The long awaited report into the February 2021 Covid-19 outbreak has found that the Steam Packet largely acted in good faith but found issues with both it and the gov’s handling of border regulations.
The 94-page report was undertaken by Stephen Hind, the director of Treasury’s Audit Advisory division. The report identifies seven key issues, and makes eight recommendations.
The seven key issues identified include; regulatory complexity, balancing risks and prioritising, managing on board risk and safeguarding crew, managing the risk in the community including self isolation, preventing spread of Infection within the community, contact tracing and statutory process, regulations and compliance.
Mr Hind states in the report that a total of eight recommendations have been made for consideration, two of which are regarding the Steam Packet and six for the Cabinet Office ranging from CRM systems to risk assessments.
The report found several incidences of communication breakdown between gov departments and the Steam Packet. Other issues include the Steam Packet’s response plan not introducing a general requirement for crews to wear face masks until January this year, the gov’s failure to provide valid documentation for Manx resident crew members and advice provided by the gov which may be viewed as inconsistent.
Below is a breakdown of the report’s key findings. You can read the full report here.
Regulatory Complexity, the Balance of Risks and Prioritisation
There were lots of people and lots of different regulations involved; Gov agencies, multiple jurisdictions and the regulations were changing quickly and frequently.
It is Mr Hind’s view that the complexities of the regulatory and statutory environment played a part. Even though everyone involved was working towards the same goal, they were coming at it from different perspectives.
When everyone got round a table prior to lockdown 3, potential solutions were identified and discussed. But even after that, the agreed approaches weren’t implemented until revised paperwork was issued immediately following the outbreak.
Two recommendations were made for this key issue.
- Issue Management: Cabinet Office should create an ‘issue log’ for IOMSPCo (and other high risk clients) to track and manage the status of issues raised/outstanding. This could form the part of a centralised CRM system and could assist in administration of travel restriction advice and documentation.
- Multi Agency Meetings: Cabinet Office should introduce regular multi-agency meetings to assist in ongoing covid-management arrangements with IOMSPCo. Meetings should consist of; IOMSPCo, Covid Response Team, Public Health, DoI. With IOM Ship Registry and IOM HSE by invitation.
Managing the Risk On Board the Vessel – Safeguarding Manx Resident Crew Members
There are two key operational risks that he says ‘need specific consideration’ in relation to protecting crew;
- Risk of infection from crew interaction with the great Manx public
- Risk of intra-crew infection, in particular, Manx crew being infected by UK crew
The second risk wasn’t specifically in risk assessments in the early days of the pandemic. Here’s a timeline of what happened next
- July 2020, senior officers within the Steam Packet raised the risk and the Steam Packet specifically requested advice from the Director of Public Health.
- August 2020, Dr Ewart advised that face coverings should be used for the management of these intra-crew risks.
- January 2021 Steam Packets Covid-19 Response plan was updated to include requirement for face masks.
Mr Hind goes on to tell us that it wasn’t until the entry certificates/exemptions were being revised by the Cabinet Office and risk assessments were challenged by Dr Ewart and the DHSC that the Steam Packet risk assessments included the requirement to wear appropriate PPE in mixed-crewing and non-public facing areas.
He goes on to state: ‘These risk assessments now incorporate on board mitigations agreed by the director of public health and compliance with those mitigations is now a requirement for all individual Manx resident crew members for them to be exempted from self-isolation when on Island.’
And he said they are ‘generally consistent with the best practice’.
Recommendation: IOMSPCo – Risk Assessment Review
- Consider Risk Assessment Gap Analysis, update risk assessment as appropriate, responding to varying infection risk levels.
Managing the Risk in the Community- Modified Self-Isolation for Manx Crew
In March 2020, the Gov advised the Steam Packet that its Manx resident crew did not have to self-isolate. However, in August 2020, Dr Ewart advised the Steam Packet that Manx resident crew in high risk positions should be in self-isolation while off-duty and on island. However, there were no substantial changes in the documentation – Mr Hind thinks that the view that the documentation infers that self-isolation was only a requirement for Non-IoM Steam Packet crew.
Mr Hind also highlights that direction notices for self-isolation should have been issued by the Chief Secretary’s Office. Consequently they were not issued until after the February outbreak. The documentation still does not impose self-isolation restrictions on Manx resident crew, as long as they have taken mitigating measures while on board. Mr Hind thinks while gov advice might have been inconsistent, prior and at the time of the outbreak, the official documents stated there was no requirement for the Manx resident crew members to self-isolate. He believes this issue has now been resolved by the relevant parties and he makes no further recommendations.
