Ambiguity over accountability may prove a key issue for the inquirypublished at 13:00 Greenwich Mean Time

13:00 GMT

Hugh Pym
Health editor, reporting from the inquiry

A thread running through many of the exchanges so far has been the issue of who was in charge of the NHS pandemic response.

Matt Hancock as health secretary had overall responsibility for policy and was answerable to Parliament.

But at the time, and has since changed, NHS England was independent and at arms length from the government.

For much of the worst of the pandemic it was run by Sir Simon Stevens. So there was confusion in the unprecedented pressures of the pandemic over who was responsible for what.

Hancock told the inquiry he had pushed for hospital capacity to be expanded though this would have meant staff in intensive care being overstretched with more patients.

Concerns were raised by NHS England but the changes were made.

Intensive care nurses then had to look after six patients each. Hancock said that had been decided by Sir Simon Stevens.

On the question of the speed of returning the NHS to normal levels of planned treatment after the first wave, Hancock said he pushed for a faster response but, again, the implementation was down to NHS England.

Stevens, now Lord Stevens, is not appearing as a witness at this stage and may well have different recollections. The ambiguity over decision making and accountability may prove to be a key issue for the inquiry.

In the final question before lunch, Matt Hancock is asked about Do Not Resuscitate (DNR) orders, external where a doctor or patient can decide not to give or receive cardiopulmonary resuscitation.

Hancock says he was made aware of concerns they were being used inappropriately - calling this "appalling".

He emphasises healthcare "has to be based on consent" and that any DNR notice without appropriate consent is "wrong" and "potentially illegal".

As for steps he took in this regard, he says he "reiterated" and "made clearer" guidance to medics.

The hearing is now taking a break for lunch so we'll catch you up on what's been said and get analysis from Hugh Pym and Jim Reed at the inquiry.

The inquiry now moves on to ambulances, and is shown testimony from one pregnant person, who complained of huge difficulty and delay after phoning for help.

Hancock says he was aware of the problems with delays, adding that a person in charge of co-ordinating ambulances "burst into tears" when he spoke to them because of how difficult the task was.

He then suggests that the UK should have people trained as ambulance drivers on standby, similar to the Territorial Army.

Image source, PA Media

During the second Covid wave, Hancock says, the ambulance service improved as the peak was not as bad.

Hancock then responds to evidence of patients being held in ambulances for six to 12 hours outside hospitals.

He says he was aware of this and that having ambulances stacked outside A&E units made existing problems worse.

The former health secretary is also pressed on regional differences in ambulance waiting times.

He answers by saying this is partly down to the fact that Covid affected different parts of the country more significantly than others, as well as different standards of care more generally.

Inquiry counsel Jacqueline Carey KC spends some time on the number of calls to 111 - the NHS non-emergency number - that were abandoned in the initial stage of the pandemic.

The public were asked to call 111 as a first port of call, but there were issues with call-handling capacity in early March 2020.

At its peak 40% of calls were not answered, Carey says.

Hancock replies saying the system of ringing 111 before going to A&E "should be our national system" – and underlines "difficult decisions" have to be made in a pandemic.

Carey then pivots slightly asking whether there was "sufficient action" to ensure those who needed healthcare still came forward.

It was a “difficult balance”, Hancock says, calling it a "two-part message" of "Stay at home unless you really need the NHS, in which case please do go".

In any similar future situation, Hancock says this needs to be a clear part of the communications.

The hearing moves onto how Hancock balanced the decision to open Nightingale temporary hospitals, but a call from NHS England for 10,000 more beds ahead of an expected second wave was not delivered on.

"Hold your horses" the KC smiles, as Hancock jumps in to stress he was "very involved" in attempts to get more beds.

Hancock says he got funding for the expansion of A&E departments across England and he also wanted to expand bed capacity, but accepts he "didn't win" on getting 10,000 more beds in the summer of 2020.

Despite this, the former health secretary says he was still worried about a second wave in the winter, and concerned about political opposition if one came, which he says he expected to be stronger than the first.

Hancock is now being quizzed on the Nightingale temporary hospitals which were commissioned to increase hospital capacity during the pandemic.

He explains these were needed to both provide care for those that used them and were "entirely justified" as an insurance policy, given the information they had at the time, adding that hundreds of patients did receive care through them.

Hancock is given an example in Birmingham where inquiry counsel Jacqueline Carey KC says the Nightingale hospital there had no patients in either the first or second Covid waves and was not used as a vaccine centre, either.

Hancock refers to "frustration" he felt that they weren't being used for other purposes, but underlines operational matters are for the NHS.

We move on to address the decisions taken by Matt Hancock to increase capacity within the NHS, and the impact this had on care not related to Covid.

