3 MR MACAULAY: Good Morning, My Lord. the Next Witness

1 Monday, 23 January 20122 (10.00 am)3 MR MACAULAY: Good morning, my Lord. The next witness4 I would like to call is Dr Fiona Johnston.5 DR FIONA ANNE JOHNSTON (sworn)6 LORD MACLEAN: I understand that you have a back problem, or7 problems?8 A. Yes. We will not talk about that.9 LORD MACLEAN: No, but if you feel the need to stop and10 walk, or whatever, please let me know. We will have11 a break.12 A. Okay, thank you.13 Examination by MR MACAULAY14 MR MACAULAY: Good morning, Dr Johnston.15 A. Good morning.16 Q. I think you are Fiona Johnston; is that right?17 A. That's correct, yes.18 Q. Perhaps you could tell the Inquiry what position you19 hold at present?20 A. I'm a consultant physician in geriatric medicine at21 Inverclyde Royal Infirmary.22 Q. For how long have you held that post?23 A. Since May 2009.24 Q. I think, if I can look at your CV -- we don't have it on25 the database, but I can put it on the screen -- if we1 1 turn to the first page -- that's the frontispiece of2 the document -- can we note that you obtained your3 medical degree at the University of Glasgow in 1980; is4 that correct?5 A. That's correct.6 Q. You became a Member of the Royal College of Physicians7 in 1983; is that right?8 A. That's right.9 Q. And I think a Fellow of the Royal College of Physicians10 in 1993?11 A. That's correct.12 Q. If we just follow through your track record, if you turn13 to page 10 of the document -- again, we will have that14 on the screen, page 10 -- after graduation, do you set15 out here some information in relation to your16 pre-registration and post-registration experience?17 A. That's correct.18 Q. Can we note in particular that, from 1982, you were19 attached to the Southern General Hospital; is that20 right?21 A. Yes, that's correct.22 Q. Then if we turn on to page 11, can we see that you were23 a senior registrar in geriatric and general medicine24 from 1984 to 1989 at Stobhill General Hospital?25 A. That's correct.2 1 Q. Perhaps moving on a bit, page 7, here I think we see2 that you held the post of consultant physician with3 special interest in elderly medicine -- I'm sorry,4 I think page 7 is a consultant physician and5 geriatrician at Stobhill from 1989 to 2002.6 A. Yes.7 Q. I think that takes us up to when you first went to work8 at the Vale of Leven. If we turn to page 4 of the CV,9 can we see here that you are a consultant physician with10 special interest in elderly medicine at the11 Vale of Leven from May 2002 to 2009?12 A. Yes.13 Q. I think what you have done in the CV is you have set out14 some detail as to the nature of the hospital and also,15 indeed, your own duties at the hospital?16 A. Yes.17 Q. I will return to that shortly. I think that takes us18 up, then, to page 2 of the document, and I think here19 you set out some details of your present post of20 consultant physician in geriatric medicine at21 Inverclyde?22 A. That's correct.23 Q. You have been there, I think, as you have told us,24 since May 2009; is that right?25 A. Yes.3 1 Q. So far as the remainder of your CV is concerned, on2 page 9, do you give us some information about a number3 of committees that you have been a member of or been4 involved in over the years?5 A. That's correct.6 Q. I think you also tell us -- and I think this is on7 page 13, you give us some information about your8 research interests; is that right?9 A. That's correct.10 Q. I think also some information about your teaching11 commitments?12 A. Yes.13 Q. Finally, at pages 14 and 15, do you set out a list of14 publications that you have participated in?15 A. Yes, that's correct.16 Q. If we focus on your position in the Vale of Leven17 Hospital, Dr Johnston, because, as I think you are18 aware, that is what the Inquiry is interested in, and,19 in particular, the period from 1 January 2007 through to20 about June 2008?21 A. Yes.22 Q. At that time, you were employed as a consultant; is that23 correct?24 A. Yes. Maybe just a bit of clarification: I was appointed25 as a consultant physician with all the duties and4 1 responsibilities of medical receiving and for continuous2 care of my medical patients and, in addition, I was3 a consultant geriatrician at the Vale of Leven; the4 difference being that in most hospitals in which5 geriatricians have some involvement in medical6 receiving, that involvement stops at 24 hours and the7 patients are handed on to the next medical unit. So8 this is, I think, a unique position in Scotland at the9 time.10 Q. Just so I can understand the point you are making, you11 were appointed as a consultant physician, but in12 addition, you were also a consultant geriatrician?13 A. Yes. It was a different emphasis and the job was14 primarily a consultant physician's post, and the duties,15 therefore, were twofold, not ending at the point of16 medical receiving handover, but continuing for all the17 time that that patient was in hospital in the medical18 wards.19 Q. Can you give me, then, a general understanding as to20 your duties, and if we begin by --21 DAME ELISH: My Lord, I hesitate to interrupt at this stage,22 but before my learned friend moves on, as a point of23 clarification, the assumption was that Dr Johnston was24 appointed throughout this period. I wonder if you could25 clarify whether or not she was actually present at the5 1 hospital for that period?2 LORD MACLEAN: This is 2002 to 2009?3 DAME ELISH: Through the focus period, my Lord.4 LORD MACLEAN: 2009, yes.5 MR MACAULAY: Perhaps I can clarify that with you, looking6 at the period we are concerned with, which7 is January 2007 through to June 2008, what was the8 position in relation to your attendance at the hospital?9 A. Right. Well, I had a period of sickness absence from10 the middle of June 2007 until the beginning of October,11 and then I had a phased return to work, which means you12 gradually increase your duties over a period of six or13 eight weeks or so. So I was absent.14 Q. Who would cover for you, then, in your absence?15 A. Well, as I was absent, I don't think I can directly say,16 but I imagine there would be locum cover.17 Q. Who would organise that?18 A. That would be through the service manager or the general19 manager to obtain locum cover.20 Q. I think I was moving on to ask you about your duties at21 the hospital. If we just focus on the wards, first of22 all, can you help me with that? Were you concerned with23 a particular ward or wards?24 A. Well, I had perhaps better put it into some context in25 time. When I first went to the Vale of Leven in 2002,6 1 I was the only substantive consultant and there were2 various locums. I started off looking after ward 14,3 along with the hospital practitioner in ward 14, who was4 a Dr Stevenson. After a period of a couple of years,5 I switched to ward 15 to work with the hospital6 practitioner there, because I wanted to spread myself7 across the patch, so to speak, because we didn't have8 full-time, permanent staff.9 My duties would therefore consist of my clinical10 duties for geriatric medicine, which would be weekly11 ward rounds in either of these wards, a weekly MDT,12 I would have a day hospital MDT, I would have two13 outpatient clinics, general clinic, movement disorders,14 and I, in addition to that, would perform the full15 consultant physician duties, which were medical16 receiving and continuous responsibility for those17 patients in all the wards of the hospital -- that's 3,18 4, 6 and MAU.19 Q. I see.20 A. So I carried out twice- or thrice-weekly ward rounds in21 the medical ward in addition to all my duties in the22 rehabilitation wards, which was at times quite stressful23 and quite difficult to spread myself suitably across24 these two systems.25 So, effectively, the geriatricians, the two posts7 1 there, provided a third of the medical cover for the2 Vale of Leven; the other four positions providing the3 remaining two-thirds.4 Q. That's quite a lengthy answer, and I think you began at5 the beginning, as it were, when you were the only6 substantive consultant; is that right?7 A. Yes.8 Q. What about when we come to January 2007? What was the9 staffing position at that time?10 A. Well, there's still no -- from the consultant point of11 view, there were long-standing locums in cardiology, and12 also in stroke medicine, which was the second13 geriatrician post. The second geriatrician post came14 into being in 2000, I think, but the post was never15 filled during the time that I was there.16 Q. But we heard last week from Dr Akhter, and he was17 a locum consultant --18 A. Yes.19 Q. --and he was a geriatrician; is that right?20 A. That's right.21 Q. He was present in 2007?22 A. He was present, but he was not accredited in general or23 geriatric medicine. He was acting up as a staff -- or24 associate specialist, I think it was, at the time.25 DAME ELISH: My Lord, I wonder, again, for clarification,8 1 before my learned friend moves on, Dr Johnston has2 indicated that she was the first consultant of that3 nature. I wonder if there could be clarification as to4 what medical staff ran the hospital prior to the5 consultant post being created in 2002?6 MR MACAULAY: Can you help us with that?7 A. Well, this is something that the people who follow me8 may be better able to tell you. Essentially, in terms9 of the -- if we are talking about the rehabilitation10 side of the hospital, it was run by GP hospital11 practitioners on a sessional basis, part time.12 The second of the hospital practitioners -- that was13 Dr Stevenson -- retired in April 2007 and his post14 wasn't replaced. There was a consultant prior to me who15 practised geriatric medicine on a single-handed basis,16 but on a much slower turnover system, and he didn't do17 general medicine.18 So the difference was, when I went there, we19 reconfigured the service and made it quicker, but our20 staffing didn't follow that.21 Q. Coming, then, to 2007, and perhaps I could put this22 document before you and see if this can help us to23 clarify the position. If we look at GGC21720001, this24 we understand to be a document given to the junior25 doctors when they started to work in the Vale of Leven9 1 Hospital to provide them with some insight into the2 nature of the hospital, and you can see on this page,3 for example, that it is suggested that the hospital had4 approximately 180 beds onsite, and we see reference to5 the various areas covered -- general medicine, coronary6 care, and so on; do you see that?7 A. I'm not so sure about the numbers of beds, though. This8 may be an old document. Acute surgical admissions were9 transferred to the RAH early in the time that I was10 there, and the ITU bed was withdrawn also in 2006. So11 the bed numbers that had been quoted earlier were12 probably more relevant.13 Q. Okay. If we turn to page 3 of the document, we're given14 some information about the number of consultants in the15 hospital; do you see that? Does that represent the16 position as at 2007?17 A. Dr Akhter was a locum. It doesn't say that. But that18 would be correct for that time, with Dr Forbat in19 cardiology.20 Q. So we have Dr Carmichael, Dr McCruden, Dr Al-Shamma,21 yourself, Dr Forbat and Dr Akhter; is that right?22 A. Yes.23 Q. You have taken us to the point where you were the first24 substantive consultant. What about Drs Carmichael and25 McCruden? Did they come after you?10 1 A. Oh, no. You will see them later this week.2 Q. They were there before you went there; is that right?3 A. Yes. Dr Carmichael was the first, I think.4 Q. I'm sorry?5 A. Dr Carmichael was the first consultant.6 Q. If you turn to page 4 of the document --7 MR PEOPLES: My Lord, I'm sorry, I am perhaps not following8 this as clearly as I might. Dr Carmichael was the first9 consultant in what?10 A. Consultant physician. Just look at them all as11 physicians and within their own specialty -- sorry,12 I maybe shouldn't have jumped in there.13 LORD MACLEAN: I think what you're saying is he was the14 principal one and, I think, the one who was there the15 longest of all those mentioned?16 A. That's correct.17 LORD MACLEAN: What was his field?18 A. Pardon?19 LORD MACLEAN: Remind me what his field was.20 A. Gastroenterology.21 MR PEOPLES: I just wondered whether he had any involvement22 in geriatric medicine, and I was just trying to tie this23 in with the appointment later of someone who was24 responsible for geriatric medicine.25 LORD MACLEAN: She hasn't said that.11 1 He wasn't, was he?2 A. Shall I go through all the consultants and tell you what3 their specialties are?4 LORD MACLEAN: Why not.5 A. Dr McCruden was diabetes and endocrine; Dr Al-Shamma was6 respiratory; Dr Forbat was cardiology; I was general7 medicine, geriatrics and movement disorders; Dr Akhter8 was general medicine, geriatrics and stroke.9 LORD MACLEAN: Thank you.10 MR MACAULAY: If we turn to page 4, then, of the document,11 this is giving information about the rehabilitation and12 assessment directorate. This document suggests that the13 consultants were yourself and Dr Akhter, who is a locum.14 A. That's right. What is missing from the document are15 continuing care beds. There was a large reduction in16 continuing care beds when I first started under the17 balance of care, and two offsite hospitals closed and18 the remaining continuing care beds in ward 15 were19 transferred into rehab beds. We actually had 32 beds in20 each of these wards when I first started, but we21 reconfigured them to make it a smaller unit with more22 physio and OT ratios for staff to make it more effective23 for rehab.24 Q. I think you did mention a moment ago what your25 commitments were to ward rounds. Can I just understand12 1 that? If we take the different departments -- and here2 we are looking at the rehabilitation directorate -- what3 was your ward round commitment?4 A. My formal ward round was weekly, and we had5 a multidisciplinary team meeting weekly that Dr Herd and6 I both attended. Dr Herd, who was the hospital7 practitioner in ward 15, had five sessions but he also8 did his own ward round on a Thursday, on the day that9 I was usually medical receiving. So that's how it10 worked.11 In between times, I would go back into the ward to12 see if anybody was unwell, but I didn't have another13 formal ward round until the following Monday. That is14 normal practice for rehabilitation ward.15 But I would say to you that, as our activity16 increased with closer links with general medicine, our17 activity increased by 40 per cent in the first year.18 The amounts of patients that we were seeing closer to19 the point of entry to the hospital meant that I wasn't20 able to provide enough in ward round terms as I would21 have liked for that category of patient.22 If I just give you an example of length of stay, the23 length of stay in rehab fell to 22 days after 18 months24 when I first started, and in comparison across25 Inverclyde, Paisley and the Vale in 2008, which would be13 1 relevant to this time period, the length of stay in the2 RAH was 32 days and the length of stay in Inverclyde was3 36.4 So it reflects that there's more than slow-stream5 rehab going on in these wards.6 Q. What does "slow-stream rehab" mean?7 A. First of all, it means it takes longer, the patients are8 much more stable and many of them will be waiting to9 move on to nursing homes. The more active the unit10 gets, when you bring patients, say, for example, who11 have had pneumonia, over to a rehabilitation ward after12 a week or less than that, there's a potential that these13 patients won't be well enough to take part in the rehab,14 and so we occasionally saw patients being sent across15 probably too soon, I would say.16 Q. Might it be said, then, that there were patients in the17 rehab wards who might have been better suited in acute18 medical wards?19 A. Well, I saw it from both sides, which gave me a sort of20 added insight, really, because I was also an acute21 physician, and my -- the way I worked it was we didn't22 have a formal letter referral system, but the23 stipulation was that patients had to be medically stable24 and to have rehab goals, and that was identified by the25 physio and the OT in the medical ward. Occasionally --14 1 most of the time they got it right, but occasionally2 patients transferred who shouldn't have done, in my3 view.4 Q. Just looking to the staffing of the wards, then, from5 the medical perspective, I just want to understand what6 other levels of doctor were available, so if we take the7 rehab wards, that's 14, 15 and F; is that right?8 A. Yes.9 Q. Can you just help me with that?10 A. I will make it slightly more complicated, in that, when11 I first went there, ward F, which was the stroke ward,12 belonged to the medicine directorate, and so they had13 a medical FY1 in that ward. Other than --14 Q. If I can just stop you there, would it be possible to15 try to focus on the period we are interested in, which16 is January 2007 through to June 2008?17 A. That would be relevant for ward F, that there was18 a medical junior there, but very junior.19 Q. So in ward F, you had an FY1?20 A. An FY1 who was supplied by medicine but used by21 Dr Akhter in ward F. In wards 14 and 15, there had been22 a traditional input over many years by local GPs who23 provided sessional cover, five sessions a week each, so24 part time, in other words. That suited a rehabilitation25 unit that was quietly turning over with not much contact15 1 with acute medicine, but both of these practitioners2 found a change when I went there and started more3 closely linking with general medicine, in that more4 medically complex patients would be coming across and5 also the medical inputs when the GPs weren't there was6 either me, if I wasn't in my clinic, or a medical junior7 would be asked to come across.8 Now, there was some input from medical SHO level9 when I first started, but that had gone by the time of10 this period. It really was an FY1 would be called if11 there was a problem.12 So I think what I'm saying is that, beyond the13 sessions, the ward medical cover was borrowed from14 medicine at a very junior level and was not a ward-based15 SHO who was there all the time. I reflect --16 Q. Are you talking there about wards 14 and 15?17 A. Yes, I'm not talking about the other wards.18 Q. What about Dr Khan? Did he have any --19 A. Right. To explain Dr Khan, you have to go back20 to April 2007, when Dr Stevenson, who was the hospital21 practitioner for ward 14, retired. Now, his post was22 not replaced and there was no attempt made to replace23 his post, as far as I could see.24 So the move there was to kind of knit things25 together with locum SHOs, and that's where Dr Khan came16 1 in for that period of time, and others after him. There2 was never a substantive appointment for that ward.3 Q. Just so I understand, then, wards 14 and 15 were covered4 part time by local GPs; is that right so far?5 A. Yes.6 Q. And if required, an FY1 would be borrowed from another7 source?8 A. Yes. Also, out of hours, I should say, just to put it9 in its context, out of hours, after 5.00 and at10 weekends, the two medical juniors who were on for the11 hospital could be called to wards 14 and 15.12 Q. What about the other wards, the medical wards? Are we13 looking at wards 3 and 6?14 A. 3/4 was CCU/HDU and 6. There were some medical juniors15 and I cannot recollect exactly how many there were.16 There were middle grade staff, but not very many, and17 FY1s. So they had to cover 3, 4, 6 and MAU.18 In a larger hospital, you would have different19 groups of doctors looking after the general wards, and20 some doctors doing medical receiving and some doctors21 doing nights, and so on. So if you have a small group22 of doctors and you put one doctor on holiday, one doing23 nights, then it doesn't leave very many to actually run24 the shop.25 Q. I think we have heard this from other sources, but you17 1 did not have any doctors at registrar level then in the2 Vale of Leven?3 A. No, we did not. There was a staff grade in cardiology,4 I remember, but no trainee registrars. So we had very5 junior doctors really acting out of their skins, I would6 say, who were excellent in many cases, covering beyond7 their means.8 Q. As a consultant, how did you find working in the9 Vale of Leven at that time with no middle-range doctors?10 A. I found it extremely difficult. I'd been a consultant11 in three different places. When I was a consultant in12 a hospital in Glasgow, I had the full team. We had ITU,13 my own registrar, and ward rounds were well informed.14 When I was a consultant in the Vale, carrying out all15 these duties across the patch, when I was on my medical16 receiving day, for example, I would often have to go to17 MAU to see patients with the juniors because they were18 very junior. My call-out rate at evenings and weekends19 was very high and I sometimes had to return to the20 hospital to see patients who required transfer to ITU.21 So it was much more hands-on than I'd experienced22 anywhere else.23 Q. Do I take it, though, that your normal commitment would24 be from a Monday to a Friday?25 A. Yes. Our oncall commitment was a one in six with18 1 prospective cover for study leave and holidays,2 et cetera, so it works out about one in four and a half,3 actually, there, because you have to do all your 524 weeks' duties in the 42 weeks.5 Q. Would you be on call at the weekends?6 A. Oh, yes. Three-day weekends, Friday, Saturday, Sunday.7 Occasionally, if I did my Thursday as well, it would be8 a four-day weekend.9 Q. Can I then just look at the area of antibiotics and, in10 particular, the prescription of antibiotics?11 A. Yes.12 Q. In the period we are concerned with, what guidelines did13 you use to assist you in the prescribing of antibiotics?14 A. Right. I think there were a number of guidelines15 floating around because the two health boards had joined16 and there were some prior formularies from Argyll and17 Clyde 2006 and then Greater Glasgow in 2007.18 The antibiotic prescribing guideline of October 200719 was the one I used. It was widely displayed in the20 hospital and I had a copy in my office.21 Q. If I can just see if I can identify what you are talking22 about, if we could look at GGC22180001, I think this is23 the 2007 empirical antibiotic therapy guideline. Is24 this what you had in mind a moment ago?25 A. Yes, but you can't actually identify this because, of19 1 course, the tiny print at the bottom right has not2 copied. It is -- yes, that is 2007. But below that3 there was -- it is in smudge.4 Q. I'm sorry?5 A. There is a smudge at the bottom which tells you when it6 is about to be reviewed. It's below the bottom line7 that you see that says "duty microbiologist" on the8 right-hand side.9 Q. Oh, yes.10 A. You can't see it. You can't read it, but it11 is October 2007 to be reviewed December 2009.12 Q. Was it, in fact, reviewed? Was there a review following13 upon June 2008?14 A. Yes.15 Q. But so far as the period we are interested in is16 concerned, this would be the document that you would17 use?18 A. Yes.19 Q. As you have pointed out, there are other documents. If20 we look, for example, at GGC21790001, this, I think, is21 the Argyll and Clyde drug formulary for 2006. There has22 been some evidence that this document, or something23 similar to it, would also have been in use. Did you use24 this particular formulary yourself?25 A. I honestly couldn't identify that as a document. It's20 1 just an index page. It doesn't tell me. The 2006 one2 was around, and