven to contemplate career changes because of how emotionally draining dealing with the pandemic protocols was.
One young intensive care nurse shared her experience as part of a new book on the experience of health care workers during the pandemic. “While the no-visitor policy has been absolutely vital, to promote staff and patient safety, it doesn’t make telling a mother she can’t visit her son (who has just been in a horrific car accident and is now in a coma) any easier,” she said.
Professor Marie Bismark is one of the book’s authors. She said that while the visitor restrictions were made “for very good reasons at the time”, with the benefit of hindsight they could have been applied in a more nuanced way.
Bismark said many people she had spoken to would have been willing to wear full protective gear or do whatever it took to be able to support a loved one.
“In some ways, the word ‘visitors’ doesn’t encompass what family and friends provide to someone in hospital,” the doctor and public health law expert with the University of Melbourne said, “They can help with making sure people are eating and drinking… they can recognise when someone is deteriorating, they can provide a lot of care that otherwise falls onto nursing staff.”
“Family and friends are really an essential part of the care team, and I don’t think that was adequately recognised.”
Bismark also mentioned the assaults, threats, and abuse that some of the health workers at the front doors of hospitals copped while communicating the visitor rules they didn’t have any control over to people.
123 cases out of the 168 sentinel event cases in the Safer Care Victoria report ended with the patient’s death. The majority of incidents are not discussed in detail, but the report does explore a case that occurred at an unnamed local Victorian health service, unrelated to COVID 19 visiting restrictions.
A woman who was holidaying in Queensland and broke her leg endured five separate cancellations of her surgery. At this time, she had gone nine days with no medication to reduce blood clots. She passed away from a pulmonary embolism (blood clot).
15 cases of medication error, 19 cases related to mental health, 13 cases related to falls, 3 patient accidents, and 1 case where a procedure was performed on the wrong side. Over a dozen newborn babies came to harm or died.
Since the lockdowns ended in Victoria, the visitor restrictions and bans have been wound back. Some people are now allowed to visit unvaccinated if they provide a negative rapid test. However, so many restrictions are still in place, with a lot of hospitals still only allowing one or two visitors per patient, per day during set times.
The deputy state controller of health service operations at Victoria’s Health Department, Jane Miller has reportedly said that hospitals had made changes to improve patient’s access to their loved ones including a growing hospital in the home program. But she suggested that the rules that were in place in 2020 and 2021 were to save lives from a highly transmissible disease.
“We know there are lots of benefits to have visitors by the bedside. And we know that restricting them was tough on everyone – the patient, the family, and the staff. But it was absolutely necessary.”
The conclusion is that visitor restrictions may have resulted in bad outcomes for some patients, contributing to falls in hospital, causing fractures or head injuries. The restrictions particularly impacted those from non-English speaking backgrounds according to Safer Care Victoria.
“Health services need to improve how they involve families/support person(s) in care discussions and may need to adopt innovative solutions, such as video calls and designated roles assigned for family communications,” the report said.
The Better Safer Care Victoria website shows the Sentinel events annual report for the 2020-21 period.
It states that between July 2020 and June 2021:
- 168 sentinel events were reported to us
- 45 percent of sentinel event reports included input from the affected consumer or their family member. This is a considerable improvement from 35 percent in 2019-20
- 1041 recommendations for improvement were developed from the review of sentinel events.
The full PDF of the report can be accessed here.
