1 Monday, 23 January 2012
2 (10.00 am)
3 MR MACAULAY: Good morning, my Lord. The next witness
4 I would like to call is Dr Fiona Johnston.
5 DR FIONA ANNE JOHNSTON (sworn)
6 LORD MACLEAN: I understand that you have a back problem, or
7 problems?
8 A. Yes. We will not talk about that.
9 LORD MACLEAN: No, but if you feel the need to stop and
10 walk, or whatever, please let me know. We will have
11 a break.
12 A. Okay, thank you.
13 Examination by MR MACAULAY
14 MR MACAULAY: Good morning, Dr Johnston.
15 A. Good morning.
16 Q. I think you are Fiona Johnston; is that right?
17 A. That's correct, yes.
18 Q. Perhaps you could tell the Inquiry what position you
19 hold at present?
20 A. I'm a consultant physician in geriatric medicine at
21 Inverclyde Royal Infirmary.
22 Q. For how long have you held that post?
23 A. Since May 2009.
24 Q. I think, if I can look at your CV -- we don't have it on
25 the database, but I can put it on the screen -- if we
1

1 turn to the first page -- that's the frontispiece of
2 the document -- can we note that you obtained your
3 medical degree at the University of Glasgow in 1980; is
4 that correct?
5 A. That's correct.
6 Q. You became a Member of the Royal College of Physicians
7 in 1983; is that right?
8 A. That's right.
9 Q. And I think a Fellow of the Royal College of Physicians
10 in 1993?
11 A. That's correct.
12 Q. If we just follow through your track record, if you turn
13 to page 10 of the document -- again, we will have that
14 on the screen, page 10 -- after graduation, do you set
15 out here some information in relation to your
16 pre-registration and post-registration experience?
17 A. That's correct.
18 Q. Can we note in particular that, from 1982, you were
19 attached to the Southern General Hospital; is that
20 right?
21 A. Yes, that's correct.
22 Q. Then if we turn on to page 11, can we see that you were
23 a senior registrar in geriatric and general medicine
24 from 1984 to 1989 at Stobhill General Hospital?
25 A. That's correct.
2

1 Q. Perhaps moving on a bit, page 7, here I think we see
2 that you held the post of consultant physician with
3 special interest in elderly medicine -- I'm sorry,
4 I think page 7 is a consultant physician and
5 geriatrician at Stobhill from 1989 to 2002.
6 A. Yes.
7 Q. I think that takes us up to when you first went to work
8 at the Vale of Leven. If we turn to page 4 of the CV,
9 can we see here that you are a consultant physician with
10 special interest in elderly medicine at the
11 Vale of Leven from May 2002 to 2009?
12 A. Yes.
13 Q. I think what you have done in the CV is you have set out
14 some detail as to the nature of the hospital and also,
15 indeed, your own duties at the hospital?
16 A. Yes.
17 Q. I will return to that shortly. I think that takes us
18 up, then, to page 2 of the document, and I think here
19 you set out some details of your present post of
20 consultant physician in geriatric medicine at
21 Inverclyde?
22 A. That's correct.
23 Q. You have been there, I think, as you have told us,
24 since May 2009; is that right?
25 A. Yes.
3

1 Q. So far as the remainder of your CV is concerned, on
2 page 9, do you give us some information about a number
3 of committees that you have been a member of or been
4 involved in over the years?
5 A. That's correct.
6 Q. I think you also tell us -- and I think this is on
7 page 13, you give us some information about your
8 research interests; is that right?
9 A. That's correct.
10 Q. I think also some information about your teaching
11 commitments?
12 A. Yes.
13 Q. Finally, at pages 14 and 15, do you set out a list of
14 publications that you have participated in?
15 A. Yes, that's correct.
16 Q. If we focus on your position in the Vale of Leven
17 Hospital, Dr Johnston, because, as I think you are
18 aware, that is what the Inquiry is interested in, and,
19 in particular, the period from 1 January 2007 through to
20 about June 2008?
21 A. Yes.
22 Q. At that time, you were employed as a consultant; is that
23 correct?
24 A. Yes. Maybe just a bit of clarification: I was appointed
25 as a consultant physician with all the duties and
4

1 responsibilities of medical receiving and for continuous
2 care of my medical patients and, in addition, I was
3 a consultant geriatrician at the Vale of Leven; the
4 difference being that in most hospitals in which
5 geriatricians have some involvement in medical
6 receiving, that involvement stops at 24 hours and the
7 patients are handed on to the next medical unit. So
8 this is, I think, a unique position in Scotland at the
9 time.
10 Q. Just so I can understand the point you are making, you
11 were appointed as a consultant physician, but in
12 addition, you were also a consultant geriatrician?
13 A. Yes. It was a different emphasis and the job was
14 primarily a consultant physician's post, and the duties,
15 therefore, were twofold, not ending at the point of
16 medical receiving handover, but continuing for all the
17 time that that patient was in hospital in the medical
18 wards.
19 Q. Can you give me, then, a general understanding as to
20 your duties, and if we begin by --
21 DAME ELISH: My Lord, I hesitate to interrupt at this stage,
22 but before my learned friend moves on, as a point of
23 clarification, the assumption was that Dr Johnston was
24 appointed throughout this period. I wonder if you could
25 clarify whether or not she was actually present at the
5

1 hospital for that period?
2 LORD MACLEAN: This is 2002 to 2009?
3 DAME ELISH: Through the focus period, my Lord.
4 LORD MACLEAN: 2009, yes.
5 MR MACAULAY: Perhaps I can clarify that with you, looking
6 at the period we are concerned with, which
7 is January 2007 through to June 2008, what was the
8 position in relation to your attendance at the hospital?
9 A. Right. Well, I had a period of sickness absence from
10 the middle of June 2007 until the beginning of October,
11 and then I had a phased return to work, which means you
12 gradually increase your duties over a period of six or
13 eight weeks or so. So I was absent.
14 Q. Who would cover for you, then, in your absence?
15 A. Well, as I was absent, I don't think I can directly say,
16 but I imagine there would be locum cover.
17 Q. Who would organise that?
18 A. That would be through the service manager or the general
19 manager to obtain locum cover.
20 Q. I think I was moving on to ask you about your duties at
21 the hospital. If we just focus on the wards, first of
22 all, can you help me with that? Were you concerned with
23 a particular ward or wards?
24 A. Well, I had perhaps better put it into some context in
25 time. When I first went to the Vale of Leven in 2002,
6

1 I was the only substantive consultant and there were
2 various locums. I started off looking after ward 14,
3 along with the hospital practitioner in ward 14, who was
4 a Dr Stevenson. After a period of a couple of years,
5 I switched to ward 15 to work with the hospital
6 practitioner there, because I wanted to spread myself
7 across the patch, so to speak, because we didn't have
8 full-time, permanent staff.
9 My duties would therefore consist of my clinical
10 duties for geriatric medicine, which would be weekly
11 ward rounds in either of these wards, a weekly MDT,
12 I would have a day hospital MDT, I would have two
13 outpatient clinics, general clinic, movement disorders,
14 and I, in addition to that, would perform the full
15 consultant physician duties, which were medical
16 receiving and continuous responsibility for those
17 patients in all the wards of the hospital -- that's 3,
18 4, 6 and MAU.
19 Q. I see.
20 A. So I carried out twice- or thrice-weekly ward rounds in
21 the medical ward in addition to all my duties in the
22 rehabilitation wards, which was at times quite stressful
23 and quite difficult to spread myself suitably across
24 these two systems.
25 So, effectively, the geriatricians, the two posts
7

1 there, provided a third of the medical cover for the
2 Vale of Leven; the other four positions providing the
3 remaining two-thirds.
4 Q. That's quite a lengthy answer, and I think you began at
5 the beginning, as it were, when you were the only
6 substantive consultant; is that right?
7 A. Yes.
8 Q. What about when we come to January 2007? What was the
9 staffing position at that time?
10 A. Well, there's still no -- from the consultant point of
11 view, there were long-standing locums in cardiology, and
12 also in stroke medicine, which was the second
13 geriatrician post. The second geriatrician post came
14 into being in 2000, I think, but the post was never
15 filled during the time that I was there.
16 Q. But we heard last week from Dr Akhter, and he was
17 a locum consultant --
18 A. Yes.
19 Q. --and he was a geriatrician; is that right?
20 A. That's right.
21 Q. He was present in 2007?
22 A. He was present, but he was not accredited in general or
23 geriatric medicine. He was acting up as a staff -- or
24 associate specialist, I think it was, at the time.
25 DAME ELISH: My Lord, I wonder, again, for clarification,
8

1 before my learned friend moves on, Dr Johnston has
2 indicated that she was the first consultant of that
3 nature. I wonder if there could be clarification as to
4 what medical staff ran the hospital prior to the
5 consultant post being created in 2002?
6 MR MACAULAY: Can you help us with that?
7 A. Well, this is something that the people who follow me
8 may be better able to tell you. Essentially, in terms
9 of the -- if we are talking about the rehabilitation
10 side of the hospital, it was run by GP hospital
11 practitioners on a sessional basis, part time.
12 The second of the hospital practitioners -- that was
13 Dr Stevenson -- retired in April 2007 and his post
14 wasn't replaced. There was a consultant prior to me who
15 practised geriatric medicine on a single-handed basis,
16 but on a much slower turnover system, and he didn't do
17 general medicine.
18 So the difference was, when I went there, we
19 reconfigured the service and made it quicker, but our
20 staffing didn't follow that.
21 Q. Coming, then, to 2007, and perhaps I could put this
22 document before you and see if this can help us to
23 clarify the position. If we look at GGC21720001, this
24 we understand to be a document given to the junior
25 doctors when they started to work in the Vale of Leven
9

1 Hospital to provide them with some insight into the
2 nature of the hospital, and you can see on this page,
3 for example, that it is suggested that the hospital had
4 approximately 180 beds onsite, and we see reference to
5 the various areas covered -- general medicine, coronary
6 care, and so on; do you see that?
7 A. I'm not so sure about the numbers of beds, though. This
8 may be an old document. Acute surgical admissions were
9 transferred to the RAH early in the time that I was
10 there, and the ITU bed was withdrawn also in 2006. So
11 the bed numbers that had been quoted earlier were
12 probably more relevant.
13 Q. Okay. If we turn to page 3 of the document, we're given
14 some information about the number of consultants in the
15 hospital; do you see that? Does that represent the
16 position as at 2007?
17 A. Dr Akhter was a locum. It doesn't say that. But that
18 would be correct for that time, with Dr Forbat in
19 cardiology.
20 Q. So we have Dr Carmichael, Dr McCruden, Dr Al-Shamma,
21 yourself, Dr Forbat and Dr Akhter; is that right?
22 A. Yes.
23 Q. You have taken us to the point where you were the first
24 substantive consultant. What about Drs Carmichael and
25 McCruden? Did they come after you?
10

1 A. Oh, no. You will see them later this week.
2 Q. They were there before you went there; is that right?
3 A. Yes. Dr Carmichael was the first, I think.
4 Q. I'm sorry?
5 A. Dr Carmichael was the first consultant.
6 Q. If you turn to page 4 of the document --
7 MR PEOPLES: My Lord, I'm sorry, I am perhaps not following
8 this as clearly as I might. Dr Carmichael was the first
9 consultant in what?
10 A. Consultant physician. Just look at them all as
11 physicians and within their own specialty -- sorry,
12 I maybe shouldn't have jumped in there.
13 LORD MACLEAN: I think what you're saying is he was the
14 principal one and, I think, the one who was there the
15 longest of all those mentioned?
16 A. That's correct.
17 LORD MACLEAN: What was his field?
18 A. Pardon?
19 LORD MACLEAN: Remind me what his field was.
20 A. Gastroenterology.
21 MR PEOPLES: I just wondered whether he had any involvement
22 in geriatric medicine, and I was just trying to tie this
23 in with the appointment later of someone who was
24 responsible for geriatric medicine.
25 LORD MACLEAN: She hasn't said that.
11

1 He wasn't, was he?
2 A. Shall I go through all the consultants and tell you what
3 their specialties are?
4 LORD MACLEAN: Why not.
5 A. Dr McCruden was diabetes and endocrine; Dr Al-Shamma was
6 respiratory; Dr Forbat was cardiology; I was general
7 medicine, geriatrics and movement disorders; Dr Akhter
8 was general medicine, geriatrics and stroke.
9 LORD MACLEAN: Thank you.
10 MR MACAULAY: If we turn to page 4, then, of the document,
11 this is giving information about the rehabilitation and
12 assessment directorate. This document suggests that the
13 consultants were yourself and Dr Akhter, who is a locum.
14 A. That's right. What is missing from the document are
15 continuing care beds. There was a large reduction in
16 continuing care beds when I first started under the
17 balance of care, and two offsite hospitals closed and
18 the remaining continuing care beds in ward 15 were
19 transferred into rehab beds. We actually had 32 beds in
20 each of these wards when I first started, but we
21 reconfigured them to make it a smaller unit with more
22 physio and OT ratios for staff to make it more effective
23 for rehab.
24 Q. I think you did mention a moment ago what your
25 commitments were to ward rounds. Can I just understand
12

1 that? If we take the different departments -- and here
2 we are looking at the rehabilitation directorate -- what
3 was your ward round commitment?
4 A. My formal ward round was weekly, and we had
5 a multidisciplinary team meeting weekly that Dr Herd and
6 I both attended. Dr Herd, who was the hospital
7 practitioner in ward 15, had five sessions but he also
8 did his own ward round on a Thursday, on the day that
9 I was usually medical receiving. So that's how it
10 worked.
11 In between times, I would go back into the ward to
12 see if anybody was unwell, but I didn't have another
13 formal ward round until the following Monday. That is
14 normal practice for rehabilitation ward.
15 But I would say to you that, as our activity
16 increased with closer links with general medicine, our
17 activity increased by 40 per cent in the first year.
18 The amounts of patients that we were seeing closer to
19 the point of entry to the hospital meant that I wasn't
20 able to provide enough in ward round terms as I would
21 have liked for that category of patient.
22 If I just give you an example of length of stay, the
23 length of stay in rehab fell to 22 days after 18 months
24 when I first started, and in comparison across
25 Inverclyde, Paisley and the Vale in 2008, which would be
13

1 relevant to this time period, the length of stay in the
2 RAH was 32 days and the length of stay in Inverclyde was
3 36.
4 So it reflects that there's more than slow-stream
5 rehab going on in these wards.
6 Q. What does "slow-stream rehab" mean?
7 A. First of all, it means it takes longer, the patients are
8 much more stable and many of them will be waiting to
9 move on to nursing homes. The more active the unit
10 gets, when you bring patients, say, for example, who
11 have had pneumonia, over to a rehabilitation ward after
12 a week or less than that, there's a potential that these
13 patients won't be well enough to take part in the rehab,
14 and so we occasionally saw patients being sent across
15 probably too soon, I would say.
16 Q. Might it be said, then, that there were patients in the
17 rehab wards who might have been better suited in acute
18 medical wards?
19 A. Well, I saw it from both sides, which gave me a sort of
20 added insight, really, because I was also an acute
21 physician, and my -- the way I worked it was we didn't
22 have a formal letter referral system, but the
23 stipulation was that patients had to be medically stable
24 and to have rehab goals, and that was identified by the
25 physio and the OT in the medical ward. Occasionally --
14

1 most of the time they got it right, but occasionally
2 patients transferred who shouldn't have done, in my
3 view.
4 Q. Just looking to the staffing of the wards, then, from
5 the medical perspective, I just want to understand what
6 other levels of doctor were available, so if we take the
7 rehab wards, that's 14, 15 and F; is that right?
8 A. Yes.
9 Q. Can you just help me with that?
10 A. I will make it slightly more complicated, in that, when
11 I first went there, ward F, which was the stroke ward,
12 belonged to the medicine directorate, and so they had
13 a medical FY1 in that ward. Other than --
14 Q. If I can just stop you there, would it be possible to
15 try to focus on the period we are interested in, which
16 is January 2007 through to June 2008?
17 A. That would be relevant for ward F, that there was
18 a medical junior there, but very junior.
19 Q. So in ward F, you had an FY1?
20 A. An FY1 who was supplied by medicine but used by
21 Dr Akhter in ward F. In wards 14 and 15, there had been
22 a traditional input over many years by local GPs who
23 provided sessional cover, five sessions a week each, so
24 part time, in other words. That suited a rehabilitation
25 unit that was quietly turning over with not much contact
15

1 with acute medicine, but both of these practitioners
2 found a change when I went there and started more
3 closely linking with general medicine, in that more
4 medically complex patients would be coming across and
5 also the medical inputs when the GPs weren't there was
6 either me, if I wasn't in my clinic, or a medical junior
7 would be asked to come across.
8 Now, there was some input from medical SHO level
9 when I first started, but that had gone by the time of
10 this period. It really was an FY1 would be called if
11 there was a problem.
12 So I think what I'm saying is that, beyond the
13 sessions, the ward medical cover was borrowed from
14 medicine at a very junior level and was not a ward-based
15 SHO who was there all the time. I reflect --
16 Q. Are you talking there about wards 14 and 15?
17 A. Yes, I'm not talking about the other wards.
18 Q. What about Dr Khan? Did he have any --
19 A. Right. To explain Dr Khan, you have to go back
20 to April 2007, when Dr Stevenson, who was the hospital
21 practitioner for ward 14, retired. Now, his post was
22 not replaced and there was no attempt made to replace
23 his post, as far as I could see.
24 So the move there was to kind of knit things
25 together with locum SHOs, and that's where Dr Khan came
16

1 in for that period of time, and others after him. There
2 was never a substantive appointment for that ward.
3 Q. Just so I understand, then, wards 14 and 15 were covered
4 part time by local GPs; is that right so far?
5 A. Yes.
6 Q. And if required, an FY1 would be borrowed from another
7 source?
8 A. Yes. Also, out of hours, I should say, just to put it
9 in its context, out of hours, after 5.00 and at
10 weekends, the two medical juniors who were on for the
11 hospital could be called to wards 14 and 15.
12 Q. What about the other wards, the medical wards? Are we
13 looking at wards 3 and 6?
14 A. 3/4 was CCU/HDU and 6. There were some medical juniors
15 and I cannot recollect exactly how many there were.
16 There were middle grade staff, but not very many, and
17 FY1s. So they had to cover 3, 4, 6 and MAU.
18 In a larger hospital, you would have different
19 groups of doctors looking after the general wards, and
20 some doctors doing medical receiving and some doctors
21 doing nights, and so on. So if you have a small group
22 of doctors and you put one doctor on holiday, one doing
23 nights, then it doesn't leave very many to actually run
24 the shop.
25 Q. I think we have heard this from other sources, but you
17

1 did not have any doctors at registrar level then in the
2 Vale of Leven?
3 A. No, we did not. There was a staff grade in cardiology,
4 I remember, but no trainee registrars. So we had very
5 junior doctors really acting out of their skins, I would
6 say, who were excellent in many cases, covering beyond
7 their means.
8 Q. As a consultant, how did you find working in the
9 Vale of Leven at that time with no middle-range doctors?
10 A. I found it extremely difficult. I'd been a consultant
11 in three different places. When I was a consultant in
12 a hospital in Glasgow, I had the full team. We had ITU,
13 my own registrar, and ward rounds were well informed.
14 When I was a consultant in the Vale, carrying out all
15 these duties across the patch, when I was on my medical
16 receiving day, for example, I would often have to go to
17 MAU to see patients with the juniors because they were
18 very junior. My call-out rate at evenings and weekends
19 was very high and I sometimes had to return to the
20 hospital to see patients who required transfer to ITU.
21 So it was much more hands-on than I'd experienced
22 anywhere else.
23 Q. Do I take it, though, that your normal commitment would
24 be from a Monday to a Friday?
25 A. Yes. Our oncall commitment was a one in six with
18

1 prospective cover for study leave and holidays,
2 et cetera, so it works out about one in four and a half,
3 actually, there, because you have to do all your 52
4 weeks' duties in the 42 weeks.
5 Q. Would you be on call at the weekends?
6 A. Oh, yes. Three-day weekends, Friday, Saturday, Sunday.
7 Occasionally, if I did my Thursday as well, it would be
8 a four-day weekend.
9 Q. Can I then just look at the area of antibiotics and, in
10 particular, the prescription of antibiotics?
11 A. Yes.
12 Q. In the period we are concerned with, what guidelines did
13 you use to assist you in the prescribing of antibiotics?
14 A. Right. I think there were a number of guidelines
15 floating around because the two health boards had joined
16 and there were some prior formularies from Argyll and
17 Clyde 2006 and then Greater Glasgow in 2007.
18 The antibiotic prescribing guideline of October 2007
19 was the one I used. It was widely displayed in the
20 hospital and I had a copy in my office.
21 Q. If I can just see if I can identify what you are talking
22 about, if we could look at GGC22180001, I think this is
23 the 2007 empirical antibiotic therapy guideline. Is
24 this what you had in mind a moment ago?
25 A. Yes, but you can't actually identify this because, of
19

1 course, the tiny print at the bottom right has not
2 copied. It is -- yes, that is 2007. But below that
3 there was -- it is in smudge.
4 Q. I'm sorry?
5 A. There is a smudge at the bottom which tells you when it
6 is about to be reviewed. It's below the bottom line
7 that you see that says "duty microbiologist" on the
8 right-hand side.
9 Q. Oh, yes.
10 A. You can't see it. You can't read it, but it
11 is October 2007 to be reviewed December 2009.
12 Q. Was it, in fact, reviewed? Was there a review following
13 upon June 2008?
14 A. Yes.
15 Q. But so far as the period we are interested in is
16 concerned, this would be the document that you would
17 use?
18 A. Yes.
19 Q. As you have pointed out, there are other documents. If
20 we look, for example, at GGC21790001, this, I think, is
21 the Argyll and Clyde drug formulary for 2006. There has
22 been some evidence that this document, or something
23 similar to it, would also have been in use. Did you use
24 this particular formulary yourself?
25 A. I honestly couldn't identify that as a document. It's
20