there is an interesting part at the3 back, which is the primary care guideline, what the GPs4 were prescribing at that time, and it wasn't there in5 the 2007 document. It is appendix 5(i), I think, at the6 back of this.7 Q. Are you saying that the GPs did not use this document?8 A. No, this is the hospital formulary, but this 2006 one9 had an appendix at the back, which was the primary care10 guideline, which differed from the hospital formulary.11 Q. If we look at the appendix, then, if we turn to12 page 156, for example, this is part of appendix 5, where13 there are lists of conditions and the recommended14 treatment?15 A. I think these are hospital ones, actually. You need to16 go further back.17 Q. When you say "further back", do you mean further into18 the document?19 A. Yes.20 Q. Appendix 5B? Is that of any assistance?21 A. It is either 5A or 5(i).22 Q. Is 5B helpful? That is page 204?23 A. Let's see. No.24 Q. Sorry, page 153.25 A. Yes, this is the GP or primary care guideline for acute21 1 community-acquired pneumonia.2 Q. If you turn to page 144?3 A. If you go further than that, to COPD --4 Q. Well, if we turn to page 145, then.5 A. Try that:6 "Acute exacerbation of COPD (local guidance), first7 line co-amoxiclav 625mg tid for five to ten days and8 cefaclor" -- now, that's second line for COPD on the9 hospital formulary and my remembrance at the time was10 that a lot of patients were coming into hospital having11 already had co-amoxiclav.12 Q. I'm just trying to identify the function of this13 document. Are you saying that appendix 5, parts of14 which we have looked at, would be used by the GPs --15 A. Yes.16 Q. -- to guide them in prescribing --17 A. Yes.18 Q. -- in the hospital?19 A. Not in the hospital; in the community.20 Q. In the community. You used the other document, the21 empirical antibiotic therapy document --22 A. Yes.23 Q. -- in the hospital?24 A. Yes.25 Q. Can you tell us in relation to the junior doctors what22 1 they would be using?2 A. They would use the hospital guideline, the EAT3 guideline.4 Q. The one that you used?5 A. Yes.6 Q. What about when the GPs are working in the hospital? Do7 you know what they used?8 A. I don't know for sure, but I'm fairly confident that9 they were prescribing more to their own guideline, but10 you could maybe ask one of the GPs later. Particularly11 in relation to urinary sepsis, there was certainly a bit12 of ciprofloxacin coming in.13 Q. If you look at GGC18270001.14 A. This is the following year, Greater Glasgow and Clyde,15 and this one doesn't have a primary care guideline.16 Q. Was this available in the Vale of Leven?17 A. Yes, this was available, but due to its large size, it18 sat in my office and I didn't carry it around with me.19 Q. I suppose the advantage of the document you made20 reference to, you have it all on one page?21 A. Mmm.22 Q. Is that right?23 A. That's correct.24 LORD MACLEAN: Could I ask you, Dr Johnston, in light of25 what you have just been saying, why is there23 1 a difference in what can be or should be prescribed2 between primary care and hospital care?3 A. I don't think I'm the person to answer that, really. It4 would be for the pharmacy to --5 LORD MACLEAN: Have a go. What do you think?6 A. I think the systems grow up separate. There is a lack7 of integration between primary and secondary care, so8 they create their own systems. I think that is broadly9 what goes on.10 I'm not sure -- I'm sure the primary care guideline11 is much toned down than it was then, but I think it's12 cultural that there were separate systems.13 LORD MACLEAN: As a layman, I find that quite difficult to14 grasp, because you'd think they'd be doing the same15 thing, or trying to do the same thing.16 A. You would, yes.17 LORD MACLEAN: Anyway, thank you.18 MR MACAULAY: I think you have indicated, Dr Johnston, that19 you think that the junior doctors would use the same20 document as you, yourself, used; is that right?21 A. Yes.22 Q. In relation to the other consultants, would they really23 be left to their own devices? They would use whatever24 they wanted to use?25 A. Well, I imagine they used the same document.24 1 Q. As you did?2 A. Yes. But it has to be said, in 2007 there was a lot of3 broad-spectrum antibiotics on the menu that were removed4 in 2008. So if something is on the menu, it will be5 chosen.6 Q. In relation to the role of junior doctors, would7 a junior doctor require to consult the consultant before8 making a prescription of antibiotics, or not?9 A. Not unless it was something unusual or unusually severe.10 They would normally make the clinical assessment -- it11 would be an FY2 or above who would be allowed to12 prescribe, and they would go by the clinical assessment,13 appropriate bloods, urine, blood culture test, and14 treat.15 Q. Looking at the period we are concerned with, what was16 your knowledge in that period in relation to the17 antibiotics that were known to precipitate C. difficile?18 A. Well, I'll answer the question and give you a reference.19 Yes, I had a knowledge that broad-spectrum antibiotics20 could cause C. difficile, but then we hadn't seen much21 evidence of C. difficile for a number of years. The22 other thing is, there is no reference in either of these23 formularies to the risk of C. difficile with24 broad-spectrum antibiotics. The formularies only refer25 to the risk of resistant infections. So it wasn't being25 1 promulgated.2 Q. I take it from that answer that you knew --3 A. Yes.4 Q. -- that broad-spectrum antibiotics could precipitate5 C. difficile?6 A. Yes.7 Q. You said in that answer, I think, that you hadn't seen8 much C. diff for a number of years; is that right?9 A. Mmm-hmm. It was an occasional event. Yes, that's true.10 Q. Just running on a bit, did you consider, in 2007 and11 into 2008, that there was more C. diff in the hospital12 than there had been in previous years?13 A. I would preface my feelings about it at the time was,14 where I was, on ward 15, the norovirus had shut the ward15 three times, so there were lots of patients with16 diarrhoea-type symptoms, and then we had one or two17 cases, I think, in the January which were presented at18 the hospital meeting, and we couldn't see any particular19 relationship to an infectious mode of transit in these20 two people. Both had broad-spectrum antibiotics in21 another hospital. But I think, generally, the norovirus22 was quite confusing. It was like the Trojan horse that23 brought in -- there were more samplings done, so you24 would pick up more carriers, anyway, and that's how it25 came to pass.26 1 As for the medical wards, I had a sixth of2 the patients, and my knowledge of cases was limited to3 the numbers of patients I had.4 Q. So in coming to my question, did you recognise that5 there was an increase in C. diff patients in that period6 than in previous years?7 A. Obviously, there must have been an increase, if they'd8 gone from zero.9 Q. Did you recognise that?10 A. But I wouldn't have recognised that one or two patients11 in a ward full of diarrhoea represented an outbreak of12 a specific organism. I couldn't have.13 DAME ELISH: My Lord, I wonder if my learned friend could14 clarify with this witness the period over which the15 norovirus resulted in the closure of the wards to get an16 indication of the timescale of that?17 MR MACAULAY: I will look at norovirus in a moment, but can18 I just get an answer to my question, if I can,19 Dr Johnston, and that is whether you recognised, in the20 period 2007 through to June 2008, that there was an21 increase in C. diff patients?22 A. An increase from zero to two, yes, another two.23 Q. The zero to two, are you talking there about ward 15?24 A. Yes.25 Q. What about the rest of the hospital, because you've27 1 indicated to us that you had commitments to other parts2 of the hospital. Did you --3 A. I don't think, at January, I had patients in the other4 part of the hospital who had C. diff.5 Q. Are you talking there about January -- what year is6 that?7 A. 2008.8 Q. I'm looking at the whole period, from January 20079 through to June 2008. Did you recognise in that period10 that there was an increase throughout the hospital of11 C. diff patients?12 A. I think if you use the word "increase", yes. If you use13 the word "outbreak", it depends what the difference in14 your definition of outbreak is. I would expect to be15 informed, if that were the case, by infection control.16 LORD MACLEAN: He didn't use the word "outbreak". He said17 "increase".18 A. I noted that.19 LORD MACLEAN: So what is the answer to the question20 "increase"?21 A. Yes.22 LORD MACLEAN: It is "increase", because you have been23 talking about nought to two at the beginning of -- early24 2007. Actually, the question was also not confined to25 your own ward but throughout the hospital; is that28 1 right, Mr MacAulay?2 MR MACAULAY: Yes, that was the second part of the question,3 yes.4 A. Well, I didn't have any knowledge of anyone else's5 patients. I couldn't have, unless I'd seen them at the6 weekend.7 MR KINROY: My Lord, I could be terribly wrong, but I think8 my learned friend would want to get it right. I may be9 wrong. I think the reference of increase from nought to10 two was early 2008, not early 2007.11 LORD MACLEAN: That may be my fault, actually.12 Which is it? I thought you said it went from nought13 to two in 2007?14 A. No, I wasn't referring to 2007.15 LORD MACLEAN: What were you referring to?16 A. It must have been 2008.17 MR MACAULAY: You made some mention of cases being presented18 at a meeting; is that correct?19 A. Yes. One of the juniors presented the two cases that20 I knew of in January, I think it was, to the Thursday21 lunchtime meeting.22 Q. The Thursday lunchtime meeting would be attended by23 whom, then?24 A. Quite a lot of the medical staff and various other25 specialties. No bacteriology, because they weren't29 1 there. Yeah. I think it was probably -- I can't -- no,2 it wasn't an audit meeting. It was just two cases.3 Q. Just to focus on the Thursday meeting, would your4 colleagues, your consultant colleagues, be in attendance5 at the Thursday meeting?6 A. Mostly, yes. I, myself, had some problems with7 attending it because I was usually on call, so I missed8 a few, but yeah.9 Q. Are you saying that throughout this whole period that we10 are focusing on, from January 2007 to June 2008, only on11 one occasion were there two cases mentioned at such12 a meeting?13 A. Yes.14 Q. The question of norovirus has been raised.15 A. Yes.16 Q. When was there a problem with the norovirus?17 A. I think you would need to check back with Anne Madden's18 statement, which I haven't relooked at in the last19 24 hours. The ward I think was closed three times20 between December and January. The last time it shut --21 it reopened on January 25th. That was when the ward22 became open again.23 Q. This is ward 15, is it?24 A. Yes. But there were three closures, as far as I recall.25 Q. So far as the junior doctors that you were dealing with30 1 were concerned, Dr Johnston, were you satisfied that2 they were aware that a patient could present with3 asymptomatic bacteriuria?4 A. If a patient has no symptoms, they tend not to present5 to hospital. Asymptomatic bacteriuria can only be6 described once you have got a result from a patient who7 presents usually with a symptom. I phrase it that way.8 All of the information or most of the information of9 asymptomatic bacteriuria is retrospective. So a patient10 without symptoms would generally not get a test unless11 you were looking for a sepsis screen, in which case you12 would test their urine. Junior doctors would be aware13 that it existed, but they would -- I think it is14 unlikely they'd see many cases in hospital unless the15 patient was catheterised.16 Q. Do I take it from that that they would be aware, then,17 with asymptomatic bacteriuria, that you would not18 prescribe antibiotics?19 A. Yes. I'm always cautious dealing with the elderly with20 very non-specific presentations, such as confusion, for21 example, which may relate to UTI, and also the people22 that send off the urine samples are usually the nursing23 staff, who might write "?UTI" and that may be described24 as asymptomatic, but it just depends how good the25 information is.31 1 Q. Would you, as the consultant, review the antibiotic2 treatment that had been prescribed by the junior doctor?3 A. If we're talking about the junior doctor, we're talking4 about the medical wards and, yes, I would on my twice or5 thrice visits to the medical wards, but antibiotic6 prescribing in ward 15 would be not so often because7 I was less often doing ward rounds there.8 Q. That was a weekly ward round, I think?9 A. A weekly ward round and seen again on an as-required10 basis.11 Q. If we are just focusing in particular on C. difficile,12 would you agree that C. difficile is an important13 clinical diagnosis in its own right?14 A. Yes.15 Q. Was that your approach to C. difficile in the period16 that we are concerned with?17 A. I think our experience of C. difficile led us -- not to18 have a -- you know, not that our approach was poor, but19 we simply hadn't seen what C. difficile can do. It's an20 important diagnosis. But until we went through that21 experience at the Vale, we were not aware of22 the potential.23 Q. Focusing on the relevant period, then, what is your24 position in relation to seeing C. difficile as an25 important clinical diagnosis in its own right?32 1 A. It is.2 Q. Did you see it as such in --3 A. Yes.4 Q. -- 2007/2008?5 A. Yes.6 Q. What were the lessons learned, then, from the experience7 in 2007/2008?8 A. Well, let me reflect back. My current experience of9 C. difficile in my new job and what I've learnt and10 taken to that, in my new post, there have been some11 cases of C. difficile, but we are not seeing the same12 rapid progression that we saw in the Vale. Equally sick13 patients with multiple comorbidities, very indolent,14 some with a weight loss, but we're not seeing that15 florid presentation that happened in the Vale, so my16 experience is that we were actually looking at17 a different disease. C. difficile for sure, but a much18 more virulent form of the disease.19 Q. I was picking you up on what the lessons were that you20 say you learnt.21 A. Well, antibiotic -- again, what I do now in my practice,22 I am responsible for training junior doctors at23 Inverclyde, and I give, every four months, a lecture24 from the consultant microbiologist and they also get25 infection control speaking to them. So every section of33 1 new doctors gets approached in this way. The occasional2 lunchtime lecture is not a substitute for an effective3 training programme.4 Q. Did you learn lessons from the experience you had in the5 Vale of Leven in 2007?6 A. Oh, yes. Antibiotic prescribing has been winnowed down,7 but I would have to say that colleagues who have not had8 the experience of the Vale of Leven are perhaps more9 relaxed about antibiotic prescribing than they should10 be. I don't think it is a general statement, but it is11 an occasional statement. So I think the experience12 changed us considerably.13 Q. What was your experience in the Vale of Leven?14 A. How do you mean? I'm not quite sure what you're saying.15 Q. You're saying the experience at the Vale of Leven16 changed you considerably. I'm asking you what was it?17 A. The experience -- what happened at the Vale of Leven was18 there was a lot of very frail patients with multiple19 comorbidities who were given broad-spectrum antibiotics,20 and the question of whether there was some21 cross-infection wasn't resolved until after the event.22 So that was my experience of it.23 Q. So that is really an after-the-event experience?24 A. It was after-the-event experience for the health board25 as well.34 1 Q. I'm sorry?2 A. For the health board too.3 Q. At the time that patients were in the Vale of Leven, and4 clearly a number died over the period we are interested5 in, from --6 A. Can I just go back to the antibiotic prescribing, just7 to answer your question? Most of the antibiotic8 prescribing was carried out in the acute wards, and then9 patients moved across to rehab and got their C. diff.10 Most of the antibiotic prescribing had already happened.11 One of the cases I had in that group who had recurrent12 C. diff wasn't given a single antibiotic over ten13 months, other than his C. diff antibiotics, so my14 experience had certainly influenced that.15 Q. I'm seeking to focus on what experience, if any, you had16 of C. diff over the relevant period, from January 200717 to June 2008. I think you have mentioned the two cases18 that we have discussed. Did you consider that you had19 any further experience of C. diff and patients dying and20 C. diff being included in --21 A. I'm not saying that there were only two cases, there22 were more cases, but I never saw them in numbers at the23 same time that would consider me to think that there was24 a particular problem.25 Q. Did there come a point when you considered there was35 1 a problem?2 A. There came a point, I think, with a clearly false3 negative sample in March, and bacteriology were involved4 in that. We didn't have an awareness at the time that5 the testing mechanism was -- had problems and that there6 were false negatives and that stools could deteriorate,7 and so on. None of these samples were issued with8 a caveat telling us that there was a significant false9 negative rate. We have heard in the Inquiry already10 that we are looking at 10 to 40 per cent. We know that11 now. We didn't know it then.12 Q. But I think we know now also there were quite a number13 of patients who did contract C. diff?14 A. Yes.15 Q. Particularly between December -- focusing on the period16 from December 2007 to June 2008. I'm just trying to17 understand whether during that -- if we focus on that18 period, whether you considered that you had patients who19 had C. diff and whether that registered with you?20 A. Yes. It registered with me, but the -- where the21 patients were and where they'd been, more particularly,22 and what medication they'd already had, seemed to me to23 be the predictors of the outcome.24 Q. What do you mean by that?25 A. As I just said, patients had been treated with36 1 broad-spectrum antibiotics already, sometimes many2 times, and they're moved to another ward, either with or3 about to get C. diff. It's very difficult to pin that4 down to any conclusion.5 LORD MACLEAN: Could I ask you, going back a bit -- I'm6 sorry to backtrack -- what you meant, and I think you7 said this, that cross-infection was an after-the-event8 experience?9 A. Yes. I think what's come through in the Inquiry is --10 that was news to me, was the length of time that could11 elapse between an indexed case and another one, and they12 could still be related as cross-infection. I had looked13 at the two early cases and I saw there was quite a long14 time between them and they weren't in any contact with15 one another in the ward. So that, at the time, was16 a lack of my knowledge, I would think.17 MR MACAULAY: I have gone down this route by asking you18 whether you considered C. diff to be an important19 clinical diagnosis, and I think you said it was. In20 this period, were you aware that C. difficile was21 a condition that could lead to death?22 A. Yes, but within the context of -- frail elderly23 admissions to hospital have a high mortality rate, in24 any case, and you are looking at the order of25 10 per cent in 30 days. So within the context of that,37 1 yes, but it would perhaps be -- perhaps I will put it2 around another way: if you or I had C. diff, we probably3 wouldn't go into hospital with it, and we may not even4 have symptoms, but it can make a big difference to an5 elderly patient and their comorbidities can interact6 with the outcome of the C. diff, as well as just the7 outcome of the comorbidities.8 Q. So the elderly are particularly vulnerable; is that what9 you are saying?10 A. Particularly vulnerable, yes.11 DAME ELISH: My Lord, I wonder -- the witness referred to12 the percentage, the average percentage, of mortality in13 elderly patients as being 10 per cent in 30 days. How14 does that compare to younger patients or more general15 medical patients and whether or not this is of16 particular significance?17 MR KINROY: My Lord, before we do that, should we perhaps18 clarify to what the statistic relates? I certainly take19 the view, perhaps erroneously, that it relates to the20 normal mortality rate in the frail elderly unconnected21 to any contraction of C. diff illness.22 A. What the figure relates to --23 LORD MACLEAN: Don't answer the question, please.24 A. I'm sorry.25 LORD MACLEAN: They have two different enquiries here.38 1 Mr MacAulay?2 MR MACAULAY: Yes, the 10 per cent in 30 days figure that3 you mentioned, to what does that relate, is the4 question?5 A. Right. Well, Glasgow will have their own figures, so6 I have not looked at those, but these are figures from7 Lanarkshire of acute admissions to hospital for elderly8 patients. It is just a ballpark figure for a unit.9 LORD MACLEAN: Then Dame Elish's question?10 MR MACAULAY: I think that --11 DAME ELISH: My Lord, that was my question.12 MR MACAULAY: That was the question she put. I think my13 learned friend Mr Kinroy's question was just to clarify14 to what the statistic relates.15 A. That is just, you know, a hospital unit. I think16 obviously you would need to look at a group of hospitals17 to get a picture. But it is not low, it is high.18 Q. Is it a rehab unit or an acute medical unit?19 A. Acute admissions of the elderly. That covers the lot.20 DAME ELISH: I wonder, my Lord, again, whether my learned21 friend could clarify whether or not that figure remains22 constant for extended periods of stay in hospitals?23 A. Okay. Do you want some more figures?24 MR MACAULAY: Perhaps you could tell us what the source of25 these figures are and we can maybe see if we can39 1 identify the source and try and put them into some sort2 of context.3 A. The first figure I have given you was Hairmyres. Okay?4 They are acute admissions of the elderly. They have an5 acute receiving unit for the elderly. Okay? There are6 other figures I can tell you to give you an idea of life7 expectancy in prolonged hospital stay in the elderly.8 Q. Are these figures in the public domain?9 A. Yes. I can give you figures from Hairmyres for patients10 who are deemed to require NHS continuing care. That is11 the very frail with lots of illnesses requiring lots of12 interventions who cannot even be fit enough to go to13 a nursing home. The figure of mortality at six months14 for this group is 80 per cent and some of15 the individuals in this Inquiry will be in that16 category.17 Q. What is the point you are trying to make here,18 Dr Johnston?19 A. It is the natural history of disease in old age. The20 fit elderly, which I should say are a different group,21 they are very active, looking after grandchildren, going22 on holidays, they are just biologically younger, but it23 is the frail elderly who are admitted to hospital who24 have the high mortality.25 Q. These are the vulnerable patients who ought to be40 1 protected against, for example, a serious infection like2 C. diff?3 A. Mmm-hmm.4 Q. Is that right?5 A. Yes.6 LORD MACLEAN: Where do these figures come from and for what7 period? You have quoted from Hairmyres. Where is that8 to be found?9 A. That is in the last three years.10 LORD MACLEAN: What publication was it in?11 A. It is not a publication. It