Hancock affirms that he agreed with the principle of expedited discharges - that's releasing people from hospital quickly even when still in need of care - to free-up space.

On suspending non-urgent elective care, he says he did so "reluctantly", but it was the "least bad" decision he could take.

Inquiry counsel Jacqueline Carey KC presses Hancock on how he made the decision about when non-Covid related care was able to resume. He says he sought advice from the boss of NHS England, Sir Simon Stevens (now Lord Stevens), on this.

To highlight the impact of these delays, the inquiry is shown a letter sent to Hancock which relates to a patient desperate to have their cancer care resume.

Then, Hancock is asked how he followed up on checking for confirmation when non-Covid care could start again, and he explains how he met Stevens for discussions on this, but stresses that resumption was ultimately for the head of NHS England.

The inquiry has resumed after the morning break with questions for Hancock around national guidance and a "tool" for situations where ICUs become overwhelmed.

Evidence submitted to the inquiry by former NHS England boss Simon Stevens said that Hancock wanted to decide "who should live and who should die" if hospitals became overwhelmed by coronavirus patients during the pandemic.

Hancock underlines multiple times that he believed those decisions - on which patients should get ICU treatment - should be taken locally.

He adds it would be "very hard" to write something that would "improve on an individual clinician making a decision... on how to save lives".

He tells the inquiry he had not really considered the "wider controversy" that such England-wide guidance might provoke.

Image source, PA Media

Former Health Secretary Matt Hancock spoke for just over an hour this morning. This is what he said:

• He defended the government's 'Stay Home, Save Lives, Protect the NHS' mantra during the pandemic, saying it "struck the right balance"
• He acknowledged it was "extremely difficult" to keep health workers safe and visited hospitals to experience conditions for himself
• He accepted the NHS was under immense pressure but stressed his aim was to ensure the system did not "collapse"
• Hancock reflected on his relationships with the UK's nations and singled out former Scottish First Minister Nicola Sturgeon for causing "all sorts of difficulties"
• On cancer care delays, Hancock suggested it simply was not safe for these treatments to go ahead due to patients' vulnerability

More to come now as the hearing resumes after the morning break. You can stream the second session of evidence by clicking Watch live above.

Matt Hancock is challenged about his belief that the NHS was not overwhelmed.

The inquiry plays Dr Kevin Fong’s evidence about the number of deaths that NHS staff experienced, and how overwhelmed they were - including one time when they ran out of body bags

Hancock says he "agrees with everything that was said" and the system "had to cope with more than it had to cope with at any other time in modern history".

He tells the inquiry it was his "duty that the public felt that the NHS was there for them".

Although Hancock says there was no national shortage of PPE he admits this doesn't mean there weren't shortages in individual hospitals.

But he maintains he was "right to use that language" because his responsibility "was for the system as a whole".

He explains the best way to solve the problem "was to have measures in place at a national level to stop the spread of the disease."

The inquiry is taking a short break and will return at 11:30 GMT.

Stay with us - we'll have a recap of this first session of evidence with you shortly.

Image source, PA Media

Jacqueline Carey KC, counsel to the inquiry, tells Hancock now about a specific case the inquiry has previously heard - that of Susan Sullivan who had Down's syndrome and was admitted to intensive care but was refused admission to the ICU.

On her notes it said she had cardiac comorbidities and Down's syndrome.

Hancock tells the inquiry he did get reports that people were being denied ICU care, as well as the misuse of so-called Do Not Resuscitate (DNR) notices, and he was "fighting" on behalf of those to whom it was happening.

Carey underlines Sullivan's hospital was over capacity at the time.

Hancock says clinicians make decisions like that in normal times and more so in a pandemic.

He adds that he passed on material like this to cabinet colleagues.

Matt Hancock is talking about the strain of the pandemic on intensive care units (ICUs) in England's hospitals and the task of having to increase hospital capacity while controlling the spread of the virus.

Listing the challenges, he tells the inquiry there were four reasons more people were dying during the pandemic:

• The direct impact of Covid itself
• Unavailability of healthcare
• Impact of measures to control the spread, such as lockdowns
• Higher hospital admittance

Although he says “the system as a whole withstood the pressure”, he talks about a visit he made to St Bartholomew's Hospital ICU in London where there were “far more beds than there was space for, I saw it for myself”.

Jim Reed
Reporting from the inquiry

There’s a lot of talk now about the pressure on intensive care units (ICU) in the pandemic.

The inquiry has already heard evidence that, at the peak of the second wave in January 2021, 6,099 ICU beds were filled across the UK, well above the pre-pandemic capacity of 3,848.

The vast majority of those were Covid patients on ventilators at the time.

Hospitals could only stretch capacity in that way by cramming in more beds or opening new overflow units in corridors, operating theatres and other spaces.