1 just an index page. It doesn't tell me. The 2006 one
2 was around, and there is an interesting part at the
3 back, which is the primary care guideline, what the GPs
4 were prescribing at that time, and it wasn't there in
5 the 2007 document. It is appendix 5(i), I think, at the
6 back of this.
7 Q. Are you saying that the GPs did not use this document?
8 A. No, this is the hospital formulary, but this 2006 one
9 had an appendix at the back, which was the primary care
10 guideline, which differed from the hospital formulary.
11 Q. If we look at the appendix, then, if we turn to
12 page 156, for example, this is part of appendix 5, where
13 there are lists of conditions and the recommended
14 treatment?
15 A. I think these are hospital ones, actually. You need to
16 go further back.
17 Q. When you say "further back", do you mean further into
18 the document?
19 A. Yes.
20 Q. Appendix 5B? Is that of any assistance?
21 A. It is either 5A or 5(i).
22 Q. Is 5B helpful? That is page 204?
23 A. Let's see. No.
24 Q. Sorry, page 153.
25 A. Yes, this is the GP or primary care guideline for acute
21

1 community-acquired pneumonia.
2 Q. If you turn to page 144?
3 A. If you go further than that, to COPD --
4 Q. Well, if we turn to page 145, then.
5 A. Try that:
6 "Acute exacerbation of COPD (local guidance), first
7 line co-amoxiclav 625mg tid for five to ten days and
8 cefaclor" -- now, that's second line for COPD on the
9 hospital formulary and my remembrance at the time was
10 that a lot of patients were coming into hospital having
11 already had co-amoxiclav.
12 Q. I'm just trying to identify the function of this
13 document. Are you saying that appendix 5, parts of
14 which we have looked at, would be used by the GPs --
15 A. Yes.
16 Q. -- to guide them in prescribing --
17 A. Yes.
18 Q. -- in the hospital?
19 A. Not in the hospital; in the community.
20 Q. In the community. You used the other document, the
21 empirical antibiotic therapy document --
22 A. Yes.
23 Q. -- in the hospital?
24 A. Yes.
25 Q. Can you tell us in relation to the junior doctors what
22

1 they would be using?
2 A. They would use the hospital guideline, the EAT
3 guideline.
4 Q. The one that you used?
5 A. Yes.
6 Q. What about when the GPs are working in the hospital? Do
7 you know what they used?
8 A. I don't know for sure, but I'm fairly confident that
9 they were prescribing more to their own guideline, but
10 you could maybe ask one of the GPs later. Particularly
11 in relation to urinary sepsis, there was certainly a bit
12 of ciprofloxacin coming in.
13 Q. If you look at GGC18270001.
14 A. This is the following year, Greater Glasgow and Clyde,
15 and this one doesn't have a primary care guideline.
16 Q. Was this available in the Vale of Leven?
17 A. Yes, this was available, but due to its large size, it
18 sat in my office and I didn't carry it around with me.
19 Q. I suppose the advantage of the document you made
20 reference to, you have it all on one page?
21 A. Mmm.
22 Q. Is that right?
23 A. That's correct.
24 LORD MACLEAN: Could I ask you, Dr Johnston, in light of
25 what you have just been saying, why is there
23

1 a difference in what can be or should be prescribed
2 between primary care and hospital care?
3 A. I don't think I'm the person to answer that, really. It
4 would be for the pharmacy to --
5 LORD MACLEAN: Have a go. What do you think?
6 A. I think the systems grow up separate. There is a lack
7 of integration between primary and secondary care, so
8 they create their own systems. I think that is broadly
9 what goes on.
10 I'm not sure -- I'm sure the primary care guideline
11 is much toned down than it was then, but I think it's
12 cultural that there were separate systems.
13 LORD MACLEAN: As a layman, I find that quite difficult to
14 grasp, because you'd think they'd be doing the same
15 thing, or trying to do the same thing.
16 A. You would, yes.
17 LORD MACLEAN: Anyway, thank you.
18 MR MACAULAY: I think you have indicated, Dr Johnston, that
19 you think that the junior doctors would use the same
20 document as you, yourself, used; is that right?
21 A. Yes.
22 Q. In relation to the other consultants, would they really
23 be left to their own devices? They would use whatever
24 they wanted to use?
25 A. Well, I imagine they used the same document.
24

1 Q. As you did?
2 A. Yes. But it has to be said, in 2007 there was a lot of
3 broad-spectrum antibiotics on the menu that were removed
4 in 2008. So if something is on the menu, it will be
5 chosen.
6 Q. In relation to the role of junior doctors, would
7 a junior doctor require to consult the consultant before
8 making a prescription of antibiotics, or not?
9 A. Not unless it was something unusual or unusually severe.
10 They would normally make the clinical assessment -- it
11 would be an FY2 or above who would be allowed to
12 prescribe, and they would go by the clinical assessment,
13 appropriate bloods, urine, blood culture test, and
14 treat.
15 Q. Looking at the period we are concerned with, what was
16 your knowledge in that period in relation to the
17 antibiotics that were known to precipitate C. difficile?
18 A. Well, I'll answer the question and give you a reference.
19 Yes, I had a knowledge that broad-spectrum antibiotics
20 could cause C. difficile, but then we hadn't seen much
21 evidence of C. difficile for a number of years. The
22 other thing is, there is no reference in either of these
23 formularies to the risk of C. difficile with
24 broad-spectrum antibiotics. The formularies only refer
25 to the risk of resistant infections. So it wasn't being
25

1 promulgated.
2 Q. I take it from that answer that you knew --
3 A. Yes.
4 Q. -- that broad-spectrum antibiotics could precipitate
5 C. difficile?
6 A. Yes.
7 Q. You said in that answer, I think, that you hadn't seen
8 much C. diff for a number of years; is that right?
9 A. Mmm-hmm. It was an occasional event. Yes, that's true.
10 Q. Just running on a bit, did you consider, in 2007 and
11 into 2008, that there was more C. diff in the hospital
12 than there had been in previous years?
13 A. I would preface my feelings about it at the time was,
14 where I was, on ward 15, the norovirus had shut the ward
15 three times, so there were lots of patients with
16 diarrhoea-type symptoms, and then we had one or two
17 cases, I think, in the January which were presented at
18 the hospital meeting, and we couldn't see any particular
19 relationship to an infectious mode of transit in these
20 two people. Both had broad-spectrum antibiotics in
21 another hospital. But I think, generally, the norovirus
22 was quite confusing. It was like the Trojan horse that
23 brought in -- there were more samplings done, so you
24 would pick up more carriers, anyway, and that's how it
25 came to pass.
26

1 As for the medical wards, I had a sixth of
2 the patients, and my knowledge of cases was limited to
3 the numbers of patients I had.
4 Q. So in coming to my question, did you recognise that
5 there was an increase in C. diff patients in that period
6 than in previous years?
7 A. Obviously, there must have been an increase, if they'd
8 gone from zero.
9 Q. Did you recognise that?
10 A. But I wouldn't have recognised that one or two patients
11 in a ward full of diarrhoea represented an outbreak of
12 a specific organism. I couldn't have.
13 DAME ELISH: My Lord, I wonder if my learned friend could
14 clarify with this witness the period over which the
15 norovirus resulted in the closure of the wards to get an
16 indication of the timescale of that?
17 MR MACAULAY: I will look at norovirus in a moment, but can
18 I just get an answer to my question, if I can,
19 Dr Johnston, and that is whether you recognised, in the
20 period 2007 through to June 2008, that there was an
21 increase in C. diff patients?
22 A. An increase from zero to two, yes, another two.
23 Q. The zero to two, are you talking there about ward 15?
24 A. Yes.
25 Q. What about the rest of the hospital, because you've
27

1 indicated to us that you had commitments to other parts
2 of the hospital. Did you --
3 A. I don't think, at January, I had patients in the other
4 part of the hospital who had C. diff.
5 Q. Are you talking there about January -- what year is
6 that?
7 A. 2008.
8 Q. I'm looking at the whole period, from January 2007
9 through to June 2008. Did you recognise in that period
10 that there was an increase throughout the hospital of
11 C. diff patients?
12 A. I think if you use the word "increase", yes. If you use
13 the word "outbreak", it depends what the difference in
14 your definition of outbreak is. I would expect to be
15 informed, if that were the case, by infection control.
16 LORD MACLEAN: He didn't use the word "outbreak". He said
17 "increase".
18 A. I noted that.
19 LORD MACLEAN: So what is the answer to the question
20 "increase"?
21 A. Yes.
22 LORD MACLEAN: It is "increase", because you have been
23 talking about nought to two at the beginning of -- early
24 2007. Actually, the question was also not confined to
25 your own ward but throughout the hospital; is that
28

1 right, Mr MacAulay?
2 MR MACAULAY: Yes, that was the second part of the question,
3 yes.
4 A. Well, I didn't have any knowledge of anyone else's
5 patients. I couldn't have, unless I'd seen them at the
6 weekend.
7 MR KINROY: My Lord, I could be terribly wrong, but I think
8 my learned friend would want to get it right. I may be
9 wrong. I think the reference of increase from nought to
10 two was early 2008, not early 2007.
11 LORD MACLEAN: That may be my fault, actually.
12 Which is it? I thought you said it went from nought
13 to two in 2007?
14 A. No, I wasn't referring to 2007.
15 LORD MACLEAN: What were you referring to?
16 A. It must have been 2008.
17 MR MACAULAY: You made some mention of cases being presented
18 at a meeting; is that correct?
19 A. Yes. One of the juniors presented the two cases that
20 I knew of in January, I think it was, to the Thursday
21 lunchtime meeting.
22 Q. The Thursday lunchtime meeting would be attended by
23 whom, then?
24 A. Quite a lot of the medical staff and various other
25 specialties. No bacteriology, because they weren't
29

1 there. Yeah. I think it was probably -- I can't -- no,
2 it wasn't an audit meeting. It was just two cases.
3 Q. Just to focus on the Thursday meeting, would your
4 colleagues, your consultant colleagues, be in attendance
5 at the Thursday meeting?
6 A. Mostly, yes. I, myself, had some problems with
7 attending it because I was usually on call, so I missed
8 a few, but yeah.
9 Q. Are you saying that throughout this whole period that we
10 are focusing on, from January 2007 to June 2008, only on
11 one occasion were there two cases mentioned at such
12 a meeting?
13 A. Yes.
14 Q. The question of norovirus has been raised.
15 A. Yes.
16 Q. When was there a problem with the norovirus?
17 A. I think you would need to check back with Anne Madden's
18 statement, which I haven't relooked at in the last
19 24 hours. The ward I think was closed three times
20 between December and January. The last time it shut --
21 it reopened on January 25th. That was when the ward
22 became open again.
23 Q. This is ward 15, is it?
24 A. Yes. But there were three closures, as far as I recall.
25 Q. So far as the junior doctors that you were dealing with
30

1 were concerned, Dr Johnston, were you satisfied that
2 they were aware that a patient could present with
3 asymptomatic bacteriuria?
4 A. If a patient has no symptoms, they tend not to present
5 to hospital. Asymptomatic bacteriuria can only be
6 described once you have got a result from a patient who
7 presents usually with a symptom. I phrase it that way.
8 All of the information or most of the information of
9 asymptomatic bacteriuria is retrospective. So a patient
10 without symptoms would generally not get a test unless
11 you were looking for a sepsis screen, in which case you
12 would test their urine. Junior doctors would be aware
13 that it existed, but they would -- I think it is
14 unlikely they'd see many cases in hospital unless the
15 patient was catheterised.
16 Q. Do I take it from that that they would be aware, then,
17 with asymptomatic bacteriuria, that you would not
18 prescribe antibiotics?
19 A. Yes. I'm always cautious dealing with the elderly with
20 very non-specific presentations, such as confusion, for
21 example, which may relate to UTI, and also the people
22 that send off the urine samples are usually the nursing
23 staff, who might write "?UTI" and that may be described
24 as asymptomatic, but it just depends how good the
25 information is.
31

1 Q. Would you, as the consultant, review the antibiotic
2 treatment that had been prescribed by the junior doctor?
3 A. If we're talking about the junior doctor, we're talking
4 about the medical wards and, yes, I would on my twice or
5 thrice visits to the medical wards, but antibiotic
6 prescribing in ward 15 would be not so often because
7 I was less often doing ward rounds there.
8 Q. That was a weekly ward round, I think?
9 A. A weekly ward round and seen again on an as-required
10 basis.
11 Q. If we are just focusing in particular on C. difficile,
12 would you agree that C. difficile is an important
13 clinical diagnosis in its own right?
14 A. Yes.
15 Q. Was that your approach to C. difficile in the period
16 that we are concerned with?
17 A. I think our experience of C. difficile led us -- not to
18 have a -- you know, not that our approach was poor, but
19 we simply hadn't seen what C. difficile can do. It's an
20 important diagnosis. But until we went through that
21 experience at the Vale, we were not aware of
22 the potential.
23 Q. Focusing on the relevant period, then, what is your
24 position in relation to seeing C. difficile as an
25 important clinical diagnosis in its own right?
32

1 A. It is.
2 Q. Did you see it as such in --
3 A. Yes.
4 Q. -- 2007/2008?
5 A. Yes.
6 Q. What were the lessons learned, then, from the experience
7 in 2007/2008?
8 A. Well, let me reflect back. My current experience of
9 C. difficile in my new job and what I've learnt and
10 taken to that, in my new post, there have been some
11 cases of C. difficile, but we are not seeing the same
12 rapid progression that we saw in the Vale. Equally sick
13 patients with multiple comorbidities, very indolent,
14 some with a weight loss, but we're not seeing that
15 florid presentation that happened in the Vale, so my
16 experience is that we were actually looking at
17 a different disease. C. difficile for sure, but a much
18 more virulent form of the disease.
19 Q. I was picking you up on what the lessons were that you
20 say you learnt.
21 A. Well, antibiotic -- again, what I do now in my practice,
22 I am responsible for training junior doctors at
23 Inverclyde, and I give, every four months, a lecture
24 from the consultant microbiologist and they also get
25 infection control speaking to them. So every section of
33

1 new doctors gets approached in this way. The occasional
2 lunchtime lecture is not a substitute for an effective
3 training programme.
4 Q. Did you learn lessons from the experience you had in the
5 Vale of Leven in 2007?
6 A. Oh, yes. Antibiotic prescribing has been winnowed down,
7 but I would have to say that colleagues who have not had
8 the experience of the Vale of Leven are perhaps more
9 relaxed about antibiotic prescribing than they should
10 be. I don't think it is a general statement, but it is
11 an occasional statement. So I think the experience
12 changed us considerably.
13 Q. What was your experience in the Vale of Leven?
14 A. How do you mean? I'm not quite sure what you're saying.
15 Q. You're saying the experience at the Vale of Leven
16 changed you considerably. I'm asking you what was it?
17 A. The experience -- what happened at the Vale of Leven was
18 there was a lot of very frail patients with multiple
19 comorbidities who were given broad-spectrum antibiotics,
20 and the question of whether there was some
21 cross-infection wasn't resolved until after the event.
22 So that was my experience of it.
23 Q. So that is really an after-the-event experience?
24 A. It was after-the-event experience for the health board
25 as well.
34

1 Q. I'm sorry?
2 A. For the health board too.
3 Q. At the time that patients were in the Vale of Leven, and
4 clearly a number died over the period we are interested
5 in, from --
6 A. Can I just go back to the antibiotic prescribing, just
7 to answer your question? Most of the antibiotic
8 prescribing was carried out in the acute wards, and then
9 patients moved across to rehab and got their C. diff.
10 Most of the antibiotic prescribing had already happened.
11 One of the cases I had in that group who had recurrent
12 C. diff wasn't given a single antibiotic over ten
13 months, other than his C. diff antibiotics, so my
14 experience had certainly influenced that.
15 Q. I'm seeking to focus on what experience, if any, you had
16 of C. diff over the relevant period, from January 2007
17 to June 2008. I think you have mentioned the two cases
18 that we have discussed. Did you consider that you had
19 any further experience of C. diff and patients dying and
20 C. diff being included in --
21 A. I'm not saying that there were only two cases, there
22 were more cases, but I never saw them in numbers at the
23 same time that would consider me to think that there was
24 a particular problem.
25 Q. Did there come a point when you considered there was
35

1 a problem?
2 A. There came a point, I think, with a clearly false
3 negative sample in March, and bacteriology were involved
4 in that. We didn't have an awareness at the time that
5 the testing mechanism was -- had problems and that there
6 were false negatives and that stools could deteriorate,
7 and so on. None of these samples were issued with
8 a caveat telling us that there was a significant false
9 negative rate. We have heard in the Inquiry already
10 that we are looking at 10 to 40 per cent. We know that
11 now. We didn't know it then.
12 Q. But I think we know now also there were quite a number
13 of patients who did contract C. diff?
14 A. Yes.
15 Q. Particularly between December -- focusing on the period
16 from December 2007 to June 2008. I'm just trying to
17 understand whether during that -- if we focus on that
18 period, whether you considered that you had patients who
19 had C. diff and whether that registered with you?
20 A. Yes. It registered with me, but the -- where the
21 patients were and where they'd been, more particularly,
22 and what medication they'd already had, seemed to me to
23 be the predictors of the outcome.
24 Q. What do you mean by that?
25 A. As I just said, patients had been treated with
36

1 broad-spectrum antibiotics already, sometimes many
2 times, and they're moved to another ward, either with or
3 about to get C. diff. It's very difficult to pin that
4 down to any conclusion.
5 LORD MACLEAN: Could I ask you, going back a bit -- I'm
6 sorry to backtrack -- what you meant, and I think you
7 said this, that cross-infection was an after-the-event
8 experience?
9 A. Yes. I think what's come through in the Inquiry is --
10 that was news to me, was the length of time that could
11 elapse between an indexed case and another one, and they
12 could still be related as cross-infection. I had looked
13 at the two early cases and I saw there was quite a long
14 time between them and they weren't in any contact with
15 one another in the ward. So that, at the time, was
16 a lack of my knowledge, I would think.
17 MR MACAULAY: I have gone down this route by asking you
18 whether you considered C. diff to be an important
19 clinical diagnosis, and I think you said it was. In
20 this period, were you aware that C. difficile was
21 a condition that could lead to death?
22 A. Yes, but within the context of -- frail elderly
23 admissions to hospital have a high mortality rate, in
24 any case, and you are looking at the order of
25 10 per cent in 30 days. So within the context of that,
37

1 yes, but it would perhaps be -- perhaps I will put it
2 around another way: if you or I had C. diff, we probably
3 wouldn't go into hospital with it, and we may not even
4 have symptoms, but it can make a big difference to an
5 elderly patient and their comorbidities can interact
6 with the outcome of the C. diff, as well as just the
7 outcome of the comorbidities.
8 Q. So the elderly are particularly vulnerable; is that what
9 you are saying?
10 A. Particularly vulnerable, yes.
11 DAME ELISH: My Lord, I wonder -- the witness referred to
12 the percentage, the average percentage, of mortality in
13 elderly patients as being 10 per cent in 30 days. How
14 does that compare to younger patients or more general
15 medical patients and whether or not this is of
16 particular significance?
17 MR KINROY: My Lord, before we do that, should we perhaps
18 clarify to what the statistic relates? I certainly take
19 the view, perhaps erroneously, that it relates to the
20 normal mortality rate in the frail elderly unconnected
21 to any contraction of C. diff illness.
22 A. What the figure relates to --
23 LORD MACLEAN: Don't answer the question, please.
24 A. I'm sorry.
25 LORD MACLEAN: They have two different enquiries here.
38

1 Mr MacAulay?
2 MR MACAULAY: Yes, the 10 per cent in 30 days figure that
3 you mentioned, to what does that relate, is the
4 question?
5 A. Right. Well, Glasgow will have their own figures, so
6 I have not looked at those, but these are figures from
7 Lanarkshire of acute admissions to hospital for elderly
8 patients. It is just a ballpark figure for a unit.
9 LORD MACLEAN: Then Dame Elish's question?
10 MR MACAULAY: I think that --
11 DAME ELISH: My Lord, that was my question.
12 MR MACAULAY: That was the question she put. I think my
13 learned friend Mr Kinroy's question was just to clarify
14 to what the statistic relates.
15 A. That is just, you know, a hospital unit. I think
16 obviously you would need to look at a group of hospitals
17 to get a picture. But it is not low, it is high.
18 Q. Is it a rehab unit or an acute medical unit?
19 A. Acute admissions of the elderly. That covers the lot.
20 DAME ELISH: I wonder, my Lord, again, whether my learned
21 friend could clarify whether or not that figure remains
22 constant for extended periods of stay in hospitals?
23 A. Okay. Do you want some more figures?
24 MR MACAULAY: Perhaps you could tell us what the source of
25 these figures are and we can maybe see if we can
39

1 identify the source and try and put them into some sort
2 of context.
3 A. The first figure I have given you was Hairmyres. Okay?
4 They are acute admissions of the elderly. They have an
5 acute receiving unit for the elderly. Okay? There are
6 other figures I can tell you to give you an idea of life
7 expectancy in prolonged hospital stay in the elderly.
8 Q. Are these figures in the public domain?
9 A. Yes. I can give you figures from Hairmyres for patients
10 who are deemed to require NHS continuing care. That is
11 the very frail with lots of illnesses requiring lots of
12 interventions who cannot even be fit enough to go to
13 a nursing home. The figure of mortality at six months
14 for this group is 80 per cent and some of
15 the individuals in this Inquiry will be in that
16 category.
17 Q. What is the point you are trying to make here,
18 Dr Johnston?
19 A. It is the natural history of disease in old age. The
20 fit elderly, which I should say are a different group,
21 they are very active, looking after grandchildren, going
22 on holidays, they are just biologically younger, but it
23 is the frail elderly who are admitted to hospital who
24 have the high mortality.
25 Q. These are the vulnerable patients who ought to be
40