is figures that have been12 kept by one of the units in Hairmyres Hospital.13 LORD MACLEAN: So over the last three years?14 A. Yes, but the health board will have perfect statistics15 on elderly admissions.16 MR MACAULAY: When, then, Dr Johnston, did you become aware17 that there may have been a problem in the Vale of Leven18 with C. difficile?19 A. I think we were aware -- there certainly were cases,20 yes. I realised there would be a problem in the middle21 of March, I think, that year, by which time the22 microbiology people were onto it as well, really from23 a false negative.24 Q. Let me just understand that. You begin by saying that25 you were aware that there were certainly cases; is that41 1 right?2 A. Mmm-hmm.3 Q. You have mentioned two, but are you saying you were4 aware there were other cases of C. difficile?5 A. I had other cases, but in ones and twos again and not6 over an extended period of time.7 Q. What was it about March, then, that caused you to think8 there was a problem? You say:9 "I realised there would be a problem in the middle10 of March ..."11 A. There was a problem with one case, in that there was12 a false negative and some delay, I think, in reporting13 it, but then I think -- now I understand it, they tended14 not to report false negatives quickly, but they were15 quick with the positives.16 LORD MACLEAN: Is that March 2008?17 A. Yes.18 MR MACAULAY: So there you are looking, really, at one19 particular case, and was that a case where the result20 was negative, but I think a post-mortem indicated21 that -- is that the case you are talking about?22 A. Yes.23 Q. There was C. diff?24 A. Yes.25 Q. That is one particular instance.42 1 A. Yes.2 Q. When were you aware that there had been a number of3 cases of C. diff?4 A. I was only aware after the infection control meeting5 in May, I think it was, that there had been a number,6 because there was a look-back exercise at four 027s,7 I think, and that's when, looking back, they discovered8 it.9 Q. So that's, you think, in about May 2008?10 A. Yes.11 Q. At that time, in 2007/2008, did you know what would12 constitute an outbreak?13 A. No, I did not. I have researched this since.14 Q. Let's leave --15 A. All right.16 Q. -- research for the moment. If you just focus on the17 period we are interested in. At that time, I think18 you're saying you did not know what would constitute an19 outbreak; is that right?20 A. We'd had experience of the norovirus with sort of half21 a dozen cases in the ward, and infection control shut22 the ward, announced an outbreak and did all the correct23 things, so I was fully confident that, if we were going24 to have any more different types of diarrhoea, that we25 would be told, in the same way as we'd been told about43 1 the norovirus.2 Q. But just looking at C. diff, because that is what we are3 interested in, as you're aware, did you or did you not4 know what would constitute an outbreak?5 A. I did not know at the time.6 Q. To what extent, if at all, did you have knowledge of7 the infection control manual?8 A. I was never issued with a copy of the infection control9 manual, at that point or since. The infection control10 manual is now available online, but no is the answer.11 Q. Were you aware of the existence of the infection control12 manual at the time we are interested in?13 A. I was aware of the existence of a number of policy14 manuals in managers' offices and in the ward manager's15 office, and I was aware of the infection control team,16 and I was aware of the broad principles of infection17 control. Did I know where there was a book in one of18 these offices? I don't know.19 Q. If we look at it, it is at GGC00780001, and if we turn20 to page 252, we are looking here at the C. difficile21 policy that was in the -- part of the manual.22 A. Excuse me, that policy is an old Glasgow policy from23 2004 that's been relabelled "Glasgow and Clyde". I see24 it is in existence to 2008, but I never received a copy25 of that at the time.44 1 Q. So --2 A. So there were a lot of policies floating around between3 the merger of the two health boards, and unless they4 reissued all of them, then we wouldn't know.5 Q. As you point out, this is headed "NHS Greater Glasgow6 and Clyde", and the Vale of Leven in 2007/2008 was part7 of NHS Glasgow and Clyde; is that right?8 A. Yes.9 Q. Did you have knowledge of any C. difficile policy?10 A. No.11 Q. If you look at this particular policy, at the section12 dealing with responsibilities, we are told that HCWs,13 that's healthcare workers, must follow this policy;14 inform a member of the ICT if this policy cannot be15 followed. Do you see that?16 A. Well, if I never received it -- I can read it.17 Q. You would fall into the category of a healthcare worker?18 A. Indeed I would, with a broad knowledge.19 Q. So I suppose, if you didn't know of the policy, you20 wouldn't know whether or not you would be following it21 or whether or not you would have to report something to22 the infection control team; is that fair?23 A. That's fair, yes.24 Q. Another policy I want you to look at is at page 258 of25 the manual. Here we are looking at a loose stools45 1 policy. Were you aware of this policy at the relevant2 time?3 A. Well, that policy ends in September 2007. Is that the4 relevant time?5 Q. There is another one, in fact, as well, which I can take6 you to, but leaving that aside for the moment, since7 this is covered by part of the period we are interested8 in, were you aware of this document at all?9 A. No. I think these would be directed at nursing staff,10 to be honest.11 Q. I can say again that it does mention healthcare workers.12 Do you see that?13 A. Mmm-hmm.14 Q. I think that would include yourself?15 A. If I'd been issued with it.16 Q. But you weren't issued with it?17 A. No.18 Q. You never saw it?19 A. No.20 Q. Page 145. We are looking now at an outbreak policy.21 Were you aware of this particular policy at the relevant22 date?23 A. This policy does not have a distribution list. The 201024 does, which says Staff Net and infection control manual,25 but there is no distribution list on this policy and46 1 I wasn't aware of it.2 Q. So you weren't aware of it?3 A. No.4 Q. Did you have any difficulty accessing a consultant5 microbiologist, if you wished to do so, in the period6 that we are interested in?7 A. That would normally be done -- either the junior doctor8 or the hospital practitioner. We didn't have9 a microbiologist onsite, which makes it a little less10 conjoined, shall we say, and the juniors often spoke to11 a series of different microbiologists over the period in12 time, so there wasn't a kind of one person that you13 could relate to.14 Q. But just looking to your own position as the consultant,15 did you, yourself, make contact on occasion with the16 consultant microbiologists?17 A. On occasion, yes, but it was most often done by the ward18 doctor.19 Q. I think, as you indicated, Dr Johnston, you didn't have20 a microbiologist on site in the Vale of Leven; is that21 correct?22 A. That's correct.23 Q. That hadn't always been the position?24 A. No. Actually, this was before my time. I think25 Dr Dancer had left in 2002.47 1 Q. So, really, that was before you went to work in the2 hospital?3 A. Yes, just look at this cross-over.4 Q. Just looking at infection control and, in particular,5 the infection control doctor, did you understand at the6 relevant time that there was an infection control doctor7 responsible for the Vale of Leven Hospital?8 A. At the time, there were just different names and9 I didn't know if there was an infection control doctor10 or if they were just all microbiologists.11 Q. One doctor that we have heard about was Dr Biggs. Did12 you have contact with Dr Biggs?13 A. No, not at that time, but through other juniors, junior14 staff, she would leave messages at the ward level.15 MR MACAULAY: My Lord, that might be an appropriate point to16 have a short break.17 (11.17 am)18 (A short break)19 (11.45 am)20 MR MACAULAY: Before the break, Dr Johnston, I had taken you21 to a number of the policies that were in the infection22 control manual, and in particular the outbreak policy,23 which you said you had not seen before; is that correct?24 A. Correct.25 Q. At the relevant time, did you have in your mind an idea48 1 as to what may constitute an outbreak of C. diff?2 A. No, I didn't.3 Q. At the time, did you become aware of there being4 patients isolated because they had C. diff?5 A. Yes.6 Q. If we're looking at ward 15, how many isolation rooms7 did you have in ward 15?8 A. There were four single rooms, but we never had more than9 one or two patients isolated.10 Q. What about the other two rooms?11 A. These were rooms for people with end-of-life care needs.12 Q. So there were two kept particularly for that purpose?13 A. Mmm-hmm. Some patients could be brought into ward 1514 from other places because there was a single room15 available.16 Q. What training, education, had you had in C. diff prior17 to January 2007?18 A. No training or education since post-graduate medical19 qualifications; none by the health board.20 Q. That was in the 1980s; is that correct, when that was?21 A. Yes.22 Q. Had you kept yourself informed in any way from then --23 A. Yes, yes.24 Q. -- in relation to C. diff infection as an infection?25 A. Yes, but there wasn't much of it at the time.49 1 Q. Did you become aware of the Stoke Mandeville problem in2 2007/2008?3 A. I recollect it in newspaper articles at the time.4 Q. Since June 2008, have you had any training or education5 in C. diff?6 A. Yes, there's training available online and Staff Net.7 Q. But in the Vale of Leven in particular?8 A. Oh, yes, we did the -- we all did formalised hand9 washing and training, which I have since repeated at10 Inverclyde.11 Q. After June 2008, were there training sessions set up --12 A. Yes, there --13 Q. -- in particular in connection with C. diff?14 A. Yes, they ran a number of sessions so that staff members15 could go in small groups.16 Q. Did you go to one of these sessions?17 A. Yes, and I do have a certificate.18 Q. Did you find that helpful?19 A. Yes, to a certain extent, about techniques of hand20 washing, but some of the other parts of the training, to21 do with cleaning out sluices and the hardware of22 the ward were not particularly referenced to medical23 staff.24 Q. Now, in the period we are concerned with, are you able25 to tell me if it was the practice of microbiologists to50 1 come to the ward to look at patients or not?2 A. Well, there was no microbiologists in the hospital, so3 unless they came at odd times, I never saw one.4 Q. So far as the management of C. diff patients is5 concerned, do you see the isolation of a patient who has6 got potentially infectious diarrhoea as important?7 A. Yes, it was important, but the problem the Vale had was8 they didn't have enough single rooms in the medical9 wards for isolation. I see it's important, but the10 fabric of the place didn't lend itself.11 Q. At the relevant time, were you aware then --12 A. Oh, yes. Yes.13 Q. Were you aware that there were patients with potentially14 infectious diarrhoea in the wards who could not be15 isolated?16 A. Not in 15. I wasn't aware of ward F at all. The17 medical wards -- well, I can't recall directly, but18 there must have been patients, due to the -- I think one19 or two single rooms in each ward, there must have been20 patients.21 Q. In particular, do you see it as important that patients22 who have been diagnosed with C. diff should be isolated?23 A. Yes.24 Q. So far as you are aware, were there patients who were25 diagnosed who were not isolated?51 1 A. I can't recall, actually.2 Q. Were you aware, looking to what you have said, that3 there were patients, then, who had potentially4 infectious diarrhoea and who were simply in the ward5 with other patients?6 A. I don't recollect that as being a factor in ward 15.7 I may be wrong, but I just don't recollect it.8 Q. What about any of the other wards that you had some9 involvement in?10 A. I don't recollect that.11 Q. Does the fact that a patient who may have infectious12 diarrhoea, the fact that such a patient is not isolated,13 put other patients at risk?14 A. Yes, it does.15 Q. Is that because of the risk of cross-infection?16 A. It could be.17 Q. Did you consider at the time whether or not in any of18 the wards there were patients in these wards who were19 being put at risk of cross-infection?20 A. I don't recall any of my patients.21 Q. Or any patients?22 A. I can't remember.23 Q. Insofar as the treatment of C. diff is concerned, what24 was the preferred first drug of choice at the time?25 A. You first had to get a specimen away to try to get52 1 a diagnosis. The drug of choice, according to the2 formulary, was metronidazole by mouth and, if that3 didn't succeed, microbiology contact, and it could4 either be metronidazole again or it could be vancomycin.5 Q. Did you consider it important at the time that there be6 a clinical assessment of the patient carried out to7 assess the severity of the infection?8 A. At the time, we didn't have the severity markers, sort9 of flowchart, but any patient who was unwell needed to10 be clinically assessed, usually by the ward doctor11 initially, but should also be seen by a consultant.12 Q. Although you may not have had a scoring system, would13 you consider it important, in any event, to clinically14 assess and see how bad the infection was?15 A. Yes, but a lot of that would be blood tests.16 Q. Would an abdominal examination be part of the clinical17 assessment?18 A. It would be part of the clinical assessment.19 Q. Should that sort of assessment be recorded in the20 medical notes?21 A. It should be, but it may not be. The overall status of22 the patient may be recorded, and the blood results.23 Q. You say "It should be, but it may not be". I can24 understand the first part. Why would it not be25 recorded?53 1 A. It might not be recorded if there is an overall summary2 of the status of the patient. The patient may be3 examined but not all the component parts recorded.4 Q. Why would that be? Why would not all the component5 parts be recorded?6 A. If they were negative, they might not be recorded. They7 should be, but they might not be.8 Q. Is it important to record negative results as well as9 positive results?10 A. Yes, it's important.11 Q. If antibiotics are prescribed to a patient who is12 suffering from C. diff, do you consider it to be13 important to have ongoing antibiotic review of such14 a patient?15 DAME ELISH: Sorry, my Lord, before moving on from the set16 of questions regarding the importance of recording of17 abdominal examinations, et cetera, I wonder if the18 witness could be asked for an explanation as to why that19 might not take place, given that she said it would be20 important?21 MR MACAULAY: Yes, I thought I had asked that.22 LORD MACLEAN: So did I.23 MR MACAULAY: Can I ask again, then? I have been prompted24 to ask you again, Dr Johnston, why wouldn't the25 component parts be recorded?54 1 A. If the doctor was conducting a ward round without junior2 staff, there may be some summarising goes on in the3 notes. If there is a junior doctor there, they might4 actually write in the notes for you. So there may be an5 element of time in completing the examination and6 recording of things before moving on to the next one.7 Q. Are you there postulating a situation where the8 consultant is reviewing the patient and the junior9 doctor is writing down what the consultant finds?10 A. That would be the ideal, in the same way as I have got11 a stenographer sitting beside me writing down everything12 I am saying. That would be ideal, because I can talk13 and think and do without having to think about writing14 down. But if there isn't a junior doctor there, the15 consultant is much more under pressure to summarise, so16 they can get on to the next patient. If there is no17 junior doctor there, they have to seek out all the18 aspects of the medical care manually from the notes, go19 and find results, put up X-rays and, in fact, function20 as an operator rather than a lead clinician.21 Q. But was it your own practice, Dr Johnston, if you22 examined a patient, to write your own notes of23 the findings?24 A. It was my own practice to do that, but because I -- I'm25 alluding to I did solo ward rounds without medical55 1 support. I would not have the time to write as full2 notes as I would like to do, which I do nowadays.3 Q. You mean you have more time nowadays to do a fuller4 note?5 A. Yes, less of the encounter is taken up looking for6 things and writing down.7 DAME ELISH: My Lord, I wonder if my learned friend could8 ascertain from the witness what time was allocated9 for -- or the average time of per patient in a ward10 round of this nature, if there was such a thing?11 LORD MACLEAN: Is that possible?12 A. Yes, I have looked at it, and also in my current -- I'm13 not talking about my medical ward rounds, which go on14 forever, but my current allocation for rehabilitation15 patients, it's still about 7 minutes per patient, but16 I currently have one or two junior doctors supporting17 the ward round, I have a clinical pharmacist who has18 already gone through all the medications right back to19 primary care, and I have a nurse who has all the20 information and various tools ready on the ward round.21 So it is a much more effective ward round than I was22 able to do at the Vale.23 MR MACAULAY: The 7 minutes per patient you have mentioned24 in that answer, is that the position now?25 A. It actually is. I have a slightly different caseload,56 1 but I have a much more efficient and effective ward2 round because of the support that I have.3 Q. But does it depend on the condition of the patient?4 A. Of course it does, yes. Of course it does.5 Q. One patient might take a few minutes and one patient6 might take much, much longer?7 A. Indeed. A medically unstable patient might finish the8 ward round.9 Q. When you're looking at a patient who is suffering from10 C. difficile infection, do you see fluid and nutritional11 management as being an important part of care?12 A. Yes, I do.13 Q. Why is that?14 A. Because you can lose 25 per cent of your body weight15 with chronic recurrent C. diff, and I have experience of16 that in Inverclyde, no matter what you do with fluid and17 nutrition, so it is a very catabolic experience for the18 patient. It is also very difficult to encourage19 patients with severe anorexia to take their diet and20 nasogastric feeds, which may be used to build up the21 patient, but may actually make the diarrhoea worse. So22 it is a very difficult situation to deal with.23 Q. I had, I think, been asking you about ongoing antibiotic24 review of a patient with C. diff?25 A. Yes.57 1 Q. Would that be important?2 A. Are you referring to the treatment of the C. diff --3 Q. Yes.4 A. -- or to other antibiotics?5 Q. I'm looking, first of all, to the treatment of6 the C. diff?7 A. Treatment of the C. diff. Well, you would be expecting8 to see some improvement within a week and, if not, you9 need to review what the treatment is.10 Q. When you say "within a week", can you give me an idea of11 how many days do you think, if there is no improvement12 on metronidazole?13 A. That's something that should be flagged up by the14 nursing staff, because the doctor isn't always in the15 ward and they should be informing you what's happening.16 You know, it has to be passed in that direction.17 Q. If we are looking at the time, timescale, if a patient18 has been prescribed metronidazole and there isn't any19 particular improvement, then what timescales are you20 talking about?21 A. I don't think you'd -- you can take a rough guess of22 about six, seven days, but I don't think -- in an23 individual patient, they might be much iller before24 that, so you'd need to be flexible on that.25 Q. In the management of such a patient, do you consider58 1 that the use of a stool chart is important?2 A. Well, it's become important. Stool charts were not3 widely used before this, but the nursing staff were4 recording things in the narrative. The practical5 difference it makes to me now is that they have a record6 which is more accurately describing what's going on, but7 the communication between the nursing staff and me is8 still verbal, and they're reciting what's in the stool9 chart, rather than reciting what happened a day or two10 back.11 Q. When you say --12 MR KINROY: My Lord, I wonder if we need to go back a bit to13 an answer? Obviously it is for your Lordship and my14 learned friend, but on the question of the condition of15 the patient should be flagged up by the nursing staff16 because the doctor isn't always in the ward, I wonder17 how long it would be before the doctor should be in the18 ward? Would this justify, for example, a doctor seeing19 the patient only once in a week unless otherwise20 notified by the nursing staff?21 LORD MACLEAN: Can you answer that?22 A. When I say "the doctor", I'm talking about -- it would23 be the hospital practitioner, in this case, or the24 junior doctor in the medical wards, because it has to be25 ward based. The consultant doesn't know what's59 1 happening outwith their visits to the ward.2 MR MACAULAY: Coming back to the position of stool charts,3 you can correct me if I am wrong, Dr Johnston, but did4 you suggest, an answer or two back, that at the time5 stool charts were not in great use?6 A. Certainly looking back over my 20 years as a consultant,7 I don't think they were in great use, unless you were8 working in a gastro ward, for example, patients with9 colitis.10 Q. But if we're looking at the period we are interested in11 in the Vale of Leven, what's your experience of stool12 charts at that time?13 A. There was a little stool charting recording. Mainly it14 was in the narrative in the nursing notes.15 Q. Did you, yourself -- well, what was your position in16 relation to the keeping of stool charts? Did you or did17 you not see that as important in the management?18 A. The keeping of some record is important.19 Q. But not necessarily a document that provided details of20 the stools?21 A. Well, it has to be something that they will do regularly22 and adhere to, whatever the method is.23 Q. What about fluid balance charts, then, if you are24 looking at fluid management? Did you see the keeping of25 fluid balance charts as important at the time we are60 1 interested in?2 A. I think the time when we had norovirus in the ward,3 there was lots of diarrhoea and vomiting, and it would4 have been, I think, impossible for nursing staff to have5 kept accurate fluid charts in that situation, in an6 outbreak situation at that.7 The fluid chart helps, but it's never accurate8 unless you're in HDU and you've got central venous9 monitoring and you're catheterising, particularly10 patients with diarrhoea. The key question is: is this11 patient eating, drinking, passing urine? If the answer12 to any of these is no, then they should have some form13 of fluid chart.14 Q. How would you know if the patient is drinking if you are15 not keeping some record of what --16 A. Nursing staff record it in the nursing notes.17 Q. So you would be looking to the narrative of the nursing18 notes then to see whether or not the patient --19 A. I didn't see the nursing notes on the ward round, but20 I'm just reflecting what I've seen looking back in the21 notes. There were fluid charts which were not very well22 kept and they were intermittent, particularly