5 LORD MACLEAN: Mr Kinroy, I Want to Ask You Certain

1 Monday, 6 June 20112 (10.00 am)3 (Proceedings delayed)4 (10.15 am)5 LORD MACLEAN: Mr Kinroy, I want to ask you certain6 questions in a minute. I have not read the submission,7 the latest submission, which I think was produced to me8 20 minutes ago, approximately. I haven't looked at9 that, because I don't think it is necessary for me to do10 so. But I would like some information from you.11 MR KINROY: Yes.12 Discussion re nurses' evidence13 LORD MACLEAN: You will appreciate that, at the same time,14 we have made enquiry of the RCN. Sadly, they are not15 here, actually. I would have expected them to attend16 this particular tract of evidence, but they haven't.17 But we have had a fairly full report from them about18 what they have done by way of preparation with at least19 their members.20 Of course, not all the nurses are members of21 the Royal College of Nursing, but we now see what they22 have been able to do in the time that they have been23 core participants; not as much as I would have wanted24 them to. That bears upon the decision I am going to25 announce in a moment.1 1 Before I do that, could you tell me, please, how2 much contact the board has had with the nurses, who are,3 of course, all board employees?4 MR KINROY: Very little, my Lord, on the basis that it would5 be improper to do so. In the written submissions that6 your Lordship has not yet seen there is a number of7 reasons why the board has not seen fit to instruct or8 prepare the nurses, the principal one being a potential9 conflict of interest.10 LORD MACLEAN: Is there, though?11 MR KINROY: My Lord, if I may make the submission, most12 definitely there is a potential conflict of interest,13 which I think the Solicitor to the Inquiry has already14 recognised.15 LORD MACLEAN: What is the conflict?16 MR KINROY: My Lord, it may be that one nurse will blame17 another or one nurse may blame the board, but they may18 all have different interests in what they might have to19 say when faced with evidence critical of them.20 LORD MACLEAN: So from the board's point of view, it was21 always going to be the case that they were not going to22 assist to prepare the nurses to give evidence?23 MR KINROY: Yes, my Lord, I think that has been quite24 evident from the correspondence to the Inquiry's25 solicitor all along, and certainly it is also the2 1 position of the board that it is for the Inquiry to do2 that, in terms of paragraph 21 of the guidance, for3 example. On the basis of that, the board understood4 that the Inquiry team would be doing this. But5 certainly, my Lord--6 LORD MACLEAN: The Inquiry team don't do that. The Inquiry7 team takes their statements because they know what they8 want to get from the individual witness.9 MR KINROY: My Lord, some of this I think may turn upon the10 proper construction of the 2005 Act and, of course,11 my Lord will know there is very little authority on it,12 but looking to that, Sir Richard Scott, as he then was,13 published an article in the Law Review about the proper14 procedure under the 2005 Act, and partly on the basis of15 that, and as a matter of law, Glasgow has taken the view16 that paragraph 21 of the guidance quite correctly17 indicates that it will be for the Inquiry team to18 prepare the nurses, but quite apart from questions of19 conflict of interest --20 LORD MACLEAN: Can I just come in on that, just cutting21 across you, does that mean, then, that the board does22 not know what the nurses are going to say?23 MR KINROY: My Lord, the board knows no more than is in the24 statements.25 LORD MACLEAN: Which we obtained?3 1 MR KINROY: Yes.2 LORD MACLEAN: Gosh!3 MR KINROY: May I say, my Lord, even whether or not4 questions of propriety and questions of function --5 because, of course, in this Inquiry, this is not an6 adversarial process, we are in many ways mere bystanders7 or observers, there is a practical problem in knowing8 exactly what it is which is to be put to the nurses.9 Now, we have heard the nursing reports, but of10 course, one would, at the very least, have to match up11 the reports to the individual nurses, but I imagine that12 the questions which are put to the nurses will involve13 examinations of the exercise by them of professional14 discretions, so it is very difficult to know precisely15 what they will be asked and, until that is known, it is16 very difficult to prepare them. This is in complete17 contrast, of course, to professional negligence actions.18 LORD MACLEAN: Yes, I see that.19 MR KINROY: It is not a proceeding where the complaint is20 well-known. The nurses tend to reflect on the specifics21 of the complaint and, if anyone is perturbed by the lack22 of specification, there are remedies available for that.23 So, my Lord, there is a plethora of reasons in the24 submissions which your Lordship will not yet have25 seen --4 1 LORD MACLEAN: It came rather late, you see.2 MR KINROY: Yes, indeed so, my Lord. This issue only arose3 on Friday. In fact, submissions are not really meant to4 be written, they are merely to assist oral submissions.5 LORD MACLEAN: Yes, I appreciate that. Doesn't the board6 feel any responsibility for its employees?7 MR KINROY: My Lord, it feels the greatest responsibility.8 LORD MACLEAN: What has it done about it?9 MR KINROY: The view taken by the board was that there is10 a potential conflict of interest. This is a view11 I think very clearly echoed by the Solicitor to the12 Inquiry. The board has been under the misapprehension13 that the Inquiry team was going to attend to this, or14 the Royal College of Nurses and, lastly, there is15 a general chapter of reasons why the board is not in16 a position to put to the nurses in sufficient detail the17 information they must address when they give their18 evidence.19 LORD MACLEAN: Even now?20 MR KINROY: Even now, my Lord. I should also add there is a21 question --22 LORD MACLEAN: Even in the light of the evidence we have23 heard thus far and the statements you have all had?24 MR KINROY: Absolutely so.25 LORD MACLEAN: And in the light of the fact that they are5 1 your records?2 MR KINROY: Absolutely so, my Lord. I should also add the3 question of the confidentiality agreement, which limits4 the exhibition of documents by the legal team to the5 client, the client being Greater Glasgow Health Board,6 and the legal team has, I think -- I hope correctly --7 taken the view that the scope of that is limited to8 those who personify the board. The board is a legal9 person and it has its personification in certain natural10 persons, but the nurses are not the personification of11 the board.12 If I may develop these reasons and explain why the13 board has taken these views, there are quite a number of14 reasons why the board has not seen fit to prepare the15 nurses.16 LORD MACLEAN: As I said, I am going to come to give my17 decision in a moment, but before I do, I wanted to be18 sure I understood the board's position. I am going to19 ask Mr MacAulay to comment on that.20 MR KINROY: My Lord, if I may just say, for the record, that21 the reasons are all articulated in the written22 submissions.23 LORD MACLEAN: That may be, but it would take a long time to24 read that, and even listen to it, and we don't have all25 that much time. I wish people understood that.6 1 MR KINROY: The board very much understands that. I should2 also make clear that the board is not asking for time.3 All the board is asking for --4 LORD MACLEAN: I know what the board is asking for, but it5 means time, actually. Mr MacAulay?6 MR MACAULAY: The one comment, my Lord, I would make is, if7 it is the board's position that, for reasons of8 conflict, they would not be able to prepare their9 employees to give evidence in an appropriate fashion,10 then that is something which ought to have been brought11 to the Inquiry's attention long ago. Indeed --12 LORD MACLEAN: Did you know that the board was taking that13 position, or it had taken that position?14 MR MACAULAY: My learned friend mentioned confidentiality to15 me on Friday. I didn't quite understand what the16 problem was. It wasn't elaborated upon. But the point17 is that, if that is the board's position, and it seems18 to have been the board's position for some time, then19 all the more reason that a body like the RCN should have20 been brought into the Inquiry much sooner, and I find it21 surprising that the board were prepared to expose their22 employees to giving evidence without being properly23 prepared.24 MR KINROY: My Lord, may I say this: there is a bundle of25 documents in which correspondence between the legal team7 1 for Glasgow and the Inquiry team exhibit that the board2 has been, for some time now, putting to the Inquiry team3 about what is it doing about preparing the witnesses.4 There has never been any departure from that position by5 the board.6 LORD MACLEAN: But an Inquiry doesn't prepare witnesses. It7 is a question of the interests involved.8 However, I don't want to lose time on this9 because -- although there is an unresolved question,10 Mr Kinroy, and that is: what about those nurses who are11 not members of the RCN?12 The RCN will represent their members, that is fine,13 and they have already taken steps. As I have said, not14 as many steps as I would like them to have taken, but15 they have already taken steps to prepare their members,16 and they also say they need more time to do that.17 Fundamentally, as you point out in your second note,18 it is a question, at the end of the day, not of19 the board's responsibility or how the board sees its20 responsibility or how it performs, it is a question of21 fairness to the individual witnesses, and that is what22 guides me.23 MR KINROY: Exactly so, my Lord. If I may reply to one24 thing my learned friend has said, it is not a question25 of the board neglecting the care for its employees. Far8 1 from it. I will explain why the board took the view it2 was improper to prepare the witnesses.3 On the other hand, this very application is designed4 to protect the nurses from unfairness. I should also5 say, my Lord, that there may be, if anything,6 a challenge that the board has no interest to do this.7 It is for the RCN or for those nurses to take the point.8 But the board has taken the point that they need to be9 properly prepared and, of course, the board recognises10 firstly that it is in everyone's interest that there11 should be fairness.12 LORD MACLEAN: I know that. That is what guides me. But13 I do find it remarkable that the board has not posted14 this clearly from way back, and also why it feels it15 cannot represent, at least prepare for evidence, people16 who are their employees?17 MR KINROY: My Lord, by my way of it, since 7 April, the18 board's position has been manifest to the Inquiry. If19 not then, from a date in early May the board has been20 saying to the Solicitors for the Inquiry team, "What are21 you doing about this?"22 It appeared that the RCN was to the rescue, but not23 it appears not.24 LORD MACLEAN: Sorry?25 MR KINROY: It appeared that the RCN was to come to the9 1 rescue, in that the RCN, as his Lordship had envisaged,2 I think, was to prepare the nurses, but there is now3 a concern for this party that the RCN has not managed to4 do -- in essence, one shares your Lordship's views that5 the RCN has not done all that one might have hoped it6 could.7 LORD MACLEAN: There is a lack of urgency being shown.8 Because of that, I have decided that the nurses will not9 give evidence until they are properly prepared and, to10 do that, I am going to postpone their evidence until11 4 July, which is four weeks away. If they can't be12 prepared in that time by reference to the documents,13 your documents, incidentally, that will be too bad. We14 need to get ahead. Already there has been anxiety about15 the delays that have taken place. I am not allocating16 responsibility for that at all, but we must get ahead17 with this.18 I take it, and we will hear from the RCN, that that19 will be sufficient time for them to do the work they20 have to and, of course, I am not sure what, if any, work21 you are going to be doing as a board.22 MR KINROY: My Lord, clearly the board wishes to assist the23 Inquiry as much as it properly can. If the question of24 conflict of interest can be resolved, if the25 confidentiality agreement can be modified and if the10 1 board can be told specifically what are the questions2 which are to be put to the nurses, then I have no doubt3 about it, the board will be gladly involved, insofar as4 time permits, in giving the nurses notice of what they5 are to be asked and giving them time to reflect on that6 and giving them time to refresh their memories, but the7 board has not wanted to do anything improper in all of8 this.9 Of course, my Lord will know that presumably under10 the 2005 Act, sadly, the board is in many ways a passive11 observer in the Inquiry.12 LORD MACLEAN: Oh, Mr Kinroy, I think you will regret saying13 that by the end of this Inquiry. You are not a passive14 observer at all. You are very much a party right at the15 forefront of the Inquiry.16 MR KINROY: My Lord, I would welcome the chance to17 cross-examine witnesses and to lead evidence.18 LORD MACLEAN: That is a different point altogether --19 altogether -- but that doesn't mean to say that you are20 passive in relation to preparing your employees for21 their giving evidence.22 Now, if it is a question of propriety, I personally,23 at the moment, don't think it is improper at all and24 welcome the board's input to that, because there will be25 some who will not be prepared by the RCN, you see, they11 1 are not members. I don't know who they are, but you2 will know who they are.3 MR KINROY: My Lord, not that there is considered to be no4 conflict of interest here, I suppose, nonetheless, that5 legal advisers, in the proper performance of their6 professional duties, will have to be very careful and7 take guidance from the professional bodies about it, but8 no doubt the bodies will be understanding about that.9 LORD MACLEAN: I shall ask Mr MacAulay for his observations10 on what I have indicated and intimated and in the light11 of what you have said. Mr MacAulay?12 MR MACAULAY: My Lord, the reality of the position appears13 to be that the nurses have not been prepared, for14 whatever reason, to give their evidence next week.15 I don't have any difficulty in accepting the proposition16 that, as a matter of fairness, they ought to be17 prepared. I would therefore support the proposition18 that they should be given time for that preparation.19 I fail to see the nature of the conflict of interest20 that my learned friend makes reference to,21 notwithstanding the fact that these are the board's22 employees and, indeed, one would have thought that,23 having regard to the broad terms of your Lordship's24 remit, the board, long ago, should have investigated the25 nursing care that was given to patients at the12 1 Vale of Leven, if only to satisfy themselves as to what2 the position was, and if they haven't entered into3 discussions with the nurses and examined the medical4 records in that context, that would suggest they haven't5 carried out --6 LORD MACLEAN: Sorry?7 MR MACAULAY: If they haven't taken the nurses through the8 medical records, and that seems to be the position, then9 it is difficult to see how the board itself has10 satisfied itself in relation to the nature of11 the nursing care given at the Vale of Leven.12 LORD MACLEAN: I share your difficulty in understanding the13 conflict, but they obviously feel, having received legal14 advice, that there is one. I personally can't see it.15 I think it may be a question for a discussion16 between you, perhaps, and Mr Kinroy as to whether such17 conflict would prevent their assisting their employees18 who are not members of the RCN to prepare for this19 Inquiry. You might discuss that with him.20 MR MACAULAY: Indeed. My learned friend seems to suggest21 that there is a conflict in the fact that one nurse22 might blame another, or indeed blame another member of23 the board, but unless and until they have actually24 spoken to the nurses and looked at the matter, that25 might be pure hypothesis that doesn't exist.13 1 Be that as it may, my Lord, ultimately the issue is2 one of fairness to the witnesses.3 LORD MACLEAN: That is what governs my thinking, actually,4 and what drives me to indicate that the nursing evidence5 will not be heard until 4 July.6 MR KINROY: Indeed so, my Lord. If I may add, part of7 the reasoning which informs the board's view is a letter8 of 20 May 2010 from the Solicitor to the Inquiry:9 "While I appreciate that your office may represent10 members of staff as well as the board in certain11 proceedings, I am bound to say I find it, in comparison12 with other legal proceedings, to be of limited value.13 It appears to me that the same solicitor can only14 properly act for more than one party where there is no15 foreseeable risk of a conflict of interest arising, and16 I understand from our conversation that you accept that17 a conflict of interest may arise. For my part, in the18 context of a public Inquiry, I find the risk of conflict19 of interest to be manifest."20 So, my Lord, there is clearly some confusion about21 this question of conflict of interest.22 LORD MACLEAN: Absolutely. It is not the first confusion23 that has arisen between the Inquiry team and the board.24 MR KINROY: That is obviously regrettable, my Lord, but may25 I also say this: the nursing reports which are the basis14 1 on which this has called into question the adequacy of2 nursing only began to appear, I think, on 1 April of3 this year and, until that point, there had been no4 suggestion that the adequacy of the nursing -- sorry,5 my Lord, until the end of 2010, there had been no6 suggestion that the adequacy of the nursing would be7 called into question, and my Lord will know that the8 independent review team had formed the view that it was9 perfectly adequate.10 LORD MACLEAN: That is many moons ago, Mr Kinroy. People11 may have their views about how thorough that12 investigation was.13 MR KINROY: What the board has had to do is to see these14 reports and deal with them as they appear from 1 April15 onwards, and it made every effort to do so in time for16 16 May.17 LORD MACLEAN: Do you want to reply to that, Mr MacAulay?18 MR MACAULAY: In relation, my Lord, to the independent19 review, Professor Cairn Smith's review, that had a very20 limited remit and its focus was on systems, not on21 nursing care. It has been perfectly evident since this22 Inquiry was set up in April 2009 that it had an23 extremely broad remit, which included looking at nursing24 care.25 The core participants have been aware15 1 since September of last year that each individual2 patient's records was going to be examined by nursing,3 geriatric and microbiological experts, so it was4 well-known what the nature of this exercise was supposed5 to be.6 Furthermore, my Lord, on 17 March, a note from7 counsel on the themes that were to be anticipated in the8 nursing reports was circulated with core participants.9 LORD MACLEAN: That is you and --10 MR MACAULAY: And Ms Sutherland. That covered matters like11 fluid balance, pressure management, and so on and so12 forth. So, my Lord, it has been clear for some time13 that this was the manner in which this whole exercise14 was to be conducted.15 LORD MACLEAN: I'm slightly bothered about this. It is not16 just in terms of the nursing, Mr Kinroy. I am thinking17 perhaps about the other areas, other employees of18 the board, that will yet have to give evidence, and I am19 thinking of the doctors here.20 You could well say the same thing about them. They21 might blame each other or blame the board or blame --22 I don't know whom, but does that give rise to a conflict23 of interest?24 MR KINROY: My Lord, undoubtedly. As of today, yes. But of25 course, I understand that the doctors are much more16 1 likely to be instructing legal representation of their2 own, if that is permitted to them.3 May I say this, there are two different things here:4 one is the position of the board in relation to the5 quality of nursing, and the board has to examine that6 and be prepared to discuss it, but in terms of7 the specific concern today, which is the preparation of8 the nurses to give evidence, that turns upon knowing9 what it is with which they are to be charged.10 LORD MACLEAN: They are not charged with anything. They are11 charged with giving evidence about what they did or12 didn't do.13 MR KINROY: In that case, I will rephrase that: the question14 is what adverse evidence should be drawn to their15 attention, if I use the words of Sir Richard Scott?16 LORD MACLEAN: There is not adverse evidence, Mr Kinroy. It17 is just evidence -- I don't know who may or may not be18 criticised. Therefore, no notices can go out at this19 stage until I have heard the evidence. I have been20 through this before in another place.21 MR KINROY: Of course, my Lord. I suggest that, when one22 looks to the views expressed by Sir Richard Scott, there23 are two stages here. Clearly, there is a stage of24 the warning letter, known as the Salmon letter, and25 I think it is paragraph 12 of the rules of procedure --17 1 LORD MACLEAN: You refer to the then Sir Richard Scott,2 which is the -- remind me of the Inquiry.3 MR KINROY: The Arms to Iraq Inquiry, yes.4 LORD MACLEAN: That's right, and of course that was one of5 the Inquiries that led up to the passage of6 the Inquiries Act 2005. That and the procedural rules7 govern the way this is conducted.8 I don't know, I have no idea, until I have heard the9 evidence, who might or might not be identified as10 somebody who is criticised professionally -- or it may11 not be professionally, but certainly who is criticised.12 Such a person will always have the opportunity of coming13 back in the light of any finding that the Inquiry might14 make. So they are not going to be without redress or an15 opportunity of reply.16 The concern at the moment is that people should be17 well-prepared for questions that are going to be asked,18 in fairness to them, by reference to the documents, and19 the documents substantially here are the hospital20 records, your records, if I might say so.21 MR KINROY: Exactly so. My Lord, if I may -- it might be22 useful if I make this submission: as I read the views of23 Sir Richard Scott, which to my mind at least are24 extremely cogent, he alludes to the stage of a warning25 