More than 43,000 people died from Covid-19 in UK care homes between March 2020 and July 2022.
Inquiry chair Heather Hallett identified the failure to advise that patients discharged from hospitals into care homes should be isolated as a significant omission. Earlier evidence showed that hospitals sent untested patients into care homes to free beds when testing and isolation facilities were not widely available; a 2022 High Court ruling later found the policy irrational.
The inquiry examined hospital discharges, testing, protective equipment, visiting restrictions, regulation and deaths across adult social care in England, Scotland, Wales and Northern Ireland. Evidence from the hearings described shortages of testing and protective equipment, staff shortages and patients being discharged without accurate information about their Covid status.
Hallett said restrictions on care-home visits caused immense emotional harm, leaving residents isolated and abandoned. Some people were unable to be with dying relatives, creating lasting distress and guilt among bereaved families.
She also said the scale of death and suffering witnessed by social care staff was unlike anything they had seen before. The inquiry recorded post-traumatic stress and suicidal thoughts among workers, including cases in which care workers died by suicide.
Hallett said action by the UK government and devolved administrations to protect people receiving and providing care came too late, and called for her recommendations to be acted on before another pandemic.