if the23 patients were unwell for a long time.24 Q. If you are looking at a patient who is suffering from25 C. difficile and has diarrhoea, then fluid management61 1 does become an important aspect of care?2 A. Oh, yes, it certainly does.3 Q. Going back to the issue of antibiotics, if you have4 a patient who is on antibiotics and that patient5 develops C. diff, what would your practice be in6 relation to the antibiotics that the patient is on?7 A. That's a very general question, but I can relate some of8 it to some of the cases that I had. A patient with9 a recurring severe pneumonia nearly landing up in ITU10 develops C. diff after several broad-spectrum11 antibiotics but still continues to have pneumonia, you12 have a problem. What are you going to treat?13 If the patient is not absolutely requiring the14 broad-spectrum antibiotic, it should be stopped. There15 certainly were cases here where I discovered a junior16 doctor has put a patient on ceftriaxone for some17 undiagnosed sepsis, which I have then put a line through18 the next day, but totally policing the antibiotic19 prescribing, unless you were there with the junior20 doctor 24/7, is not actually possible, but you can21 educate and encourage.22 Q. Is that an example of the junior doctor prescribing an23 antibiotic which you considered to be inappropriate?24 A. Yes. Yes, that's right.25 Q. So you would then review that and --62 1 A. Yes --2 Q. -- change the antibiotic?3 A. My point about the antibiotic EAT guideline is, whenever4 there is something on the menu, it will be chosen. So5 they were prescribing, whether or not it was6 appropriate, broad-spectrum antibiotics which now are no7 longer on the menu, and that is the difference.8 Q. Did you -- I think you have touched upon this already --9 at the relevant time have any knowledge about the10 possibility of false negative results for C. diff?11 A. None. Normally, what happens with false negatives and12 false positives is they are reported on the report form13 with the result. Tumour markers, for example, D-dimers,14 for example, but we got no report or knowledge from15 microbiology that we were maybe seeing false negatives.16 Q. What you would get, if the result was positive, you'd17 get a positive result --18 A. Mmm-hmm.19 Q. -- and that usually would be phoned in to the ward or20 infection control?21 A. Yes.22 Q. But if it is a negative result, then it is simply looked23 upon as a negative result?24 A. At that time, and I have to place myself in that time.25 DAME ELISH: My Lord, my friend moved quickly there to the63 1 issue of false negatives. I wonder if I could ask my2 learned friend to move back to the issue of the stopping3 of antibiotics and clarify with this witness, from her4 experience, whether or not the decision to stop5 antibiotics where there were significant comorbidities6 was a difficult or easy judgment to make in7 circumstances where C. difficile arose?8 A. Do you want me to answer that?9 LORD MACLEAN: Yes. You are faced with a dilemma, aren't10 you, in that situation? Was it easy or difficult to11 resolve?12 A. That was difficult, and that is a senior decision,13 because, in some instances, what you are actually14 looking at is palliative care and when you move off the15 active treatment to treatment of symptoms, and there can16 be very difficult decisions to be made about that. So17 it is never a quick answer.18 MR MACAULAY: If you had a patient who tested positive for19 C. diff and was on antibiotics, would you review the20 antibiotic treatment?21 A. Oh, yes. Yes.22 Q. If you came to the view that there was an infection that23 did require antibiotic treatment quite separate from the24 C. diff, you could still consider whether or not to25 introduce a narrower-spectrum antibiotic?64 1 A. You would, at that point, consult microbiology for2 a better plan.3 Q. If you were going to deal with a patient who had4 C. diff, would you take any particular precautions?5 A. Yes. You wear your protective apron and gloves.6 Q. Can we just understand what dealings, if any, you had7 with infection control? Can you help me with that: did8 you have any dealings generally with the infection9 control nurse or nurses in the Vale of Leven?10 A. Yes, I did. As I recall, there were two initially and11 then one retired and so there was one. I think it was12 Jean Murray and Helen O'Neill, who remained. I'm not13 sure to what extent they were full time or whether14 Helen, when she was on her own, was full time or not.15 I can't remember. They normally related directly to the16 nursing staff on the ward, but they would also tell me,17 generally, issues of where patients were going and18 I would ask them about how long patients needed to be in19 isolation. It was to do with isolation, mainly. But20 they never came with a graph showing me all the21 instances of C. diff across the patch.22 Q. Would you see the infection control nurse, then, on the23 ward to have these discussions with her?24 A. I did see them on the ward. Certainly on the medical25 wards and to some extent in ward 15, I did see them.65 1 Q. If you have a patient who develops diarrhoea, should2 loperamide be given to such a patient?3 A. It depends what the cause of the diarrhoea is. If it is4 a problem with diverticular disease, then you would give5 loperamide. If you don't know the cause of6 the diarrhoea or if you think it might be infectious,7 then you shouldn't.8 Q. Does it follow from that answer that if you know the9 patient has got C. difficile, you should not give them10 loperamide?11 A. You shouldn't. And if nurses know the patient has12 C. difficile, they shouldn't give out any loperamide13 anyway. They can stop a medicine on the basis of they14 think it might do detriment and then call the doctor to15 have it scored off.16 Q. When you're dealing with elderly people, can such17 patients become dehydrated very quickly?18 A. Yes.19 Q. Is the risk even more so if the patient is suffering20 from an illness such as C. difficile?21 A. Yes, that's true.22 Q. That can sort of tip them over the edge; is that23 correct?24 A. Yes.25 MR KINROY: My Lord, I think there was evidence earlier from66 1 an expert that managing the fluid balance of the frail2 elderly so as to prevent mortality is a very difficult3 thing, indeed, to do. I wonder if we could perhaps have4 the views of this witness on that proposition?5 A. Yes. Most of these elderly patients will have chronic6 renal impairment and many will have a degree of cardiac7 failure. These are the patients that can be8 simultaneously wet and dry; in other words, they may be9 losing fluids and dehydrated, but if you put in fluids10 too quickly, then, if their albumin is low, the fluid11 can leak through the circulation into the lungs. If12 they have cardiac failure, they can develop pump failure13 with overload. So they are very difficult to manage.14 There is an argument that, to properly manage them,15 you should manage them in HDU with central monitoring16 and catheterisation, but I think that is a step perhaps17 in the high-tech pathway.18 MR MACAULAY: Does the difficulty in managing such patients19 indicate that it is important to have their fluids20 properly monitored and managed?21 A. I think it does, yes, but it depends also on what you22 are able to do for them. For example, if you have23 a patient who is unable to swallow and has got C. diff24 and they can't take their medication for it, then you've25 got a bit of a problem, if you can't get venous access,67 1 to go onto a PEG tube. How far do you go up the pathway2 of invasive care?3 Q. Can I ask you some questions about the resuscitation4 policy? Were you aware of the policy that was in place5 at the time?6 A. There was the Vale of Leven one, but there was also7 a national guideline in 2007 from the Resuscitation8 Council that came out which changed things a little.9 Q. In relation to the Vale of Leven policy, you were aware10 of that policy?11 A. Yes.12 Q. Insofar as DNAR orders were concerned, did these require13 to be countersigned by the consultant in charge of14 the case?15 A. Not if it was a senior doctor in general practice, and16 in the case of oncall juniors, it was the most senior17 junior that would countersign, but it would have to be18 signed by the consultant the following day, but if the19 patient dies overnight, for example, there will not be20 a second signature on the form.21 Q. Can you tell me what staff morale was like during this22 period, Dr Johnston? I think we have heard some23 evidence that there was some uncertainty over the future24 of the hospital?25 A. I think the Vale had a very strong collegiate, corporate68 1 kind of status. It was a -- its own little fishbowl.2 But uncertainty was the biggest problem with morale.3 They were waiting for the big answer for years, and the4 big answer, which is now in place, has reduced the5 hospital to a more restricted facility, albeit all the6 more stable for that, but I think that was the case.7 Q. Did the uncertainty that you mentioned impact upon8 morale?9 A. Not in the sense of patient care, but in the sense of --10 I kind of -- the identity of the place. It was very11 much a local hospital, but there was a certain loss of12 identity as people didn't know what direction it was13 taking.14 DAME ELISH: My Lord, on that particular issue, I wonder15 whether or not my friend could confirm whether or not16 this witness is aware whether or not that uncertainty17 had any impact on prospective recruitment of clinicians18 and junior doctors?19 LORD MACLEAN: Would you know the answer to that question?20 A. Well, it was possible, yes, for the recruitment side,21 but the other more obvious thing was, if people left,22 a post may not necessarily be replaced, so it was23 a double thing.24 MR MACAULAY: I think you, yourself, had some25 correspondence, going back in time, in connection with69 1 the proposed loss of a consultant physician at the2 Vale of Leven; is that right?3 A. Yes.4 Q. If we look at INQ02390001, I think we have there5 a letter or it may be an email, in fact -- it may be6 dated 5 December 2005, from you to Mr Divers; is that7 correct?8 A. That's correct.9 Q. What was Mr Divers' position at the time?10 A. He was the chief executive of Greater Glasgow Health11 Board at that time, and this time was about three months12 before Greater Glasgow took over Argyll and Clyde.13 Q. What was the problem at this point that you wanted to14 draw to Mr Divers' attention?15 A. The problem was simply that the outgoing health board16 had decided on an action to remove a consultant post17 without consulting the consultants or without recourse18 to a plan B which would be a replacement for this. This19 was done very quietly through a small committee in the20 community, known as the Older People Services Forum, and21 I was kept unaware of this, although it had been22 discussed in other hospitals in Argyll and Clyde, until23 a knock at the door came and a nurse manager told me24 I was about to lose a post.25 So what I did was I took it as an employment issue70 1 to the BMA and I put in a grievance with the then2 medical director, Liz Jordan, but she didn't bring it to3 the table and, as they were going to really pass it on4 the nod in the December board meeting, that's when5 I wrote to Tom Divers and I copied it to6 Catriona Renfrew.7 Q. Did that have the desired effect? Did it prevent the8 loss of the consultant?9 A. Yes, it did, and I got it in writing.10 LORD MACLEAN: What was the post that was --11 A. The post was a post -- it was an acute post in stroke12 medicine, general medicine and geriatric medicine and13 I had prepared it for -- an advertisement, and gone14 through national panellists, et cetera, but if the15 consequence of removing that post would mean that the16 remaining consultant, that was me, would be17 unsustainable as a single consultant geriatrician and18 the remaining four general physicians would have an19 unsustainable rota, so it was a tipping point for the20 Vale. The Glasgow Health Board came in and shut that21 down. I then got the post through the vacancy22 management committee in March, which was just before the23 wire came down on Argyll and Clyde.24 The post was thereafter readvertised in Glasgow, but25 there were no applicants, but the post remained intact.71 1 DAME ELISH: My Lord, for the sake of clarification,2 I wonder if my learned friend could indicate whether or3 not this was a post covered by the witness Dr Akhter?4 A. This is correct. The funding for that post -- I don't5 know a great deal about it, but half of it came from6 acute general medicine and the other half came from the7 CHP, but the funding moved to the CHP at some point and8 I think that's when they thought they could cut it.9 MR MACAULAY: Just to be clear, then, the post that was10 going to be removed was the one that was being held by11 Dr Akhter at the time?12 A. No, he wouldn't have been in the post at the time. It13 would be another locum. The six posts required the six14 posts for -- in order for -- at that stage, for the15 hospital to function, and taking anyone out is like16 taking a leg off a stool.17 Q. I think -- we needn't look at the detail of this -- if18 we turn to page 2 of what is on the screen, I think you19 had discussed a detailed memorandum setting out the20 arguments in favour of the retention of the post; is21 that right?22 A. Yes, that's correct.23 Q. The other thing I want to ask you about at this point24 relates to induction. When new doctors came to work at25 the Vale, would they undergo an induction process?72 1 A. They did.2 Q. If we turn to this document, GGC21120001, we are looking3 here at a document headed "Doctors' Induction Day", and4 can we see that this sets out a programme in relation to5 which a number of doctors participate? We see, I think,6 your name is mentioned towards the bottom, once or twice7 in the list. Would this be the sort of programme that8 would be prepared for the new doctors?9 A. I would have to say that I was never involved in this,10 because I had a movement disorder clinic on a Wednesday11 morning, and my name would appear as being the clinical12 supervisor, but I never took part in any of these13 inductions.14 Q. In any event, these inductions for new doctors would15 take place along the lines set out in this document; is16 that right?17 A. Yes.18 Q. We heard last week from Dr Khan to the effect that he19 did not receive an induction training when he went to20 the Vale of Leven. First of all, was that correct, so21 far as you're aware?22 A. I was off sick at that time. He was in July, I think,23 2007. I wasn't at work.24 Q. But a locum doctor who was coming to the Vale of Leven25 for the first time, would such a doctor also be given73 1 some form of induction training?2 A. They should be, yes.3 MR PEOPLES: My Lord, I wonder whether my learned friend4 could perhaps deal with a matter at this point about the5 induction of junior doctors? We have heard some6 evidence about a continual throughput of doctors every7 three or four months or six months. I'm not sure8 whether Dr Johnston could perhaps give us a very brief9 education in that process, because we have heard there10 is quite a lot of change of junior doctors within the11 hospital or within specific boards.12 LORD MACLEAN: Do you want to deal with that with this13 witness or do you want to deal with it later, with14 Dr McCruden, for example? It is up to you.15 MR MACAULAY: I can take Dr Johnston's views on that.16 A. I suggest it would be better done by Dr McCruden or17 Dr Carmichael.18 Q. Very well.19 A. Yes.20 Q. After it became evident that there may have been21 a problem with C. diff in the Vale of Leven Hospital,22 was the approach taken to antibiotic prescribing23 changed?24 A. June 2008.25 Q. If we look at this document, GGC16530001, we are looking74 1 here at an E mail. I think we see Dr McCruden's name at2 the top, but we also see your name listed. It seems to3 be signed by John Dickson, and we see the date is4 13 June 2008:5 "I am writing to inform you that as of today6 (13/6/08) the following antibiotic policy applies7 throughout the RAH."8 The focus there is on the RAH, but did that also9 include the Vale of Leven?10 A. I don't recollect the email, but it's fairly likely that11 it includes the Vale of Leven.12 Q. If we look at the attachment on page 2 of the document,13 does this ring a bell with you, that this was the plan14 at this time, that this was to be the new policy?15 A. That doesn't ring a bell, but it's perfectly reasonable.16 Q. But, in any event, there was a change?17 A. Oh, yes.18 Q. Was there also some advice given in relation to19 infection control guidance at about this time? If I can20 put this on the screen, can we look at GGC16520001,21 there's a heading here in this email of "Infection22 control guidance". It seems to be 12 June 2008. If you23 turn to page 2, there's a document headed "Infection24 control guidance for medical staff". Do you recognise25 this document?75 1 A. I don't, actually, but, again, it's perfectly2 reasonable.3 Q. If we could look at another document, please,4 GGC05040001, we are looking at the minutes of a clinical5 governance meeting held on 16 June 2008. I think we can6 see that your name is listed as one of the people7 present; is that correct?8 A. It looks -- yes.9 Q. Were you a member of this particular group?10 A. I ran it.11 Q. Did you have regular meetings?12 A. We had monthly meetings and -- some of it was13 educational, some of it was to do with governance.14 Q. At any meetings prior to this meeting, had infection15 control been a matter for discussion or not?16 A. Probably norovirus, yes.17 Q. I'm focusing on C. diff. So far as C. diff was18 concerned, was there any discussion about C. diff?19 A. I don't recollect, no.20 Q. This meeting seems to be focusing upon the fact that21 through the media and the health board there had been22 a number of C. difficile cases identified; is that23 right?24 A. Yes, it looks like it.25 Q. You have listed under the heading "Factors were76 1 considered in the discussion" a number of areas. The2 first, for example, is:3 "Hospital fabric and state of refurbishment,4 including washing facilities and lack of investment by5 health board noted."6 What was the position at this time, Dr Johnston, in7 relation, for example, to the availability of washing8 facilities?9 A. I think that was more critically acute in the medical10 wards. There were reasonable facilities in the11 rehabilitation wards.12 Q. What was the position in the medical wards?13 A. Not enough hand basins.14 Q. Had that been made known?15 A. Oh, I think that had been made known for years, but16 nothing had been done about it.17 LORD MACLEAN: Forgive me for asking this -- I should know18 it -- what is the acronym RAD? What does that stand19 for?20 A. Rehabilitation and assessment directorate.21 LORD MACLEAN: Thank you.22 MR MACAULAY: Item 2 I think deals with the change in23 antibiotics which we have touched upon. Item 3, "Lack24 of confidence in current testing systems for25 C. difficile", is that something you have already77 1 touched upon?2 A. I think that is.3 Q. In relation to --4 A. I don't actually remember this document, but I think it5 captures quite a lot in it.6 Q. If we turn to page 2 of the document, under the heading7 "Next steps", at 2, it mentions that you, yourself, and8 Dr McCruden were to meet with Dr Linda Bagrade to9 discuss clinical cases. What was the purpose behind10 that?11 A. We, the consultants, felt at the time that one of12 the best ways of going through this was going back13 through cases with -- sort of a peer review thing, with14 bacteriology as well, but we were never afforded that15 opportunity. We weren't allowed to see the case notes16 or deal with it at that level. It was taken out of our17 hands with the various enquiries.18 MR KINROY: My Lord, I wonder if we could enquire whether19 this witness knows if some of that was because there was20 an independent review instructed by the Scottish21 Government and it was thought best that that review22 should explore what had happened, rather than this23 particular witness going about it in the way she had24 hoped?25 LORD MACLEAN: Is that not implicit in her answer, the very78 1 last sentence of her answer?2 MR KINROY: Well, it is, my Lord, except the reason for why3 she was not allowed to explore it as she might have4 hoped is not clear from her evidence. She may not know5 it.6 LORD MACLEAN: Well, she says, "It was taken out of our7 hands with the various inquiries".8 MR KINROY: My Lord, I overlooked that. Thank you.9 LORD MACLEAN: That is what I was getting at, and I think10 that is understandable, actually.11 Interesting, actually, when you look at the minute,12 the first matter of "Next steps" was actually:13 "Consultants to have access to casenotes to review14 causes of death."15 Why was that put in?16 A. I can't recollect at the time, but in light of all the17 reviews that had taken place, it is clear that a lot of18 information has been lost over time and clinicians19 themselves could have provided a basis of discussion at20 the very beginning, rather than leaving it to case21 notes. That is just my view.22 MR MACAULAY: When you say "a lot of information has been23 lost", what do you mean by that?24 A. Well, the case notes will only give you a percentage of25 what's happening, and clinicians can give you exactly79 1 what's going on and all the thinking behind what's2 happening. But I think that's been lost through the3 passage of time.4 Q. Should the case notes not tell us what's happening?5 A. I think they'll give you a very limited amount of6 information as to what's happening.7 Q. Why is that?8 A. Because a lot of what happens, dialogue, clinical9 discussions, discussions with patients, is not written10 down. You will get prescriptions and letters, but a lot11 of what happens in clinical activity is lost.12 LORD MACLEAN: While that may be so -- I wouldn't know --13 what item 1 says is that consultants should have access14 to case notes to review causes of death. So you must15 have thought that the case notes themselves would be16 useful in reviewing the causes of death.17 A. Yes, but we were also the clinicians, and we would have18 been able to put our clinical colour into what is in the19 case notes, and that aspect has been lost.20 LORD MACLEAN: I don't understand that. I'm sorry.21 MR MACAULAY: There are duties on doctors in practice in22 relation, for example, to record keeping; is that23 correct, Dr Johnston?24 A. Yes, that's correct.25 Q. Should a third party not be able to pick up a patient's80 1 case records and obtain from that a reasonable account2 as to how the patient is being managed?3 A. I would have great difficulty in looking at a set of4 case notes and coming out with a full and accurate5 description of what's gone on with any particular6 patient. I have this difficulty in my clinical7 practice, looking back at patients who had been in other8 wards in the hospital and piecing together what's been9 happening.10 Q. If we look, then, at the guidance for doctors provided11 by the General Medical Council, this is at INQ00270001,12 and we see that is what the document is from the front13 page. If we turn to page 3, we see that this is the14 version for November 2006; do you see that? It is on15 the screen.16 A. Yes.17 Q. If we go on to page 10, there's a section that reads:18 "In providing care, you must: ...19 "(f) keep clear, accurate and legible records,20 reporting