The Iatrogenesis Hypothesis

A spike in non-COVID deaths during spring 2020 is defying explanation and points to what I’m calling Catastrophic Health Collapse (CHEC). Could dangerous policies be the root cause?

In a recent article entitled The Deadly Initial Spring 2020 Covid Wave Professors Norman Fenton and Martin Neil of QMUL usefully bring together information from various sources that point to iatrogenesis as a possible underlying cause of death of the vulnerable and elderly in spring 2020 - the iatrogenesis hypothesis. For those unfamiliar with the Latin word Merriam-Webster defines it as:

The unintentional causation of an unfavorable health condition (such as disease, injury, infection, or an adverse drug reaction) during the process of providing medical care (such as surgery, drug treatment, hospitalization, or diagnostic testing).

As I have stated in previous articles iatrogenic death is unavoidable in systems of healthcare even when extreme vigilance and total dedication are brought to bear. Negligence and error in diagnosis, treatment and patient management are a fact of clinical life, and so the tricky question is whether sloppiness of an individual, unit or entire service is beyond the pale and leading to excess harm, suffering and death.

The Protocol Prison

In addition to clinical performance of individuals and groups of individuals we’ve got the effectiveness of protocols and guidelines to consider. These may be determined locally, regionally or nationally, with national guidelines being established by professional bodies such as the Royal College of Physicians, Royal College of Nursing and the National Institute for Health and Care Excellence. These serve to define minimum standards of care against which the clinical performance of individuals, units, hospitals and entire NHS Trusts may be formally assessed in a process called clinical audit.

Clinical effectiveness is the name of the game and it can be a long haul to lick a unit into shape. This, of course, assumes that the guidelines and protocols have been carefully designed and thought-through using state-of-the-art knowledge. Though this is usually the case any senior healthcare professional will tell you that this top-down approach is not infallible, especially when these stray into ‘one size fits all’ thinking. One size fits all may benefit the service in terms of delivery, cost and efficiency but it may not fit the sorry souls in ward 16.

Since national guidelines and protocols affect every corner of the healthcare system in the UK, with professionals pretty much duty bound to follow them, then such rules had better be sounder than the pound. But what if a set of guidelines wasn’t just ineffective but misguided and harmful? How much damage could be done?

NICE NG163

The answer seems to be an awful lot, and we seem to be unearthing evidence of this. The National Institute for Health and Care Excellence issued NICE rapid guideline NG163 on 3 April 2020, which has since been deleted from their website. Fortunately you can still find it on waybackmachine and, for the time being, you can also download the original PDF from here.

The title of this guideline is: COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community, for which the NICE landing page is here, upon which we learn that NG163 has been updated and replaced with NG191. Revising guidelines is standard practice and I am going to leave it to others to discuss the content of NG163 vs NG191, but I shall just point out that a rapid guideline isn’t the same beast as a full guideline.

NG163 gave GPs and other medical professionals the green light to use powerful drugs such as morphine sulphate, midazolam and levomepromazine in end-of-life (EOL) situations arising from COVID-19. All of these drugs come with cautions and contra-indications, as well as warning of side effects including respiratory depression and respiratory arrest, and so I was particularly surprised to read this last sentence:

I was surprised because we're not talking about high-end ICU care in which heavy sedation and paralysis of the respiratory muscles are utilised for beneficial effect. No indeed, we’re talking about the very basic level of care provided in care homes. And, as we shall soon see, we’re talking about application of these guidelines to elderly folk who were not suffering from COVID. But, of course, prescription drugs will only be one piece of the jigsaw when it comes to patient care and management within the community: dehydration is a real issue, as is nutrition, monitoring and companionship.

Out Of Whack

I first realised something was out of whack back on 7 August 2021 when I started looking at care home deaths. This was in the days before my Substack publishing account. In a facebook post I stated:

The third slide is quite something. We now see that the incredible surge in care home deaths during the spring of 2020 wasn’t due to COVID. This is the spike that had been camouflaged by presenting the data as an accumulated series, and this is the spike that shocked me when I unpicked the data. There is no doubt that a massive surge in non-COVID death occurred within our care homes during spring of 2020. We don’t see such a surge during the so-called third ‘wave’ of what is going to be seasonal death during the winter of 2020/21, with weekly deaths now running well below the 5-year baseline, so something unique happened back in spring 2020.

Herewith extracts from a facebook post dated 8 August 2021:

In my first post on this subject I sketched a little of the background surrounding concerns over treatment of the sick and elderly in care homes during the first wave of the pandemic after many of them were moved there to free hospital beds that, in hindsight, were never needed. I talked about an end-of-life care pathway involving DNR, nil by mouth and heavy use of morphine and midazolam, the latter being a respiratory suppressant in high doses. In my second post we saw evidence of EOL policies in action with a substantial spike in weekly non-COVID deaths between March and May 2020, and I promised to derive figures for excess deaths.

