1
Tuesday, 31 January 2012
2
(10.00 am)
3
MR MACAULAY:
4
The next witness
I would like to call is Dr Gordon Herd.
5
6
Good morning, my Lord.
DR GORDON WILLIAM HERD (affirmed)
LORD MACLEAN:
7
I'm sorry you had to wait so long yesterday.
It must have been pretty annoying and frustrating --
8
A.
It was a bit.
9
LORD MACLEAN:
-- but it did take longer than we expected to
10
complete Dr McCruden's evidence.
11
things, you just can't always gauge accurately, if I can
12
put it that way.
13
A.
It is one of those
Yes.
14
Examination by MR MACAULAY
15
MR MACAULAY:
16
A.
I am, yes.
17
Q.
Perhaps you can tell the Inquiry what position you hold
18
19
Are you Gordon William Herd?
at present?
A.
I'm a hospital practitioner at the
20
Vale of Leven Hospital.
21
practitioner.
22
23
24
25
Q.
I'm also a general
Perhaps we could look at your CV, and I will put that on
the screen for you.
It is at INQ03240001.
Do you begin by setting out your educational
qualifications, and do we see that your first degree was
1
1
a Bachelor of Science degree in 1978?
2
A.
Yes.
3
Q.
That was, I think, from the University of Glasgow?
4
A.
It was, yes.
5
Q.
Then your medical degree, MB ChB, you acquired that in
6
1981; is that right?
7
A.
That's right.
8
Q.
I think we then see that you are a Member of the Royal
9
College of Physicians; is that right?
10
A.
Yes, the Royal College.
11
Q.
And also a Fellow in 1995?
12
A.
That's right.
13
Q.
If we look at the next section of your report, you set
14
out your hospital training.
For example, we see at
15
section 6 you were an SHO in obstetrics and gynaecology
16
at Paisley Maternity Hospital and the Royal Alexandra
17
Hospital, Paisley, from 1987 -- for a period of, what,
18
about six months or so in 1987; is that right?
19
A.
That's right.
20
Q.
Is it after that that you went into general practice?
21
A.
Yes -- well, the following post is a trainee post in
22
23
general practice.
Q.
24
25
You, I think, indicate that you worked in Crieff and
also in Keith?
A.
Yes.
2
1
Q.
Moving on to page 2 of the CV, at item 9, do you set out
2
that you became a principal in general practice with
3
a partnership in Alexandria, and that was from
4
1 May 1992?
5
A.
Yes.
6
Q.
In relation to becoming a hospital practitioner at the
7
Vale of Leven Hospital, when did you take up that
8
particular post?
9
A.
I'm not sure exactly.
I was initially a clinical
10
assistant and was later made a hospital practitioner.
11
It was shortly after I came to Alexandria, but I can't
12
remember exactly when I became a clinical assistant.
13
Q.
Shortly after 1992 --
14
A.
Yes.
15
Q.
-- you became a clinical assistant and then
16
17
subsequently -A.
18
19
Yes.
I gradually increased my commitment to the
hospital.
Q.
At item 10, do you set out your present position in
20
general practice?
You indicate you are a practitioner
21
in the Oakview Medical Practice in Alexandria; is that
22
correct?
23
A.
Yes.
24
Q.
I think you tell us that there are currently seven
25
partners in the partnership?
3
1
A.
Yes.
2
Q.
I think you then set out some of your medical interests
3
and activities.
You tell us you have a particular
4
interest in cardiovascular medicine; is that right?
5
A.
That's right, yes.
6
Q.
Another interest I think you indicate is diabetes?
7
A.
Yes.
8
Q.
The use of computers and internet in medicine, you also
9
put that forward as an interest.
10
11
What does that
involve, can you elaborate?
A.
Well, I just -- in the past, I have used computers a lot
12
to help in the practice, in terms of spreadsheets,
13
et cetera, and databases to organise the practice,
14
prior -- especially prior to the availability of
15
practice software, for doing the same sort of thing.
16
Q.
You then set out, in the final section of your CV,
17
a number of publications that you have had some
18
involvement in; is that correct?
19
A.
Yes.
20
Q.
The books, we see that on page 3.
21
You have published
a "Clinician's Illustrated Dictionary of Hypertension"?
22
A.
Yes.
23
Q.
Can I then, Dr Herd, focus on your duties in relation to
24
the Vale of Leven Hospital, particularly your duties as
25
a hospital practitioner?
We are particularly interested
4
1
in the period from January 2007 through to
2
about June 2008, in the first instance.
3
period, were you employed as a hospital practitioner in
4
the Vale of Leven?
5
A.
During that
I can't remember exactly whether I was a clinical
6
assistant or a hospital practitioner at that point.
7
I can't remember at the point where I changed over from
8
one to the other, but the post was basically the same,
9
it was just a recognition of my experience.
10
Q.
