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1 Monday, 6 June 2011

2 (10.00 am)

3 (Proceedings delayed)

4 (10.15 am)

5 LORD MACLEAN: Mr Kinroy, I want to ask you certain

6 questions in a minute. I have not read the submission,

7 the latest submission, which I think was produced to me

8 20 minutes ago, approximately. I haven't looked at

9 that, because I don't think it is necessary for me to do

10 so. But I would like some information from you.

11 MR KINROY: Yes.

12 Discussion re nurses' evidence

13 LORD MACLEAN: You will appreciate that, at the same time,

14 we have made enquiry of the RCN. Sadly, they are not

15 here, actually. I would have expected them to attend

16 this particular tract of evidence, but they haven't.

17 But we have had a fairly full report from them about

18 what they have done by way of preparation with at least

19 their members.

20 Of course, not all the nurses are members of

21 the Royal College of Nursing, but we now see what they

22 have been able to do in the time that they have been

23 core participants; not as much as I would have wanted

24 them to. That bears upon the decision I am going to

25 announce in a moment.

1 1 Before I do that, could you tell me, please, how

2 much contact the board has had with the nurses, who are,

3 of course, all board employees?

4 MR KINROY: Very little, my Lord, on the basis that it would

5 be improper to do so. In the written submissions that

6 your Lordship has not yet seen there is a number of

7 reasons why the board has not seen fit to instruct or

8 prepare the nurses, the principal one being a potential

9 conflict of interest.

10 LORD MACLEAN: Is there, though?

11 MR KINROY: My Lord, if I may make the submission, most

12 definitely there is a potential conflict of interest,

13 which I think the Solicitor to the Inquiry has already

14 recognised.

15 LORD MACLEAN: What is the conflict?

16 MR KINROY: My Lord, it may be that one nurse will blame

17 another or one nurse may blame the board, but they may

18 all have different interests in what they might have to

19 say when faced with evidence critical of them.

20 LORD MACLEAN: So from the board's point of view, it was

21 always going to be the case that they were not going to

22 assist to prepare the nurses to give evidence?

23 MR KINROY: Yes, my Lord, I think that has been quite

24 evident from the correspondence to the Inquiry's

25 solicitor all along, and certainly it is also the

2 1 position of the board that it is for the Inquiry to do

2 that, in terms of paragraph 21 of the guidance, for

3 example. On the basis of that, the board understood

4 that the Inquiry team would be doing this. But

5 certainly, my Lord--

6 LORD MACLEAN: The Inquiry team don't do that. The Inquiry

7 team takes their statements because they know what they

8 want to get from the individual witness.

9 MR KINROY: My Lord, some of this I think may turn upon the

10 proper construction of the 2005 Act and, of course,

11 my Lord will know there is very little authority on it,

12 but looking to that, Sir Richard Scott, as he then was,

13 published an article in the Law Review about the proper

14 procedure under the 2005 Act, and partly on the basis of

15 that, and as a matter of law, Glasgow has taken the view

16 that paragraph 21 of the guidance quite correctly

17 indicates that it will be for the Inquiry team to

18 prepare the nurses, but quite apart from questions of

19 conflict of interest --

20 LORD MACLEAN: Can I just come in on that, just cutting

21 across you, does that mean, then, that the board does

22 not know what the nurses are going to say?

23 MR KINROY: My Lord, the board knows no more than is in the

24 statements.

25 LORD MACLEAN: Which we obtained?

3 1 MR KINROY: Yes.

2 LORD MACLEAN: Gosh!

3 MR KINROY: May I say, my Lord, even whether or not

4 questions of propriety and questions of function --

5 because, of course, in this Inquiry, this is not an

6 adversarial process, we are in many ways mere bystanders

7 or observers, there is a practical problem in knowing

8 exactly what it is which is to be put to the nurses.

9 Now, we have heard the nursing reports, but of

10 course, one would, at the very least, have to match up

11 the reports to the individual nurses, but I imagine that

12 the questions which are put to the nurses will involve

13 examinations of the exercise by them of professional

14 discretions, so it is very difficult to know precisely

15 what they will be asked and, until that is known, it is

16 very difficult to prepare them. This is in complete

17 contrast, of course, to professional negligence actions.

18 LORD MACLEAN: Yes, I see that.

19 MR KINROY: It is not a proceeding where the complaint is

20 well-known. The nurses tend to reflect on the specifics

21 of the complaint and, if anyone is perturbed by the lack

22 of specification, there are remedies available for that.

23 So, my Lord, there is a plethora of reasons in the

24 submissions which your Lordship will not yet have

25 seen --

4 1 LORD MACLEAN: It came rather late, you see.

2 MR KINROY: Yes, indeed so, my Lord. This issue only arose

3 on Friday. In fact, submissions are not really meant to

4 be written, they are merely to assist oral submissions.

5 LORD MACLEAN: Yes, I appreciate that. Doesn't the board

6 feel any responsibility for its employees?

7 MR KINROY: My Lord, it feels the greatest responsibility.

8 LORD MACLEAN: What has it done about it?

9 MR KINROY: The view taken by the board was that there is

10 a potential conflict of interest. This is a view

11 I think very clearly echoed by the Solicitor to the

12 Inquiry. The board has been under the misapprehension

13 that the Inquiry team was going to attend to this, or

14 the Royal College of Nurses and, lastly, there is

15 a general chapter of reasons why the board is not in

16 a position to put to the nurses in sufficient detail the

17 information they must address when they give their

18 evidence.

19 LORD MACLEAN: Even now?

20 MR KINROY: Even now, my Lord. I should also add there is a

21 question --

22 LORD MACLEAN: Even in the light of the evidence we have

23 heard thus far and the statements you have all had?

24 MR KINROY: Absolutely so.

25 LORD MACLEAN: And in the light of the fact that they are

5 1 your records?

2 MR KINROY: Absolutely so, my Lord. I should also add the

3 question of the confidentiality agreement, which limits

4 the exhibition of documents by the legal team to the

5 client, the client being Greater Glasgow Health Board,

6 and the legal team has, I think -- I hope correctly --

7 taken the view that the scope of that is limited to

8 those who personify the board. The board is a legal

9 person and it has its personification in certain natural

10 persons, but the nurses are not the personification of

11 the board.

12 If I may develop these reasons and explain why the

13 board has taken these views, there are quite a number of

14 reasons why the board has not seen fit to prepare the

15 nurses.

16 LORD MACLEAN: As I said, I am going to come to give my

17 decision in a moment, but before I do, I wanted to be

18 sure I understood the board's position. I am going to

19 ask Mr MacAulay to comment on that.

20 MR KINROY: My Lord, if I may just say, for the record, that

21 the reasons are all articulated in the written

22 submissions.

23 LORD MACLEAN: That may be, but it would take a long time to

24 read that, and even listen to it, and we don't have all

25 that much time. I wish people understood that.

6 1 MR KINROY: The board very much understands that. I should

2 also make clear that the board is not asking for time.

3 All the board is asking for --

4 LORD MACLEAN: I know what the board is asking for, but it

5 means time, actually. Mr MacAulay?

6 MR MACAULAY: The one comment, my Lord, I would make is, if

7 it is the board's position that, for reasons of

8 conflict, they would not be able to prepare their

9 employees to give evidence in an appropriate fashion,

10 then that is something which ought to have been brought

11 to the Inquiry's attention long ago. Indeed --

12 LORD MACLEAN: Did you know that the board was taking that

13 position, or it had taken that position?

14 MR MACAULAY: My learned friend mentioned confidentiality to

15 me on Friday. I didn't quite understand what the

16 problem was. It wasn't elaborated upon. But the point

17 is that, if that is the board's position, and it seems

18 to have been the board's position for some time, then

19 all the more reason that a body like the RCN should have

20 been brought into the Inquiry much sooner, and I find it

21 surprising that the board were prepared to expose their

22 employees to giving evidence without being properly

23 prepared.

24 MR KINROY: My Lord, may I say this: there is a bundle of

25 documents in which correspondence between the legal team

7 1 for Glasgow and the Inquiry team exhibit that the board

2 has been, for some time now, putting to the Inquiry team

3 about what is it doing about preparing the witnesses.

4 There has never been any departure from that position by

5 the board.

6 LORD MACLEAN: But an Inquiry doesn't prepare witnesses. It

7 is a question of the interests involved.

8 However, I don't want to lose time on this

9 because -- although there is an unresolved question,

10 Mr Kinroy, and that is: what about those nurses who are

11 not members of the RCN?

12 The RCN will represent their members, that is fine,

13 and they have already taken steps. As I have said, not

14 as many steps as I would like them to have taken, but

15 they have already taken steps to prepare their members,

16 and they also say they need more time to do that.

17 Fundamentally, as you point out in your second note,

18 it is a question, at the end of the day, not of

19 the board's responsibility or how the board sees its

20 responsibility or how it performs, it is a question of

21 fairness to the individual witnesses, and that is what

22 guides me.

23 MR KINROY: Exactly so, my Lord. If I may reply to one

24 thing my learned friend has said, it is not a question

25 of the board neglecting the care for its employees. Far

8 1 from it. I will explain why the board took the view it

2 was improper to prepare the witnesses.

3 On the other hand, this very application is designed

4 to protect the nurses from unfairness. I should also

5 say, my Lord, that there may be, if anything,

6 a challenge that the board has no interest to do this.

7 It is for the RCN or for those nurses to take the point.

8 But the board has taken the point that they need to be

9 properly prepared and, of course, the board recognises

10 firstly that it is in everyone's interest that there

11 should be fairness.

12 LORD MACLEAN: I know that. That is what guides me. But

13 I do find it remarkable that the board has not posted

14 this clearly from way back, and also why it feels it

15 cannot represent, at least prepare for evidence, people

16 who are their employees?

17 MR KINROY: My Lord, by my way of it, since 7 April, the

18 board's position has been manifest to the Inquiry. If

19 not then, from a date in early May the board has been

20 saying to the Solicitors for the Inquiry team, "What are

21 you doing about this?"

22 It appeared that the RCN was to the rescue, but not

23 it appears not.

24 LORD MACLEAN: Sorry?

25 MR KINROY: It appeared that the RCN was to come to the

9 1 rescue, in that the RCN, as his Lordship had envisaged,

2 I think, was to prepare the nurses, but there is now

3 a concern for this party that the RCN has not managed to

4 do -- in essence, one shares your Lordship's views that

5 the RCN has not done all that one might have hoped it

6 could.

7 LORD MACLEAN: There is a lack of urgency being shown.

8 Because of that, I have decided that the nurses will not

9 give evidence until they are properly prepared and, to

10 do that, I am going to postpone their evidence until

11 4 July, which is four weeks away. If they can't be

12 prepared in that time by reference to the documents,

13 your documents, incidentally, that will be too bad. We

14 need to get ahead. Already there has been anxiety about

15 the delays that have taken place. I am not allocating

16 responsibility for that at all, but we must get ahead

17 with this.

18 I take it, and we will hear from the RCN, that that

19 will be sufficient time for them to do the work they

20 have to and, of course, I am not sure what, if any, work

21 you are going to be doing as a board.

22 MR KINROY: My Lord, clearly the board wishes to assist the

23 Inquiry as much as it properly can. If the question of

24 conflict of interest can be resolved, if the

25 confidentiality agreement can be modified and if the

10 1 board can be told specifically what are the questions

2 which are to be put to the nurses, then I have no doubt

3 about it, the board will be gladly involved, insofar as

4 time permits, in giving the nurses notice of what they

5 are to be asked and giving them time to reflect on that

6 and giving them time to refresh their memories, but the

7 board has not wanted to do anything improper in all of

8 this.

9 Of course, my Lord will know that presumably under

10 the 2005 Act, sadly, the board is in many ways a passive

11 observer in the Inquiry.

12 LORD MACLEAN: Oh, Mr Kinroy, I think you will regret saying

13 that by the end of this Inquiry. You are not a passive

14 observer at all. You are very much a party right at the

15 forefront of the Inquiry.

16 MR KINROY: My Lord, I would welcome the chance to

17 cross-examine witnesses and to lead evidence.

18 LORD MACLEAN: That is a different point altogether --

19 altogether -- but that doesn't mean to say that you are

20 passive in relation to preparing your employees for

21 their giving evidence.

22 Now, if it is a question of propriety, I personally,

23 at the moment, don't think it is improper at all and

24 welcome the board's input to that, because there will be

25 some who will not be prepared by the RCN, you see, they

11 1 are not members. I don't know who they are, but you

2 will know who they are.

3 MR KINROY: My Lord, not that there is considered to be no

4 conflict of interest here, I suppose, nonetheless, that

5 legal advisers, in the proper performance of their

6 professional duties, will have to be very careful and

7 take guidance from the professional bodies about it, but

8 no doubt the bodies will be understanding about that.

9 LORD MACLEAN: I shall ask Mr MacAulay for his observations

10 on what I have indicated and intimated and in the light

11 of what you have said. Mr MacAulay?

12 MR MACAULAY: My Lord, the reality of the position appears

13 to be that the nurses have not been prepared, for

14 whatever reason, to give their evidence next week.

15 I don't have any difficulty in accepting the proposition

16 that, as a matter of fairness, they ought to be

17 prepared. I would therefore support the proposition

18 that they should be given time for that preparation.

19 I fail to see the nature of the conflict of interest

20 that my learned friend makes reference to,

21 notwithstanding the fact that these are the board's

22 employees and, indeed, one would have thought that,

23 having regard to the broad terms of your Lordship's

24 remit, the board, long ago, should have investigated the

25 nursing care that was given to patients at the

12 1 Vale of Leven, if only to satisfy themselves as to what

2 the position was, and if they haven't entered into

3 discussions with the nurses and examined the medical

4 records in that context, that would suggest they haven't

5 carried out --

6 LORD MACLEAN: Sorry?

7 MR MACAULAY: If they haven't taken the nurses through the

8 medical records, and that seems to be the position, then

9 it is difficult to see how the board itself has

10 satisfied itself in relation to the nature of

11 the nursing care given at the Vale of Leven.

12 LORD MACLEAN: I share your difficulty in understanding the

13 conflict, but they obviously feel, having received legal

14 advice, that there is one. I personally can't see it.

15 I think it may be a question for a discussion

16 between you, perhaps, and Mr Kinroy as to whether such

17 conflict would prevent their assisting their employees

18 who are not members of the RCN to prepare for this

19 Inquiry. You might discuss that with him.

20 MR MACAULAY: Indeed. My learned friend seems to suggest

21 that there is a conflict in the fact that one nurse

22 might blame another, or indeed blame another member of

23 the board, but unless and until they have actually

24 spoken to the nurses and looked at the matter, that

25 might be pure hypothesis that doesn't exist.

13 1 Be that as it may, my Lord, ultimately the issue is

2 one of fairness to the witnesses.

3 LORD MACLEAN: That is what governs my thinking, actually,

4 and what drives me to indicate that the nursing evidence

5 will not be heard until 4 July.

6 MR KINROY: Indeed so, my Lord. If I may add, part of

7 the reasoning which informs the board's view is a letter

8 of 20 May 2010 from the Solicitor to the Inquiry:

9 "While I appreciate that your office may represent

10 members of staff as well as the board in certain

11 proceedings, I am bound to say I find it, in comparison

12 with other legal proceedings, to be of limited value.

13 It appears to me that the same solicitor can only

14 properly act for more than one party where there is no

15 foreseeable risk of a conflict of interest arising, and

16 I understand from our conversation that you accept that

17 a conflict of interest may arise. For my part, in the

18 context of a public Inquiry, I find the risk of conflict

19 of interest to be manifest."

20 So, my Lord, there is clearly some confusion about

21 this question of conflict of interest.

22 LORD MACLEAN: Absolutely. It is not the first confusion

23 that has arisen between the Inquiry team and the board.

24 MR KINROY: That is obviously regrettable, my Lord, but may

25 I also say this: the nursing reports which are the basis

14 1 on which this has called into question the adequacy of

2 nursing only began to appear, I think, on 1 April of

3 this year and, until that point, there had been no

4 suggestion that the adequacy of the nursing -- sorry,

5 my Lord, until the end of 2010, there had been no

6 suggestion that the adequacy of the nursing would be

7 called into question, and my Lord will know that the

8 independent review team had formed the view that it was

9 perfectly adequate.

10 LORD MACLEAN: That is many moons ago, Mr Kinroy. People

11 may have their views about how thorough that

12 investigation was.

13 MR KINROY: What the board has had to do is to see these

14 reports and deal with them as they appear from 1 April

15 onwards, and it made every effort to do so in time for

16 16 May.

17 LORD MACLEAN: Do you want to reply to that, Mr MacAulay?

18 MR MACAULAY: In relation, my Lord, to the independent

19 review, Professor Cairn Smith's review, that had a very

20 limited remit and its focus was on systems, not on

21 nursing care. It has been perfectly evident since this

22 Inquiry was set up in April 2009 that it had an

23 extremely broad remit, which included looking at nursing

24 care.

25 The core participants have been aware

15 1 since September of last year that each individual

2 patient's records was going to be examined by nursing,

3 geriatric and microbiological experts, so it was

4 well-known what the nature of this exercise was supposed

5 to be.

6 Furthermore, my Lord, on 17 March, a note from

7 counsel on the themes that were to be anticipated in the

8 nursing reports was circulated with core participants.

9 LORD MACLEAN: That is you and --

10 MR MACAULAY: And Ms Sutherland. That covered matters like

11 fluid balance, pressure management, and so on and so

12 forth. So, my Lord, it has been clear for some time

13 that this was the manner in which this whole exercise

14 was to be conducted.

15 LORD MACLEAN: I'm slightly bothered about this. It is not

16 just in terms of the nursing, Mr Kinroy. I am thinking

17 perhaps about the other areas, other employees of

18 the board, that will yet have to give evidence, and I am

19 thinking of the doctors here.

20 You could well say the same thing about them. They

21 might blame each other or blame the board or blame --

22 I don't know whom, but does that give rise to a conflict

23 of interest?

24 MR KINROY: My Lord, undoubtedly. As of today, yes. But of

25 course, I understand that the doctors are much more

16 1 likely to be instructing legal representation of their

2 own, if that is permitted to them.

3 May I say this, there are two different things here:

4 one is the position of the board in relation to the

5 quality of nursing, and the board has to examine that

6 and be prepared to discuss it, but in terms of

7 the specific concern today, which is the preparation of

8 the nurses to give evidence, that turns upon knowing

9 what it is with which they are to be charged.

10 LORD MACLEAN: They are not charged with anything. They are

11 charged with giving evidence about what they did or

12 didn't do.

13 MR KINROY: In that case, I will rephrase that: the question

14 is what adverse evidence should be drawn to their

15 attention, if I use the words of Sir Richard Scott?

16 LORD MACLEAN: There is not adverse evidence, Mr Kinroy. It

17 is just evidence -- I don't know who may or may not be

18 criticised. Therefore, no notices can go out at this

19 stage until I have heard the evidence. I have been

20 through this before in another place.

21 MR KINROY: Of course, my Lord. I suggest that, when one

22 looks to the views expressed by Sir Richard Scott, there

23 are two stages here. Clearly, there is a stage of

24 the warning letter, known as the Salmon letter, and

25 I think it is paragraph 12 of the rules of procedure --

17 1 LORD MACLEAN: You refer to the then Sir Richard Scott,

2 which is the -- remind me of the Inquiry.

3 MR KINROY: The Arms to Iraq Inquiry, yes.

4 LORD MACLEAN: That's right, and of course that was one of

5 the Inquiries that led up to the passage of

6 the Inquiries Act 2005. That and the procedural rules

7 govern the way this is conducted.

8 I don't know, I have no idea, until I have heard the

9 evidence, who might or might not be identified as

10 somebody who is criticised professionally -- or it may

11 not be professionally, but certainly who is criticised.

12 Such a person will always have the opportunity of coming

13 back in the light of any finding that the Inquiry might

14 make. So they are not going to be without redress or an

15 opportunity of reply.

16 The concern at the moment is that people should be

17 well-prepared for questions that are going to be asked,

18 in fairness to them, by reference to the documents, and

19 the documents substantially here are the hospital

20 records, your records, if I might say so.