letter being given, that is the stage to which18 1 your Lordship has also referred, but he also refers to2 an antecedent stage, that is the stage with which we are3 concerned now.4 His view -- of course, it is for your Lordship to5 either accept or reject the fact -- is that, where there6 is adverse evidence prejudicial to a witness, at the7 stage of giving evidence and being called, the witness8 should be alerted to it. Now, my Lord --9 LORD MACLEAN: That is true. That will happen here, won't10 it?11 MR KINROY: Exactly so.12 LORD MACLEAN: By the time the nurses come, most of13 the expert evidence will have been given, will be known14 and understood, and can be put to the individual nurse15 for his or her comment.16 MR KINROY: One of the difficulties at this stage, my Lord,17 for, I think, anyone, is knowing what allegations --18 I correct myself, what adverse evidence is to be put to19 which nurse.20 LORD MACLEAN: I don't understand that. I really don't, I'm21 sorry. But all you need to do is prepare the nurse for22 giving evidence in light of the documents and find out23 what it is she has to say. I don't know what she is24 going to say.25 MR KINROY: My Lord, in light of these discussions, I have19 1 no doubt the parties will collaborate in seeing that2 this is properly done.3 LORD MACLEAN: I certainly hope so.4 MR KINROY: There is certainly, I think, great willingness5 on all sides to cooperate in an Inquiry which is not6 about attributing blame, but about getting to the bottom7 of things, and that is certainly Greater Glasgow8 Health Board's desire.9 LORD MACLEAN: That is what I am charged with doing, is10 fulfilling the remit that I have got.11 I think what I am going to do in the future, to12 avoid these misunderstandings, is to ask parties from13 time to time what their position is in terms of being14 prepared for this or prepared for that, because I can't,15 frankly, allow this to happen again.16 After all, you have made an application to me -- not17 you personally, perhaps, but there was an application18 made to me to have more time given, and you got more19 time. That was for your own benefit.20 MR KINROY: Inadvertently perhaps, my Lord, but there was no21 application made in advance of 6 May for more time by22 Greater Glasgow Health Board. Indeed, my Lord, it would23 have been contradictory to do that, because Glasgow24 Health Board had already been told there would be no25 postponement.20 1 So, my Lord, the first application was not concerned2 with getting more time, it was concerned with the3 question, one, of preparing the nurses, that was the4 alternative submission, and the antecedent question was,5 in fairness, could it be clarified why certain issues,6 for example, falls risk assessments, should be explored7 in these hearings when there was no obvious connection8 to the fundamental question of: why did certain patients9 contract the C. diff illness and the mortality rate?10 LORD MACLEAN: Mr Kinroy, I have a totally different11 understanding of why the board did make application, and12 I am going to ask Mr MacAulay to clarify my thinking for13 me.14 MR MACAULAY: I understand, my Lord, that the board sought15 more time because they wanted more time to consider the16 nursing expert reports.17 LORD MACLEAN: Yes. I agree. You didn't have very much18 time to consider them.19 MR MACAULAY: Your Lordship took the view that more time20 should be given, and that is what happened.21 LORD MACLEAN: Anyway --22 MR KINROY: My Lord, I will be governed by the terms --23 LORD MACLEAN: Can we draw a line under all of this?24 Because it is going nowhere, really. But you know what25 I think. I don't think it is in the least bit improper21 1 for you to prepare your employees, the nurses who are2 not members of the RCN particularly, to give evidence,3 and four weeks is ample time for that to be done.4 MR KINROY: Of course, my Lord.5 LORD MACLEAN: Right. We do have a witness?6 MR MACAULAY: We do, my Lord. I would like to call7 Sharon Stower.8 MS SHARON STOWER (sworn)9 Examination by MR MACAULAY10 MR MACAULAY: Are you Sharon Stower?11 A. I am.12 Q. Could I ask you to have your CV in front of you, please,13 it is INQ01820001. Could I ask you what position you14 hold at present, Mrs Stower?15 A. The position that I hold at present is that I am an16 independent healthcare consultant and I also am an17 expert nurse.18 Q. If we look to the first page of your CV, can we see19 under the heading "Current Employment" that you describe20 yourself as an independent nursing and healthcare21 consultant and you have been that since 2004; is that22 correct?23 A. That's correct.24 Q. You also act as a clinical adviser to the healthcare25 Commission; is that right?22 1 A. I was a clinical adviser to the Healthcare Commission,2 now the CQC, but since the Healthcare Commission became3 the CQC, I have no longer worked for them.4 Q. Can you give the Inquiry some sort of understanding then5 as to what the nature of your work is at present?6 A. Yes, of course. As an independent nursing and7 healthcare consultant, I work with a large group of8 professionals. I basically work on an instruction9 basis. My work comes from a variety of different10 sources. I do work, or I have worked, and I am still11 working, for the Royal College of Nursing. They give me12 extracts of work on projects to do as they need them13 doing. I also, over the past year, have worked with14 the -- in England, the national safe and sustainable15 teams reviewing the second part of children's cardiac16 surgery and the ongoing national review of children's17 neurosurgery. That is basically my consultancy work.18 I also work on a retainer basis for other companies,19 for example, independent healthcare companies, again20 working with them on any projects that they may need to21 have undertaken, and then, separate to that, I have my22 legal expert nurse work, which again is done on an23 instruction basis from solicitors.24 Q. You tell us that you get instructions from both the25 claimant and from the defence?23 1 A. I beg your pardon?2 Q. You are instructed by both claimants and by defence?3 A. That's correct.4 Q. If you turn to the second page of your CV, and we look5 to the bottom, can you tell me, when did you qualify as6 a registered nurse?7 A. I qualified as a registered general nurse in 1978, and8 then, after that, I went on to do a second registration9 in sick children's nursing.10 Q. If we just look at your CV, you were a sister from 198311 to 1984; is that correct?12 A. That's correct.13 Q. Then we see the different positions that you have held.14 If we look towards the top, the second entry, you were15 registered manager/matron in a hospital in Peterborough;16 is that right?17 A. Correct.18 Q. Was that the last nursing post you held before your19 present position?20 A. No. After I worked at the orthopaedic hospital in21 Peterborough, I then took a post as the lead nurse in22 one of the English private schools.23 Q. Is that the position that we see from 2008 to 2010?24 A. Yes, that's correct.25 Q. Was that a part-time position?24 1 A. Yes, it was four days a week. I was employed as the2 lead nurse.3 Q. If we go to the first page of your CV, you set out your4 professional education and your higher education. You5 seem to have had an MA in Philosophical, Medical and6 Healthcare Ethics in 1997; is that right?7 A. That's correct.8 Q. Can you tell me when you last worked in the capacity as9 a senior charge nurse, if I can look at that sort of10 pigeonhole?11 A. The answer to that is, in the role of a ward sister or12 a nurse in charge of a ward, would have been in13 Peterborough, but also when I worked as the lead nurse14 in the school.15 Q. So the Peterborough position was in 2004 to 2006?16 A. That's correct.17 Q. Have you ever worked in Scotland?18 A. I have never worked in Scotland, no.19 Q. Have you ever been to the Vale of Leven Hospital?20 A. No, I have not.21 Q. In preparation for giving your evidence, were you22 provided with some information as to the nature of23 the hospital?24 A. Yes, I was provided with the Junior Doctors' Handbook.25 Q. Perhaps we can look quickly at that, please, if you25 1 could look at GGC21720001. Do you recognise that as the2 first page of the document that you were given?3 A. That's correct.4 Q. You were given information as to the size of5 the hospital and the nature of the services provided?6 A. That's correct.7 Q. I think you have prepared a number of reports for this8 Inquiry in respect of a number of individual patients;9 is that right?10 A. Yes, I have prepared nine reports for nine patients,11 plus a summary report.12 Q. The summary report was designed to summarise what you13 had ascertained from carrying out the individual14 reports?15 A. That's correct. It was just to bring together the16 reoccurring themes.17 Q. In looking at the patient records, did you seek to put18 yourself in the shoes of the nurses on the ward?19 A. Yes, I did. I approached the reports from the point of20 view of the nursing care of the nurses on the ward, but21 equally from the patient's point of view as well.22 LORD MACLEAN: I think that is slightly too close to you,23 actually. That is better.24 A. Is that better? Okay.25 MR MACAULAY: Could I ask you to look at a number of26 1 documents. First of all, all registered nurses have to2 be registered with a regulatory body, is that right, the3 Nursing & Midwifery Council?4 A. That's correct.5 Q. If you could look, please, at the Code of Practice,6 which is to be found at INQ01970001, and if you could7 turn, please, to page 3 of the code, can we see that8 this document sets out a number of principles that are9 to guide nurses in their practice?10 A. Yes, it does.11 Q. Is this an important document?12 A. Yes, it is a very important document for registered13 nurses.14 Q. Why is that?15 A. The Nursing & Midwifery Council is the regulatory body16 for registered nurses, and it is there not only for that17 but also for the protection of the public. These18 underlying principles are principles that are engrained19 into the clinical practice of nurses.20 Q. If we look to this page that we are looking at at the21 moment, page 3, we are told:22 "As a registered nurse, midwife or specialist23 community public health nurse, you are personally24 accountable for your practice."25 Then there are a number of propositions set out that27 1 are relevant when caring for patients; is that right?2 A. That's correct.3 Q. Can we see that this section ends with this:4 "These are the shared values of all the5 United Kingdom healthcare regulatory bodies."6 A. Yes.7 Q. We know that you have never practised in Scotland, but8 do you think that that in any way affects your ability9 to assist the Inquiry in relation to what you discovered10 in looking at the medical records of the patients you11 looked at?12 A. No, I don't think it prohibits that at all.13 Q. I should perhaps indicate that, when we see you dabbing14 your eyes, it is not because you are distressed, but15 because you suffer from hayfever; is that right?16 A. Yes, thank you.17 Q. Why do you think that you are able to comment upon the18 nursing records of patients in Scotland?19 A. In terms of nursing and the NMC and, indeed, the Royal20 College of Nursing, the organisation, as it says here,21 shared values across the United Kingdom -- that's the22 four countries of the United Kingdom, which obviously23 includes Scotland -- and in those organisations there is24 representative of the countries. I support and am part25 of that, so a lot of my professional dealings with those28 1 are shared with the four countries, including Scotland,2 of course, and they are all fully represented, so I feel3 that that is sufficient reason to be able to confidently4 say that I can do that.5 Q. If you look at page 4 of the code, and we have looked at6 this in detail before and I just want to pick up one or7 two points, at 1.4, do we read that the nurse has a duty8 of care to your patients and clients who are entitled to9 receive safe and competent care? Is that a fundamental10 duty?11 A. It is a fundamental principle of practice.12 Q. When you came to look at the records of patients you13 looked at, were you in any way looking at these records14 in any specialised way?15 A. No, not in a specialised way, just in a general context16 of patient care.17 Q. Were you looking for certain core and fundamental18 principles of nursing?19 A. Yes, I was.20 Q. The next document I want you to look at, please, is21 INQ02090001. You will see on the screen a document22 headed "Record keeping", and we see again it has been23 produced by the NMC.24 Can you just tell us about record keeping? How25 important is record keeping when you are looking at29 1 care?2 A. Well, record keeping is a fundamental element of3 clinical care. The two things sit very closely4 together. In terms of what clinical care is delivered5 to the patient, record keeping should always reflect6 that.7 Q. Why? Why is that?8 A. Because it is important to have a record of care that9 has been delivered to patients. If the record -- if10 there are no records, then we have no way of knowing11 what has been undertaken.12 Q. If we just read the introduction, do we see that it13 reads as follows:14 "Record keeping is an integral part of nursing,15 midwifery and specialist community public health and16 nursing practice. It is a tool of professional practice17 and one that should help the care process. It is not18 separate from this process and it is not an optional19 extra to be fitted in if circumstances allow."20 Do you agree with that statement?21 A. Absolutely.22 Q. If you turn to the fourth page of the document, the23 first main paragraph, can we read:24 "The approach to record keeping that courts of law25 adopt tends to be that 'if it is not recorded, it has30 1 not been done'."2 Is that within your experience?3 A. That is within my experience.4 Q. If you go back to the first page of the document, we are5 given some information as to what good record keeping6 does, and it promotes, for example, continuity of care.7 Do you see that?8 A. Yes.9 Q. Moving on to the next paragraph:10 "Members of the public have the right to expect that11 healthcare professionals will practice a high standard12 of record keeping. The quality of a registrant's record13 keeping is a reflection of the standard of their14 professional practice. Good record keeping is a mark of15 a skilled and safe practitioner, while careless or16 incomplete record keeping often highlights wider17 problems with that individual's practice."18 Looking to these propositions, does that accord with19 your experience?20 A. Yes, it can well be reflective. I have actually21 referred to that particular paragraph, I believe, in my22 summary report.23 Q. In the preparation of your reports, did you also have24 regard to policies that you understood to be local25 policies relevant for the Vale of Leven?31 1 A. Yes, I did.2 Q. Could you now look, please, at GGC00780001? We have3 already looked at this with other witnesses, but can you4 see that this is part of the infection control manual5 that we understand was in place in the Vale of Leven?6 If you look, please, at page 252, I think you see7 here that part of the manual that is dealing with8 C. difficile associated diarrhoea. Did you look at this9 document in preparation for giving evidence?10 A. Yes, I did.11 Q. Can we see that, at 1, the responsibilities on health12 workers is that they must follow this policy and inform13 a member of the infection control team if this policy14 cannot be followed?15 A. Yes, correct.16 Q. If you turn to page 254, we can read here at section 3,17 against the reference to "Accommodation":18 "A risk assessment should be carried out by the ICT19 to determine if the patient requires isolation nursing."20 Do you see that?21 A. Yes.22 Q. I think you looked at, as you said, nine cases. We will23 look at the detail shortly, but was there evidence of24 risk assessments being carried out in relation to25 patients who contracted C. difficile?32 1 A. Not in the way I would understand risk assessments to be2 carried out. No, not really.3 Q. We will look at that in due course. The next reference4 I want you to look at makes reference to "care plan5 available". Would you envisage that, if a patient was6 to be suffering from C. difficile, there would be a care7 plan prepared for that patient?8 A. Yes, I would expect that.9 Q. If you could now look, please, at, I think, another10 document you looked at, and that is page 258 in the same11 production. You will see this is headed "Loose stools".12 Again, was this a policy document that you looked at in13 preparation for giving evidence?14 A. Yes, I did.15 Q. If you turn to page 259, against the heading16 "Accommodation", are we told that a patient with loose17 stools should be placed -- start again:18 "Place a patient who could contaminate the19 environment with faeces in a single room."20 Is that the general principle that, if a patient has21 loose stools, the desirable position is to isolate the22 patient?23 A. Yes, it is.24 Q. If that is not possible for whatever reason, let's say,25 for example, there are no single rooms available, then33 1 what would the position be?2 A. If there is difficulty in providing a single room, then3 I would expect the nursing staff on the ward, if the4 patient was going to go to a ward, to try to find5 a suitable alternative.6 For example, there may be a two-bed room that could7 accommodate the patient, providing there wasn't a second8 person in that room. They could also contact the9 infection control team to ask for advice regarding how10 to manage the process -- they are the experts in the11 field -- to give them advice. Also, the infection12 control team should have a more global view of what13 rooms would be available in the hospital, so there may14 be single rooms available somewhere else that may be15 able to accommodate that patient.16 Equally, if that wasn't the case, then there are17 possible other alternatives, such as defining a specific18 area for the patient with providing them with their own19 commode, et cetera, to try to reduce any degree of20 contamination to other patients.21 Q. What about cohorting with other patients who may be22 suffering from the same problem? Would that be an23 option?24 A. It is an option if you are confident that the organism25 is the same.34 1 Q. The next section deals with "Care plan available", and2 it says:3 "Yes. See care plan for patients with loose4 stools."5 Would you expect there to be a care plan prepared if6 a patient develops loose stools?7 A. Yes, I would.8 Q. Under the heading "Documentation" a few lines down, can9 we read:10 "Document all episodes of loose stools and actions11 taken on a stool or fluid balance chart and12 medical/nursing notes."13 Again, would you expect that all episodes of loose14 stools would be documented?15 A. Yes, I would.16 Q. I think another policy document that you looked at we17 find at GGC26540001. You will see that this document is18 headed "NH Greater Glasgow and Clyde acute services19 division". It is dated 21 December 2006. It relates to20 the management of inpatient falls. Again, did you look21 at this before coming to give evidence?22 A. Yes, I did.23 Q. If we turn to page 3 of the document, we are given some24 information about falls. Can falls be a problem if they25 occur, particularly for older patients?35 1 A. Well, particularly, falls are a problem for elderly2 patients. Very often, they have unsteady gait which3 gives them a tendency to fall. It is an area that is4 known to be greater.5 Q. If we turn to page 4, we are told what the aims of6 the policy are:7 "To identify patients at risk of falling in8 hospital."9 Generally, how is that done?10 A. Generally, that is done with a falls risk assessment11 document, risk assessment tool, so when the patient is12 being admitted and a variety of data is being collected13 to combine together to provide them with a nursing care14 plan, a falls risk assessment would be undertaken.15 Q. In the cases you looked at, was the tool available in16 these cases?17 A. Yes, the hospital did have a falls assessment, risk18 assessment tool, yes.19 Q. Turn to page 5, please, of the policy. You will see at20 5.1 the advice is:21 "All patients presenting with a fall or with22 a condition which might render them susceptible to23 a fall will have the following documentation completed24 within 24 hours of admission:25 "The Cannard falls risk assessment:36 1 "A core nursing care plan to record interventions2 undertaken to promote the patient's safety.3 "If used, the mobility risk assessment card should4 be completed."5 Focusing on the second bullet point, would you6 expect a care plan to be prepared, particularly if7 a patient was at risk?8 A. Most definitely, yes.9 Q. Can I then start looking at the cases you looked at,10 Mrs Stower, and the first case I want you to look at is11 that of Catherine Stewart.12 First of all, if you could have your report in front13 of you, and I will put it on the screen as well, it is14 EXP00100001. If you could also have the medical15 records, GGC00530001. If we turn to your report, first16 of all, and go to page 2 of the report, you set out17 under the heading "Instructions" what you are asked to18 do in relation to the records; is that correct?19 A. That's correct.20 Q. In particular, you indicate that you were not being21 asked to interview the patient, relatives or members of22 staff in providing your opinion, and you confirm that23 you have not reviewed any statements at this stage in24 the preparation of your opinion or transcripts of oral25 evidence.37 1 I understand from that that, essentially, your2 primary focus was on the medical records; is that right?3 A. The medical and nursing records. Yes, that's correct.4 Q. I have been asked to put this to you, and I will, and5 that is that you would accept, of course, that at the6 end of the day, what patients may say or families or7 nursing staff, and so on, will be important and has to8 be considered in the whole picture before a decision can9 be made as to what the standard of care was?10 A. Yes, of course.11 Q. If we then turn to page 3 of your report, I think I am12 right in saying that Mrs Stewart was 56 when she was13 admitted to the Vale of Leven? I think her date of14 birth was 17 August 1951?15 A. That's correct.16 Q. Can you then tell us what you took from the records in17 relation to her medical