1 protected against, for example, a serious infection like
2 C. diff?
3 A. Mmm-hmm.
4 Q. Is that right?
5 A. Yes.
6 LORD MACLEAN: Where do these figures come from and for what
7 period? You have quoted from Hairmyres. Where is that
8 to be found?
9 A. That is in the last three years.
10 LORD MACLEAN: What publication was it in?
11 A. It is not a publication. It is figures that have been
12 kept by one of the units in Hairmyres Hospital.
13 LORD MACLEAN: So over the last three years?
14 A. Yes, but the health board will have perfect statistics
15 on elderly admissions.
16 MR MACAULAY: When, then, Dr Johnston, did you become aware
17 that there may have been a problem in the Vale of Leven
18 with C. difficile?
19 A. I think we were aware -- there certainly were cases,
20 yes. I realised there would be a problem in the middle
21 of March, I think, that year, by which time the
22 microbiology people were onto it as well, really from
23 a false negative.
24 Q. Let me just understand that. You begin by saying that
25 you were aware that there were certainly cases; is that
41

1 right?
2 A. Mmm-hmm.
3 Q. You have mentioned two, but are you saying you were
4 aware there were other cases of C. difficile?
5 A. I had other cases, but in ones and twos again and not
6 over an extended period of time.
7 Q. What was it about March, then, that caused you to think
8 there was a problem? You say:
9 "I realised there would be a problem in the middle
10 of March ..."
11 A. There was a problem with one case, in that there was
12 a false negative and some delay, I think, in reporting
13 it, but then I think -- now I understand it, they tended
14 not to report false negatives quickly, but they were
15 quick with the positives.
16 LORD MACLEAN: Is that March 2008?
17 A. Yes.
18 MR MACAULAY: So there you are looking, really, at one
19 particular case, and was that a case where the result
20 was negative, but I think a post-mortem indicated
21 that -- is that the case you are talking about?
22 A. Yes.
23 Q. There was C. diff?
24 A. Yes.
25 Q. That is one particular instance.
42

1 A. Yes.
2 Q. When were you aware that there had been a number of
3 cases of C. diff?
4 A. I was only aware after the infection control meeting
5 in May, I think it was, that there had been a number,
6 because there was a look-back exercise at four 027s,
7 I think, and that's when, looking back, they discovered
8 it.
9 Q. So that's, you think, in about May 2008?
10 A. Yes.
11 Q. At that time, in 2007/2008, did you know what would
12 constitute an outbreak?
13 A. No, I did not. I have researched this since.
14 Q. Let's leave --
15 A. All right.
16 Q. -- research for the moment. If you just focus on the
17 period we are interested in. At that time, I think
18 you're saying you did not know what would constitute an
19 outbreak; is that right?
20 A. We'd had experience of the norovirus with sort of half
21 a dozen cases in the ward, and infection control shut
22 the ward, announced an outbreak and did all the correct
23 things, so I was fully confident that, if we were going
24 to have any more different types of diarrhoea, that we
25 would be told, in the same way as we'd been told about
43

1 the norovirus.
2 Q. But just looking at C. diff, because that is what we are
3 interested in, as you're aware, did you or did you not
4 know what would constitute an outbreak?
5 A. I did not know at the time.
6 Q. To what extent, if at all, did you have knowledge of
7 the infection control manual?
8 A. I was never issued with a copy of the infection control
9 manual, at that point or since. The infection control
10 manual is now available online, but no is the answer.
11 Q. Were you aware of the existence of the infection control
12 manual at the time we are interested in?
13 A. I was aware of the existence of a number of policy
14 manuals in managers' offices and in the ward manager's
15 office, and I was aware of the infection control team,
16 and I was aware of the broad principles of infection
17 control. Did I know where there was a book in one of
18 these offices? I don't know.
19 Q. If we look at it, it is at GGC00780001, and if we turn
20 to page 252, we are looking here at the C. difficile
21 policy that was in the -- part of the manual.
22 A. Excuse me, that policy is an old Glasgow policy from
23 2004 that's been relabelled "Glasgow and Clyde". I see
24 it is in existence to 2008, but I never received a copy
25 of that at the time.
44

1 Q. So --
2 A. So there were a lot of policies floating around between
3 the merger of the two health boards, and unless they
4 reissued all of them, then we wouldn't know.
5 Q. As you point out, this is headed "NHS Greater Glasgow
6 and Clyde", and the Vale of Leven in 2007/2008 was part
7 of NHS Glasgow and Clyde; is that right?
8 A. Yes.
9 Q. Did you have knowledge of any C. difficile policy?
10 A. No.
11 Q. If you look at this particular policy, at the section
12 dealing with responsibilities, we are told that HCWs,
13 that's healthcare workers, must follow this policy;
14 inform a member of the ICT if this policy cannot be
15 followed. Do you see that?
16 A. Well, if I never received it -- I can read it.
17 Q. You would fall into the category of a healthcare worker?
18 A. Indeed I would, with a broad knowledge.
19 Q. So I suppose, if you didn't know of the policy, you
20 wouldn't know whether or not you would be following it
21 or whether or not you would have to report something to
22 the infection control team; is that fair?
23 A. That's fair, yes.
24 Q. Another policy I want you to look at is at page 258 of
25 the manual. Here we are looking at a loose stools
45

1 policy. Were you aware of this policy at the relevant
2 time?
3 A. Well, that policy ends in September 2007. Is that the
4 relevant time?
5 Q. There is another one, in fact, as well, which I can take
6 you to, but leaving that aside for the moment, since
7 this is covered by part of the period we are interested
8 in, were you aware of this document at all?
9 A. No. I think these would be directed at nursing staff,
10 to be honest.
11 Q. I can say again that it does mention healthcare workers.
12 Do you see that?
13 A. Mmm-hmm.
14 Q. I think that would include yourself?
15 A. If I'd been issued with it.
16 Q. But you weren't issued with it?
17 A. No.
18 Q. You never saw it?
19 A. No.
20 Q. Page 145. We are looking now at an outbreak policy.
21 Were you aware of this particular policy at the relevant
22 date?
23 A. This policy does not have a distribution list. The 2010
24 does, which says Staff Net and infection control manual,
25 but there is no distribution list on this policy and
46

1 I wasn't aware of it.
2 Q. So you weren't aware of it?
3 A. No.
4 Q. Did you have any difficulty accessing a consultant
5 microbiologist, if you wished to do so, in the period
6 that we are interested in?
7 A. That would normally be done -- either the junior doctor
8 or the hospital practitioner. We didn't have
9 a microbiologist onsite, which makes it a little less
10 conjoined, shall we say, and the juniors often spoke to
11 a series of different microbiologists over the period in
12 time, so there wasn't a kind of one person that you
13 could relate to.
14 Q. But just looking to your own position as the consultant,
15 did you, yourself, make contact on occasion with the
16 consultant microbiologists?
17 A. On occasion, yes, but it was most often done by the ward
18 doctor.
19 Q. I think, as you indicated, Dr Johnston, you didn't have
20 a microbiologist on site in the Vale of Leven; is that
21 correct?
22 A. That's correct.
23 Q. That hadn't always been the position?
24 A. No. Actually, this was before my time. I think
25 Dr Dancer had left in 2002.
47

1 Q. So, really, that was before you went to work in the
2 hospital?
3 A. Yes, just look at this cross-over.
4 Q. Just looking at infection control and, in particular,
5 the infection control doctor, did you understand at the
6 relevant time that there was an infection control doctor
7 responsible for the Vale of Leven Hospital?
8 A. At the time, there were just different names and
9 I didn't know if there was an infection control doctor
10 or if they were just all microbiologists.
11 Q. One doctor that we have heard about was Dr Biggs. Did
12 you have contact with Dr Biggs?
13 A. No, not at that time, but through other juniors, junior
14 staff, she would leave messages at the ward level.
15 MR MACAULAY: My Lord, that might be an appropriate point to
16 have a short break.
17 (11.17 am)
18 (A short break)
19 (11.45 am)
20 MR MACAULAY: Before the break, Dr Johnston, I had taken you
21 to a number of the policies that were in the infection
22 control manual, and in particular the outbreak policy,
23 which you said you had not seen before; is that correct?
24 A. Correct.
25 Q. At the relevant time, did you have in your mind an idea
48

1 as to what may constitute an outbreak of C. diff?
2 A. No, I didn't.
3 Q. At the time, did you become aware of there being
4 patients isolated because they had C. diff?
5 A. Yes.
6 Q. If we're looking at ward 15, how many isolation rooms
7 did you have in ward 15?
8 A. There were four single rooms, but we never had more than
9 one or two patients isolated.
10 Q. What about the other two rooms?
11 A. These were rooms for people with end-of-life care needs.
12 Q. So there were two kept particularly for that purpose?
13 A. Mmm-hmm. Some patients could be brought into ward 15
14 from other places because there was a single room
15 available.
16 Q. What training, education, had you had in C. diff prior
17 to January 2007?
18 A. No training or education since post-graduate medical
19 qualifications; none by the health board.
20 Q. That was in the 1980s; is that correct, when that was?
21 A. Yes.
22 Q. Had you kept yourself informed in any way from then --
23 A. Yes, yes.
24 Q. -- in relation to C. diff infection as an infection?
25 A. Yes, but there wasn't much of it at the time.
49

1 Q. Did you become aware of the Stoke Mandeville problem in
2 2007/2008?
3 A. I recollect it in newspaper articles at the time.
4 Q. Since June 2008, have you had any training or education
5 in C. diff?
6 A. Yes, there's training available online and Staff Net.
7 Q. But in the Vale of Leven in particular?
8 A. Oh, yes, we did the -- we all did formalised hand
9 washing and training, which I have since repeated at
10 Inverclyde.
11 Q. After June 2008, were there training sessions set up --
12 A. Yes, there --
13 Q. -- in particular in connection with C. diff?
14 A. Yes, they ran a number of sessions so that staff members
15 could go in small groups.
16 Q. Did you go to one of these sessions?
17 A. Yes, and I do have a certificate.
18 Q. Did you find that helpful?
19 A. Yes, to a certain extent, about techniques of hand
20 washing, but some of the other parts of the training, to
21 do with cleaning out sluices and the hardware of
22 the ward were not particularly referenced to medical
23 staff.
24 Q. Now, in the period we are concerned with, are you able
25 to tell me if it was the practice of microbiologists to
50

1 come to the ward to look at patients or not?
2 A. Well, there was no microbiologists in the hospital, so
3 unless they came at odd times, I never saw one.
4 Q. So far as the management of C. diff patients is
5 concerned, do you see the isolation of a patient who has
6 got potentially infectious diarrhoea as important?
7 A. Yes, it was important, but the problem the Vale had was
8 they didn't have enough single rooms in the medical
9 wards for isolation. I see it's important, but the
10 fabric of the place didn't lend itself.
11 Q. At the relevant time, were you aware then --
12 A. Oh, yes. Yes.
13 Q. Were you aware that there were patients with potentially
14 infectious diarrhoea in the wards who could not be
15 isolated?
16 A. Not in 15. I wasn't aware of ward F at all. The
17 medical wards -- well, I can't recall directly, but
18 there must have been patients, due to the -- I think one
19 or two single rooms in each ward, there must have been
20 patients.
21 Q. In particular, do you see it as important that patients
22 who have been diagnosed with C. diff should be isolated?
23 A. Yes.
24 Q. So far as you are aware, were there patients who were
25 diagnosed who were not isolated?
51

1 A. I can't recall, actually.
2 Q. Were you aware, looking to what you have said, that
3 there were patients, then, who had potentially
4 infectious diarrhoea and who were simply in the ward
5 with other patients?
6 A. I don't recollect that as being a factor in ward 15.
7 I may be wrong, but I just don't recollect it.
8 Q. What about any of the other wards that you had some
9 involvement in?
10 A. I don't recollect that.
11 Q. Does the fact that a patient who may have infectious
12 diarrhoea, the fact that such a patient is not isolated,
13 put other patients at risk?
14 A. Yes, it does.
15 Q. Is that because of the risk of cross-infection?
16 A. It could be.
17 Q. Did you consider at the time whether or not in any of
18 the wards there were patients in these wards who were
19 being put at risk of cross-infection?
20 A. I don't recall any of my patients.
21 Q. Or any patients?
22 A. I can't remember.
23 Q. Insofar as the treatment of C. diff is concerned, what
24 was the preferred first drug of choice at the time?
25 A. You first had to get a specimen away to try to get
52

1 a diagnosis. The drug of choice, according to the
2 formulary, was metronidazole by mouth and, if that
3 didn't succeed, microbiology contact, and it could
4 either be metronidazole again or it could be vancomycin.
5 Q. Did you consider it important at the time that there be
6 a clinical assessment of the patient carried out to
7 assess the severity of the infection?
8 A. At the time, we didn't have the severity markers, sort
9 of flowchart, but any patient who was unwell needed to
10 be clinically assessed, usually by the ward doctor
11 initially, but should also be seen by a consultant.
12 Q. Although you may not have had a scoring system, would
13 you consider it important, in any event, to clinically
14 assess and see how bad the infection was?
15 A. Yes, but a lot of that would be blood tests.
16 Q. Would an abdominal examination be part of the clinical
17 assessment?
18 A. It would be part of the clinical assessment.
19 Q. Should that sort of assessment be recorded in the
20 medical notes?
21 A. It should be, but it may not be. The overall status of
22 the patient may be recorded, and the blood results.
23 Q. You say "It should be, but it may not be". I can
24 understand the first part. Why would it not be
25 recorded?
53

1 A. It might not be recorded if there is an overall summary
2 of the status of the patient. The patient may be
3 examined but not all the component parts recorded.
4 Q. Why would that be? Why would not all the component
5 parts be recorded?
6 A. If they were negative, they might not be recorded. They
7 should be, but they might not be.
8 Q. Is it important to record negative results as well as
9 positive results?
10 A. Yes, it's important.
11 Q. If antibiotics are prescribed to a patient who is
12 suffering from C. diff, do you consider it to be
13 important to have ongoing antibiotic review of such
14 a patient?
15 DAME ELISH: Sorry, my Lord, before moving on from the set
16 of questions regarding the importance of recording of
17 abdominal examinations, et cetera, I wonder if the
18 witness could be asked for an explanation as to why that
19 might not take place, given that she said it would be
20 important?
21 MR MACAULAY: Yes, I thought I had asked that.
22 LORD MACLEAN: So did I.
23 MR MACAULAY: Can I ask again, then? I have been prompted
24 to ask you again, Dr Johnston, why wouldn't the
25 component parts be recorded?
54

1 A. If the doctor was conducting a ward round without junior
2 staff, there may be some summarising goes on in the
3 notes. If there is a junior doctor there, they might
4 actually write in the notes for you. So there may be an
5 element of time in completing the examination and
6 recording of things before moving on to the next one.
7 Q. Are you there postulating a situation where the
8 consultant is reviewing the patient and the junior
9 doctor is writing down what the consultant finds?
10 A. That would be the ideal, in the same way as I have got
11 a stenographer sitting beside me writing down everything
12 I am saying. That would be ideal, because I can talk
13 and think and do without having to think about writing
14 down. But if there isn't a junior doctor there, the
15 consultant is much more under pressure to summarise, so
16 they can get on to the next patient. If there is no
17 junior doctor there, they have to seek out all the
18 aspects of the medical care manually from the notes, go
19 and find results, put up X-rays and, in fact, function
20 as an operator rather than a lead clinician.
21 Q. But was it your own practice, Dr Johnston, if you
22 examined a patient, to write your own notes of
23 the findings?
24 A. It was my own practice to do that, but because I -- I'm
25 alluding to I did solo ward rounds without medical
55

1 support. I would not have the time to write as full
2 notes as I would like to do, which I do nowadays.
3 Q. You mean you have more time nowadays to do a fuller
4 note?
5 A. Yes, less of the encounter is taken up looking for
6 things and writing down.
7 DAME ELISH: My Lord, I wonder if my learned friend could
8 ascertain from the witness what time was allocated
9 for -- or the average time of per patient in a ward
10 round of this nature, if there was such a thing?
11 LORD MACLEAN: Is that possible?
12 A. Yes, I have looked at it, and also in my current -- I'm
13 not talking about my medical ward rounds, which go on
14 forever, but my current allocation for rehabilitation
15 patients, it's still about 7 minutes per patient, but
16 I currently have one or two junior doctors supporting
17 the ward round, I have a clinical pharmacist who has
18 already gone through all the medications right back to
19 primary care, and I have a nurse who has all the
20 information and various tools ready on the ward round.
21 So it is a much more effective ward round than I was
22 able to do at the Vale.
23 MR MACAULAY: The 7 minutes per patient you have mentioned
24 in that answer, is that the position now?
25 A. It actually is. I have a slightly different caseload,
56

1 but I have a much more efficient and effective ward
2 round because of the support that I have.
3 Q. But does it depend on the condition of the patient?
4 A. Of course it does, yes. Of course it does.
5 Q. One patient might take a few minutes and one patient
6 might take much, much longer?
7 A. Indeed. A medically unstable patient might finish the
8 ward round.
9 Q. When you're looking at a patient who is suffering from
10 C. difficile infection, do you see fluid and nutritional
11 management as being an important part of care?
12 A. Yes, I do.
13 Q. Why is that?
14 A. Because you can lose 25 per cent of your body weight
15 with chronic recurrent C. diff, and I have experience of
16 that in Inverclyde, no matter what you do with fluid and
17 nutrition, so it is a very catabolic experience for the
18 patient. It is also very difficult to encourage
19 patients with severe anorexia to take their diet and
20 nasogastric feeds, which may be used to build up the
21 patient, but may actually make the diarrhoea worse. So
22 it is a very difficult situation to deal with.
23 Q. I had, I think, been asking you about ongoing antibiotic
24 review of a patient with C. diff?
25 A. Yes.
57

1 Q. Would that be important?
2 A. Are you referring to the treatment of the C. diff --
3 Q. Yes.
4 A. -- or to other antibiotics?
5 Q. I'm looking, first of all, to the treatment of
6 the C. diff?
7 A. Treatment of the C. diff. Well, you would be expecting
8 to see some improvement within a week and, if not, you
9 need to review what the treatment is.
10 Q. When you say "within a week", can you give me an idea of
11 how many days do you think, if there is no improvement
12 on metronidazole?
13 A. That's something that should be flagged up by the
14 nursing staff, because the doctor isn't always in the
15 ward and they should be informing you what's happening.
16 You know, it has to be passed in that direction.
17 Q. If we are looking at the time, timescale, if a patient
18 has been prescribed metronidazole and there isn't any
19 particular improvement, then what timescales are you
20 talking about?
21 A. I don't think you'd -- you can take a rough guess of
22 about six, seven days, but I don't think -- in an
23 individual patient, they might be much iller before
24 that, so you'd need to be flexible on that.
25 Q. In the management of such a patient, do you consider
58

1 that the use of a stool chart is important?
2 A. Well, it's become important. Stool charts were not
3 widely used before this, but the nursing staff were
4 recording things in the narrative. The practical
5 difference it makes to me now is that they have a record
6 which is more accurately describing what's going on, but
7 the communication between the nursing staff and me is
8 still verbal, and they're reciting what's in the stool
9 chart, rather than reciting what happened a day or two
10 back.
11 Q. When you say --
12 MR KINROY: My Lord, I wonder if we need to go back a bit to
13 an answer? Obviously it is for your Lordship and my
14 learned friend, but on the question of the condition of
15 the patient should be flagged up by the nursing staff
16 because the doctor isn't always in the ward, I wonder
17 how long it would be before the doctor should be in the
18 ward? Would this justify, for example, a doctor seeing
19 the patient only once in a week unless otherwise
20 notified by the nursing staff?
21 LORD MACLEAN: Can you answer that?
22 A. When I say "the doctor", I'm talking about -- it would
23 be the hospital practitioner, in this case, or the
24 junior doctor in the medical wards, because it has to be
25 ward based. The consultant doesn't know what's
59

1 happening outwith their visits to the ward.
2 MR MACAULAY: Coming back to the position of stool charts,
3 you can correct me if I am wrong, Dr Johnston, but did
4 you suggest, an answer or two back, that at the time
5 stool charts were not in great use?
6 A. Certainly looking back over my 20 years as a consultant,
7 I don't think they were in great use, unless you were
8 working in a gastro ward, for example, patients with
9 colitis.
10 Q. But if we're looking at the period we are interested in
11 in the Vale of Leven, what's your experience of stool
12 charts at that time?
13 A. There was a little stool charting recording. Mainly it
14 was in the narrative in the nursing notes.
15 Q. Did you, yourself -- well, what was your position in
16 relation to the keeping of stool charts? Did you or did
17 you not see that as important in the management?
18 A. The keeping of some record is important.
19 Q. But not necessarily a document that provided details of
20 the stools?
21 A. Well, it has to be something that they will do regularly
22 and adhere to, whatever the method is.
23 Q. What about fluid balance charts, then, if you are
24 looking at fluid management? Did you see the keeping of
25 fluid balance charts as important at the time we are
60

1 interested in?
2 A. I think the time when we had norovirus in the ward,
3 there was lots of diarrhoea and vomiting, and it would
4 have been, I think, impossible for nursing staff to have
5 kept accurate fluid charts in that situation, in an
6 outbreak situation at that.
7 The fluid chart helps, but it's never accurate
8 unless you're in HDU and you've got central venous
9 monitoring and you're catheterising, particularly
10 patients with diarrhoea. The key question is: is this
11 patient eating, drinking, passing urine? If the answer
12 to any of these is no, then they should have some form
13 of fluid chart.
14 Q. How would you know if the patient is drinking if you are
15 not keeping some record of what --
16 A. Nursing staff record it in the nursing notes.
17 Q. So you would be looking to the narrative of the nursing
18 notes then to see whether or not the patient --
19 A. I didn't see the nursing notes on the ward round, but
20 I'm just reflecting what I've seen looking back in the
21 notes. There were fluid charts which were not very well
22 kept and they were intermittent, particularly if the
23 patients were unwell for a long time.
24 Q. If you are looking at a patient who is suffering from
25 C. difficile and has diarrhoea, then fluid management
61