21 MR KINROY: Exactly so. My Lord, if I may -- it might be

22 useful if I make this submission: as I read the views of

23 Sir Richard Scott, which to my mind at least are

24 extremely cogent, he alludes to the stage of a warning

25 letter being given, that is the stage to which

18 1 your Lordship has also referred, but he also refers to

2 an antecedent stage, that is the stage with which we are

3 concerned now.

4 His view -- of course, it is for your Lordship to

5 either accept or reject the fact -- is that, where there

6 is adverse evidence prejudicial to a witness, at the

7 stage of giving evidence and being called, the witness

8 should be alerted to it. Now, my Lord --

9 LORD MACLEAN: That is true. That will happen here, won't

10 it?

11 MR KINROY: Exactly so.

12 LORD MACLEAN: By the time the nurses come, most of

13 the expert evidence will have been given, will be known

14 and understood, and can be put to the individual nurse

15 for his or her comment.

16 MR KINROY: One of the difficulties at this stage, my Lord,

17 for, I think, anyone, is knowing what allegations --

18 I correct myself, what adverse evidence is to be put to

19 which nurse.

20 LORD MACLEAN: I don't understand that. I really don't, I'm

21 sorry. But all you need to do is prepare the nurse for

22 giving evidence in light of the documents and find out

23 what it is she has to say. I don't know what she is

24 going to say.

25 MR KINROY: My Lord, in light of these discussions, I have

19 1 no doubt the parties will collaborate in seeing that

2 this is properly done.

3 LORD MACLEAN: I certainly hope so.

4 MR KINROY: There is certainly, I think, great willingness

5 on all sides to cooperate in an Inquiry which is not

6 about attributing blame, but about getting to the bottom

7 of things, and that is certainly Greater Glasgow

8 Health Board's desire.

9 LORD MACLEAN: That is what I am charged with doing, is

10 fulfilling the remit that I have got.

11 I think what I am going to do in the future, to

12 avoid these misunderstandings, is to ask parties from

13 time to time what their position is in terms of being

14 prepared for this or prepared for that, because I can't,

15 frankly, allow this to happen again.

16 After all, you have made an application to me -- not

17 you personally, perhaps, but there was an application

18 made to me to have more time given, and you got more

19 time. That was for your own benefit.

20 MR KINROY: Inadvertently perhaps, my Lord, but there was no

21 application made in advance of 6 May for more time by

22 Greater Glasgow Health Board. Indeed, my Lord, it would

23 have been contradictory to do that, because Glasgow

24 Health Board had already been told there would be no

25 postponement.

20 1 So, my Lord, the first application was not concerned

2 with getting more time, it was concerned with the

3 question, one, of preparing the nurses, that was the

4 alternative submission, and the antecedent question was,

5 in fairness, could it be clarified why certain issues,

6 for example, falls risk assessments, should be explored

7 in these hearings when there was no obvious connection

8 to the fundamental question of: why did certain patients

9 contract the C. diff illness and the mortality rate?

10 LORD MACLEAN: Mr Kinroy, I have a totally different

11 understanding of why the board did make application, and

12 I am going to ask Mr MacAulay to clarify my thinking for

13 me.

14 MR MACAULAY: I understand, my Lord, that the board sought

15 more time because they wanted more time to consider the

16 nursing expert reports.

17 LORD MACLEAN: Yes. I agree. You didn't have very much

18 time to consider them.

19 MR MACAULAY: Your Lordship took the view that more time

20 should be given, and that is what happened.

21 LORD MACLEAN: Anyway --

22 MR KINROY: My Lord, I will be governed by the terms --

23 LORD MACLEAN: Can we draw a line under all of this?

24 Because it is going nowhere, really. But you know what

25 I think. I don't think it is in the least bit improper

21 1 for you to prepare your employees, the nurses who are

2 not members of the RCN particularly, to give evidence,

3 and four weeks is ample time for that to be done.

4 MR KINROY: Of course, my Lord.

5 LORD MACLEAN: Right. We do have a witness?

6 MR MACAULAY: We do, my Lord. I would like to call

7 Sharon Stower.

8 MS SHARON STOWER (sworn)

9 Examination by MR MACAULAY

10 MR MACAULAY: Are you Sharon Stower?

11 A. I am.

12 Q. Could I ask you to have your CV in front of you, please,

13 it is INQ01820001. Could I ask you what position you

14 hold at present, Mrs Stower?

15 A. The position that I hold at present is that I am an

16 independent healthcare consultant and I also am an

17 expert nurse.

18 Q. If we look to the first page of your CV, can we see

19 under the heading "Current Employment" that you describe

20 yourself as an independent nursing and healthcare

21 consultant and you have been that since 2004; is that

22 correct?

23 A. That's correct.

24 Q. You also act as a clinical adviser to the healthcare

25 Commission; is that right?

22 1 A. I was a clinical adviser to the Healthcare Commission,

2 now the CQC, but since the Healthcare Commission became

3 the CQC, I have no longer worked for them.

4 Q. Can you give the Inquiry some sort of understanding then

5 as to what the nature of your work is at present?

6 A. Yes, of course. As an independent nursing and

7 healthcare consultant, I work with a large group of

8 professionals. I basically work on an instruction

9 basis. My work comes from a variety of different

10 sources. I do work, or I have worked, and I am still

11 working, for the Royal College of Nursing. They give me

12 extracts of work on projects to do as they need them

13 doing. I also, over the past year, have worked with

14 the -- in England, the national safe and sustainable

15 teams reviewing the second part of children's cardiac

16 surgery and the ongoing national review of children's

17 neurosurgery. That is basically my consultancy work.

18 I also work on a retainer basis for other companies,

19 for example, independent healthcare companies, again

20 working with them on any projects that they may need to

21 have undertaken, and then, separate to that, I have my

22 legal expert nurse work, which again is done on an

23 instruction basis from solicitors.

24 Q. You tell us that you get instructions from both the

25 claimant and from the defence?

23 1 A. I beg your pardon?

2 Q. You are instructed by both claimants and by defence?

3 A. That's correct.

4 Q. If you turn to the second page of your CV, and we look

5 to the bottom, can you tell me, when did you qualify as

6 a registered nurse?

7 A. I qualified as a registered general nurse in 1978, and

8 then, after that, I went on to do a second registration

9 in sick children's nursing.

10 Q. If we just look at your CV, you were a sister from 1983

11 to 1984; is that correct?

12 A. That's correct.

13 Q. Then we see the different positions that you have held.

14 If we look towards the top, the second entry, you were

15 registered manager/matron in a hospital in Peterborough;

16 is that right?

17 A. Correct.

18 Q. Was that the last nursing post you held before your

19 present position?

20 A. No. After I worked at the orthopaedic hospital in

21 Peterborough, I then took a post as the lead nurse in

22 one of the English private schools.

23 Q. Is that the position that we see from 2008 to 2010?

24 A. Yes, that's correct.

25 Q. Was that a part-time position?

24 1 A. Yes, it was four days a week. I was employed as the

2 lead nurse.

3 Q. If we go to the first page of your CV, you set out your

4 professional education and your higher education. You

5 seem to have had an MA in Philosophical, Medical and

6 Healthcare Ethics in 1997; is that right?

7 A. That's correct.

8 Q. Can you tell me when you last worked in the capacity as

9 a senior charge nurse, if I can look at that sort of

10 pigeonhole?

11 A. The answer to that is, in the role of a ward sister or

12 a nurse in charge of a ward, would have been in

13 Peterborough, but also when I worked as the lead nurse

14 in the school.

15 Q. So the Peterborough position was in 2004 to 2006?

16 A. That's correct.

17 Q. Have you ever worked in Scotland?

18 A. I have never worked in Scotland, no.

19 Q. Have you ever been to the Vale of Leven Hospital?

20 A. No, I have not.

21 Q. In preparation for giving your evidence, were you

22 provided with some information as to the nature of

23 the hospital?

24 A. Yes, I was provided with the Junior Doctors' Handbook.

25 Q. Perhaps we can look quickly at that, please, if you

25 1 could look at GGC21720001. Do you recognise that as the

2 first page of the document that you were given?

3 A. That's correct.

4 Q. You were given information as to the size of

5 the hospital and the nature of the services provided?

6 A. That's correct.

7 Q. I think you have prepared a number of reports for this

8 Inquiry in respect of a number of individual patients;

9 is that right?

10 A. Yes, I have prepared nine reports for nine patients,

11 plus a summary report.

12 Q. The summary report was designed to summarise what you

13 had ascertained from carrying out the individual

14 reports?

15 A. That's correct. It was just to bring together the

16 reoccurring themes.

17 Q. In looking at the patient records, did you seek to put

18 yourself in the shoes of the nurses on the ward?

19 A. Yes, I did. I approached the reports from the point of

20 view of the nursing care of the nurses on the ward, but

21 equally from the patient's point of view as well.

22 LORD MACLEAN: I think that is slightly too close to you,

23 actually. That is better.

24 A. Is that better? Okay.

25 MR MACAULAY: Could I ask you to look at a number of

26 1 documents. First of all, all registered nurses have to

2 be registered with a regulatory body, is that right, the

3 Nursing & Midwifery Council?

4 A. That's correct.

5 Q. If you could look, please, at the Code of Practice,

6 which is to be found at INQ01970001, and if you could

7 turn, please, to page 3 of the code, can we see that

8 this document sets out a number of principles that are

9 to guide nurses in their practice?

10 A. Yes, it does.

11 Q. Is this an important document?

12 A. Yes, it is a very important document for registered

13 nurses.

14 Q. Why is that?

15 A. The Nursing & Midwifery Council is the regulatory body

16 for registered nurses, and it is there not only for that

17 but also for the protection of the public. These

18 underlying principles are principles that are engrained

19 into the clinical practice of nurses.

20 Q. If we look to this page that we are looking at at the

21 moment, page 3, we are told:

22 "As a registered nurse, midwife or specialist

23 community public health nurse, you are personally

24 accountable for your practice."

25 Then there are a number of propositions set out that

27 1 are relevant when caring for patients; is that right?

2 A. That's correct.

3 Q. Can we see that this section ends with this:

4 "These are the shared values of all the

5 United Kingdom healthcare regulatory bodies."

6 A. Yes.

7 Q. We know that you have never practised in Scotland, but

8 do you think that that in any way affects your ability

9 to assist the Inquiry in relation to what you discovered

10 in looking at the medical records of the patients you

11 looked at?

12 A. No, I don't think it prohibits that at all.

13 Q. I should perhaps indicate that, when we see you dabbing

14 your eyes, it is not because you are distressed, but

15 because you suffer from hayfever; is that right?

16 A. Yes, thank you.

17 Q. Why do you think that you are able to comment upon the

18 nursing records of patients in Scotland?

19 A. In terms of nursing and the NMC and, indeed, the Royal

20 College of Nursing, the organisation, as it says here,

21 shared values across the United Kingdom -- that's the

22 four countries of the United Kingdom, which obviously

23 includes Scotland -- and in those organisations there is

24 representative of the countries. I support and am part

25 of that, so a lot of my professional dealings with those

28 1 are shared with the four countries, including Scotland,

2 of course, and they are all fully represented, so I feel

3 that that is sufficient reason to be able to confidently

4 say that I can do that.

5 Q. If you look at page 4 of the code, and we have looked at

6 this in detail before and I just want to pick up one or

7 two points, at 1.4, do we read that the nurse has a duty

8 of care to your patients and clients who are entitled to

9 receive safe and competent care? Is that a fundamental

10 duty?

11 A. It is a fundamental principle of practice.

12 Q. When you came to look at the records of patients you

13 looked at, were you in any way looking at these records

14 in any specialised way?

15 A. No, not in a specialised way, just in a general context

16 of patient care.

17 Q. Were you looking for certain core and fundamental

18 principles of nursing?

19 A. Yes, I was.

20 Q. The next document I want you to look at, please, is

21 INQ02090001. You will see on the screen a document

22 headed "Record keeping", and we see again it has been

23 produced by the NMC.

24 Can you just tell us about record keeping? How

25 important is record keeping when you are looking at

29 1 care?

2 A. Well, record keeping is a fundamental element of

3 clinical care. The two things sit very closely

4 together. In terms of what clinical care is delivered

5 to the patient, record keeping should always reflect

6 that.

7 Q. Why? Why is that?

8 A. Because it is important to have a record of care that

9 has been delivered to patients. If the record -- if

10 there are no records, then we have no way of knowing

11 what has been undertaken.

12 Q. If we just read the introduction, do we see that it

13 reads as follows:

14 "Record keeping is an integral part of nursing,

15 midwifery and specialist community public health and

16 nursing practice. It is a tool of professional practice

17 and one that should help the care process. It is not

18 separate from this process and it is not an optional

19 extra to be fitted in if circumstances allow."

20 Do you agree with that statement?

21 A. Absolutely.

22 Q. If you turn to the fourth page of the document, the

23 first main paragraph, can we read:

24 "The approach to record keeping that courts of law

25 adopt tends to be that 'if it is not recorded, it has

30 1 not been done'."

2 Is that within your experience?

3 A. That is within my experience.

4 Q. If you go back to the first page of the document, we are

5 given some information as to what good record keeping

6 does, and it promotes, for example, continuity of care.

7 Do you see that?

8 A. Yes.

9 Q. Moving on to the next paragraph:

10 "Members of the public have the right to expect that

11 healthcare professionals will practice a high standard

12 of record keeping. The quality of a registrant's record

13 keeping is a reflection of the standard of their

14 professional practice. Good record keeping is a mark of

15 a skilled and safe practitioner, while careless or

16 incomplete record keeping often highlights wider

17 problems with that individual's practice."

18 Looking to these propositions, does that accord with

19 your experience?

20 A. Yes, it can well be reflective. I have actually

21 referred to that particular paragraph, I believe, in my

22 summary report.

23 Q. In the preparation of your reports, did you also have

24 regard to policies that you understood to be local

25 policies relevant for the Vale of Leven?

31 1 A. Yes, I did.

2 Q. Could you now look, please, at GGC00780001? We have

3 already looked at this with other witnesses, but can you

4 see that this is part of the infection control manual

5 that we understand was in place in the Vale of Leven?

6 If you look, please, at page 252, I think you see

7 here that part of the manual that is dealing with

8 C. difficile associated diarrhoea. Did you look at this

9 document in preparation for giving evidence?

10 A. Yes, I did.

11 Q. Can we see that, at 1, the responsibilities on health

12 workers is that they must follow this policy and inform

13 a member of the infection control team if this policy

14 cannot be followed?

15 A. Yes, correct.

16 Q. If you turn to page 254, we can read here at section 3,

17 against the reference to "Accommodation":

18 "A risk assessment should be carried out by the ICT

19 to determine if the patient requires isolation nursing."

20 Do you see that?

21 A. Yes.

22 Q. I think you looked at, as you said, nine cases. We will

23 look at the detail shortly, but was there evidence of

24 risk assessments being carried out in relation to

25 patients who contracted C. difficile?

32 1 A. Not in the way I would understand risk assessments to be

2 carried out. No, not really.

3 Q. We will look at that in due course. The next reference

4 I want you to look at makes reference to "care plan

5 available". Would you envisage that, if a patient was

6 to be suffering from C. difficile, there would be a care

7 plan prepared for that patient?

8 A. Yes, I would expect that.

9 Q. If you could now look, please, at, I think, another

10 document you looked at, and that is page 258 in the same

11 production. You will see this is headed "Loose stools".

12 Again, was this a policy document that you looked at in

13 preparation for giving evidence?

14 A. Yes, I did.

15 Q. If you turn to page 259, against the heading

16 "Accommodation", are we told that a patient with loose

17 stools should be placed -- start again:

18 "Place a patient who could contaminate the

19 environment with faeces in a single room."

20 Is that the general principle that, if a patient has

21 loose stools, the desirable position is to isolate the

22 patient?

23 A. Yes, it is.

24 Q. If that is not possible for whatever reason, let's say,

25 for example, there are no single rooms available, then

33 1 what would the position be?

2 A. If there is difficulty in providing a single room, then

3 I would expect the nursing staff on the ward, if the

4 patient was going to go to a ward, to try to find

5 a suitable alternative.

6 For example, there may be a two-bed room that could

7 accommodate the patient, providing there wasn't a second

8 person in that room. They could also contact the

9 infection control team to ask for advice regarding how

10 to manage the process -- they are the experts in the

11 field -- to give them advice. Also, the infection

12 control team should have a more global view of what

13 rooms would be available in the hospital, so there may

14 be single rooms available somewhere else that may be

15 able to accommodate that patient.

16 Equally, if that wasn't the case, then there are

17 possible other alternatives, such as defining a specific

18 area for the patient with providing them with their own

19 commode, et cetera, to try to reduce any degree of

20 contamination to other patients.

21 Q. What about cohorting with other patients who may be

22 suffering from the same problem? Would that be an

23 option?

24 A. It is an option if you are confident that the organism

25 is the same.

34 1 Q. The next section deals with "Care plan available", and

2 it says:

3 "Yes. See care plan for patients with loose

4 stools."

5 Would you expect there to be a care plan prepared if

6 a patient develops loose stools?

7 A. Yes, I would.

8 Q. Under the heading "Documentation" a few lines down, can

9 we read:

10 "Document all episodes of loose stools and actions

11 taken on a stool or fluid balance chart and

12 medical/nursing notes."

13 Again, would you expect that all episodes of loose

14 stools would be documented?

15 A. Yes, I would.

16 Q. I think another policy document that you looked at we

17 find at GGC26540001. You will see that this document is

18 headed "NH Greater Glasgow and Clyde acute services

19 division". It is dated 21 December 2006. It relates to

20 the management of inpatient falls. Again, did you look

21 at this before coming to give evidence?

22 A. Yes, I did.

23 Q. If we turn to page 3 of the document, we are given some

24 information about falls. Can falls be a problem if they

25 occur, particularly for older patients?

35 1 A. Well, particularly, falls are a problem for elderly

2 patients. Very often, they have unsteady gait which

3 gives them a tendency to fall. It is an area that is

4 known to be greater.

5 Q. If we turn to page 4, we are told what the aims of

6 the policy are:

7 "To identify patients at risk of falling in

8 hospital."

9 Generally, how is that done?

10 A. Generally, that is done with a falls risk assessment

11 document, risk assessment tool, so when the patient is

12 being admitted and a variety of data is being collected

13 to combine together to provide them with a nursing care

14 plan, a falls risk assessment would be undertaken.

15 Q. In the cases you looked at, was the tool available in

16 these cases?

17 A. Yes, the hospital did have a falls assessment, risk

18 assessment tool, yes.

19 Q. Turn to page 5, please, of the policy. You will see at

20 5.1 the advice is:

21 "All patients presenting with a fall or with

22 a condition which might render them susceptible to

23 a fall will have the following documentation completed

24 within 24 hours of admission:

25 "The Cannard falls risk assessment:

36 1 "A core nursing care plan to record interventions

2 undertaken to promote the patient's safety.

3 "If used, the mobility risk assessment card should

4 be completed."

5 Focusing on the second bullet point, would you

6 expect a care plan to be prepared, particularly if

7 a patient was at risk?

8 A. Most definitely, yes.

9 Q. Can I then start looking at the cases you looked at,

10 Mrs Stower, and the first case I want you to look at is

11 that of Catherine Stewart.

12 First of all, if you could have your report in front

13 of you, and I will put it on the screen as well, it is

14 EXP00100001. If you could also have the medical

15 records, GGC00530001. If we turn to your report, first

16 of all, and go to page 2 of the report, you set out

17 under the heading "Instructions" what you are asked to

18 do in relation to the records; is that correct?

19 A. That's correct.

20 Q. In particular, you indicate that you were not being

21 asked to interview the patient, relatives or members of

22 staff in providing your opinion, and you confirm that

23 you have not reviewed any statements at this stage in

24 the preparation of your opinion or transcripts of oral

25 evidence.

37 1 I understand from that that, essentially, your

2 primary focus was on the medical records; is that right?

3 A. The medical and nursing records. Yes, that's correct.

4 Q. I have been asked to put this to you, and I will, and

5 that is that you would accept, of course, that at the

6 end of the day, what patients may say or families or

7 nursing staff, and so on, will be important and has to

8 be considered in the whole picture before a decision can

9 be made as to what the standard of care was?

10 A. Yes, of course.

11 Q. If we then turn to page 3 of your report, I think I am

12 right in saying that Mrs Stewart was 56 when she was

13 admitted to the Vale of Leven? I think her date of

14 birth was 17 August 1951?

