ABSTRACT
We previously reported a study of features of emergency healthcare response to COVID-19 that could be modified to mitigate against future excess deaths. Here we determined what themes persisted in later waves. This was an expert panel review of all components of care delivered to COVID-19 patients who died (primary and secondary care, community services, NHS 111 and 999, COVID oximetry at home, virtual wards). 174 deaths were included. 5% were deemed >50% avoidable, 75% included avoidability themes. Contact with primary care remains mostly via telephone, creating diagnostic risk. Patient decision to avoid healthcare contact was common. Recommendations include: better utilisation of home monitoring in future pandemics; improved avoidance of nosocomial spread; patients be encouraged to seek medical advice earlier.