history?18 A. Mrs Stewart was admitted into the --19 Q. Can I ask you to pull the mic towards you?20 A. Better?21 Q. Yes, thank you.22 A. Mrs Stewart was admitted to the Vale of Leven Hospital23 via the MAU, which is the medical assessment unit, on24 11/12, following a referral from her general25 practitioner. The general practitioner recorded that38 1 the presenting -- her presenting symptoms were of2 confusion. There was also previous medical history of3 alcoholic liver disease, gastric ulcer, hiatus hernia4 and an attempted suicide. The patient had also had5 recent upper gastrointestinal bleed and had undergone6 endoscopy at the Royal Alexandra Hospital on 26/11/07.7 Q. She was admitted, just to be clear, on 11 December8 initially into the medical assessment unit?9 A. That's correct.10 Q. What was the problem then on admission --11 MR PEOPLES: Sorry, could I just correct -- I think the12 report says 11 December 2008. I think it should13 probably be 2007. It is just a small point.14 LORD MACLEAN: Is that right?15 MR MACAULAY: That is right, isn't it?16 A. Sorry, I didn't hear that.17 Q. If you look at page 3 of the report, in the second line18 you say 11 December 2008. It should be 2007?19 A. Yes.20 Q. Then you go on to tell us about what had happened in the21 Royal Alexandra Hospital in November 2007.22 A. Yes.23 Q. To be clear, then, she was admitted on 11 December 2007.24 What was the problem on admission?25 A. The patient came into the Vale of Leven with a referral39 1 with symptoms of confusion. She had also complained of2 abdominal pain, query peritonitis and, following an3 initial examination by the doctors, a decision was made4 to transfer the patient to the Royal Alexandra Hospital5 for a surgical opinion, and so that's essentially what6 happened.7 Q. I think you record in the notes that, when the patient8 was being referred by the GP, there was reference to9 falls and also increased confusion and diarrhoea?10 A. Yes, that's correct.11 Q. Was that on admission, that there was a suggestion that12 she'd been suffering from diarrhoea?13 A. Yes, that would have been in the information given by14 the GP on admission.15 Q. So far as the Royal Alexandra Hospital was concerned,16 what happened there?17 A. At the Royal Alexandra Hospital there was an initial18 diagnosis of an acute abdomen and she was also noted to19 be dehydrated. She was initially given some treatment20 with some intravenous antibiotics and, when she had21 a rectal examination, there was found to be some22 foul-smelling diarrhoea.23 At that point, doctors there were of the opinion24 that there was not an acute abdomen, there was a pleural25 effusion and there was also a question that there might40 1 have been some C. difficile contamination, some2 C. difficile diarrhoea. So a decision was then made to3 transfer this patient back to the Vale of Leven Hospital4 as there was considered to be no presenting surgical5 issues. The patient was, at that point, considered to6 be stable.7 Q. So the patient then returned to the medical assessment8 unit at the Vale of Leven; is that correct?9 A. Yes, she was.10 Q. Was a stool sample then taken --11 A. It was, yes.12 Q. -- on admission to the MAU?13 A. Correct.14 Q. Then I think you tell us in your report that there was15 a concern that Mrs Stewart had C. difficile infection16 and the decision to admit was made, to ward 3; is that17 correct?18 A. Correct, yes.19 Q. But there was no isolation bed available at that time?20 A. Correct.21 Q. Can I just ask you to turn to page 104 of the records.22 Can we see that this bears to be a nursing admission23 assessment form, and does this relate to the admission24 of Mrs Stewart after the transfer back from the Royal25 Alexandra Hospital?41 1 A. Yes, that's correct.2 Q. We see the admission date is now 12/12. I think in your3 report you say 12/11, but you mean the 12th; isn't that4 right?5 A. Correct.6 Q. We see a reference to ward 3. You make some7 observations in your report about this document. What8 do you tell us about it on page 4 of your report?9 A. This document is essentially not completed -- completely10 completed. There is some key information that hasn't11 been recorded for the patient.12 Q. Again, if I could ask you, please, to make sure you13 speak into the microphone so we can hear you. You say14 the document is not fully completed?15 A. That's correct.16 Q. What has been left out?17 A. Some of the essential personal information for the18 patient, such as a name for the consultant, GP, next of19 kin, although that has been blocked out -- I apologise20 for that -- but certainly the history below, and the key21 issue, really, is around about the observations of22 the vital signs, temperature, pulse, blood pressure,23 respiratory, there is no weight recorded on admission or24 sats or the MEWS or BM scores and there is no Waterlow25 score or urinalysis. There is quite a lot of42 1 information at the lower section that has not been2 completed for this patient on admission.3 Q. Is this sort of document a document that is familiar to4 you?5 A. Yes.6 Q. It is a standard type of document that would be used7 when admitting a patient to a hospital?8 A. Yes, it is, particularly if it is coming through -- the9 patient is coming through a medical assessment unit.10 Q. We see at the bottom left the observation section is not11 completed and then the heading "Other information" that12 also looks -- seems to be blank.13 A. That's correct.14 Q. If you then carry on and go back to page 4 of your15 report, you also make mention in that paragraph under16 the heading "Admission into ward 3" to the multiproblem17 care plan. If we could look at that, that is on18 page 108 of the records, again this appears to be an19 acute medical unit multiproblem care plan, and you20 discuss this in that paragraph.21 What observations do you make in relation to this22 care plan?23 A. Basically, this is a multiproblem care plan. It is24 identifying the problems as being dehydration and25 diarrhoea. Then it goes on to identify a goal, which is43 1 to treat the symptoms and to find out the cause, which2 is, in my opinion, rather vague in terms of what the3 goal is.4 The interventions, of which there are a large5 number, are requested -- are basically interventions6 that have been requested by the doctor. They are what7 we would call doctor's orders, in order to undertake an8 ECG, a chest X-ray, et cetera, et cetera. What I have9 identified here is that this isn't actually elements of10 nursing care intervention, but a list of activities and11 interventions that the doctor has ordered.12 I have also said that this document does not have13 the patient's unit number and date of birth identified14 on it and I have also said that I was unsure which ward15 this was completed on because the ward isn't identified.16 Q. If we look at the document, you point out at the top box17 the unit number and date of birth have not been entered18 in, but looking to the problem, "Dehydrated, diarrhoea",19 is that --20 A. Hyponatremia.21 Q. -- "hyponatremia"? Did that cover all the problems this22 lady had?23 A. No, it is not a nursing intervention. It is a care plan24 for a patient with dehydration and diarrhoea. The25 effects and consequences of that, I would expect more44 1 specific nursing interventions.2 There are some on that list there; for example,3 four-hourly MEWS, two-hourly urine volumes, and4 dietician. But it is just a list of activities the5 doctor has asked to be completed, it is not actually how6 they are going to actively nurse a patient in the ward7 with the presenting symptoms.8 Q. You can see that the first date is 12/12, but then there9 is another entry for 13/12, which says, I think,10 "dietician". Do you see that?11 A. I do, yes.12 Q. Would that be a relevant intervention to have on an13 appropriate care plan?14 A. Yes, that is satisfactory.15 Q. What about the next entry, for the 16th?16 A. That is an abdominal/chest X-ray. Again, a doctor would17 have requested that. To catheterise the patient, blood18 gases done and an albumin. These are basically, again,19 activities requested, mainly laboratory and X-rays20 requested by the doctor, but not specific nursing21 interventions.22 Q. Is this an appropriate care plan then for this lady?23 A. No, it is not an appropriate nursing care plan.24 Q. What would you expect to see in an appropriate nursing25 care plan for this lady?45 1 A. I would expect a care plan that is designed around --2 the hospital, in some of the wards, did have core care3 plans which identify the specific symptoms or presenting4 features that the patients had. So I would expect5 a care plan that was identifying the patient had6 diarrhoea and dehydration, that would identify specific7 interventions.8 For example, isolating a patient; precautions and9 instructions on what takes place, when you isolate the10 patient, for staff and relatives, involving the11 infection control team. There would be a list of very12 specific nursing interventions that should be included,13 rather than laboratory tests and X-rays.14 Q. I think we saw that Mrs Stewart was initially admitted15 to ward 3. Was she also thereafter admitted to ward 6?16 A. That's correct.17 Q. If you turn to page 110 of the records, we see the first18 entry for 12 December at 0300 and we are told that she19 was admitted via RAH to MAU then ward 3. Do you see20 that?21 A. Yes, correct.22 Q. If you move down the page to 1235, can we see an entry23 "Transferred from ward 3"? Is that where you understand24 the transfer had been to ward 6?25 A. Yes.46 1 Q. If you move on to page 113 of the records, can we see2 the heading at the top "Ward 6 - evaluation sheet"?3 A. Yes. I would assume that that's when the transfer took4 place, although there were occasions when I did have5 difficulty identifying that specifically.6 Q. If you go back to page 110, three lines from the bottom7 can we read:8 "Patient is now C. diff positive. Needs to be9 isolated."10 So it would appear that the result from the specimen11 that had been taken earlier was a positive one, but that12 the patient was still not isolated at this point; is13 that right?14 A. That's my understanding.15 Q. If you turn over to the next page, page 111, the second16 line from the top are we told:17 "Patient isolated this afternoon."18 So it would appear the patient was isolated some --19 in the afternoon of 12 December?20 A. Yes, that's correct.21 Q. Can we then move on and look at some aspects of the22 medical and nursing care and turn to page 5 of your23 report? Here I think you are looking first at the24 doctor's records; is that right?25 A. Correct.47 1 Q. On the 16th, that's four days after her admission, it2 seems that Mrs Stewart was seen by Dr Carmichael, and3 the instruction was that she urgently needed intravenous4 fluids; is that correct?5 A. Yes, that's correct.6 Q. What did you understand the position to be at this7 point?8 A. Well, the medical records identify that the patient was9 seen by Dr Carmichael and had been acutely unwell for10 two days with dehydration, and they tried to establish11 IV lines, IV access. That had obviously been quite12 difficult for them to achieve.13 However, following on from this, they make the14 decision to discuss this matter with the anaesthetist to15 try to get IV access and one of the comments I make,16 I believe, later in the report is why this particular17 referral to a colleague hadn't been done earlier in18 order to get IV access achieved earlier for this19 patient.20 Q. We are now on 16 December, some four days after21 admission; is that right?22 A. Yes.23 Q. If we go to the records, page 77 of the records, towards24 the bottom of the page the entry for the 16th, is this25 where we see the plan "Urgently needs IV fluids". Is48 1 that where it has been noted?2 A. Yes.3 Q. How did that come about? Were you able to work out from4 the records how it came to be that she was so5 dehydrated?6 A. Well, it was difficult, but clearly there had been7 difficulty in accessing her intravenously, and without8 going further into the report, I would need to check my9 further notes, but in terms of other fluids that she'd,10 you know, not been given either, clearly, when the11 consultant saw her she was very dehydrated, and that was12 the immediate impression that he got, that she needed13 immediate access.14 Q. Turn to page 78 of the medical notes. We are still on15 the 16th. Towards the bottom, four or five lines from16 the bottom, there is a reference to "Catheterise". Then17 "Clear dark [something], monitor hourly"? What does18 that mean?19 A. Sorry, catheterise, the urine is clear but dark, that20 would suggest dehydration. Monitor --21 Q. Hourly.22 A. I'm not sure what the other -- oh, urinary output. It23 would be urinary output.24 Q. How would you monitor urinary output on an hourly basis?25 A. If she was catheterised, you would monitor it hourly.49 1 You would go and you would observe the urine and monitor2 it.3 Q. Where would you record what you monitored?4 A. On the fluid balance chart in the urinary output5 section.6 MR MACAULAY: My Lord, if your Lordship would have a break,7 this would be an appropriate moment.8 LORD MACLEAN: We will have a break now.9 (11.30 am)10 (A short break)11 MR MACAULAY: If you can have your report in front of you,12 Mrs Stower, and go back to page 5, I think we'd been13 looking at the entry for 16 December. Then moving on to14 page 6 of your summary of the medical notes, can we see15 that on the 17th Mrs Stewart died?16 A. Sorry, I didn't get that question.17 Q. We were looking at page 6, and we can see the entry for18 17 December --19 A. Yes.20 Q. -- to indicate that Mrs Stewart died and death was21 declared at 2055?22 A. Yes, I can see that.23 Q. Looking at the nursing notes, if we look at the first24 entry, and perhaps we can look at page 110 of25 the records, if you could have that up on the screen,50 1 please, you have noted in your report that Mrs Stewart2 returned from the RAH, who excluded any acute surgical3 problem, "Has ongoing loose stools, C. difficile".4 If we turn to the records themselves, can we see5 that in that first entry, just about a third of the way6 down from the top of the page, "Has ongoing loose7 stools" and then "? C. difficile. For intravenous8 fluids". Do you see that?9 A. No, I can't see that at the moment.10 Q. If you look at the time 0610, it is a few lines above11 that?12 A. Yes.13 Q. We see, "Has ongoing loose stools". Can you make that14 out?15 A. Yes, I can see that.16 Q. And "? C. difficile"?17 A. Correct, yes.18 Q. It was then that the specimen was taken for analysis?19 A. Yes.20 Q. If you go to your report, you indicate that Mrs Stewart21 has some pressure damage; is that right?22 A. Yes, that's correct.23 Q. Then the pressure damage was there on admission to the24 hospital --25 A. Yes, correct.51 1 Q. -- to the Vale of Leven? What was the problem?2 A. From my report, Mrs Stewart had excoriated groin and3 both of her heels were red, and also her vulva area was4 quite swollen.5 Q. I think you have noted also, as we noted earlier this6 morning, that the specimen must have been taken --7 I think we actually see that, at 1120, on page 110, that8 the stool specimen was still to be obtained, but it must9 have been obtained because, as we noted before, at 1650,10 the patient is now C. difficile positive. Is that what11 we see? Is that right? We see that she was12 C. difficile positive on the 12th?13 A. Yes, that's right.14 Q. The ward were aware of that?15 A. Yes.16 Q. Did you find a report, a microbiological report, in the17 records or not?18 A. There is a microbiology report, which is GGC00530089 --19 Q. But that's not reporting C. diff --20 A. -- but that is not in relation to this, no. That was21 the only one. So in relation to this, no, I didn't find22 a microbiology report.23 Q. But in any event, the ward were informed that24 Mrs Stewart was positive; that's correct, isn't it?25 A. Yes, it is my understanding.52 1 Q. If we look at the infection control card, which you will2 find at SPF00740001, I think you do make reference to3 this document in your report, but you can take it that4 this was a card kept by the infection control nurse that5 was used to record certain details for each patient. If6 you look here, towards the top right, we are told it is7 ward 6 and that the date positive is down here as8 13 December, and then the entry, 13 December 2007:9 "Informed by lab staff. Nursed in isolation.10 Commenced on oral Metronidazole."11 So it would appear that the lab told the infection12 control nurse that the patient was positive, at least as13 of 13 December?14 A. Yes, that's correct.15 Q. Moving on then through your report, if you go to page 716 of the report, the first entry you make reference to is17 you record the patient still has loose stools; is that18 right?19 A. Yes.20 Q. Then you have an entry you have taken from the records21 for the 13th. What was the significance of this entry?22 A. The significance of this entry was that the patient had23 two large alopecia partings on her scalp, so that would24 be areas -- an area on her scalp where hair was missing.25 It was also quite matted, hard to brush and hair was53 1 falling out. I noted that because clearly the patient2 had that and it was also something that would need3 particular attention in terms of her nursing care.4 Q. You also noted, I think, that on the 13th she was5 referred to a dietician and a physiotherapist?6 A. That's correct.7 Q. On the 14th, what was the position with the patient, as8 you have noted it?9 A. Again, the Venflon with access was dislodged and was10 still awaiting replacement, which would indicate that11 there was no fluid access taking place.12 She was also reluctant to eat or drink, so there was13 no fluid being taken by this patient. It was a number14 of hours before the Venflon was finally resited and then15 was dislodged again. So the emphasis there was to16 encourage oral fluids in order to get some fluids into17 the patient.18 Q. Then the entry for the 15th, you have taken some19 information from the records for that particular date.20 What have you noted?21 A. I have noted that there were positional changes22 performed and that, at 6.30 in the morning, the patient23 was known to be hypotensive, her blood pressure was low,24 and that she started to have subcut fluids commenced,25 and that was indicated by the medical staff. Her BP was54 1 low. Sometimes the nursing staff were unable to get2 a reading at all. Subcut fluids were continued. The3 patient refused to have any feeds or her mouth cleaned.4 Later, 2315 hours, "Patient not responsive tonight to5 tolerate oral medication", and then "Venflon inserted.6 IV fluids commenced".7 LORD MACLEAN: What are "subcut" fluids? Subcutaneous?8 A. Yes.9 MR MACAULAY: Moving on to page 8 of your report, for the10 16th I think you have noted there that the patient's11 condition is poor, at the very end of that entry.12 A. Yes, that's correct.13 Q. Then moving on to the next entry you have got for the14 16th, she is obviously in a very poor condition because15 you note that she is leaking from all her limbs, that16 the Venflon was resited and the fluids restarted and she17 was very cold?18 A. Yes, that's correct.19 Q. There is some reference there to the DNAR status.20 A. Yes, that's correct. The doctor was going to speak to21 the family regarding the DNAR status.22 Q. Then, for the 17th, I think you have noted again that23 the catheter output is poor, both arms leaking large24 amounts of fluid, and the Bair Hugger was in situ and25 she was then pronounced dead on that particular date.55 1 A. That's correct.2 Q. If we look at the death certificate, which you'll find3 at SPF00340001, I think you can see, when you look at4 section 10 of the death certificate dealing with the5 cause of death, that a number of items are listed6 including Clostridium difficile infection?7 A. Yes, that's correct.8 Q. If you could turn to page 11 of your report, you here9 are looking at the infection control card we looked at10 a moment ago, and perhaps we can put it back on the11 screen, SPF00740001. What observations have you made in12 relation to this particular document?13 A. My observations of this document was that I personally14 had some issues around the status of the document. All15 I see is a blank sheet of paper with freehand on it,16 which indicates to me that the document doesn't have any17 particular status. There is no title, there is no -- it18 is not in a format, it is just a plain piece of paper19 with what is freehand detail written on it.20 Q. I think I said to you this morning, this was the -- the21 system in the Vale of Leven was for the infection22 control nurse to record on what was a T Card, a T-shaped23 card, and you can just make that out in the copy,24 information in relation to the infection control status25 of the patient. That was the purpose of it.56 1 In your report, you have noted the entries that have2 been made, and I think you make some reference to the3 infection control policy that we looked at this morning.4 A. Yes.5 Q. What observations were you making there?6 A. Basically, the infection control policy indicates that,7 when there is evidence of infection, such as in this8 case, a risk assessment should be made. What I am9 saying is, from what is actually written on this10 document, this isn't, in my opinion, a risk assessment,11 it is just a chronology of events.12 Q. What would you say a risk assessment would say in a case13 like Mrs Stewart's case?14 A. A risk assessment to be made by an infection control15 nurse would be visiting a patient and assessing the16 patient in the situation and circumstances that the17 patient is in. So that would be environmental, but it18 may well also be from a clinical point of view and how19 the patient's presenting clinical situation could be20 improved throughout the process of infection control21 with C. difficile diarrhoea.22 There isn't any of that indicated, other than there23 is an entry here that says that the patient was isolated24 in a single room, but we know that to be some time after25 the event, where actually, originally, even at the Royal57 1 Alexandra Hospital there was a view there that it may2 well have been colonised diarrhoea with C. difficile.3 Q. We saw this from the previous note, some reference to4 a Bair Hugger? What is that?5 A. A Bair Hugger is a piece of equipment that we use for6 warming patients or for maintaining