15 A. That's correct.

16 Q. Can you then tell us what you took from the records in

17 relation to her medical history?

18 A. Mrs Stewart was admitted into the --

19 Q. Can I ask you to pull the mic towards you?

20 A. Better?

21 Q. Yes, thank you.

22 A. Mrs Stewart was admitted to the Vale of Leven Hospital

23 via the MAU, which is the medical assessment unit, on

24 11/12, following a referral from her general

25 practitioner. The general practitioner recorded that

38 1 the presenting -- her presenting symptoms were of

2 confusion. There was also previous medical history of

3 alcoholic liver disease, gastric ulcer, hiatus hernia

4 and an attempted suicide. The patient had also had

5 recent upper gastrointestinal bleed and had undergone

6 endoscopy at the Royal Alexandra Hospital on 26/11/07.

7 Q. She was admitted, just to be clear, on 11 December

8 initially into the medical assessment unit?

9 A. That's correct.

10 Q. What was the problem then on admission --

11 MR PEOPLES: Sorry, could I just correct -- I think the

12 report says 11 December 2008. I think it should

13 probably be 2007. It is just a small point.

14 LORD MACLEAN: Is that right?

15 MR MACAULAY: That is right, isn't it?

16 A. Sorry, I didn't hear that.

17 Q. If you look at page 3 of the report, in the second line

18 you say 11 December 2008. It should be 2007?

19 A. Yes.

20 Q. Then you go on to tell us about what had happened in the

21 Royal Alexandra Hospital in November 2007.

22 A. Yes.

23 Q. To be clear, then, she was admitted on 11 December 2007.

24 What was the problem on admission?

25 A. The patient came into the Vale of Leven with a referral

39 1 with symptoms of confusion. She had also complained of

2 abdominal pain, query peritonitis and, following an

3 initial examination by the doctors, a decision was made

4 to transfer the patient to the Royal Alexandra Hospital

5 for a surgical opinion, and so that's essentially what

6 happened.

7 Q. I think you record in the notes that, when the patient

8 was being referred by the GP, there was reference to

9 falls and also increased confusion and diarrhoea?

10 A. Yes, that's correct.

11 Q. Was that on admission, that there was a suggestion that

12 she'd been suffering from diarrhoea?

13 A. Yes, that would have been in the information given by

14 the GP on admission.

15 Q. So far as the Royal Alexandra Hospital was concerned,

16 what happened there?

17 A. At the Royal Alexandra Hospital there was an initial

18 diagnosis of an acute abdomen and she was also noted to

19 be dehydrated. She was initially given some treatment

20 with some intravenous antibiotics and, when she had

21 a rectal examination, there was found to be some

22 foul-smelling diarrhoea.

23 At that point, doctors there were of the opinion

24 that there was not an acute abdomen, there was a pleural

25 effusion and there was also a question that there might

40 1 have been some C. difficile contamination, some

2 C. difficile diarrhoea. So a decision was then made to

3 transfer this patient back to the Vale of Leven Hospital

4 as there was considered to be no presenting surgical

5 issues. The patient was, at that point, considered to

6 be stable.

7 Q. So the patient then returned to the medical assessment

8 unit at the Vale of Leven; is that correct?

9 A. Yes, she was.

10 Q. Was a stool sample then taken --

11 A. It was, yes.

12 Q. -- on admission to the MAU?

13 A. Correct.

14 Q. Then I think you tell us in your report that there was

15 a concern that Mrs Stewart had C. difficile infection

16 and the decision to admit was made, to ward 3; is that

17 correct?

18 A. Correct, yes.

19 Q. But there was no isolation bed available at that time?

20 A. Correct.

21 Q. Can I just ask you to turn to page 104 of the records.

22 Can we see that this bears to be a nursing admission

23 assessment form, and does this relate to the admission

24 of Mrs Stewart after the transfer back from the Royal

25 Alexandra Hospital?

41 1 A. Yes, that's correct.

2 Q. We see the admission date is now 12/12. I think in your

3 report you say 12/11, but you mean the 12th; isn't that

4 right?

5 A. Correct.

6 Q. We see a reference to ward 3. You make some

7 observations in your report about this document. What

8 do you tell us about it on page 4 of your report?

9 A. This document is essentially not completed -- completely

10 completed. There is some key information that hasn't

11 been recorded for the patient.

12 Q. Again, if I could ask you, please, to make sure you

13 speak into the microphone so we can hear you. You say

14 the document is not fully completed?

15 A. That's correct.

16 Q. What has been left out?

17 A. Some of the essential personal information for the

18 patient, such as a name for the consultant, GP, next of

19 kin, although that has been blocked out -- I apologise

20 for that -- but certainly the history below, and the key

21 issue, really, is around about the observations of

22 the vital signs, temperature, pulse, blood pressure,

23 respiratory, there is no weight recorded on admission or

24 sats or the MEWS or BM scores and there is no Waterlow

25 score or urinalysis. There is quite a lot of

42 1 information at the lower section that has not been

2 completed for this patient on admission.

3 Q. Is this sort of document a document that is familiar to

4 you?

5 A. Yes.

6 Q. It is a standard type of document that would be used

7 when admitting a patient to a hospital?

8 A. Yes, it is, particularly if it is coming through -- the

9 patient is coming through a medical assessment unit.

10 Q. We see at the bottom left the observation section is not

11 completed and then the heading "Other information" that

12 also looks -- seems to be blank.

13 A. That's correct.

14 Q. If you then carry on and go back to page 4 of your

15 report, you also make mention in that paragraph under

16 the heading "Admission into ward 3" to the multiproblem

17 care plan. If we could look at that, that is on

18 page 108 of the records, again this appears to be an

19 acute medical unit multiproblem care plan, and you

20 discuss this in that paragraph.

21 What observations do you make in relation to this

22 care plan?

23 A. Basically, this is a multiproblem care plan. It is

24 identifying the problems as being dehydration and

25 diarrhoea. Then it goes on to identify a goal, which is

43 1 to treat the symptoms and to find out the cause, which

2 is, in my opinion, rather vague in terms of what the

3 goal is.

4 The interventions, of which there are a large

5 number, are requested -- are basically interventions

6 that have been requested by the doctor. They are what

7 we would call doctor's orders, in order to undertake an

8 ECG, a chest X-ray, et cetera, et cetera. What I have

9 identified here is that this isn't actually elements of

10 nursing care intervention, but a list of activities and

11 interventions that the doctor has ordered.

12 I have also said that this document does not have

13 the patient's unit number and date of birth identified

14 on it and I have also said that I was unsure which ward

15 this was completed on because the ward isn't identified.

16 Q. If we look at the document, you point out at the top box

17 the unit number and date of birth have not been entered

18 in, but looking to the problem, "Dehydrated, diarrhoea",

19 is that --

20 A. Hyponatremia.

21 Q. -- "hyponatremia"? Did that cover all the problems this

22 lady had?

23 A. No, it is not a nursing intervention. It is a care plan

24 for a patient with dehydration and diarrhoea. The

25 effects and consequences of that, I would expect more

44 1 specific nursing interventions.

2 There are some on that list there; for example,

3 four-hourly MEWS, two-hourly urine volumes, and

4 dietician. But it is just a list of activities the

5 doctor has asked to be completed, it is not actually how

6 they are going to actively nurse a patient in the ward

7 with the presenting symptoms.

8 Q. You can see that the first date is 12/12, but then there

9 is another entry for 13/12, which says, I think,

10 "dietician". Do you see that?

11 A. I do, yes.

12 Q. Would that be a relevant intervention to have on an

13 appropriate care plan?

14 A. Yes, that is satisfactory.

15 Q. What about the next entry, for the 16th?

16 A. That is an abdominal/chest X-ray. Again, a doctor would

17 have requested that. To catheterise the patient, blood

18 gases done and an albumin. These are basically, again,

19 activities requested, mainly laboratory and X-rays

20 requested by the doctor, but not specific nursing

21 interventions.

22 Q. Is this an appropriate care plan then for this lady?

23 A. No, it is not an appropriate nursing care plan.

24 Q. What would you expect to see in an appropriate nursing

25 care plan for this lady?

45 1 A. I would expect a care plan that is designed around --

2 the hospital, in some of the wards, did have core care

3 plans which identify the specific symptoms or presenting

4 features that the patients had. So I would expect

5 a care plan that was identifying the patient had

6 diarrhoea and dehydration, that would identify specific

7 interventions.

8 For example, isolating a patient; precautions and

9 instructions on what takes place, when you isolate the

10 patient, for staff and relatives, involving the

11 infection control team. There would be a list of very

12 specific nursing interventions that should be included,

13 rather than laboratory tests and X-rays.

14 Q. I think we saw that Mrs Stewart was initially admitted

15 to ward 3. Was she also thereafter admitted to ward 6?

16 A. That's correct.

17 Q. If you turn to page 110 of the records, we see the first

18 entry for 12 December at 0300 and we are told that she

19 was admitted via RAH to MAU then ward 3. Do you see

20 that?

21 A. Yes, correct.

22 Q. If you move down the page to 1235, can we see an entry

23 "Transferred from ward 3"? Is that where you understand

24 the transfer had been to ward 6?

25 A. Yes.

46 1 Q. If you move on to page 113 of the records, can we see

2 the heading at the top "Ward 6 - evaluation sheet"?

3 A. Yes. I would assume that that's when the transfer took

4 place, although there were occasions when I did have

5 difficulty identifying that specifically.

6 Q. If you go back to page 110, three lines from the bottom

7 can we read:

8 "Patient is now C. diff positive. Needs to be

9 isolated."

10 So it would appear that the result from the specimen

11 that had been taken earlier was a positive one, but that

12 the patient was still not isolated at this point; is

13 that right?

14 A. That's my understanding.

15 Q. If you turn over to the next page, page 111, the second

16 line from the top are we told:

17 "Patient isolated this afternoon."

18 So it would appear the patient was isolated some --

19 in the afternoon of 12 December?

20 A. Yes, that's correct.

21 Q. Can we then move on and look at some aspects of the

22 medical and nursing care and turn to page 5 of your

23 report? Here I think you are looking first at the

24 doctor's records; is that right?

25 A. Correct.

47 1 Q. On the 16th, that's four days after her admission, it

2 seems that Mrs Stewart was seen by Dr Carmichael, and

3 the instruction was that she urgently needed intravenous

4 fluids; is that correct?

5 A. Yes, that's correct.

6 Q. What did you understand the position to be at this

7 point?

8 A. Well, the medical records identify that the patient was

9 seen by Dr Carmichael and had been acutely unwell for

10 two days with dehydration, and they tried to establish

11 IV lines, IV access. That had obviously been quite

12 difficult for them to achieve.

13 However, following on from this, they make the

14 decision to discuss this matter with the anaesthetist to

15 try to get IV access and one of the comments I make,

16 I believe, later in the report is why this particular

17 referral to a colleague hadn't been done earlier in

18 order to get IV access achieved earlier for this

19 patient.

20 Q. We are now on 16 December, some four days after

21 admission; is that right?

22 A. Yes.

23 Q. If we go to the records, page 77 of the records, towards

24 the bottom of the page the entry for the 16th, is this

25 where we see the plan "Urgently needs IV fluids". Is

48 1 that where it has been noted?

2 A. Yes.

3 Q. How did that come about? Were you able to work out from

4 the records how it came to be that she was so

5 dehydrated?

6 A. Well, it was difficult, but clearly there had been

7 difficulty in accessing her intravenously, and without

8 going further into the report, I would need to check my

9 further notes, but in terms of other fluids that she'd,

10 you know, not been given either, clearly, when the

11 consultant saw her she was very dehydrated, and that was

12 the immediate impression that he got, that she needed

13 immediate access.

14 Q. Turn to page 78 of the medical notes. We are still on

15 the 16th. Towards the bottom, four or five lines from

16 the bottom, there is a reference to "Catheterise". Then

17 "Clear dark [something], monitor hourly"? What does

18 that mean?

19 A. Sorry, catheterise, the urine is clear but dark, that

20 would suggest dehydration. Monitor --

21 Q. Hourly.

22 A. I'm not sure what the other -- oh, urinary output. It

23 would be urinary output.

24 Q. How would you monitor urinary output on an hourly basis?

25 A. If she was catheterised, you would monitor it hourly.

49 1 You would go and you would observe the urine and monitor

2 it.

3 Q. Where would you record what you monitored?

4 A. On the fluid balance chart in the urinary output

5 section.

6 MR MACAULAY: My Lord, if your Lordship would have a break,

7 this would be an appropriate moment.

8 LORD MACLEAN: We will have a break now.

9 (11.30 am)

10 (A short break)

11 MR MACAULAY: If you can have your report in front of you,

12 Mrs Stower, and go back to page 5, I think we'd been

13 looking at the entry for 16 December. Then moving on to

14 page 6 of your summary of the medical notes, can we see

15 that on the 17th Mrs Stewart died?

16 A. Sorry, I didn't get that question.

17 Q. We were looking at page 6, and we can see the entry for

18 17 December --

19 A. Yes.

20 Q. -- to indicate that Mrs Stewart died and death was

21 declared at 2055?

22 A. Yes, I can see that.

23 Q. Looking at the nursing notes, if we look at the first

24 entry, and perhaps we can look at page 110 of

25 the records, if you could have that up on the screen,

50 1 please, you have noted in your report that Mrs Stewart

2 returned from the RAH, who excluded any acute surgical

3 problem, "Has ongoing loose stools, C. difficile".

4 If we turn to the records themselves, can we see

5 that in that first entry, just about a third of the way

6 down from the top of the page, "Has ongoing loose

7 stools" and then "? C. difficile. For intravenous

8 fluids". Do you see that?

9 A. No, I can't see that at the moment.

10 Q. If you look at the time 0610, it is a few lines above

11 that?

12 A. Yes.

13 Q. We see, "Has ongoing loose stools". Can you make that

14 out?

15 A. Yes, I can see that.

16 Q. And "? C. difficile"?

17 A. Correct, yes.

18 Q. It was then that the specimen was taken for analysis?

19 A. Yes.

20 Q. If you go to your report, you indicate that Mrs Stewart

21 has some pressure damage; is that right?

22 A. Yes, that's correct.

23 Q. Then the pressure damage was there on admission to the

24 hospital --

25 A. Yes, correct.

51 1 Q. -- to the Vale of Leven? What was the problem?

2 A. From my report, Mrs Stewart had excoriated groin and

3 both of her heels were red, and also her vulva area was

4 quite swollen.

5 Q. I think you have noted also, as we noted earlier this

6 morning, that the specimen must have been taken --

7 I think we actually see that, at 1120, on page 110, that

8 the stool specimen was still to be obtained, but it must

9 have been obtained because, as we noted before, at 1650,

10 the patient is now C. difficile positive. Is that what

11 we see? Is that right? We see that she was

12 C. difficile positive on the 12th?

13 A. Yes, that's right.

14 Q. The ward were aware of that?

15 A. Yes.

16 Q. Did you find a report, a microbiological report, in the

17 records or not?

18 A. There is a microbiology report, which is GGC00530089 --

19 Q. But that's not reporting C. diff --

20 A. -- but that is not in relation to this, no. That was

21 the only one. So in relation to this, no, I didn't find

22 a microbiology report.

23 Q. But in any event, the ward were informed that

24 Mrs Stewart was positive; that's correct, isn't it?

25 A. Yes, it is my understanding.

52 1 Q. If we look at the infection control card, which you will

2 find at SPF00740001, I think you do make reference to

3 this document in your report, but you can take it that

4 this was a card kept by the infection control nurse that

5 was used to record certain details for each patient. If

6 you look here, towards the top right, we are told it is

7 ward 6 and that the date positive is down here as

8 13 December, and then the entry, 13 December 2007:

9 "Informed by lab staff. Nursed in isolation.

10 Commenced on oral Metronidazole."

11 So it would appear that the lab told the infection

12 control nurse that the patient was positive, at least as

13 of 13 December?

14 A. Yes, that's correct.

15 Q. Moving on then through your report, if you go to page 7

16 of the report, the first entry you make reference to is

17 you record the patient still has loose stools; is that

18 right?

19 A. Yes.

20 Q. Then you have an entry you have taken from the records

21 for the 13th. What was the significance of this entry?

22 A. The significance of this entry was that the patient had

23 two large alopecia partings on her scalp, so that would

24 be areas -- an area on her scalp where hair was missing.

25 It was also quite matted, hard to brush and hair was

53 1 falling out. I noted that because clearly the patient

2 had that and it was also something that would need

3 particular attention in terms of her nursing care.

4 Q. You also noted, I think, that on the 13th she was

5 referred to a dietician and a physiotherapist?

6 A. That's correct.

7 Q. On the 14th, what was the position with the patient, as

8 you have noted it?

9 A. Again, the Venflon with access was dislodged and was

10 still awaiting replacement, which would indicate that

11 there was no fluid access taking place.

12 She was also reluctant to eat or drink, so there was

13 no fluid being taken by this patient. It was a number

14 of hours before the Venflon was finally resited and then

15 was dislodged again. So the emphasis there was to

16 encourage oral fluids in order to get some fluids into

17 the patient.

18 Q. Then the entry for the 15th, you have taken some

19 information from the records for that particular date.

20 What have you noted?

21 A. I have noted that there were positional changes

22 performed and that, at 6.30 in the morning, the patient

23 was known to be hypotensive, her blood pressure was low,

24 and that she started to have subcut fluids commenced,

25 and that was indicated by the medical staff. Her BP was

54 1 low. Sometimes the nursing staff were unable to get

2 a reading at all. Subcut fluids were continued. The

3 patient refused to have any feeds or her mouth cleaned.

4 Later, 2315 hours, "Patient not responsive tonight to

5 tolerate oral medication", and then "Venflon inserted.

6 IV fluids commenced".

7 LORD MACLEAN: What are "subcut" fluids? Subcutaneous?

8 A. Yes.

9 MR MACAULAY: Moving on to page 8 of your report, for the

10 16th I think you have noted there that the patient's

11 condition is poor, at the very end of that entry.

12 A. Yes, that's correct.

13 Q. Then moving on to the next entry you have got for the

14 16th, she is obviously in a very poor condition because

15 you note that she is leaking from all her limbs, that

16 the Venflon was resited and the fluids restarted and she

17 was very cold?

18 A. Yes, that's correct.

19 Q. There is some reference there to the DNAR status.

20 A. Yes, that's correct. The doctor was going to speak to

21 the family regarding the DNAR status.

22 Q. Then, for the 17th, I think you have noted again that

23 the catheter output is poor, both arms leaking large

24 amounts of fluid, and the Bair Hugger was in situ and

25 she was then pronounced dead on that particular date.

55 1 A. That's correct.

2 Q. If we look at the death certificate, which you'll find

3 at SPF00340001, I think you can see, when you look at

4 section 10 of the death certificate dealing with the

5 cause of death, that a number of items are listed

6 including Clostridium difficile infection?

7 A. Yes, that's correct.

8 Q. If you could turn to page 11 of your report, you here

9 are looking at the infection control card we looked at

10 a moment ago, and perhaps we can put it back on the

11 screen, SPF00740001. What observations have you made in

12 relation to this particular document?

13 A. My observations of this document was that I personally

14 had some issues around the status of the document. All

15 I see is a blank sheet of paper with freehand on it,

16 which indicates to me that the document doesn't have any

17 particular status. There is no title, there is no -- it

18 is not in a format, it is just a plain piece of paper

19 with what is freehand detail written on it.

20 Q. I think I said to you this morning, this was the -- the

21 system in the Vale of Leven was for the infection

22 control nurse to record on what was a T Card, a T-shaped

23 card, and you can just make that out in the copy,

24 information in relation to the infection control status

25 of the patient. That was the purpose of it.

56 1 In your report, you have noted the entries that have

2 been made, and I think you make some reference to the

3 infection control policy that we looked at this morning.

4 A. Yes.

5 Q. What observations were you making there?

6 A. Basically, the infection control policy indicates that,

7 when there is evidence of infection, such as in this

8 case, a risk assessment should be made. What I am

9 saying is, from what is actually written on this

10 document, this isn't, in my opinion, a risk assessment,

11 it is just a chronology of events.

12 Q. What would you say a risk assessment would say in a case

13 like Mrs Stewart's case?