I now present two further slides using the method adopted by the Office for National Statistics (ONS) for estimating excess death, this being to subtract the prior 5-year (2015 – 19) mean count from observed counts for the corresponding week. In the first slide we may observe the excess for all care home death and in the second slide we may observe the excess for non-COVID care home death.

Over the 11 week period w/e 20th March 2020 - w/e 29th May 2020 some 57,314 care home residents within England & Wales died, 26,575 of which would have normally been expected in accordance with the 5-year mean rate (46.4%). Of the remaining 30,739 excess deaths some 18,104 can be attributed to COVID (58.9%) leaving a somewhat shocking 12,635 inexplicable non-COVID excess deaths (41.1%).

Some of the comments under these facebook posts are well worth reading, especially anecdotal evidence of poor management of relatives. It can be hard reading these at times.

Dee’s Substack Years

Continual censorship by facebook forced a flip to Substack in December 2021, which makes referencing further relevant articles a doddle. Those interested in following the deeper story may wish to get the coffee on the stove and peruse the following links:

April 2022

Weekly Deaths Update (part 2)

Weekly Deaths Update (part 3)

June 2022

Non-COVID Care Home Deaths (Data)

COVID & non-COVID Care Home Deaths By Region (part 1)

COVID & non-COVID Care Home Deaths By Region (part 2)

COVID & non-COVID Care Home Deaths By Region (part 3)

Underlying Cause Of Death (part 1)

Underlying Cause Of Death (part 2)

January 2023

Trends In Causality for England, 2014/w23 – 2022/w46 (part 1)

Trends In Causality for England, 2014/w23 – 2022/w46 (part 2)

Trends In Causality for England, 2014/w23 – 2022/w46 (part 3)

Trends In Causality for England, 2014/w23 – 2022/w46 (part 4)

Excess Deaths by Cause, England 2020/w1 – 2022/w46 (part 1)

Excess Deaths by Cause, England 2020/w1 – 2022/w46 (part 2)

February 2023

Excess Deaths by Cause, England 2020/w1 – 2022/w46 (part 3)

Excess Deaths by Cause, England 2020/w1 – 2022/w46 (part 4)

Excess Deaths by Cause, England 2020/w1 – 2022/w46 (part 5)

Catalogued Comment

What we have here, then, is a whole pile of dated, published analyses in which I continually express my grave concern that something went terribly wrong in the knee-jerk reaction back in spring 2020. We’ve got an inexplicable spike in non-COVID care home death and inexplicable spikes for non-COVID diseases and conditions across several chapters of ICD-10 (particularly so for mental/behavioural disorders and diseases of the nervous system). These inexplicable spikes fall among the older age groups, and all of them are synchronised in time to just a couple of weeks in April 2020 just after issue of NG163.

A signal this persistent, this synchronised, this broad and this large should have raised alarm bells amongst many professionals and authorities like a tactical nuke going off in a small library. This is not a subtle situation - I didn’t call it the Catastrophic Health Collapse (CHEC) death spike for nothing.

Mouse Level Revelations

It wasn’t until recent revelations by Jikkyleaks on Twitter that I realised NICE rapid guidance note NG163 could be to blame for opening the door to unwarranted prescribing, this being published around a week or so before the CHEC bomb went off. Here’s a snapshot for midazolam use c/o our furry friend - feel free to compare this with any of the many slides I have produced…

…and it’s not just mice. The impeccable Dr John Campbell isn’t a happy bunny either. Though prescribing clearly needs to be investigated I would suggest this is only part of a disgraceful whole that I’m calling dangerous policy.

Difficult Signals To Ignore

From my point of view as an experienced NHS allied health professional who has spent eight years auditing and assessing clinical performance at individual, unit, hospital, regional and national levels these are difficult signals to ignore. There is little doubt in my mind that during spring 2020 non-COVID cases were subject to unwarranted EOL protocols and attendant use of powerful medication designed for severe COVID cases and severe COVID cases only.

Given the enormity of this we have to also consider whether a proportion of hospitalised COVID deaths were also iatrogenic in nature - a sobering thought indeed.

All I can do with this sorry state of affairs is turn the handle on the numbers, and so I shall trust that those who should come forward to investigate and comment authoritatively on this matter will now do so. Coming up will be an article series dedicated to flushing this issue. In particular I shall be examining the hypothesis that, without the spring 2020 dangerous policy spike, there is no visible sign of the pandemic in terms of variation within all cause death, excess death and age-standardised mortality over time. My weapon of choice will be formal intervention analysis based around ARIMA time series modelling.

Kettle On!