1 does become an important aspect of care?
2 A. Oh, yes, it certainly does.
3 Q. Going back to the issue of antibiotics, if you have
4 a patient who is on antibiotics and that patient
5 develops C. diff, what would your practice be in
6 relation to the antibiotics that the patient is on?
7 A. That's a very general question, but I can relate some of
8 it to some of the cases that I had. A patient with
9 a recurring severe pneumonia nearly landing up in ITU
10 develops C. diff after several broad-spectrum
11 antibiotics but still continues to have pneumonia, you
12 have a problem. What are you going to treat?
13 If the patient is not absolutely requiring the
14 broad-spectrum antibiotic, it should be stopped. There
15 certainly were cases here where I discovered a junior
16 doctor has put a patient on ceftriaxone for some
17 undiagnosed sepsis, which I have then put a line through
18 the next day, but totally policing the antibiotic
19 prescribing, unless you were there with the junior
20 doctor 24/7, is not actually possible, but you can
21 educate and encourage.
22 Q. Is that an example of the junior doctor prescribing an
23 antibiotic which you considered to be inappropriate?
24 A. Yes. Yes, that's right.
25 Q. So you would then review that and --
62

1 A. Yes --
2 Q. -- change the antibiotic?
3 A. My point about the antibiotic EAT guideline is, whenever
4 there is something on the menu, it will be chosen. So
5 they were prescribing, whether or not it was
6 appropriate, broad-spectrum antibiotics which now are no
7 longer on the menu, and that is the difference.
8 Q. Did you -- I think you have touched upon this already --
9 at the relevant time have any knowledge about the
10 possibility of false negative results for C. diff?
11 A. None. Normally, what happens with false negatives and
12 false positives is they are reported on the report form
13 with the result. Tumour markers, for example, D-dimers,
14 for example, but we got no report or knowledge from
15 microbiology that we were maybe seeing false negatives.
16 Q. What you would get, if the result was positive, you'd
17 get a positive result --
18 A. Mmm-hmm.
19 Q. -- and that usually would be phoned in to the ward or
20 infection control?
21 A. Yes.
22 Q. But if it is a negative result, then it is simply looked
23 upon as a negative result?
24 A. At that time, and I have to place myself in that time.
25 DAME ELISH: My Lord, my friend moved quickly there to the
63

1 issue of false negatives. I wonder if I could ask my
2 learned friend to move back to the issue of the stopping
3 of antibiotics and clarify with this witness, from her
4 experience, whether or not the decision to stop
5 antibiotics where there were significant comorbidities
6 was a difficult or easy judgment to make in
7 circumstances where C. difficile arose?
8 A. Do you want me to answer that?
9 LORD MACLEAN: Yes. You are faced with a dilemma, aren't
10 you, in that situation? Was it easy or difficult to
11 resolve?
12 A. That was difficult, and that is a senior decision,
13 because, in some instances, what you are actually
14 looking at is palliative care and when you move off the
15 active treatment to treatment of symptoms, and there can
16 be very difficult decisions to be made about that. So
17 it is never a quick answer.
18 MR MACAULAY: If you had a patient who tested positive for
19 C. diff and was on antibiotics, would you review the
20 antibiotic treatment?
21 A. Oh, yes. Yes.
22 Q. If you came to the view that there was an infection that
23 did require antibiotic treatment quite separate from the
24 C. diff, you could still consider whether or not to
25 introduce a narrower-spectrum antibiotic?
64

1 A. You would, at that point, consult microbiology for
2 a better plan.
3 Q. If you were going to deal with a patient who had
4 C. diff, would you take any particular precautions?
5 A. Yes. You wear your protective apron and gloves.
6 Q. Can we just understand what dealings, if any, you had
7 with infection control? Can you help me with that: did
8 you have any dealings generally with the infection
9 control nurse or nurses in the Vale of Leven?
10 A. Yes, I did. As I recall, there were two initially and
11 then one retired and so there was one. I think it was
12 Jean Murray and Helen O'Neill, who remained. I'm not
13 sure to what extent they were full time or whether
14 Helen, when she was on her own, was full time or not.
15 I can't remember. They normally related directly to the
16 nursing staff on the ward, but they would also tell me,
17 generally, issues of where patients were going and
18 I would ask them about how long patients needed to be in
19 isolation. It was to do with isolation, mainly. But
20 they never came with a graph showing me all the
21 instances of C. diff across the patch.
22 Q. Would you see the infection control nurse, then, on the
23 ward to have these discussions with her?
24 A. I did see them on the ward. Certainly on the medical
25 wards and to some extent in ward 15, I did see them.
65

1 Q. If you have a patient who develops diarrhoea, should
2 loperamide be given to such a patient?
3 A. It depends what the cause of the diarrhoea is. If it is
4 a problem with diverticular disease, then you would give
5 loperamide. If you don't know the cause of
6 the diarrhoea or if you think it might be infectious,
7 then you shouldn't.
8 Q. Does it follow from that answer that if you know the
9 patient has got C. difficile, you should not give them
10 loperamide?
11 A. You shouldn't. And if nurses know the patient has
12 C. difficile, they shouldn't give out any loperamide
13 anyway. They can stop a medicine on the basis of they
14 think it might do detriment and then call the doctor to
15 have it scored off.
16 Q. When you're dealing with elderly people, can such
17 patients become dehydrated very quickly?
18 A. Yes.
19 Q. Is the risk even more so if the patient is suffering
20 from an illness such as C. difficile?
21 A. Yes, that's true.
22 Q. That can sort of tip them over the edge; is that
23 correct?
24 A. Yes.
25 MR KINROY: My Lord, I think there was evidence earlier from
66

1 an expert that managing the fluid balance of the frail
2 elderly so as to prevent mortality is a very difficult
3 thing, indeed, to do. I wonder if we could perhaps have
4 the views of this witness on that proposition?
5 A. Yes. Most of these elderly patients will have chronic
6 renal impairment and many will have a degree of cardiac
7 failure. These are the patients that can be
8 simultaneously wet and dry; in other words, they may be
9 losing fluids and dehydrated, but if you put in fluids
10 too quickly, then, if their albumin is low, the fluid
11 can leak through the circulation into the lungs. If
12 they have cardiac failure, they can develop pump failure
13 with overload. So they are very difficult to manage.
14 There is an argument that, to properly manage them,
15 you should manage them in HDU with central monitoring
16 and catheterisation, but I think that is a step perhaps
17 in the high-tech pathway.
18 MR MACAULAY: Does the difficulty in managing such patients
19 indicate that it is important to have their fluids
20 properly monitored and managed?
21 A. I think it does, yes, but it depends also on what you
22 are able to do for them. For example, if you have
23 a patient who is unable to swallow and has got C. diff
24 and they can't take their medication for it, then you've
25 got a bit of a problem, if you can't get venous access,
67

1 to go onto a PEG tube. How far do you go up the pathway
2 of invasive care?
3 Q. Can I ask you some questions about the resuscitation
4 policy? Were you aware of the policy that was in place
5 at the time?
6 A. There was the Vale of Leven one, but there was also
7 a national guideline in 2007 from the Resuscitation
8 Council that came out which changed things a little.
9 Q. In relation to the Vale of Leven policy, you were aware
10 of that policy?
11 A. Yes.
12 Q. Insofar as DNAR orders were concerned, did these require
13 to be countersigned by the consultant in charge of
14 the case?
15 A. Not if it was a senior doctor in general practice, and
16 in the case of oncall juniors, it was the most senior
17 junior that would countersign, but it would have to be
18 signed by the consultant the following day, but if the
19 patient dies overnight, for example, there will not be
20 a second signature on the form.
21 Q. Can you tell me what staff morale was like during this
22 period, Dr Johnston? I think we have heard some
23 evidence that there was some uncertainty over the future
24 of the hospital?
25 A. I think the Vale had a very strong collegiate, corporate
68

1 kind of status. It was a -- its own little fishbowl.
2 But uncertainty was the biggest problem with morale.
3 They were waiting for the big answer for years, and the
4 big answer, which is now in place, has reduced the
5 hospital to a more restricted facility, albeit all the
6 more stable for that, but I think that was the case.
7 Q. Did the uncertainty that you mentioned impact upon
8 morale?
9 A. Not in the sense of patient care, but in the sense of --
10 I kind of -- the identity of the place. It was very
11 much a local hospital, but there was a certain loss of
12 identity as people didn't know what direction it was
13 taking.
14 DAME ELISH: My Lord, on that particular issue, I wonder
15 whether or not my friend could confirm whether or not
16 this witness is aware whether or not that uncertainty
17 had any impact on prospective recruitment of clinicians
18 and junior doctors?
19 LORD MACLEAN: Would you know the answer to that question?
20 A. Well, it was possible, yes, for the recruitment side,
21 but the other more obvious thing was, if people left,
22 a post may not necessarily be replaced, so it was
23 a double thing.
24 MR MACAULAY: I think you, yourself, had some
25 correspondence, going back in time, in connection with
69

1 the proposed loss of a consultant physician at the
2 Vale of Leven; is that right?
3 A. Yes.
4 Q. If we look at INQ02390001, I think we have there
5 a letter or it may be an email, in fact -- it may be
6 dated 5 December 2005, from you to Mr Divers; is that
7 correct?
8 A. That's correct.
9 Q. What was Mr Divers' position at the time?
10 A. He was the chief executive of Greater Glasgow Health
11 Board at that time, and this time was about three months
12 before Greater Glasgow took over Argyll and Clyde.
13 Q. What was the problem at this point that you wanted to
14 draw to Mr Divers' attention?
15 A. The problem was simply that the outgoing health board
16 had decided on an action to remove a consultant post
17 without consulting the consultants or without recourse
18 to a plan B which would be a replacement for this. This
19 was done very quietly through a small committee in the
20 community, known as the Older People Services Forum, and
21 I was kept unaware of this, although it had been
22 discussed in other hospitals in Argyll and Clyde, until
23 a knock at the door came and a nurse manager told me
24 I was about to lose a post.
25 So what I did was I took it as an employment issue
70

1 to the BMA and I put in a grievance with the then
2 medical director, Liz Jordan, but she didn't bring it to
3 the table and, as they were going to really pass it on
4 the nod in the December board meeting, that's when
5 I wrote to Tom Divers and I copied it to
6 Catriona Renfrew.
7 Q. Did that have the desired effect? Did it prevent the
8 loss of the consultant?
9 A. Yes, it did, and I got it in writing.
10 LORD MACLEAN: What was the post that was --
11 A. The post was a post -- it was an acute post in stroke
12 medicine, general medicine and geriatric medicine and
13 I had prepared it for -- an advertisement, and gone
14 through national panellists, et cetera, but if the
15 consequence of removing that post would mean that the
16 remaining consultant, that was me, would be
17 unsustainable as a single consultant geriatrician and
18 the remaining four general physicians would have an
19 unsustainable rota, so it was a tipping point for the
20 Vale. The Glasgow Health Board came in and shut that
21 down. I then got the post through the vacancy
22 management committee in March, which was just before the
23 wire came down on Argyll and Clyde.
24 The post was thereafter readvertised in Glasgow, but
25 there were no applicants, but the post remained intact.
71

1 DAME ELISH: My Lord, for the sake of clarification,
2 I wonder if my learned friend could indicate whether or
3 not this was a post covered by the witness Dr Akhter?
4 A. This is correct. The funding for that post -- I don't
5 know a great deal about it, but half of it came from
6 acute general medicine and the other half came from the
7 CHP, but the funding moved to the CHP at some point and
8 I think that's when they thought they could cut it.
9 MR MACAULAY: Just to be clear, then, the post that was
10 going to be removed was the one that was being held by
11 Dr Akhter at the time?
12 A. No, he wouldn't have been in the post at the time. It
13 would be another locum. The six posts required the six
14 posts for -- in order for -- at that stage, for the
15 hospital to function, and taking anyone out is like
16 taking a leg off a stool.
17 Q. I think -- we needn't look at the detail of this -- if
18 we turn to page 2 of what is on the screen, I think you
19 had discussed a detailed memorandum setting out the
20 arguments in favour of the retention of the post; is
21 that right?
22 A. Yes, that's correct.
23 Q. The other thing I want to ask you about at this point
24 relates to induction. When new doctors came to work at
25 the Vale, would they undergo an induction process?
72

1 A. They did.
2 Q. If we turn to this document, GGC21120001, we are looking
3 here at a document headed "Doctors' Induction Day", and
4 can we see that this sets out a programme in relation to
5 which a number of doctors participate? We see, I think,
6 your name is mentioned towards the bottom, once or twice
7 in the list. Would this be the sort of programme that
8 would be prepared for the new doctors?
9 A. I would have to say that I was never involved in this,
10 because I had a movement disorder clinic on a Wednesday
11 morning, and my name would appear as being the clinical
12 supervisor, but I never took part in any of these
13 inductions.
14 Q. In any event, these inductions for new doctors would
15 take place along the lines set out in this document; is
16 that right?
17 A. Yes.
18 Q. We heard last week from Dr Khan to the effect that he
19 did not receive an induction training when he went to
20 the Vale of Leven. First of all, was that correct, so
21 far as you're aware?
22 A. I was off sick at that time. He was in July, I think,
23 2007. I wasn't at work.
24 Q. But a locum doctor who was coming to the Vale of Leven
25 for the first time, would such a doctor also be given
73

1 some form of induction training?
2 A. They should be, yes.
3 MR PEOPLES: My Lord, I wonder whether my learned friend
4 could perhaps deal with a matter at this point about the
5 induction of junior doctors? We have heard some
6 evidence about a continual throughput of doctors every
7 three or four months or six months. I'm not sure
8 whether Dr Johnston could perhaps give us a very brief
9 education in that process, because we have heard there
10 is quite a lot of change of junior doctors within the
11 hospital or within specific boards.
12 LORD MACLEAN: Do you want to deal with that with this
13 witness or do you want to deal with it later, with
14 Dr McCruden, for example? It is up to you.
15 MR MACAULAY: I can take Dr Johnston's views on that.
16 A. I suggest it would be better done by Dr McCruden or
17 Dr Carmichael.
18 Q. Very well.
19 A. Yes.
20 Q. After it became evident that there may have been
21 a problem with C. diff in the Vale of Leven Hospital,
22 was the approach taken to antibiotic prescribing
23 changed?
24 A. June 2008.
25 Q. If we look at this document, GGC16530001, we are looking
74

1 here at an E mail. I think we see Dr McCruden's name at
2 the top, but we also see your name listed. It seems to
3 be signed by John Dickson, and we see the date is
4 13 June 2008:
5 "I am writing to inform you that as of today
6 (13/6/08) the following antibiotic policy applies
7 throughout the RAH."
8 The focus there is on the RAH, but did that also
9 include the Vale of Leven?
10 A. I don't recollect the email, but it's fairly likely that
11 it includes the Vale of Leven.
12 Q. If we look at the attachment on page 2 of the document,
13 does this ring a bell with you, that this was the plan
14 at this time, that this was to be the new policy?
15 A. That doesn't ring a bell, but it's perfectly reasonable.
16 Q. But, in any event, there was a change?
17 A. Oh, yes.
18 Q. Was there also some advice given in relation to
19 infection control guidance at about this time? If I can
20 put this on the screen, can we look at GGC16520001,
21 there's a heading here in this email of "Infection
22 control guidance". It seems to be 12 June 2008. If you
23 turn to page 2, there's a document headed "Infection
24 control guidance for medical staff". Do you recognise
25 this document?
75

1 A. I don't, actually, but, again, it's perfectly
2 reasonable.
3 Q. If we could look at another document, please,
4 GGC05040001, we are looking at the minutes of a clinical
5 governance meeting held on 16 June 2008. I think we can
6 see that your name is listed as one of the people
7 present; is that correct?
8 A. It looks -- yes.
9 Q. Were you a member of this particular group?
10 A. I ran it.
11 Q. Did you have regular meetings?
12 A. We had monthly meetings and -- some of it was
13 educational, some of it was to do with governance.
14 Q. At any meetings prior to this meeting, had infection
15 control been a matter for discussion or not?
16 A. Probably norovirus, yes.
17 Q. I'm focusing on C. diff. So far as C. diff was
18 concerned, was there any discussion about C. diff?
19 A. I don't recollect, no.
20 Q. This meeting seems to be focusing upon the fact that
21 through the media and the health board there had been
22 a number of C. difficile cases identified; is that
23 right?
24 A. Yes, it looks like it.
25 Q. You have listed under the heading "Factors were
76

1 considered in the discussion" a number of areas. The
2 first, for example, is:
3 "Hospital fabric and state of refurbishment,
4 including washing facilities and lack of investment by
5 health board noted."
6 What was the position at this time, Dr Johnston, in
7 relation, for example, to the availability of washing
8 facilities?
9 A. I think that was more critically acute in the medical
10 wards. There were reasonable facilities in the
11 rehabilitation wards.
12 Q. What was the position in the medical wards?
13 A. Not enough hand basins.
14 Q. Had that been made known?
15 A. Oh, I think that had been made known for years, but
16 nothing had been done about it.
17 LORD MACLEAN: Forgive me for asking this -- I should know
18 it -- what is the acronym RAD? What does that stand
19 for?
20 A. Rehabilitation and assessment directorate.
21 LORD MACLEAN: Thank you.
22 MR MACAULAY: Item 2 I think deals with the change in
23 antibiotics which we have touched upon. Item 3, "Lack
24 of confidence in current testing systems for
25 C. difficile", is that something you have already
77

1 touched upon?
2 A. I think that is.
3 Q. In relation to --
4 A. I don't actually remember this document, but I think it
5 captures quite a lot in it.
6 Q. If we turn to page 2 of the document, under the heading
7 "Next steps", at 2, it mentions that you, yourself, and
8 Dr McCruden were to meet with Dr Linda Bagrade to
9 discuss clinical cases. What was the purpose behind
10 that?
11 A. We, the consultants, felt at the time that one of
12 the best ways of going through this was going back
13 through cases with -- sort of a peer review thing, with
14 bacteriology as well, but we were never afforded that
15 opportunity. We weren't allowed to see the case notes
16 or deal with it at that level. It was taken out of our
17 hands with the various enquiries.
18 MR KINROY: My Lord, I wonder if we could enquire whether
19 this witness knows if some of that was because there was
20 an independent review instructed by the Scottish
21 Government and it was thought best that that review
22 should explore what had happened, rather than this
23 particular witness going about it in the way she had
24 hoped?
25 LORD MACLEAN: Is that not implicit in her answer, the very
78

1 last sentence of her answer?
2 MR KINROY: Well, it is, my Lord, except the reason for why
3 she was not allowed to explore it as she might have
4 hoped is not clear from her evidence. She may not know
5 it.
6 LORD MACLEAN: Well, she says, "It was taken out of our
7 hands with the various inquiries".
8 MR KINROY: My Lord, I overlooked that. Thank you.
9 LORD MACLEAN: That is what I was getting at, and I think
10 that is understandable, actually.
11 Interesting, actually, when you look at the minute,
12 the first matter of "Next steps" was actually:
13 "Consultants to have access to casenotes to review
14 causes of death."
15 Why was that put in?
16 A. I can't recollect at the time, but in light of all the
17 reviews that had taken place, it is clear that a lot of
18 information has been lost over time and clinicians
19 themselves could have provided a basis of discussion at
20 the very beginning, rather than leaving it to case
21 notes. That is just my view.
22 MR MACAULAY: When you say "a lot of information has been
23 lost", what do you mean by that?
24 A. Well, the case notes will only give you a percentage of
25 what's happening, and clinicians can give you exactly
79

1 what's going on and all the thinking behind what's
2 happening. But I think that's been lost through the
3 passage of time.
4 Q. Should the case notes not tell us what's happening?
5 A. I think they'll give you a very limited amount of
6 information as to what's happening.
7 Q. Why is that?
8 A. Because a lot of what happens, dialogue, clinical
9 discussions, discussions with patients, is not written
10 down. You will get prescriptions and letters, but a lot
11 of what happens in clinical activity is lost.
12 LORD MACLEAN: While that may be so -- I wouldn't know --
13 what item 1 says is that consultants should have access
14 to case notes to review causes of death. So you must
15 have thought that the case notes themselves would be
16 useful in reviewing the causes of death.
17 A. Yes, but we were also the clinicians, and we would have
18 been able to put our clinical colour into what is in the
19 case notes, and that aspect has been lost.
20 LORD MACLEAN: I don't understand that. I'm sorry.
21 MR MACAULAY: There are duties on doctors in practice in
22 relation, for example, to record keeping; is that
23 correct, Dr Johnston?
24 A. Yes, that's correct.
25 Q. Should a third party not be able to pick up a patient's
80

1 case records and obtain from that a reasonable account
2 as to how the patient is being managed?
3 A. I would have great difficulty in looking at a set of
4 case notes and coming out with a full and accurate
5 description of what's gone on with any particular
6 patient. I have this difficulty in my clinical
7 practice, looking back at patients who had been in other
8 wards in the hospital and piecing together what's been
9 happening.
10 Q. If we look, then, at the guidance for doctors provided
11 by the General Medical Council, this is at INQ00270001,
12 and we see that is what the document is from the front
13 page. If we turn to page 3, we see that this is the
14 version for November 2006; do you see that? It is on
15 the screen.
16 A. Yes.
17 Q. If we go on to page 10, there's a section that reads:
18 "In providing care, you must: ...
19 "(f) keep clear, accurate and legible records,
20 reporting the relevant clinical findings, the decisions
21 made, the information given to patients, and any drugs
22 prescribed or other investigation or treatment."
23 If that guidance were to be followed, would it not
24 then be possible for a third party picking up the notes
25 to form a reasonable view as to how the patient had been
81