14 A. A risk assessment to be made by an infection control

15 nurse would be visiting a patient and assessing the

16 patient in the situation and circumstances that the

17 patient is in. So that would be environmental, but it

18 may well also be from a clinical point of view and how

19 the patient's presenting clinical situation could be

20 improved throughout the process of infection control

21 with C. difficile diarrhoea.

22 There isn't any of that indicated, other than there

23 is an entry here that says that the patient was isolated

24 in a single room, but we know that to be some time after

25 the event, where actually, originally, even at the Royal

57 1 Alexandra Hospital there was a view there that it may

2 well have been colonised diarrhoea with C. difficile.

3 Q. We saw this from the previous note, some reference to

4 a Bair Hugger? What is that?

5 A. A Bair Hugger is a piece of equipment that we use for

6 warming patients or for maintaining heat, body heat, of

7 course. This lady was, fairly early on, identified as

8 being hypothermic, she had a low temperature, which is

9 why the entry I make is about putting blankets one on

10 top of another, because a Bair Hugger was not available

11 for this patient, even though her temperature was quite

12 low. From the MAU, the nursing staff asked if they

13 could borrow one, but it was refused. It was actually,

14 though, put on the patient -- they did manage to acquire

15 one the following day.

16 Q. A Bair Hugger then is something that gives you more heat

17 than, say, putting on a number of blankets?

18 A. Yes, it is basically -- I don't know the makeup of it,

19 but it is basically a large blanket, if you like, made

20 of certain fibres that enables the patient to stay warm

21 and/or to try to improve warmth. It is very often used

22 in a patient who is anaesthetised in the operating

23 theatre, for example, to keep them warm when they are

24 very cold and very still.

25 Q. If you move on to page 12 of your report, where you

58 1 express some opinions in relation to Mrs Stewart's care,

2 the first point you raise is in relation to the

3 C. difficile infection. What is the point you are

4 making there?

5 A. The point I am making is really the point I have just

6 made, that there was a very early -- there were very

7 early thoughts that the patient was colonised as

8 C. difficile, and the nursing staff would have been

9 aware of that on admission, because she had been

10 identified as having foul-smelling diarrhoea, but it was

11 actually waited -- they waited until they received the

12 conclusive tests, laboratory test report, before they

13 isolated the patient.

14 Q. Then, after, you raise a number of specific nursing

15 issues that Mrs Stewart had; for example, the third

16 bullet point you note that she was admitted with

17 confusion, history of falls, dehydration, diarrhoea, and

18 so on, and you also note for the diarrhoea that she had

19 compromised skin integrity, and I think we saw that from

20 the medical records.

21 A. That's correct.

22 Q. If you move on then to page 13 of the report, under the

23 heading "Record keeping" you make a general observation

24 in relation to record keeping. What was your

25 conclusion?

59 1 A. My conclusion is that I felt, overall, the record

2 keeping was quite poor.

3 Q. Then you go on to give some reasons for that conclusion;

4 is that right?

5 A. Yes. I identify that under the separate headings.

6 Q. If you look at the next heading, it is headed "Nursing

7 care plans", and what observations do you make there?

8 A. I identify here that, when devising a care plan at ward

9 level for a patient, it is usually a multidisciplinary

10 approach and a thorough assessment is made regarding the

11 patient that encompasses, really, a whole raft of

12 different activities.

13 There was, in this case, in Mrs Stewart's case,

14 a nursing admission assessment form.

15 Q. I think we looked at that this morning.

16 A. We did, yes. That was quite poorly completed. It had

17 a lot of the essential clinical details, such as

18 observations, for example, missing.

19 In addition to that, there was the risk assessments,

20 such as the actives of daily living, which is a very

21 helpful assessment of mobility, so the patient's ability

22 to wash or dress or cook or mobilise. That kind of

23 assessment is usually done in conjunction with the

24 physiotherapist and the occupational therapist,

25 et cetera.

60 1 There were no activities of daily living assessment

2 completed for Mrs Stewart in order to identify her needs

3 and abilities to care for herself or, indeed, the

4 assistance that she'd actually require from the nursing

5 staff. I was quite critical of that.

6 Q. The activities of daily living tool, did you see that

7 tool available in other cases that you looked at?

8 A. Yes. Yes, I did.

9 Q. But it wasn't in these records?

10 A. No, it wasn't.

11 Q. I think we did observe earlier that there was what was

12 described as a multiproblem care plan?

13 A. Yes, that's correct.

14 Q. Perhaps just go back briefly to that on page 108 of

15 the records. Again, we looked at this this morning, and

16 I think we have your observations on it. Were there any

17 other care plans in the records?

18 A. Well, there were some care plans. There were -- some of

19 the items were present in the bundles that I examined

20 but weren't completed. For example, there was a falls

21 risk assessment --

22 Q. I will come to look at that. But in relation to

23 specific care plans, for example, was there a care plan

24 for C. difficile?

25 A. Oh, no, sorry, I beg your pardon, there were no other

61 1 specific care plans that I saw.

2 Q. So the only care plan that you saw was the one we looked

3 at earlier this morning on page 108?

4 A. The multiproblem care plan, yes, that's correct.

5 Q. Looking then at the matter more broadly, in your

6 opinion, ought there to have been other care plans in

7 place for this lady's care?

8 A. Yes, there should have been.

9 Q. Can you give me some examples of what care plans you say

10 ought to have been in place?

11 A. Well, we have already discussed that. The lady was --

12 Mrs Stewart was admitted with dehydration and diarrhoea,

13 so we would expect to see care plans specifically for

14 that. Mrs Stewart was identified as high risk, for

15 example, with falls, which we will talk about, so

16 that -- we would expect to see a care plan following

17 that risk assessment for that.

18 We would expect care plans in relation to the

19 activities of daily living, so had that been assessed

20 and the number of different elements pertaining of

21 the activities of daily living, such as eating,

22 drinking, mobility, sleeping, pain, depending on what

23 results were identified from that, we'd expect to see

24 a care plan that recognised those needs and that would

25 suggest interventions for improving it.

62 1 Q. If we leave the reference to skin integrity for the

2 moment, because I think you deal with that later, the

3 second-last bullet point -- the third-last you say:

4 "Monitor blood chemistry."

5 And you say, in this case of Mrs Stewart, this was

6 done?

7 A. Yes, I do say that, yes.

8 Q. The next point:

9 "Assess the patient's pain with the use of a pain

10 assessment tool/chart."

11 You go on to say:

12 "From the documents I have examined, this assessment

13 was not undertaken and I am critical of this because the

14 patient was in pain and discomfort."

15 Can I just understand that? What are you envisaging

16 there, Mrs Stower, as to what should have been in place?

17 A. None of the documents that was available at ward level,

18 certainly, for example, the observation charts, and

19 there was a number of other charts, there is a section

20 on the bottom of them that is a pain assessment chart.

21 You can also have a document that is purely a pain

22 assessment chart. None of these documents where there

23 was the ability to record an assessment of pain were

24 actually completed for this patient.

25 Q. If we look at page 135 of the medical records, is that

63 1 the type of chart you have in mind?

2 A. That is one of the charts, yes.

3 Q. Towards the bottom, can we see that there are sections

4 that deal with BM level, weight, pain score. Do you see

5 that?

6 A. Yes, that is the column I am referring to. Actually, on

7 that column on the screen in front of me, although it is

8 only filled in five days out of a range, or five

9 occasions out of a range, it records the pain as zero,

10 and, in fact, on one of the occasions it has got what

11 I perceive -- I may be wrong -- "0?", so query the

12 patient was in pain.

13 Q. But what was the position, in fact, so far as you could

14 assess from the records? Was the patient in pain?

15 A. The patient would have been in pain, yes.

16 Q. Because?

17 A. Because -- for probably a number of reasons, but

18 certainly from the point of view of her skin integrity,

19 for example, she had -- we have already heard she had

20 a very swollen vulval area and reddening and sore areas,

21 so that is just one area where she may well have been in

22 pain.

23 Q. Moving on then to the next bullet point on page 13 and

24 moving on to page 14, what is the point you are making

25 there, dealing with the patient and the family?

64 1 A. Sorry, could you repeat the question, please?

2 Q. Yes. Towards the bottom of page 13 of the report, you

3 make an observation in relation to the understanding of

4 the patient and her family. I am asking you, what point

5 are you making in this context?

6 A. Mrs Stewart was known to have a confused state, so it

7 would be difficult to understand whether the nursing

8 staff were able to achieve this particular objective,

9 but, also, she did have a relative -- my understanding

10 is that she lived at home with her sister, but there was

11 very little -- in fact, I didn't see anything really

12 that acknowledged that the family were involved in her

13 care or that they were given any detail regarding her

14 condition.

15 Q. You do say at the top of page 14 that you have taken

16 from the records that family members were kept informed?

17 A. Yes, I have written that down, so I think it was just in

18 case of her general condition.

19 Q. I think what you are saying is that, so far as she

20 herself was concerned, she was in a somewhat confused

21 state, but her family members were kept informed as to

22 her condition?

23 A. That's correct.

24 Q. In relation to the patient's psychosocial situation,

25 this was difficult to determine in Mrs Stewart's case?

65 1 A. Because of her confusion.

2 Q. What do you mean by that, what do you mean by

3 "psychosocial"?

4 A. Basically, by that I mean her psychological -- her level

5 of understanding, her level of capacity to understand

6 what was going on because of her confused state.

7 Q. The next section of your report, you are looking at

8 matters such as temperature, pulse and respiration

9 charts. What observations do you make there?

10 A. I am indicating that there were entries on the TPR

11 charts for all of the days that Mrs Stewart was in

12 hospital during her admission. I comment that there are

13 four entries made, I believe to be on ward 3.

14 I did have an issue around the dates, because we

15 talked about 11/11, 12/11, 12/11. Whether that was

16 somebody was recording them the different way around,

17 I don't know, but I found that rather confusing, when it

18 was actually in the month of December, so whether that

19 was an error or not, I'm not quite sure. I think these

20 were probably date errors. But then, when Mrs Stewart

21 actually goes -- is transferred to ward 6, the dates

22 then run correctly.

23 Q. Yes. You make a point about temperature, I think, as

24 well, which you have touched upon already.

25 A. Yes. The temperature was recorded as 35 degrees. It

66 1 does then gradually increase and then it decreases

2 again. So basically, the patient was very cold.

3 That is when we see an entry that refers to having

4 blankets put on to accommodate her low body temperature,

5 but actually the blankets are put on at a later date

6 where she's actually been very cold prior to that, but

7 it isn't recorded, so I'm not in a position of knowing

8 whether any intervention was taken at that time or not.

9 Q. We have talked about the pain score, we have looked at

10 that earlier. If you look at the next section of your

11 report, on page 15, where you look at fluid balance,

12 I think you begin by saying that there were fluid

13 balance charts recorded for the duration of

14 Mrs Stewart's admission; is that right?

15 A. Yes, that's correct.

16 Q. What conclusions did you come to, having regard to your

17 examination of the fluid balance charts?

18 A. My conclusion regarding the completion of the fluid

19 balance charts was that the standard overall was really

20 extremely poor.

21 The reasons I indicate that; for example, sometimes

22 there was very little input or output information

23 recorded at all, input being fluids taken in either by

24 the oral route or by an intravenous route, and output

25 being obviously urine when she was catheterised, that

67 1 should have been quite an easy issue to record because

2 it would have been there ready for you to do it, and

3 also output, this lady had diarrhoea so I would have

4 expected indications of the amount of fluid loss through

5 diarrhoea as well.

6 I also refer to one particular day on GGC00530126,

7 there was nothing recorded at all for that day, and

8 I was particularly concerned here because, as we have

9 already identified, this lady was meant to be having

10 intravenous fluids, she wasn't able to tolerate, or

11 refused, oral foods and fluids, and there were times

12 when the intravenous access route was not patent because

13 the Venflon was dislodged, or whatever.

14 So because of all of those factors, it really is

15 important, or was important, that the fluid balance for

16 this lady was completed as well as it possibly could be

17 in order for the medical staff to be aware of what was

18 happening to the patients -- to the patient and, on the

19 basis of that, to determine her overall fluid status.

20 Q. Let's look at some of these charts. If you could look

21 at page 129 of the records, the chart for the -- it is

22 dated 12 November, but it probably should be either

23 12 December or 11 December. We can see there are some

24 entries for output and intake, but the chart hasn't been

25 completed; is that right?

68 1 A. Yes, that's right. This is an example, really, of what

2 I have been saying. It is interesting that these charts

3 commence at 1300 hours on a day and then they finish at

4 12 midday the following day, so it is midday to midday

5 almost, which is a little bit unusual and not something

6 that I am terribly familiar with.

7 Q. What is the normal period covered by --

8 A. The normal would be commencing from 12 midnight through

9 to 12 midnight. There are good reasons for that, in

10 terms of the ability to do what I am going to explain in

11 a minute should have happened to the form.

12 So in this particular example, the chart commences

13 at 1300 hours and the first entry is an intravenous

14 entry at 0600 the following morning, although in the --

15 and that is the only intake recorded for this patient.

16 So that really is quite a concern. There is nothing

17 taken orally and just -- I think that is 500, probably

18 600ml, one is 5 per cent dextrose, the other is Flagyl,

19 which is Metronidazole, in that period of time.

20 Moving on to the output side, again there is no

21 entry until midnight, so that is 12 hours since the form

22 was changed, and then there is -- you know, there are

23 clearly some entries, a reasonable number of entries, of

24 output given. There is no mention of diarrhoea on that

25 particular form.

69 1 Then there's no totals. There's no totals at all in

2 terms of the total input and output which one would

3 expect to see, and then a balance in order to determine

4 the hydration status of the patient.

5 Q. So that hasn't been done. Now, if you move on to

6 page 128, the next one, which is for the 12th to the

7 13th, we can see there are perhaps a number of entries

8 on this form, including, at 0300 hours, "liquid stool +

9 + +". Do you see that?

10 A. Yes, I see that.

11 Q. Again, what are your comments in relation to this chart?

12 A. This chart is slightly better completed. It does

13 include more intake volume. It also records that the

14 Venflon is out. That is helpful, because we know,

15 therefore, from there on in that, if there is no Venflon

16 in, that is why the fluids -- the IV fluids have ceased,

17 although it could be written more accurately than that.

18 Then the urine is -- the volumes are recorded and

19 added. It does also indicate the patient was

20 incontinent, but there is no estimated volume. The

21 "loose stools + + +" is there, but again, there is no

22 estimated volume. Again, my previous comment, there are

23 no totals at the bottom, total in and total out, balance

24 recorded.

25 Q. It looks like "two-hourly volumes"; is that what that

70 1 means towards the top right?

2 A. Yes, that is correct. That is requiring -- the order is

3 to have two-hourly volumes of everything, really, in

4 terms of intake and output. The output has been

5 achieved to some degree, but the others haven't,

6 although the incontinence and the loose stools, that

7 should have been recorded as and when it occurred, which

8 may not have been two-hourly, but --

9 Q. Page 127 of the records, if we go to that, this is for

10 the 13th to the 14th. There are, I think, four entries

11 on the document. Any comments in relation to this

12 document?

13 A. It is difficult for me to make the comment. It looks to

14 me as if it is very poorly completed and that there may

15 be entries missing, but because it is not recorded, it

16 is really difficult for me to ascertain whether it is or

17 not. But looking at it, there is not a lot of

18 information on that document and, again, there's no

19 totals in, out or balance.

20 Q. The next one, page 126, this is for the 14th to the

21 15th. So far as intake and output is concerned, this

22 one is totally blank?

23 A. Absolutely.

24 Q. Is that of any assistance at all?

25 A. I beg your pardon?

71 1 Q. Is that of any assistance at all?

2 A. No, it is of no assistance at all.

3 Q. On page 125?

4 A. Yes, that has just got two entries, at 1800 and 0500,

5 which would be a litre of fluid, and there is no output

6 whatsoever. That is very poorly completed.

7 Q. I think we had observed from your report, if you go back

8 to this page 5 of your report, that, on the 16th,

9 Dr Carmichael examined her and noted that she urgently

10 needed IV fluids. Do you remember seeing that in your

11 report?

12 A. Yes.

13 Q. If we look then to page 123 of the medical records, we

14 are now looking at a fluid balance chart for the 16th.

15 Any observations to make in relation to this?

16 A. It would appear the patient was seen by Dr Carmichael

17 and there were some real concerns about the fluid

18 intake, and it is documented at the top what is

19 required. In terms of the intake, it is there. There

20 is quite a lot of fluid and solutions indicated. It

21 looks to me reasonably well-completed. The lady is nil

22 by mouth and there is quite a lot of IV fluids going in

23 and there is a reasonable amount of entries regarding

24 urine, but of course, at the bottom, we do have

25 a balance.

72 1 This isn't surprising to me, given there has been

2 a specific instruction here by the consultant, so, you

3 know, one would really expect it to be done, but the

4 balance is really very -- is in a negative, quite

5 a significant negative.

6 Q. Is that an indication of dehydration?

7 A. Yes, that's right. It is an indication that things, you

8 know, are not really looking very good in terms of

9 hydration; that's correct. But I would defer the detail

10 of that to my medical colleagues.

11 Q. But this form, on the face of it, has quite a number of

12 entries. Totals have been calculated and the balance

13 has been calculated?

14 A. That's correct. So that is an example of how all of

15 them should have been.

16 Q. So we can contrast this document, this form, to the

17 other forms that we have looked at that were not

18 completed in the same way?

19 A. Absolutely not.

20 Q. I may have got this wrong, but does the balance figure

21 indicate overhydration or underhydration?

22 A. The basis of this, it's looking as if it is

23 overhydrating the patient, but of course, it's difficult

24 for me, sitting here, to tell you how she was prior to

25 that. We already know that she was leaking fluid from

73 1 all of her limbs. So this gives me a picture of

2 somebody who is very, very sick.

3 As I said, I think that the actual -- the

4 biochemical part of this is something really for

5 a doctor to comment on, really, rather than myself.

6 Q. Very well. But the instruction had been, of course, by

7 Dr Carmichael, to give her fluids on an urgent basis?

8 A. That's right.

9 Q. That was because she had become dehydrated during her

10 time in the hospital; is that correct?

11 A. She was dehydrated. He noticed that. I don't know

12 whether he specifically has prescribed the intravenous

13 regime or whether it was done by one of his juniors.

14 How it was monitored, whether the patient actually was

15 becoming overloaded with fluid, as I say, it's a picture

16 where clearly this was a very sick patient and it is not

17 really for me to comment on the management of

18 the fluids, but it doesn't look very satisfactory to me.

19 Q. Is overhydration something that is not welcome, then, in

20 a patient?

21 A. Yes, of course.

22 Q. If you go back to your report on page 15, the paragraph

23 that begins just below halfway, what conclusions have

24 you arrived at in relation to fluid monitoring?

25 A. Well, I am very critical of all of the things that

74 1 I have mentioned, and this -- what we have just been

2 discussing that is on the screen at the moment is an

3 example of that. I think -- well, I don't think, it is

4 very clear to me that fluid management in any sick

5 patient is a fundamental element of their clinical care,

6 and it is the responsibility of the nursing staff to

7 ensure that it is undertaken properly and accurately.

8 But in Mrs Stewart's case in particular, she was

9 a very sick lady and she was not tolerating oral fluids,

10 she had -- there was clearly issues with intravenous

11 access and she went for a large number of hours without

12 any intravenous access in order to put fluids into her.

13 She is dehydrated. She has, you know, very loose

14 diarrhoea stools with her C. difficile, and she is

15 leaking fluid from her limbs. It is -- in terms of

16 the fluid balance, it is really very, very poor indeed.

17 LORD MACLEAN: As a matter of interest -- perhaps I should

18 understand this -- how do you leak fluid from your

19 limbs, unless -- well, you tell me.

20 A. Actually, it is not really my area of expertise. I have

21 seen it happen on a couple of occasions in my career,

22 but it is something really I think the medical staff

23 should --

24 LORD MACLEAN: What did you see?

25 A. Exactly that. A lady -- she was a rather obese lady,

75 1 she was in heart failure and all her limbs were just

2 leaking fluid.

3 LORD MACLEAN: Gosh!

4 A. It wasn't very pleasant.

5 LORD MACLEAN: No, I can understand that. Is it unusual?

6 It must be very unusual.

7 A. I have only seen it twice in my career.

8 MR MACAULAY: Is it sometimes associated with liver failure?

9 A. Pardon?

10 Q. Is this leaking fluid from limbs associated with liver

11 failure?