the relevant clinical findings, the decisions21 made, the information given to patients, and any drugs22 prescribed or other investigation or treatment."23 If that guidance were to be followed, would it not24 then be possible for a third party picking up the notes25 to form a reasonable view as to how the patient had been81 1 treated?2 A. You will have a reasonable view, but you won't have the3 whole view.4 Q. If you are dealing with a patient and you are asked5 a year down the line what had happened, would you really6 remember what had happened?7 A. Some cases, yes, I carry with me for years.8 Q. The other point I want to raise with you in connection9 with this document is at page 11, where there is10 a section headed "Raising concerns about patient11 safety". I will read that to you:12 "If you have good reason to think that patient13 safety is or may be seriously compromised by inadequate14 premises, equipment, or other resources, policies or15 systems, you should put the matter right if that is16 possible. In all other cases you should draw the matter17 to the attention of your employing or contracting body."18 If I just stop there, did you have any good reason19 to think that patient safety was being compromised in20 the Vale of Leven at the relevant time?21 A. I think at the relevant time, as in the years before,22 concerns had been raised broadly across the hospital,23 and I continued to raise my concerns with the service24 manager as well, and she had made many representations25 to get things fixed, which never materialised. But82 1 I don't think it was a lack of people raising concerns,2 it was a lack of action, and eventually people saying,3 "There's no money, we can't do this, put wash basins4 in".5 Q. Let's take it in bits. You see, first of all -- and6 this may be implicit in your answer -- did you have good7 reason to think, at the relevant time, that patient8 safety was or may have been seriously compromised?9 A. I think that was a continuation of what the situation10 was all the time I was there. So, yes and yes.11 Q. What caused you to be of the view that patient safety12 was seriously compromised?13 A. I wouldn't say safety would be seriously compromised14 because the roof leaked, but, you know, there's the15 external fabric which wasn't being kept up. The16 internal -- the wards 14 and 15 had adequate facilities.17 They were outdated, but the main issue for the medical18 wards was lack of hand basins.19 Q. So that is dealing with premises and equipment. What20 about resources?21 A. I don't have a great deal of knowledge about resources.22 Q. If we include in that the number of staff available from23 the medical perspective?24 A. All right. It was inadequate for the RAD side of25 things, with part-time hospital practitioners being83 1 backfilled by FY1s when they weren't there. In the2 general medical side, I would say there was a layer of3 staffing missing that would have ensured more continuity4 of care, more senior juniors. I think it was always the5 least of the least that they got.6 Q. Then moving on to what could be done about it, I think7 you mentioned that you, yourself, had brought these8 issues to the attention of your service manager; is that9 right?10 A. Yes, the fabric and so on, yes.11 Q. What about staffing?12 A. The staffing?13 Q. Yes.14 A. I think if you look at my appraisal documents from 2003,15 I lay out very clearly my concerns about staffing.16 I don't know if you've got those in the Inquiry.17 Q. We may --18 A. I was constantly recording it, yep.19 Q. Your service manager then, who was made aware of these20 concerns at the time, who was that?21 A. Liz Rawle.22 Q. Do you know what Liz Rawle did about it?23 A. Well, I think she did quite a lot, and she's coming to24 speak to the Inquiry, so it would be better maybe25 leaving that to her.84 1 Q. What feedback, then, did you get from her?2 A. The feedback was always, "No money".3 Q. Did you, yourself, as the consultant, feel under4 pressure, looking to the amount of work and areas you5 had to cover within the hospital?6 A. Oh, yes. Basically, Dr Akhter and I had, I would7 describe, two jobs -- one and a half, at least, for the8 amount of patients we had and different sites.9 I continue to do medical receiving in my new job, but10 I have a block of days in which my own geriatrician job11 is backfilled by a staff grade and my clinics aren't on,12 so I can separate the two. I couldn't then.13 LORD MACLEAN: When you say lack of staffing, do you include14 nursing, the nursing staff, or is it just medical?15 A. No, that would be medical. The solution which has been16 formed is that there are two geriatricians at the Vale17 now with ward-based junior staff and they're not doing18 general medicine, so it's sorted.19 MR MACAULAY: You didn't have that position at the time we20 are concerned with?21 A. No, I didn't.22 Q. Do you consider that the pressure that you were under23 then did impact upon the level of care that you were24 able to give to your patients?25 A. I think what you need -- what a consultant relies on is85 1 a system of good juniors with -- some senior juniors who2 will completely control the ward all the time that you3 are not in it. If you rely on a system with4 a consultant, for example, who is called out of clinic5 to see somebody who has got sepsis in the ward, that is6 not a system. I, quite often, when I was receiving,7 would end up, as I said, in medical assessment seeing8 patients.9 MR WOOD: My Lord, I wonder if I might intervene?10 Dr Johnston is probably looking to see who is speaking.11 It is me.12 She described how she and Dr Akhter had, I think,13 two jobs or one and a half jobs, and then went on to14 describe her commitments. I wonder if the fact that15 Dr Akhter had also responsibility for ward F changes16 matters and whether Dr Johnston could be asked to17 comment on that?18 A. I think Dr Akhter -- should I comment?19 LORD MACLEAN: Yes.20 A. Dr Akhter's position was unworkable, I would have to21 say. He had stroke ward as well as ward 14 as well as22 his medical receiving, often covering or filling in for23 other consultants in an ad hoc fashion, so that some of24 his work was interfered with.25 MR MACAULAY: I think I'd asked you, and I'm not absolutely86 1 sure what the answer was, but you have indicated the2 pressure that you were under and why. What I had been3 seeking to clarify with you is whether that pressure did4 impact upon the care that you were able to give to your5 patients?6 A. I think it would impact on the follow-through of7 the care. It wouldn't impact on what I did when I was8 there. But in terms of progressing investigations,9 following up sick patients -- the hospital practitioner10 did sessions, but not at the same time with my major11 ward round, and so would come and go. So it wasn't an12 ideal situation.13 Q. You mentioned a moment ago that Liz Rawle was your14 service manager. Do I take from that that she was your15 line manager?16 A. My line manager would be a doctor, and it would be17 Dr McCruden, who was notionally the site clinical lead18 at that time. I'm not sure whether he still officially19 was or not, but he did all my appraisals, and his line20 manager would be Dr Curry in Inverclyde. That would be21 the clinical director for medicine. When RAD was22 adopted into the -- Glasgow, my line manager changed, so23 I went from acute medicine to the rehabilitation24 assessment directorate, and my line manager then was25 Graeme Simpson, who was based at Paisley, and above that87 1 was Margaret Roberts who was associate medical director.2 Q. When did that happen, then?3 A. There was a bit of an overlap, I think. The health4 board took over in April 2006. RAD for Glasgow took in5 the Vale in October 2007, but for a period of6 a year-plus, I was still having my appraisals done7 through the acute medicine side, so there was a kind of8 overlap period, I think.9 Q. That would be Dr McCruden then?10 A. Yes.11 Q. I think you say in your statement that your line manager12 in the emergency care and medicine directorate was13 Dr Graham Curry, but that is, I think, through14 Dr McCruden; is that right?15 A. Yes. All of these line managers were at different16 hospitals.17 Q. What's the point of that? Does that make it more18 difficult?19 A. Well, apart from Dr McCruden, that is -- everyone else20 was in another place. That is what directorates do:21 they cover a number of different clinical sites.22 Q. Did that cause you a problem?23 A. I think we were quite isolated. In the Vale,24 Dr McCruden and -- the six of us, basically, functioned25 as a unit, a site-based unit, although the actual lines88 1 of management were more outside the hospital. I think2 we were pretty much left to get on with it.3 Q. By whom?4 A. By the next-ups, that's the CD for medicine and the CD5 for RAD.6 Q. Sorry, the CD for medicine?7 A. Dr Curry and Dr Simpson.8 Q. I now want to move on, Dr Johnston, to look at some9 patients with you that you may have had some involvement10 with during this particular time that we are looking at.11 The first patient that I want to look at is12 Mary Broadley.13 A. Could I have the notes?14 DAME ELISH: My Lord, before moving on to specific patients,15 I wonder whether or not -- two issues: whether or not my16 learned friend could take from the witness -- reference17 was made regarding the path of treatment and18 progressively what you would do to address hydration,19 and the witness referred to PEG being a possibility,20 although that wasn't tolerated well. I wonder if the21 doctor could indicate whether or not that was22 a particular issue for frail geriatric patients with PEG23 systems and the degree of how unpleasant it was for24 those patients?25 LORD MACLEAN: Hold on. What is PEG? Have I heard about89 1 PEG?2 DAME ELISH: Yes, you have, it is a form of gastro feeding3 for those who are not taking food in -- feeding orally.4 LORD MACLEAN: Mr MacAulay, do you want to deal with it5 here?6 MR MACAULAY: Yes, I'm quite happy to deal with it now,7 my Lord, before we look at the cases.8 We had some discussion about hydration, and I think9 you indicated that, with certain patients, hydration can10 be a challenge; is that right?11 A. Yes. A confused patient who is pulling lines out and12 can't swallow, you have a problem.13 Q. Looking at the paths of treatment that you mentioned,14 nutrition by way of a tube was something that you15 envisaged; is that correct?16 A. Well, it's something that had to be considered.17 Q. How would that work in practice?18 A. In practice, it's an invasive procedure. It's an19 endoscopic gastrostomy tube, and for the very reasons20 that a patient might be pulling out intravenous lines --21 confusion, agitation -- they could easily pull out a PEG22 tube and injure themselves. It is really more suitable23 for patients who lack normal bowel activity and need to24 be PEG-fed for a while, but it is not often considered,25 if only to exclude it. It is occasionally used in90 1 stroke patients who have lost their swallow, but there2 is generally a very high mortality in these patients and3 it is not often used.4 Q. You would assess each patient individually and come to5 a view as to what you should do?6 A. Mmm-hmm.7 Q. You can't generalise, you look at each individual8 patient?9 A. That's right. Essentially, if a patient can't swallow,10 they will aspirate their secretions into their chest and11 develop a pneumonia and die. It is an end-of-life type12 of phenomenon. You have to balance the treatment you13 are offering with the prospects for survival and quality14 of life.15 Q. The end-of-life point you raise is something that16 reminds me I should have taken up with you. What was17 the approach at the relevant time to end of life in18 patients who were terminally ill? We have heard19 reference to the Liverpool pathway, for example.20 A. Yeah. We use the Liverpool care pathway nowadays, which21 essentially documents that the patient is no longer able22 to swallow and take normal medication and they just have23 symptomatic relief. We didn't, I don't think, have the24 Liverpool care pathway at that time, but the principles25 are broadly similar, that you go into a symptom91 1 management pathway for the patient, rather than2 a treatment pathway.3 LORD MACLEAN: Before we go to any of the cases themselves,4 could I ask you, going back a little bit, what does the5 acronym CD stand for?6 A. Clinical director.7 LORD MACLEAN: Director?8 A. Yes.9 LORD MACLEAN: That is in each of these directorates; is10 that right?11 A. That's correct, yes.12 MR MACAULAY: We were looking at the PEG approach within the13 context of nutrition and hydration. I may have asked14 you about this already, about fluid balance charts, but15 in particular, if a patient was in receipt of IV fluids,16 would you expect fluid balance charts to be kept in that17 situation?18 A. They do, yes. They would. I have to say that in19 palliative care, one would not normally be doing blood20 tests or keeping charts of any sort, they'd just be21 doing symptom management.22 Q. Just if we can come back to that, if you had a patient23 who was in receipt of IV fluids, would you, in that24 situation, check to see if proper fluid balance charts25 were being kept?92 1 A. You would need to have -- I would check, but you'd also2 need to have somebody checking it every day. It needs3 to be a systemic approach.4 Q. Do you mean by that the junior doctor?5 A. Yes.6 Q. So when you did your ward round, you would check?7 A. Yes.8 Q. Perhaps another point in relation to palliative care, if9 that was the route that was being adopted, then, would10 that be recorded in the notes?11 A. I see this coming up. In these particular12 circumstances, active treatment to palliative treatment13 happened very, very quickly in some of these cases. The14 word "palliative" may or may not be in the notes, but15 you will see other clues as to what's being stepped16 down.17 Q. So whether the word "palliative" was used or not, you18 would say there should be some indication in the19 records?20 A. Say, for example, you've got a patient who can't swallow21 and who is on IV fluids and there is a discussion as to22 what to do about it, and it says the patient is not for23 PEG or NG and they have a DNAR, then even if the ward24 "palliative" doesn't appear in the notes, it's fairly25 obvious looking at the pointers that that is what is93 1 happening.2 Q. Does that set out a plan of management, then, if that is3 what you have in the notes?4 A. You have to document what you are not going to do. It5 is not just putting in a DNAR. You have to document.6 Q. Would you document what you would be doing as well?7 A. You would be, yes.8 Q. Perhaps I can just pick up a point that was raised with9 you, I think possibly by his Lordship, in relation to10 staffing and, in particular, the staffing from the11 nursing perspective, did you have any discussions with,12 for example, Liz Rawle as to what the position was in13 relation to nurse staffing?14 A. I had lots of discussions with Liz Rawle on an almost15 daily basis for all aspects of the Vale, including16 nursing, and I would always take a problem that nurses17 had expressed to me to Liz Rawle to see if it could be18 dealt with.19 Numbers of staffing -- if the nursing staff said,20 "Oh, we're short", then I would double-check it with21 Liz Rawle to make sure that she -- she was usually aware22 of the position already and had usually dealt with it,23 but I formed a close working relationship with her.24 Q. Did that happen, that nurses would say to you that they25 were short staffed and you would take that up with94 1 Mrs Rawle?2 A. Yes, and sometimes they were and sometimes they weren't.3 It depends what their template was and whether people4 were off sick and so on.5 MR MACAULAY: I do propose to move on to look at6 Mrs Broadley, but, my Lord, looking to the hour, that7 might be best dealt with after lunch.8 LORD MACLEAN: Yes, all right. 2 o'clock, please.9 (12.57 pm)10 (The short adjournment)11 (2.00 pm)12 MR MACAULAY: Good afternoon, my Lord.13 Good afternoon, Dr Johnston. Can I then move on to14 look first at the case of Mrs Broadley? The medical15 records for the Vale of Leven for Mrs Broadley are at16 GGC00050001. You may have a hard copy, do you,17 Dr Johnston? Would you prefer to have a hard copy?18 A. I have got a hard copy. Thank you.19 Q. Mrs Broadley was initially admitted to the20 Royal Alexandra Hospital following upon a fall, and she21 fractured the neck of her right femur; is that correct?22 A. I wasn't involved in her initial admission, so I don't23 know.24 Q. Have you had the chance of looking at the records?25 A. She was to and fro, yes.95 1 Q. She was transferred to the Vale of Leven, ward 14, on2 27 September 2007, and she had a fall in the3 Vale of Leven on 13 October 2007, when she fractured her4 left wrist, and she required to be transferred back to5 the Royal Alexandra Hospital, but then she was back6 again in the Vale of Leven on 15 October, and then, on7 15 November, she had another fall, when she fractured8 her radius and ulna and also the right femur. Were you9 able to ascertain from the records that she had a number10 of falls and a number of fractures?11 A. Yes.12 Q. It is when she returns to the Vale of Leven on13 23 November 2007, after having been treated in the14 Royal Alexandra Hospital for that fall, that she comes15 under your care; is that right?16 A. That's right.17 Q. If we look at the notes at page 28, I think, as we see18 there, for 23 November it is noted that she's returned19 to ward 15; is that correct?20 A. Yes, that's her first admission to ward 15.21 Q. That is when you first dealt with her?22 A. That's right. I think that was a Friday.23 Q. I'm sorry, you didn't see her yourself on that day --24 A. No.25 Q. -- but this is the time when she came under your care?96 1 A. That's correct.2 Q. You do first see her, if we look to the next entry,3 26 November, that is your handwriting; is that correct?4 A. That's correct.5 Q. What you have noted there, I think -- is that "Falls"6 and is that "Dementia"?7 A. Yes.8 Q. You give some information about what the result of9 the fall had been; is that correct?10 A. And I also talk about medication.11 Q. Yes. So that is the first time you have seen her after12 her admission to ward 15?13 A. Yes.14 Q. You see her again on 3 December. We see that towards15 the bottom of the page; is that correct?16 A. Yes.17 Q. The gap in the medical notes -- I'm not suggesting that18 you should necessarily have seen her again yourself, but19 do you consider there should have been some medical20 review between these two dates?21 A. I'm just checking the days. The 26th is a Monday and22 the 3rd is also a Monday, so there should have been23 a note of Dr Herd's ward round in between those two24 days.25 Q. What about any ongoing review? Would you expect any97 1 other input, apart from Dr Herd?2 A. Well, there wasn't any other input, apart from Dr Herd.3 The point about the medication is that these medications4 rendered her at increased falls risk, and so what I was5 doing was dealing with the reduction of that risk by6 taking away these medications. Olanzapine is an7 antipsychotic that has side effects of parkinsonism, and8 can lead to poor balance and falls, so that's why that9 was withdrawn.10 Q. You're suggesting she should at least have been seen by11 Dr Herd during this period --12 A. He did a ward round on a Thursday, so I would normally13 expect his writing to be in the notes.14 Q. What we see in the next entry, for 4 December, is an15 entry by an SHO; is that correct? Page 29.16 A. Yes. That would be somebody who was called in the17 afternoon to see the patient, on the Tuesday afternoon.18 Q. This person has formed the view that she may be19 suffering from C. diff; is that correct?20 A. I see that, yes.21 Q. If we look at microbiology, if we turn to page 80, can22 we see here that a sample was collected on 4 December,23 received by the lab on the 5th, and that proved to be24 a positive result?25 A. Yes, that's correct.98 1 Q. If we turn then to page 30 of the records, on2 5 December, that note that we have for the 5th, is that3 Dr Herd?4 A. That's Dr Herd.5 Q. I think it reads:6 "C. diff confirmed. Already on metronidazole."7 Is that correct?8 A. I think that's correct.9 Q. Would you have expected Dr Herd to have carried out10 a clinical examination of the patient?11 A. He may well have carried out a clinical examination, but12 it's not recorded.13 Q. Would you have expected him to have recorded such an14 examination?15 A. Yes, I would have.16 Q. Just so I understand the position with a patient with17 C. diff, if a patient is diagnosed with C. diff, would18 you expect to be contacted by the junior staff?19 A. If you asked me -- yes, now I would expect to be20 contacted --21 Q. No, then. Please, we are looking at this time frame.22 A. At that time, I can see that patients had diarrhoea,23 then stool samples and positive C. diff, but I was not24 necessarily always informed at the time.25 Q. So you have taken that from the records you have looked99 1 at?2 A. Yes.3 Q. What I am asking you is, would you have expected to have4 been contacted --5 A. Yes, I would expect to have been contacted.6 Q. Because I think, as we discussed this morning, C. diff7 can be a serious illness, particularly in the elderly?8 A. Yes.9 Q. So you'd expect to have some input --10 A. Yes.11 Q. -- at an early stage?12 A. Yes.13 Q. If we look at the entries following the one we have just14 looked at for 5 December, there is a short entry on15 6 December. I think, again -- is that Dr Herd again?16 A. That looks like it.17 Q. For --18 A. That's subcutaneous, I think.19 Q. For subcutaneous fluids. Then we have the next entry on20 the 12th, which is to do with her plaster; is that21 right?22 A. It looks like it.23 Q. So when is the next medical review, then, after the 5th24 and the 6th?25 A. Judging by the calendar, there should be an entry by me100 1 on Monday the 10th, but I don't see one.2 Q. Can I ask you this before we look at that: with3 a patient who is elderly, as this patient is, and4 I think she was 92 when she died, on 22 January, and5 she's tested positive for C. diff, would you have6 expected some ongoing review of that patient?7 A. I would, yes.8 Q. Do you see any evidence of that in the records?9 A. Not in that point, no.10 Q. The next page, if we can put the next page beside the11 one we have on the screen, is page 31. We have another12 entry I think by Dr Herd on the top of the page for13 13 December; is that correct?14 A. Yes.15 Q. So far as medical input in relation to her C. diff is16 concerned, we had this entry on the 6th, and we have17 this entry on the 13th, and no further input. Would you18 have expected some more input than that for a patient of19 this type who is ill with C. difficile?20 A. I would have expected, yes.21 Q. So far as your own input is concerned, Dr Johnston, am22 I right in thinking that the next entry after the 13th23 is yourself, on 17 December?24 A. Yes.25 Q. This is, I think, the third time, in fact, you had seen101 1 the patient. You had last seen the patient on2 3 December?3 A. I cannot explain the gap at the moment.4 Q. We have a two-week gap there?5 A. Yes, because I did a weekly ward round, so I can't6 explain it.7 Q. What have you noted for the 17th?8 A. That she'd had a number of -- well, she had MRSA, she9 had had the norovirus and she'd had C. diff and that she10 was not mobile at