The Covid-19 Bereaved Families for Justice Cymru have come to this Inquiry seeking truth, justice, and accountability for all those bereaved by Covid-19 in Wales. At the outset of this module we set out in stark terms the total number of Covid-19 deaths registered in Wales up to 2 February 2022: 12,510. That figure increased to 12,559 by 16 February 2024.
The impact film and the powerful evidence of Elizabeth Grant and Amanda Provis served as a tangible heartbreaking reminder of the tremendous loss of life and trauma experienced by the bereaved. As Elizabeth Grant reminded us, thousands of deaths on the dashboard were desensitising people to the fact that this was actually people. They were loved people, they’d just become statistics and numbers.
The deceased must not be reduced to statistics and the trauma experienced by the Welsh bereaved must not go unheard.
Individual and systemic failure
The Welsh bereaved witnessed day after day the individual and systemic failure to adequately protect their loved ones as Covid-19 spread like wildfire through hospitals and care homes, fuelled by inadequate testing regimes and insufficient PPE. The Welsh bereaved want answers.
Against this poignant backdrop, the Welsh Government has repeatedly shirked a granular inspection of Welsh decision-making by refusing to open itself up to scrutiny in a Wales-specific inquiry, seeking instead to blame the UK government.
It is also regrettable that this Inquiry, and indeed this module, has been forced to spend so much time asking about missing evidence and destroyed WhatsApps. The Welsh Government has consistently sought to deflect blame by asserting what appears to have been a party line, that decision-making was not made on WhatsApp.
As you rightly identified, my Lady, the real issue is one of record-keeping and public accountability, and it is worrying that many of the witnesses before you, including the First Minister for Wales, Mr Drakeford, did not appear to appreciate this. It was not the policy that was wrong, what was wrong was that government communication during a national emergency was deleted.
My Lady, we invite the Inquiry to publish all the WhatsApps so that the Welsh people can see what their government was using informal messaging for.
At the outset of this hearing, the Welsh bereaved invited witnesses to be transparent, reflective, and accountable. A reasonable request of Wales’ democratic leaders, one might think. The Welsh Government does not appear to have heeded this plea.
The qualification of hindsight
The evidence given to this Inquiry can be characterised by a lack of willingness, in many quarters of Welsh Government, to give open accounts of what went wrong and why, and to accept that mistakes were made, which they undoubtedly were. Much like the tenor of the Welsh Government’s written evidence, its oral evidence has been laden with the heavy caveat of hindsight, while seeking to deflect blame onto others. The Welsh Government has approached this Inquiry determined to robustly defend their decisions.
This was most starkly illustrated by the way Mr Drakeford and Mr Gething gave their evidence to you. Both refused to accept that any mistakes had been made. For example, they refused to accept that a precautionary approach should have been taken to asymptomatic transmission in April 2020, which is simply staggering given the evidence we know they had from SAGE, the UK government, and their own advisers.
Between them they also refused to accept a failure in planning for this pandemic. Mr Drakeford did not accept that he should have cancelled mass gatherings and Mr Gething only accepted this with the qualification of hindsight.
They both defended the delays by the Welsh Government in introducing testing in care homes and tried to explain away the Welsh Government’s obviously illogical divergence on face coverings. Mr Drakeford even failed to accept that he should have attended COBR early, while in the same breath criticising Boris Johnson for exactly the same thing.
In all the other modules, my Lady, you’ve heard some reflection and some acceptance that mistakes were made, and it is deeply worrying to the Welsh bereaved that their government seems incapable of doing the same. This ought to raise a real concern that lessons have not truly been learnt here in Wales.
Early response
The Welsh Government’s initial response can be summarised in three words: passive, slow, and disjointed. Valuable time was lost in January, February, and the early part of March 2020, when the virus was allowed to spread, with ministers and advisers complacently waiting for the first case to arrive in Wales and, thereafter, responding with sloth-like urgency. It was obvious from late January 2020 that what was happening internationally could soon happen in Wales.
The Chief Medical Officer for Wales, Frank Atherton, warned the First Minister by 24 January 2020 that there was a significant risk the virus would arrive in Wales. At the 29 January 2020 COBR meeting, the UK government confirmed its intention to prepare for the reasonable worst-case scenario.
The Welsh Government should have been electrified at this point, but it was not. Instead, it took a laissez-faire approach, only discussing Covid-19 in Cabinet on 25 February, notwithstanding the clear risk and the evidence that the NHS in Wales was at risk of becoming overwhelmed.