12 A. It can be, yes.

13 Q. Coming back to your report, the second-last paragraph on

14 page 15, you make reference again to Dr Carmichael's

15 intervention and how it came to be that an anaesthetist

16 was involved in obtaining access for the intravenous

17 fluids. Can I just understand how that is managed? You

18 have a patient who, I think, for one reason or another,

19 the Venflon does not remain in situ, so what do you then

20 do to ensure the patient is hydrated?

21 A. Very similar to what occurred here: clearly, if you

22 cannot get access -- if a doctor cannot get intravenous

23 access for a patient, the patient has to have fluids,

24 there are a number of interventions that can happen,

25 other than trying to put a Venflon in or a deeper line,

76 1 for example. If the doctors on duty cannot do that, for

2 whatever reason -- it may be that the patient has

3 particular difficulty with getting access, it may be

4 that they are not very skilled as a doctor, if they are

5 a very junior doctor, for example -- and so

6 anaesthetists are people who are really experts in

7 gaining access to patients' IV or also by various other

8 methods of putting lines in, central lines in, or

9 whatever, so it would be eminently sensible to gain the

10 cooperation of a colleague to come and assist you in

11 that.

12 Q. That is what happened here --

13 A. That is what happened on this occasion --

14 Q. -- in due course?

15 A. -- in due course.

16 Q. You also say that, on the 16th, the doctor asked for the

17 urine output to be measured hourly. I think we did see

18 that in the medical records. You make the point that,

19 looking at the chart, that doesn't appear to have

20 happened; is that right?

21 A. That's correct. That is on 16/12.

22 Q. The doctor has asked for the urine output to be measured

23 every hour, so what have we got here, then, if we are

24 looking at the measurement of the output?

25 A. Is this the 16th or the 15th that is on the screen? The

77 1 16th, is it?

2 Q. Yes, I am looking at page 123.

3 A. Yes, I wasn't sure if that was the 15th or the 16th.

4 Q. I think it is a 16, although it is not clear.

5 A. It hasn't occurred on that occasion. That particular

6 request by the doctor has not been complied with.

7 Q. While we are back on the form, if we look at the total

8 in and the total out, the total in is 2,300, and the

9 total out is 155, according to this. Should that be

10 a plus as opposed to a minus balance? It says minus

11 2145, but should that not be plus? Maybe I'm

12 misunderstanding it.

13 A. It looks as though actually, yes, because that -- yes,

14 it is what is going in, so, yes, it should.

15 Q. So she was overhydrated, so it is a plus?

16 A. Yes, clearly, from the amount of intravenous fluid

17 that's gone in, yes.

18 Q. The next section of your report then, Mrs Stower, if you

19 could turn to that on page 16 of the report, you are

20 dealing with pressure management. You did, I think,

21 look at a Waterlow score document in the medical

22 records; is that right?

23 A. Yes.

24 Q. If you can turn to page 131 of the records, this is the

25 document you looked at, and the comment you make in your

78 1 report that, on the face of it, this document hasn't

2 been completed.

3 A. Not at all.

4 Q. In other cases we have seen similar documents but it

5 would have another page associated with it, and that

6 page doesn't appear to be in the records that you saw.

7 A. No, I couldn't find it.

8 Q. If we look to what we have, we see that the document

9 doesn't even have a patient's name inserted; is that

10 correct?

11 A. No, it is a completely blank form.

12 Q. You, yourself, I think, took the opportunity to make

13 some sort of assessment of what Mrs Stewart's level of

14 risk might have been; is that right?

15 A. Yes, that's correct.

16 Q. Can you tell us then -- I think your conclusion is on

17 page 17. What conclusion did you arrive at?

18 A. I decided to make an estimation myself of Mrs Stewart's

19 pressure management -- pressure and skin integrity

20 score, and I worked with a number of assumptions.

21 I have calculated her weight as average for her height

22 on admission, giving her the benefit of the doubt.

23 I didn't know specifically, because she wasn't weighed.

24 I have calculated her skin to be discoloured, because it

25 was reported on admission to be red. Her age as being

79 1 56, which it was. I have also made this assessment on

2 the fact that she was nil by mouth and/or fluids only,

3 as this was the case certainly at the beginning of

4 the admission, and also that she was bed-bound.

5 Q. Against that background, then, if we turn to page 17,

6 without going through the details of the scoring, what

7 conclusion did you come to as to what her category would

8 be, in your opinion?

9 A. I came to a total of 21 to 22 points, which would have

10 put Mrs Stewart in the very high risk category.

11 Q. What, then, would that demand from the perspective of

12 care?

13 A. A very high risk category would have meant that there

14 would have been a number of nursing interventions put in

15 place. This document would need to be reviewed. There

16 should have been a referral to the tissue viability

17 nurse specialist for advice. She would have been, as

18 per their protocol, provided with some specialised

19 pressure-relieving equipment, mattress, bed, and a care

20 plan and really proactive intervention.

21 She was -- we know, from what we have spoken about

22 previously, she did have number of red areas. Her skin

23 was excoriated. So all of those interventions and

24 a very proactive approach to the management of her skin

25 integrity should have taken place.

80 1 Q. Did you see any evidence of that in the medical records?

2 A. I did note on one occasion that there was some

3 positional tilts had taken place and the positional

4 tilts were being given, but they weren't specified. It

5 was just positional tilts, which really, as someone

6 looking at the records, tells me very little about what

7 actually took place, and there was nothing in the

8 records to indicate the detail regarding that.

9 Q. Was there a turning chart in the records?

10 A. No, there was no chart. There was no information.

11 Q. Was there a care plan?

12 A. Pardon?

13 Q. Was there a care plan?

14 A. No.

15 Q. I think you say in your report that there should have

16 been a care plan to manage this particular aspect of

17 care.

18 A. Certainly, as soon as the Waterlow score had been

19 completed and the risk category known, then there should

20 be automatically a care plan identified to put

21 a prevention strategy in place.

22 Q. Should there have been a turning chart?

23 A. Yes.

24 Q. In the penultimate paragraph on page 17 -- I think you

25 made mention of this already when you were looking at

81 1 the records -- you say there were some partings on

2 Mrs Stewart's scalp. What did you infer from that?

3 A. It was difficult really for me to ascertain this

4 particular element from the admission. We know from the

5 documents that there was some redness of some of her

6 pressure areas when she was admitted, but specifically

7 this, I'm not sure.

8 However, it did say that the alopecia partings on

9 her scalp -- it is difficult to sort of quantify what

10 that was, but it then does go on to say that her hair is

11 matted, and matted hair, certainly at the back, which is

12 where it usually matts, is due to pressure on the bony

13 prominence of the skull, on the pillows, and it

14 basically means that that patient has been in a position

15 for quite a long time, there is a lot of friction and

16 rubbing, which is what causes the matting, and the

17 nurses indicate that they had to be very careful in

18 trying to comb it out.

19 My concern regarding that is how it occurred in the

20 first place and that a good prevention strategy for

21 pressure area care, that particular issue should have

22 been addressed, and the matting, as we see described,

23 should have been prevented.

24 Q. If you accept that what you have seen from the records

25 is the position, in fact: namely, that there was no

82 1 Waterlow assessment carried out, no care plan, no

2 turning chart, what conclusions would you arrive at in

3 relation to this aspect of her care?

4 A. I think it's very suggestive to me personally that her

5 personal care was not of the standard that I would have

6 expected.

7 Q. The next section of your report on page 18, you look at

8 nutrition. You make some general remarks first of all,

9 and I think this is -- we can take this from you in this

10 report, and I think it is something you generally repeat

11 in a number of reports, but what observations are you

12 making in the first paragraph of this section?

13 A. The observation that I'm making here is that diarrhoea,

14 particularly in a patient with very profuse, loose,

15 foul-smelling stools, can have a profound psychological

16 and physiological effect on the patient. It is

17 something possibly that is very underestimated, but that

18 is absolutely the case.

19 For example, associated with loose, foul-smelling

20 diarrhoea there's -- it can cause a patient quite a lot

21 of embarrassment, but equally, it can deteriorate or

22 accel the deterioration of the skin, particularly if

23 personal hygiene is not robust and proactive. Severe or

24 extended periods of diarrhoea can result, as we know

25 from Mrs Stewart's case, in dehydration, electrolyte

83 1 imbalance -- that's an imbalance of the chemicals in the

2 body -- loss of weight and malnutrition, and in terms of

3 nutrition, this is a key element of helping to assist in

4 the process of that and encouraging the patient to take

5 oral fluids, but equally, oral fluids or food may not be

6 sufficient. A patient may not feel, with the nausea,

7 the vomiting and the diarrhoea, that they are able to

8 eat or drink, so there is very often a need to

9 supplement their diet with the use of either oral

10 rehydration solutions or other IV solutions, which we

11 have already talked about.

12 In order to do that, patients really should be

13 provided with the specialist advice from somebody in

14 nutrition management, which is a dietician.

15 Q. I think we saw in the nursing records, when we perused

16 them, that there was a record to say that Mrs Stewart

17 was to be referred to the dietician?

18 A. That's correct. In fact, on the multiproblem care plan

19 that we saw at the very beginning, just the day after

20 admission the dietician was -- it was put in the care

21 plan that she should be referred to the dietician, and

22 I think there is a tick after it, which would indicate

23 that it had been done.

24 We do also see in the nursing documentation that

25 a referral has been made, but I couldn't see any

84 1 evidence that there was any actual active intervention

2 from a dietician in this case.

3 Q. I think in some of the cases we see that there is a tool

4 available in the Vale of Leven for carrying out

5 a nutritional assessment. Did you see that tool in some

6 of the cases you looked at?

7 A. Yes, I did.

8 Q. Was there such a tool in the records here?

9 A. No, there wasn't.

10 Q. In any event, although there is reference to the

11 dietician, I think what you are saying is you saw no

12 record in the records to indicate the dietician had been

13 involved?

14 A. In some of the notes that I examined, whenever

15 a dietician did attend a patient and gave advice, there

16 was always an entry from the dietician, usually in the

17 medical record rather than the nursing record, but it

18 was clear, mostly it was clear. I saw no evidence of

19 this in these documents.

20 Q. In the next section you deal with the stool charts. You

21 tell us that there were two stool charts in the records.

22 Perhaps we can look at these briefly. Page 119, first

23 of all. We can see that we have a chart, and there are

24 two entries, both for the same date, reference to

25 stools, and then, if you turn to page 118, there is

85 1 another stool chart with one entry for 17 December.

2 Was that all that there was in relation to stool

3 charting?

4 A. Yes, that's correct.

5 Q. I think we had noted that there was a reference on one

6 of the fluid balance charts to loose stools.

7 A. That's right. "Loose stools + + +", yes.

8 Q. What conclusions then -- if that is all there is, and

9 that is a true reflection of what was done, what

10 conclusion do you arrive at on page 18 of your report?

11 A. On the first stool chart that you showed me on the

12 screen that has disappeared now --

13 Q. Page 119, yes.

14 A. -- there are two entries and then there is a great big

15 scribble through it, but I'm not quite sure what that

16 means. There is also no date of birth recorded on the

17 document as well, but there are only two entries. That

18 was at 2.45 in the morning and at 6 am, so throughout

19 the rest of that day there is nothing recorded.

20 Then on the second chart there is just, again,

21 a very, very minimal amount, even though we know that

22 Mrs Stewart had "loose stools + + +", that means quite

23 a lot and quite frequent, and that is not indicated on

24 these two documents.

25 There is also three or four days between the two of

86 1 them, so presumably there was nothing recorded on these

2 documents during that period either.

3 Q. So what conclusion, then, do you arrive at? If that is

4 all there is, or all there was?

5 A. Well, clearly it is very poor record keeping, and it is

6 also not compliant with the trust's own policy on the

7 management of a patient with loose stools.

8 Q. Did you see any evidence in these records or, indeed, in

9 any of the records that you looked at, that nurses were

10 using the Bristol stool chart tool in assessing stools?

11 A. No, not at all.

12 Q. We have heard some evidence about the Bristol stool

13 chart. Is that a beneficial tool to use when you are

14 seeking to assess stools?

15 A. Yes, it is a very useful tool. It is a tool that is

16 considered to be one of the best of its kind. It is

17 a visual as well as actually quite descriptive and it

18 quantifies the stool.

19 So by doing that, it enables nursing staff -- where

20 in a hospital ward you will have a number of staff

21 coming on duty on a shift system, it therefore enables

22 more accurate recording of the consistency and type of

23 stool, and that can indicate any improvement or

24 deterioration in the level of diarrhoea that the patient

25 may have.

87 1 MR MACAULAY: My Lord, that might be an appropriate time to

2 adjourn for lunch.

3 LORD MACLEAN: 2 o'clock.

4 (1.00 pm)

5 (The short adjournment)

6 (2.00 pm)

7 MR MACAULAY: Mrs Stower, I think you still have your report

8 in front of you; is that correct?

9 A. Yes, I do.

10 Q. If we could now turn to page 19 of the report, there at

11 section 10 you are dealing with falls risk. You say:

12 "A risk of falls plan should be instigated as

13 necessary."

14 In this particular case, was Mrs Stewart's risk of

15 falls assessed in the Vale of Leven?

16 A. Yes, it was.

17 Q. If we could look at the relevant document, if you could

18 turn to page 132 of the records, did you have regard to

19 this patient fall risk assessment chart?

20 A. I beg your pardon, sorry?

21 Q. Did you look at this chart?

22 A. I did, yes.

23 Q. Can we see that entries have been inserted to bring out

24 a risk category of 3? Do you see that? The score is

25 16, which puts her into the 3 category, and that is

88 1 a very high risk category; is that right?

2 A. That's correct.

3 Q. Turning on to page 133, do we see that the second part

4 of this form sets out 11 points that can be addressed in

5 the course of the assessment?

6 A. Yes.

7 Q. What conclusion did you come to in relation to the way

8 in which falls risk was managed then in the

9 Vale of Leven?

10 A. In the case of Mrs Stewart, is that what you are

11 referring to?

12 Q. In this case, yes.

13 A. Obviously the assessment form was completed on the day

14 of admission, putting her in the high risk bracket.

15 I wasn't in a position to comment on whether or not --

16 the document does not assess her mental state. It does

17 say that she is confused and unable to understand verbal

18 commands. The safety of the bed height was

19 a consideration, and cot sides was addressed.

20 Really, apart from movements being monitored within

21 the ward, it is my understanding that Mrs Stewart was in

22 bed for the period of time that she was in hospital, so

23 that wasn't particularly an issue. In terms of

24 the items on this 11-point plan, there is no other

25 additional entries detailed.

89 1 Q. Were you satisfied with the assessment that was carried

2 out in this particular case?

3 A. In the case of this lady and the circumstances, yes.

4 Q. What you say in your report doesn't appear to have been

5 reviewed, but of course, we know that Mrs Stewart died

6 some five days later.

7 Do you consider that there should have been a review

8 between 12 and 17 December?

9 A. Because the patient was in bed, cot sides had been

10 applied, she hadn't made any real attempt to get out of

11 bed. There wasn't a review done, so I wasn't unduly

12 concerned about that on this occasion.

13 Q. If you look then at the next section of the report,

14 which is headed "Manual handling risk assessment",

15 I think you say that you saw no evidence that such an

16 assessment had been carried out?

17 A. That's correct.

18 Q. Should there have been manual handling risk assessment

19 in this case?

20 A. It would largely depend on whether the hospital required

21 a manual handling assessment to be taken on every

22 patient as a condition on admission, and most hospitals

23 do, particularly if they are concerned about a patient

24 who is on bed rest or who is contained to their bed; for

25 example, if they were to fall, then clearly an

90 1 assessment of the risk of her -- risk of her falling

2 should have been assessed.

3 Q. Having regard to this particular patient, she was

4 clearly not mobile --

5 A. It would have been ideal if one had been completed for

6 the purposes of consistency, but it is not an issue,

7 really, in this particular case.

8 Q. If she was to be moved from the bed to another location

9 to be bathed --

10 A. Clearly that would have been an issue, but by -- the way

11 that I am approaching this is that that wasn't the case

12 for this lady, given her general condition.

13 Q. I see. So you are working on the basis that she really

14 wasn't going to be moved and, therefore, this sort of

15 assessment wouldn't be necessary?

16 A. Yes, I am.

17 Q. You make mention of the DNAR form, which you say has

18 been signed but you cannot read the date. Has the

19 preparation of the DNAR form been recorded in the

20 nursing records?

21 A. I cannot recall that.

22 Q. Should there be some record made in the nursing

23 records --

24 A. Yes, there should.

25 Q. -- that a DNAR form has been agreed?

91 1 A. Absolutely, yes.

2 Q. We see the document on page 52 of the records. You will

3 see that a decision has been taken that -- for some

4 reason "Mr" has been circled. We know we are dealing

5 with Mrs Stewart. It looks as if it has been signed by

6 Dr Forbat and dated 12 December. I think that was the

7 date of admission?

8 A. It was. That's correct.

9 Q. Can we then look at what you say about the nursing

10 management of C. difficile, which is section 13 of your

11 report. What observations do you make here?

12 A. The nursing management of C. difficile was very limited

13 in the case of Mrs Stewart. I am commenting, as I have

14 mentioned previously, that the doctor that examined her

15 at the Royal Alexandra Hospital was of the opinion that

16 there was foul-smelling diarrhoea and it was a likely

17 C. difficile contaminant and that it was reasonably

18 likely that she had C. difficile.

19 In my opinion, that should have determined her

20 immediate management until proven otherwise by the

21 laboratory report, but actually, it is -- I believe it

22 is documented that it is only after there is a positive

23 laboratory report that she is actually isolated, and

24 I am referring here to the fact that I think that is

25 quite poor infection control management.

92 1 Q. I think we observed that there was no care plan prepared

2 for C. difficile?

3 A. No, not at all.

4 Q. I think you saw from the policy that that is something

5 that seems to be envisaged in the policy.

6 A. That's right.

7 Q. And, likewise, a risk assessment.

8 A. Yes.

9 Q. Then, if you turn on to page 20 of the report, can you

10 summarise your conclusion in relation to what you took

11 from the hospital records in respect of this lady's

12 care?

13 A. Mrs Stewart was admitted to the hospital with

14 a confusion, history of falls, alcoholic liver disease,

15 diarrhoea and dehydration.

16 One of the main issues of concern that I had was

17 that the direct involvement of the infection control

18 team and the control management was very minimal indeed.

19 I was also quite critical that there was no specific

20 risk assessment or plan of care for the patient's -- the

21 management of the patient's infection. I couldn't

22 determine whether the infection control nurse actually

23 visited the patient to monitor the patient or to support

24 the staff with the relevant infection control policies

25 and procedures or, indeed, what actual infection control

93 1 advice was given to them.

2 C. difficile infection is a very debilitating

3 illness for patients, the elderly and sick elderly in

4 particular, and I didn't get a sense from the documents

5 that this appeared to be a significant consideration by

6 the nursing staff for this patient.

7 Furthermore, this lady was in hospital for six days

8 and had numerous problems and, in my opinion, really was

9 quite -- really quite sick. There was no end of life

10 care pathway commenced for her, even though it was

11 evident that she was going to die and, indeed, the DNAR

12 form was completed on the day of her admission.

13 In summary, really, I believe that the care this

14 patient received was really quite woefully lacking up

15 until her death, and I feel that, in conclusion, there

16 was a number of issues where the care fell below the

17 level that could be reasonably expected of her last week

18 of her life, and that pertains to very poor nursing

19 assessment and care planning in the beginning, and

20 evaluation and monitoring of that care, poor record

21 keeping and illegible handwriting, particularly of

22 the nursing staff.

23 As we have said, poor management of the C. difficile

24 contamination and care, fluid management and recording

25 was poor, skin care and management of her tissue

94 1 integrity was poor, the poor management and control of

2 this lady's body temperature, poor nutrition management

3 and poor end of life care are the reasons why I believe

4 that to be so.

5 Q. In passing, I think you said that an illness such as

6 C. difficile can be particularly debilitating for the

7 elderly. If only just to protect myself, we must remind

8 ourselves that this lady was only 56.

9 A. Of course.

10 Q. But standing her physical condition, nevertheless was

11 the disease debilitating for her?