that stage, but I wouldn't expect her11 to be if she'd had these infections.12 Q. Is it at all acceptable, then, Dr Johnston, that this13 particular patient did not get more regular review,14 particularly after she contracted C. diff?15 A. I think it's not acceptable, but in the light of16 the knowledge at the time, it was fairly typical,17 I think, of getting caught up.18 Q. Sorry, could you elaborate upon that? What do you mean19 by that?20 A. I think it's understandable at the time, in that I don't21 think we realised quite what was going to happen at the22 Vale, so this might be a very early case -- in fact, it23 was.24 Q. I still don't understand that, Dr Johnston. This25 morning, I think you said that it was recognised that102 1 C. diff could be a serious illness; is that right?2 A. Yes, I'm not denying that.3 Q. So what are you saying? If you have a 90-year-old4 patient who has contracted C. diff, could there be any5 excuse for such a patient not being seen on a more6 regular basis by the doctors?7 A. I think a lack of doctors might explain some of that,8 but not -- I would -- I did a weekly ward round, unless9 I was doing medical receiving at that time. But I can't10 evidence that I was medical receiving that day.11 Q. You say a lack of doctors might explain it, but is that12 an excuse for a patient not being seen, if a patient is13 ill?14 A. I think if you're trying to systemically manage an15 infection such as C. diff, it has to be a daily basis,16 and it is not one individual that can cover all domains.17 A weekly or twice-weekly ward round still leaves the18 possibility that the patient may deteriorate in between19 times, so there needs to be a mechanism that can20 identify, and that usually involves staff.21 Q. Are you suggesting to the Inquiry, then, that the reason22 why we may see this in some of your other cases, the23 reason why there may be these gaps in review is down to24 short staff?25 A. Partly, but also staff working elsewhere. But also103 1 there's the possibility that I've seen the patient and2 I haven't noted anything in the notes. I don't know.3 LORD MACLEAN: But surely that answer, "Partly, but also4 staff working elsewhere", that must all come within the5 lack of staffing, mustn't it?6 A. Yes.7 MR MACAULAY: You saw Mrs Broadley on 17 December, and8 I think you noted, "Has had MRSA, C. diff and9 norovirus". At that time, do you know if she was10 suffering from diarrhoea or not?11 A. I can't tell you that.12 Q. If we look at page 73 of the records, do we see here13 that on the same day that you saw her, a specimen seems14 to have been collected from her, received by the lab on15 18 December, and that tested positive for C. diff?16 A. I can see that a specimen has been collected on the17 17th, but not the time at which it was collected.18 Q. I fully understand that, and I'm not suggesting it19 happened before you saw her, but as far as the date is20 concerned, it coincides with the date you saw her?21 A. Yes.22 Q. You can see that the specimen comment is that it is23 liquid. Can you see that?24 A. I do see that.25 Q. If we go back to the clinical notes themselves, on104 1 page 31, can we see that the next entry is by Dr Herd;2 is that right?3 A. Yes.4 Q. If we look at the nursing notes on page 126, and we can5 keep page 31 on the screen, we see towards the bottom of6 that page that there is an entry for the 16th which7 suggests "Loose stools before going to bed". Do you see8 that?9 A. I see that.10 Q. We know that on the 17th a specimen was collected. If11 we go back to the clinical notes, the fact that she may12 have had loose stools or be suffering from loose stools13 is not something that you were able to elicit, or if you14 did elicit it, you didn't note it?15 A. I think this illustrates that -- well, sorry, I should16 answer your question. It is something that may not have17 been given to me.18 Q. Do you think that, particularly if you are looking at19 a patient who, as you have noted, indeed, had been20 suffering from C. diff, that that is the sort of21 information you should have obtained?22 A. Yes.23 Q. What I'm putting to you is that, really, you should have24 inquired to see what the position was with her loose25 stools; is that fair?105 1 A. My experience of asking for information from different2 nursing staff is that with shift changes, you get3 a slightly different version or a different version, and4 the information that you ask for may come out as5 negative or positive, depending on who is on.6 DAME ELISH: My Lord, I wonder if my learned friend could7 have the witness look at the next entry, for8 17 December, which relates to the ward round which9 Dr Johnston carried out on the 17th and whether or not10 there is any mention in the nursing note of C. diff11 being discussed with the doctor?12 LORD MACLEAN: Before that may be explored, what was your13 practice when you did carry out a ward round? Did you14 look at the nursing notes that preceded it?15 A. The nursing notes were kept in the ward manager's16 office. I didn't have access to the nursing notes17 during ward rounds or afterwards. I mean, I could have18 gone and looked for them, but I would expect that the19 nurse who was on the ward round was up to date and would20 be able to tell me the things that I needed to know.21 The notes are all filed together when the case note22 is returned for filing, and you see the notes as a whole23 piece, but at the time, these parts were separate.24 LORD MACLEAN: So that is why you say you were dependent on25 getting information from the nurse?106 1 A. Yes.2 LORD MACLEAN: I mean verbally, orally.3 A. Yes.4 LORD MACLEAN: Do you want to take up Dame Elish's question?5 MR MACAULAY: I will pick that up, but perhaps before I do,6 in case I lose sight of it, you made a point there about7 nurse shift changes and getting different versions on8 shift changes from nurses. What did you mean by that?9 A. Well, what can happen is that a piece of information10 gets lost the more times it passes through groups of11 nursing staff, and what may seem a priority at the time12 becomes less of a priority by the time it hits the ward13 round.14 MR MACAULAY: Is this a situation, particularly if you are15 looking to see what a patient's history with regard to16 diarrhoea and loose stools might have been, where17 a stool chart can play an important role?18 A. Yes. I think it draws the attention of the staff in19 order to make the chart in the first place, but you're20 still reliant on the verbal contact, and if you've got21 a nurse who's not done the previous day's stool chart,22 you might not get the right information unless they23 bring the chart with them.24 Q. I will come to the nursing note in a minute, but if we25 go back to your own record, then, of the 17th, that does107 1 not give us any information at all in relation to her2 diarrhoeal status at that time; is that fair?3 A. It says past tense, but inferred perhaps that it's over,4 but we can't say for definite from that.5 Q. It doesn't mention diarrhoea or loose stools, certainly?6 A. No, it doesn't.7 Q. If we look at the nursing note that my learned friend8 raised with me, it is at page 126. We looked at the9 loose stools reference, then the 17th, "Ward round10 1510". Would that be about the correct time for your11 ward round?12 A. That's not a ward round comment. 1510 is a visiting13 time comment, because I did my ward rounds in the14 morning.15 Q. You are quite right. The first reference is "Ward16 round - to discuss future care with family", and that's17 been signed off.18 A. That's right.19 Q. So that's when you would be present?20 A. I would be present, but the second one would be the21 nurse telling the family to make an appointment.22 Q. I'm not sure where that takes us. So there was some23 discussion, then, between you and the nursing staff that24 there would be some discussion about future care with25 the family. Is that what one takes from that?108 1 A. Yes.2 Q. If we go back then to the clinical notes, the next entry3 is on 18 December, and I think you did confirm for me4 that this again was Dr Herd; is that right?5 A. Yes.6 Q. Is this dealing with the discussion that had taken place7 between Dr Herd and family members?8 A. Yes, that's not a ward round, that is a meeting with9 family.10 Q. What medical assessment, if any, has there been of this11 second diagnosis of C. difficile with this patient?12 A. Sorry, could you repeat that?13 Q. Yes. What medical assessment has there been of14 Mrs Broadley following upon the diagnosis of C. diff at15 this time?16 A. I'm not sure what you're referring to.17 Q. Can we look at the records, then? You have indicated18 that the entry for the 18th is Dr Herd dealing with the19 family. If we look to page 32 of the records, I think20 that is the next entry we have. Can we put that page21 next to the page on the left? So on the 20th, there is22 an entry which is a referral to a consultant23 psychiatrist; is that correct?24 A. Yes.25 Q. On the 20th also there is an entry dealing with her109 1 plaster; is that right?2 A. Yes.3 Q. And similarly on the 21st; is that right?4 A. Yes, that's right.5 Q. Is the next clinical entry that indicates that there may6 have been some examination of the patient on7 27 December?8 A. Yes, that's Thursday.9 Q. So if we look to the left-hand side, we have got your10 entry for 17 December. We know that Mrs Broadley tested11 positive at about that time. What I was asking you is,12 is there any evidence of a medical review of13 Mrs Broadley after she had tested positive for C. diff14 on this occasion?15 A. I would expect my medical review to be contained within16 the ward round, which, on the 24th, Christmas Eve,17 of December that year, I was doing medical receiving, so18 there wouldn't have been a ward round that day.19 Q. We'll come to the reasons why there may not be, but the20 first point is, is there any evidence of a medical21 review?22 A. No, there's no evidence.23 Q. Should there have been a medical review of this patient24 who's now tested positive for a second time?25 A. Yes, there should have been.110 1 Q. I think you were moving on, Dr Johnston, to explain why2 you may not have been able to see the patient; is that3 right?4 A. Yes.5 Q. What was the position?6 A. Sorry, Monday, I don't -- didn't normally do medical7 receiving, but because of the Christmas arrangements,8 I was down for that. So that meant that my morning9 would be taken up doing my acute receiving ward round10 and another ward round later in the afternoon. I would11 normally pop into the ward to see if there were any12 problems that the ward was aware of, but I didn't have13 a formal round.14 Q. But if you have a patient under your care that tests15 positive, as we know, on or about 17 December, why is it16 not possible for someone, a doctor, to carry out17 a medical review of that patient at about that time?18 A. Well, Dr Herd was in on a Monday afternoon. He would19 have been available to see the patient.20 Q. So this would be a matter for Dr Herd to explain, then,21 as to why he didn't review the patient?22 A. He sort of -- not quite covered for me, but he was23 certainly there.24 Q. Dr Herd, he was one of the GP practitioners; is that25 correct?111 1 A. That is correct, yes.2 Q. Who worked part time?3 A. Part time in the hospital, yes.4 Q. In the hospital?5 A. Yes.6 Q. But you say Monday would be one of his days; is that --7 A. Yes.8 Q. Can you help me with that? I think you may have touched9 upon it this morning. What other days did he work in10 the ward?11 A. I think he -- you need to ask him when you see him, but12 the Tuesday morning I recall was done by Dr Garthwaite,13 another partner, and the other three days Dr Herd was14 in, but which part of the day, I can't recall.15 Q. Here we have a situation, Dr Johnston, as we can see,16 where the patient has tested positive for C. diff.17 There has been no medical investigation into that18 diagnosis. It could be said that this indicates that19 C. diff was not looked upon as of particularly high20 priority in the Vale of Leven at that time; would that21 be fair comment or not?22 A. I think at that time -- well, the lady had two other23 infections. The ward was closed at one point24 in December with norovirus. There was a lot happening25 in the ward. I'm not saying that by way of excuse, but112 1 I think there was a lot of other things going on.2 DAME ELISH: Sorry, my Lord, I wonder if I could also ask my3 learned friend to confirm whether or not the record of4 20 December suggests that MRSA had been eradicated in5 the patient, which is, as I understand it, a potentially6 life-threatening condition?7 MR MACAULAY: I think that is the 27th. I may be wrong8 about that.9 DAME ELISH: The 27th, yes.10 A. This patient was already isolated because of MRSA.11 MR MACAULAY: The question I put to you is whether one can12 infer from the lack of medical input for the13 C. difficile infection at this time whether it could be14 said that that's indicative of C. difficile not being15 given particularly high priority at that time?16 A. I don't think you can infer that. It's just probably17 a general lack of cases and experience, rather than not18 thinking it's a high priority.19 DAME ELISH: I wonder again, my Lord, if my learned friend20 could refer the witness, if he considers it appropriate,21 to page 127 and to the entry dated 19 December?22 MR MACAULAY: I'm quite happy to do that, if it helps.23 Let's put 127 on the screen. We now have it on the24 screen. I think the ward is aware of the positive25 C. diff result, certainly on the 19th. I'm looking to113 1 see what the reason I'm being referred to this2 particular note is.3 DAME ELISH: The reference, my Lord, to the consultation4 with the microbiologist.5 MR MACAULAY: Yes, I see that.6 This is with the nurses and the microbiologist?7 DAME ELISH: I think also the microbiologist orders an8 escalation of the treatment to vancomycin.9 MR MACAULAY: Does this help you at all in giving us10 assistance as to what is going on at this time?11 A. Yes. The nurses can't prescribe vancomycin, so clearly12 there is evidence of involvement of the junior doctor,13 whoever that is, and microbiology. It is also written14 in retrospect due to busyness of the ward, which I think15 gives some insight as well.16 Q. Certainly there is nothing I think we have seen in the17 clinical notes to indicate that this sort of discussion18 took place?19 A. You have to look at all the nursing notes and the20 medical notes to get the feel of where the communication21 was going, because sometimes the microbiologist was just22 leaving messages with nursing staff who then passed on23 to doctors.24 Q. You should be able to tell from the clinical notes what25 input the doctors --114 1 A. It should be written down, yes, but the treatment must2 have changed.3 LORD MACLEAN: Of course, the prescription would have to be4 authorised by a doctor, wouldn't it?5 A. Yes.6 LORD MACLEAN: That's why you infer this was the input of7 a junior doctor?8 A. Yes.9 LORD MACLEAN: But, of course, the vancomycin is not10 recorded in the clinical notes. It will be in the11 Kardex.12 A. It will be in the Kardex, yes.13 MR KINROY: My Lord, I wonder if we could look at the14 Kardex?15 MR MACAULAY: Yes, GGC27170007. Is this the vancomycin16 being prescribed on 20 December?17 A. That's correct.18 Q. Can you help as to who may have prescribed the19 vancomycin?20 A. That is Dr Herd's writing.21 Q. Do we take from this that the first administration of22 this medication, then, was on 20 December?23 A. If that's the complete record, yes.24 Q. We can check this out, but if that is correct, does it25 appear that there may have been a delay?115 1 A. If that's correct, yes.2 MR KINROY: My Lord, I'm not sure, does this establish that3 there was not, then, a failure to review the patient4 between 17 December and 27 December, but a different5 point, that the vancomycin was not prescribed until the6 20th? I'm not sure how my learned friend sees this.7 LORD MACLEAN: So far as I see it, Mr Kinroy, and so far as8 the clinical records go -- I mean the actual medical9 clinical records -- there is no assessment. But plainly10 there must have been something done in order for the11 vancomycin to be prescribed, presumably following the12 metronidazole.13 A. Yes. I think it's a point Dr Herd might be able to14 answer.15 LORD MACLEAN: Yes. Thank you.16 MR MACAULAY: If we go back to the clinical records, then,17 with you, Dr Johnston. We, I think, had got to page 32.18 If we go back to page 32, I think I'd taken you to the19 point where there was some involvement with her plaster20 on 21 December, and then we have the gap from the 21st21 to the 27th where there is reference by Dr Herd to MRSA.22 The next involvement we have from yourself is on23 31 December; is that right?24 A. That's correct.25 Q. You have now noted she's been C. diff positive times 2;116 1 is that correct?2 A. Yes.3 Q. Did you, as at this time, looking to the two occasions4 that Mrs Broadley tested positive for C. diff, have any5 input at all into her management for C. diff?6 A. Apart from my ward rounds, I don't recollect, although7 I was in the ward on -- once or twice during the week8 each week, so I may have discussed it, but there is9 nothing in the notes.10 Q. If we turn to page 33 of the records, I think we have11 another entry by Dr Herd. Is that 2 or 7 January? It12 is difficult to --13 A. I can't work that one out.14 Q. Is the next entry we have, then, for yourself on15 10 January?16 A. Yes.17 Q. What was the plan at that point?18 A. Well, that was really a combined entry from the ward19 rounds, multidisciplinary assessment and a meeting20 thereafter with Mrs Broadley's son and Sister Rawle. So21 the first part deals with her functional capabilities,22 considers that she remains a high falls risk and23 a little bit about psychiatry, and then the meeting with24 the son.25 Q. Then if we move on to the next positive result for117 1 C. diff, if we can put the lab report on the screen, at2 page 67, can we see here, Dr Johnston, that there's3 a specimen collected on 12 January, received by the lab4 on the 15th, and this, again, is a positive result?5 A. Yes.6 Q. Although the receipt date for the lab is the 15th, if we7 look at page 131 of the records, can we see that for8 the 14th, at 1810, the ward is in fact aware that9 Mrs Broadley is once again C. diff positive?10 A. The 14th?11 Q. It reads:12 "Phone call earlier this evening from the labs.13 Mary is C. diff positive."14 A. Yes.15 Q. If we go back to the clinical records, on page 33,16 there's an entry for the 14th. Is that you or is17 that --18 A. I think that's me.19 Q. It looks like your handwriting. What does it read,20 "Awaits ..."?21 A. "... ARG", area resource group, which is -- where22 patients are moving on to nursing homes, their23 applications go for assessment.24 Q. Then we have an entry on the 15th?25 A. I think that's Dr Garthwaite.118 1 Q. He has, I think --2 A. He's dealt with the result and phoned Dr De Villiers.3 Q. He's been given some advice by Dr De Villiers as to the4 treatment; is that correct?5 A. That's correct.6 Q. So far as you can make out from Dr Garthwaite's note, is7 there evidence here of a clinical assessment being8 carried out?9 A. I can't see evidence of it.10 Q. Then if we turn to page 34 of the notes, there's an11 entry on the 17th which suggests that Mrs Broadley has12 a rectal prolapse, or question mark; is that right?13 A. Yes.14 Q. I think that is Dr Herd. I think we're beginning to15 understand his handwriting.16 A. Yes.17 Q. Then we have an entry by you on the 21st; is that18 correct?19 A. Yes.20 Q. I think you had last seen her on the 14th, so this is21 about a week after that. This would be on your ward22 round, would it?23 A. That would be right, yes.24 Q. I'm sorry?25 A. Yes.119 1 Q. What have you noted on this occasion?2 A. What did I ...?3 Q. What have you noted in your note for the 21st?4 A. That she was dying.5 Q. First of all, you said, "3rd episode C. diff"?6 A. Yes, that's first thing. But she's had a week of7 treatment with vancomycin and immunoglobulin and it8 didn't make any difference.9 Q. You have noted "Terminally ill"?10 A. Yes.11 Q. Can you tell me what your thinking was as to why that12 was your conclusion?13 A. From my clinical experience, this lady was dying.14 Q. Did you relate it to her persistent C. diff infection,15 or to some other cause or causes?16 A. I think the C. diff would be the major contributory17 factor.18 LORD MACLEAN: You wrote "Terminally ill" following "3rd19 episode of C. diff". In a previous entry you said,20 "C. diff x2", that's 31 December. When you said "x2",21 what did you mean?22 A. Had it twice.23 LORD MACLEAN: Were you satisfied that she ever was without24 C. diff?25 A. Well, there is no guidance or suggestion that we should120 1 repeat stool assessments after a patient has C. diff2 because it will be positive for weeks afterwards, so you3 can move the patient from isolation after 48 hours if4 the diarrhoea's stopped, but you can't retest them, and5 you would only know by the lack of diarrhoea that they'd6 recovered, and also inflammatory markers will come back7 to normal.8 LORD MACLEAN: Did you form the opinion that she had three9 episodes of C. diff, or is it not possible to say that?10 A. I don't -- I honestly don't remember the detail of it11 now, because it's a few years ago, but it's possible12 that -- it's really for the microbiologist to say that13 she could have persisted.14 LORD MACLEAN: Yes.15 A. But I think, from our perspective, we thought at the16 time that it was three separate episodes.17 LORD MACLEAN: Right. Thank you.18 MR MACAULAY: By that you mean she had relapsed --19 A. Yes.20 Q. -- on two occasions after the first episode?21 A. Yes.22 Q. Correct me if I am wrong, but shortly before this23 particular diagnosis by you that she was terminally ill,24 had you been contemplating Mrs Broadley's discharge to25 a nursing home?121 1 A. Yes, and the thing about all these cases is the2 difference between frail ambulant and very unwell indeed3 can be a matter of days in a frail elderly person. So4 if it was only the C. diff that was keeping her back --5 I have described all her functional state to the son.6 If she'd had an episode that finished and didn't come7 back again, then she would have been suitable for8 discharge to 24-hour care, not discharged home.9 Q. Are you saying it was only the C. diff that was keeping10 her back, and can we see from the records we have looked11 at that the medical review of her C. diff, so far as the12 records go to show, was really quite minimal?13 A. It looks that way from the records, yes.14 Q. Looking at the DNAR position here with this patient, if15 we turn to page 10 of the records, there is a DNAR order16 that's been completed here, I think by Dr Herd, on17 10 December; is that right?18 A. That looks right.19 Q. "CPR is unlikely to be successful due to dementia and20 general frailty" is what he's noted?21 A. That's what he's done.22 Q. We also have a second DNAR order in this case at page 423 of the records, if we could look at that. Here, the24 DNAR order has been completed by Dr Shaikh, I think, but25 reviewed by yourself on 21/1/2008?122 1 A. Yes, I'm puzzled why there are two DNARs.2 Q. That's the point I was going to raise with you, but you3 can't explain that?4 A. The timing is quite different. There is the 15th --5 what was the first one?6 Q. Dr Herd's DNAR was 10 December.7 