The source of the outbreak which claimed the lives of 20 residents at the Abbotswood nursing home occurred in all likelihood without any fault on the part of the home, the Brunner review concludes.

Abbotswood is described in the report as having been ‘one of the greatest tragedies during the pandemic’.

The first resident at the home tested positive in early April 2020 and the facility descended into a crisis as many members of staff became unable to work, as they were required to self-isolate or had symptoms themselves.

It is not possible to trace the source of the outbreak, note the report but ‘in all likelihood it occurred without any fault on the part of the home’.

The virus may have been introduced into the home by people who were transferred from the hospital into Abbotswood without being tested for Covid, or by a member of staff at a time when personal protective equipment was not required or provided.

The report says there was insufficient planning to support care homes to avoid outbreaks. It was an obvious area for increased support, given the vulnerability of older people,

Rather than adequately support Abbotswood, the DHSC increased pressures on the home. ‘Management at Abbotswood felt that some senior civil servants at DHSC were judgmental and hostile towards the home,’ the report notes.

The DHSC took over Abbotswood without a clear plan in place, which created uncertainty and may have led to ‘suboptimal’ care, it adds.

Following the DHSC takeover, a number of investigations into Abbotswood were launched.

Police initially thought there was little prospect of proving any criminal offences that fell within its remit but following inquiries by private investigators Expol they concluded that offences may have occurred.

The only charge considered that was related to the pandemic was one of ill treatment, it being alleged that a resident had not been moved out of his room, which was in the Covid isolation wing, and that they subsequently contracted Covid.

But it was confirmed in June 2021 that no criminal charges would be brought against any individual or company in respect of the events that unfolded at Abbotswood and that included health and safety offences.

However, the investigation had had devastating consequences for those that were being investigated as they were prohibited from speaking publicly about what had happened and were often subject to abuse from members of the public.

The report says there is relatively consistent evidence that some residents were dehydrated both before and after DHSC took over care, and there is also clear evidence that two medication errors were made by the same DHSC employee as well as issues with paracetamol not being available on one day, and delay in provision of a drip.

But the Review is satisfied on the evidence obtained that those who were working at Abbotswood, whether employed by DHSC or not, were doing their best in difficult and harrowing circumstances.