The problem is they only had a limited number of highly trained staff so staffing ratios were then stretched to the limit.

In normal times you would have one critical care nurse for each patient. Hancock said at times that was stretched to one nurse to every six patients.

And he accepted that did have an impact – not just on those staff but also on the care some of those patients received.

“I was acutely aware of this, and it weighed heavily on our decision-making at the time,” he said.

The inquiry now turns to staff-patient ratios that were stretched in a bid to increase capacity in the NHS.

Hancock tells the inquiry he wanted to stretch them "as much as clinically possible" at the same time as building new hospitals - the temporary Nightingale hospitals which were created in existing buildings like conference centres.

He explains that as well as the pressure stemming from the sheer numbers needing care, it was also concentrated in the sense that there would be very large numbers "presenting with the same condition".

Asked about the decision to stretch ratios to one nurse to six ICU patients, he says he thinks that would have been an NHS decision.

As for whether he accepts that in intensive care that could lead to a "different level of care", he responds that he doesn't only "appreciate" it - he saw it himself.

He underlines that as to the specific ratio, he had to rely on clinical advisors and NHS England advice.

His role, he adds, was "strategic".

Matt Hancock is talking about how stretched the NHS became as Covid spread in the spring of 2020.

He tells the inquiry that in normal times one nurse would care for one patient in ICU, but during the pandemic he says "we stretched that so that one nurse cared for six people, it was a deeply challenging situation".

Hancock goes on to talk about the need to protect the NHS while encouraging patients to come forward if they need it, saying "it was always in my mind".

The former health secretary admits that some cancer treatments were delayed but says it was not clinically safe to continue them when they could affect a patient's immune system.

He says that "whilst individual parts were under pressure the overall point is we did not have a collapse in the system".

Image source, PA Media

Jacqueline Carey KC Counsel now asks Hancock about asymptomatic transmission of Covid-19 and its effect on hospitals and staff.

Hancock describes the challenge here as the "system as a whole" and the "clinical advice to the system".

He says asymptomatic transmission was not considered a "material factor" initially - something that only changed in April 2020.

He adds that his failure was his "inability" to override that global consensus.

However, in early March he did take the decision to increase PPE requirements. He explains one of the reasons for the "sharp increase" in demand was the increase in the recommended use.

He agrees with the inquiry counsel that World Health Organization guidance is not "binding" but adds that it does influence public health views and that of Public Health England.

It was not something he could overrule "with the stroke of a pen", he tells the inquiry.

When asked about his relationship collaborating with the four UK nations, Matt Hancock explains how important it was to bring the health ministers from each nation together.

He says it was “incredibly helpful for understanding and discussing decisions we were making".

However, counsel to the inquiry Jacqueline Carey KC reads out some quotes from one of their meetings where Hancock spoke about Nicola Sturgeon - the former First Minister of Scotland - “causing all types of difficulties”.

Hancock says there was excellent collaboration between the four health ministers of the UK.

Hancock hit with quickfire round of questionspublished at 10:26 Greenwich Mean Time

10:26 GMT

Jim Reed
Reporting from the inquiry

Rather unusually counsel to the inquiry Jacqueline Carey KC has started with a series of quickfire questions covering major topics.

Matt Hancock was asked about the message to "Stay at home and protect the NHS" repeated by ministers in the pandemic.

Did it strike the right balance? "Yes," he replied, “because it was literally true that if we didn’t stop the spread of the virus, then the NHS would be overwhelmed".

He also said the government did “everything it could” to keep NHS staff safe though that was “extremely difficult”.

He said hospital visiting restriction means balancing “difficult considerations” on both sides but felt the balance was “broadly right”.

He agreed that the NHS started 2020 with a high proportion of hospital beds already full and that placed it under “more strain” when Covid hit. And he said the decision to suspend all non-urgent planned care in the pandemic was the right one.

All these subjects are going to be explored in much more detail over the next day and a half.

Emotions are running high here among members of the public watching his testimony.

Baroness Hallett has already had to ask people in the public sitting area to lower pictures of relatives who lost their lives to Covid which were being held up in the inquiry room.

Hancock is now asked about the insight he gained by way of visits during the pandemic to health facilities such as GPs and hospitals.

He gives an example he has provided before - of a night he spent in Basildon Hospital helping to turn over patients on ventilators.

He describes being in an intensive care unit where a patient was "lucid" and "talking" but whose oxygen levels were low and falling.

The doctor decided, with consent, to anaesthetize and intubate the patient telling Hancock afterwards that the patient had a 50-50 chance of waking up.

Pushed on what insight this visit gave him, Hancock says it "stiffened" his "resolve" to not lift measures preventing the spread of the virus too soon.