1 treated?
2 A. You will have a reasonable view, but you won't have the
3 whole view.
4 Q. If you are dealing with a patient and you are asked
5 a year down the line what had happened, would you really
6 remember what had happened?
7 A. Some cases, yes, I carry with me for years.
8 Q. The other point I want to raise with you in connection
9 with this document is at page 11, where there is
10 a section headed "Raising concerns about patient
11 safety". I will read that to you:
12 "If you have good reason to think that patient
13 safety is or may be seriously compromised by inadequate
14 premises, equipment, or other resources, policies or
15 systems, you should put the matter right if that is
16 possible. In all other cases you should draw the matter
17 to the attention of your employing or contracting body."
18 If I just stop there, did you have any good reason
19 to think that patient safety was being compromised in
20 the Vale of Leven at the relevant time?
21 A. I think at the relevant time, as in the years before,
22 concerns had been raised broadly across the hospital,
23 and I continued to raise my concerns with the service
24 manager as well, and she had made many representations
25 to get things fixed, which never materialised. But
82

1 I don't think it was a lack of people raising concerns,
2 it was a lack of action, and eventually people saying,
3 "There's no money, we can't do this, put wash basins
4 in".
5 Q. Let's take it in bits. You see, first of all -- and
6 this may be implicit in your answer -- did you have good
7 reason to think, at the relevant time, that patient
8 safety was or may have been seriously compromised?
9 A. I think that was a continuation of what the situation
10 was all the time I was there. So, yes and yes.
11 Q. What caused you to be of the view that patient safety
12 was seriously compromised?
13 A. I wouldn't say safety would be seriously compromised
14 because the roof leaked, but, you know, there's the
15 external fabric which wasn't being kept up. The
16 internal -- the wards 14 and 15 had adequate facilities.
17 They were outdated, but the main issue for the medical
18 wards was lack of hand basins.
19 Q. So that is dealing with premises and equipment. What
20 about resources?
21 A. I don't have a great deal of knowledge about resources.
22 Q. If we include in that the number of staff available from
23 the medical perspective?
24 A. All right. It was inadequate for the RAD side of
25 things, with part-time hospital practitioners being
83

1 backfilled by FY1s when they weren't there. In the
2 general medical side, I would say there was a layer of
3 staffing missing that would have ensured more continuity
4 of care, more senior juniors. I think it was always the
5 least of the least that they got.
6 Q. Then moving on to what could be done about it, I think
7 you mentioned that you, yourself, had brought these
8 issues to the attention of your service manager; is that
9 right?
10 A. Yes, the fabric and so on, yes.
11 Q. What about staffing?
12 A. The staffing?
13 Q. Yes.
14 A. I think if you look at my appraisal documents from 2003,
15 I lay out very clearly my concerns about staffing.
16 I don't know if you've got those in the Inquiry.
17 Q. We may --
18 A. I was constantly recording it, yep.
19 Q. Your service manager then, who was made aware of these
20 concerns at the time, who was that?
21 A. Liz Rawle.
22 Q. Do you know what Liz Rawle did about it?
23 A. Well, I think she did quite a lot, and she's coming to
24 speak to the Inquiry, so it would be better maybe
25 leaving that to her.
84

1 Q. What feedback, then, did you get from her?
2 A. The feedback was always, "No money".
3 Q. Did you, yourself, as the consultant, feel under
4 pressure, looking to the amount of work and areas you
5 had to cover within the hospital?
6 A. Oh, yes. Basically, Dr Akhter and I had, I would
7 describe, two jobs -- one and a half, at least, for the
8 amount of patients we had and different sites.
9 I continue to do medical receiving in my new job, but
10 I have a block of days in which my own geriatrician job
11 is backfilled by a staff grade and my clinics aren't on,
12 so I can separate the two. I couldn't then.
13 LORD MACLEAN: When you say lack of staffing, do you include
14 nursing, the nursing staff, or is it just medical?
15 A. No, that would be medical. The solution which has been
16 formed is that there are two geriatricians at the Vale
17 now with ward-based junior staff and they're not doing
18 general medicine, so it's sorted.
19 MR MACAULAY: You didn't have that position at the time we
20 are concerned with?
21 A. No, I didn't.
22 Q. Do you consider that the pressure that you were under
23 then did impact upon the level of care that you were
24 able to give to your patients?
25 A. I think what you need -- what a consultant relies on is
85

1 a system of good juniors with -- some senior juniors who
2 will completely control the ward all the time that you
3 are not in it. If you rely on a system with
4 a consultant, for example, who is called out of clinic
5 to see somebody who has got sepsis in the ward, that is
6 not a system. I, quite often, when I was receiving,
7 would end up, as I said, in medical assessment seeing
8 patients.
9 MR WOOD: My Lord, I wonder if I might intervene?
10 Dr Johnston is probably looking to see who is speaking.
11 It is me.
12 She described how she and Dr Akhter had, I think,
13 two jobs or one and a half jobs, and then went on to
14 describe her commitments. I wonder if the fact that
15 Dr Akhter had also responsibility for ward F changes
16 matters and whether Dr Johnston could be asked to
17 comment on that?
18 A. I think Dr Akhter -- should I comment?
19 LORD MACLEAN: Yes.
20 A. Dr Akhter's position was unworkable, I would have to
21 say. He had stroke ward as well as ward 14 as well as
22 his medical receiving, often covering or filling in for
23 other consultants in an ad hoc fashion, so that some of
24 his work was interfered with.
25 MR MACAULAY: I think I'd asked you, and I'm not absolutely
86

1 sure what the answer was, but you have indicated the
2 pressure that you were under and why. What I had been
3 seeking to clarify with you is whether that pressure did
4 impact upon the care that you were able to give to your
5 patients?
6 A. I think it would impact on the follow-through of
7 the care. It wouldn't impact on what I did when I was
8 there. But in terms of progressing investigations,
9 following up sick patients -- the hospital practitioner
10 did sessions, but not at the same time with my major
11 ward round, and so would come and go. So it wasn't an
12 ideal situation.
13 Q. You mentioned a moment ago that Liz Rawle was your
14 service manager. Do I take from that that she was your
15 line manager?
16 A. My line manager would be a doctor, and it would be
17 Dr McCruden, who was notionally the site clinical lead
18 at that time. I'm not sure whether he still officially
19 was or not, but he did all my appraisals, and his line
20 manager would be Dr Curry in Inverclyde. That would be
21 the clinical director for medicine. When RAD was
22 adopted into the -- Glasgow, my line manager changed, so
23 I went from acute medicine to the rehabilitation
24 assessment directorate, and my line manager then was
25 Graeme Simpson, who was based at Paisley, and above that
87

1 was Margaret Roberts who was associate medical director.
2 Q. When did that happen, then?
3 A. There was a bit of an overlap, I think. The health
4 board took over in April 2006. RAD for Glasgow took in
5 the Vale in October 2007, but for a period of
6 a year-plus, I was still having my appraisals done
7 through the acute medicine side, so there was a kind of
8 overlap period, I think.
9 Q. That would be Dr McCruden then?
10 A. Yes.
11 Q. I think you say in your statement that your line manager
12 in the emergency care and medicine directorate was
13 Dr Graham Curry, but that is, I think, through
14 Dr McCruden; is that right?
15 A. Yes. All of these line managers were at different
16 hospitals.
17 Q. What's the point of that? Does that make it more
18 difficult?
19 A. Well, apart from Dr McCruden, that is -- everyone else
20 was in another place. That is what directorates do:
21 they cover a number of different clinical sites.
22 Q. Did that cause you a problem?
23 A. I think we were quite isolated. In the Vale,
24 Dr McCruden and -- the six of us, basically, functioned
25 as a unit, a site-based unit, although the actual lines
88

1 of management were more outside the hospital. I think
2 we were pretty much left to get on with it.
3 Q. By whom?
4 A. By the next-ups, that's the CD for medicine and the CD
5 for RAD.
6 Q. Sorry, the CD for medicine?
7 A. Dr Curry and Dr Simpson.
8 Q. I now want to move on, Dr Johnston, to look at some
9 patients with you that you may have had some involvement
10 with during this particular time that we are looking at.
11 The first patient that I want to look at is
12 Mary Broadley.
13 A. Could I have the notes?
14 DAME ELISH: My Lord, before moving on to specific patients,
15 I wonder whether or not -- two issues: whether or not my
16 learned friend could take from the witness -- reference
17 was made regarding the path of treatment and
18 progressively what you would do to address hydration,
19 and the witness referred to PEG being a possibility,
20 although that wasn't tolerated well. I wonder if the
21 doctor could indicate whether or not that was
22 a particular issue for frail geriatric patients with PEG
23 systems and the degree of how unpleasant it was for
24 those patients?
25 LORD MACLEAN: Hold on. What is PEG? Have I heard about
89

1 PEG?
2 DAME ELISH: Yes, you have, it is a form of gastro feeding
3 for those who are not taking food in -- feeding orally.
4 LORD MACLEAN: Mr MacAulay, do you want to deal with it
5 here?
6 MR MACAULAY: Yes, I'm quite happy to deal with it now,
7 my Lord, before we look at the cases.
8 We had some discussion about hydration, and I think
9 you indicated that, with certain patients, hydration can
10 be a challenge; is that right?
11 A. Yes. A confused patient who is pulling lines out and
12 can't swallow, you have a problem.
13 Q. Looking at the paths of treatment that you mentioned,
14 nutrition by way of a tube was something that you
15 envisaged; is that correct?
16 A. Well, it's something that had to be considered.
17 Q. How would that work in practice?
18 A. In practice, it's an invasive procedure. It's an
19 endoscopic gastrostomy tube, and for the very reasons
20 that a patient might be pulling out intravenous lines --
21 confusion, agitation -- they could easily pull out a PEG
22 tube and injure themselves. It is really more suitable
23 for patients who lack normal bowel activity and need to
24 be PEG-fed for a while, but it is not often considered,
25 if only to exclude it. It is occasionally used in
90

1 stroke patients who have lost their swallow, but there
2 is generally a very high mortality in these patients and
3 it is not often used.
4 Q. You would assess each patient individually and come to
5 a view as to what you should do?
6 A. Mmm-hmm.
7 Q. You can't generalise, you look at each individual
8 patient?
9 A. That's right. Essentially, if a patient can't swallow,
10 they will aspirate their secretions into their chest and
11 develop a pneumonia and die. It is an end-of-life type
12 of phenomenon. You have to balance the treatment you
13 are offering with the prospects for survival and quality
14 of life.
15 Q. The end-of-life point you raise is something that
16 reminds me I should have taken up with you. What was
17 the approach at the relevant time to end of life in
18 patients who were terminally ill? We have heard
19 reference to the Liverpool pathway, for example.
20 A. Yeah. We use the Liverpool care pathway nowadays, which
21 essentially documents that the patient is no longer able
22 to swallow and take normal medication and they just have
23 symptomatic relief. We didn't, I don't think, have the
24 Liverpool care pathway at that time, but the principles
25 are broadly similar, that you go into a symptom
91

1 management pathway for the patient, rather than
2 a treatment pathway.
3 LORD MACLEAN: Before we go to any of the cases themselves,
4 could I ask you, going back a little bit, what does the
5 acronym CD stand for?
6 A. Clinical director.
7 LORD MACLEAN: Director?
8 A. Yes.
9 LORD MACLEAN: That is in each of these directorates; is
10 that right?
11 A. That's correct, yes.
12 MR MACAULAY: We were looking at the PEG approach within the
13 context of nutrition and hydration. I may have asked
14 you about this already, about fluid balance charts, but
15 in particular, if a patient was in receipt of IV fluids,
16 would you expect fluid balance charts to be kept in that
17 situation?
18 A. They do, yes. They would. I have to say that in
19 palliative care, one would not normally be doing blood
20 tests or keeping charts of any sort, they'd just be
21 doing symptom management.
22 Q. Just if we can come back to that, if you had a patient
23 who was in receipt of IV fluids, would you, in that
24 situation, check to see if proper fluid balance charts
25 were being kept?
92

1 A. You would need to have -- I would check, but you'd also
2 need to have somebody checking it every day. It needs
3 to be a systemic approach.
4 Q. Do you mean by that the junior doctor?
5 A. Yes.
6 Q. So when you did your ward round, you would check?
7 A. Yes.
8 Q. Perhaps another point in relation to palliative care, if
9 that was the route that was being adopted, then, would
10 that be recorded in the notes?
11 A. I see this coming up. In these particular
12 circumstances, active treatment to palliative treatment
13 happened very, very quickly in some of these cases. The
14 word "palliative" may or may not be in the notes, but
15 you will see other clues as to what's being stepped
16 down.
17 Q. So whether the word "palliative" was used or not, you
18 would say there should be some indication in the
19 records?
20 A. Say, for example, you've got a patient who can't swallow
21 and who is on IV fluids and there is a discussion as to
22 what to do about it, and it says the patient is not for
23 PEG or NG and they have a DNAR, then even if the ward
24 "palliative" doesn't appear in the notes, it's fairly
25 obvious looking at the pointers that that is what is
93

1 happening.
2 Q. Does that set out a plan of management, then, if that is
3 what you have in the notes?
4 A. You have to document what you are not going to do. It
5 is not just putting in a DNAR. You have to document.
6 Q. Would you document what you would be doing as well?
7 A. You would be, yes.
8 Q. Perhaps I can just pick up a point that was raised with
9 you, I think possibly by his Lordship, in relation to
10 staffing and, in particular, the staffing from the
11 nursing perspective, did you have any discussions with,
12 for example, Liz Rawle as to what the position was in
13 relation to nurse staffing?
14 A. I had lots of discussions with Liz Rawle on an almost
15 daily basis for all aspects of the Vale, including
16 nursing, and I would always take a problem that nurses
17 had expressed to me to Liz Rawle to see if it could be
18 dealt with.
19 Numbers of staffing -- if the nursing staff said,
20 "Oh, we're short", then I would double-check it with
21 Liz Rawle to make sure that she -- she was usually aware
22 of the position already and had usually dealt with it,
23 but I formed a close working relationship with her.
24 Q. Did that happen, that nurses would say to you that they
25 were short staffed and you would take that up with
94

1 Mrs Rawle?
2 A. Yes, and sometimes they were and sometimes they weren't.
3 It depends what their template was and whether people
4 were off sick and so on.
5 MR MACAULAY: I do propose to move on to look at
6 Mrs Broadley, but, my Lord, looking to the hour, that
7 might be best dealt with after lunch.
8 LORD MACLEAN: Yes, all right. 2 o'clock, please.
9 (12.57 pm)
10 (The short adjournment)
11 (2.00 pm)
12 MR MACAULAY: Good afternoon, my Lord.
13 Good afternoon, Dr Johnston. Can I then move on to
14 look first at the case of Mrs Broadley? The medical
15 records for the Vale of Leven for Mrs Broadley are at
16 GGC00050001. You may have a hard copy, do you,
17 Dr Johnston? Would you prefer to have a hard copy?
18 A. I have got a hard copy. Thank you.
19 Q. Mrs Broadley was initially admitted to the
20 Royal Alexandra Hospital following upon a fall, and she
21 fractured the neck of her right femur; is that correct?
22 A. I wasn't involved in her initial admission, so I don't
23 know.
24 Q. Have you had the chance of looking at the records?
25 A. She was to and fro, yes.
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1 Q. She was transferred to the Vale of Leven, ward 14, on
2 27 September 2007, and she had a fall in the
3 Vale of Leven on 13 October 2007, when she fractured her
4 left wrist, and she required to be transferred back to
5 the Royal Alexandra Hospital, but then she was back
6 again in the Vale of Leven on 15 October, and then, on
7 15 November, she had another fall, when she fractured
8 her radius and ulna and also the right femur. Were you
9 able to ascertain from the records that she had a number
10 of falls and a number of fractures?
11 A. Yes.
12 Q. It is when she returns to the Vale of Leven on
13 23 November 2007, after having been treated in the
14 Royal Alexandra Hospital for that fall, that she comes
15 under your care; is that right?
16 A. That's right.
17 Q. If we look at the notes at page 28, I think, as we see
18 there, for 23 November it is noted that she's returned
19 to ward 15; is that correct?
20 A. Yes, that's her first admission to ward 15.
21 Q. That is when you first dealt with her?
22 A. That's right. I think that was a Friday.
23 Q. I'm sorry, you didn't see her yourself on that day --
24 A. No.
25 Q. -- but this is the time when she came under your care?
96

1 A. That's correct.
2 Q. You do first see her, if we look to the next entry,
3 26 November, that is your handwriting; is that correct?
4 A. That's correct.
5 Q. What you have noted there, I think -- is that "Falls"
6 and is that "Dementia"?
7 A. Yes.
8 Q. You give some information about what the result of
9 the fall had been; is that correct?
10 A. And I also talk about medication.
11 Q. Yes. So that is the first time you have seen her after
12 her admission to ward 15?
13 A. Yes.
14 Q. You see her again on 3 December. We see that towards
15 the bottom of the page; is that correct?
16 A. Yes.
17 Q. The gap in the medical notes -- I'm not suggesting that
18 you should necessarily have seen her again yourself, but
19 do you consider there should have been some medical
20 review between these two dates?
21 A. I'm just checking the days. The 26th is a Monday and
22 the 3rd is also a Monday, so there should have been
23 a note of Dr Herd's ward round in between those two
24 days.
25 Q. What about any ongoing review? Would you expect any
97

1 other input, apart from Dr Herd?
2 A. Well, there wasn't any other input, apart from Dr Herd.
3 The point about the medication is that these medications
4 rendered her at increased falls risk, and so what I was
5 doing was dealing with the reduction of that risk by
6 taking away these medications. Olanzapine is an
7 antipsychotic that has side effects of parkinsonism, and
8 can lead to poor balance and falls, so that's why that
9 was withdrawn.
10 Q. You're suggesting she should at least have been seen by
11 Dr Herd during this period --
12 A. He did a ward round on a Thursday, so I would normally
13 expect his writing to be in the notes.
14 Q. What we see in the next entry, for 4 December, is an
15 entry by an SHO; is that correct? Page 29.
16 A. Yes. That would be somebody who was called in the
17 afternoon to see the patient, on the Tuesday afternoon.
18 Q. This person has formed the view that she may be
19 suffering from C. diff; is that correct?
20 A. I see that, yes.
21 Q. If we look at microbiology, if we turn to page 80, can
22 we see here that a sample was collected on 4 December,
23 received by the lab on the 5th, and that proved to be
24 a positive result?
25 A. Yes, that's correct.
98

1 Q. If we turn then to page 30 of the records, on
2 5 December, that note that we have for the 5th, is that
3 Dr Herd?
4 A. That's Dr Herd.
5 Q. I think it reads:
6 "C. diff confirmed. Already on metronidazole."
7 Is that correct?
8 A. I think that's correct.
9 Q. Would you have expected Dr Herd to have carried out
10 a clinical examination of the patient?
11 A. He may well have carried out a clinical examination, but
12 it's not recorded.
13 Q. Would you have expected him to have recorded such an
14 examination?
15 A. Yes, I would have.
16 Q. Just so I understand the position with a patient with
17 C. diff, if a patient is diagnosed with C. diff, would
18 you expect to be contacted by the junior staff?
19 A. If you asked me -- yes, now I would expect to be
20 contacted --
21 Q. No, then. Please, we are looking at this time frame.
22 A. At that time, I can see that patients had diarrhoea,
23 then stool samples and positive C. diff, but I was not
24 necessarily always informed at the time.
25 Q. So you have taken that from the records you have looked
99

1 at?
2 A. Yes.
3 Q. What I am asking you is, would you have expected to have
4 been contacted --
5 A. Yes, I would expect to have been contacted.
6 Q. Because I think, as we discussed this morning, C. diff
7 can be a serious illness, particularly in the elderly?
8 A. Yes.
9 Q. So you'd expect to have some input --
10 A. Yes.
11 Q. -- at an early stage?
12 A. Yes.
13 Q. If we look at the entries following the one we have just
14 looked at for 5 December, there is a short entry on
15 6 December. I think, again -- is that Dr Herd again?
16 A. That looks like it.
17 Q. For --
18 A. That's subcutaneous, I think.
19 Q. For subcutaneous fluids. Then we have the next entry on
20 the 12th, which is to do with her plaster; is that
21 right?
22 A. It looks like it.
23 Q. So when is the next medical review, then, after the 5th
24 and the 6th?
25 A. Judging by the calendar, there should be an entry by me
100

1 on Monday the 10th, but I don't see one.
2 Q. Can I ask you this before we look at that: with
3 a patient who is elderly, as this patient is, and
4 I think she was 92 when she died, on 22 January, and
5 she's tested positive for C. diff, would you have
6 expected some ongoing review of that patient?
7 A. I would, yes.
8 Q. Do you see any evidence of that in the records?
9 A. Not in that point, no.
10 Q. The next page, if we can put the next page beside the
11 one we have on the screen, is page 31. We have another
12 entry I think by Dr Herd on the top of the page for
13 13 December; is that correct?
14 A. Yes.
15 Q. So far as medical input in relation to her C. diff is
16 concerned, we had this entry on the 6th, and we have
17 this entry on the 13th, and no further input. Would you
18 have expected some more input than that for a patient of
19 this type who is ill with C. difficile?
20 A. I would have expected, yes.
21 Q. So far as your own input is concerned, Dr Johnston, am
22 I right in thinking that the next entry after the 13th
23 is yourself, on 17 December?
24 A. Yes.
25 Q. This is, I think, the third time, in fact, you had seen
101

1 the patient. You had last seen the patient on
2 3 December?
3 A. I cannot explain the gap at the moment.
4 Q. We have a two-week gap there?
5 A. Yes, because I did a weekly ward round, so I can't
6 explain it.
7 Q. What have you noted for the 17th?
8 A. That she'd had a number of -- well, she had MRSA, she
9 had had the norovirus and she'd had C. diff and that she
10 was not mobile at that stage, but I wouldn't expect her
11 to be if she'd had these infections.
12 Q. Is it at all acceptable, then, Dr Johnston, that this
13 particular patient did not get more regular review,
14 particularly after she contracted C. diff?
15 A. I think it's not acceptable, but in the light of
16 the knowledge at the time, it was fairly typical,
17 I think, of getting caught up.
18 Q. Sorry, could you elaborate upon that? What do you mean
19 by that?
20 A. I think it's understandable at the time, in that I don't
21 think we realised quite what was going to happen at the
22 Vale, so this might be a very early case -- in fact, it
23 was.
24 Q. I still don't understand that, Dr Johnston. This
25 morning, I think you said that it was recognised that
102

