“We’re used to death – death is part of life in intensive care – but not in the kind of numbers that we’re seeing, and that’s really quite hard to take,” says Tom Billyard, a consultant at University hospital in Coventry, as he reflects on the unprecedented challenges of the Covid-19 pandemic.

In preparation for his latest 12-hour shift in ITU, where the worst affected patients are given life support, Billyard begins to don several layers of personal protective equipment (PPE) over his blue scrubs.

First a pair of latex gloves, then a surgical hat. Next a full-length gown tied together at the rear, followed by an additional pair of latex gloves which are meticulously taped on to the sleeves for extra security.

Finally, an FFP3 mask, which grips his face so tightly it will leave red marks across his cheeks, and a yellow-rimmed plastic visor to provide a secondary barrier against the disease.

“I feel trepidation,” he says softly, before entering. “There’s a load of patients in there and I don’t know if they’re going to survive this.”

Tom Billyard, a consultant at University hospital, which is part of the University Hospitals Coventry and Warwickshire trust (UHCW). Roger Townsend, clinical lead for intensive care. All photographs by Jonny Weeks.

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Struggling for breath



Billyard is one of more than 9,000 employees at the hospital, all of whom – porters and nurses, cleaners and chaplains, consultants and volunteers – have a vital role to play in the treatment of patients and the functioning of the hospital.

Emily Jones, a senior sister in the emergency department (ED), works on the hospital’s frontline. “ED is usually quite noisy,” she says. “But that’s not the case now – you don’t see the patients immediately, until you look through the curtains, and then you realise quite how unwell they can be.

“We’ve had everything from patients who have self-presented at the door saying: ‘I’ve had a cough for a few days,’ to people who have walked up the stairs to get to the emergency department and can barely hold a sentence with you. We’re also getting crews bringing in patients of various ages who are struggling to get breaths while they’re on oxygen.”

The West Midlands is one of the UK’s most affected regions. At the time of writing, University hospital has admitted 568 patients with Covid-19 and recorded 161 deaths from it, while 316 patients have been discharged after making full recoveries. It has transferred its minor injuries unit to a neighbouring hospital within the Trust, allowing it to prioritise the influx of Covid-19 patients.

“Wow,” Jones says, pausing at the severity of the symptoms she’s treating. “The acuity of our patients has gone up so much. They are so much sicker than we previously saw.”

A blizzard of healthcare staff whirls around her – some reading patient notes, others making telephone calls, washing hands, cleaning everything in sight and, heartbreakingly, placing a picture of a dove on to the door of one of the patients.

“That’s to show they’re on the end-of-life care pathway,” a nurse explains. “It means we should give them peace.”

Patients and staff in the emergency department.

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Isolation

Patients who present with less life-threatening difficulties are often transferred to the respiratory wards on level three for round-the-clock care. There, the eerie silence continues. With no families visiting and the corridors all but empty, it feels like a ghost hospital.

University hospital currently has 91 Covid-positive patients, 12 of whom are in ITU, with a further 72 designated “query Covid” who are yet to be tested. Some lie in isolation rooms, texting friends and loved ones, others in wards of six beds; many seem in a state of shock and weariness, barely registering the world around them.

Patients and staff on wards 30, 31 and 32.

Mark Anders, a local paramedic, was himself struck down by Covid-19. “We all joked about going to emergency coughs and high temperatures, because that’s all we were going to.”

He fell ill during a Saturday night shift. “I got halfway through the shift and I said to my crew mate: ‘I don’t know what it is; I just don’t feel right,’” he says.

“Then I got home and the temperature started. I had a week at home of self-isolating, looking after myself, taking paracetamol every four hours, fluids, just trying to do everything to keep my temperature down. After a week I couldn’t control it. From there on: nightmare.”

Anders was lucky. As doctors readied him for transfer to ITU, his body began to fight back. Sitting in his pyjamas and still bearing bloody scars around his septum from the oxygen supply that kept him alive, he has been told he can soon return home to his family.