heat, body heat, of7 course. This lady was, fairly early on, identified as8 being hypothermic, she had a low temperature, which is9 why the entry I make is about putting blankets one on10 top of another, because a Bair Hugger was not available11 for this patient, even though her temperature was quite12 low. From the MAU, the nursing staff asked if they13 could borrow one, but it was refused. It was actually,14 though, put on the patient -- they did manage to acquire15 one the following day.16 Q. A Bair Hugger then is something that gives you more heat17 than, say, putting on a number of blankets?18 A. Yes, it is basically -- I don't know the makeup of it,19 but it is basically a large blanket, if you like, made20 of certain fibres that enables the patient to stay warm21 and/or to try to improve warmth. It is very often used22 in a patient who is anaesthetised in the operating23 theatre, for example, to keep them warm when they are24 very cold and very still.25 Q. If you move on to page 12 of your report, where you58 1 express some opinions in relation to Mrs Stewart's care,2 the first point you raise is in relation to the3 C. difficile infection. What is the point you are4 making there?5 A. The point I am making is really the point I have just6 made, that there was a very early -- there were very7 early thoughts that the patient was colonised as8 C. difficile, and the nursing staff would have been9 aware of that on admission, because she had been10 identified as having foul-smelling diarrhoea, but it was11 actually waited -- they waited until they received the12 conclusive tests, laboratory test report, before they13 isolated the patient.14 Q. Then, after, you raise a number of specific nursing15 issues that Mrs Stewart had; for example, the third16 bullet point you note that she was admitted with17 confusion, history of falls, dehydration, diarrhoea, and18 so on, and you also note for the diarrhoea that she had19 compromised skin integrity, and I think we saw that from20 the medical records.21 A. That's correct.22 Q. If you move on then to page 13 of the report, under the23 heading "Record keeping" you make a general observation24 in relation to record keeping. What was your25 conclusion?59 1 A. My conclusion is that I felt, overall, the record2 keeping was quite poor.3 Q. Then you go on to give some reasons for that conclusion;4 is that right?5 A. Yes. I identify that under the separate headings.6 Q. If you look at the next heading, it is headed "Nursing7 care plans", and what observations do you make there?8 A. I identify here that, when devising a care plan at ward9 level for a patient, it is usually a multidisciplinary10 approach and a thorough assessment is made regarding the11 patient that encompasses, really, a whole raft of12 different activities.13 There was, in this case, in Mrs Stewart's case,14 a nursing admission assessment form.15 Q. I think we looked at that this morning.16 A. We did, yes. That was quite poorly completed. It had17 a lot of the essential clinical details, such as18 observations, for example, missing.19 In addition to that, there was the risk assessments,20 such as the actives of daily living, which is a very21 helpful assessment of mobility, so the patient's ability22 to wash or dress or cook or mobilise. That kind of23 assessment is usually done in conjunction with the24 physiotherapist and the occupational therapist,25 et cetera.60 1 There were no activities of daily living assessment2 completed for Mrs Stewart in order to identify her needs3 and abilities to care for herself or, indeed, the4 assistance that she'd actually require from the nursing5 staff. I was quite critical of that.6 Q. The activities of daily living tool, did you see that7 tool available in other cases that you looked at?8 A. Yes. Yes, I did.9 Q. But it wasn't in these records?10 A. No, it wasn't.11 Q. I think we did observe earlier that there was what was12 described as a multiproblem care plan?13 A. Yes, that's correct.14 Q. Perhaps just go back briefly to that on page 108 of15 the records. Again, we looked at this this morning, and16 I think we have your observations on it. Were there any17 other care plans in the records?18 A. Well, there were some care plans. There were -- some of19 the items were present in the bundles that I examined20 but weren't completed. For example, there was a falls21 risk assessment --22 Q. I will come to look at that. But in relation to23 specific care plans, for example, was there a care plan24 for C. difficile?25 A. Oh, no, sorry, I beg your pardon, there were no other61 1 specific care plans that I saw.2 Q. So the only care plan that you saw was the one we looked3 at earlier this morning on page 108?4 A. The multiproblem care plan, yes, that's correct.5 Q. Looking then at the matter more broadly, in your6 opinion, ought there to have been other care plans in7 place for this lady's care?8 A. Yes, there should have been.9 Q. Can you give me some examples of what care plans you say10 ought to have been in place?11 A. Well, we have already discussed that. The lady was --12 Mrs Stewart was admitted with dehydration and diarrhoea,13 so we would expect to see care plans specifically for14 that. Mrs Stewart was identified as high risk, for15 example, with falls, which we will talk about, so16 that -- we would expect to see a care plan following17 that risk assessment for that.18 We would expect care plans in relation to the19 activities of daily living, so had that been assessed20 and the number of different elements pertaining of21 the activities of daily living, such as eating,22 drinking, mobility, sleeping, pain, depending on what23 results were identified from that, we'd expect to see24 a care plan that recognised those needs and that would25 suggest interventions for improving it.62 1 Q. If we leave the reference to skin integrity for the2 moment, because I think you deal with that later, the3 second-last bullet point -- the third-last you say:4 "Monitor blood chemistry."5 And you say, in this case of Mrs Stewart, this was6 done?7 A. Yes, I do say that, yes.8 Q. The next point:9 "Assess the patient's pain with the use of a pain10 assessment tool/chart."11 You go on to say:12 "From the documents I have examined, this assessment13 was not undertaken and I am critical of this because the14 patient was in pain and discomfort."15 Can I just understand that? What are you envisaging16 there, Mrs Stower, as to what should have been in place?17 A. None of the documents that was available at ward level,18 certainly, for example, the observation charts, and19 there was a number of other charts, there is a section20 on the bottom of them that is a pain assessment chart.21 You can also have a document that is purely a pain22 assessment chart. None of these documents where there23 was the ability to record an assessment of pain were24 actually completed for this patient.25 Q. If we look at page 135 of the medical records, is that63 1 the type of chart you have in mind?2 A. That is one of the charts, yes.3 Q. Towards the bottom, can we see that there are sections4 that deal with BM level, weight, pain score. Do you see5 that?6 A. Yes, that is the column I am referring to. Actually, on7 that column on the screen in front of me, although it is8 only filled in five days out of a range, or five9 occasions out of a range, it records the pain as zero,10 and, in fact, on one of the occasions it has got what11 I perceive -- I may be wrong -- "0?", so query the12 patient was in pain.13 Q. But what was the position, in fact, so far as you could14 assess from the records? Was the patient in pain?15 A. The patient would have been in pain, yes.16 Q. Because?17 A. Because -- for probably a number of reasons, but18 certainly from the point of view of her skin integrity,19 for example, she had -- we have already heard she had20 a very swollen vulval area and reddening and sore areas,21 so that is just one area where she may well have been in22 pain.23 Q. Moving on then to the next bullet point on page 13 and24 moving on to page 14, what is the point you are making25 there, dealing with the patient and the family?64 1 A. Sorry, could you repeat the question, please?2 Q. Yes. Towards the bottom of page 13 of the report, you3 make an observation in relation to the understanding of4 the patient and her family. I am asking you, what point5 are you making in this context?6 A. Mrs Stewart was known to have a confused state, so it7 would be difficult to understand whether the nursing8 staff were able to achieve this particular objective,9 but, also, she did have a relative -- my understanding10 is that she lived at home with her sister, but there was11 very little -- in fact, I didn't see anything really12 that acknowledged that the family were involved in her13 care or that they were given any detail regarding her14 condition.15 Q. You do say at the top of page 14 that you have taken16 from the records that family members were kept informed?17 A. Yes, I have written that down, so I think it was just in18 case of her general condition.19 Q. I think what you are saying is that, so far as she20 herself was concerned, she was in a somewhat confused21 state, but her family members were kept informed as to22 her condition?23 A. That's correct.24 Q. In relation to the patient's psychosocial situation,25 this was difficult to determine in Mrs Stewart's case?65 1 A. Because of her confusion.2 Q. What do you mean by that, what do you mean by3 "psychosocial"?4 A. Basically, by that I mean her psychological -- her level5 of understanding, her level of capacity to understand6 what was going on because of her confused state.7 Q. The next section of your report, you are looking at8 matters such as temperature, pulse and respiration9 charts. What observations do you make there?10 A. I am indicating that there were entries on the TPR11 charts for all of the days that Mrs Stewart was in12 hospital during her admission. I comment that there are13 four entries made, I believe to be on ward 3.14 I did have an issue around the dates, because we15 talked about 11/11, 12/11, 12/11. Whether that was16 somebody was recording them the different way around,17 I don't know, but I found that rather confusing, when it18 was actually in the month of December, so whether that19 was an error or not, I'm not quite sure. I think these20 were probably date errors. But then, when Mrs Stewart21 actually goes -- is transferred to ward 6, the dates22 then run correctly.23 Q. Yes. You make a point about temperature, I think, as24 well, which you have touched upon already.25 A. Yes. The temperature was recorded as 35 degrees. It66 1 does then gradually increase and then it decreases2 again. So basically, the patient was very cold.3 That is when we see an entry that refers to having4 blankets put on to accommodate her low body temperature,5 but actually the blankets are put on at a later date6 where she's actually been very cold prior to that, but7 it isn't recorded, so I'm not in a position of knowing8 whether any intervention was taken at that time or not.9 Q. We have talked about the pain score, we have looked at10 that earlier. If you look at the next section of your11 report, on page 15, where you look at fluid balance,12 I think you begin by saying that there were fluid13 balance charts recorded for the duration of14 Mrs Stewart's admission; is that right?15 A. Yes, that's correct.16 Q. What conclusions did you come to, having regard to your17 examination of the fluid balance charts?18 A. My conclusion regarding the completion of the fluid19 balance charts was that the standard overall was really20 extremely poor.21 The reasons I indicate that; for example, sometimes22 there was very little input or output information23 recorded at all, input being fluids taken in either by24 the oral route or by an intravenous route, and output25 being obviously urine when she was catheterised, that67 1 should have been quite an easy issue to record because2 it would have been there ready for you to do it, and3 also output, this lady had diarrhoea so I would have4 expected indications of the amount of fluid loss through5 diarrhoea as well.6 I also refer to one particular day on GGC00530126,7 there was nothing recorded at all for that day, and8 I was particularly concerned here because, as we have9 already identified, this lady was meant to be having10 intravenous fluids, she wasn't able to tolerate, or11 refused, oral foods and fluids, and there were times12 when the intravenous access route was not patent because13 the Venflon was dislodged, or whatever.14 So because of all of those factors, it really is15 important, or was important, that the fluid balance for16 this lady was completed as well as it possibly could be17 in order for the medical staff to be aware of what was18 happening to the patients -- to the patient and, on the19 basis of that, to determine her overall fluid status.20 Q. Let's look at some of these charts. If you could look21 at page 129 of the records, the chart for the -- it is22 dated 12 November, but it probably should be either23 12 December or 11 December. We can see there are some24 entries for output and intake, but the chart hasn't been25 completed; is that right?68 1 A. Yes, that's right. This is an example, really, of what2 I have been saying. It is interesting that these charts3 commence at 1300 hours on a day and then they finish at4 12 midday the following day, so it is midday to midday5 almost, which is a little bit unusual and not something6 that I am terribly familiar with.7 Q. What is the normal period covered by --8 A. The normal would be commencing from 12 midnight through9 to 12 midnight. There are good reasons for that, in10 terms of the ability to do what I am going to explain in11 a minute should have happened to the form.12 So in this particular example, the chart commences13 at 1300 hours and the first entry is an intravenous14 entry at 0600 the following morning, although in the --15 and that is the only intake recorded for this patient.16 So that really is quite a concern. There is nothing17 taken orally and just -- I think that is 500, probably18 600ml, one is 5 per cent dextrose, the other is Flagyl,19 which is Metronidazole, in that period of time.20 Moving on to the output side, again there is no21 entry until midnight, so that is 12 hours since the form22 was changed, and then there is -- you know, there are23 clearly some entries, a reasonable number of entries, of24 output given. There is no mention of diarrhoea on that25 particular form.69 1 Then there's no totals. There's no totals at all in2 terms of the total input and output which one would3 expect to see, and then a balance in order to determine4 the hydration status of the patient.5 Q. So that hasn't been done. Now, if you move on to6 page 128, the next one, which is for the 12th to the7 13th, we can see there are perhaps a number of entries8 on this form, including, at 0300 hours, "liquid stool +9 + +". Do you see that?10 A. Yes, I see that.11 Q. Again, what are your comments in relation to this chart?12 A. This chart is slightly better completed. It does13 include more intake volume. It also records that the14 Venflon is out. That is helpful, because we know,15 therefore, from there on in that, if there is no Venflon16 in, that is why the fluids -- the IV fluids have ceased,17 although it could be written more accurately than that.18 Then the urine is -- the volumes are recorded and19 added. It does also indicate the patient was20 incontinent, but there is no estimated volume. The21 "loose stools + + +" is there, but again, there is no22 estimated volume. Again, my previous comment, there are23 no totals at the bottom, total in and total out, balance24 recorded.25 Q. It looks like "two-hourly volumes"; is that what that70 1 means towards the top right?2 A. Yes, that is correct. That is requiring -- the order is3 to have two-hourly volumes of everything, really, in4 terms of intake and output. The output has been5 achieved to some degree, but the others haven't,6 although the incontinence and the loose stools, that7 should have been recorded as and when it occurred, which8 may not have been two-hourly, but --9 Q. Page 127 of the records, if we go to that, this is for10 the 13th to the 14th. There are, I think, four entries11 on the document. Any comments in relation to this12 document?13 A. It is difficult for me to make the comment. It looks to14 me as if it is very poorly completed and that there may15 be entries missing, but because it is not recorded, it16 is really difficult for me to ascertain whether it is or17 not. But looking at it, there is not a lot of18 information on that document and, again, there's no19 totals in, out or balance.20 Q. The next one, page 126, this is for the 14th to the21 15th. So far as intake and output is concerned, this22 one is totally blank?23 A. Absolutely.24 Q. Is that of any assistance at all?25 A. I beg your pardon?71 1 Q. Is that of any assistance at all?2 A. No, it is of no assistance at all.3 Q. On page 125?4 A. Yes, that has just got two entries, at 1800 and 0500,5 which would be a litre of fluid, and there is no output6 whatsoever. That is very poorly completed.7 Q. I think we had observed from your report, if you go back8 to this page 5 of your report, that, on the 16th,9 Dr Carmichael examined her and noted that she urgently10 needed IV fluids. Do you remember seeing that in your11 report?12 A. Yes.13 Q. If we look then to page 123 of the medical records, we14 are now looking at a fluid balance chart for the 16th.15 Any observations to make in relation to this?16 A. It would appear the patient was seen by Dr Carmichael17 and there were some real concerns about the fluid18 intake, and it is documented at the top what is19 required. In terms of the intake, it is there. There20 is quite a lot of fluid and solutions indicated. It21 looks to me reasonably well-completed. The lady is nil22 by mouth and there is quite a lot of IV fluids going in23 and there is a reasonable amount of entries regarding24 urine, but of course, at the bottom, we do have25 a balance.72 1 This isn't surprising to me, given there has been2 a specific instruction here by the consultant, so, you3 know, one would really expect it to be done, but the4 balance is really very -- is in a negative, quite5 a significant negative.6 Q. Is that an indication of dehydration?7 A. Yes, that's right. It is an indication that things, you8 know, are not really looking very good in terms of9 hydration; that's correct. But I would defer the detail10 of that to my medical colleagues.11 Q. But this form, on the face of it, has quite a number of12 entries. Totals have been calculated and the balance13 has been calculated?14 A. That's correct. So that is an example of how all of15 them should have been.16 Q. So we can contrast this document, this form, to the17 other forms that we have looked at that were not18 completed in the same way?19 A. Absolutely not.20 Q. I may have got this wrong, but does the balance figure21 indicate overhydration or underhydration?22 A. The basis of this, it's looking as if it is23 overhydrating the patient, but of course, it's difficult24 for me, sitting here, to tell you how she was prior to25 that. We already know that she was leaking fluid from73 1 all of her limbs. So this gives me a picture of2 somebody who is very, very sick.3 As I said, I think that the actual -- the4 biochemical part of this is something really for5 a doctor to comment on, really, rather than myself.6 Q. Very well. But the instruction had been, of course, by7 Dr Carmichael, to give her fluids on an urgent basis?8 A. That's right.9 Q. That was because she had become dehydrated during her10 time in the hospital; is that correct?11 A. She was dehydrated. He noticed that. I don't know12 whether he specifically has prescribed the intravenous13 regime or whether it was done by one of his juniors.14 How it was monitored, whether the patient actually was15 becoming overloaded with fluid, as I say, it's a picture16 where clearly this was a very sick patient and it is not17 really for me to comment on the management of18 the fluids, but it doesn't look very satisfactory to me.19 Q. Is overhydration something that is not welcome, then, in20 a patient?21 A. Yes, of course.22 Q. If you go back to your report on page 15, the paragraph23 that begins just below halfway, what conclusions have24 you arrived at in relation to fluid monitoring?25 A. Well, I am very critical of all of the things that74 1 I have mentioned, and this -- what we have just been2 discussing that is on the screen at the moment is an3 example of that. I think -- well, I don't think, it is4 very clear to me that fluid management in any sick5 patient is a fundamental element of their clinical care,6 and it is the responsibility of the nursing staff to7 ensure that it is undertaken properly and accurately.8 But in Mrs Stewart's case in particular, she was9 a very sick lady and she was not tolerating oral fluids,10 she had -- there was clearly issues with intravenous11 access and she went for a large number of hours without12 any intravenous access in order to put fluids into her.13 She is dehydrated. She has, you know, very loose14 diarrhoea stools with her C. difficile, and she is15 leaking fluid from her limbs. It is -- in terms of16 the fluid balance, it is really very, very poor indeed.17 LORD MACLEAN: As a matter of interest -- perhaps I should18 understand this -- how do you leak fluid from your19 limbs, unless -- well, you tell me.20 A. Actually, it is not really my area of expertise. I have21 seen it happen on a couple of occasions in my career,22 but it is something really I think the medical staff23 should --24 LORD MACLEAN: What did you see?25 A. Exactly that. A lady -- she was a rather obese lady,75 1 she was in heart failure and all her limbs were just2 leaking fluid.3 LORD MACLEAN: Gosh!4 A. It wasn't very pleasant.5 LORD MACLEAN: No, I can understand that. Is it unusual?6 It must be very unusual.7 A. I have only seen it twice in my career.8 MR MACAULAY: Is it sometimes associated with liver failure?9 A. Pardon?10 Q. Is this leaking fluid from limbs associated with liver11 failure?12 A. It can be, yes.13 Q. Coming back to your report, the second-last paragraph on14 page 15, you make reference again to Dr Carmichael's15 intervention and how it came to be that an anaesthetist16 was involved in obtaining access for the intravenous17 fluids. Can