1 C. diff could be a serious illness; is that right?
2 A. Yes, I'm not denying that.
3 Q. So what are you saying? If you have a 90-year-old
4 patient who has contracted C. diff, could there be any
5 excuse for such a patient not being seen on a more
6 regular basis by the doctors?
7 A. I think a lack of doctors might explain some of that,
8 but not -- I would -- I did a weekly ward round, unless
9 I was doing medical receiving at that time. But I can't
10 evidence that I was medical receiving that day.
11 Q. You say a lack of doctors might explain it, but is that
12 an excuse for a patient not being seen, if a patient is
13 ill?
14 A. I think if you're trying to systemically manage an
15 infection such as C. diff, it has to be a daily basis,
16 and it is not one individual that can cover all domains.
17 A weekly or twice-weekly ward round still leaves the
18 possibility that the patient may deteriorate in between
19 times, so there needs to be a mechanism that can
20 identify, and that usually involves staff.
21 Q. Are you suggesting to the Inquiry, then, that the reason
22 why we may see this in some of your other cases, the
23 reason why there may be these gaps in review is down to
24 short staff?
25 A. Partly, but also staff working elsewhere. But also
103

1 there's the possibility that I've seen the patient and
2 I haven't noted anything in the notes. I don't know.
3 LORD MACLEAN: But surely that answer, "Partly, but also
4 staff working elsewhere", that must all come within the
5 lack of staffing, mustn't it?
6 A. Yes.
7 MR MACAULAY: You saw Mrs Broadley on 17 December, and
8 I think you noted, "Has had MRSA, C. diff and
9 norovirus". At that time, do you know if she was
10 suffering from diarrhoea or not?
11 A. I can't tell you that.
12 Q. If we look at page 73 of the records, do we see here
13 that on the same day that you saw her, a specimen seems
14 to have been collected from her, received by the lab on
15 18 December, and that tested positive for C. diff?
16 A. I can see that a specimen has been collected on the
17 17th, but not the time at which it was collected.
18 Q. I fully understand that, and I'm not suggesting it
19 happened before you saw her, but as far as the date is
20 concerned, it coincides with the date you saw her?
21 A. Yes.
22 Q. You can see that the specimen comment is that it is
23 liquid. Can you see that?
24 A. I do see that.
25 Q. If we go back to the clinical notes themselves, on
104

1 page 31, can we see that the next entry is by Dr Herd;
2 is that right?
3 A. Yes.
4 Q. If we look at the nursing notes on page 126, and we can
5 keep page 31 on the screen, we see towards the bottom of
6 that page that there is an entry for the 16th which
7 suggests "Loose stools before going to bed". Do you see
8 that?
9 A. I see that.
10 Q. We know that on the 17th a specimen was collected. If
11 we go back to the clinical notes, the fact that she may
12 have had loose stools or be suffering from loose stools
13 is not something that you were able to elicit, or if you
14 did elicit it, you didn't note it?
15 A. I think this illustrates that -- well, sorry, I should
16 answer your question. It is something that may not have
17 been given to me.
18 Q. Do you think that, particularly if you are looking at
19 a patient who, as you have noted, indeed, had been
20 suffering from C. diff, that that is the sort of
21 information you should have obtained?
22 A. Yes.
23 Q. What I'm putting to you is that, really, you should have
24 inquired to see what the position was with her loose
25 stools; is that fair?
105

1 A. My experience of asking for information from different
2 nursing staff is that with shift changes, you get
3 a slightly different version or a different version, and
4 the information that you ask for may come out as
5 negative or positive, depending on who is on.
6 DAME ELISH: My Lord, I wonder if my learned friend could
7 have the witness look at the next entry, for
8 17 December, which relates to the ward round which
9 Dr Johnston carried out on the 17th and whether or not
10 there is any mention in the nursing note of C. diff
11 being discussed with the doctor?
12 LORD MACLEAN: Before that may be explored, what was your
13 practice when you did carry out a ward round? Did you
14 look at the nursing notes that preceded it?
15 A. The nursing notes were kept in the ward manager's
16 office. I didn't have access to the nursing notes
17 during ward rounds or afterwards. I mean, I could have
18 gone and looked for them, but I would expect that the
19 nurse who was on the ward round was up to date and would
20 be able to tell me the things that I needed to know.
21 The notes are all filed together when the case note
22 is returned for filing, and you see the notes as a whole
23 piece, but at the time, these parts were separate.
24 LORD MACLEAN: So that is why you say you were dependent on
25 getting information from the nurse?
106

1 A. Yes.
2 LORD MACLEAN: I mean verbally, orally.
3 A. Yes.
4 LORD MACLEAN: Do you want to take up Dame Elish's question?
5 MR MACAULAY: I will pick that up, but perhaps before I do,
6 in case I lose sight of it, you made a point there about
7 nurse shift changes and getting different versions on
8 shift changes from nurses. What did you mean by that?
9 A. Well, what can happen is that a piece of information
10 gets lost the more times it passes through groups of
11 nursing staff, and what may seem a priority at the time
12 becomes less of a priority by the time it hits the ward
13 round.
14 MR MACAULAY: Is this a situation, particularly if you are
15 looking to see what a patient's history with regard to
16 diarrhoea and loose stools might have been, where
17 a stool chart can play an important role?
18 A. Yes. I think it draws the attention of the staff in
19 order to make the chart in the first place, but you're
20 still reliant on the verbal contact, and if you've got
21 a nurse who's not done the previous day's stool chart,
22 you might not get the right information unless they
23 bring the chart with them.
24 Q. I will come to the nursing note in a minute, but if we
25 go back to your own record, then, of the 17th, that does
107

1 not give us any information at all in relation to her
2 diarrhoeal status at that time; is that fair?
3 A. It says past tense, but inferred perhaps that it's over,
4 but we can't say for definite from that.
5 Q. It doesn't mention diarrhoea or loose stools, certainly?
6 A. No, it doesn't.
7 Q. If we look at the nursing note that my learned friend
8 raised with me, it is at page 126. We looked at the
9 loose stools reference, then the 17th, "Ward round
10 1510". Would that be about the correct time for your
11 ward round?
12 A. That's not a ward round comment. 1510 is a visiting
13 time comment, because I did my ward rounds in the
14 morning.
15 Q. You are quite right. The first reference is "Ward
16 round - to discuss future care with family", and that's
17 been signed off.
18 A. That's right.
19 Q. So that's when you would be present?
20 A. I would be present, but the second one would be the
21 nurse telling the family to make an appointment.
22 Q. I'm not sure where that takes us. So there was some
23 discussion, then, between you and the nursing staff that
24 there would be some discussion about future care with
25 the family. Is that what one takes from that?
108

1 A. Yes.
2 Q. If we go back then to the clinical notes, the next entry
3 is on 18 December, and I think you did confirm for me
4 that this again was Dr Herd; is that right?
5 A. Yes.
6 Q. Is this dealing with the discussion that had taken place
7 between Dr Herd and family members?
8 A. Yes, that's not a ward round, that is a meeting with
9 family.
10 Q. What medical assessment, if any, has there been of this
11 second diagnosis of C. difficile with this patient?
12 A. Sorry, could you repeat that?
13 Q. Yes. What medical assessment has there been of
14 Mrs Broadley following upon the diagnosis of C. diff at
15 this time?
16 A. I'm not sure what you're referring to.
17 Q. Can we look at the records, then? You have indicated
18 that the entry for the 18th is Dr Herd dealing with the
19 family. If we look to page 32 of the records, I think
20 that is the next entry we have. Can we put that page
21 next to the page on the left? So on the 20th, there is
22 an entry which is a referral to a consultant
23 psychiatrist; is that correct?
24 A. Yes.
25 Q. On the 20th also there is an entry dealing with her
109

1 plaster; is that right?
2 A. Yes.
3 Q. And similarly on the 21st; is that right?
4 A. Yes, that's right.
5 Q. Is the next clinical entry that indicates that there may
6 have been some examination of the patient on
7 27 December?
8 A. Yes, that's Thursday.
9 Q. So if we look to the left-hand side, we have got your
10 entry for 17 December. We know that Mrs Broadley tested
11 positive at about that time. What I was asking you is,
12 is there any evidence of a medical review of
13 Mrs Broadley after she had tested positive for C. diff
14 on this occasion?
15 A. I would expect my medical review to be contained within
16 the ward round, which, on the 24th, Christmas Eve,
17 of December that year, I was doing medical receiving, so
18 there wouldn't have been a ward round that day.
19 Q. We'll come to the reasons why there may not be, but the
20 first point is, is there any evidence of a medical
21 review?
22 A. No, there's no evidence.
23 Q. Should there have been a medical review of this patient
24 who's now tested positive for a second time?
25 A. Yes, there should have been.
110

1 Q. I think you were moving on, Dr Johnston, to explain why
2 you may not have been able to see the patient; is that
3 right?
4 A. Yes.
5 Q. What was the position?
6 A. Sorry, Monday, I don't -- didn't normally do medical
7 receiving, but because of the Christmas arrangements,
8 I was down for that. So that meant that my morning
9 would be taken up doing my acute receiving ward round
10 and another ward round later in the afternoon. I would
11 normally pop into the ward to see if there were any
12 problems that the ward was aware of, but I didn't have
13 a formal round.
14 Q. But if you have a patient under your care that tests
15 positive, as we know, on or about 17 December, why is it
16 not possible for someone, a doctor, to carry out
17 a medical review of that patient at about that time?
18 A. Well, Dr Herd was in on a Monday afternoon. He would
19 have been available to see the patient.
20 Q. So this would be a matter for Dr Herd to explain, then,
21 as to why he didn't review the patient?
22 A. He sort of -- not quite covered for me, but he was
23 certainly there.
24 Q. Dr Herd, he was one of the GP practitioners; is that
25 correct?
111

1 A. That is correct, yes.
2 Q. Who worked part time?
3 A. Part time in the hospital, yes.
4 Q. In the hospital?
5 A. Yes.
6 Q. But you say Monday would be one of his days; is that --
7 A. Yes.
8 Q. Can you help me with that? I think you may have touched
9 upon it this morning. What other days did he work in
10 the ward?
11 A. I think he -- you need to ask him when you see him, but
12 the Tuesday morning I recall was done by Dr Garthwaite,
13 another partner, and the other three days Dr Herd was
14 in, but which part of the day, I can't recall.
15 Q. Here we have a situation, Dr Johnston, as we can see,
16 where the patient has tested positive for C. diff.
17 There has been no medical investigation into that
18 diagnosis. It could be said that this indicates that
19 C. diff was not looked upon as of particularly high
20 priority in the Vale of Leven at that time; would that
21 be fair comment or not?
22 A. I think at that time -- well, the lady had two other
23 infections. The ward was closed at one point
24 in December with norovirus. There was a lot happening
25 in the ward. I'm not saying that by way of excuse, but
112

1 I think there was a lot of other things going on.
2 DAME ELISH: Sorry, my Lord, I wonder if I could also ask my
3 learned friend to confirm whether or not the record of
4 20 December suggests that MRSA had been eradicated in
5 the patient, which is, as I understand it, a potentially
6 life-threatening condition?
7 MR MACAULAY: I think that is the 27th. I may be wrong
8 about that.
9 DAME ELISH: The 27th, yes.
10 A. This patient was already isolated because of MRSA.
11 MR MACAULAY: The question I put to you is whether one can
12 infer from the lack of medical input for the
13 C. difficile infection at this time whether it could be
14 said that that's indicative of C. difficile not being
15 given particularly high priority at that time?
16 A. I don't think you can infer that. It's just probably
17 a general lack of cases and experience, rather than not
18 thinking it's a high priority.
19 DAME ELISH: I wonder again, my Lord, if my learned friend
20 could refer the witness, if he considers it appropriate,
21 to page 127 and to the entry dated 19 December?
22 MR MACAULAY: I'm quite happy to do that, if it helps.
23 Let's put 127 on the screen. We now have it on the
24 screen. I think the ward is aware of the positive
25 C. diff result, certainly on the 19th. I'm looking to
113

1 see what the reason I'm being referred to this
2 particular note is.
3 DAME ELISH: The reference, my Lord, to the consultation
4 with the microbiologist.
5 MR MACAULAY: Yes, I see that.
6 This is with the nurses and the microbiologist?
7 DAME ELISH: I think also the microbiologist orders an
8 escalation of the treatment to vancomycin.
9 MR MACAULAY: Does this help you at all in giving us
10 assistance as to what is going on at this time?
11 A. Yes. The nurses can't prescribe vancomycin, so clearly
12 there is evidence of involvement of the junior doctor,
13 whoever that is, and microbiology. It is also written
14 in retrospect due to busyness of the ward, which I think
15 gives some insight as well.
16 Q. Certainly there is nothing I think we have seen in the
17 clinical notes to indicate that this sort of discussion
18 took place?
19 A. You have to look at all the nursing notes and the
20 medical notes to get the feel of where the communication
21 was going, because sometimes the microbiologist was just
22 leaving messages with nursing staff who then passed on
23 to doctors.
24 Q. You should be able to tell from the clinical notes what
25 input the doctors --
114

1 A. It should be written down, yes, but the treatment must
2 have changed.
3 LORD MACLEAN: Of course, the prescription would have to be
4 authorised by a doctor, wouldn't it?
5 A. Yes.
6 LORD MACLEAN: That's why you infer this was the input of
7 a junior doctor?
8 A. Yes.
9 LORD MACLEAN: But, of course, the vancomycin is not
10 recorded in the clinical notes. It will be in the
11 Kardex.
12 A. It will be in the Kardex, yes.
13 MR KINROY: My Lord, I wonder if we could look at the
14 Kardex?
15 MR MACAULAY: Yes, GGC27170007. Is this the vancomycin
16 being prescribed on 20 December?
17 A. That's correct.
18 Q. Can you help as to who may have prescribed the
19 vancomycin?
20 A. That is Dr Herd's writing.
21 Q. Do we take from this that the first administration of
22 this medication, then, was on 20 December?
23 A. If that's the complete record, yes.
24 Q. We can check this out, but if that is correct, does it
25 appear that there may have been a delay?
115

1 A. If that's correct, yes.
2 MR KINROY: My Lord, I'm not sure, does this establish that
3 there was not, then, a failure to review the patient
4 between 17 December and 27 December, but a different
5 point, that the vancomycin was not prescribed until the
6 20th? I'm not sure how my learned friend sees this.
7 LORD MACLEAN: So far as I see it, Mr Kinroy, and so far as
8 the clinical records go -- I mean the actual medical
9 clinical records -- there is no assessment. But plainly
10 there must have been something done in order for the
11 vancomycin to be prescribed, presumably following the
12 metronidazole.
13 A. Yes. I think it's a point Dr Herd might be able to
14 answer.
15 LORD MACLEAN: Yes. Thank you.
16 MR MACAULAY: If we go back to the clinical records, then,
17 with you, Dr Johnston. We, I think, had got to page 32.
18 If we go back to page 32, I think I'd taken you to the
19 point where there was some involvement with her plaster
20 on 21 December, and then we have the gap from the 21st
21 to the 27th where there is reference by Dr Herd to MRSA.
22 The next involvement we have from yourself is on
23 31 December; is that right?
24 A. That's correct.
25 Q. You have now noted she's been C. diff positive times 2;
116

1 is that correct?
2 A. Yes.
3 Q. Did you, as at this time, looking to the two occasions
4 that Mrs Broadley tested positive for C. diff, have any
5 input at all into her management for C. diff?
6 A. Apart from my ward rounds, I don't recollect, although
7 I was in the ward on -- once or twice during the week
8 each week, so I may have discussed it, but there is
9 nothing in the notes.
10 Q. If we turn to page 33 of the records, I think we have
11 another entry by Dr Herd. Is that 2 or 7 January? It
12 is difficult to --
13 A. I can't work that one out.
14 Q. Is the next entry we have, then, for yourself on
15 10 January?
16 A. Yes.
17 Q. What was the plan at that point?
18 A. Well, that was really a combined entry from the ward
19 rounds, multidisciplinary assessment and a meeting
20 thereafter with Mrs Broadley's son and Sister Rawle. So
21 the first part deals with her functional capabilities,
22 considers that she remains a high falls risk and
23 a little bit about psychiatry, and then the meeting with
24 the son.
25 Q. Then if we move on to the next positive result for
117

1 C. diff, if we can put the lab report on the screen, at
2 page 67, can we see here, Dr Johnston, that there's
3 a specimen collected on 12 January, received by the lab
4 on the 15th, and this, again, is a positive result?
5 A. Yes.
6 Q. Although the receipt date for the lab is the 15th, if we
7 look at page 131 of the records, can we see that for
8 the 14th, at 1810, the ward is in fact aware that
9 Mrs Broadley is once again C. diff positive?
10 A. The 14th?
11 Q. It reads:
12 "Phone call earlier this evening from the labs.
13 Mary is C. diff positive."
14 A. Yes.
15 Q. If we go back to the clinical records, on page 33,
16 there's an entry for the 14th. Is that you or is
17 that --
18 A. I think that's me.
19 Q. It looks like your handwriting. What does it read,
20 "Awaits ..."?
21 A. "... ARG", area resource group, which is -- where
22 patients are moving on to nursing homes, their
23 applications go for assessment.
24 Q. Then we have an entry on the 15th?
25 A. I think that's Dr Garthwaite.
118

1 Q. He has, I think --
2 A. He's dealt with the result and phoned Dr De Villiers.
3 Q. He's been given some advice by Dr De Villiers as to the
4 treatment; is that correct?
5 A. That's correct.
6 Q. So far as you can make out from Dr Garthwaite's note, is
7 there evidence here of a clinical assessment being
8 carried out?
9 A. I can't see evidence of it.
10 Q. Then if we turn to page 34 of the notes, there's an
11 entry on the 17th which suggests that Mrs Broadley has
12 a rectal prolapse, or question mark; is that right?
13 A. Yes.
14 Q. I think that is Dr Herd. I think we're beginning to
15 understand his handwriting.
16 A. Yes.
17 Q. Then we have an entry by you on the 21st; is that
18 correct?
19 A. Yes.
20 Q. I think you had last seen her on the 14th, so this is
21 about a week after that. This would be on your ward
22 round, would it?
23 A. That would be right, yes.
24 Q. I'm sorry?
25 A. Yes.
119

1 Q. What have you noted on this occasion?
2 A. What did I ...?
3 Q. What have you noted in your note for the 21st?
4 A. That she was dying.
5 Q. First of all, you said, "3rd episode C. diff"?
6 A. Yes, that's first thing. But she's had a week of
7 treatment with vancomycin and immunoglobulin and it
8 didn't make any difference.
9 Q. You have noted "Terminally ill"?
10 A. Yes.
11 Q. Can you tell me what your thinking was as to why that
12 was your conclusion?
13 A. From my clinical experience, this lady was dying.
14 Q. Did you relate it to her persistent C. diff infection,
15 or to some other cause or causes?
16 A. I think the C. diff would be the major contributory
17 factor.
18 LORD MACLEAN: You wrote "Terminally ill" following "3rd
19 episode of C. diff". In a previous entry you said,
20 "C. diff x2", that's 31 December. When you said "x2",
21 what did you mean?
22 A. Had it twice.
23 LORD MACLEAN: Were you satisfied that she ever was without
24 C. diff?
25 A. Well, there is no guidance or suggestion that we should
120

1 repeat stool assessments after a patient has C. diff
2 because it will be positive for weeks afterwards, so you
3 can move the patient from isolation after 48 hours if
4 the diarrhoea's stopped, but you can't retest them, and
5 you would only know by the lack of diarrhoea that they'd
6 recovered, and also inflammatory markers will come back
7 to normal.
8 LORD MACLEAN: Did you form the opinion that she had three
9 episodes of C. diff, or is it not possible to say that?
10 A. I don't -- I honestly don't remember the detail of it
11 now, because it's a few years ago, but it's possible
12 that -- it's really for the microbiologist to say that
13 she could have persisted.
14 LORD MACLEAN: Yes.
15 A. But I think, from our perspective, we thought at the
16 time that it was three separate episodes.
17 LORD MACLEAN: Right. Thank you.
18 MR MACAULAY: By that you mean she had relapsed --
19 A. Yes.
20 Q. -- on two occasions after the first episode?
21 A. Yes.
22 Q. Correct me if I am wrong, but shortly before this
23 particular diagnosis by you that she was terminally ill,
24 had you been contemplating Mrs Broadley's discharge to
25 a nursing home?
121

1 A. Yes, and the thing about all these cases is the
2 difference between frail ambulant and very unwell indeed
3 can be a matter of days in a frail elderly person. So
4 if it was only the C. diff that was keeping her back --
5 I have described all her functional state to the son.
6 If she'd had an episode that finished and didn't come
7 back again, then she would have been suitable for
8 discharge to 24-hour care, not discharged home.
9 Q. Are you saying it was only the C. diff that was keeping
10 her back, and can we see from the records we have looked
11 at that the medical review of her C. diff, so far as the
12 records go to show, was really quite minimal?
13 A. It looks that way from the records, yes.
14 Q. Looking at the DNAR position here with this patient, if
15 we turn to page 10 of the records, there is a DNAR order
16 that's been completed here, I think by Dr Herd, on
17 10 December; is that right?
18 A. That looks right.
19 Q. "CPR is unlikely to be successful due to dementia and
20 general frailty" is what he's noted?
21 A. That's what he's done.
22 Q. We also have a second DNAR order in this case at page 4
23 of the records, if we could look at that. Here, the
24 DNAR order has been completed by Dr Shaikh, I think, but
25 reviewed by yourself on 21/1/2008?
122