A. They are quite far apart.8 Q. We can put them both on the screen, page 10.9 A. If there is no review date on the first one, then that10 still stands, although there should be a review date,11 but it has not been revoked by a line through the12 middle, so the second one is superfluous.13 Q. Is one to assume that when the second one was being14 completed, it had not been realised that there was15 a first one?16 A. I think that's fair enough, yes.17 Q. Insofar as the second one is concerned, whether18 superfluous or not, you reviewed it on 21 January; is19 that right?20 A. Yes.21 Q. You have maintained the position that dementia was the22 reason for there to be no CPR?23 A. I think a combination of extreme old age and dementia.24 LORD MACLEAN: What is noticeable, actually, is that these25 forms are not the same, obviously.123 1 A. There were various --2 LORD MACLEAN: But "The CPR is unlikely to be successful due3 to", and there's a blank in the second one. Dementia is4 mentioned on that, but only in connection with the5 patient and why the patient was not consulted. Isn't6 that right?7 A. Yes, that's right.8 MR MACAULAY: We can put back on the screen your note for9 the 21st at page 34, and we can keep that second DNAR10 order on the screen as well. So your note on the 21st11 was that she was terminally ill, and I think what you12 have told us today is that you consider that that was13 because of the C. diff infection.14 A. Mmm.15 Q. Is that right?16 A. Yes.17 Q. Now, then, how would you have completed the DNAR order18 fully if you were to complete the section which says19 "CPR is unlikely to be successful"?20 A. I think the C. diff is a treatable infection and it21 could always be questioned if you put that on a DNAR.22 It would be more suitable to go with the dementia and23 frailty.24 Q. So far as the death certificate is concerned, if we can25 put that on the screen at SPF00030001, do we see that124 1 death has been certified by Dr Herd for 22 January 2008,2 and that Clostridium difficile enteritis is at3 part I for the cause of death?4 A. Yes, I see that.5 Q. If there had been a medical review of this patient6 during the times that she suffered from C. diff, would7 that review have involved obtaining blood results to8 assess the source of the infection?9 A. It should be, yes. It should do.10 Q. If we turn to page 39 of the records, we are looking at11 a report from the biochemistry department in relation to12 a specimen collected on 19 December 2007. Do you see13 that?14 A. Yes.15 Q. What do you take from this report?16 A. Well, this would be a first report, an early report,17 from C. diff. What do I see on it? It basically -- it18 shows urea and electrolyte function and serum albumin.19 There's a minimal disturbance of urea. Albumin is20 a little bit reduced. So there is not much amiss with21 this record.22 Q. Does that give any indication in relation to hydration?23 A. Not much amiss, I would say from that. Indeed, her24 filtration rate, eGFR, at 59 is -- well, normal is 60,25 so she's doing very well.125 1 Q. You will have had the opportunity of going through the2 records, Dr Johnston. Have you seen any other blood3 results after 19 December in the records?4 A. I don't recollect. I don't know whether I have seen5 them and forgotten. I don't know.6 Q. Looking to the situation of a patient who has had7 C. diff on three occasions at about this time8 in December and subsequently in January, I think you9 indicated a moment ago there should have been some10 further blood sampling done?11 A. Yes. Blood sampling is something that is normally12 generated at ward level by the junior doctor on13 a regular basis. If what you are saying is true, then14 this hasn't been done.15 Q. Should you pick that up on your ward rounds and that16 hasn't happened?17 A. I should have picked it up on my ward rounds.18 Q. Taking blood results provides the clinician with some19 idea as to the severity of the infection; is that right?20 A. That's correct.21 Q. Can you put forward a reason why this hasn't happened?22 Is it maybe because the records show that the medical23 review that took place of this patient was really24 minimal?25 A. I think it looks like it was minimal and it should be126 1 something, as I say, that's generated by the ward doctor2 on a regular basis, according to patient.3 Q. Who do we look at for this, then? Would this be4 Dr Herd?5 A. This would be Dr Herd. I would expect him to have6 monitored this patient.7 Q. From the records that we have seen, the clinical records8 that we have seen, and Dr Herd's involvement with the9 patient, is there any evidence in what he's noted that10 he carried out any clinical examinations of the patient?11 A. No.12 MR PEOPLES: My Lord, I wonder -- before Mr MacAulay goes13 on, there was reference, when looking at the report on14 the screen, that her filtration rate was 59 and normal15 was 60. I just wondered what the reference to the range16 in brackets is from 90 to 140? Is that an indication of17 normality?18 MR MACAULAY: I think we are looking towards the top right19 section of the actual report. Can you help us with20 that?21 A. 60 and above is normal. There is a range of normal.22 Below 60 there is a degree of chronic renal failure.23 I would describe that as a normal.24 Q. Because it is 59?25 A. Yes.127 1 MR KINROY: My Lord, I don't think we have had an2 explanation of what this filtration really is? I wonder3 if we could get that clarified.4 MR MACAULAY: Can you help us with that?5 A. Glomerular filtration is the method by which waste6 products are excreted by the kidney into the urine. It7 is like a continuously moving cycle of excretion and it8 tends to decrease as you get older, and it would be9 regarded as a normal feature in a lady of this age to10 have a reduced glomerular filtration rate. The fact11 that hers is normal means she's physiologically younger12 than her age.13 MR KINROY: My Lord, I wonder if I could just clarify what14 that tells us about the state of hydration of15 the patient from moment to moment, then?16 A. The actual hydration of the patient, the creatinine17 gives you the baseline renal function, the urea gives18 you the state of hydration, so you'd be looking at the19 urea mainly to look for state of hydration. Anything20 below 7 is completely normal, and many elderly people21 are on medications, such as diuretics, which will22 produce a slight dehydration picture, so I would say23 that this patient's blood sample is normal.24 MR MACAULAY: You mentioned, I think, a little while ago,25 Dr Johnston, that you did carry out some assessment of128 1 this patient in connection with her falls; is that2 correct?3 A. Yes, I did.4 Q. That was a problem this patient had in the5 Vale of Leven: she had a number of--6 A. Yes, this lady had a number of falls, yes.7 Q. What were you seeking to achieve in your assessment?8 A. Well, I was looking at the medical side of her falls.9 The nursing staff, physiotherapists, do their own falls10 assessment and environment of the ward, et cetera, and11 supervision, but the medical side has to be looked at as12 well to see if there are any neurological features that13 might make the patient fall, what the medication was, if14 there's a postural drop in blood pressure, so it is just15 removing things that might cause harm.16 Q. If we look at page 141 of the records, there's a record17 here recording Mrs Broadley's weight during the time18 that she was in the Vale of Leven. Do you see that?19 A. Yes, I do.20 Q. If you look at page 140, can we see that her weight has21 reduced from 41.3kg to 35.4kg shortly before she died.22 A. Yes.23 Q. So she has become very frail over that period; is that24 right?25 A. That's right.129 1 Q. Would you relate that, at least to some extent, to the2 fact that she contracted C. diff and was suffering from3 C. diff for a period --4 A. Yes, she had a marked weight loss in C. diff plus the5 anorexia from taking the medication, because some of6 the medication leaves a very metallic taste in the7 mouth.8 Q. If we turn also, please, to page 94 of the records, we9 are looking here at the Kardex, the second entry on the10 Kardex, beginning -- it is for lactulose, beginning on11 20 December 2007, and can you see, as you move along the12 page, that that prescription for lactulose continues13 through into January?14 A. I see that. I'm not quite sure what 14 means at the15 top.16 Q. Sorry?17 A. The number "14" at the top.18 Q. "14" in the code means "refer to records for the patient19 not getting the medication"?20 A. Does that mean the patient didn't get the medication?21 Q. Yes. That is my understanding, Dr Johnston.22 A. Okay.23 Q. If you turn to page 101 of the records, just to pick24 that up, we are given here the code for25 non-administration of drugs:130 1 "14. Other - record in nursing notes."2 If we go back to the Kardex on page 94, can we see3 that there are quite a number of occasions when the4 patient did not get lactulose, but there are also many5 occasions when she did?6 A. Yes.7 Q. With a patient who is suffering from C. diff, and she8 was suffering from C. diff during this period, should9 that happen?10 A. No. If the nursing staff are not giving a medication,11 they should report it to the ward doctor, whoever the12 ward doctor is, and it should have been scored off.13 Q. She should not have been given lactulose?14 A. No. If they start putting these numbers up, then they15 need to inform the ward doctor.16 Q. I understand that. But in principle, if you have17 a patient with C. diff diarrhoea, should that patient18 with given lactulose at all?19 A. No, not at all.20 Q. Is this something that the doctor should pick up?21 A. Yes.22 Q. Clearly, you, yourself, did not pick that up when you23 were carrying out your ward rounds. Is that a fair24 comment?25 A. I would have to draw that conclusion, I'm afraid.131 1 Q. Are you able to express a view, Dr Johnston, as to how2 you consider Mrs Broadley was managed in the3 Vale of Leven Hospital?4 A. I think her management was adequate but it could have5 been a lot better.6 Q. If we are looking at the positive side of that, "it7 could have been a lot better", in what way do you8 envisage it could have been a lot better?9 A. In a systemic way, in that, you know, the entire10 organisation is geared towards surveillance, monitoring,11 looking at medications. It can't be a one fix, there12 has to be a systemic improvement.13 Q. In what way would you consider her management was14 adequate?15 A. Well, I'd have to place that against the background of16 what a mortality risk of a 92-year-old being admitted to17 hospital was. You're looking at 10 per cent mortality18 during that time, so any additional mortality would be19 due to C. diff. In what way did I consider it adequate?20 I think she was given appropriate nursing care while she21 was in hospital. In fact, they eradicated her MRSA.22 I think that medication was given under microbiological23 advice up to and including immunoglobulin. I think the24 monitoring side was poor. That's it, really.25 Q. If one is to focus on the medical input into her care,132 1 do you consider that to be adequate or inadequate?2 A. I think the medical input was less than it should have3 been.4 Q. Is it possible for you to couch that in terms of5 adequate or inadequate?6 A. I think it was adequate, as I said, in so much that she7 was treated for her illness and the monitoring wasn't8 adequate, but there was adequate treatment of her9 illness.10 Q. Do you consider, having looked at the records, that the11 medical staff truly appreciated how ill she was with the12 C. diff diarrhoea?13 A. I'm not sure that I could answer that.14 MR MACAULAY: I'm now finished with Mrs Broadley's case and15 I want to move on to another case, and that is Mr Boyle.16 My Lord, that might be a point at which to give17 Dr Johnston a short rest and have a short break.18 LORD MACLEAN: Just before we do that, could I ask you --19 the question put to you was whether the medical staff20 truly appreciated how ill she was. Now, I understand21 perfectly well that you were not the only treating22 doctor. What about your own view as to how ill she was?23 A. At this stage, four years later, it's not clear to me,24 I have to say.25 LORD MACLEAN: You can't recall?133 1 A. No, I can't recall it, really.2 MR MACAULAY: If I just follow through his Lordship's3 question, ultimately, as the consultant in charge of4 the case, would it not be down to you to know how ill or5 otherwise the patient was?6 A. Provided I have all the information, yes, it is my7 responsibility.8 DAME ELISH: My Lord, I wonder if I could ask my learned9 friend if he could clarify here, did Dr Johnston not10 indicate in the records that she considered the patient11 to be terminally ill, and is that an indicator as to12 what she considered at that time?13 LORD MACLEAN: Well, of course it is, because it is very14 shortly before she died. The point is, she'd got to15 that stage, you see, and it is a progression, isn't it?16 Isn't it, Doctor?17 A. Yes.18 LORD MACLEAN: We will have a short break.19 (3.10 pm)20 (A short break)21 (3.30 pm)22 MR MACAULAY: Dr Johnston, the next case I want to look at23 with you is that of John Boyle. Again, if you could24 have the medical records in front of you. For the25 screen, the records are at GGC00030001.134 1 The background, I think, to Mr Boyle is he was2 admitted, I think, to the Royal Alexandra Hospital on3 3 January, having had a fall. I don't think he had4 a fracture. He was transferred to the Vale of Leven on5 10 January 2008. I think, at that point, he came under6 your care; is that correct?7 A. Correct.8 Q. If we look at the medical records, at page 11, do we see9 here that the admission date is the 10th, and that you10 are noted as being the consultant in charge; is that11 correct? That is at page 11?12 A. Can I just say a quick point: I don't have the Vale13 record. I have the RAH record here.14 Q. We can maybe make sure you have the records in front of15 you.16 A. I take that back. I have found it.17 Q. We are looking at page 11. You are noted as the18 consultant in charge for the admission to ward 15 on19 10 January?20 A. Yes.21 Q. If we look at the clinical records, on page 15, can we22 see that on the 14th there is an entry by Dr Herd; is23 that correct?24 A. It's me, first of all.25 Q. I'm sorry?135 1 A. I'm at the top of that page.2 Q. You're at the top, indeed.3 A. So that is the Monday morning.4 Q. You have noted in the second reference that his swallow5 was okay. Had there been some concern about his swallow6 before he was transferred?7 A. We didn't have much information about John at first,8 because we had no medical handover letter, but we had9 the nursing handover, and I asked the staff to phone10 over to Paisley to find out what the basis of11 the admission was. My understanding was that he had had12 what they thought might have been a stroke in the RAH,13 but they couldn't find the result of a stroke on the14 CT scan, and that his swallow had been poor there and15 that he was prescribed broad-spectrum antibiotics. That16 was my understanding of the background.17 Q. At the time you see him, do you prescribe any medication18 for him at that point?19 A. No. From the nursing point of view, his swallow was all20 right, but I think he was yet to be assessed by speech21 and language. He was very confused, he had no focal22 neurology. I don't actually mention his chest, but his23 chest had a few creps at the bases, and the background24 was he was frail ambulant, a bit confused at home, but25 not as bad as he was when he came in.136 1 Q. You didn't see any need to prescribe medication at that2 time?3 A. Not at that point. We were just trying to get the4 picture of the patient and get more information.5 Q. When we look at the entry for the same day by Dr Herd,6 he has, I think, prescribed amoxicillin and7 flucloxacillin; is that correct?8 A. I see that, and he is querying cellulitis. I hadn't9 been directed to his legs, I don't think. I had noted10 the chest. But Dr Herd considers he was a bit more11 chesty when he saw him, so prescribed an antibiotic.12 Q. What was the reasoning, then, behind the prescription of13 antibiotics?14 A. Well, I think Dr Herd will answer that directly, but in15 quotes "chesty" means he may have some secretions in his16 chest that are audible on auscultation.17 Q. Is the amoxicillin then designed to --18 A. I think -- I should say, actually, the other -- the19 background was somebody with a poor swallow, so they20 would likely be intermittently aspirating secretions21 from their upper airway down the way, so he was maybe22 considering that.23 Q. That is what the amoxicillin was being prescribed for,24 a possible chest infection?25 A. Yes, I think that's possible.137 1 Q. The other antibiotic, the flucloxacillin?2 A. Yes, it is anti-staphylococcal and first line treatment3 for cellulitis.4 Q. Would you have expected a chest X-ray to be instructed5 here?6 A. I think in a hospital-based patient, I would. But in7 general practice, that might have been the sort of8 patient who had been prescribed an antibiotic anyway.9 Q. But we are in a hospital situation?10 A. But we are in a hospital, so I can see it within11 a hospital regime, yes.12 Q. Was there, in fact, a chest X-ray ordered or not?13 A. I don't think there was.14 Q. In any event, he was prescribed the amoxicillin. Are15 you able to tell me how long that prescription was16 given?17 A. How long for? It doesn't say on the notes.18 Q. I can't focus on the Kardex at the moment. To confirm19 the chest infection, would the X-ray be the appropriate20 route to take?21 A. It would be one of the things, plus observations and22 some blood tests, to give a general idea if there's any23 infection.24 Q. If we move on and leave that aside just now and look at25 the position with regard to C. difficile, if you turn to138 1 page 25 of the records, do we see here that there was2 a positive sample collected on 22 January, received by3 the lab on the 25th, and that is a positive result?4 A. Yes, I see that.5 Q. If we turn to page 42 of the records, can we see that on6 the 25th, at 1450, there's a note, "Received7 notification that Jake is C. diff positive". Do you see8 that?9 A. That's a Friday afternoon.10 Q. So the ward is aware then that he is positive at that11 time?12 A. Yes.13 Q. Do you see that there is a delay between the collection14 of the specimen on the 22nd and the intimation to the15 ward of the positive result?16 A. I do see that, and I don't see in the medical notes17 before then any mention of diarrhoea.18 Q. In the medical notes. I will look at the medical notes19 in a moment.20 A. Sorry.21 Q. If there is a delay in the intimation of a positive22 result, then that can result in a treatment delay; is23 that --24 A. Yes.25 Q. If we look at the clinical notes on page 16, do we see139 1 on the 25th there's a note:2 "I have started Mr Boyle on metronidazole ..."3 A. Yes, I can see what's happened. I would be in the4 hospital at that time, in my office, and the ward has5 phoned an FY1 to get a prescription for metronidazole6 written up, which is what happens, but I can see7 I wasn't informed.8 Q. When we look at the entry, there is no suggestion here9 that the doctor has carried out any sort of clinical10 examination; is that correct?11 A. No, but it's also the timing of that, 1545, it's within12 office hours.13 Q. Are you saying that you were available and could have14 been contacted to review the patient?15 A. Yes, but it also illustrates that the cover for the ward16 at 1545 was an FY1 from medicine.17 Q. Again, is this a patient where, having tested positive18 for C. diff, there should have been a medical review of19 the patient?20 A. There should have been a medical review by somebody21 other than an FY1.22 Q. Again, we are dealing with an elderly patient. I think23 Mr Boyle, when he died on 6 February 2008, was 90 years24 of age?25 A. Yes, the other thing that had been happening prior to140 1 this diagnosis was his swallow was deteriorating and2 fluctuating, so his general condition was going down and3 he was pulling out IV lines and subcut lines.4 Q. Although I think, if we look at the preceding entry to5 the one we have looked at, which is by yourself on the6 21st, on page 16, you have noted that the swallow is7 much better at that time?8 A. Yes, coming and going, that is what was happening.9 Q. We can perhaps keep page 16 on the screen and turn to10 page 17 and put that on the screen as well. Do we see11 that you see the patient on the 28th; is that right?12 A. Monday, the 28th, yes. That was when the ward reopened,13 following the last norovirus outbreak.14 Q. But can we note that this patient has tested positive15 for C. diff following upon a sample that was collected16 on 22 January, and you see him for the first time after17 that positive diagnosis on 28 January?18 A. Yes, that would be the Monday following the Friday.19 Q. Should there have been some form of medical review20 before then?21 A. Yes. Yes, there should have been.22 Q. If we look back to page 17, there's an entry for the23 31st, I think we can recognise that as Dr Herd. I think24 it reads:25 "Still severe diarrhoea despite metronidazole."141 1 Is that right?2 A. Yes. Can I reference it back to the 28th, when I saw3 the patient? Because the information I had from the4 nursing staff was it was getting better. I did go and5 see Mr Boyle and took a look at him, but it appears to6 be that it continued after that and I wasn't informed7 about it, but Dr Herd was on the 27th.8 Q. Sorry?9 A. Sorry, I have maybe lost that reference there.10 Q. Can we get the page up?11 A. We are on the 31st, are we?12 Q. We have your entry on the 28th.13 A. I have got that.14 Q. We have an entry on the 29th --15 A. Three days later --16 Q. -- and then, on the 31st, the diarrhoea --17 A. Right. It says -- the 31st says "Still severe18 diarrhoea" which doesn't accord with my assessment a few19 days previously. So either the patient has got worse or20 the information I had on the Monday wasn't sufficient.21 Q. We have an entry, again, for 3 February, from the junior22 doctor:23 "Patient is not swallowing. Diarrhoea not24 improved."25 A. Yes, that's right. The swallow became the feature142 1 because he couldn't take the medication, he couldn't2 swallow it.3 Q. By 3 February, this is a patient who has been tested4 positive for C. diff, started on metronidazole and has5 not improved over that whole period; is that how it6 looks?7 A. He globally hadn't improved because of his chest. He8 was --9 Q. Well, what it says on the 3rd is "Diarrhoea not10 improved"?11 A. That's part of it, yes.12 Q. Is there any evidence of any clinical assessment at that13 time?14 A. On the 31st, there isn't.15 Q. On the 3rd?16 A. "Patient is not swallowing. Diarrhoea not improved.17 Started subcut fluids". I think what you are looking at18 is a patient who's gone from the acute phase to19 palliative.20 Q. Just looking at my question, I think you accepted there21 is no assessment on the 31st.22 A. No.23 Q. Is there any clinical assessment on 3 February, when the24 patient is next seen?25 A. A clinical assessment would include the swallowing, but143 1 there is nothing made about abdominal examination.2 Q. Looking to a patient of this age who has C. diff and, it3 is clear, not improving, should there have been more4 medical input than what we see here in these records?5 A. I think the previous week Dr Herd has seen the