I just understand how that is managed? You18 have a patient who, I think, for one reason or another,19 the Venflon does not remain in situ, so what do you then20 do to ensure the patient is hydrated?21 A. Very similar to what occurred here: clearly, if you22 cannot get access -- if a doctor cannot get intravenous23 access for a patient, the patient has to have fluids,24 there are a number of interventions that can happen,25 other than trying to put a Venflon in or a deeper line,76 1 for example. If the doctors on duty cannot do that, for2 whatever reason -- it may be that the patient has3 particular difficulty with getting access, it may be4 that they are not very skilled as a doctor, if they are5 a very junior doctor, for example -- and so6 anaesthetists are people who are really experts in7 gaining access to patients' IV or also by various other8 methods of putting lines in, central lines in, or9 whatever, so it would be eminently sensible to gain the10 cooperation of a colleague to come and assist you in11 that.12 Q. That is what happened here --13 A. That is what happened on this occasion --14 Q. -- in due course?15 A. -- in due course.16 Q. You also say that, on the 16th, the doctor asked for the17 urine output to be measured hourly. I think we did see18 that in the medical records. You make the point that,19 looking at the chart, that doesn't appear to have20 happened; is that right?21 A. That's correct. That is on 16/12.22 Q. The doctor has asked for the urine output to be measured23 every hour, so what have we got here, then, if we are24 looking at the measurement of the output?25 A. Is this the 16th or the 15th that is on the screen? The77 1 16th, is it?2 Q. Yes, I am looking at page 123.3 A. Yes, I wasn't sure if that was the 15th or the 16th.4 Q. I think it is a 16, although it is not clear.5 A. It hasn't occurred on that occasion. That particular6 request by the doctor has not been complied with.7 Q. While we are back on the form, if we look at the total8 in and the total out, the total in is 2,300, and the9 total out is 155, according to this. Should that be10 a plus as opposed to a minus balance? It says minus11 2145, but should that not be plus? Maybe I'm12 misunderstanding it.13 A. It looks as though actually, yes, because that -- yes,14 it is what is going in, so, yes, it should.15 Q. So she was overhydrated, so it is a plus?16 A. Yes, clearly, from the amount of intravenous fluid17 that's gone in, yes.18 Q. The next section of your report then, Mrs Stower, if you19 could turn to that on page 16 of the report, you are20 dealing with pressure management. You did, I think,21 look at a Waterlow score document in the medical22 records; is that right?23 A. Yes.24 Q. If you can turn to page 131 of the records, this is the25 document you looked at, and the comment you make in your78 1 report that, on the face of it, this document hasn't2 been completed.3 A. Not at all.4 Q. In other cases we have seen similar documents but it5 would have another page associated with it, and that6 page doesn't appear to be in the records that you saw.7 A. No, I couldn't find it.8 Q. If we look to what we have, we see that the document9 doesn't even have a patient's name inserted; is that10 correct?11 A. No, it is a completely blank form.12 Q. You, yourself, I think, took the opportunity to make13 some sort of assessment of what Mrs Stewart's level of14 risk might have been; is that right?15 A. Yes, that's correct.16 Q. Can you tell us then -- I think your conclusion is on17 page 17. What conclusion did you arrive at?18 A. I decided to make an estimation myself of Mrs Stewart's19 pressure management -- pressure and skin integrity20 score, and I worked with a number of assumptions.21 I have calculated her weight as average for her height22 on admission, giving her the benefit of the doubt.23 I didn't know specifically, because she wasn't weighed.24 I have calculated her skin to be discoloured, because it25 was reported on admission to be red. Her age as being79 1 56, which it was. I have also made this assessment on2 the fact that she was nil by mouth and/or fluids only,3 as this was the case certainly at the beginning of4 the admission, and also that she was bed-bound.5 Q. Against that background, then, if we turn to page 17,6 without going through the details of the scoring, what7 conclusion did you come to as to what her category would8 be, in your opinion?9 A. I came to a total of 21 to 22 points, which would have10 put Mrs Stewart in the very high risk category.11 Q. What, then, would that demand from the perspective of12 care?13 A. A very high risk category would have meant that there14 would have been a number of nursing interventions put in15 place. This document would need to be reviewed. There16 should have been a referral to the tissue viability17 nurse specialist for advice. She would have been, as18 per their protocol, provided with some specialised19 pressure-relieving equipment, mattress, bed, and a care20 plan and really proactive intervention.21 She was -- we know, from what we have spoken about22 previously, she did have number of red areas. Her skin23 was excoriated. So all of those interventions and24 a very proactive approach to the management of her skin25 integrity should have taken place.80 1 Q. Did you see any evidence of that in the medical records?2 A. I did note on one occasion that there was some3 positional tilts had taken place and the positional4 tilts were being given, but they weren't specified. It5 was just positional tilts, which really, as someone6 looking at the records, tells me very little about what7 actually took place, and there was nothing in the8 records to indicate the detail regarding that.9 Q. Was there a turning chart in the records?10 A. No, there was no chart. There was no information.11 Q. Was there a care plan?12 A. Pardon?13 Q. Was there a care plan?14 A. No.15 Q. I think you say in your report that there should have16 been a care plan to manage this particular aspect of17 care.18 A. Certainly, as soon as the Waterlow score had been19 completed and the risk category known, then there should20 be automatically a care plan identified to put21 a prevention strategy in place.22 Q. Should there have been a turning chart?23 A. Yes.24 Q. In the penultimate paragraph on page 17 -- I think you25 made mention of this already when you were looking at81 1 the records -- you say there were some partings on2 Mrs Stewart's scalp. What did you infer from that?3 A. It was difficult really for me to ascertain this4 particular element from the admission. We know from the5 documents that there was some redness of some of her6 pressure areas when she was admitted, but specifically7 this, I'm not sure.8 However, it did say that the alopecia partings on9 her scalp -- it is difficult to sort of quantify what10 that was, but it then does go on to say that her hair is11 matted, and matted hair, certainly at the back, which is12 where it usually matts, is due to pressure on the bony13 prominence of the skull, on the pillows, and it14 basically means that that patient has been in a position15 for quite a long time, there is a lot of friction and16 rubbing, which is what causes the matting, and the17 nurses indicate that they had to be very careful in18 trying to comb it out.19 My concern regarding that is how it occurred in the20 first place and that a good prevention strategy for21 pressure area care, that particular issue should have22 been addressed, and the matting, as we see described,23 should have been prevented.24 Q. If you accept that what you have seen from the records25 is the position, in fact: namely, that there was no82 1 Waterlow assessment carried out, no care plan, no2 turning chart, what conclusions would you arrive at in3 relation to this aspect of her care?4 A. I think it's very suggestive to me personally that her5 personal care was not of the standard that I would have6 expected.7 Q. The next section of your report on page 18, you look at8 nutrition. You make some general remarks first of all,9 and I think this is -- we can take this from you in this10 report, and I think it is something you generally repeat11 in a number of reports, but what observations are you12 making in the first paragraph of this section?13 A. The observation that I'm making here is that diarrhoea,14 particularly in a patient with very profuse, loose,15 foul-smelling stools, can have a profound psychological16 and physiological effect on the patient. It is17 something possibly that is very underestimated, but that18 is absolutely the case.19 For example, associated with loose, foul-smelling20 diarrhoea there's -- it can cause a patient quite a lot21 of embarrassment, but equally, it can deteriorate or22 accel the deterioration of the skin, particularly if23 personal hygiene is not robust and proactive. Severe or24 extended periods of diarrhoea can result, as we know25 from Mrs Stewart's case, in dehydration, electrolyte83 1 imbalance -- that's an imbalance of the chemicals in the2 body -- loss of weight and malnutrition, and in terms of3 nutrition, this is a key element of helping to assist in4 the process of that and encouraging the patient to take5 oral fluids, but equally, oral fluids or food may not be6 sufficient. A patient may not feel, with the nausea,7 the vomiting and the diarrhoea, that they are able to8 eat or drink, so there is very often a need to9 supplement their diet with the use of either oral10 rehydration solutions or other IV solutions, which we11 have already talked about.12 In order to do that, patients really should be13 provided with the specialist advice from somebody in14 nutrition management, which is a dietician.15 Q. I think we saw in the nursing records, when we perused16 them, that there was a record to say that Mrs Stewart17 was to be referred to the dietician?18 A. That's correct. In fact, on the multiproblem care plan19 that we saw at the very beginning, just the day after20 admission the dietician was -- it was put in the care21 plan that she should be referred to the dietician, and22 I think there is a tick after it, which would indicate23 that it had been done.24 We do also see in the nursing documentation that25 a referral has been made, but I couldn't see any84 1 evidence that there was any actual active intervention2 from a dietician in this case.3 Q. I think in some of the cases we see that there is a tool4 available in the Vale of Leven for carrying out5 a nutritional assessment. Did you see that tool in some6 of the cases you looked at?7 A. Yes, I did.8 Q. Was there such a tool in the records here?9 A. No, there wasn't.10 Q. In any event, although there is reference to the11 dietician, I think what you are saying is you saw no12 record in the records to indicate the dietician had been13 involved?14 A. In some of the notes that I examined, whenever15 a dietician did attend a patient and gave advice, there16 was always an entry from the dietician, usually in the17 medical record rather than the nursing record, but it18 was clear, mostly it was clear. I saw no evidence of19 this in these documents.20 Q. In the next section you deal with the stool charts. You21 tell us that there were two stool charts in the records.22 Perhaps we can look at these briefly. Page 119, first23 of all. We can see that we have a chart, and there are24 two entries, both for the same date, reference to25 stools, and then, if you turn to page 118, there is85 1 another stool chart with one entry for 17 December.2 Was that all that there was in relation to stool3 charting?4 A. Yes, that's correct.5 Q. I think we had noted that there was a reference on one6 of the fluid balance charts to loose stools.7 A. That's right. "Loose stools + + +", yes.8 Q. What conclusions then -- if that is all there is, and9 that is a true reflection of what was done, what10 conclusion do you arrive at on page 18 of your report?11 A. On the first stool chart that you showed me on the12 screen that has disappeared now --13 Q. Page 119, yes.14 A. -- there are two entries and then there is a great big15 scribble through it, but I'm not quite sure what that16 means. There is also no date of birth recorded on the17 document as well, but there are only two entries. That18 was at 2.45 in the morning and at 6 am, so throughout19 the rest of that day there is nothing recorded.20 Then on the second chart there is just, again,21 a very, very minimal amount, even though we know that22 Mrs Stewart had "loose stools + + +", that means quite23 a lot and quite frequent, and that is not indicated on24 these two documents.25 There is also three or four days between the two of86 1 them, so presumably there was nothing recorded on these2 documents during that period either.3 Q. So what conclusion, then, do you arrive at? If that is4 all there is, or all there was?5 A. Well, clearly it is very poor record keeping, and it is6 also not compliant with the trust's own policy on the7 management of a patient with loose stools.8 Q. Did you see any evidence in these records or, indeed, in9 any of the records that you looked at, that nurses were10 using the Bristol stool chart tool in assessing stools?11 A. No, not at all.12 Q. We have heard some evidence about the Bristol stool13 chart. Is that a beneficial tool to use when you are14 seeking to assess stools?15 A. Yes, it is a very useful tool. It is a tool that is16 considered to be one of the best of its kind. It is17 a visual as well as actually quite descriptive and it18 quantifies the stool.19 So by doing that, it enables nursing staff -- where20 in a hospital ward you will have a number of staff21 coming on duty on a shift system, it therefore enables22 more accurate recording of the consistency and type of23 stool, and that can indicate any improvement or24 deterioration in the level of diarrhoea that the patient25 may have.87 1 MR MACAULAY: My Lord, that might be an appropriate time to2 adjourn for lunch.3 LORD MACLEAN: 2 o'clock.4 (1.00 pm)5 (The short adjournment)6 (2.00 pm)7 MR MACAULAY: Mrs Stower, I think you still have your report8 in front of you; is that correct?9 A. Yes, I do.10 Q. If we could now turn to page 19 of the report, there at11 section 10 you are dealing with falls risk. You say:12 "A risk of falls plan should be instigated as13 necessary."14 In this particular case, was Mrs Stewart's risk of15 falls assessed in the Vale of Leven?16 A. Yes, it was.17 Q. If we could look at the relevant document, if you could18 turn to page 132 of the records, did you have regard to19 this patient fall risk assessment chart?20 A. I beg your pardon, sorry?21 Q. Did you look at this chart?22 A. I did, yes.23 Q. Can we see that entries have been inserted to bring out24 a risk category of 3? Do you see that? The score is25 16, which puts her into the 3 category, and that is88 1 a very high risk category; is that right?2 A. That's correct.3 Q. Turning on to page 133, do we see that the second part4 of this form sets out 11 points that can be addressed in5 the course of the assessment?6 A. Yes.7 Q. What conclusion did you come to in relation to the way8 in which falls risk was managed then in the9 Vale of Leven?10 A. In the case of Mrs Stewart, is that what you are11 referring to?12 Q. In this case, yes.13 A. Obviously the assessment form was completed on the day14 of admission, putting her in the high risk bracket.15 I wasn't in a position to comment on whether or not --16 the document does not assess her mental state. It does17 say that she is confused and unable to understand verbal18 commands. The safety of the bed height was19 a consideration, and cot sides was addressed.20 Really, apart from movements being monitored within21 the ward, it is my understanding that Mrs Stewart was in22 bed for the period of time that she was in hospital, so23 that wasn't particularly an issue. In terms of24 the items on this 11-point plan, there is no other25 additional entries detailed.89 1 Q. Were you satisfied with the assessment that was carried2 out in this particular case?3 A. In the case of this lady and the circumstances, yes.4 Q. What you say in your report doesn't appear to have been5 reviewed, but of course, we know that Mrs Stewart died6 some five days later.7 Do you consider that there should have been a review8 between 12 and 17 December?9 A. Because the patient was in bed, cot sides had been10 applied, she hadn't made any real attempt to get out of11 bed. There wasn't a review done, so I wasn't unduly12 concerned about that on this occasion.13 Q. If you look then at the next section of the report,14 which is headed "Manual handling risk assessment",15 I think you say that you saw no evidence that such an16 assessment had been carried out?17 A. That's correct.18 Q. Should there have been manual handling risk assessment19 in this case?20 A. It would largely depend on whether the hospital required21 a manual handling assessment to be taken on every22 patient as a condition on admission, and most hospitals23 do, particularly if they are concerned about a patient24 who is on bed rest or who is contained to their bed; for25 example, if they were to fall, then clearly an90 1 assessment of the risk of her -- risk of her falling2 should have been assessed.3 Q. Having regard to this particular patient, she was4 clearly not mobile --5 A. It would have been ideal if one had been completed for6 the purposes of consistency, but it is not an issue,7 really, in this particular case.8 Q. If she was to be moved from the bed to another location9 to be bathed --10 A. Clearly that would have been an issue, but by -- the way11 that I am approaching this is that that wasn't the case12 for this lady, given her general condition.13 Q. I see. So you are working on the basis that she really14 wasn't going to be moved and, therefore, this sort of15 assessment wouldn't be necessary?16 A. Yes, I am.17 Q. You make mention of the DNAR form, which you say has18 been signed but you cannot read the date. Has the19 preparation of the DNAR form been recorded in the20 nursing records?21 A. I cannot recall that.22 Q. Should there be some record made in the nursing23 records --24 A. Yes, there should.25 Q. -- that a DNAR form has been agreed?91 1 A. Absolutely, yes.2 Q. We see the document on page 52 of the records. You will3 see that a decision has been taken that -- for some4 reason "Mr" has been circled. We know we are dealing5 with Mrs Stewart. It looks as if it has been signed by6 Dr Forbat and dated 12 December. I think that was the7 date of admission?8 A. It was. That's correct.9 Q. Can we then look at what you say about the nursing10 management of C. difficile, which is section 13 of your11 report. What observations do you make here?12 A. The nursing management of C. difficile was very limited13 in the case of Mrs Stewart. I am commenting, as I have14 mentioned previously, that the doctor that examined her15 at the Royal Alexandra Hospital was of the opinion that16 there was foul-smelling diarrhoea and it was a likely17 C. difficile contaminant and that it was reasonably18 likely that she had C. difficile.19 In my opinion, that should have determined her20 immediate management until proven otherwise by the21 laboratory report, but actually, it is -- I believe it22 is documented that it is only after there is a positive23 laboratory report that she is actually isolated, and24 I am referring here to the fact that I think that is25 quite poor infection control management.92 1 Q. I think we observed that there was no care plan prepared2 for C. difficile?3 A. No, not at all.4 Q. I think you saw from the policy that that is something5 that seems to be envisaged in the policy.6 A. That's right.7 Q. And, likewise, a risk assessment.8 A. Yes.9 Q. Then, if you turn on to page 20 of the report, can you10 summarise your conclusion in relation to what you took11 from the hospital records in respect of this lady's12 care?13 A. Mrs Stewart was admitted to the hospital with14 a confusion, history of falls, alcoholic liver disease,15 diarrhoea and dehydration.16 One of the main issues of concern that I had was17 that the direct involvement of the infection control18 team and the control management was very minimal indeed.19 I was also quite critical that there was no specific20 risk assessment or plan of care for the patient's -- the21 management of the patient's infection. I couldn't22 determine whether the infection control nurse actually23 visited the patient to monitor the patient or to support24 the staff with the relevant infection control policies25 and procedures or, indeed, what actual infection control93 1 advice was given to them.2 C. difficile infection is a very debilitating3 illness for patients, the elderly and sick elderly in4 particular, and I didn't get a sense from the documents5 that this appeared to be a significant consideration by6 the nursing staff for this patient.7 Furthermore, this lady was in hospital for six days8 and had numerous problems and, in my opinion, really was9 quite -- really quite sick. There was no end of life10 care pathway commenced for her, even though it was11 evident that she was going to die and, indeed, the DNAR12 form was completed on the day of her admission.13 In summary, really, I believe that the care this14 patient received was really quite woefully lacking up15 until her death, and I feel that, in conclusion, there16 was a number of issues where the care fell below the17 level that could be reasonably expected of her last week18 of her life, and that pertains to very poor nursing19 assessment and care planning in the beginning, and20 evaluation and monitoring of that care, poor record21 keeping and illegible handwriting, particularly of22 the nursing staff.23 As we have said, poor management of the C. difficile24 contamination and care, fluid management and recording25 was poor, skin care and management of her tissue94 1 integrity was poor, the poor management and control of2 this lady's body temperature, poor nutrition management3 and poor end of life care are the reasons why I believe4 that to be so.5 Q. In passing, I think you said that an illness such as6 C. difficile can be particularly debilitating for the7 elderly. If only just to protect myself, we must remind8 ourselves that this lady was only 56.9 A. Of course.10 Q. But standing her physical condition, nevertheless was11 the disease debilitating for her?12 A. Yes.13 Q. Can I then move on to your next report that I want to14 look at, and that is the case of [Patient