1 A. Yes, I'm puzzled why there are two DNARs.
2 Q. That's the point I was going to raise with you, but you
3 can't explain that?
4 A. The timing is quite different. There is the 15th --
5 what was the first one?
6 Q. Dr Herd's DNAR was 10 December.
7 A. They are quite far apart.
8 Q. We can put them both on the screen, page 10.
9 A. If there is no review date on the first one, then that
10 still stands, although there should be a review date,
11 but it has not been revoked by a line through the
12 middle, so the second one is superfluous.
13 Q. Is one to assume that when the second one was being
14 completed, it had not been realised that there was
15 a first one?
16 A. I think that's fair enough, yes.
17 Q. Insofar as the second one is concerned, whether
18 superfluous or not, you reviewed it on 21 January; is
19 that right?
20 A. Yes.
21 Q. You have maintained the position that dementia was the
22 reason for there to be no CPR?
23 A. I think a combination of extreme old age and dementia.
24 LORD MACLEAN: What is noticeable, actually, is that these
25 forms are not the same, obviously.
123

1 A. There were various --
2 LORD MACLEAN: But "The CPR is unlikely to be successful due
3 to", and there's a blank in the second one. Dementia is
4 mentioned on that, but only in connection with the
5 patient and why the patient was not consulted. Isn't
6 that right?
7 A. Yes, that's right.
8 MR MACAULAY: We can put back on the screen your note for
9 the 21st at page 34, and we can keep that second DNAR
10 order on the screen as well. So your note on the 21st
11 was that she was terminally ill, and I think what you
12 have told us today is that you consider that that was
13 because of the C. diff infection.
14 A. Mmm.
15 Q. Is that right?
16 A. Yes.
17 Q. Now, then, how would you have completed the DNAR order
18 fully if you were to complete the section which says
19 "CPR is unlikely to be successful"?
20 A. I think the C. diff is a treatable infection and it
21 could always be questioned if you put that on a DNAR.
22 It would be more suitable to go with the dementia and
23 frailty.
24 Q. So far as the death certificate is concerned, if we can
25 put that on the screen at SPF00030001, do we see that
124

1 death has been certified by Dr Herd for 22 January 2008,
2 and that Clostridium difficile enteritis is at
3 part I for the cause of death?
4 A. Yes, I see that.
5 Q. If there had been a medical review of this patient
6 during the times that she suffered from C. diff, would
7 that review have involved obtaining blood results to
8 assess the source of the infection?
9 A. It should be, yes. It should do.
10 Q. If we turn to page 39 of the records, we are looking at
11 a report from the biochemistry department in relation to
12 a specimen collected on 19 December 2007. Do you see
13 that?
14 A. Yes.
15 Q. What do you take from this report?
16 A. Well, this would be a first report, an early report,
17 from C. diff. What do I see on it? It basically -- it
18 shows urea and electrolyte function and serum albumin.
19 There's a minimal disturbance of urea. Albumin is
20 a little bit reduced. So there is not much amiss with
21 this record.
22 Q. Does that give any indication in relation to hydration?
23 A. Not much amiss, I would say from that. Indeed, her
24 filtration rate, eGFR, at 59 is -- well, normal is 60,
25 so she's doing very well.
125

1 Q. You will have had the opportunity of going through the
2 records, Dr Johnston. Have you seen any other blood
3 results after 19 December in the records?
4 A. I don't recollect. I don't know whether I have seen
5 them and forgotten. I don't know.
6 Q. Looking to the situation of a patient who has had
7 C. diff on three occasions at about this time
8 in December and subsequently in January, I think you
9 indicated a moment ago there should have been some
10 further blood sampling done?
11 A. Yes. Blood sampling is something that is normally
12 generated at ward level by the junior doctor on
13 a regular basis. If what you are saying is true, then
14 this hasn't been done.
15 Q. Should you pick that up on your ward rounds and that
16 hasn't happened?
17 A. I should have picked it up on my ward rounds.
18 Q. Taking blood results provides the clinician with some
19 idea as to the severity of the infection; is that right?
20 A. That's correct.
21 Q. Can you put forward a reason why this hasn't happened?
22 Is it maybe because the records show that the medical
23 review that took place of this patient was really
24 minimal?
25 A. I think it looks like it was minimal and it should be
126

1 something, as I say, that's generated by the ward doctor
2 on a regular basis, according to patient.
3 Q. Who do we look at for this, then? Would this be
4 Dr Herd?
5 A. This would be Dr Herd. I would expect him to have
6 monitored this patient.
7 Q. From the records that we have seen, the clinical records
8 that we have seen, and Dr Herd's involvement with the
9 patient, is there any evidence in what he's noted that
10 he carried out any clinical examinations of the patient?
11 A. No.
12 MR PEOPLES: My Lord, I wonder -- before Mr MacAulay goes
13 on, there was reference, when looking at the report on
14 the screen, that her filtration rate was 59 and normal
15 was 60. I just wondered what the reference to the range
16 in brackets is from 90 to 140? Is that an indication of
17 normality?
18 MR MACAULAY: I think we are looking towards the top right
19 section of the actual report. Can you help us with
20 that?
21 A. 60 and above is normal. There is a range of normal.
22 Below 60 there is a degree of chronic renal failure.
23 I would describe that as a normal.
24 Q. Because it is 59?
25 A. Yes.
127

1 MR KINROY: My Lord, I don't think we have had an
2 explanation of what this filtration really is? I wonder
3 if we could get that clarified.
4 MR MACAULAY: Can you help us with that?
5 A. Glomerular filtration is the method by which waste
6 products are excreted by the kidney into the urine. It
7 is like a continuously moving cycle of excretion and it
8 tends to decrease as you get older, and it would be
9 regarded as a normal feature in a lady of this age to
10 have a reduced glomerular filtration rate. The fact
11 that hers is normal means she's physiologically younger
12 than her age.
13 MR KINROY: My Lord, I wonder if I could just clarify what
14 that tells us about the state of hydration of
15 the patient from moment to moment, then?
16 A. The actual hydration of the patient, the creatinine
17 gives you the baseline renal function, the urea gives
18 you the state of hydration, so you'd be looking at the
19 urea mainly to look for state of hydration. Anything
20 below 7 is completely normal, and many elderly people
21 are on medications, such as diuretics, which will
22 produce a slight dehydration picture, so I would say
23 that this patient's blood sample is normal.
24 MR MACAULAY: You mentioned, I think, a little while ago,
25 Dr Johnston, that you did carry out some assessment of
128

1 this patient in connection with her falls; is that
2 correct?
3 A. Yes, I did.
4 Q. That was a problem this patient had in the
5 Vale of Leven: she had a number of--
6 A. Yes, this lady had a number of falls, yes.
7 Q. What were you seeking to achieve in your assessment?
8 A. Well, I was looking at the medical side of her falls.
9 The nursing staff, physiotherapists, do their own falls
10 assessment and environment of the ward, et cetera, and
11 supervision, but the medical side has to be looked at as
12 well to see if there are any neurological features that
13 might make the patient fall, what the medication was, if
14 there's a postural drop in blood pressure, so it is just
15 removing things that might cause harm.
16 Q. If we look at page 141 of the records, there's a record
17 here recording Mrs Broadley's weight during the time
18 that she was in the Vale of Leven. Do you see that?
19 A. Yes, I do.
20 Q. If you look at page 140, can we see that her weight has
21 reduced from 41.3kg to 35.4kg shortly before she died.
22 A. Yes.
23 Q. So she has become very frail over that period; is that
24 right?
25 A. That's right.
129

1 Q. Would you relate that, at least to some extent, to the
2 fact that she contracted C. diff and was suffering from
3 C. diff for a period --
4 A. Yes, she had a marked weight loss in C. diff plus the
5 anorexia from taking the medication, because some of
6 the medication leaves a very metallic taste in the
7 mouth.
8 Q. If we turn also, please, to page 94 of the records, we
9 are looking here at the Kardex, the second entry on the
10 Kardex, beginning -- it is for lactulose, beginning on
11 20 December 2007, and can you see, as you move along the
12 page, that that prescription for lactulose continues
13 through into January?
14 A. I see that. I'm not quite sure what 14 means at the
15 top.
16 Q. Sorry?
17 A. The number "14" at the top.
18 Q. "14" in the code means "refer to records for the patient
19 not getting the medication"?
20 A. Does that mean the patient didn't get the medication?
21 Q. Yes. That is my understanding, Dr Johnston.
22 A. Okay.
23 Q. If you turn to page 101 of the records, just to pick
24 that up, we are given here the code for
25 non-administration of drugs:
130

1 "14. Other - record in nursing notes."
2 If we go back to the Kardex on page 94, can we see
3 that there are quite a number of occasions when the
4 patient did not get lactulose, but there are also many
5 occasions when she did?
6 A. Yes.
7 Q. With a patient who is suffering from C. diff, and she
8 was suffering from C. diff during this period, should
9 that happen?
10 A. No. If the nursing staff are not giving a medication,
11 they should report it to the ward doctor, whoever the
12 ward doctor is, and it should have been scored off.
13 Q. She should not have been given lactulose?
14 A. No. If they start putting these numbers up, then they
15 need to inform the ward doctor.
16 Q. I understand that. But in principle, if you have
17 a patient with C. diff diarrhoea, should that patient
18 with given lactulose at all?
19 A. No, not at all.
20 Q. Is this something that the doctor should pick up?
21 A. Yes.
22 Q. Clearly, you, yourself, did not pick that up when you
23 were carrying out your ward rounds. Is that a fair
24 comment?
25 A. I would have to draw that conclusion, I'm afraid.
131

1 Q. Are you able to express a view, Dr Johnston, as to how
2 you consider Mrs Broadley was managed in the
3 Vale of Leven Hospital?
4 A. I think her management was adequate but it could have
5 been a lot better.
6 Q. If we are looking at the positive side of that, "it
7 could have been a lot better", in what way do you
8 envisage it could have been a lot better?
9 A. In a systemic way, in that, you know, the entire
10 organisation is geared towards surveillance, monitoring,
11 looking at medications. It can't be a one fix, there
12 has to be a systemic improvement.
13 Q. In what way would you consider her management was
14 adequate?
15 A. Well, I'd have to place that against the background of
16 what a mortality risk of a 92-year-old being admitted to
17 hospital was. You're looking at 10 per cent mortality
18 during that time, so any additional mortality would be
19 due to C. diff. In what way did I consider it adequate?
20 I think she was given appropriate nursing care while she
21 was in hospital. In fact, they eradicated her MRSA.
22 I think that medication was given under microbiological
23 advice up to and including immunoglobulin. I think the
24 monitoring side was poor. That's it, really.
25 Q. If one is to focus on the medical input into her care,
132

1 do you consider that to be adequate or inadequate?
2 A. I think the medical input was less than it should have
3 been.
4 Q. Is it possible for you to couch that in terms of
5 adequate or inadequate?
6 A. I think it was adequate, as I said, in so much that she
7 was treated for her illness and the monitoring wasn't
8 adequate, but there was adequate treatment of her
9 illness.
10 Q. Do you consider, having looked at the records, that the
11 medical staff truly appreciated how ill she was with the
12 C. diff diarrhoea?
13 A. I'm not sure that I could answer that.
14 MR MACAULAY: I'm now finished with Mrs Broadley's case and
15 I want to move on to another case, and that is Mr Boyle.
16 My Lord, that might be a point at which to give
17 Dr Johnston a short rest and have a short break.
18 LORD MACLEAN: Just before we do that, could I ask you --
19 the question put to you was whether the medical staff
20 truly appreciated how ill she was. Now, I understand
21 perfectly well that you were not the only treating
22 doctor. What about your own view as to how ill she was?
23 A. At this stage, four years later, it's not clear to me,
24 I have to say.
25 LORD MACLEAN: You can't recall?
133

1 A. No, I can't recall it, really.
2 MR MACAULAY: If I just follow through his Lordship's
3 question, ultimately, as the consultant in charge of
4 the case, would it not be down to you to know how ill or
5 otherwise the patient was?
6 A. Provided I have all the information, yes, it is my
7 responsibility.
8 DAME ELISH: My Lord, I wonder if I could ask my learned
9 friend if he could clarify here, did Dr Johnston not
10 indicate in the records that she considered the patient
11 to be terminally ill, and is that an indicator as to
12 what she considered at that time?
13 LORD MACLEAN: Well, of course it is, because it is very
14 shortly before she died. The point is, she'd got to
15 that stage, you see, and it is a progression, isn't it?
16 Isn't it, Doctor?
17 A. Yes.
18 LORD MACLEAN: We will have a short break.
19 (3.10 pm)
20 (A short break)
21 (3.30 pm)
22 MR MACAULAY: Dr Johnston, the next case I want to look at
23 with you is that of John Boyle. Again, if you could
24 have the medical records in front of you. For the
25 screen, the records are at GGC00030001.
134

1 The background, I think, to Mr Boyle is he was
2 admitted, I think, to the Royal Alexandra Hospital on
3 3 January, having had a fall. I don't think he had
4 a fracture. He was transferred to the Vale of Leven on
5 10 January 2008. I think, at that point, he came under
6 your care; is that correct?
7 A. Correct.
8 Q. If we look at the medical records, at page 11, do we see
9 here that the admission date is the 10th, and that you
10 are noted as being the consultant in charge; is that
11 correct? That is at page 11?
12 A. Can I just say a quick point: I don't have the Vale
13 record. I have the RAH record here.
14 Q. We can maybe make sure you have the records in front of
15 you.
16 A. I take that back. I have found it.
17 Q. We are looking at page 11. You are noted as the
18 consultant in charge for the admission to ward 15 on
19 10 January?
20 A. Yes.
21 Q. If we look at the clinical records, on page 15, can we
22 see that on the 14th there is an entry by Dr Herd; is
23 that correct?
24 A. It's me, first of all.
25 Q. I'm sorry?
135

1 A. I'm at the top of that page.
2 Q. You're at the top, indeed.
3 A. So that is the Monday morning.
4 Q. You have noted in the second reference that his swallow
5 was okay. Had there been some concern about his swallow
6 before he was transferred?
7 A. We didn't have much information about John at first,
8 because we had no medical handover letter, but we had
9 the nursing handover, and I asked the staff to phone
10 over to Paisley to find out what the basis of
11 the admission was. My understanding was that he had had
12 what they thought might have been a stroke in the RAH,
13 but they couldn't find the result of a stroke on the
14 CT scan, and that his swallow had been poor there and
15 that he was prescribed broad-spectrum antibiotics. That
16 was my understanding of the background.
17 Q. At the time you see him, do you prescribe any medication
18 for him at that point?
19 A. No. From the nursing point of view, his swallow was all
20 right, but I think he was yet to be assessed by speech
21 and language. He was very confused, he had no focal
22 neurology. I don't actually mention his chest, but his
23 chest had a few creps at the bases, and the background
24 was he was frail ambulant, a bit confused at home, but
25 not as bad as he was when he came in.
136

1 Q. You didn't see any need to prescribe medication at that
2 time?
3 A. Not at that point. We were just trying to get the
4 picture of the patient and get more information.
5 Q. When we look at the entry for the same day by Dr Herd,
6 he has, I think, prescribed amoxicillin and
7 flucloxacillin; is that correct?
8 A. I see that, and he is querying cellulitis. I hadn't
9 been directed to his legs, I don't think. I had noted
10 the chest. But Dr Herd considers he was a bit more
11 chesty when he saw him, so prescribed an antibiotic.
12 Q. What was the reasoning, then, behind the prescription of
13 antibiotics?
14 A. Well, I think Dr Herd will answer that directly, but in
15 quotes "chesty" means he may have some secretions in his
16 chest that are audible on auscultation.
17 Q. Is the amoxicillin then designed to --
18 A. I think -- I should say, actually, the other -- the
19 background was somebody with a poor swallow, so they
20 would likely be intermittently aspirating secretions
21 from their upper airway down the way, so he was maybe
22 considering that.
23 Q. That is what the amoxicillin was being prescribed for,
24 a possible chest infection?
25 A. Yes, I think that's possible.
137

1 Q. The other antibiotic, the flucloxacillin?
2 A. Yes, it is anti-staphylococcal and first line treatment
3 for cellulitis.
4 Q. Would you have expected a chest X-ray to be instructed
5 here?
6 A. I think in a hospital-based patient, I would. But in
7 general practice, that might have been the sort of
8 patient who had been prescribed an antibiotic anyway.
9 Q. But we are in a hospital situation?
10 A. But we are in a hospital, so I can see it within
11 a hospital regime, yes.
12 Q. Was there, in fact, a chest X-ray ordered or not?
13 A. I don't think there was.
14 Q. In any event, he was prescribed the amoxicillin. Are
15 you able to tell me how long that prescription was
16 given?
17 A. How long for? It doesn't say on the notes.
18 Q. I can't focus on the Kardex at the moment. To confirm
19 the chest infection, would the X-ray be the appropriate
20 route to take?
21 A. It would be one of the things, plus observations and
22 some blood tests, to give a general idea if there's any
23 infection.
24 Q. If we move on and leave that aside just now and look at
25 the position with regard to C. difficile, if you turn to
138

1 page 25 of the records, do we see here that there was
2 a positive sample collected on 22 January, received by
3 the lab on the 25th, and that is a positive result?
4 A. Yes, I see that.
5 Q. If we turn to page 42 of the records, can we see that on
6 the 25th, at 1450, there's a note, "Received
7 notification that Jake is C. diff positive". Do you see
8 that?
9 A. That's a Friday afternoon.
10 Q. So the ward is aware then that he is positive at that
11 time?
12 A. Yes.
13 Q. Do you see that there is a delay between the collection
14 of the specimen on the 22nd and the intimation to the
15 ward of the positive result?
16 A. I do see that, and I don't see in the medical notes
17 before then any mention of diarrhoea.
18 Q. In the medical notes. I will look at the medical notes
19 in a moment.
20 A. Sorry.
21 Q. If there is a delay in the intimation of a positive
22 result, then that can result in a treatment delay; is
23 that --
24 A. Yes.
25 Q. If we look at the clinical notes on page 16, do we see
139

1 on the 25th there's a note:
2 "I have started Mr Boyle on metronidazole ..."
3 A. Yes, I can see what's happened. I would be in the
4 hospital at that time, in my office, and the ward has
5 phoned an FY1 to get a prescription for metronidazole
6 written up, which is what happens, but I can see
7 I wasn't informed.
8 Q. When we look at the entry, there is no suggestion here
9 that the doctor has carried out any sort of clinical
10 examination; is that correct?
11 A. No, but it's also the timing of that, 1545, it's within
12 office hours.
13 Q. Are you saying that you were available and could have
14 been contacted to review the patient?
15 A. Yes, but it also illustrates that the cover for the ward
16 at 1545 was an FY1 from medicine.
17 Q. Again, is this a patient where, having tested positive
18 for C. diff, there should have been a medical review of
19 the patient?
20 A. There should have been a medical review by somebody
21 other than an FY1.
22 Q. Again, we are dealing with an elderly patient. I think
23 Mr Boyle, when he died on 6 February 2008, was 90 years
24 of age?
25 A. Yes, the other thing that had been happening prior to
140

1 this diagnosis was his swallow was deteriorating and
2 fluctuating, so his general condition was going down and
3 he was pulling out IV lines and subcut lines.
4 Q. Although I think, if we look at the preceding entry to
5 the one we have looked at, which is by yourself on the
6 21st, on page 16, you have noted that the swallow is
7 much better at that time?
8 A. Yes, coming and going, that is what was happening.
9 Q. We can perhaps keep page 16 on the screen and turn to
10 page 17 and put that on the screen as well. Do we see
11 that you see the patient on the 28th; is that right?
12 A. Monday, the 28th, yes. That was when the ward reopened,
13 following the last norovirus outbreak.
14 Q. But can we note that this patient has tested positive
15 for C. diff following upon a sample that was collected
16 on 22 January, and you see him for the first time after
17 that positive diagnosis on 28 January?
18 A. Yes, that would be the Monday following the Friday.
19 Q. Should there have been some form of medical review
20 before then?
21 A. Yes. Yes, there should have been.
22 Q. If we look back to page 17, there's an entry for the
23 31st, I think we can recognise that as Dr Herd. I think
24 it reads:
25 "Still severe diarrhoea despite metronidazole."
141

1 Is that right?
2 A. Yes. Can I reference it back to the 28th, when I saw
3 the patient? Because the information I had from the
4 nursing staff was it was getting better. I did go and
5 see Mr Boyle and took a look at him, but it appears to
6 be that it continued after that and I wasn't informed
7 about it, but Dr Herd was on the 27th.
8 Q. Sorry?
9 A. Sorry, I have maybe lost that reference there.
10 Q. Can we get the page up?
11 A. We are on the 31st, are we?
12 Q. We have your entry on the 28th.
13 A. I have got that.
14 Q. We have an entry on the 29th --
15 A. Three days later --
16 Q. -- and then, on the 31st, the diarrhoea --
17 A. Right. It says -- the 31st says "Still severe
18 diarrhoea" which doesn't accord with my assessment a few
19 days previously. So either the patient has got worse or
20 the information I had on the Monday wasn't sufficient.
21 Q. We have an entry, again, for 3 February, from the junior
22 doctor:
23 "Patient is not swallowing. Diarrhoea not
24 improved."
25 A. Yes, that's right. The swallow became the feature
142