“Massive,” he says, when asked about the value of the NHS. “It’s the first time I’ve been this ill in my life. They have been brilliant.”

Mark Anders, a paramedic who caught Covid-19, receives the thumbs up from a nurse.

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Frightened

The first case of Covid-19 in Coventry was on ward 50, the renal ward. Lakhbir Kaur, known to her colleagues as Lacky, has been a sister there for five years. She treated Coventry’s “patient zero” and has watched with concern as the virus has spread through the local community. She fears that it may also transition from patients to staff.

For much of her shift, she wears only an apron, gloves and surgical mask – the kind you would find in a dentist’s surgery.

“It’s scary,” she says. “Our masks already have an expiry date on them and the NHS have covered up the existing expiry date with a further expiry date. What is that? Are they hiding something or are they legitimately tested?

“Infection control have said they have been retested [and are fit for purpose] for another 10 years. I’m wary about that. I really am. I’m a single parent – I’ve got a daughter. She’s the thing I live for. The thought of taking this home from work to her freaks me out.”

A close-up of the cracked skin on her hands caused by washing them so frequently.

University hospital follows guidance on PPE requirements from Public Health England, the government body.

Fiona Wells, who works in infection prevention control, is one of those responsible for dispensing and teaching safe use of PPE. “PPE is an extremely emotive topic,” she says. “People are very frightened about the possibility that it might not be enough.

“Some of the images we see [from abroad] show people dressed up in hazard suits … and it adds to the tension around PPE. But it comes back to the key question: what is necessary? And then using it appropriately.”

Each procedure and each ward might require different levels of protection. In ITU patients might undergo aerosol procedures, which are more likely to spread Covid-19 particles through the air; hence the extra layers of protection worn by Billyard and his colleagues.

Approximately 5,000 University hospital staff have so far been fit-tested for FFP3 masks since January and, though the hospital has plenty of PPE in stock, it relies on unpredictable army drops for replenishment. “We have to carefully manage it to ensure we have the longevity because this pandemic isn’t going to be finished next week,” Wells warns.

PPE supplies; Tom Billyard adjusts the nose-bridge on a colleague’s FFP3 mask.

Lei Dayrit, a nurse who worked at Hospital of St Cross in Rugby, University hospital’s sister hospital, died from Covid-19-related complications last week. She was one of several nurses who treated an asymptomatic Covid-19 patient who later became symptomatic.

Her death was mourned on Thursday evening during the weekly “clap for carers” gathering outside University hospital, where a banner was unfurled in her honour.

With tears in her eyes, the staff nurse Gail Hobley, a long-time colleague, said: “She was a special nurse to work with. Very caring, very supportive. We had a little discussion about Covid and she said everybody will look after each other, and we are. The support we have from everybody [in the community] is terrific.”

Colleagues gather to mourn the death of Lei Dayrit, a nurse who died of Covid-19.

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Loved and cared for

In the hospital’s faith centre, the Rev John Matipano, one of the chaplains at University hospital, offers reassurance to those in need.

“We’ve been doing rounds, supporting staff, and we’ve had staff say: ‘Please pray for us’ – something that you would never imagine happening given the way people are quite private about their faith,” he says.

“Even if we don’t speak to staff, if you just go around ED and they see that a chaplain is here, they feel that someone cares, someone is there for them. Now, more than anything else, presence is very important.”

Of all the heartbreak caused by Covid-19, nothing compares with the inability of families to see – and say goodbye to – their loved ones in person. Only in ITU can a dying patient receive one visitor.

Some patients have, at least, been able to communicate with friends and family via video conferencing apps on tablets donated to the hospital. Wells found this especially moving when her grandfather was admitted with Covid-19.

“He was able to tell my family he loved them and to sign goodbye via FaceTime before he died,” she says. “I knew the staff on the ward he was on. They were amazing. They stepped up and fulfilled a role that we weren’t able to fulfil. My mum feels happy that he was well loved and cared for.”