B].15 If you could have in front of you your report,16 please, which is to be found at EXP00430001. If you17 could also have the medical records that are relevant18 here, GGC26380001. If we look to your report and pick19 the report up on page 3, can you just summarise for us20 [Patient B]'s medical history?21 A. This case concerns a lady, [Patient B], who was22 a 77-year-old lady who was admitted to the medical23 assessment unit at the Vale of Leven Hospital on24 7 December 2007 under the care of Dr M Al-Shamma. She25 was admitted from an emergency respite care centre where95 1 she had been admitted a few days before following an2 increased frequency of falls at home. She'd had no3 significant past medical history other than a stroke,4 which had left her with a left-sided hemiparesis.5 Prior to this, she had been living alone at home,6 but had some help assistance seven days a week. She was7 primarily admitted then to ward 6 for treatment of8 dehydration with a plan to commence intravenous fluids9 and oral antibiotics, to monitor the fluid balance and10 a chest X-ray.11 On admission to the ward, she was receiving all12 personal care, but given with maximum assistance. She13 was able to sit out by the side of her bed and it was14 thought that she would require intensive physiotherapy15 and occupational therapy.16 Q. Do you tell us in your report that [Patient B] was17 reported to be C. difficile positive on 17 December?18 A. That's correct.19 Q. That, in fact, was the day that Mrs Stewart died in the20 same ward, I think; is that right?21 A. Correct.22 Q. If you look at the section dealing with admission to23 ward 6, which is on page 4, you say that the nursing24 staff completed a nursing admission assessment form.25 Perhaps we can look at that, page 76 of the records. If96 1 we just look at the body of this document, we will see2 it is ward 6, admission date 7/12, and there are3 a number of entries inserted.4 If we look to the bottom left under the heading5 "Observations", in contrast to Mrs Stewart's case, we6 can see that there are details entered here; isn't that7 right? Under the heading "Observations"?8 A. Yes, there are some details. The observation of vital9 signs has been completed and the provisional diagnosis10 is also completed. There are still some elements of11 this section that have not been completed, such as there12 is no weight recorded on admission, MEWS or BM, and13 there is no Waterlow score or urinalysis, one or two14 others, but those are the main features of that15 document.16 Q. Although I think we do see, and we will come to this,17 that there was a Waterlow assessment in this case?18 A. Yes.19 Q. You also make mention in that paragraph on page 4 that20 you could find no evidence that an activities of daily21 living assessment was completed for [Patient B], but22 I think we see that the tool is in the bundle, if you23 look at page 77 of the records.24 This document was in the records, but it has no25 name, no date and nothing has been entered into it?97 1 A. Yes.2 Q. It is totally blank?3 A. A completely blank document.4 Q. If we then look briefly at the medical input, medical5 notes, and this begins on page 5 of your report, we see6 that Dr Al-Shamma, it would appear, on the ward round,7 has made reference to her being admitted for dehydration8 due to poor oral intake at home plus poor urine output.9 Do you see that?10 A. Yes, that's correct.11 Q. She was started on antibiotics; is that correct?12 A. Yes.13 Q. Perhaps we should look at the page number in the14 records. Turn to page 15. I think, in fact, your first15 entry should probably be 7 rather than 18 December,16 because then we move on to the 10th.17 A. Okay.18 Q. If you turn to page 14 of the records, we see part of19 the medical admission notes. Go back a page to page 13.20 Can we see that the date for this entry is 7 December?21 A. Yes.22 Q. Then the next entry you have noted is for 10 December,23 and it begins by recording, "Looks well today" but then24 there is some reference to "inflamed and painful vulval25 area"; is that correct?98 1 A. Yes, that is correct.2 Q. What is this we are seeing?3 A. The doctor was called as soon as possible regarding an4 inflamed and painful vulval area. The patient stated5 that it had been painful since an attempt at a catheter6 insertion had been made and an examination was taken,7 I think in the presence of Sister Fox.8 It was identified that the area was very9 erythematous and painful to the touch and the soreness10 was extending around the vulva, tops of the thighs and11 groin and there was some bleeding and pus, but the12 doctor was unable to examine the patient thoroughly13 because it was so painful.14 Q. If we look at the records on page 15, we do see, four or15 five lines from the bottom of that page, "Examined with16 Sister Fox", so Sister Fox was involved in the17 examination and there is a description given.18 Now, when it talks about bleeding, when you have19 a little circle "bleeding", does that mean there is20 bleeding or there is no bleeding? Does that mean no21 bleeding?22 A. I took it as meaning bleeding.23 Q. On the 16th, if you go back to your report on page 5,24 there is now some reference in the medical records to25 bad diarrhoea; is that right?99 1 A. Yes, that's correct.2 Q. Moving on to page 6 of your report, there are still some3 entries there on the 17th saying that she has diarrhoea;4 is that correct?5 A. That's correct.6 Q. Now it has been noted that she is C. difficile positive?7 A. Correct.8 Q. Then, on the 24th, is that a note by the dietician?9 A. Yes, it is.10 Q. So the dietician has been called in, in order to provide11 some nutritional support?12 A. That's correct.13 Q. If you look, then, to your entry for the 31st -- and can14 we just look at the records for that on page 19? I just15 want to understand the reference you have in your notes16 to "fall".17 If we look at the entry for the 31st, which is about18 three-quarters of the way down the page, does that read19 "Came with fall"?20 A. I actually found this quite difficult to read. Because21 the patient had had a history of falls prior to being22 admitted, which is why she had gone into respite care,23 I wasn't quite sure if she'd had a fall or if it was24 a fall that she had had previously but was then25 complaining of the pain.100 1 Q. I think we saw from the history that she'd had a history2 of falls?3 A. Yes.4 Q. So we mustn't take from this that she had a fall in5 hospital, because the reference "came with fall" tends6 to suggest it was something that happened before she was7 admitted to hospital?8 A. Yes, that's right. That's what I thought, that it was9 probable that what she was complaining of was probably10 as a result of the fall previous.11 Q. Can we then turn to look at the nursing records and the12 entries you have taken from them, and for the 10th we13 see a similar reference to the sacral and vulval area14 being sore and swollen and Cavilon is to be applied.15 Are you able to assist us in relation to what has16 caused this soreness and swelling, what the mechanism17 is?18 A. Well, not really, other than what has been previously19 documented, that it may have been in relation to the20 catheter attempt, the insertion of the catheter. There21 is nothing else to indicate why that was the case.22 Q. If we move on to page 7 of the report, you tell us that,23 on the 14th, there is a record made that she has passed24 large, soft formed bowel movement and then large amount25 of diarrhoea; is that correct?101 1 A. That's correct.2 Q. It is at this point that the stool sample is sent for3 analysis?4 A. Correct.5 Q. We see, again on the 14th, that she continued to have6 several episodes of loose stools; is that correct?7 A. Correct.8 Q. It is on the 17th that, according to the records,9 C. diff has been confirmed to the ward; is that right?10 A. Yes, that's correct.11 Q. What about -- if we look at the infection control card,12 please, SPF01430001. Again, if we just orientate13 ourselves, we see the reference is ward 6 at the top14 right-hand side, and the date positive is said to be15 17 December. Do you see that?16 A. Yes, I do.17 Q. Just to read the text:18 "Informed by lab staff. Asked ward to isolate in19 2-bedded and commence oral Metronidazole. Visited ward.20 Spoke with SHO and asked him to discontinue oral21 antibiotics."22 Here we do have a situation where the infection23 control nurse has recorded that she has visited the24 ward?25 A. Correct.102 1 Q. If we look at page 45 of the records, we are looking now2 at the report from the microbiological department, and3 can we see that the sample has been collected on the4 15th -- received on the 15th and reported on the 17th?5 If we go back then to page 7 of your report, you had6 observed that the stool sample was taken from the7 patient on 14 December?8 A. Sorry, what page was that on?9 Q. Page 7 of your report.10 A. It says "Stool charts commenced".11 Q. Sorry, the second-top entry for 14 December, you have:12 "Passed large, soft formed bowel movement, then13 passed large amount of diarrhoea. Stool specimen sent."14 A. Yes, that's correct, sorry.15 Q. It would seem, at least on the face of it, that the16 confirmation of being positive has only happened some17 three days later, on 17 December, and then the patient18 is put in another room?19 A. Yes.20 Q. Do you have any comments to make on that form of21 management?22 A. Clearly, the patient had diarrhoea prior to this. That23 is why the specimen was collected and sent to the24 laboratory. And there has been a delay in isolating the25 patient. As per their own policy, really, as soon as103 1 there is diarrhoea, where there may be an infectious2 element to it, that isolation should take place as soon3 as that and not wait for laboratory confirmation.4 Q. I think we saw that this morning when we looked at the5 loose stools policy.6 A. Yes.7 Q. If you go back then to your report, page 7 of your8 report, I think you have noted that this patient9 continued to have diarrhoea. You say for the 17th, the10 last entry, there were 300ml of green, semi-formed11 stool, and then, on the 19th, you have noted "diarrhoea"12 and the "sacral area is excoriated but improving".13 Now, looking to the reference to the sacral area, is14 this pressure damage we are looking at or something15 different?16 A. It could be pressure damage, but clearly, with a patient17 that has got diarrhoea, diarrhoea is an indicator that,18 actually, because of the consistency of it, it actually19 does exacerbate the general skin integrity. So it could20 be a combination of both.21 Q. If you turn to page 8 of your report, it would appear22 that, on the 22nd, the patient is "mobilising with stick23 around the ward" but that she still has loose stools?24 A. That's correct.25 Q. Should a patient who has been found positive for104 1 C. difficile and still having loose stools be mobilising2 around the ward?3 A. No, she should not be.4 Q. If we --5 A. Can I just go back on that point?6 Q. Yes.7 A. As far as I can recall, from the infection control card8 there was a request for her to be placed into the9 two-bedded ward, so if that entry is referring to her10 mobilising around her own ward, then that would be11 acceptable.12 Q. Do we see, if we read on in your notes, that [Patient B]13 improved and was discharged on 3 January?14 A. That's correct.15 Q. Can we then turn to page 11 of your report? Once again,16 here you make -- pass some observations on the infection17 control card, and we had some discussion about that this18 morning where I think I indicated to you that this was19 a document kept by the infection control team.20 Looking to the entries, again, if we can have the21 card back on the screen, that's SPF01430001, we did22 observe, I think, that this was a case where the23 infection control nurse visited the ward and spoke to24 the senior house officer in connection with25 [Patient B]'s management?105 1 A. Mmm-hmm.2 Q. Again, we saw from the policy that one of3 the instructions in the policy was for there to be4 a risk assessment carried out.5 Do you consider that what you read in relation to6 the way in which this patient was managed does comply7 with that element of the policy?8 A. I would make two comments, really, in regards to this.9 First of all, I read this entry as:10 "Visited the ward and spoke with the SHO regarding11 discontinuing the antibiotics."12 I read it that that was the purpose of the visit, so13 whether or not there was any other communication with14 the nursing staff or -- I'm not sure about that, but my15 comments remain the same for this patient as the16 previous patient in terms of a risk assessment. This17 doesn't, to me, look like a risk assessment for18 a specific patient based on their circumstances in19 relation to the ward and a documented care plan to go20 alongside that.21 Q. Was there any evidence of a care plan being put into22 place for C. difficile for [Patient B]?23 A. No.24 Q. If you look then at the section dealing with your25 opinion, in the last paragraph on page 11 you do say106 1 that [Patient B] was referred to the occupational2 therapist and the physiotherapist to improve her3 mobility and capability of independence, and you go on4 about the loose stools and the very sore sacrum.5 Turning on to page 12, you identify some specific6 nursing issues that [Patient B] had following upon the7 diagnosis of C. difficile.8 Now, the development of a red, sore sacrum, again,9 are you relating that to pressure damage or some other10 mechanism?11 A. I would consider that both would probably apply in this12 case. There would have been some degree of pressure,13 but that was probably exacerbated through the diarrhoea.14 Q. The other points that you make there, as you say, she15 was incontinent and had diarrhoea, she suffered from16 confusion. Is that what you took from the history?17 A. Yes.18 Q. And some reluctance to eat and drink; is that right?19 A. That's correct.20 Q. Turning then to record keeping, what conclusions did you21 arrive at in relation to record keeping generally?22 A. The record keeping in general terms I found to be -- the23 content, or lack of it, and the completion of24 the nursing records to be very poor and below25 the standard that I would have expected for this107 1 patient.2 Q. Are you applying the NMC standards?3 A. Yes, I am.4 Q. I note in your next sentence you say:5 "[Patient B] was an inpatient of ward 6 and ward F."6 Was she transferred at some point to ward F, so far7 as you are aware?8 A. I saw some entries for ward F, but I did have difficulty9 discerning where the patient was at any one point in10 time.11 Q. If you turn to page 87 of the records, we see here12 entries going up to the 29th still on the ward 613 evaluation sheet.14 A. Yes.15 Q. So it would appear that certainly up until that date16 she's in ward 6, but there is an entry at the very17 bottom for the 29th at 12 midday, I think:18 "Transferred from ward 6. Settled into ward.19 Mobilising with stick. Plus supervision."20 So there may have been another transfer very shortly21 before she was discharged?22 A. Yes. I had difficulty -- I saw that, but I had23 difficulty knowing -- it wasn't clearly documented24 whether it was a transfer or where it was to.25 Q. If you turn then to page 13 of the report, can you just108 1 explain what point you are making in the first bullet2 point that we see on that page?3 A. This entry is under the section relating to nursing care4 planning, and I think I alluded to this in the previous5 report. One would expect a thorough assessment of6 the patient's presenting conditions, and this is usually7 determined through a range of nursing tools, most of8 which we have talked about before, such as activities of9 daily living, care plans, risk assessments for falls,10 Waterlow, et cetera, et cetera.11 Q. I think we will look at some of these documents shortly,12 but you do say here that you did see -- we have looked13 at this already -- the nursing admission assessment14 form.15 A. That's correct.16 Q. We looked and saw a blank activities of daily living17 assessment?18 A. That's correct.19 Q. The nursing summary document, which we perhaps should go20 back to because you make some specific comments on that21 in the next paragraph, could you turn to page 72? This22 may be a different document, actually, to the one we23 looked at before. Is this what you are talking about in24 that second paragraph?25 A. Yes, it is.109 1 Q. We can see that it is headed "Patient nursing summary"2 and then there is a box headed "Activities of daily3 living" and some areas are circled.4 Then, if you turn to page 71, which I think is5 probably the second page of the document -- you may not6 have focused on this -- you are going back, in a way, as7 it were, to page 71. Can you see that there are some8 further entries made and the document is signed,9 although it is difficult to make out the signature, and10 dated?11 A. Yes, that's correct.12 Q. Looking to what you say, you say this document is very13 poorly completed and does not state the date and source14 of the admission. Do you expect there to be a date at15 the top on page 72? Is that the point?16 A. With this document, depending on where it was in the17 bundle -- it's difficult to see that the two sheets were18 associated together. I take the point that it is dated19 on the bottom of the second sheet, but the point I'm20 trying to make in this first paragraph is that the date21 of admission and source of admission is not completed,22 so I had difficulty knowing when it was completed, and23 because it is transferred from 6, which I presume to24 mean ward 6, this would have been used -- in quite a few25 of the cases that I looked at, the patient nursing110 1 summary document, this one, was often used as a transfer2 document.3 Q. That is what it suggests, that this is completed because4 the patient has been transferred from one ward to5 another.6 A. Yes, that is what I believe to be the case.7 Q. Although there isn't a date of admission on page 72 --8 I think one can assume, I think, that page 71 is9 actually the second page of the document, albeit it is10 going backwards in the records. But we do see that11 there is a date for the transfer of 29 December?12 A. Yes, that is acceptable, yes.13 Q. The other boxes have been -- apart from pain score, the14 other boxes have been either ticked or circled?15 A. That's correct.16 Q. So generally speaking, although I think you described it17 as being very poorly completed, I don't know if you18 focused on page 71 or not, but --19 A. That is possibly the case.20 Q. On the face of it, the document seems to be, in the21 main, completed by whomever completed it?22 A. Yes.23 Q. Because we also have some discussion on page 71 giving24 some information as to what the original problems had25 been; is that correct?111 1 A. Yes, that's correct.2 Q. I think we have already observed, if you look at the3 next bullet point, that the other activities of daily4 living form was blank, but you also observed that there5 was evidence that the physiotherapy and occupational6 therapy departments were involved in this patient's7 care?8 A. Yes, that's correct.9 Q. You go on to say:10 "I am very critical of the level of assessment and11 documentation in a patient where the doctor writes 'is12 going to require a great deal of physiotherapy and OT'."13 There you are making reference to one of14 the observations you already looked at in the medical15 notes. Can you just elaborate on that? What is your16 concern? Do you need to go to the medical --17 A. I think actually -- I'm just reading that, if it is18 okay. Oh, right. My criticism is in relation to the19 physiotherapy and the occupational therapy documents.20 The doctor writes:21 "Is going to require a great deal of physiotherapy22 and OT."23 I can't recall whilst I'm sitting here, but that was24 in relation to following that entry when the25 physiotherapy and the occupational therapist visited,112 1 the amount of intervention that was documented, and2 I believe they said they would review, and it --3 Q. If we look at the physiotherapy documentation first of4 all on page 22 of the records, this is headed5 "Physiotherapy update" and it would appear to have been6 carried out when [Patient B] was in ward 6. The date we7 see on the form is 17 December.8 You looked at this document, I take it, when you9 were making the comments you make on page 13 of your10 report?11 A. Yes, I did.12 Q. What conclusions are you coming to?13 A. The title of the document is "Physiotherapy update", so14 whether there exists a physiotherapy assessment document15 or not, I don't know.16 Q. Did you find such a document in the records?17 A. No, I didn't, but it is something that I would have18 expected to have seen if a patient was referred to19 a physiotherapist, referred to an occupational20 therapist, for intensive physiotherapy and OT in order21 to get this lady's mobility to the point at which she22 can go back to her home, where, prior to going into23 respite care, she was, and she was coping reasonably24 well. But I couldn't see that, so I took this as being25 an update document.113 1 My other comment of it is that I think there is2 a paucity of detail on it. Just ticking the problem3 list: pain, mobility, balance, exercise tolerance, to me4 observing that document, what does that mean? There is5 no detail, it doesn't tell me any facts.6 Q. If we look at the occupational therapy report, which is7 on page 21 of the records, you will see that again8 relates to ward 6. There are some comments under the9 heading "Transfer assessment" and then, at the bottom:10 "Patient demonstrated safe and [something] transfers11 on the ward. No outstanding OT issues."12 This is dated 28 December, shortly before discharge.13 Was there anything else apart from this document that14 you were able to see from the point of view of15 occupational therapy?16 A. I just felt that it was very slim in detail. It doesn't17 really give a great deal of information at all,18 particularly -- I mean, it does say it is a transfer19 assessment, so I'm assuming that's transferring from20 chair to, you know, whatever, it is transferring from21 one to another, but it just doesn't have a great deal of22 detail on it.23 Q. If we go back to where this discussion began, I think,24 for you, and that is on page 15 of the medical notes, if25 you could look at that, the entry for 10 December,114 1 shortly after [Patient B]'s admission, four lines from2 the top I think reads:3 "Is going to require a great deal of physio and OT."4 And is that:5 "Potentially may require future care."6 Was that then what caused you to consider whether or7 not the physiotherapy and OT was -- could satisfy that8 instruction?9 A. Yes.10 Q. If the documents that you have looked at are all we have11 in relation to physiotherapy and occupational therapy,12 then did what you see in that documentation satisfy that13 instruction from the doctors?14 A. No, it didn't. Not at all.15 Q. In relation to care planning, could you look, please, at16 51 of the records? Once again, here we have17 a multiproblem care plan. The problems are described.18 Problem 1 is chest infection, and then dehydration and19 falls.20 Did you have regard to this document when you were21 preparing your report?22 A. Yes, I did.23 Q. What conclusions did you come to in relation to this?24 A. The multiproblem care plan, as you say, identifies one25 problem as being a chest infection and the second115 1 problem as dehydration and falls. That is actually2 three problems. They are three very distinct problems.3 In my opinion, and the way that I would be used to4 working and documenting these, there would be a separate5 plan and a separate document for each one of those items6 that would have specific interventions and activities,7 nursing, identified for each of them, not just8 everything on one form, because it is difficult to9 discern from it which activity relates to which.10 If that had been the case, then, when reviewing it,11 you could outline any improvement or deterioration with12 regard to that specific problem.13 Q. If you look at the interventions that are listed here,14 have you any comments to make on the nature of15 the interventions from a nursing perspective?16 A. My comments are the same as they were for the previous17 case, in that, to me, these are a list of orders or18 activities that have been identified, I would most19 likely imagine, by the doctors.20 Some of them are nursing interventions. So, for21 example, observations. Routine bloods isn't that --22 clearly, a doctor wants bloods to be done and a physio23 and social work referral, and OT, et cetera, ECG, chest24 X-ray. They are a list of activities that need to be25 undertaken to (a) diagnose this, but they are not116 1 specific nursing care interventions and activities.2 Q. Looking to the other entries that appear to have3 different dates, there is 15 December, "Stool" and4 16 December, "Blood cultures". Are these nursing5 interventions?6 A. No, they are not.7 Q. If you turn on to page 52 of the records, here we do8 see, I think as part of the care plan, a problem number9 and then "C. difficile positive" has been entered in for10 17 December. We know that was the date the diagnosis11 was confirmed. This bears to be a C. difficile care12 plan. Is that how you see it?13 A. Yes, I do.14 Q. Have you any observations to make in relation to this?15 A. Well, my observations are that it is very lacking in16 detail in terms of a nursing care plan.17 Q. We see that the goal is to ensure hydration and18 nutritional intake are sufficient. Would these at least19 be part of the planning?20 A. Yes, it would be, but I would expect to see that as21 being -- you know, the goal is to ensure hydration and22 to monitor intake and output, but a list of specific23 things that can be done to allow the activity to take24 place. So, for example, you know, to give the patient25 hourly or two-hourly fluids, to identify what drinks are117 1 the patient's favourite drinks so you are more likely to2 encourage them to want to take the drinks; to maintain3 adequate fluid balance.4 You would identify a number of other things below5 that that specifically related to that one item.6 Q. I think, as you say in your report, would you expect7 some references to infection control practices, such as8 isolation and the prevention of spread of infection?9 A. Absolutely.10 Q. What about stool charts? Would you have expected some11 reference to that?12 A. Yes.13 Q. Would the care plan for C. diff normally contain14 instruction as to what information should be passed on15 to family members?16 A. Absolutely, yes. Ward staff -- or ward staff on the17 ward, cleaning staff, family members, visitors, yes.18 Q. The comment you make -- the fourth bullet point down on19 page 14, you say the evaluation sheets -- and these are20 the nursing notes I think you are referring to:21 "... are then completed as a general nursing care22 continuation sheet and do not address the problems23 outlined in the problem care plan."24 Could you elaborate on what you mean by that?25 A. As I have just indicated, with a problem care plan,118 1 which is what we have just been looking at in relation2 to C. difficile and diarrhoea stools, the problem3 sheet -- you have got a goal, ie, it is whatever you4 want to achieve, and you have got the interventions,5 which is how you are going to try and achieve it, and6 then you would evaluate that specific item.7 So it is very clear, there is a process of8 identifying these factors with an outcome. So once9 you've identified what your intervention is, you will10 then evaluate what you have done, you will document what11 you have done or how you have evaluated it: is it12 working, isn't it working, do I need to review what I am13 doing? That will all be identified specifically in14 relation to this.15 What I mean by evaluation sheets, they are just16 completed as a general nursing continuation sheet. In17 other words, it is like a status report of, you know,18 "The patient got up, had a good day". It is filled in19 with a number of different things that are very20 disconnected and disjointed and that do not pertain21 specifically to the problem at hand.22 Q. If you turn to page 53, which is the next page we come23 to, can we see that it is headed "Acute medical unit24 evaluation sheet", and for the column "Problem number"25 the practice seems to have been to put in the time of119 1 the entry. Do you see that?2 A. Yes.3 Q. Thereafter, we read a narrative. I mean, for example,4 just before 1400, "Patient bright and cheery". Is that5 what you mean, that we have this general narrative, but6 you say that is not the development of a care plan as7 you would envisage it?8 A. It is the patient's day as seen by the nurse caring for9 them.10 Q. Going back to the report then, in the next bullet point11 you say:12 "Monitor blood chemistry."13 This was done in the case of [Patient B]; is that14 correct? Page 14 of the report. I am just asking you15 to confirm -- you have looked at the blood chemistry16 that's been monitored, and this was done for17 [Patient B]?18 A. That's correct.19 Q. Then you talk about, once again, the patient's pain.20 What do you say here?21 A. The patient's pain with the use of a pain assessment or22 tool chart, from the documents that I examined, this was23 not undertaken at all. I was critical of that because24 the patient clearly was in pain and discomfort because25 she required analgesia on a number of occasions, and it120 1 is documented that the patient was in pain, particularly2 around her vulval area, her bottom. I think she also3 complained of pain and soreness underneath her breasts.4 Then, added to that, there are entries on the bottom of5 some of the observation charts where they score the6 patient's level of pain as zero.7 Q. If we turn to page 65 of the records, can we see, if we8 look to the bottom section, where the zeros have been9 entered to describe the pain? Is that what you are10 meaning?11 A. Yes, that's correct.12 Q. I think I have a recollection of one where there might13 have been different numbers. Yes, turn to page 66. It14 would appear that on this form, for two days, the15 pain -- and that is, I think, for the 11th and the 13th,16 or the 12th, has been marked as 1?17 A. That's correct.18 Q. But the other forms, if we go to page 64, I think again19 we see it is zeros there that are inserted?20 A. Yes.21 Q. Then, on page 63, which is the other one, it would22 appear that also we have a run of zeros for pain. You23 say that just doesn't add up, withstanding the fact that24 she had these problems which were causing her pain?25 A. If a patient is complaining of pain and requiring121 1 analgesia, then they clearly have pain. So a score of2 zero is not accurate.3 Q. You are critical of that in your report?4 A. That's correct.5 Q. In the next bullet point you have noted that you could6 find no evidence that the patient and the family had7 what, been communicated with?8 A. I couldn't find any evidence that they had been9 communicated with, no.10 Q. What about the patient's psychosocial situation and11 expectation of recovery? What conclusions did you come12 to there?13 A. From the documents I examined, it was difficult to14 determine if that had actually been done. I couldn't15 see it documented.16 Q. Discharge planning. You make some mention of that. Can17 we look at the documents, page 61 first of all? I think18 the date is 28 December, which is a couple of days19 before discharge. It is called a short care plan.20 What's wrong with this as a discharge plan?21 A. Is it possible to have the lower section highlighted,22 please? I can't read it very well.23 Q. Yes, if we could do that, please.24 A. The point I'm trying to make here is that this lady is25 scheduled for discharge and clearly there would need to122 1 be a number of services put into place for her to be2 able to go back to her home. There is some detail in3 the intervention section that relates to home care4 services, but it is not very detailed.5 Q. It is very difficult to read, I'm bound to say. What6 sort of information would you expect in the care plan --7 in the discharge care plan for this sort of patient?8 A. Well, if you go back to the activities of daily living,9 which is a really good tool because it does what it10 says, it looks at every function that a patient has in11 terms of their ability to wash themselves, cook for12 themselves, whatever their physical situation may be,13 their psychosocial situation may be, and how they cope14 and manage at home.15 Given that this refers here to the medical social16 worker being involved, we know from our previous17 conversations regarding the intensive physiotherapy and18 occupational therapy that this lady, it was said, was19 going to require, and I have already commented on that,20 so I would expect all of those elements in the21 activities of daily living to be almost listed. You22 would have a document -- most places, in my experience,23 would have a core care plan for discharge which would24 address every little nuance of the discharge, in terms25 of enabling a patient to cope at home and, if they123 1 couldn't cope, the exigencies that had been put into2 place to provide that help and support for them for when3 they get home. I didn't see any of that here, and4 I wasn't sure -- well, I couldn't make an assumption5 that that ties in with the fact it isn't here because it6 actually wasn't in the original physiotherapy and7 occupational therapy assessments to begin with.8 Possibly, if it had been, this may have been a little9 more detailed.10 Q. If you look at another document, page 75 of the records,11 I think in this same context, you will see that this12 seems to have emanated from ward F, the other two have13 been scored out, "Discharge plan", and the problem is14 "discharge from ward F" and there are a number of15 interventions, some of which have been remarked upon and16 some of which have not.17 Would this perform the sort of functions that you18 were talking about a moment ago?19 A. It addresses some of them, but this, to me, is more of20 a tick list. It is a check list: discharge date,21 discharge to, transport arranged, that's fine.22 Some of the elements I would expect are there, but23 this is essentially a tick list to make sure that things24 are not forgotten or to act as a prompt or as an25 aide-memoire.124 1 MR MACAULAY: If your Lordship were to be having a short2 break this afternoon, this would be a good point.3 (3.10 pm)4 (A short break)5 (3.30 pm)6 MR MACAULAY: Turning to page 15 of your report then,7 Mrs Stower, you have a section dealing with temperature,8 pulse and respiration charts. You make some comments9 here. What observations do you make?10 A. There were observation charts. There was no observation11 charts recorded for the period 24 to 28 December.12 The other comments I make are that -- on the13 observation charts at the bottom, the BM, the weight,14 pain score, as we have already referred to/discussed,15 sedation score, nausea score and bowel movement is not16 completed in a consistent manner. That is mainly my17 observations.18 Q. Just to clarify the period you focus upon for there19 being no observations, if you could turn to page 64 of20 the records, it is quite difficult to work out, but if21 we look at the dates, do we have a date of the 24th in22 the top left, and is the next date -- do you think that23 is the 28th? I certainly see a date for the 27th.24 Could it be the 25th and 27th?25 A. I think now that I can see it enlarged, I can see 24,125 1 I think that probably is 25 --2 Q. You have overstated the position then on page 15?3 A. Yes, I have, yes.4 Q. You have made the point already about the references to5 pain score that we can see at the bottom.6 Now, fluid balance charts and fluid management is7 the next section you address. What conclusions do you8 come to here?9 A. There were fluid balance charts recorded for ten days10 only of [Patient B]'s 27-day stay in hospital, and11 I consider that the standard of completion of these12 charts is very poor.13 Q. You give some reasons for that?14 A. I do.15 Q. What are these?16 A. One of the documents, GGC26380111, is undated. There17 was very little output information recorded. Stools,18 although [Patient B] had diarrhoea, were rarely recorded19 on this sheet. There was no calculation of fluid20 balance, input and output, with a total and a balance21 for the doctors to observe in order to make the relevant22 IV fluid adjustments.23 Q. If we then look at a number of these forms, if you turn24 to page 111, first of all, the one you say was undated,25 we see, I think, that there is no date. There are some126 1 entries on the form itself; is that correct?2 A. Yes, that's correct.3 Q. But no totals and, indeed, there is no output recorded;4 is that right?5 A. That's correct.6 Q. Is this of any assistance in assessing the position of7 fluid balance?8 A. No, it isn't.9 Q. If you turn to page 109, again you have another form10 with some entries, but, again, is that of any assistance11 in assessing fluid balance?12 A. No, it isn't.13 Q. Perhaps we can look at two more. Page 105. Here we14 have some entries and some reference to green stools in15 the output. This is for 19 to 20 December. But there16 is very little by way of information. Is this of any17 assistance in assessing fluid balance?18 A. It is only one entry, apart from the green stool entry,19 in a 24-hour period. It is very poor.20 Q. Finally, perhaps, for page 104, this is dated the 18th21 to the 19th. I think we see here there are some22 entries, at least for the intake, and indeed a total,23 and also at least the urine has been totalled. Is this24 better?25 A. Yes, it is a much more concerted effort to complete the127 1 form on this occasion. Yes, it is.2 Q. Going to your report, the last paragraph on page 15,3 what conclusion do you come to on this topic?4 A. Overall, regarding the fluid balance charts and the5 fluid management, I was critical, particularly as the6 interventions on the C. difficile care plan, which we7 saw earlier, are specifically identified as -- an8 intervention is to monitor intake and output and to9 maintain a fluid balance chart. So, therefore, it fell10 well below the standard that I would have expected,11 again of any sick patient, but particularly one who is12 dehydrated, has diarrhoea and is vomiting and reluctant13 to take oral fluids.14 Q. Moving on to page 16 of the report, you make some15 comments towards the top of the page about the infusion16 system observation chart. What is the point you are17 making here?18 A. There were infusion system observation charts. I could19 see that the sheets -- there are a certain number of20 sheets covering the dates 7 December to the 12th, but21 I note that I am unsure when the intravenous infusion22 was discontinued, as it is not documented in a nursing23 record.24 Also, I couldn't see it prescribed on the25 prescription sheet or see that it states that it was to128 1 be discontinued, which is where I would have expected it2 to have been.3 Q. You are not saying it should not have been discontinued,4 or are you?5 A. No, I'm not saying that. I'm saying that, normally, you6 would expect, if an intravenous infusion is being7 discontinued, it would normally be documented -- either8 documented by the doctor for it to be completed or9 documented on these sheets.10 Q. Is this a medical matter, rather than nursing?11 A. No, I would have expected the nursing staff to have12 identified that the intravenous infusion had been13 discontinued.14 Q. So this is really a recording issue per se? This is15 a matter of lack of recording that something has been16 discontinued?17 A. Yes, it is.18 Q. You then deal with the pressure management and skin19 integrity, and you suggest that the assessment was not20 undertaken in either ward 6 or ward F. Can we just look21 at the documentation?22 On page 74, we see the Waterlow form and we note23 that this appears to have been instigated in ward F24 because we see the reference to ward F towards the top.25 Do you see that?129 1 A. Yes.2 Q. It doesn't appear that the numbers have been circled, as3 we sometimes find, but if you turn to page 73, which is4 the previous page, can we see that against the date5 30 December an assessment has been made which brings out6 a total of 17, which is a high-risk assessment. Do you7 see that?8 A. Yes, I do.9 Q. It is difficult to understand the next assessment date10 because that suggests 4 December 2007, which seems to be11 going backwards. Can you understand that?12 A. I think that must be an error and that it presumably13 means 4 January 2008.14 Q. You, yourself, if we look at your report, do you,15 yourself, also carry out an assessment and you come out16 with the same figure of 17, which is the high-risk17 assessment in your report?18 A. Yes, that's correct.19 Q. We note here that this assessment was done in ward F20 I think the day before [Patient B] was discharged from21 the hospital. Should this have been done much sooner?22 A. Yes, it should have been done. There are two points23 I would like to make regarding this document. The24 Waterlow assessment calculator, the one that is used in25 the Vale of Leven Hospital, is a two-page document. It130 1 has what I call a front sheet, which is the number 12 sheet, and it has a second sheet, which is the sheet3 that we have on the screen.4 Now, it is my understanding that the front sheet,5 the sheet that is circled, which is the one that was in6 the bundle that had no information on it at all, is the7 primary sheet, the sheet you look at and visibly you can8 see the assessment and the comparators on it. So you9 have a number of things and you circle which is the10 relevant one for that patient at that time.11 So to me that is the main informing sheet.12 The sheet we have in front of us is the sheet that13 I would consider to be the evaluation and the review14 sheet, so clearly, when it is done, you would fill the15 front sheet in, you would probably transpose that16 information over onto this sheet and then you would17 identify when the reviews would be taken, but that is18 absolutely right, this wasn't done -- this assessment19 was not done on [Patient B]'s admission to either of20 the wards but just only prior to her discharge, and21 I would have expected it to have been done within22 24 hours of admission.23 Q. When you say in your report:24 "The assessment of [Patient B]'s skin was not25 undertaken in either ward 6 ..."131 1 You say that because you do not see any2 documentation in the records to suggest that it was done3 in ward 6; is that correct?4 A. That's correct.5 Q. "... or ward F."6 You say on admission, but at least it appears that,7 at the time she was in ward F, there was an assessment8 carried out. Obviously, I take the point you make about9 the use of the form, but the assessment did assess her10 at high risk?11 A. That's correct.12 Q. If we look back to page 73, can we read, just above the13 assessment tool, that -- I think it says:14 "All patients at risk must have a care plan15 indicative of prevention/treatment plan."16 Do you see that?17 A. That's correct, yes.18 Q. Did you see any evidence in the records that there was,19 first of all, a care plan for pressure management?20 A. No, I don't recall that at all.21 Q. Did you see any evidence of either reference to22 a special mattress or turning charts in the records?23 A. No, I could see no reference to the patient being nursed24 with a special mattress or any referral being made to25 the tissue viability nurse specialist.132 1 Q. If you look, then, to page 17 of the report where you2 deal with nutrition, this is a case where I think the3 dietician was involved; is that right?4 A. The dietician was, yes, that's correct.5 Q. You tell us, indeed, that the referral to the dietician6 was made and that she visits the patient on 24 December.7 What observations then do you make in relation to this8 aspect of care?9 A. The dietician -- the involvement of the dietician is10 important, for her to come and carry out a nutritional11 assessment of the patient to identify her nutritional12 status. That would usually be based upon the factors13 identified in a comprehensively completed nursing14 assessment, just to identify the level of nourishment or15 undernourishment that the patient may have. This is16 important in order for her to provide a baseline of17 information, and then, on that basis, care can be18 planned.19 A referral was made and she did visit on20 24 December. The dietician requests Fortisip21 supplements, but I couldn't find any evidence from the22 nursing documents that I examined that those supplements23 were prescribed by the doctors, which they normally are.24 Q. Are they normally given on prescription?25 A. They normally are, yes. Neither could I actually133 1 