1 because he couldn't take the medication, he couldn't
2 swallow it.
3 Q. By 3 February, this is a patient who has been tested
4 positive for C. diff, started on metronidazole and has
5 not improved over that whole period; is that how it
6 looks?
7 A. He globally hadn't improved because of his chest. He
8 was --
9 Q. Well, what it says on the 3rd is "Diarrhoea not
10 improved"?
11 A. That's part of it, yes.
12 Q. Is there any evidence of any clinical assessment at that
13 time?
14 A. On the 31st, there isn't.
15 Q. On the 3rd?
16 A. "Patient is not swallowing. Diarrhoea not improved.
17 Started subcut fluids". I think what you are looking at
18 is a patient who's gone from the acute phase to
19 palliative.
20 Q. Just looking at my question, I think you accepted there
21 is no assessment on the 31st.
22 A. No.
23 Q. Is there any clinical assessment on 3 February, when the
24 patient is next seen?
25 A. A clinical assessment would include the swallowing, but
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1 there is nothing made about abdominal examination.
2 Q. Looking to a patient of this age who has C. diff and, it
3 is clear, not improving, should there have been more
4 medical input than what we see here in these records?
5 A. I think the previous week Dr Herd has seen the patient
6 three or four times and had a discussion with the family
7 about the extent to which attempts to rehydrate the
8 patient could go.
9 Q. But we have an entry by Dr Herd on the 31st where
10 Mr Boyle is suffering from severe diarrhoea.
11 A. Yes.
12 Q. Then there is a gap of, what, three days, until there is
13 a junior doctor on call?
14 A. I think that would probably best be answered by Dr Herd,
15 but what would normally happen in this case is the
16 microbiologist would be informed. I think Dr Herd can
17 answer that. But the practical difficulty is, in this
18 patient, how to actually get medication into him, and he
19 was pulling out lines, so hydration was not possible.
20 Q. Can we look at the drug Kardex at page 65? Can we see
21 here that the metronidazole -- it is the second entry --
22 is started on 25 January; is that right?
23 A. That looks it, yes.
24 Q. It appears that Mr Boyle is in receipt of metronidazole
25 for ten days?
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1 A. Up until the 3rd, when he's no longer swallowing.
2 Q. If you have a patient who has been prescribed an
3 antibiotic such as metronidazole and he is not
4 improving, should his antibiotic treatment have been
5 reviewed before 3 or 4 February?
6 A. Yes, but if you've got a problem with intermittent
7 swallow difficulties, you'd need to go to an IV
8 preparation for the medication, IV metronidazole, and
9 I think we can see that this patient wasn't tolerating
10 lines.
11 Q. So far as treatment with metronidazole is concerned, and
12 looking at the drug Kardex, does it seem to be the
13 position that he certainly seems to have been receiving
14 the medication up until about 4 February?
15 A. It doesn't say in what form the medication was given.
16 It might have been syrup.
17 Q. I think --
18 A. Some form or other.
19 Q. The point is that if a patient is being treated with
20 a particular antibiotic and he's not recovering, then
21 there should be review at some point along the line; is
22 that right?
23 A. There should be review, but it has to be in the clinical
24 context of the patient's overall condition.
25 Q. If we go back to page 17 of the records, then,
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1 Dr Johnston, what is the position here, in your opinion,
2 when you see a patient whose diarrhoea is not improving,
3 as has been noted? On the 31st, there is a gap of three
4 days until the next entry, when, again, the diarrhoea is
5 not improving. What should have happened here?
6 A. Well, I reflect that the second of the two entries is
7 24 hours before my assessment which says he's slowly
8 dying. I think what has happening here was that the
9 patient was deteriorating from his C. diff plus or minus
10 his chest. There should have been a discussion with
11 microbiology if it was felt, on the 31st, that he was
12 able to tolerate a change of oral medication.
13 Q. Is there any evidence that there was any such
14 discussion, so far as you can see from the records?
15 A. No, I can't see from the records, but, again, it might
16 be something that Dr Herd can answer.
17 DAME ELISH: My Lord, I wonder if my learned friend can
18 clarify if, hypothetically, vancomycin was administered,
19 would it be possible to do that intravenously with this
20 patient, if there was still a difficulty with his
21 swallow?
22 MR MACAULAY: I think we know the answer, but perhaps
23 Dr Johnston can give us her answer. Yes?
24 A. Well, IV vancomycin can be used for pneumonia as
25 a third-line agent, but for C. diff it has to be given
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1 orally, and we've been through with the family the
2 status of his precarious swallow and to what extent they
3 would wish him to have PEG feeding, and they declined
4 that. So I think it was a law of diminishing returns.
5 MR MACAULAY: If we go back to your note on 4 February,
6 then, Dr Johnston, you have noted the patient is slowly
7 dying. What was your reasoning at that time?
8 A. To make the patient as comfortable as possible.
9 Q. No, but what drew you to the conclusion that the patient
10 was slowly dying?
11 A. I can't precisely recall exactly the clinical scenario
12 now, years on, but you'd have to accept my word for it.
13 Q. Well, did C. diff feature in the scenario?
14 A. The two things: the chest and the C. diff featured in
15 the scenario, and the failure of the swallow, because
16 that would be fatal in any case within a few days or
17 weeks, if there was a complete loss of swallow in the
18 patient.
19 Q. I think, although IV vancomycin is not appropriate for
20 C. diff, you can use IV metronidazole to treat C. diff?
21 A. You can, but in this instance the patient was pulling
22 things out.
23 Q. If we look at the DNAR position here, at page 4, we have
24 the DNAR order, again I think completed by Dr Herd, and
25 the date seems to be 24 January; is that correct?
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1 A. I didn't issue this form, and there is a confusion,
2 because I think there is another form for a different
3 date.
4 Q. We had two forms in the last case, I think.
5 A. There was a date on which Dr Herd met with the family,
6 which is 18 January, I think.
7 Q. We see that on the form.
8 A. Right.
9 Q. There is a form at page 10, if we look at that. Is this
10 the other form you had in mind?
11 A. Yes.
12 Q. This is another case where we have two DNAR order forms;
13 is that how it looks?
14 A. Yes, that is not appropriate either.
15 Q. No.
16 A. They are very close together.
17 Q. If we go back to page 4, the reason why the order has
18 been put into place has not been inserted.
19 A. Yes. That should have been done.
20 Q. Indeed, on page 10, I think that has also been left
21 blank; is that right?
22 A. I see that, yes.
23 Q. If we look at the death certificate --
24 MR KINROY: I'm sorry, my Lord, I have been distracted.
25 I am sure my concern is unnecessary, but where do we see
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1 that the reason the order has been put into place has
2 not been inserted?
3 LORD MACLEAN: I think, really, by looking at the forms.
4 MR KINROY: Of course, my Lord, that would be the obvious
5 place to look, I see that, and I wasn't, but I now
6 wonder if it is correct to conclude that the reason was
7 not there? If I am looking to the one on the left, it
8 appears to be completed by a tick in a box.
9 LORD MACLEAN: I see that.
10 MR KINROY: So the possibility on the three dotted lines of
11 putting in a specific reason appears to be there if the
12 three potential reasons below do not fit the
13 circumstances.
14 LORD MACLEAN: Actually, the same is true in the other
15 document, Mr Kinroy. It is exactly the same, isn't it?
16 What is interesting is -- we haven't really looked at
17 this more closely before -- "Successful CPR is likely to
18 be followed by a length and quality of life", which you
19 might think was a good thing, but "which has been
20 assessed as not being in the best interests of
21 the patient to sustain". Is that a reason, Doctor?
22 A. Since 2010, the forms have changed basically to whether
23 it is possible to resuscitate the patient or not and not
24 to go on quality. It's just because they're very
25 unreliable.
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1 LORD MACLEAN: At this time, it looks as if it was
2 a question of the quality of life that was being
3 assessed?
4 A. Yes. That was the problem at this time, actually,
5 because people saw this as an overall treatment plan, as
6 opposed to a CPR decision, and both these forms are
7 inadequately filled out.
8 LORD MACLEAN: In what respect, though? Because the CPR has
9 not been completed?
10 A. "CPR is unlikely to be successful" has to be filled in.
11 You can't leave that. That is the key --
12 LORD MACLEAN: You can't leave that?
13 A. You can't leave that. That is the key issue.
14 MR MACAULAY: Indeed, if we look at the two little stars
15 against that sentence and look at the code at the
16 bottom, we see the two little stars mean:
17 "Record underlying conditions, eg, very poor LV
18 function", and so on and so forth; is that right?
19 A. That's correct.
20 Q. So that is what has not happened in either of these two
21 forms?
22 A. No, they're not -- I did an education session on DNAR
23 in October 2007 because the guideline had just changed
24 and there was a lot of forms which were poorly filled
25 out like this at the time. It is a continuing education
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1 process.
2 Q. I think I was taking you to the death certificate, which
3 we now have on the screen, at SPF00020001. Can we see
4 that Dr Herd has again certified the death, this time
5 for 6 February 2008, and, again, Clostridium difficile
6 enteritis is at section I of the death certificate?
7 A. I see that, yes.
8 Q. Do you see, then, that C. diff did play a primary role
9 in Mr Boyle's death?
10 A. Yes. There's some discussion about death certification,
11 but that's correct.
12 Q. The impaired swallow that you have mentioned for
13 Mr Boyle, how would you manage that? By that, I mean,
14 how would that be treated?
15 A. If the swallow is impaired, the patient will be
16 constantly silently aspirating secretions from the upper
17 airway. To tube feed the patient will deal with the
18 nutrition side but will not stop aspiration, so the
19 patient will continue to be at risk of pneumonia, and
20 most patients who have PEG tubes put in in this
21 condition do not survive a year.
22 Q. What about speech and language therapy, then?
23 A. They were involved with this man as well on assessing
24 his swallow, and its variability.
25 Q. If you have a patient who has impaired swallow, does the
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1 issue of hydration gain a particular importance?
2 A. Yes, it does, and that's -- you have to consider how you
3 would get access and to what extent you would escalate
4 that to get a permanent system in place.
5 Q. Would you, in particular, assess as to see whether or
6 not the patient was dehydrated?
7 A. Well, they will be dehydrated if they can't swallow
8 successfully.
9 Q. What was the position with this patient, then? Was he
10 dehydrated?
11 A. Well, I would say that he, to a certain extent, would
12 have been dehydrated if he was intermittently taking
13 fluids.
14 Q. Do you know what steps were taken to assess his state of
15 hydration, having looked at the records?
16 A. I know that initially blood tests were taken but then
17 discontinued after the decision was taken that he
18 wouldn't be for PEG.
19 Q. I think the position is, is it, that there were no blood
20 samples, specimens, taken after 15 January 2008? Is
21 that right?
22 A. I think -- yes, that may be right, but that may have
23 followed also the discussion with the family.
24 Q. Would you want to carry on taking blood specimens so
25 that you could assess the hydration position?
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1 A. It depends on to what extent the patient is terminally
2 ill or not. If they're doing reasonably sufficiently,
3 then you would do some blood tests, but you wouldn't do
4 it if the patient was absolutely palliative.
5 Q. Although, at that time, 15 January, I think we have
6 noted, if you turn to page 16 of the notes, that there
7 appears to have been some improvement in his condition;
8 is that correct?
9 A. Yes.
10 Q. Then what happens is that he contracts C. diff, which
11 has been diagnosed for 22 January?
12 A. That's correct. Yes.
13 Q. Having contracted C. diff, would that place at greater
14 risk his hydration position?
15 A. It would, but he was pulling lines out, so there wasn't
16 a practical solution.
17 Q. While I'm looking at Mr Boyle, I have been asked to ask
18 you some particular questions on behalf of the families,
19 and I think, since we have been looking at the records,
20 it is probably desirable to do that at this point.
21 A. Okay.
22 Q. Having reviewed Mr Boyle's records, do you consider
23 there was adequate consultant review of this patient?
24 A. There was weekly review, yes.
25 Q. When he became ill with C. diff, if we just look at
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1 medical review, do you consider the medical review was
2 adequate or not?
3 A. I think, when I saw him last, he was improving, and then
4 he was seen again by Dr Herd during the week, and during
5 that time deteriorated. So when I saw him following
6 upon that, he was terminally ill. There was a very
7 quick deterioration.
8 Q. So are we back to the point of the gap in medical review
9 from 31 January to 3 February, when he was ill and
10 didn't appear to have been seen by a doctor?
11 A. The 2nd -- sorry, 2 and 3 February were weekend days, so
12 the days that Dr Herd was available would have been
13 before that.
14 Q. So what's the position, then? You are the consultant in
15 charge of the patient. Should he have been seen by
16 a doctor or not over that period of three days?
17 A. Well, the only other opportunity for Dr Herd would have
18 been Friday, the -- what was it? -- the 1st. He should
19 have been seen then.
20 Q. I have been asked to put to you, why didn't you carry
21 out a more frequent review of Mr Boyle once he was
22 diagnosed with C. diff?
23 A. I think the combination of his comorbidities plus the
24 fact that, when I did see him, he seemed to be
25 improving, would be the answer to that.
154

1 Q. When you did see him, did you always carry out
2 a physical examination?
3 A. I examined Mr Boyle certainly on more than one occasion
4 when he arrived and also when I knew he had C. diff.
5 Q. If we look at the entries, let's say, for example, on
6 the 21st, that's page 16, can we tell from that whether
7 you carried out a physical examination or not?
8 A. You can't tell from that, no.
9 Q. Would it be your practice to carry out a physical
10 examination?
11 A. The 21st was before he had C. diff.
12 Q. What about the 28th, on page 17, if we are looking at
13 that point?
14 A. I did examine him that day. I just haven't recorded it.
15 Q. Why haven't you recorded it?
16 A. The ward was extremely busy. It had just reopened again
17 from norovirus and there were patients queuing to get
18 into the ward. So the nursing staff were somewhat
19 distracted. I had to record what I did in a fairly
20 short space of time. But I did examine him.
21 Q. In relation to the DNAR order, do you know if there was
22 any family discussion about that or not, or is that
23 something for Dr --
24 A. What I'd say to that is, I did a ward round on a Monday
25 morning and, if there were patients that might be
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1 considered for DNAR, I left word for Dr Herd to speak
2 with the families, because visiting was in the
3 afternoon. He'd already spoken to the family about PEG
4 tube feeding and I think from his DNAR note it notes
5 from the 18th that he's spoken to the family, on one of
6 the DNAR forms, anyway.
7 I recorded in the notes, on the 21st, I think, that
8 following that family meeting --
9 Q. The 21st is on page 16.
10 A. Yes, my note about not for CPR followed upon his family
11 meeting.
12 Q. Why did you come to that view at that point, when the
13 rest of the entry you have made there seems positive, in
14 that you say his swallow is much better and he's eating
15 a normal diet?
16 A. Yes, the -- it is the discussion on the variability of
17 the swallow and that not wanting a PEG tube means that
18 the patient is not going to have active treatment, so
19 CPR would be inappropriate.
20 LORD MACLEAN: What does the entry actually say on that
21 line? I can't read the first word.
22 A. The first word is "Swallow much better" --
23 LORD MACLEAN: No, the third line.
24 A. That is very bad writing. It says:
25 "Not for CPR or ventilation" which goes along with
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1 the PEG tube --
2 LORD MACLEAN: Oh, it is "not"?
3 A. Yes.
4 LORD MACLEAN: Thank you very much.
5 MR MACAULAY: During this admission, can you say from the
6 records if Mr Boyle was ever formally assessed for
7 dementia?
8 A. It's not -- sorry, his admission was too short to
9 formally assess him for dementia. He had delirium on
10 the background of cognitive impairment, which was
11 referenced by the family to members of nursing staff and
12 OTs. You can't cognitively assess a patient who is
13 acutely unwell until they have recovered, so you would
14 be looking at, you know, a month later. So he couldn't
15 have been formally assessed.
16 He had an abbreviated mental test score done, which
17 was very low and consistent with acute confusion, but
18 you wouldn't do a formal assessment until much later.
19 Q. We do see reference in one of the DNAR forms, and
20 I think also in the death certificate, to dementia?
21 A. Yes. I think that is an assumption. It would be
22 a reasonable assumption. Those patients who have
23 dementia are most at risk of delirium. Patients with
24 normal cognitive function don't get delirium. So the
25 patients we see in hospital tend to be acute delirious
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1 states on a background of cognitive impairment. But to
2 be perfectly correct you can't definitely say they have
3 dementia until they are formally assessed, but that
4 would be at a later time.
5 Q. So should dementia have appeared on the death
6 certificate?
7 A. I think it's a reasonable assumption, but there are
8 still many patients who are not positively diagnosed
9 with dementia who may have dementia put on their death
10 certificate, but a gentleman of 90 who has not been
11 assessed by a psychiatrist -- it's a reasonable
12 assumption there would be some cognitive impairment,
13 because 20 per cent of the over 80s have got cognitive
14 impairment, so it is a question of numbers, really.
15 Q. So what's the answer to the question: do you consider it
16 should have appeared in the death certificate, in the
17 circumstances of this case?
18 A. I wouldn't have done so, but I wouldn't criticise anyone
19 who did do so.
20 Q. If you had seen Mr Boyle between 28 January and
21 4 February and found that his diarrhoea was not in fact
22 improving, despite the metronidazole, what would your
23 response have been?
24 A. Well, I don't recollect the total details of this
25 patient now, but my response would be to discuss with
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1 microbiology and kind of factor that into the plan.
2 Q. Do we take from the notes that, during that period, you
3 would not be aware that the patient was deteriorating?
4 A. I wouldn't be aware of that unless I was told.
5 Q. Would you expect to have been told, if one of your
6 patients is deteriorating?
7 A. I would prefer to be told, rather than to find out on
8 a ward round, you know, a routine ward round. I'd
9 prefer to be told.
10 Q. Were the staff instructed to tell you if a patient of
11 yours was deteriorating?
12 A. The staff would always contact me on any patient who was
13 deteriorating, but because they had a hospital
14 practitioner, they might go direct to him, first of all,
15 or he might come to me.
16 Q. Would you expect Dr Herd then to contact you to let you
17 know that the patient was deteriorating?
18 A. I think if you record something of that nature in the
19 notes, then there needs to be a follow-up to that
20 comment. So yes.
21 Q. If a patient under your care is deteriorating, is it
22 your duty, as that patient's consultant, to review the
23 patient to determine whether there are any steps that
24 can be taken to halt the deterioration?
25 A. Well, there's layers of review, and certainly ward-based
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1 review is the first one. I would expect to be told if
2 there is a deteriorating patient and, yes, I would
3 become involved.
4 Q. Mr Boyle, I think, had a fall when he fell out of bed on
5 12 January 2008 and he sustained a head injury. Do you
6 consider that Mr Boyle ought to have had a medical
7 review at that point?
8 A. I'm just checking the date. It was a Saturday, so they
9 would have to call the oncall junior doctor. I don't
10 see any evidence of that in the notes. I do consider
11 that the doctor should have been called.
12 Q. Did you become aware of that, can you tell me, that he
13 had had a fall and suffered a head injury?
14 A. I can't recollect.
15 Q. There is nothing in the records, is there, to --
16 A. No, I can't recollect it.
17 Q. Is that something you ought to have been told?
18 A. The first step is to get the medical review of
19 the patient by the junior doctor and, if there was
20 something that came out of that, I would expect to be
21 told; for example, that the patient had an obvious
22 injury or they were unwell, for some reason. Because
23 patients often fall because they have something else
24 wrong with them.
25 Q. We have seen, I think, Dr Johnston, that there was
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1 a delay between the taking of the sample that tested
2 positive for C. diff, which was on 22 January, which was
3 a Tuesday, and its receipt by the laboratory on the
4 Friday, the 25th.
5 Had treatment for C. diff begun earlier than
6 25 January and had there been a change of therapy if the
7 infection was responding (sic) to that treatment, do you
8 accept that the outcome for Mr Boyle might have been
9 different?
10 MR PEOPLES: My Lord, I think it should be "if the infection
11 was not responding to the treatment". I think it is
12 a mistake in the note.
13 MR MACAULAY: I will put that to you again.
14 The focus here is on the delay that I think we have
15 seen from the records existed between the taking of
16 the specimen and the treatment beginning, a delay from
17 22 to 25 January. What I have been asked to put to you
18 is, if the treatment had begun sooner, do you accept
19 that the outcome for Mr Boyle might have been different?
20 A. No. The overall mortality rate for C. diff in the
21 over 90s is very high. Earlier treatment of a patient
22 who has got major problems with swallowing and got chest
23 symptoms from that, he would be unlikely to survive
24 30 days in hospital for that alone.
25 DAME ELISH: My Lord, I wonder whether my learned friend
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1 could also clarify whether or not the earlier
2 prescription would have had any effect, given the
3 patient's difficulty in cooperating because of
4 the swallow and the pulling out of the IV line?
5 Therefore, there were missed doses because of those
6 variables.
7 LORD MACLEAN: What is the answer to that? Is there an
8 answer there?
9 A. Could you repeat that?
10 LORD MACLEAN: Earlier treatment.
11 A. Earlier --
12 LORD MACLEAN: "Earlier prescription"? I'm not quite sure
13 what that means.
14 DAME ELISH: The suggestion is that, had there not been
15 a delay and the prescription had been administered at an
16 earlier point, he would have had a greater opportunity
17 of surviving. I understand from the doctor's evidence
18 that the patient, not through any fault of his own, but
19 because of the delirium or dementia, was pulling the IV
20 lines out and was not capable of swallowing and,
21 therefore, was missing a number of his doses. In light
22 of those factors, whether earlier prescription would
23 have assisted is something which I would ask my learned
24 friend to clarify with the doctor.
25 LORD MACLEAN: Well, you heard that question. Is it
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1 possible to say?
2 A. It's a difficult one, but just dealing with that type of
3 patient with the swallow problems, it is a very bad
4 prognostic sign by itself, and also dealing with the
5 cases we had of C. diff, many of which were quite
6 rapidly progressive in spite of all treatments, I don't
7 think it would have made the difference in this case.
8 MR MACAULAY: The point you make about pulling the IV line
9 out, so far as the clinical notes go to show, is there
10 more than one note making reference to that?
11 A. If you look at the fluid charts, you can see when his
12 IVs were put up and when it was changed to subcut, and
13 the nursing notes record when he pulled things out.
14 Q. So that is where you take that inference from, is it?
15 A. Mmm-hmm.
16 MR MACAULAY: My Lord, I'm not going to finish this
17 particular case today. This might be a point to stop.
18 LORD MACLEAN: Tomorrow morning, 10 o'clock.
19 (4.17 pm)
20 (The hearing was adjourned to
21 Tuesday, 24 January 2012 at 10.00 am)
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