Mr Drakeford’s response was to refer to informal chats in the corridors of power and a suggestion that Covid-19 was happening elsewhere, suggesting that the signals were not there at the time, as it was low risk and so “not pressing”. Mr Drakeford appears to have conveniently forgotten that on 31 January 2020 his Chief Medical Officer, Frank Atherton, formally increased the risk level from low to moderate, alongside the other UK chief medical officers, and issued a press statement on that date stating that this meant the UK should plan for all eventualities.
We invite the Inquiry to publish this notice from Sir Frank of 31 January so that the public can see the evidence for themselves.
Waiting for the virus to arrive
The Welsh Government could and should have acted sooner in the areas where they did have responsibility, namely health and social care. They could have ensured infection prevention and control measures were in place, that hospitals were prepared, that there was surge capacity, that care homes knew what to do in the event of an outbreak. They could have started earlier to count up the PPE. They could have liaised with key partners, establishing effective consultative fora, and formulated co-produced plans on a whole range of non-pharmaceutical interventions.
Instead, they did not act with urgency at this stage but waited for the virus to arrive. This was not national strategic leadership.
Chris Williams and Tracey Cooper from Public Health Wales were aware of the looming threat of Covid-19 and were mobilising from mid- to late-January 2020. In a call to arms they called for prompt action from the Welsh Government. The frustration felt by Chris Williams and Tracey Cooper was palpable in their evidence to this Inquiry. If Public Health Wales could see the threat “coming down the line”, why couldn’t the Welsh Government?
Mr Drakeford in his evidence suggested the reason he didn’t hear from Public Health Wales was because their concerns were not being passed to him by his Chief Medical Officer. This was a very poor example of blaming others, and another example of deflection from Mr Drakeford. Again, this was not national strategic leadership.
Introduction of lockdown
The sentiments expressed by Dr Quentin Sandifer, then lead strategic director of Public Health Wales, have been borne out by the evidence that you have heard: “What I think was missing in the first few weeks, from 8 January 2020 when I first became aware to 20 February 2020 when the [Health and Social Services Group] Coronavirus Planning and Response Group first met, was national strategic leadership and coordination from the Welsh Government.”
Now, Mr Drakeford was very dismissive of Dr Quentin Sandifer in his evidence to the Inquiry, but on his own admission little was being done in that early period. It might be suggested that, rather than gallivanting around Brussels attending cultural events on St David’s Day on 4 March 2020, Mr Drakeford would have better served the Welsh people by attending COBR and also communicating with Public Health Wales and Dr Sandifer.
Now, in relation to lockdown, Dr Hoyle, Dr Williams, Dr Cooper, and Professor Gravenor all say that the national lockdown should have been introduced two weeks earlier as a minimum. Mr Drakeford in his evidence said that it was only on 21 and 22 March 2020 that he and Nicola Sturgeon were calling for a national lockdown. The Welsh bereaved question why on earth was more pressure not being exerted earlier by the Welsh Government on the UK government?
PPE
By the end of January 2020 at the very latest it must have been obvious that if Covid-19 arrived in Wales, PPE was bound to be needed and potentially in large quantities and very quickly. However, we heard that the Welsh Government’s health countermeasures group, which was tasked with operational coordination and oversight for PPE, did not start that work until 12 February 2020.
The lack of urgency this shows in thinking through the supply and delivery of PPE is difficult to understand. Why was this crucial work not started at the very first opportunity?
As regards PPE for social care, the evidence showed the first decision by the Welsh Government to provide substantial help to the sector was not taken until 19 March 2020. Care providers could approach local health boards for PPE, but only if a case of Covid-19 had been confirmed. Well into April 2020, serious problems with PPE continued, as evidenced by the Welsh local governments’ call for action and the joint statement on 12 April 2020 from the British Medical Association and Wales TUC, calling for assurances from the Welsh Government that health and social care staff would get the PPE they needed.
There is no doubt that those in dire need of PPE in these early weeks were profoundly failed by the Welsh Government.
Mass gatherings
The Welsh Government was slow to ban mass gatherings in the face of known rising rates of community transmission. The scientific evidence by 11 March 2020 was that banning mass gatherings could result in a reduction in infection-related deaths by 2%. The Scottish Government took the decision to cancel mass gatherings of over 500 people to release pressures on the emergency services.
Notwithstanding these known benefits, the Welsh Government recklessly declined to take the initiative to cancel a Wales v Scotland rugby match scheduled for 14 March 2020 in the face of significant concerns raised and a recommendation to do so by Public Health Wales, leaving it to the Welsh Rugby Union to make the decision whether to do so, which of course they did.