determine that they were given by the nursing staff, as2 I couldn't find them recorded in the nursing documents.3 Q. Would you normally have food charts to document the4 recording of these supplements?5 A. Yes. You would expect to see it in the prescription6 chart, on a feed chart, and most likely also possibly on7 the fluid balance chart when that is being completed as8 well, because on the fluid balance charts you normally9 identify what fluid is being taken as well as when.10 The dietician also says she will monitor and review,11 but I couldn't see that -- I couldn't find any food12 charts documented and I didn't see that the review did13 actually take place prior to the patient's discharge.14 Q. You then, at section 9 of the report, make some15 observations in relation to a stool chart. I think you16 say that there were no stool charts in the records you17 examined; is that right?18 A. That's correct.19 Q. You make mention of the loose stools policy. In20 particular, the reference there to a care plan.21 A. Yes, the loose stools policy does state that the care22 plan should be completed for patients with loose stools,23 but I could not find that in the documents that24 I examined.25 Q. A falls risk plan, was there such an assessment in the134 1 papers, in the records?2 A. No, there was no falls risk assessment at all.3 Q. Should there have been?4 A. Yes, there should have been.5 Q. So far as you could say from your understanding of6 the patient's condition, was she at risk of falls?7 A. Yes, she was at risk of falling.8 Q. You say you are highly critical of the lack of this9 assessment, if the records truly reflect the position.10 A. Yes, I am.11 Q. What about the next item, manual handling assessment.12 Did you see any evidence in the records that this13 assessment had been carried out?14 A. No, there is none -- there was none carried out.15 Q. What is your conclusion on that?16 A. I am critical of that because, in a 77-year-old patient17 who has decreased mobility and a recent history of18 falls, one would expect that, the manual handling risk19 assessment form to be completed for both the safety of20 the patient and the practitioners who are caring for21 her.22 Q. You say in your report that, if the records truly23 reflect the true position, you are critical of this24 omission?25 A. Yes, that's correct.135 1 Q. The nursing management of C. difficile, which is the2 final section that you have in this report, can you just3 elaborate on what conclusions you arrived at, having4 regard to the records you saw in relation to this aspect5 of care?6 A. I could see no real evidence of C. difficile management.7 There was a care plan of sorts, but there was little8 involvement of the infection control team. There was no9 evidence to say that the infection control team were10 visible and working with the nursing staff and11 supporting them in the management of this patient.12 As I said to you before, there is an entry to say13 that the infection control nurse attended the ward, but14 my understanding of that was that that was specifically15 to discuss the issue of Metronidazole with the doctor16 and other antibiotics, and also there was no involvement17 of the microbiologist that I could see.18 Q. I think we touched upon this before, but we know that,19 under the policy, a risk assessment should be carried20 out. Did you see what was done here as amounting to21 a risk assessment?22 A. No, there was none.23 Q. Then you finally set out some final remarks under the24 heading "Conclusion". Generally speaking, what were25 your conclusions here?136 1 A. [Patient B] was admitted to the Vale of Leven Hospital2 with an initial diagnosis of dehydration, chest3 infection and a recent history of falling. Therefore,4 in my opinion, the care that she received while she was5 a patient in the hospital fell well below the standard6 that she could have reasonably expected, based on:7 a poor nursing assessment, relevant care planning and8 evaluation on ward 6 and ward F; the absence of a falls9 risk assessment when, in fact, actually there was a real10 recent history of falls; absence of manual handling11 assessment; and in terms of the Waterlow score, we have12 said that there was a score there but no real plan of13 care based on the outcome of that score; and a lack of14 assessment of skin integrity on admission to both wards15 and the follow-through planning of care as a result of16 that.17 Q. I think you make some further remarks on page 19, which18 I think we can probably read for ourselves. You talk19 about failure to isolate, poor C. difficile management,20 absence of stool charts, poor record keeping and poor21 fluid balance recording?22 A. That's correct.23 Q. You say that they fell far below the standards she could24 reasonably have expected, but in relation to the NMC25 code that we looked at this morning, did the standard of137 1 care comply with the propositions set out in the code?2 A. No, it didn't, because there were quite a number of3 omissions and lack of recording and, as we heard this4 morning, recording is inherent, it should be inherent in5 what nursing practice is all about. If it is not6 recorded, then we have got no evidence that it has been7 undertaken and, therefore, it can certainly be8 detrimental to the patient as a result of that.9 Q. We can leave that report aside and then go to look at10 the next case that you looked at, and that is the case11 of Mathew Macfarlane. Your report is at EXP00380001.12 The medical records that are relevant here are at13 GGC00380001.14 If we turn to page 3 of the report, can you give us15 a summary of Mr Macfarlane's medical history?16 A. Mr Macfarlane was a 78-year-old gentleman who was17 admitted to the Vale of Leven Hospital via the medical18 assessment unit on 4 February 2008 under the care of19 Dr M Al-Shamma. This was following a referral from his20 general practitioner. Mr Macfarlane's presenting21 symptoms were shortness of breath and query pleural22 effusion, query a urinary tract infection and a gradual23 general deterioration.24 I noted also that the medical staff when he25 presented also noted that there was a question of --138 1 that there might be a malignancy associated with his2 shortness of breath and possible pleural effusion.3 In terms of previous medical history, he had4 a medical history of recurrent UTIs, that's urinary5 tract infections, a recent urinary sepsis, renal6 failure, obesity, atrial fibrillation, hypertension,7 diabetes, which was non-insulin dependent, and gout.8 Q. Moving on to page 4, I think you give us some social9 background, and you also noted that he was known to have10 poor mobility and walked with a frame; is that right?11 A. That's correct.12 Q. He was admitted, I think, to ward 6; is that right?13 That's what you have noted?14 A. Yes, he was.15 Q. On admission, what was the position?16 A. On admission to the medical assessment unit, he was seen17 and examined by the doctor. There was a query that he18 had a pleural effusion and an increasing shortness of19 breath. His observations were recorded. He was known20 to be on a number of medications, and these were21 recorded in the documents. The MAU documentation was22 somewhat incomplete.23 Q. If we read on, we see that he was commenced on24 antibiotic therapy and aggressive physiotherapy and25 occupational therapy and was found to be C. diff139 1 positive on 12 February. Do you see that at the top of2 page 4?3 A. Yes, that's correct.4 Q. That is some eight days after his admission, if we5 remember that he was admitted on the 8th (sic). So some6 eight days later he's diagnosed to be C. diff positive;7 is that right?8 A. That's correct.9 Q. But his condition improved, as you have noted, and he10 was discharged home on 21 February?11 A. That's correct.12 Q. You have noted he was later admitted to the Royal13 Alexandra Hospital and he died subsequently on14 23 April 2008?15 A. Yes, that's correct.16 Q. If we look at the death certificate, SPF00240001, can we17 see that he died of respiratory failure and chronic18 sepsis?19 A. Yes, that's correct.20 Q. I don't know if you said earlier on that he was admitted21 to the Vale of Leven on the 8th, but it was 4 February,22 if you go back to page 3. I think I said it.23 So he was admitted on the 4th and he was found24 C. diff positive eight days later on the 12th, I think.25 That is what I intended to say.140 1 Looking then to the admission to ward 6 that you2 look at towards the bottom of page 4, you say that there3 was a nursing admission assessment form which was4 completed, but that there was no activities of daily5 living assessment completed, or you didn't see such a6 form in the papers.7 A. That's correct.8 Q. Looking to the admission, nursing admission assessment9 form, if you could turn to page 72 of the medical10 records, I think this is the document that you have made11 reference to in your report; is that right?12 A. Yes, I think so.13 Q. You see the date -- we see "Ward 6" at the top, and the14 admission date is 4/2/2008.15 A. Yes.16 Q. The consultant is Dr Akhtar, there is some information17 given. The observations seem to have been completed18 here and the other information boxes have been ticked,19 but the Waterlow box is blank in the form?20 A. That's correct.21 Q. You did not find an activities of daily living22 assessment form in the records?23 A. No, I didn't.24 Q. Would you have expected to find such a document in the25 records?141 1 A. Yes, I would.2 Q. Can we then just look briefly at the medical notes which3 you look at on page 5, and perhaps just observe that you4 have noted that, on 9 February, Mr Macfarlane is5 transferred to ward 3. Do you see you say that towards6 the top of page 5?7 A. Sorry, what date was that?8 Q. I'm just looking at your report, where you have observed9 at the top of the page that Mr Macfarlane is admitted to10 ward 3 --11 A. I beg your pardon, yes.12 Q. -- on the 9th. So he's spent some five days in ward 6;13 is that right?14 A. Yes, that's correct.15 Q. Did you find that there was movement between wards,16 looking at the cases as a whole?17 A. Yes, there were a lot of moves to different wards18 overall.19 Q. Could you work out what the reasons were here for20 Mr Macfarlane being moved from ward 6 to ward 3 after21 five days in hospital?22 A. The reasons were not clear, no.23 Q. Should you be able to understand from the records why24 a patient is being moved from one ward to another?25 A. Yes, you should. One would expect to see a nursing142 1 entry saying specifically the reason for transfer to2 another ward.3 Q. The medical notes on page 5, can we see that we are4 given some information about his medical condition. If5 I could just perhaps look at an entry that I don't think6 you have actually incorporated, but if I can turn to7 page 21 of the medical notes, I think this is something8 you do discuss later, but I will just flag it up now.9 Can we see that for 11 February there is a note made by10 the dietician towards the bottom of the page? It would11 appear that the dietician has seen Mr Macfarlane:12 "Thank you for referring this gentleman for weight13 reduction advice. Spoke to patient with his wife", and14 so on.15 So there was a referral to the dietician and the16 dietician gave certain advice?17 A. That's correct.18 Q. Then, if we go back to the report, can we see that on19 the 12th certainly he has been given antibiotics. Do20 you see that?21 A. Yes, that's correct.22 Q. There is also an entry that you have noted from the23 medical records that he had diarrhoea for two days?24 A. Yes, that's correct.25 Q. Then, on the 13th, can we see that the entry, reading on143 1 to page 6, is that he is C. diff positive and he's2 started the Metronidazole?3 A. That's correct, yes.4 Q. If we are now on the 13th, is Mr Macfarlane now in5 ward 3 when the diagnosis is confirmed?6 A. Yes, I believe so, yes.7 Q. If you go to page 65 of the medical records, we are8 looking at the report from the microbiology department,9 which we can see is addressed to ward 3 in the top10 right, and can we see the sample is collected on the11 12th, received on the 12th and printed on the 14th?12 A. That's correct.13 Q. Would it appear, looking to the medical records, that14 Mr Macfarlane improved and he was due to be discharged15 on 20 February? That's on page 6. Have we got that?16 A. Sorry? I've lost that.17 Q. Page 6 of your report. In short, I think from the18 medical records he's improved and he is discharged to go19 home on 20 February.20 A. Yes.21 Q. If we look at the nursing entries, for 8 February22 Mr Macfarlane is complaining of feeling sore with aches23 and pains, and there is a question mark whether it is24 due to gout. Do you see that?25 A. Yes, that's correct.144 1 Q. On the 9th, there is an entry -- this is perhaps just to2 clarify that entry on page 77 of the records. You have3 written:4 "Reluctant to mobilise."5 I think if we look at the entry towards the bottom6 of page 77, what is recorded here is:7 "Patient dislodged ... in sleep."8 A. It says "Patient dislodged the Venflon ..."9 Q. "... in sleep".10 Then:11 "Slightly reluctant to mobilise and difficulty12 getting out of bed."13 A. That's correct.14 Q. I think it may be actually "Patient talking in sleep".15 Is that what's been recorded? It may not matter, but16 the note is that he was slightly reluctant to mobilise17 and he had difficulty getting out of bed?18 A. That's correct.19 Q. We then see, on page 7 of your report, the reference to20 being transferred from ward 6 on 9 February, and then,21 on the 10th, there are references to being incontinent22 of faeces and loose stools. Is that right?23 A. That's correct.24 Q. So it would appear that the first reference to loose25 stools is on 10 February, which is the day after he was145 1 transferred from ward 6?2 A. Yes, that's correct.3 Q. We read some further information, that he is incontinent4 of loose, foul-smelling stools on the 12th, and then, at5 1615 on the 12th, the ward are aware that he is positive6 for C. difficile?7 A. That's correct.8 Q. If we look at page 8 of your report, can we see there9 are further references to loose stools in the records?10 A. Yes.11 Q. On the 15th, if we can move on to there, has it been12 noted that he is very confused and found to be climbing13 out of bed on several occasions?14 A. That's correct.15 Q. He has also had a small skin tear to his right forearm16 on the 16th; is that right?17 A. Correct, yes.18 Q. Can we note here that the date of discharge is, in fact,19 21 February? That is on page 9 of your report?20 A. That's correct.21 MR MACAULAY: My Lord, I am next going to go into the body22 of the report, which I am quite happy to do for a while,23 if people can bear with that. Alternatively, I can24 revisit it tomorrow morning?25 LORD MACLEAN: It is a matter for you entirely.146 1 MR MACAULAY: I think the witness has probably had a long2 day, my Lord.3 LORD MACLEAN: Yes, that is true. Has it been a long day?4 A. I don't mind.5 MR MACAULAY: I'm happy to proceed for perhaps another ten6 minutes or so.7 LORD MACLEAN: Can I just ask before we go on, I was just8 looking to the point at which he was discharged, on9 the 21st. Can you identify what he was treated with for10 the C. diff? There must be a list of medication11 somewhere?12 A. He was prescribed Metronidazole --13 LORD MACLEAN: That's right.14 A. -- on 13/2.15 LORD MACLEAN: Yes, which was discontinued the day he left?16 A. It was discontinued on the day of discharge.17 MR MACAULAY: If we then go to page 13 of your report, where18 I think you follow the format in your previous reports19 and you look early on at the infection control card20 here, which you will find at SPF00630001, we are given21 some information here. Can we see, first of all, the22 date positive is noted as 12/2/2008, and then, on the23 13th:24 "Unable to isolate. Remains symptomatic."25 So would it seem that at this point it wasn't147 1 possible to isolate the patient?2 A. That's correct.3 Q. Do you know why that was?4 A. No, I have no way of identifying that, no.5 Q. By the 18th, has the infection control nurse noted that6 he was asymptomatic?7 A. That's correct.8 Q. We looked before at the C. difficile policy that may9 have been relevant, and it made some mention of risk10 assessment. Do you see within this document evidence of11 a risk assessment?12 A. There is no risk assessment in this document, no.13 Q. Did you see any evidence that the infection control14 nurse had visited the ward to see the patient and assess15 the patient?16 A. No. I don't see anything to indicate that the infection17 control nurse visited. I wasn't sure what SCIPS stands18 for because it does say "reinforce SCIPS and enhanced19 cleaning". Unless that is something to do with special20 infection control precautions, it could do, but21 I can't -- I don't understand the abbreviation.22 Q. We will see if we can work out that before tomorrow23 morning. Again, the date of discharge has also been24 recorded, 21 February?25 A. That's correct.148 1 Q. The number of the ward that is given on the card is2 ward 3. Of course, I think that is where Mr Macfarlane3 was when the diagnosis was actually confirmed; that's4 correct, isn't it?5 A. Yes.6 Q. But the admission initially was to ward 6?7 A. Yes.8 Q. You then go on to look at certain aspects of his care.9 If you turn to page 14, I think you identify a number of10 nursing issues that Mr Macfarlane had during his time in11 the hospital; is that right?12 A. That's correct.13 Q. You say in the second bullet point that we have touched14 upon that it is documented in the infection control card15 that the staff were unable to isolate him, although it16 does not say why. Then you speculate that the most17 likely reason being that there was no single room18 available. Ought there to have been some explanation as19 to why it wasn't possible to isolate in the infection20 control documentation?21 A. Sorry, I didn't quite catch that question.22 Q. Should there have been some explanation in the infection23 control documents as to why it wasn't possible to24 isolate?25 A. Yes, I believe there should be.149 1 Q. But the lack of a single room would be the most obvious2 reason?3 A. To my opinion, yes, that's correct.4 Q. On page 15 you deal with record keeping. What5 conclusion did you come to, having regard to your6 examination of the records?7 A. Overall, I felt that the standard of records was very8 poor, and the reasons for that I identify under the9 separate headings that go further on into my report.10 Q. If we look at some of the points you make under the11 heading "Nursing care plans", the first reference you12 make is to the nursing admission assessment. We looked13 at that form a moment ago, and we can do so again, but14 the point you make there I think is that the Waterlow15 wasn't completed. Is that the main point?16 A. Yes, that's correct.17 Q. Was there a Waterlow assessment at all? I don't think18 there was.19 A. No.20 Q. What about the next bullet point? You say:21 "Risk assessments in relation to the activities of22 daily living and functional ability are usually done in23 conjunction with the physiotherapist and occupational24 therapist. The ADL was not completed on either ward for25 this period and I am critical of this."150 1 Was there such a form in the records?2 A. Not that I observed.3 Q. I'm sorry?4 A. Not that I observed.5 Q. If we leave the next bit and come back to that later,6 you say:7 "There is an acute medical unit multiproblem care8 plan."9 Perhaps we can look at that, at page 74 of10 the records. We see this is dated 4 February. Four11 problems are identified, and we see a list of12 interventions in the body of the document. What13 observations do you make in relation to this document?14 A. There are four problems identified. There is a left --15 I think it is left -- pleural effusion.16 Q. Could you make sure you speak to the microphone, please.17 A. Sorry, I can't read it very well.18 Q. Can we make it a bit bigger?19 A. Yes, that would be good, if you could, thank you. That20 is better. There is a left pleural effusion. There is21 a "[something] UTI". I'm not quite sure what that is at22 the beginning. NIDDM and chronic anaemia.23 Q. Does that NIDDM mean?24 A. Non-insulin dependent diabetes mellitus, and chronic25 anaemia.151 1 Q. There is also a reference to mobility, which suggests2 the arrow going downwards, that means reduced mobility?3 A. I beg your pardon?4 Q. Before we get to the entry that focuses upon non-insulin5 dependent diabetes, there is a little arrow to the right6 pointing down for mobility, so that is reduced mobility,7 is it?8 A. That's correct, yes.9 Q. And chronic anaemia is the final reference?10 A. Yes.11 Q. What about the interventions then that are recorded?12 A. Generally, my comments there are the same as they have13 been in the previous reports. There is a list of14 interventions required in terms of -- some of these are15 nursing interventions, such as observations, ward16 urinalysis and obtaining specimens. There is17 a transfusion, there is rather a large number of18 investigations, there are referrals to physiotherapy,19 antibiotic therapy, but again, this is a list of20 interventions that would have been requested following21 the doctor clerking the patient and, although there are22 some elements of the 13 that are listed that are nursing23 activities, it doesn't actually constitute a nursing24 care plan.25 Also, I refer to the previous comment that I made,152 1 we have a problem sheet with five different -- well,2 there are actually three -- there are four clinical3 diagnoses and then one specific problem, ie, mobility.4 There would have been, within those four clinical5 diagnoses, a number of other probable problems that6 would have been identified, but here we have one7 document with a lot of information on it. It doesn't,8 again, specify problem by problem, as I have previously9 explained it should do.10 LORD MACLEAN: If that is a convenient time?11 MR MACAULAY: Yes, my Lord, that is probably a good point.12 We will adjourn until 10 o'clock tomorrow.13 (4.18 pm)14 (The hearing was adjourned until15 Tuesday, 7 June 2011 at 10.00 am)16171819202122232425153 1 I N D E X23 Discussion re nurses' evidence ...... 145 MS SHARON STOWER (sworn) ...... 2267 Examination by MR MACAULAY ...... 228910111213141516171819202122232425154

5 LORD MACLEAN: Mr Kinroy, I Want to Ask You Certain

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