Preventing the Spread of an Infection in the Community- Contact Tracing
When the first member of the UK Steam Packet crew tested positive, seven ‘high risk contacts’ were told to isolate. None tested positive. However, seven days later, four Steam Packet crew members tested positive for Covid seven days later. It is clear that the test and trace strategy was inefficient at that time. Mr Hind thinks that further mitigation measures would have been justified. He says: ‘As the operations of the Steam Packet are such a critical continuity and border management risk for the Island it is my view that further risk mitigation measures would be justified in addition to reliance on Contact Tracing.’
Recommendation: Cabinet Office – IOMSPCo Rapid Response Plan
A ‘Standard Operating Procedure’ should be developed to manage any further outbreak amongst IOMSPCo crew. Examples of considerations include that, on notification of the first positive case, there should be a removal of on-Island self-isolation exemptions for all crew, and that all crew should be tested- not just high-risk contacts.
Statutory Process and Documentation
Initially, the Emergency Powers permitted the exemption of a company (a ‘corporate certificate’) and all its employees on a ‘key worker’ basis – making no distinction between Manx residents and those who were not. In July 2020, regulations were amended which essentially introduced two processes- one for non-resident key workers and one for all Manx residents. Corporate certificates could only be issued for non-resident key workers, while Manx residents needed an individual certificate. The Steam Packet’s corporate certificate from March 2020 could have still been interpreted as valid, as its end date was ‘the end of the Coronavirus period’.
In September 2020, the Steam Packet was issued a new corporate certificate – that only covered non-residents, however Mr Hind thinks that the Steam Packet was made to think that this was sufficient to cover both Manx resident and non-resident crew. Valid documentation was not in place for Manx Crew members until it was changed and individual certificates commenced following the February 2021 outbreak. However, he believes the Steam Packet acted in good faith, and that they are now compliant with the regulations.
Recommendation: Cabinet Office- Regulatory Procedures. Consultation with the Steam Packet to develop the required health declaration/landing card procedures for Manx Resident Crew Members.
Compliance and Enforcement
The Steam Packet is required to maintain a ‘Safety Management System’ which is required to be internally and externally audited. The Steam Packet has a system of Internal Audit, but has no specific internal audit of Covid management and mitigations over the pandemic period. Part of the ‘internal audit’ is sourced externally- Mr Hind reckons there’s an opportunity to obtain an external specialist to review their Covid management plans and protocol as part of the internal audit.
There is a complex regulatory framework within which the Steam Packet is required to maintain continuity of operations under the pandemic. Mr Hind thinks that a Memorandum of Understanding between relevant agencies could be beneficial.
Recommendations: IOMSPCo- Internal Audit Programme
The Steam Packet should ensure its future internal audit programme includes an internal audit of Coronavirus risk management mitigation.
Cabinet Office- Memorandum of Understanding
This should be introduced between gov advisory and regulatory authorities in relation to the management of IOMSPCO related Coronavirus risks. This should include:
- Cabinet Office
- Director of Public Health
- DEFA H&SE
- DOI Ports Authority
- IOM Ship Registry
Mr Hind believes that there needs to be a review of the resourcing in regards to the specialist clinical resources available to Public Health. He doesn’t think this is the cause of any current issues, but it is a vulnerability.
Recommendation: The Cabinet Office should undertake a review of clinical Public Health resourcing, implement the most appropriate option and, if feasible, expand the clinical expertise.
Mr Hind thinks that the Steam Packet represents a critical ‘Covid risk point’ to the island. ‘The safe continuity of its services should be a priority for all relevant parties involved.
‘It should be noted that there had not been any outbreak among Manx resident crew prior to February 2021, and the ‘Kent variant’ was a significant factor. Improvements have already been made to reduce identified risks.’
He concludes that: ‘It is my view that the current position for the management of these risks has already been significantly improved, when compared to the position at the time of the February outbreak.’
In a followup press release from the gov, the Chief Minister said: ‘The difference of opinion that emerged in February as to the Steam Packet’s Covid-19 mitigations was concerning and I therefore asked for a report, to establish the facts. It was important we understood what additional measures were needed to reduce the risk of the virus entering our Island, and to ensure any lessons to prevent a recurrence were learned.
‘We didn’t get everything right, and the report tells us that. We weren’t always as joined-up as we should have been and perhaps inevitably, mistakes were made. However, I am heartened to see that a number of the recommendations for improvement made in the report are already in place. I will ensure that we see through any actions required by government.
‘This is an extensive, analytical report but I accept that there remain unanswered questions – and issues which are for others to answer. I have therefore referred the report to the Isle of Man Ship Registry, to consider whether further investigation is required and if necessary, to refer matters to other agencies. In picking over the detail however, we should remember that this was a period of intense pressure for those involved in the Island’s pandemic response, who were doing their best to serve the public. We will learn from this episode and continue to do our utmost to protect our community.’
He is due to address the House of Keys on Tuesday Morning.