patient6 three or four times and had a discussion with the family7 about the extent to which attempts to rehydrate the8 patient could go.9 Q. But we have an entry by Dr Herd on the 31st where10 Mr Boyle is suffering from severe diarrhoea.11 A. Yes.12 Q. Then there is a gap of, what, three days, until there is13 a junior doctor on call?14 A. I think that would probably best be answered by Dr Herd,15 but what would normally happen in this case is the16 microbiologist would be informed. I think Dr Herd can17 answer that. But the practical difficulty is, in this18 patient, how to actually get medication into him, and he19 was pulling out lines, so hydration was not possible.20 Q. Can we look at the drug Kardex at page 65? Can we see21 here that the metronidazole -- it is the second entry --22 is started on 25 January; is that right?23 A. That looks it, yes.24 Q. It appears that Mr Boyle is in receipt of metronidazole25 for ten days?144 1 A. Up until the 3rd, when he's no longer swallowing.2 Q. If you have a patient who has been prescribed an3 antibiotic such as metronidazole and he is not4 improving, should his antibiotic treatment have been5 reviewed before 3 or 4 February?6 A. Yes, but if you've got a problem with intermittent7 swallow difficulties, you'd need to go to an IV8 preparation for the medication, IV metronidazole, and9 I think we can see that this patient wasn't tolerating10 lines.11 Q. So far as treatment with metronidazole is concerned, and12 looking at the drug Kardex, does it seem to be the13 position that he certainly seems to have been receiving14 the medication up until about 4 February?15 A. It doesn't say in what form the medication was given.16 It might have been syrup.17 Q. I think --18 A. Some form or other.19 Q. The point is that if a patient is being treated with20 a particular antibiotic and he's not recovering, then21 there should be review at some point along the line; is22 that right?23 A. There should be review, but it has to be in the clinical24 context of the patient's overall condition.25 Q. If we go back to page 17 of the records, then,145 1 Dr Johnston, what is the position here, in your opinion,2 when you see a patient whose diarrhoea is not improving,3 as has been noted? On the 31st, there is a gap of three4 days until the next entry, when, again, the diarrhoea is5 not improving. What should have happened here?6 A. Well, I reflect that the second of the two entries is7 24 hours before my assessment which says he's slowly8 dying. I think what has happening here was that the9 patient was deteriorating from his C. diff plus or minus10 his chest. There should have been a discussion with11 microbiology if it was felt, on the 31st, that he was12 able to tolerate a change of oral medication.13 Q. Is there any evidence that there was any such14 discussion, so far as you can see from the records?15 A. No, I can't see from the records, but, again, it might16 be something that Dr Herd can answer.17 DAME ELISH: My Lord, I wonder if my learned friend can18 clarify if, hypothetically, vancomycin was administered,19 would it be possible to do that intravenously with this20 patient, if there was still a difficulty with his21 swallow?22 MR MACAULAY: I think we know the answer, but perhaps23 Dr Johnston can give us her answer. Yes?24 A. Well, IV vancomycin can be used for pneumonia as25 a third-line agent, but for C. diff it has to be given146 1 orally, and we've been through with the family the2 status of his precarious swallow and to what extent they3 would wish him to have PEG feeding, and they declined4 that. So I think it was a law of diminishing returns.5 MR MACAULAY: If we go back to your note on 4 February,6 then, Dr Johnston, you have noted the patient is slowly7 dying. What was your reasoning at that time?8 A. To make the patient as comfortable as possible.9 Q. No, but what drew you to the conclusion that the patient10 was slowly dying?11 A. I can't precisely recall exactly the clinical scenario12 now, years on, but you'd have to accept my word for it.13 Q. Well, did C. diff feature in the scenario?14 A. The two things: the chest and the C. diff featured in15 the scenario, and the failure of the swallow, because16 that would be fatal in any case within a few days or17 weeks, if there was a complete loss of swallow in the18 patient.19 Q. I think, although IV vancomycin is not appropriate for20 C. diff, you can use IV metronidazole to treat C. diff?21 A. You can, but in this instance the patient was pulling22 things out.23 Q. If we look at the DNAR position here, at page 4, we have24 the DNAR order, again I think completed by Dr Herd, and25 the date seems to be 24 January; is that correct?147 1 A. I didn't issue this form, and there is a confusion,2 because I think there is another form for a different3 date.4 Q. We had two forms in the last case, I think.5 A. There was a date on which Dr Herd met with the family,6 which is 18 January, I think.7 Q. We see that on the form.8 A. Right.9 Q. There is a form at page 10, if we look at that. Is this10 the other form you had in mind?11 A. Yes.12 Q. This is another case where we have two DNAR order forms;13 is that how it looks?14 A. Yes, that is not appropriate either.15 Q. No.16 A. They are very close together.17 Q. If we go back to page 4, the reason why the order has18 been put into place has not been inserted.19 A. Yes. That should have been done.20 Q. Indeed, on page 10, I think that has also been left21 blank; is that right?22 A. I see that, yes.23 Q. If we look at the death certificate --24 MR KINROY: I'm sorry, my Lord, I have been distracted.25 I am sure my concern is unnecessary, but where do we see148 1 that the reason the order has been put into place has2 not been inserted?3 LORD MACLEAN: I think, really, by looking at the forms.4 MR KINROY: Of course, my Lord, that would be the obvious5 place to look, I see that, and I wasn't, but I now6 wonder if it is correct to conclude that the reason was7 not there? If I am looking to the one on the left, it8 appears to be completed by a tick in a box.9 LORD MACLEAN: I see that.10 MR KINROY: So the possibility on the three dotted lines of11 putting in a specific reason appears to be there if the12 three potential reasons below do not fit the13 circumstances.14 LORD MACLEAN: Actually, the same is true in the other15 document, Mr Kinroy. It is exactly the same, isn't it?16 What is interesting is -- we haven't really looked at17 this more closely before -- "Successful CPR is likely to18 be followed by a length and quality of life", which you19 might think was a good thing, but "which has been20 assessed as not being in the best interests of21 the patient to sustain". Is that a reason, Doctor?22 A. Since 2010, the forms have changed basically to whether23 it is possible to resuscitate the patient or not and not24 to go on quality. It's just because they're very25 unreliable.149 1 LORD MACLEAN: At this time, it looks as if it was2 a question of the quality of life that was being3 assessed?4 A. Yes. That was the problem at this time, actually,5 because people saw this as an overall treatment plan, as6 opposed to a CPR decision, and both these forms are7 inadequately filled out.8 LORD MACLEAN: In what respect, though? Because the CPR has9 not been completed?10 A. "CPR is unlikely to be successful" has to be filled in.11 You can't leave that. That is the key --12 LORD MACLEAN: You can't leave that?13 A. You can't leave that. That is the key issue.14 MR MACAULAY: Indeed, if we look at the two little stars15 against that sentence and look at the code at the16 bottom, we see the two little stars mean:17 "Record underlying conditions, eg, very poor LV18 function", and so on and so forth; is that right?19 A. That's correct.20 Q. So that is what has not happened in either of these two21 forms?22 A. No, they're not -- I did an education session on DNAR23 in October 2007 because the guideline had just changed24 and there was a lot of forms which were poorly filled25 out like this at the time. It is a continuing education150 1 process.2 Q. I think I was taking you to the death certificate, which3 we now have on the screen, at SPF00020001. Can we see4 that Dr Herd has again certified the death, this time5 for 6 February 2008, and, again, Clostridium difficile6 enteritis is at section I of the death certificate?7 A. I see that, yes.8 Q. Do you see, then, that C. diff did play a primary role9 in Mr Boyle's death?10 A. Yes. There's some discussion about death certification,11 but that's correct.12 Q. The impaired swallow that you have mentioned for13 Mr Boyle, how would you manage that? By that, I mean,14 how would that be treated?15 A. If the swallow is impaired, the patient will be16 constantly silently aspirating secretions from the upper17 airway. To tube feed the patient will deal with the18 nutrition side but will not stop aspiration, so the19 patient will continue to be at risk of pneumonia, and20 most patients who have PEG tubes put in in this21 condition do not survive a year.22 Q. What about speech and language therapy, then?23 A. They were involved with this man as well on assessing24 his swallow, and its variability.25 Q. If you have a patient who has impaired swallow, does the151 1 issue of hydration gain a particular importance?2 A. Yes, it does, and that's -- you have to consider how you3 would get access and to what extent you would escalate4 that to get a permanent system in place.5 Q. Would you, in particular, assess as to see whether or6 not the patient was dehydrated?7 A. Well, they will be dehydrated if they can't swallow8 successfully.9 Q. What was the position with this patient, then? Was he10 dehydrated?11 A. Well, I would say that he, to a certain extent, would12 have been dehydrated if he was intermittently taking13 fluids.14 Q. Do you know what steps were taken to assess his state of15 hydration, having looked at the records?16 A. I know that initially blood tests were taken but then17 discontinued after the decision was taken that he18 wouldn't be for PEG.19 Q. I think the position is, is it, that there were no blood20 samples, specimens, taken after 15 January 2008? Is21 that right?22 A. I think -- yes, that may be right, but that may have23 followed also the discussion with the family.24 Q. Would you want to carry on taking blood specimens so25 that you could assess the hydration position?152 1 A. It depends on to what extent the patient is terminally2 ill or not. If they're doing reasonably sufficiently,3 then you would do some blood tests, but you wouldn't do4 it if the patient was absolutely palliative.5 Q. Although, at that time, 15 January, I think we have6 noted, if you turn to page 16 of the notes, that there7 appears to have been some improvement in his condition;8 is that correct?9 A. Yes.10 Q. Then what happens is that he contracts C. diff, which11 has been diagnosed for 22 January?12 A. That's correct. Yes.13 Q. Having contracted C. diff, would that place at greater14 risk his hydration position?15 A. It would, but he was pulling lines out, so there wasn't16 a practical solution.17 Q. While I'm looking at Mr Boyle, I have been asked to ask18 you some particular questions on behalf of the families,19 and I think, since we have been looking at the records,20 it is probably desirable to do that at this point.21 A. Okay.22 Q. Having reviewed Mr Boyle's records, do you consider23 there was adequate consultant review of this patient?24 A. There was weekly review, yes.25 Q. When he became ill with C. diff, if we just look at153 1 medical review, do you consider the medical review was2 adequate or not?3 A. I think, when I saw him last, he was improving, and then4 he was seen again by Dr Herd during the week, and during5 that time deteriorated. So when I saw him following6 upon that, he was terminally ill. There was a very7 quick deterioration.8 Q. So are we back to the point of the gap in medical review9 from 31 January to 3 February, when he was ill and10 didn't appear to have been seen by a doctor?11 A. The 2nd -- sorry, 2 and 3 February were weekend days, so12 the days that Dr Herd was available would have been13 before that.14 Q. So what's the position, then? You are the consultant in15 charge of the patient. Should he have been seen by16 a doctor or not over that period of three days?17 A. Well, the only other opportunity for Dr Herd would have18 been Friday, the -- what was it? -- the 1st. He should19 have been seen then.20 Q. I have been asked to put to you, why didn't you carry21 out a more frequent review of Mr Boyle once he was22 diagnosed with C. diff?23 A. I think the combination of his comorbidities plus the24 fact that, when I did see him, he seemed to be25 improving, would be the answer to that.154 1 Q. When you did see him, did you always carry out2 a physical examination?3 A. I examined Mr Boyle certainly on more than one occasion4 when he arrived and also when I knew he had C. diff.5 Q. If we look at the entries, let's say, for example, on6 the 21st, that's page 16, can we tell from that whether7 you carried out a physical examination or not?8 A. You can't tell from that, no.9 Q. Would it be your practice to carry out a physical10 examination?11 A. The 21st was before he had C. diff.12 Q. What about the 28th, on page 17, if we are looking at13 that point?14 A. I did examine him that day. I just haven't recorded it.15 Q. Why haven't you recorded it?16 A. The ward was extremely busy. It had just reopened again17 from norovirus and there were patients queuing to get18 into the ward. So the nursing staff were somewhat19 distracted. I had to record what I did in a fairly20 short space of time. But I did examine him.21 Q. In relation to the DNAR order, do you know if there was22 any family discussion about that or not, or is that23 something for Dr --24 A. What I'd say to that is, I did a ward round on a Monday25 morning and, if there were patients that might be155 1 considered for DNAR, I left word for Dr Herd to speak2 with the families, because visiting was in the3 afternoon. He'd already spoken to the family about PEG4 tube feeding and I think from his DNAR note it notes5 from the 18th that he's spoken to the family, on one of6 the DNAR forms, anyway.7 I recorded in the notes, on the 21st, I think, that8 following that family meeting --9 Q. The 21st is on page 16.10 A. Yes, my note about not for CPR followed upon his family11 meeting.12 Q. Why did you come to that view at that point, when the13 rest of the entry you have made there seems positive, in14 that you say his swallow is much better and he's eating15 a normal diet?16 A. Yes, the -- it is the discussion on the variability of17 the swallow and that not wanting a PEG tube means that18 the patient is not going to have active treatment, so19 CPR would be inappropriate.20 LORD MACLEAN: What does the entry actually say on that21 line? I can't read the first word.22 A. The first word is "Swallow much better" --23 LORD MACLEAN: No, the third line.24 A. That is very bad writing. It says:25 "Not for CPR or ventilation" which goes along with156 1 the PEG tube --2 LORD MACLEAN: Oh, it is "not"?3 A. Yes.4 LORD MACLEAN: Thank you very much.5 MR MACAULAY: During this admission, can you say from the6 records if Mr Boyle was ever formally assessed for7 dementia?8 A. It's not -- sorry, his admission was too short to9 formally assess him for dementia. He had delirium on10 the background of cognitive impairment, which was11 referenced by the family to members of nursing staff and12 OTs. You can't cognitively assess a patient who is13 acutely unwell until they have recovered, so you would14 be looking at, you know, a month later. So he couldn't15 have been formally assessed.16 He had an abbreviated mental test score done, which17 was very low and consistent with acute confusion, but18 you wouldn't do a formal assessment until much later.19 Q. We do see reference in one of the DNAR forms, and20 I think also in the death certificate, to dementia?21 A. Yes. I think that is an assumption. It would be22 a reasonable assumption. Those patients who have23 dementia are most at risk of delirium. Patients with24 normal cognitive function don't get delirium. So the25 patients we see in hospital tend to be acute delirious157 1 states on a background of cognitive impairment. But to2 be perfectly correct you can't definitely say they have3 dementia until they are formally assessed, but that4 would be at a later time.5 Q. So should dementia have appeared on the death6 certificate?7 A. I think it's a reasonable assumption, but there are8 still many patients who are not positively diagnosed9 with dementia who may have dementia put on their death10 certificate, but a gentleman of 90 who has not been11 assessed by a psychiatrist -- it's a reasonable12 assumption there would be some cognitive impairment,13 because 20 per cent of the over 80s have got cognitive14 impairment, so it is a question of numbers, really.15 Q. So what's the answer to the question: do you consider it16 should have appeared in the death certificate, in the17 circumstances of this case?18 A. I wouldn't have done so, but I wouldn't criticise anyone19 who did do so.20 Q. If you had seen Mr Boyle between 28 January and21 4 February and found that his diarrhoea was not in fact22 improving, despite the metronidazole, what would your23 response have been?24 A. Well, I don't recollect the total details of this25 patient now, but my response would be to discuss with158 1 microbiology and kind of factor that into the plan.2 Q. Do we take from the notes that, during that period, you3 would not be aware that the patient was deteriorating?4 A. I wouldn't be aware of that unless I was told.5 Q. Would you expect to have been told, if one of your6 patients is deteriorating?7 A. I would prefer to be told, rather than to find out on8 a ward round, you know, a routine ward round. I'd9 prefer to be told.10 Q. Were the staff instructed to tell you if a patient of11 yours was deteriorating?12 A. The staff would always contact me on any patient who was13 deteriorating, but because they had a hospital14 practitioner, they might go direct to him, first of all,15 or he might come to me.16 Q. Would you expect Dr Herd then to contact you to let you17 know that the patient was deteriorating?18 A. I think if you record something of that nature in the19 notes, then there needs to be a follow-up to that20 comment. So yes.21 Q. If a patient under your care is deteriorating, is it22 your duty, as that patient's consultant, to review the23 patient to determine whether there are any steps that24 can be taken to halt the deterioration?25 A. Well, there's layers of review, and certainly ward-based159 1 review is the first one. I would expect to be told if2 there is a deteriorating patient and, yes, I would3 become involved.4 Q. Mr Boyle, I think, had a fall when he fell out of bed on5 12 January 2008 and he sustained a head injury. Do you6 consider that Mr Boyle ought to have had a medical7 review at that point?8 A. I'm just checking the date. It was a Saturday, so they9 would have to call the oncall junior doctor. I don't10 see any evidence of that in the notes. I do consider11 that the doctor should have been called.12 Q. Did you become aware of that, can you tell me, that he13 had had a fall and suffered a head injury?14 A. I can't recollect.15 Q. There is nothing in the records, is there, to --16 A. No, I can't recollect it.17 Q. Is that something you ought to have been told?18 A. The first step is to get the medical review of19 the patient by the junior doctor and, if there was20 something that came out of that, I would expect to be21 told; for example, that the patient had an obvious22 injury or they were unwell, for some reason. Because23 patients often fall because they have something else24 wrong with them.25 Q. We have seen, I think, Dr Johnston, that there was160 1 a delay between the taking of the sample that tested2 positive for C. diff, which was on 22 January, which was3 a Tuesday, and its receipt by the laboratory on the4 Friday, the 25th.5 Had treatment for C. diff begun earlier than6 25 January and had there been a change of therapy if the7 infection was responding (sic) to that treatment, do you8 accept that the outcome for Mr Boyle might have been9 different?10 MR PEOPLES: My Lord, I think it should be "if the infection11 was not responding to the treatment". I think it is12 a mistake in the note.13 MR MACAULAY: I will put that to you again.14 The focus here is on the delay that I think we have15 seen from the records existed between the taking of16 the specimen and the treatment beginning, a delay from17 22 to 25 January. What I have been asked to put to you18 is, if the treatment had begun sooner, do you accept19 that the outcome for Mr Boyle might have been different?20 A. No. The overall mortality rate for C. diff in the21 over 90s is very high. Earlier treatment of a patient22 who has got major problems with swallowing and got chest23 symptoms from that, he would be unlikely to survive24 30 days in hospital for that alone.25 DAME ELISH: My Lord, I wonder whether my learned friend161 1 could also clarify whether or not the earlier2 prescription would have had any effect, given the3 patient's difficulty in cooperating because of4 the swallow and the pulling out of the IV line?5 Therefore, there were missed doses because of those6 variables.7 LORD MACLEAN: What is the answer to that? Is there an8 answer there?9 A. Could you repeat that?10 LORD MACLEAN: Earlier treatment.11 A. Earlier --12 LORD MACLEAN: "Earlier prescription"? I'm not quite sure13 what that means.14 DAME ELISH: The suggestion is that, had there not been15 a delay and the prescription had been administered at an16 earlier point, he would have had a greater opportunity17 of surviving. I understand from the doctor's evidence18 that the patient, not through any fault of his own, but19 because of the delirium or dementia, was pulling the IV20 lines out and was not capable of swallowing and,21 therefore, was missing a number of his doses. In light22 of those factors, whether earlier prescription would23 have assisted is something which I would ask my learned24 friend to clarify with the doctor.25 LORD MACLEAN: Well, you heard that question. Is it162 1 possible to say?2 A. It's a difficult one, but just dealing with that type of3 patient with the swallow problems, it is a very bad4 prognostic sign by itself, and also dealing with the5 cases we had of C. diff, many of which were quite6 rapidly progressive in spite of all treatments, I don't7 think it would have made the difference in this case.8 MR MACAULAY: The point you make about pulling the IV line9 out, so far as the clinical notes go to show, is there10 more than one note making reference to that?11 A. If you look at the fluid charts, you can see when his12 IVs were put up and when it was changed to subcut, and13 the nursing notes record when he pulled things out.14 Q. So that is where you take that inference from, is it?15 A. Mmm-hmm.16 MR MACAULAY: My Lord, I'm not going to finish this17 particular case today. This might be a point to stop.18 LORD MACLEAN: Tomorrow morning, 10 o'clock.19 (4.17 pm)20 (The hearing was adjourned to21 Tuesday, 24 January 2012 at 10.00 am)22232425163 1 I N D E X23 DR FIONA ANNE JOHNSTON (sworn) ...... 145 Examination by MR MACAULAY ...... 1678910111213141516171819202122232425164

3 MR MACAULAY: Good Morning, My Lord. the Next Witness

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