Play Video 4:16

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A personal promise



Throughout the hospital, one unexpected sound punctuates the silence: laughter. In these dark times, a joke between colleagues provides a flicker of normality to offset the stress.

Thierno Siedou Diallo, a cleaner, puts it simply: “You must come in and laugh. You give assurance to everybody.”

In the medical decisions unit, Stacey Gavin, a band six sister in acute medicine, is sporting a “bride to be” sash. “I was supposed to be in Benidorm this weekend for my hen do. About 13 of us were going, a mixture of family and friends. Unfortunately it got cancelled about a month ago. So I said if I’m not going on my hen do, I’ll bring my hen do to work.

“The girls put on a little celebration at break time in the staff room. They got Shloer, pretending to be champagne!”

Stacey Gavin, a sister in acute medicine, celebrating her hen do at work. Ash Patini, a volunteer.

Like most staff, Gavin has offered to worked extra shifts, forgoing her annual leave. She and her colleagues are helped by a group of dedicated volunteers and charity workers, among them Ash Patini.

“I lost my mum 17 years ago to terminal cancer and that absolutely changed my views on life what I wanted to do. She was made to feel very, very happy and comfortable here, right to the very end. It’s something I can never forget.

“I promised myself that one day I would give something back. I kept that vision for 17 years [until taking early retirement]. And that’s why I’m back here; that’s why I do what I do.”

The charity stock room is piled high with donations such as Easter eggs, crisps, sweets, fruit bars and toiletries. Elsewhere, local manufacturers such as Jaguar Land Rover have supplied visors for hospital staff, while many nurses have been given homemade headbands to alleviate the sores caused by wearing face masks.

Visors and head-guards given to the hospital.

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Privileged position



In preparation for the pandemic, significant changes were made throughout the hospital’s infrastructure: wards were repurposed, staff retrained, junior doctors given greater responsibilities, and strategies put in place to manage the trajectory of the disease.

Kiran Patel, chief medical officer, says: “We’ve probably had about 20 years’ worth of transformation happen in the space of a month. And we’ve probably had over 135 year-one to year-three students, and about 150 graduates, who have basically just hit the ground running and been brilliant.”

Following teleconferences with hospitals in China, Japan and Italy, University hospital has already prepared a reserve ITU ward of 32 beds and could raise capacity even higher, if needed. The hospital has also joined studies run by the World Health Organization.

Nicolas Aldridge, lead nurse for research and development, says: “We’ve been looking at a mixture of anti-viral medications such as hydroxychloroquine, the anti-malaria medication. We’re gaining large numbers of patients for research because most of the existing research is only from small samples.”

Questioned on Donald Trump’s recent support for the drug, despite limited evidence to support its efficacy in fighting Covid-19, Aldridge says diplomatically: “If we knew it would work, we wouldn’t be doing research on it.”

“Historically, I think the last vaccine took 15 years to create. But technology has moved a huge distance since then and so has our understanding of how vaccines work.

“When you step back at the end of the shift, you realise we’re doing something that’s of immense importance. We’re in a privileged job where we can try to find a treatment for it.”

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Quick and painless



In the meantime, testing is critical. University hospital now has a dedicated swab-testing pod which can cater for up to 120 patients a day.

Initially, testing was open to members of the public, but it has recently been scaled back to NHS staff and their families (members of the public can attend neighbouring centres).

“It’s very quick, relatively painless. It’s just uncomfortable,” says the modern matron Amanda Jarvis. “It’s two swabs for an adult: nasal swab and throat – right at the back of the throat. It takes a couple of minutes.”

Leo Harris-Mortimer, four, is swab tested.

Alex Mortimer, a paediatrician, has brought his four-year-old son, Leo Harris-Mortimer, for a test. Leo has had a dry cough for several days; Alex’s wife had previously displayed symptoms, too.

