Background The United Kingdom COVID-19 pandemic response included large scale changes to emergency healthcare delivery across primary care, secondary care and ambulance services without fully understanding potential unintended effects. Our aim was to ascertain themes within the emergency response that could be modified to mitigate against future excess deaths.

Methods A structured judgement review of the entire care pathway (primary care, secondary care, 111 and 999 calls) for deaths registered in Salford during weeks 12-19 of 2020, creating a single integrated record of all Healthcare interactions and outcomes between 1^stMarch 2020 and death for all patients. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale, and themes associated with potential harm.

Results 522 deaths (197 hospital, 190 care homes): 51% female, 81% Caucasian, 35% dementia, age 79±9 years, 44% COVID-19 cause of death.

18% of deaths contained avoidability themes. In people aged ≥75 years who lived at home this was 53%, in care home residents 29%, in learning disability patients 44%. For COVID-19 and non-COVID-19 deaths the figures were 49% and 23%. 15 deaths were judged more than 50:50 avoidable. For higher avoidability (score 2 or 3), 44% had >2 themes.

Common themes were delays in patients presenting to care providers (10%, n=53), delays in testing (27%, 139), avoidable exposure to COVID-19 (29%, 149), delays in provider response (6%, 32), and sub-optimal care (34%, 177).

Pre-hospital healthcare contact frequently was primary care 81%, 999 56%, NHS 111 11%. The most common outcome of 111 calls was advice to contact GP (34%). 46 patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9).

Conclusions The initial emergency response to COVID-19 was associated with late presentation, sub-optimal assessments, and delays in receiving care. The effects had multifaceted impacts and will require complex remedy.