12 A. Yes.

13 Q. Can I then move on to your next report that I want to

14 look at, and that is the case of [Patient B].

15 If you could have in front of you your report,

16 please, which is to be found at EXP00430001. If you

17 could also have the medical records that are relevant

18 here, GGC26380001. If we look to your report and pick

19 the report up on page 3, can you just summarise for us

20 [Patient B]'s medical history?

21 A. This case concerns a lady, [Patient B], who was

22 a 77-year-old lady who was admitted to the medical

23 assessment unit at the Vale of Leven Hospital on

24 7 December 2007 under the care of Dr M Al-Shamma. She

25 was admitted from an emergency respite care centre where

95 1 she had been admitted a few days before following an

2 increased frequency of falls at home. She'd had no

3 significant past medical history other than a stroke,

4 which had left her with a left-sided hemiparesis.

5 Prior to this, she had been living alone at home,

6 but had some help assistance seven days a week. She was

7 primarily admitted then to ward 6 for treatment of

8 dehydration with a plan to commence intravenous fluids

9 and oral antibiotics, to monitor the fluid balance and

10 a chest X-ray.

11 On admission to the ward, she was receiving all

12 personal care, but given with maximum assistance. She

13 was able to sit out by the side of her bed and it was

14 thought that she would require intensive physiotherapy

15 and occupational therapy.

16 Q. Do you tell us in your report that [Patient B] was

17 reported to be C. difficile positive on 17 December?

18 A. That's correct.

19 Q. That, in fact, was the day that Mrs Stewart died in the

20 same ward, I think; is that right?

21 A. Correct.

22 Q. If you look at the section dealing with admission to

23 ward 6, which is on page 4, you say that the nursing

24 staff completed a nursing admission assessment form.

25 Perhaps we can look at that, page 76 of the records. If

96 1 we just look at the body of this document, we will see

2 it is ward 6, admission date 7/12, and there are

3 a number of entries inserted.

4 If we look to the bottom left under the heading

5 "Observations", in contrast to Mrs Stewart's case, we

6 can see that there are details entered here; isn't that

7 right? Under the heading "Observations"?

8 A. Yes, there are some details. The observation of vital

9 signs has been completed and the provisional diagnosis

10 is also completed. There are still some elements of

11 this section that have not been completed, such as there

12 is no weight recorded on admission, MEWS or BM, and

13 there is no Waterlow score or urinalysis, one or two

14 others, but those are the main features of that

15 document.

16 Q. Although I think we do see, and we will come to this,

17 that there was a Waterlow assessment in this case?

18 A. Yes.

19 Q. You also make mention in that paragraph on page 4 that

20 you could find no evidence that an activities of daily

21 living assessment was completed for [Patient B], but

22 I think we see that the tool is in the bundle, if you

23 look at page 77 of the records.

24 This document was in the records, but it has no

25 name, no date and nothing has been entered into it?

97 1 A. Yes.

2 Q. It is totally blank?

3 A. A completely blank document.

4 Q. If we then look briefly at the medical input, medical

5 notes, and this begins on page 5 of your report, we see

6 that Dr Al-Shamma, it would appear, on the ward round,

7 has made reference to her being admitted for dehydration

8 due to poor oral intake at home plus poor urine output.

9 Do you see that?

10 A. Yes, that's correct.

11 Q. She was started on antibiotics; is that correct?

12 A. Yes.

13 Q. Perhaps we should look at the page number in the

14 records. Turn to page 15. I think, in fact, your first

15 entry should probably be 7 rather than 18 December,

16 because then we move on to the 10th.

17 A. Okay.

18 Q. If you turn to page 14 of the records, we see part of

19 the medical admission notes. Go back a page to page 13.

20 Can we see that the date for this entry is 7 December?

21 A. Yes.

22 Q. Then the next entry you have noted is for 10 December,

23 and it begins by recording, "Looks well today" but then

24 there is some reference to "inflamed and painful vulval

25 area"; is that correct?

98 1 A. Yes, that is correct.

2 Q. What is this we are seeing?

3 A. The doctor was called as soon as possible regarding an

4 inflamed and painful vulval area. The patient stated

5 that it had been painful since an attempt at a catheter

6 insertion had been made and an examination was taken,

7 I think in the presence of Sister Fox.

8 It was identified that the area was very

9 erythematous and painful to the touch and the soreness

10 was extending around the vulva, tops of the thighs and

11 groin and there was some bleeding and pus, but the

12 doctor was unable to examine the patient thoroughly

13 because it was so painful.

14 Q. If we look at the records on page 15, we do see, four or

15 five lines from the bottom of that page, "Examined with

16 Sister Fox", so Sister Fox was involved in the

17 examination and there is a description given.

18 Now, when it talks about bleeding, when you have

19 a little circle "bleeding", does that mean there is

20 bleeding or there is no bleeding? Does that mean no

21 bleeding?

22 A. I took it as meaning bleeding.

23 Q. On the 16th, if you go back to your report on page 5,

24 there is now some reference in the medical records to

25 bad diarrhoea; is that right?

99 1 A. Yes, that's correct.

2 Q. Moving on to page 6 of your report, there are still some

3 entries there on the 17th saying that she has diarrhoea;

4 is that correct?

5 A. That's correct.

6 Q. Now it has been noted that she is C. difficile positive?

7 A. Correct.

8 Q. Then, on the 24th, is that a note by the dietician?

9 A. Yes, it is.

10 Q. So the dietician has been called in, in order to provide

11 some nutritional support?

12 A. That's correct.

13 Q. If you look, then, to your entry for the 31st -- and can

14 we just look at the records for that on page 19? I just

15 want to understand the reference you have in your notes

16 to "fall".

17 If we look at the entry for the 31st, which is about

18 three-quarters of the way down the page, does that read

19 "Came with fall"?

20 A. I actually found this quite difficult to read. Because

21 the patient had had a history of falls prior to being

22 admitted, which is why she had gone into respite care,

23 I wasn't quite sure if she'd had a fall or if it was

24 a fall that she had had previously but was then

25 complaining of the pain.

100 1 Q. I think we saw from the history that she'd had a history

2 of falls?

3 A. Yes.

4 Q. So we mustn't take from this that she had a fall in

5 hospital, because the reference "came with fall" tends

6 to suggest it was something that happened before she was

7 admitted to hospital?

8 A. Yes, that's right. That's what I thought, that it was

9 probable that what she was complaining of was probably

10 as a result of the fall previous.

11 Q. Can we then turn to look at the nursing records and the

12 entries you have taken from them, and for the 10th we

13 see a similar reference to the sacral and vulval area

14 being sore and swollen and Cavilon is to be applied.

15 Are you able to assist us in relation to what has

16 caused this soreness and swelling, what the mechanism

17 is?

18 A. Well, not really, other than what has been previously

19 documented, that it may have been in relation to the

20 catheter attempt, the insertion of the catheter. There

21 is nothing else to indicate why that was the case.

22 Q. If we move on to page 7 of the report, you tell us that,

23 on the 14th, there is a record made that she has passed

24 large, soft formed bowel movement and then large amount

25 of diarrhoea; is that correct?

101 1 A. That's correct.

2 Q. It is at this point that the stool sample is sent for

3 analysis?

4 A. Correct.

5 Q. We see, again on the 14th, that she continued to have

6 several episodes of loose stools; is that correct?

7 A. Correct.

8 Q. It is on the 17th that, according to the records,

9 C. diff has been confirmed to the ward; is that right?

10 A. Yes, that's correct.

11 Q. What about -- if we look at the infection control card,

12 please, SPF01430001. Again, if we just orientate

13 ourselves, we see the reference is ward 6 at the top

14 right-hand side, and the date positive is said to be

15 17 December. Do you see that?

16 A. Yes, I do.

17 Q. Just to read the text:

18 "Informed by lab staff. Asked ward to isolate in

19 2-bedded and commence oral Metronidazole. Visited ward.

20 Spoke with SHO and asked him to discontinue oral

21 antibiotics."

22 Here we do have a situation where the infection

23 control nurse has recorded that she has visited the

24 ward?

25 A. Correct.

102 1 Q. If we look at page 45 of the records, we are looking now

2 at the report from the microbiological department, and

3 can we see that the sample has been collected on the

4 15th -- received on the 15th and reported on the 17th?

5 If we go back then to page 7 of your report, you had

6 observed that the stool sample was taken from the

7 patient on 14 December?

8 A. Sorry, what page was that on?

9 Q. Page 7 of your report.

10 A. It says "Stool charts commenced".

11 Q. Sorry, the second-top entry for 14 December, you have:

12 "Passed large, soft formed bowel movement, then

13 passed large amount of diarrhoea. Stool specimen sent."

14 A. Yes, that's correct, sorry.

15 Q. It would seem, at least on the face of it, that the

16 confirmation of being positive has only happened some

17 three days later, on 17 December, and then the patient

18 is put in another room?

19 A. Yes.

20 Q. Do you have any comments to make on that form of

21 management?

22 A. Clearly, the patient had diarrhoea prior to this. That

23 is why the specimen was collected and sent to the

24 laboratory. And there has been a delay in isolating the

25 patient. As per their own policy, really, as soon as

103 1 there is diarrhoea, where there may be an infectious

2 element to it, that isolation should take place as soon

3 as that and not wait for laboratory confirmation.

4 Q. I think we saw that this morning when we looked at the

5 loose stools policy.

6 A. Yes.

7 Q. If you go back then to your report, page 7 of your

8 report, I think you have noted that this patient

9 continued to have diarrhoea. You say for the 17th, the

10 last entry, there were 300ml of green, semi-formed

11 stool, and then, on the 19th, you have noted "diarrhoea"

12 and the "sacral area is excoriated but improving".

13 Now, looking to the reference to the sacral area, is

14 this pressure damage we are looking at or something

15 different?

16 A. It could be pressure damage, but clearly, with a patient

17 that has got diarrhoea, diarrhoea is an indicator that,

18 actually, because of the consistency of it, it actually

19 does exacerbate the general skin integrity. So it could

20 be a combination of both.

21 Q. If you turn to page 8 of your report, it would appear

22 that, on the 22nd, the patient is "mobilising with stick

23 around the ward" but that she still has loose stools?

24 A. That's correct.

25 Q. Should a patient who has been found positive for

104 1 C. difficile and still having loose stools be mobilising

2 around the ward?

3 A. No, she should not be.

4 Q. If we --

5 A. Can I just go back on that point?

6 Q. Yes.

7 A. As far as I can recall, from the infection control card

8 there was a request for her to be placed into the

9 two-bedded ward, so if that entry is referring to her

10 mobilising around her own ward, then that would be

11 acceptable.

12 Q. Do we see, if we read on in your notes, that [Patient B]

13 improved and was discharged on 3 January?

14 A. That's correct.

15 Q. Can we then turn to page 11 of your report? Once again,

16 here you make -- pass some observations on the infection

17 control card, and we had some discussion about that this

18 morning where I think I indicated to you that this was

19 a document kept by the infection control team.

20 Looking to the entries, again, if we can have the

21 card back on the screen, that's SPF01430001, we did

22 observe, I think, that this was a case where the

23 infection control nurse visited the ward and spoke to

24 the senior house officer in connection with

25 [Patient B]'s management?

105 1 A. Mmm-hmm.

2 Q. Again, we saw from the policy that one of

3 the instructions in the policy was for there to be

4 a risk assessment carried out.

5 Do you consider that what you read in relation to

6 the way in which this patient was managed does comply

7 with that element of the policy?

8 A. I would make two comments, really, in regards to this.

9 First of all, I read this entry as:

10 "Visited the ward and spoke with the SHO regarding

11 discontinuing the antibiotics."

12 I read it that that was the purpose of the visit, so

13 whether or not there was any other communication with

14 the nursing staff or -- I'm not sure about that, but my

15 comments remain the same for this patient as the

16 previous patient in terms of a risk assessment. This

17 doesn't, to me, look like a risk assessment for

18 a specific patient based on their circumstances in

19 relation to the ward and a documented care plan to go

20 alongside that.

21 Q. Was there any evidence of a care plan being put into

22 place for C. difficile for [Patient B]?

23 A. No.

24 Q. If you look then at the section dealing with your

25 opinion, in the last paragraph on page 11 you do say

106 1 that [Patient B] was referred to the occupational

2 therapist and the physiotherapist to improve her

3 mobility and capability of independence, and you go on

4 about the loose stools and the very sore sacrum.

5 Turning on to page 12, you identify some specific

6 nursing issues that [Patient B] had following upon the

7 diagnosis of C. difficile.

8 Now, the development of a red, sore sacrum, again,

9 are you relating that to pressure damage or some other

10 mechanism?

11 A. I would consider that both would probably apply in this

12 case. There would have been some degree of pressure,

13 but that was probably exacerbated through the diarrhoea.

14 Q. The other points that you make there, as you say, she

15 was incontinent and had diarrhoea, she suffered from

16 confusion. Is that what you took from the history?

17 A. Yes.

18 Q. And some reluctance to eat and drink; is that right?

19 A. That's correct.

20 Q. Turning then to record keeping, what conclusions did you

21 arrive at in relation to record keeping generally?

22 A. The record keeping in general terms I found to be -- the

23 content, or lack of it, and the completion of

24 the nursing records to be very poor and below

25 the standard that I would have expected for this

107 1 patient.

2 Q. Are you applying the NMC standards?

3 A. Yes, I am.

4 Q. I note in your next sentence you say:

5 "[Patient B] was an inpatient of ward 6 and ward F."

6 Was she transferred at some point to ward F, so far

7 as you are aware?

8 A. I saw some entries for ward F, but I did have difficulty

9 discerning where the patient was at any one point in

10 time.

11 Q. If you turn to page 87 of the records, we see here

12 entries going up to the 29th still on the ward 6

13 evaluation sheet.

14 A. Yes.

15 Q. So it would appear that certainly up until that date

16 she's in ward 6, but there is an entry at the very

17 bottom for the 29th at 12 midday, I think:

18 "Transferred from ward 6. Settled into ward.

19 Mobilising with stick. Plus supervision."

20 So there may have been another transfer very shortly

21 before she was discharged?

22 A. Yes. I had difficulty -- I saw that, but I had

23 difficulty knowing -- it wasn't clearly documented

24 whether it was a transfer or where it was to.

25 Q. If you turn then to page 13 of the report, can you just

108 1 explain what point you are making in the first bullet

2 point that we see on that page?

3 A. This entry is under the section relating to nursing care

4 planning, and I think I alluded to this in the previous

5 report. One would expect a thorough assessment of

6 the patient's presenting conditions, and this is usually

7 determined through a range of nursing tools, most of

8 which we have talked about before, such as activities of

9 daily living, care plans, risk assessments for falls,

10 Waterlow, et cetera, et cetera.

11 Q. I think we will look at some of these documents shortly,

12 but you do say here that you did see -- we have looked

13 at this already -- the nursing admission assessment

14 form.

15 A. That's correct.

16 Q. We looked and saw a blank activities of daily living

17 assessment?

18 A. That's correct.

19 Q. The nursing summary document, which we perhaps should go

20 back to because you make some specific comments on that

21 in the next paragraph, could you turn to page 72? This

22 may be a different document, actually, to the one we

23 looked at before. Is this what you are talking about in

24 that second paragraph?

25 A. Yes, it is.

109 1 Q. We can see that it is headed "Patient nursing summary"

2 and then there is a box headed "Activities of daily

3 living" and some areas are circled.

4 Then, if you turn to page 71, which I think is

5 probably the second page of the document -- you may not

6 have focused on this -- you are going back, in a way, as

7 it were, to page 71. Can you see that there are some

8 further entries made and the document is signed,

9 although it is difficult to make out the signature, and

10 dated?

11 A. Yes, that's correct.

12 Q. Looking to what you say, you say this document is very

13 poorly completed and does not state the date and source

14 of the admission. Do you expect there to be a date at

15 the top on page 72? Is that the point?

16 A. With this document, depending on where it was in the

17 bundle -- it's difficult to see that the two sheets were

18 associated together. I take the point that it is dated

19 on the bottom of the second sheet, but the point I'm

20 trying to make in this first paragraph is that the date

21 of admission and source of admission is not completed,

22 so I had difficulty knowing when it was completed, and

23 because it is transferred from 6, which I presume to

24 mean ward 6, this would have been used -- in quite a few

25 of the cases that I looked at, the patient nursing

110 1 summary document, this one, was often used as a transfer

2 document.

3 Q. That is what it suggests, that this is completed because

4 the patient has been transferred from one ward to

5 another.

6 A. Yes, that is what I believe to be the case.

7 Q. Although there isn't a date of admission on page 72 --

8 I think one can assume, I think, that page 71 is

9 actually the second page of the document, albeit it is

10 going backwards in the records. But we do see that

11 there is a date for the transfer of 29 December?

12 A. Yes, that is acceptable, yes.

13 Q. The other boxes have been -- apart from pain score, the

14 other boxes have been either ticked or circled?

15 A. That's correct.

16 Q. So generally speaking, although I think you described it

17 as being very poorly completed, I don't know if you

18 focused on page 71 or not, but --

19 A. That is possibly the case.

20 Q. On the face of it, the document seems to be, in the

21 main, completed by whomever completed it?

22 A. Yes.

23 Q. Because we also have some discussion on page 71 giving

24 some information as to what the original problems had

25 been; is that correct?

111 1 A. Yes, that's correct.

2 Q. I think we have already observed, if you look at the

3 next bullet point, that the other activities of daily

4 living form was blank, but you also observed that there

5 was evidence that the physiotherapy and occupational

6 therapy departments were involved in this patient's

7 care?

8 A. Yes, that's correct.

9 Q. You go on to say:

10 "I am very critical of the level of assessment and

11 documentation in a patient where the doctor writes 'is

12 going to require a great deal of physiotherapy and OT'."

13 There you are making reference to one of

14 the observations you already looked at in the medical

15 notes. Can you just elaborate on that? What is your

16 concern? Do you need to go to the medical --

17 A. I think actually -- I'm just reading that, if it is

18 okay. Oh, right. My criticism is in relation to the

19 physiotherapy and the occupational therapy documents.

20 The doctor writes:

21 "Is going to require a great deal of physiotherapy

22 and OT."

23 I can't recall whilst I'm sitting here, but that was

24 in relation to following that entry when the

25 physiotherapy and the occupational therapist visited,

112 1 the amount of intervention that was documented, and

2 I believe they said they would review, and it --

3 Q. If we look at the physiotherapy documentation first of

4 all on page 22 of the records, this is headed

5 "Physiotherapy update" and it would appear to have been

6 carried out when [Patient B] was in ward 6. The date we

7 see on the form is 17 December.

8 You looked at this document, I take it, when you

9 were making the comments you make on page 13 of your

10 report?

11 A. Yes, I did.

12 Q. What conclusions are you coming to?

13 A. The title of the document is "Physiotherapy update", so

14 whether there exists a physiotherapy assessment document

15 or not, I don't know.

16 Q. Did you find such a document in the records?

17 A. No, I didn't, but it is something that I would have

18 expected to have seen if a patient was referred to

19 a physiotherapist, referred to an occupational

20 therapist, for intensive physiotherapy and OT in order

21 to get this lady's mobility to the point at which she

22 can go back to her home, where, prior to going into

23 respite care, she was, and she was coping reasonably

24 well. But I couldn't see that, so I took this as being

25 an update document.

113 1 My other comment of it is that I think there is

2 a paucity of detail on it. Just ticking the problem

3 list: pain, mobility, balance, exercise tolerance, to me

4 observing that document, what does that mean? There is

5 no detail, it doesn't tell me any facts.

6 Q. If we look at the occupational therapy report, which is

7 on page 21 of the records, you will see that again

8 relates to ward 6. There are some comments under the

9 heading "Transfer assessment" and then, at the bottom:

10 "Patient demonstrated safe and [something] transfers

11 on the ward. No outstanding OT issues."

12 This is dated 28 December, shortly before discharge.

13 Was there anything else apart from this document that

14 you were able to see from the point of view of

15 occupational therapy?

16 A. I just felt that it was very slim in detail. It doesn't

17 really give a great deal of information at all,

18 particularly -- I mean, it does say it is a transfer

19 assessment, so I'm assuming that's transferring from

20 chair to, you know, whatever, it is transferring from

21 one to another, but it just doesn't have a great deal of

22 detail on it.

