Nick's story

“On 6 January, PHE called to say there was something funny going on in Wuhan. It soon became obvious it (COVID-19) had spread widely across China, and the decision was taken to include it as a High Consequence Infectious Disease (HCID). It was the right thing to do. It was a novel coronavirus, there wasn’t much we knew about it and we were better off being on the safe side. But as the pandemic developed that became a problem.

We had admitted a patient with monkey pox to the HCID unit in December and he was in hospital for 6 weeks. I didn’t have a Christmas holiday as a result. As UK director of HCID for airborne pathogens, I lead a national network of 5 hospitals around the country.

The first 2 UK patients were diagnosed in Hull on 28 January. We stood the network up and decided to place them in Newcastle. They were Chinese and had travelled from China.

We took the 3rd case [diagnosed in Brighton] at St Thomas’. We placed others round the country. We have 15 HCID beds between the 5 hospitals and we squeezed that up to 40. Most were pretty mild but our job was to isolate and contain the virus from a public health point of view.

I was very much involved in those early COVID-19 cases, placing them one by one. It was a very stressful time for me. It was the uncertainty. I felt I was in the vanguard of a developing pandemic.

I would get an urgent telephone call from PHE at any time of the day or night after a positive diagnosis, we would have to assemble in half an hour and we would have to decide where to admit them. We had to identify, admit and contain. But it was never going to be sustainable. Our job was to contain it for as long as possible to allow others to get up to speed.

In early March there were more cases being diagnosed than we had beds left – multiple cases widely dispersed. London was particularly hard hit. The challenge was expanding the number of inpatient beds. When we had filled 20-30 isolation rooms then we started to have cohorts on the wards. That was around 6-9 March.

I went on a skiing holiday in February, after the patient with monkey pox went home. With hindsight it was a crazy decision. I came back after 3 days. I couldn’t stay away. You build something [the HCID network was established in 2018 after the Ebola outbreak in west Africa] and you want to see it succeed.

We sat down and planned the worst case scenario for 2 to 3 weeks ahead. We agreed potentially we would need 60% of all acute medicine beds. We had to think about training staff, obtaining PPE, obtaining supplies.

Once we were getting 5, 6, or 7 cases a week we knew it was the tip of the iceberg. For every 2 or 3 in hospital we knew there would be 7 in the community. There was no longer value in trying to contain it by moving patients to specialist units because we had no beds left.

It was actually a relief when the network was finally overwhelmed. Up to that point I had been carrying the burden. But the network did a pretty good job. It took 39 days for cases in the UK to reach 500. In Italy, Spain, France it took 18, 19, 22 days.

I was no longer in charge of allocating 60-70 cases a day on a national level. My focus switched more to St Thomas’. I felt like I was coming home to support the efforts here.

My role was managing and training the staff for the rapidly expanding ICU. Everything you do has to be based on sound infection control principles and staff need to be trained and provided with the equipment that protects them. It was a case of another day and we opened another ICU ward. We were a step ahead of the disease. But at that point the HCID designation became a positively unhelpful thing. COVID-19 was not derogated from HCID status till 19 March.

Under HCID we required staff to wear long sleeve gowns, leggings, two pairs of gloves, a powered respirator, visor and hood. Now we were telling them it was sufficient to wear an apron, surgical mask and gloves. We had marched them up to the top of the hill and now we were marching them down again. Managing that was one of the greatest challenges. We had to deal with a lot of anxiety.

We very much believed in our PPE – we had a firm idea of what was acceptable. That varied round the country. Some trusts said what you wear on your head is important, others that you must have long sleeved gowns.

You have to have people who stand in front of the staff and say this is what we have to do and why. You have to be honest and say it may not be ideal but we need to keep the wheels turning. It’s about leadership and communication and having a degree of humility. It’s having colleagues prepared to roll their sleeves up.

The anxiety was mostly in the first 2 weeks. It was all of us together – dealing with whatever came through the front door. It brought out the best in most people. They are healthcare workers – they want to help people. Morale stayed high.

The admission of the PM? I got a call from No 10 early on. We are their local hospital – that’s how I got involved. I went to see the Prime Minister 2 or 3 times. At some point it was not going the right way. It was obviously right to say it was time to look after him in hospital.

I remember driving in and I called the Chief Executive [Ian Abbs] and said I want Nick Hart [Head of Intensive Care]. I needed to have him involved in that eventuality [needing admission to intensive care].

The PM was on the ward for the first day then he deteriorated over 24 hours. That was the trajectory he was on.

It was a highly pressurised time. I made a conscious effort not to listen to or read the news. I had to focus on my decision-making – it was hard enough without all the distraction. I didn’t want to see my face in the papers. It was a relief when the media focused on Richard Leach [consultant physician]. Only after he [the PM] turned the corner I began to read what had been going on.

I didn’t sleep the first night. I had a colleague – we had been junior doctors together years ago, when I was a registrar and he was a houseman. He had known I was doing something outside the hospital but he didn’t know what. After the PM was admitted he came to me and said: 'You’ve been up all night. I’ll be your houseman again, I’ll do the nights, and you get some rest.' He kept him under observation and I got the reports in the morning. That friendship and solidarity was an enormous boost for me.

The most difficult time was the night he went to ICU. You obviously say it was precautionary and that was true. But there was an explosion of interest from all around the world.

We had some bizarre offers from other countries, ideas for what we should do. Some from very senior people. We didn’t accept them. Ian Abbs [Chief Executive] dealt with those.

I found that [ICU admission] most difficult. You think about what could have gone wrong. I didn’t want it [the worst] to happen. It was on my watch. My name was on his bed. He was my patient.

I don’t know what it does to you emotionally – making decisions at pace and not being able to reflect on them. It was a thrill – my hour as an infectious disease specialist. I was coming in to work and being at the centre of things - first nationally as head of the HCID network, and then looking after the PM. Now the wind has dropped and you wonder what’s next. There is a feeling of loss.

What made me angry? The way guidance came out on a Friday night which meant I had to re-write everything we had been doing during the week – and do it over the weekend when it’s the most challenging time to change anything. I felt undermined by that.

And there was a misunderstanding about PPE – first being told there was plenty of it and then not getting the right face-fitted masks. There were requirements you couldn’t meet. We could have spent hours and hours fitting new masks, only to find they had run out. It was immensely frustrating because of the anxiety it generated.

I wasn’t worried for my own safety. I and my partner have a small flat in London where I stayed. He is an architect and was working from home so he stayed in our house in the country with our dogs.

We know about a quarter of my department have had the virus. I held on to the fact that for a lot of people it is mild or asymptomatic. As it gathered pace, we realised what it could do at the severe end. As with the PM, when you get it badly, you get it badly.   

What has the experience taught me? There is always a better way of saying something. I learnt how to communicate better with people. So long as you level with them and are straight with them you can always find something positive and reassuring to say. I discovered that about myself.”