In his evidence, Frank Atherton and indeed Mr Drakeford clung desperately to the absence of direct SAGE advice on banning mass gatherings to justify the position, accepting only with the caveat of hindsight that banning mass gatherings would have given the correct signal to the public.
In his evidence, Mr Gething drew a comparison between indoor and outdoor events and the cultural significance of rugby. This does not explain why the Welsh Government allowed two Stereophonics concerts to proceed on 14 and 15 March 2020. This was not national strategic leadership but rather a total abdication of responsibility by the Welsh Government.
Care homes
It is of course the case that the Welsh Government had to protect hospitals, but this should not have been at the expense of vulnerable care home residents who were in effect locked in without visitors and without a voice.
The Welsh Government had a duty to protect all vulnerable people, yet when the virus erupted in March and April 2020, the Welsh Government recklessly exposed those in care homes to Covid-19, when on 9 April 2020 they introduced a policy directing care homes to accept people with symptoms of Covid-19.
This was at a time when they knew from the Welsh Local Government Association and the Older People’s Commissioner, Helena Herklots, that the virus was spreading like wildfire in care homes. This was also at a time when they knew there was an inadequate and inconsistent supply of PPE, that there was no testing regime, and that residents were dying in circumstances where, in the words of Ms Herklots, those deaths were not even being counted.
It is deeply upsetting to those who lost loved ones in care homes to hear Frank Atherton dismiss their concerns because “the numbers were not large”, and assert that there was PPE when we know this was simply not consistently the case, and then to pass the buck on to Public Health Wales who apparently were left to give some advice on infection control.
The obvious questions were simply not asked. For example, who was going to care for the sick, supposedly isolated residents? It was of course the healthcare workers, who would also be caring for many others in a context where there were no tests and quite possibly no adequate PPE.
Later in Wales
The Welsh Government’s decisions on 22 and 29 April 2020 to test everyone being discharged to a care home and provide step-down facilities for those who tested positive was a change that came later in Wales as compared to England. Similarly, the decision to extend testing to all staff and residents in care homes was not taken until 16 May 2020, slower than all the other three nations.
Why did the Welsh Government simply wait for leadership from the UK government on these matters? Why was it not leading the field in the area of testing and being proactive rather than reactive? The Welsh Government wants to be compared in this Inquiry to the UK government, and indeed all the other nations. Well, in respect of testing in care homes and of health care workers, the Welsh Government clearly came last.
Transmission
As early as 28 January 2020, SAGE and in turn the Chief Scientific Adviser for Wales were aware of the possibility of asymptomatic transmission.
In the absence of certainty on asymptomatic transmission, but in the context of clear evidence of risk, Welsh Government decision-makers could and should have adopted a precautionary approach. The failure to do so is unacceptable and had devastating consequences in Wales.
Mr Gething was presented in this Inquiry with a wealth of evidence demonstrating a growing awareness of asymptomatic transmission from as early as 4 February 2020. Mr Gething accepts that he knew about much of this evidence, and at an early stage. And on his own admission he knew about the CDC report of 27 March 2020, which clearly stated that asymptomatic transmission is real and should be assumed, and “once Covid is introduced into a long-term nursing facility, rapid transmission can occur”.
Failure in public health messaging
It is difficult to understand, then, how Mr Gething could think it appropriate to make a public press statement on 2 May 2020 stating: “At the moment, the evidence does not support the blanket testing of everyone who does not have symptoms.” When a different position was being taken by the UK government in England, this was a clear failure in public health messaging, which directly conflicted with the four nations approach.
Despite the overwhelming evidence at his disposal, Mr Gething was unable to share Matt Hancock’s biggest regret of not pushing harder for asymptomatic transmission to be a baseline assumption. Instead, Mr Gething referred again to hindsight, and sought to fall back on the advice he claimed to be receiving, and the fact that he was not being told to act, again seeking to blame others. But why did Mr Gething need to be told what to do by his advisers? And why was he looking for scientific certainty on asymptomatic transmission and taking a pick and mix approach to the science?
As soon as it became obvious that the UK government had changed its approach to testing, why did Mr Gething not simply ring up Matt Hancock as a matter of urgency to understand the rationale for the change, and to better understand the science, and to understand what immediate action was required in Wales? Sitting back and simply waiting is not an example of ministerial leadership.
Ignoring the evidence
Mr Drakeford also relied on hindsight and said with no caveats or nuance that, when it came to asymptomatic transmission, the scientific evidence simply wasn’t there in April 2020. And we know that he told the Senedd on 29 April 2020 that there was no value in testing asymptomatic patients. Again, we know from the evidence disclosed to this Inquiry that this was simply not the case. How could Mr Drakeford have been so ignorant of what the evidence and the science showed, we ask?