“With this particular illness, the profile is that the older population are much more vulnerable to it, but there are a number of case studies that show children have been infected and have been affected badly. So it’s an important illness to take very seriously,” he says.

The test result takes between 48 and 72 hours to arrive, meaning Mortimer could soon be back at work if his son gets the all clear. Were it not for this rapid testing, he would have to undergo a precautionary period of isolation, excluding him from service for weeks.

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Halfway up Mount Everest



Back in the dimly lit corridors surrounding ITU, nurses and consultants prepare to enter the highly infectious wards. Just like Billyard before them, they too must don – and later doff – every piece of equipment with the utmost precision, otherwise the risk of contaminating themselves, the safe zones and future patients is extreme.

Yellow and black hazard tape marks the flooring – tread on the wrong side of it and you will be quickly admonished – and white plastic sheets with red zippers seal the outer perimeter of the changing zone.

Each person who enters ITU is likely to stay inside for three hours or more before they take a 20-minute break. The sweat caused by wearing so much plastic is instantaneous and the FFP3 masks irritate the nose and skin. Yet there can be no distractions in critical care, where half of all patients with Covid-19 will not survive.

(The NHS says it hopes that by allowing a photojournalist to document the care provided in ITU, it may reinforce the need to stay at home and protect the NHS. Some viewers may find the following images distressing.)

Medics in and around ITU, where signs warn of the extreme infection risk within.

Roger Townsend is a clinical lead for ITU. “Working in the PPE is hot, uncomfortable, and because you can’t take your mask off in the critical care area, you can’t drink a glass of water,” he says.

“There’s always the temptation to do one more job before you leave. So when you say to yourself: ‘I’ll wear this for two hours and then go out and have a drink and then come back in,’ you find sometimes three, four hours have gone by or even longer.”

Inside ITU, many patients are in comas and connected to a vast array of machinery – ventilators, monitors, infusion pumps and sometimes dialysis machines – while groups of nurses and doctors check their vital signs.

Nurses in ITU attend to their patients.

Heart monitors flicker and nurses confer; Billyard wanders the ward, scanning for problems. Many of the patients he surveys are middle-aged.

Behind a curtain, a patient is flipped on to their front – a process known as “proning”. It takes five people to roll one patient. Each of them has their name written across their front and back, because there would be no other way to recognise who was who.

A patient is ‘proned’ – turned on to their front – to assist with breathing.

In another bay, one of the few conscious patients is wearing a pressurised breathing apparatus. His head is entirely encased.

“By the time a patient comes to critical care, they have got the kind of oxygen levels that you would have not quite half way up Mount Everest,” says Townsend, “and that’s on supplemental oxygen to push their oxygen levels up. If we didn’t intervene then the oxygen levels in their blood would fall away and they would die. The intervention that we do is essentially buying some time for mother nature to fix things.”

The hospital has two ITU wards and Townsend, speaking earlier in the week when ITU was busier, revealed the scale of the challenge when he said: “Normally when we hand over at the end or beginning of the day, we might say that two or three patients are really sick, but we’ve got 15 or 16 patients on each unit who I would say fit that definition. You do go home shell-shocked.”

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One second closer



Far away from the trauma of ITU, in a scientific laboratory filled with test tubes, refrigerators and unfathomable machines, Ranveer Singh Chaven, a bio medical scientist, is busy analysing results from Covid-19 swab tests.

“Optimism is everything, otherwise you wouldn’t come to work. I’m sure I speak for everyone here at the hospital when I say we’ll work day and night.”

Ranveer Singh Chaven, a bio medical scientist, and his phone, which shows how long it has been since he last gave his mum and niece a hug.

He digs into his pocket and shows me an app on his phone. “I’ve got a timer on my phone,” he says. “This is how long it’s been since I’ve seen my mum and given her a hug, or kissed my niece goodnight: 24 days, 10 hours, 26 minutes, 53 seconds.”

He pauses, then adds: “I keep that with me just to keep me going. If it brings me a second closer to seeing them … that’s why we do this.”