23 Q. If we go back to where this discussion began, I think,

24 for you, and that is on page 15 of the medical notes, if

25 you could look at that, the entry for 10 December,

114 1 shortly after [Patient B]'s admission, four lines from

2 the top I think reads:

3 "Is going to require a great deal of physio and OT."

4 And is that:

5 "Potentially may require future care."

6 Was that then what caused you to consider whether or

7 not the physiotherapy and OT was -- could satisfy that

8 instruction?

9 A. Yes.

10 Q. If the documents that you have looked at are all we have

11 in relation to physiotherapy and occupational therapy,

12 then did what you see in that documentation satisfy that

13 instruction from the doctors?

14 A. No, it didn't. Not at all.

15 Q. In relation to care planning, could you look, please, at

16 51 of the records? Once again, here we have

17 a multiproblem care plan. The problems are described.

18 Problem 1 is chest infection, and then dehydration and

19 falls.

20 Did you have regard to this document when you were

21 preparing your report?

22 A. Yes, I did.

23 Q. What conclusions did you come to in relation to this?

24 A. The multiproblem care plan, as you say, identifies one

25 problem as being a chest infection and the second

115 1 problem as dehydration and falls. That is actually

2 three problems. They are three very distinct problems.

3 In my opinion, and the way that I would be used to

4 working and documenting these, there would be a separate

5 plan and a separate document for each one of those items

6 that would have specific interventions and activities,

7 nursing, identified for each of them, not just

8 everything on one form, because it is difficult to

9 discern from it which activity relates to which.

10 If that had been the case, then, when reviewing it,

11 you could outline any improvement or deterioration with

12 regard to that specific problem.

13 Q. If you look at the interventions that are listed here,

14 have you any comments to make on the nature of

15 the interventions from a nursing perspective?

16 A. My comments are the same as they were for the previous

17 case, in that, to me, these are a list of orders or

18 activities that have been identified, I would most

19 likely imagine, by the doctors.

20 Some of them are nursing interventions. So, for

21 example, observations. Routine bloods isn't that --

22 clearly, a doctor wants bloods to be done and a physio

23 and social work referral, and OT, et cetera, ECG, chest

24 X-ray. They are a list of activities that need to be

25 undertaken to (a) diagnose this, but they are not

116 1 specific nursing care interventions and activities.

2 Q. Looking to the other entries that appear to have

3 different dates, there is 15 December, "Stool" and

4 16 December, "Blood cultures". Are these nursing

5 interventions?

6 A. No, they are not.

7 Q. If you turn on to page 52 of the records, here we do

8 see, I think as part of the care plan, a problem number

9 and then "C. difficile positive" has been entered in for

10 17 December. We know that was the date the diagnosis

11 was confirmed. This bears to be a C. difficile care

12 plan. Is that how you see it?

13 A. Yes, I do.

14 Q. Have you any observations to make in relation to this?

15 A. Well, my observations are that it is very lacking in

16 detail in terms of a nursing care plan.

17 Q. We see that the goal is to ensure hydration and

18 nutritional intake are sufficient. Would these at least

19 be part of the planning?

20 A. Yes, it would be, but I would expect to see that as

21 being -- you know, the goal is to ensure hydration and

22 to monitor intake and output, but a list of specific

23 things that can be done to allow the activity to take

24 place. So, for example, you know, to give the patient

25 hourly or two-hourly fluids, to identify what drinks are

117 1 the patient's favourite drinks so you are more likely to

2 encourage them to want to take the drinks; to maintain

3 adequate fluid balance.

4 You would identify a number of other things below

5 that that specifically related to that one item.

6 Q. I think, as you say in your report, would you expect

7 some references to infection control practices, such as

8 isolation and the prevention of spread of infection?

9 A. Absolutely.

10 Q. What about stool charts? Would you have expected some

11 reference to that?

12 A. Yes.

13 Q. Would the care plan for C. diff normally contain

14 instruction as to what information should be passed on

15 to family members?

16 A. Absolutely, yes. Ward staff -- or ward staff on the

17 ward, cleaning staff, family members, visitors, yes.

18 Q. The comment you make -- the fourth bullet point down on

19 page 14, you say the evaluation sheets -- and these are

20 the nursing notes I think you are referring to:

21 "... are then completed as a general nursing care

22 continuation sheet and do not address the problems

23 outlined in the problem care plan."

24 Could you elaborate on what you mean by that?

25 A. As I have just indicated, with a problem care plan,

118 1 which is what we have just been looking at in relation

2 to C. difficile and diarrhoea stools, the problem

3 sheet -- you have got a goal, ie, it is whatever you

4 want to achieve, and you have got the interventions,

5 which is how you are going to try and achieve it, and

6 then you would evaluate that specific item.

7 So it is very clear, there is a process of

8 identifying these factors with an outcome. So once

9 you've identified what your intervention is, you will

10 then evaluate what you have done, you will document what

11 you have done or how you have evaluated it: is it

12 working, isn't it working, do I need to review what I am

13 doing? That will all be identified specifically in

14 relation to this.

15 What I mean by evaluation sheets, they are just

16 completed as a general nursing continuation sheet. In

17 other words, it is like a status report of, you know,

18 "The patient got up, had a good day". It is filled in

19 with a number of different things that are very

20 disconnected and disjointed and that do not pertain

21 specifically to the problem at hand.

22 Q. If you turn to page 53, which is the next page we come

23 to, can we see that it is headed "Acute medical unit

24 evaluation sheet", and for the column "Problem number"

25 the practice seems to have been to put in the time of

119 1 the entry. Do you see that?

2 A. Yes.

3 Q. Thereafter, we read a narrative. I mean, for example,

4 just before 1400, "Patient bright and cheery". Is that

5 what you mean, that we have this general narrative, but

6 you say that is not the development of a care plan as

7 you would envisage it?

8 A. It is the patient's day as seen by the nurse caring for

9 them.

10 Q. Going back to the report then, in the next bullet point

11 you say:

12 "Monitor blood chemistry."

13 This was done in the case of [Patient B]; is that

14 correct? Page 14 of the report. I am just asking you

15 to confirm -- you have looked at the blood chemistry

16 that's been monitored, and this was done for

17 [Patient B]?

18 A. That's correct.

19 Q. Then you talk about, once again, the patient's pain.

20 What do you say here?

21 A. The patient's pain with the use of a pain assessment or

22 tool chart, from the documents that I examined, this was

23 not undertaken at all. I was critical of that because

24 the patient clearly was in pain and discomfort because

25 she required analgesia on a number of occasions, and it

120 1 is documented that the patient was in pain, particularly

2 around her vulval area, her bottom. I think she also

3 complained of pain and soreness underneath her breasts.

4 Then, added to that, there are entries on the bottom of

5 some of the observation charts where they score the

6 patient's level of pain as zero.

7 Q. If we turn to page 65 of the records, can we see, if we

8 look to the bottom section, where the zeros have been

9 entered to describe the pain? Is that what you are

10 meaning?

11 A. Yes, that's correct.

12 Q. I think I have a recollection of one where there might

13 have been different numbers. Yes, turn to page 66. It

14 would appear that on this form, for two days, the

15 pain -- and that is, I think, for the 11th and the 13th,

16 or the 12th, has been marked as 1?

17 A. That's correct.

18 Q. But the other forms, if we go to page 64, I think again

19 we see it is zeros there that are inserted?

20 A. Yes.

21 Q. Then, on page 63, which is the other one, it would

22 appear that also we have a run of zeros for pain. You

23 say that just doesn't add up, withstanding the fact that

24 she had these problems which were causing her pain?

25 A. If a patient is complaining of pain and requiring

121 1 analgesia, then they clearly have pain. So a score of

2 zero is not accurate.

3 Q. You are critical of that in your report?

4 A. That's correct.

5 Q. In the next bullet point you have noted that you could

6 find no evidence that the patient and the family had

7 what, been communicated with?

8 A. I couldn't find any evidence that they had been

9 communicated with, no.

10 Q. What about the patient's psychosocial situation and

11 expectation of recovery? What conclusions did you come

12 to there?

13 A. From the documents I examined, it was difficult to

14 determine if that had actually been done. I couldn't

15 see it documented.

16 Q. Discharge planning. You make some mention of that. Can

17 we look at the documents, page 61 first of all? I think

18 the date is 28 December, which is a couple of days

19 before discharge. It is called a short care plan.

20 What's wrong with this as a discharge plan?

21 A. Is it possible to have the lower section highlighted,

22 please? I can't read it very well.

23 Q. Yes, if we could do that, please.

24 A. The point I'm trying to make here is that this lady is

25 scheduled for discharge and clearly there would need to

122 1 be a number of services put into place for her to be

2 able to go back to her home. There is some detail in

3 the intervention section that relates to home care

4 services, but it is not very detailed.

5 Q. It is very difficult to read, I'm bound to say. What

6 sort of information would you expect in the care plan --

7 in the discharge care plan for this sort of patient?

8 A. Well, if you go back to the activities of daily living,

9 which is a really good tool because it does what it

10 says, it looks at every function that a patient has in

11 terms of their ability to wash themselves, cook for

12 themselves, whatever their physical situation may be,

13 their psychosocial situation may be, and how they cope

14 and manage at home.

15 Given that this refers here to the medical social

16 worker being involved, we know from our previous

17 conversations regarding the intensive physiotherapy and

18 occupational therapy that this lady, it was said, was

19 going to require, and I have already commented on that,

20 so I would expect all of those elements in the

21 activities of daily living to be almost listed. You

22 would have a document -- most places, in my experience,

23 would have a core care plan for discharge which would

24 address every little nuance of the discharge, in terms

25 of enabling a patient to cope at home and, if they

123 1 couldn't cope, the exigencies that had been put into

2 place to provide that help and support for them for when

3 they get home. I didn't see any of that here, and

4 I wasn't sure -- well, I couldn't make an assumption

5 that that ties in with the fact it isn't here because it

6 actually wasn't in the original physiotherapy and

7 occupational therapy assessments to begin with.

8 Possibly, if it had been, this may have been a little

9 more detailed.

10 Q. If you look at another document, page 75 of the records,

11 I think in this same context, you will see that this

12 seems to have emanated from ward F, the other two have

13 been scored out, "Discharge plan", and the problem is

14 "discharge from ward F" and there are a number of

15 interventions, some of which have been remarked upon and

16 some of which have not.

17 Would this perform the sort of functions that you

18 were talking about a moment ago?

19 A. It addresses some of them, but this, to me, is more of

20 a tick list. It is a check list: discharge date,

21 discharge to, transport arranged, that's fine.

22 Some of the elements I would expect are there, but

23 this is essentially a tick list to make sure that things

24 are not forgotten or to act as a prompt or as an

25 aide-memoire.

124 1 MR MACAULAY: If your Lordship were to be having a short

2 break this afternoon, this would be a good point.

3 (3.10 pm)

4 (A short break)

5 (3.30 pm)

6 MR MACAULAY: Turning to page 15 of your report then,

7 Mrs Stower, you have a section dealing with temperature,

8 pulse and respiration charts. You make some comments

9 here. What observations do you make?

10 A. There were observation charts. There was no observation

11 charts recorded for the period 24 to 28 December.

12 The other comments I make are that -- on the

13 observation charts at the bottom, the BM, the weight,

14 pain score, as we have already referred to/discussed,

15 sedation score, nausea score and bowel movement is not

16 completed in a consistent manner. That is mainly my

17 observations.

18 Q. Just to clarify the period you focus upon for there

19 being no observations, if you could turn to page 64 of

20 the records, it is quite difficult to work out, but if

21 we look at the dates, do we have a date of the 24th in

22 the top left, and is the next date -- do you think that

23 is the 28th? I certainly see a date for the 27th.

24 Could it be the 25th and 27th?

25 A. I think now that I can see it enlarged, I can see 24,

125 1 I think that probably is 25 --

2 Q. You have overstated the position then on page 15?

3 A. Yes, I have, yes.

4 Q. You have made the point already about the references to

5 pain score that we can see at the bottom.

6 Now, fluid balance charts and fluid management is

7 the next section you address. What conclusions do you

8 come to here?

9 A. There were fluid balance charts recorded for ten days

10 only of [Patient B]'s 27-day stay in hospital, and

11 I consider that the standard of completion of these

12 charts is very poor.

13 Q. You give some reasons for that?

14 A. I do.

15 Q. What are these?

16 A. One of the documents, GGC26380111, is undated. There

17 was very little output information recorded. Stools,

18 although [Patient B] had diarrhoea, were rarely recorded

19 on this sheet. There was no calculation of fluid

20 balance, input and output, with a total and a balance

21 for the doctors to observe in order to make the relevant

22 IV fluid adjustments.

23 Q. If we then look at a number of these forms, if you turn

24 to page 111, first of all, the one you say was undated,

25 we see, I think, that there is no date. There are some

126 1 entries on the form itself; is that correct?

2 A. Yes, that's correct.

3 Q. But no totals and, indeed, there is no output recorded;

4 is that right?

5 A. That's correct.

6 Q. Is this of any assistance in assessing the position of

7 fluid balance?

8 A. No, it isn't.

9 Q. If you turn to page 109, again you have another form

10 with some entries, but, again, is that of any assistance

11 in assessing fluid balance?

12 A. No, it isn't.

13 Q. Perhaps we can look at two more. Page 105. Here we

14 have some entries and some reference to green stools in

15 the output. This is for 19 to 20 December. But there

16 is very little by way of information. Is this of any

17 assistance in assessing fluid balance?

18 A. It is only one entry, apart from the green stool entry,

19 in a 24-hour period. It is very poor.

20 Q. Finally, perhaps, for page 104, this is dated the 18th

21 to the 19th. I think we see here there are some

22 entries, at least for the intake, and indeed a total,

23 and also at least the urine has been totalled. Is this

24 better?

25 A. Yes, it is a much more concerted effort to complete the

127 1 form on this occasion. Yes, it is.

2 Q. Going to your report, the last paragraph on page 15,

3 what conclusion do you come to on this topic?

4 A. Overall, regarding the fluid balance charts and the

5 fluid management, I was critical, particularly as the

6 interventions on the C. difficile care plan, which we

7 saw earlier, are specifically identified as -- an

8 intervention is to monitor intake and output and to

9 maintain a fluid balance chart. So, therefore, it fell

10 well below the standard that I would have expected,

11 again of any sick patient, but particularly one who is

12 dehydrated, has diarrhoea and is vomiting and reluctant

13 to take oral fluids.

14 Q. Moving on to page 16 of the report, you make some

15 comments towards the top of the page about the infusion

16 system observation chart. What is the point you are

17 making here?

18 A. There were infusion system observation charts. I could

19 see that the sheets -- there are a certain number of

20 sheets covering the dates 7 December to the 12th, but

21 I note that I am unsure when the intravenous infusion

22 was discontinued, as it is not documented in a nursing

23 record.

24 Also, I couldn't see it prescribed on the

25 prescription sheet or see that it states that it was to

128 1 be discontinued, which is where I would have expected it

2 to have been.

3 Q. You are not saying it should not have been discontinued,

4 or are you?

5 A. No, I'm not saying that. I'm saying that, normally, you

6 would expect, if an intravenous infusion is being

7 discontinued, it would normally be documented -- either

8 documented by the doctor for it to be completed or

9 documented on these sheets.

10 Q. Is this a medical matter, rather than nursing?

11 A. No, I would have expected the nursing staff to have

12 identified that the intravenous infusion had been

13 discontinued.

14 Q. So this is really a recording issue per se? This is

15 a matter of lack of recording that something has been

16 discontinued?

17 A. Yes, it is.

18 Q. You then deal with the pressure management and skin

19 integrity, and you suggest that the assessment was not

20 undertaken in either ward 6 or ward F. Can we just look

21 at the documentation?

22 On page 74, we see the Waterlow form and we note

23 that this appears to have been instigated in ward F

24 because we see the reference to ward F towards the top.

25 Do you see that?

129 1 A. Yes.

2 Q. It doesn't appear that the numbers have been circled, as

3 we sometimes find, but if you turn to page 73, which is

4 the previous page, can we see that against the date

5 30 December an assessment has been made which brings out

6 a total of 17, which is a high-risk assessment. Do you

7 see that?

8 A. Yes, I do.

9 Q. It is difficult to understand the next assessment date

10 because that suggests 4 December 2007, which seems to be

11 going backwards. Can you understand that?

12 A. I think that must be an error and that it presumably

13 means 4 January 2008.

14 Q. You, yourself, if we look at your report, do you,

15 yourself, also carry out an assessment and you come out

16 with the same figure of 17, which is the high-risk

17 assessment in your report?

18 A. Yes, that's correct.

19 Q. We note here that this assessment was done in ward F

20 I think the day before [Patient B] was discharged from

21 the hospital. Should this have been done much sooner?

22 A. Yes, it should have been done. There are two points

23 I would like to make regarding this document. The

24 Waterlow assessment calculator, the one that is used in

25 the Vale of Leven Hospital, is a two-page document. It

130 1 has what I call a front sheet, which is the number 1

2 sheet, and it has a second sheet, which is the sheet

3 that we have on the screen.

4 Now, it is my understanding that the front sheet,

5 the sheet that is circled, which is the one that was in

6 the bundle that had no information on it at all, is the

7 primary sheet, the sheet you look at and visibly you can

8 see the assessment and the comparators on it. So you

9 have a number of things and you circle which is the

10 relevant one for that patient at that time.

11 So to me that is the main informing sheet.

12 The sheet we have in front of us is the sheet that

13 I would consider to be the evaluation and the review

14 sheet, so clearly, when it is done, you would fill the

15 front sheet in, you would probably transpose that

16 information over onto this sheet and then you would

17 identify when the reviews would be taken, but that is

18 absolutely right, this wasn't done -- this assessment

19 was not done on [Patient B]'s admission to either of

20 the wards but just only prior to her discharge, and

21 I would have expected it to have been done within

22 24 hours of admission.

23 Q. When you say in your report:

24 "The assessment of [Patient B]'s skin was not

25 undertaken in either ward 6 ..."

131 1 You say that because you do not see any

2 documentation in the records to suggest that it was done

3 in ward 6; is that correct?

4 A. That's correct.

5 Q. "... or ward F."

6 You say on admission, but at least it appears that,

7 at the time she was in ward F, there was an assessment

8 carried out. Obviously, I take the point you make about

9 the use of the form, but the assessment did assess her

10 at high risk?

11 A. That's correct.

12 Q. If we look back to page 73, can we read, just above the

13 assessment tool, that -- I think it says:

14 "All patients at risk must have a care plan

15 indicative of prevention/treatment plan."

16 Do you see that?

17 A. That's correct, yes.

18 Q. Did you see any evidence in the records that there was,

19 first of all, a care plan for pressure management?

20 A. No, I don't recall that at all.

21 Q. Did you see any evidence of either reference to

22 a special mattress or turning charts in the records?

23 A. No, I could see no reference to the patient being nursed

24 with a special mattress or any referral being made to

25 the tissue viability nurse specialist.

132 1 Q. If you look, then, to page 17 of the report where you

2 deal with nutrition, this is a case where I think the

3 dietician was involved; is that right?

4 A. The dietician was, yes, that's correct.

5 Q. You tell us, indeed, that the referral to the dietician

6 was made and that she visits the patient on 24 December.

7 What observations then do you make in relation to this

8 aspect of care?

9 A. The dietician -- the involvement of the dietician is

10 important, for her to come and carry out a nutritional

11 assessment of the patient to identify her nutritional

12 status. That would usually be based upon the factors

13 identified in a comprehensively completed nursing

14 assessment, just to identify the level of nourishment or

15 undernourishment that the patient may have. This is

16 important in order for her to provide a baseline of

17 information, and then, on that basis, care can be

18 planned.

19 A referral was made and she did visit on

20 24 December. The dietician requests Fortisip

21 supplements, but I couldn't find any evidence from the

22 nursing documents that I examined that those supplements

23 were prescribed by the doctors, which they normally are.

24 Q. Are they normally given on prescription?

25 A. They normally are, yes. Neither could I actually

133 1 determine that they were given by the nursing staff, as

2 I couldn't find them recorded in the nursing documents.

3 Q. Would you normally have food charts to document the

4 recording of these supplements?

5 A. Yes. You would expect to see it in the prescription

6 chart, on a feed chart, and most likely also possibly on

7 the fluid balance chart when that is being completed as

8 well, because on the fluid balance charts you normally

9 identify what fluid is being taken as well as when.