My Lady, we ask you to pay very close attention to the witness statement of Albert Heaney, the then-Director of Social Services. This is a very important statement, but it clearly tells you that on 23 to 24 April Public Health England shared the results of a survey of care homes which indicated asymptomatic transmission with NERVTAG and with the Welsh Government, and it noted growing international evidence of asymptomatic transmission of Covid-19 in care homes.
The Welsh bereaved want to know why Mr Drakeford and Mr Gething did not tell the Welsh people the unvarnished truth, which was that there was evidence that the virus might be spreading asymptomatically and that testing was crucial. The people of Wales needed to know this information in order to best protect themselves. Was the reality that the Welsh Government was trying to hide from the Welsh people their chaotic response and the fact that they were lagging behind the United Kingdom government?
Masks
Engaging in unjustifiable divergence is most starkly illustrated by the approach to face coverings taken by the Welsh Government, with Frank Atherton at the helm. There is simply no justification for there to have been any divergence on face coverings in the community across the four nations. Divergence on face coverings would obviously confuse the public and undermine public trust in the science. It was divergence and weak public messaging that created a risk of mask discrimination or face mask militancy in a public who didn’t understand or trust the inconsistent and contradictory advice they were being given.
It ought to have been obvious that to leave the public mystified by the so-called scientific advice would do untold damage to the public’s willingness to trust their government. There was, in truth, no downside to mandating face coverings in the community. These things ought to have been obvious to Frank Atherton and to the First Minister for Wales, Mark Drakeford, and indeed to the whole Welsh Government. And it’s simply incredible to the Welsh bereaved that not even on this topic could Frank Atherton accept that he had failed the Welsh people, but he only accepted that, looking back, “I do wonder whether it would have been a better decision just to simply align.”
As for Mr Drakeford, this is another area in which leadership was simply absent. It is also deeply concerning to the Welsh bereaved that in early June 2020 TAC advice was apparently amended following discussions with Mr Gething, resulting in the Welsh public not being told that the World Health Organization was recommending that vulnerable people in the community, where they were 60 and had underlying comorbidities, needed access to medical masks. The Welsh bereaved ask: when was the Welsh public actually given this piece of information?
Autumn firebreak
The Welsh Government knew in September 2020 from SAGE and TAG that they needed to act decisively. They knew local lockdowns were a failed experiment. But when the Welsh Government did decide to diverge and go it alone on a firebreak, they did so in a way that was slow and ineffectual, waiting too long for the lead to be taken by the UK government, such that the steps that were taken were too little and too late.
The modelling request was delayed, the parameters were overly limited, and there’s no evidence of advance planning on financial scope for action. It is simply not good enough for the Welsh Government to blame the UK government for the timing of the firebreak. The evidence simply does not support this assertion.
The Inquiry’s not been able to get to the bottom of whether ministers knew that four weeks would push the virus deep into December, close to the time when the vaccine would arrive. This was an obvious and vital piece of information that ministers ought to have at least weighed in the balance. The consequences of not doing so will not be lost on the Inquiry, given the high death rates in Wales in late 2020 and early 2021. And of course then, when it came to easing restrictions after the firebreak, the Welsh Government opened up society too quickly, contrary to the advice of Frank Atherton and the Chief Scientific Adviser for Health, Rob Orford.
Questions by the bereaved
Now, the Covid-19 Bereaved Families for Justice Cymru wish to make clear, on this topic of firebreak and modelling more widely, that the Swansea modelling team did their absolute best and this should be recognised by the Inquiry. As should the disregard at the way these academics were treated by the Welsh Government, who had to work for free in their evenings whilst also living through a pandemic. These were dedicated professional members of the Welsh public who stepped up to fill the void caused by the Welsh Governments’ woeful planning failures. They were treated badly and this is nothing short of a scandal.
The Welsh bereaved question whether the Welsh Government genuinely did seek to forge relations that would enable the best chance of alignment of policy and public messaging with the UK government, or whether there was in fact a tendency towards silos and a default position of one-upping and blaming the UK government. There should have been no place for playing politics in a pandemic with lives at stake.
So, finally, my Lady, as you know, the Welsh bereaved are incredibly grateful for your efforts and that of the Inquiry team in coming to Wales and bringing some scrutiny to bear on the handling of the pandemic. The Welsh bereaved feel very keenly that you have gone to great lengths to listen to the Welsh people and to hear their stories of bereavement and for that they are very grateful.