10 The dietician also says she will monitor and review,

11 but I couldn't see that -- I couldn't find any food

12 charts documented and I didn't see that the review did

13 actually take place prior to the patient's discharge.

14 Q. You then, at section 9 of the report, make some

15 observations in relation to a stool chart. I think you

16 say that there were no stool charts in the records you

17 examined; is that right?

18 A. That's correct.

19 Q. You make mention of the loose stools policy. In

20 particular, the reference there to a care plan.

21 A. Yes, the loose stools policy does state that the care

22 plan should be completed for patients with loose stools,

23 but I could not find that in the documents that

24 I examined.

25 Q. A falls risk plan, was there such an assessment in the

134 1 papers, in the records?

2 A. No, there was no falls risk assessment at all.

3 Q. Should there have been?

4 A. Yes, there should have been.

5 Q. So far as you could say from your understanding of

6 the patient's condition, was she at risk of falls?

7 A. Yes, she was at risk of falling.

8 Q. You say you are highly critical of the lack of this

9 assessment, if the records truly reflect the position.

10 A. Yes, I am.

11 Q. What about the next item, manual handling assessment.

12 Did you see any evidence in the records that this

13 assessment had been carried out?

14 A. No, there is none -- there was none carried out.

15 Q. What is your conclusion on that?

16 A. I am critical of that because, in a 77-year-old patient

17 who has decreased mobility and a recent history of

18 falls, one would expect that, the manual handling risk

19 assessment form to be completed for both the safety of

20 the patient and the practitioners who are caring for

21 her.

22 Q. You say in your report that, if the records truly

23 reflect the true position, you are critical of this

24 omission?

25 A. Yes, that's correct.

135 1 Q. The nursing management of C. difficile, which is the

2 final section that you have in this report, can you just

3 elaborate on what conclusions you arrived at, having

4 regard to the records you saw in relation to this aspect

5 of care?

6 A. I could see no real evidence of C. difficile management.

7 There was a care plan of sorts, but there was little

8 involvement of the infection control team. There was no

9 evidence to say that the infection control team were

10 visible and working with the nursing staff and

11 supporting them in the management of this patient.

12 As I said to you before, there is an entry to say

13 that the infection control nurse attended the ward, but

14 my understanding of that was that that was specifically

15 to discuss the issue of Metronidazole with the doctor

16 and other antibiotics, and also there was no involvement

17 of the microbiologist that I could see.

18 Q. I think we touched upon this before, but we know that,

19 under the policy, a risk assessment should be carried

20 out. Did you see what was done here as amounting to

21 a risk assessment?

22 A. No, there was none.

23 Q. Then you finally set out some final remarks under the

24 heading "Conclusion". Generally speaking, what were

25 your conclusions here?

136 1 A. [Patient B] was admitted to the Vale of Leven Hospital

2 with an initial diagnosis of dehydration, chest

3 infection and a recent history of falling. Therefore,

4 in my opinion, the care that she received while she was

5 a patient in the hospital fell well below the standard

6 that she could have reasonably expected, based on:

7 a poor nursing assessment, relevant care planning and

8 evaluation on ward 6 and ward F; the absence of a falls

9 risk assessment when, in fact, actually there was a real

10 recent history of falls; absence of manual handling

11 assessment; and in terms of the Waterlow score, we have

12 said that there was a score there but no real plan of

13 care based on the outcome of that score; and a lack of

14 assessment of skin integrity on admission to both wards

15 and the follow-through planning of care as a result of

16 that.

17 Q. I think you make some further remarks on page 19, which

18 I think we can probably read for ourselves. You talk

19 about failure to isolate, poor C. difficile management,

20 absence of stool charts, poor record keeping and poor

21 fluid balance recording?

22 A. That's correct.

23 Q. You say that they fell far below the standards she could

24 reasonably have expected, but in relation to the NMC

25 code that we looked at this morning, did the standard of

137 1 care comply with the propositions set out in the code?

2 A. No, it didn't, because there were quite a number of

3 omissions and lack of recording and, as we heard this

4 morning, recording is inherent, it should be inherent in

5 what nursing practice is all about. If it is not

6 recorded, then we have got no evidence that it has been

7 undertaken and, therefore, it can certainly be

8 detrimental to the patient as a result of that.

9 Q. We can leave that report aside and then go to look at

10 the next case that you looked at, and that is the case

11 of Mathew Macfarlane. Your report is at EXP00380001.

12 The medical records that are relevant here are at

13 GGC00380001.

14 If we turn to page 3 of the report, can you give us

15 a summary of Mr Macfarlane's medical history?

16 A. Mr Macfarlane was a 78-year-old gentleman who was

17 admitted to the Vale of Leven Hospital via the medical

18 assessment unit on 4 February 2008 under the care of

19 Dr M Al-Shamma. This was following a referral from his

20 general practitioner. Mr Macfarlane's presenting

21 symptoms were shortness of breath and query pleural

22 effusion, query a urinary tract infection and a gradual

23 general deterioration.

24 I noted also that the medical staff when he

25 presented also noted that there was a question of --

138 1 that there might be a malignancy associated with his

2 shortness of breath and possible pleural effusion.

3 In terms of previous medical history, he had

4 a medical history of recurrent UTIs, that's urinary

5 tract infections, a recent urinary sepsis, renal

6 failure, obesity, atrial fibrillation, hypertension,

7 diabetes, which was non-insulin dependent, and gout.

8 Q. Moving on to page 4, I think you give us some social

9 background, and you also noted that he was known to have

10 poor mobility and walked with a frame; is that right?

11 A. That's correct.

12 Q. He was admitted, I think, to ward 6; is that right?

13 That's what you have noted?

14 A. Yes, he was.

15 Q. On admission, what was the position?

16 A. On admission to the medical assessment unit, he was seen

17 and examined by the doctor. There was a query that he

18 had a pleural effusion and an increasing shortness of

19 breath. His observations were recorded. He was known

20 to be on a number of medications, and these were

21 recorded in the documents. The MAU documentation was

22 somewhat incomplete.

23 Q. If we read on, we see that he was commenced on

24 antibiotic therapy and aggressive physiotherapy and

25 occupational therapy and was found to be C. diff

139 1 positive on 12 February. Do you see that at the top of

2 page 4?

3 A. Yes, that's correct.

4 Q. That is some eight days after his admission, if we

5 remember that he was admitted on the 8th (sic). So some

6 eight days later he's diagnosed to be C. diff positive;

7 is that right?

8 A. That's correct.

9 Q. But his condition improved, as you have noted, and he

10 was discharged home on 21 February?

11 A. That's correct.

12 Q. You have noted he was later admitted to the Royal

13 Alexandra Hospital and he died subsequently on

14 23 April 2008?

15 A. Yes, that's correct.

16 Q. If we look at the death certificate, SPF00240001, can we

17 see that he died of respiratory failure and chronic

18 sepsis?

19 A. Yes, that's correct.

20 Q. I don't know if you said earlier on that he was admitted

21 to the Vale of Leven on the 8th, but it was 4 February,

22 if you go back to page 3. I think I said it.

23 So he was admitted on the 4th and he was found

24 C. diff positive eight days later on the 12th, I think.

25 That is what I intended to say.

140 1 Looking then to the admission to ward 6 that you

2 look at towards the bottom of page 4, you say that there

3 was a nursing admission assessment form which was

4 completed, but that there was no activities of daily

5 living assessment completed, or you didn't see such a

6 form in the papers.

7 A. That's correct.

8 Q. Looking to the admission, nursing admission assessment

9 form, if you could turn to page 72 of the medical

10 records, I think this is the document that you have made

11 reference to in your report; is that right?

12 A. Yes, I think so.

13 Q. You see the date -- we see "Ward 6" at the top, and the

14 admission date is 4/2/2008.

15 A. Yes.

16 Q. The consultant is Dr Akhtar, there is some information

17 given. The observations seem to have been completed

18 here and the other information boxes have been ticked,

19 but the Waterlow box is blank in the form?

20 A. That's correct.

21 Q. You did not find an activities of daily living

22 assessment form in the records?

23 A. No, I didn't.

24 Q. Would you have expected to find such a document in the

25 records?

141 1 A. Yes, I would.

2 Q. Can we then just look briefly at the medical notes which

3 you look at on page 5, and perhaps just observe that you

4 have noted that, on 9 February, Mr Macfarlane is

5 transferred to ward 3. Do you see you say that towards

6 the top of page 5?

7 A. Sorry, what date was that?

8 Q. I'm just looking at your report, where you have observed

9 at the top of the page that Mr Macfarlane is admitted to

10 ward 3 --

11 A. I beg your pardon, yes.

12 Q. -- on the 9th. So he's spent some five days in ward 6;

13 is that right?

14 A. Yes, that's correct.

15 Q. Did you find that there was movement between wards,

16 looking at the cases as a whole?

17 A. Yes, there were a lot of moves to different wards

18 overall.

19 Q. Could you work out what the reasons were here for

20 Mr Macfarlane being moved from ward 6 to ward 3 after

21 five days in hospital?

22 A. The reasons were not clear, no.

23 Q. Should you be able to understand from the records why

24 a patient is being moved from one ward to another?

25 A. Yes, you should. One would expect to see a nursing

142 1 entry saying specifically the reason for transfer to

2 another ward.

3 Q. The medical notes on page 5, can we see that we are

4 given some information about his medical condition. If

5 I could just perhaps look at an entry that I don't think

6 you have actually incorporated, but if I can turn to

7 page 21 of the medical notes, I think this is something

8 you do discuss later, but I will just flag it up now.

9 Can we see that for 11 February there is a note made by

10 the dietician towards the bottom of the page? It would

11 appear that the dietician has seen Mr Macfarlane:

12 "Thank you for referring this gentleman for weight

13 reduction advice. Spoke to patient with his wife", and

14 so on.

15 So there was a referral to the dietician and the

16 dietician gave certain advice?

17 A. That's correct.

18 Q. Then, if we go back to the report, can we see that on

19 the 12th certainly he has been given antibiotics. Do

20 you see that?

21 A. Yes, that's correct.

22 Q. There is also an entry that you have noted from the

23 medical records that he had diarrhoea for two days?

24 A. Yes, that's correct.

25 Q. Then, on the 13th, can we see that the entry, reading on

143 1 to page 6, is that he is C. diff positive and he's

2 started the Metronidazole?

3 A. That's correct, yes.

4 Q. If we are now on the 13th, is Mr Macfarlane now in

5 ward 3 when the diagnosis is confirmed?

6 A. Yes, I believe so, yes.

7 Q. If you go to page 65 of the medical records, we are

8 looking at the report from the microbiology department,

9 which we can see is addressed to ward 3 in the top

10 right, and can we see the sample is collected on the

11 12th, received on the 12th and printed on the 14th?

12 A. That's correct.

13 Q. Would it appear, looking to the medical records, that

14 Mr Macfarlane improved and he was due to be discharged

15 on 20 February? That's on page 6. Have we got that?

16 A. Sorry? I've lost that.

17 Q. Page 6 of your report. In short, I think from the

18 medical records he's improved and he is discharged to go

19 home on 20 February.

20 A. Yes.

21 Q. If we look at the nursing entries, for 8 February

22 Mr Macfarlane is complaining of feeling sore with aches

23 and pains, and there is a question mark whether it is

24 due to gout. Do you see that?

25 A. Yes, that's correct.

144 1 Q. On the 9th, there is an entry -- this is perhaps just to

2 clarify that entry on page 77 of the records. You have

3 written:

4 "Reluctant to mobilise."

5 I think if we look at the entry towards the bottom

6 of page 77, what is recorded here is:

7 "Patient dislodged ... in sleep."

8 A. It says "Patient dislodged the Venflon ..."

9 Q. "... in sleep".

10 Then:

11 "Slightly reluctant to mobilise and difficulty

12 getting out of bed."

13 A. That's correct.

14 Q. I think it may be actually "Patient talking in sleep".

15 Is that what's been recorded? It may not matter, but

16 the note is that he was slightly reluctant to mobilise

17 and he had difficulty getting out of bed?

18 A. That's correct.

19 Q. We then see, on page 7 of your report, the reference to

20 being transferred from ward 6 on 9 February, and then,

21 on the 10th, there are references to being incontinent

22 of faeces and loose stools. Is that right?

23 A. That's correct.

24 Q. So it would appear that the first reference to loose

25 stools is on 10 February, which is the day after he was

145 1 transferred from ward 6?

2 A. Yes, that's correct.

3 Q. We read some further information, that he is incontinent

4 of loose, foul-smelling stools on the 12th, and then, at

5 1615 on the 12th, the ward are aware that he is positive

6 for C. difficile?

7 A. That's correct.

8 Q. If we look at page 8 of your report, can we see there

9 are further references to loose stools in the records?

10 A. Yes.

11 Q. On the 15th, if we can move on to there, has it been

12 noted that he is very confused and found to be climbing

13 out of bed on several occasions?

14 A. That's correct.

15 Q. He has also had a small skin tear to his right forearm

16 on the 16th; is that right?

17 A. Correct, yes.

18 Q. Can we note here that the date of discharge is, in fact,

19 21 February? That is on page 9 of your report?

20 A. That's correct.

21 MR MACAULAY: My Lord, I am next going to go into the body

22 of the report, which I am quite happy to do for a while,

23 if people can bear with that. Alternatively, I can

24 revisit it tomorrow morning?

25 LORD MACLEAN: It is a matter for you entirely.

146 1 MR MACAULAY: I think the witness has probably had a long

2 day, my Lord.

3 LORD MACLEAN: Yes, that is true. Has it been a long day?

4 A. I don't mind.

5 MR MACAULAY: I'm happy to proceed for perhaps another ten

6 minutes or so.

7 LORD MACLEAN: Can I just ask before we go on, I was just

8 looking to the point at which he was discharged, on

9 the 21st. Can you identify what he was treated with for

10 the C. diff? There must be a list of medication

11 somewhere?

12 A. He was prescribed Metronidazole --

13 LORD MACLEAN: That's right.

14 A. -- on 13/2.

15 LORD MACLEAN: Yes, which was discontinued the day he left?

16 A. It was discontinued on the day of discharge.

17 MR MACAULAY: If we then go to page 13 of your report, where

18 I think you follow the format in your previous reports

19 and you look early on at the infection control card

20 here, which you will find at SPF00630001, we are given

21 some information here. Can we see, first of all, the

22 date positive is noted as 12/2/2008, and then, on the

23 13th:

24 "Unable to isolate. Remains symptomatic."

25 So would it seem that at this point it wasn't

147 1 possible to isolate the patient?

2 A. That's correct.

3 Q. Do you know why that was?

4 A. No, I have no way of identifying that, no.

5 Q. By the 18th, has the infection control nurse noted that

6 he was asymptomatic?

7 A. That's correct.

8 Q. We looked before at the C. difficile policy that may

9 have been relevant, and it made some mention of risk

10 assessment. Do you see within this document evidence of

11 a risk assessment?

12 A. There is no risk assessment in this document, no.

13 Q. Did you see any evidence that the infection control

14 nurse had visited the ward to see the patient and assess

15 the patient?

16 A. No. I don't see anything to indicate that the infection

17 control nurse visited. I wasn't sure what SCIPS stands

18 for because it does say "reinforce SCIPS and enhanced

19 cleaning". Unless that is something to do with special

20 infection control precautions, it could do, but

21 I can't -- I don't understand the abbreviation.

22 Q. We will see if we can work out that before tomorrow

23 morning. Again, the date of discharge has also been

24 recorded, 21 February?

25 A. That's correct.

148 1 Q. The number of the ward that is given on the card is

2 ward 3. Of course, I think that is where Mr Macfarlane

3 was when the diagnosis was actually confirmed; that's

4 correct, isn't it?

5 A. Yes.

6 Q. But the admission initially was to ward 6?

7 A. Yes.

8 Q. You then go on to look at certain aspects of his care.

9 If you turn to page 14, I think you identify a number of

10 nursing issues that Mr Macfarlane had during his time in

11 the hospital; is that right?

12 A. That's correct.

13 Q. You say in the second bullet point that we have touched

14 upon that it is documented in the infection control card

15 that the staff were unable to isolate him, although it

16 does not say why. Then you speculate that the most

17 likely reason being that there was no single room

18 available. Ought there to have been some explanation as

19 to why it wasn't possible to isolate in the infection

20 control documentation?

21 A. Sorry, I didn't quite catch that question.

22 Q. Should there have been some explanation in the infection

23 control documents as to why it wasn't possible to

24 isolate?

25 A. Yes, I believe there should be.

149 1 Q. But the lack of a single room would be the most obvious

2 reason?

3 A. To my opinion, yes, that's correct.

4 Q. On page 15 you deal with record keeping. What

5 conclusion did you come to, having regard to your

6 examination of the records?

7 A. Overall, I felt that the standard of records was very

8 poor, and the reasons for that I identify under the

9 separate headings that go further on into my report.

10 Q. If we look at some of the points you make under the

11 heading "Nursing care plans", the first reference you

12 make is to the nursing admission assessment. We looked

13 at that form a moment ago, and we can do so again, but

14 the point you make there I think is that the Waterlow

15 wasn't completed. Is that the main point?

16 A. Yes, that's correct.

17 Q. Was there a Waterlow assessment at all? I don't think

18 there was.

19 A. No.

20 Q. What about the next bullet point? You say:

21 "Risk assessments in relation to the activities of

22 daily living and functional ability are usually done in

23 conjunction with the physiotherapist and occupational

24 therapist. The ADL was not completed on either ward for

25 this period and I am critical of this."

150 1 Was there such a form in the records?

2 A. Not that I observed.

3 Q. I'm sorry?

4 A. Not that I observed.

5 Q. If we leave the next bit and come back to that later,

6 you say:

7 "There is an acute medical unit multiproblem care

8 plan."

9 Perhaps we can look at that, at page 74 of

10 the records. We see this is dated 4 February. Four

11 problems are identified, and we see a list of

12 interventions in the body of the document. What

13 observations do you make in relation to this document?

14 A. There are four problems identified. There is a left --

15 I think it is left -- pleural effusion.

16 Q. Could you make sure you speak to the microphone, please.

17 A. Sorry, I can't read it very well.

18 Q. Can we make it a bit bigger?

19 A. Yes, that would be good, if you could, thank you. That

20 is better. There is a left pleural effusion. There is

21 a "[something] UTI". I'm not quite sure what that is at

22 the beginning. NIDDM and chronic anaemia.

23 Q. Does that NIDDM mean?

24 A. Non-insulin dependent diabetes mellitus, and chronic

25 anaemia.

151 1 Q. There is also a reference to mobility, which suggests

2 the arrow going downwards, that means reduced mobility?

3 A. I beg your pardon?

4 Q. Before we get to the entry that focuses upon non-insulin

5 dependent diabetes, there is a little arrow to the right

6 pointing down for mobility, so that is reduced mobility,

7 is it?

8 A. That's correct, yes.

9 Q. And chronic anaemia is the final reference?

10 A. Yes.

11 Q. What about the interventions then that are recorded?

12 A. Generally, my comments there are the same as they have

13 been in the previous reports. There is a list of

14 interventions required in terms of -- some of these are

15 nursing interventions, such as observations, ward

16 urinalysis and obtaining specimens. There is

17 a transfusion, there is rather a large number of

18 investigations, there are referrals to physiotherapy,

19 antibiotic therapy, but again, this is a list of

20 interventions that would have been requested following

21 the doctor clerking the patient and, although there are

22 some elements of the 13 that are listed that are nursing

23 activities, it doesn't actually constitute a nursing

24 care plan.

25 Also, I refer to the previous comment that I made,

152 1 we have a problem sheet with five different -- well,

2 there are actually three -- there are four clinical

3 diagnoses and then one specific problem, ie, mobility.

4 There would have been, within those four clinical

5 diagnoses, a number of other probable problems that

6 would have been identified, but here we have one

7 document with a lot of information on it. It doesn't,

8 again, specify problem by problem, as I have previously

9 explained it should do.

10 LORD MACLEAN: If that is a convenient time?

11 MR MACAULAY: Yes, my Lord, that is probably a good point.

12 We will adjourn until 10 o'clock tomorrow.

13 (4.18 pm)

14 (The hearing was adjourned until

15 Tuesday, 7 June 2011 at 10.00 am)

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