11
12
Can you then help us and give us an idea as to what the
post involved?
A.
Well, the post involved primarily seeing patients who
13
were admitted to the ward, and ward 15 was primarily
14
involved in rehabilitation at that stage, rehabilitation
15
of patients either who had been in the acute medical
16
wards in the Vale of Leven Hospital or in patients who
17
were transferred from the Royal Alexandra Hospital in
18
Paisley, often with orthopaedic problems, particularly
19
with fractured neck of femur.
20
Q.
But was it ward 15 you were primarily involved with?
21
A.
Ward 15, yes.
22
Q.
Exclusively ward 15?
23
A.
Exclusively ward 15, yes.
24
Q.
Again, just looking to your duties in relation to
25
ward 15, then, can you help me on that?
5
What did that
1
2
involve?
A.
Well, I would see patients when they first arrived in
3
the ward and clerk them in; in other words, take
4
a detailed history of what had happened to them prior to
5
them being -- prior to them coming to the ward, and also
6
see them on a regular basis when they were in the ward.
7
Q.
What about your hours of work in the hospital?
8
A.
Well, the hours of work were approximately three
9
hours -- three to three and a half hours each day,
10
Monday to Friday.
11
Q.
What time of day would that be?
12
A.
Usually arriving in the ward about 11 o'clock, or
13
thereabouts.
14
Q.
So 11 o'clock in the morning?
15
A.
On a Tuesday, it was slightly different, in that --
16
well, on Tuesdays and Thursdays it was slightly
17
different, because on Tuesdays my partner,
18
Dr Garthwaite, would do a session in the morning, so
19
I would arrive after his session and do any work that
20
was still to be done in the ward.
21
On Thursdays, I had a ward round in the mornings,
22
and I would often actually arrive about 8 o'clock and
23
deal with things that needed to be done before the ward
24
round and would leave after the -- the ward round was
25
then followed by the multidisciplinary meeting, and
6
1
2
I would leave after that.
Q.
3
Do I take it that you also had your general practitioner
commitments?
4
A.
Yes.
5
Q.
In Alexandria?
6
A.
Yes.
7
Q.
What about weekends?
8
Did you work at weekends in the
hospital?
9
A.
No, I didn't work weekends at all.
10
Q.
In relation to the rota, were you involved in the rota
11
and being on call?
12
A.
No, no.
13
Q.
Just to be clear, your normal day for ward rounds, did
14
you say that was Thursday?
15
A.
Thursday.
16
Q.
What time on Thursday?
17
A.
We would try to get started at 9 o'clock and try to be
18
finished at 11 o'clock, because that's when the
19
multidisciplinary meeting was held, and obviously the
20
various people involved in that, they were timetabled to
21
start at 11 o'clock.
22
Q.
Did you have a line manager?
23
A.
I'm not sure who would be regarded as my line manager,
24
to be honest.
I regarded Dr Johnston as my clinical
25
supervisor, if you like, but I don't -- I think -7
1
although in my statement I use the term "line manager"
2
referring to Dr Johnston, I think that is actually
3
wrong.
4
to be honest.
5
Q.
6
So I'm not quite sure who my line manager was,
In relation to your role in connection with Dr Johnston,
and Dr Johnston was the consultant --
7
A.
Yes.
8
Q.
--was she your supervisor?
9
10
Can you help me on how you
saw the relationship?
A.
11
Yes, I think that would be -- I saw her as my
supervisor.
12
Q.
Did you have regular contact with her?
13
A.
Yes.
14
Q.
Would that contact involve seeking her advice in
15
16
connection with particular patients?
A.
17
18
I would also see her regularly, if
only at the MDT meeting.
Q.
19
20
It would do, yes.
In the ward itself, are you able to say how often you
would see Dr Johnston?
A.
Well, obviously, if she visited the ward and I was there
21
at the time, I would see her in passing, and, if
22
necessary, you know, interact with her, but if -- at
23
other times, if I ever wanted to contact her, I never
24
had any difficulty contacting her.
25
Q.
At the times that you were present on the ward, apart
8
1
from the nurses, was there any other medical presence?
2
A.
Not usually.
3
Q.
Did you form any view as to the adequacy of the staffing
4
in ward 15, which was the ward that you were concerned
5
with?
6
A.
Do you mean medical staffing?
7
Q.
Let's look at medical staffing first of all.
8
A.
I think the medical staffing seemed to be adequate most
9
of the time.
Obviously, if people are off sick or on
10
holiday, then there are extra pressures, et cetera, but
11
when everyone was there, it seemed to be -- it seemed to
12
work quite well.
13
Q.
14
15
And from the nursing perspective?
Did you form any view
as to the adequacy of the staffing?
A.
I mean, again, most of the time my impression was that
16
the nursing staffing was adequate, but, you know, often
17
if patients were sick and there was more nursing input
18
required to those individual patients, there could be
19
pressures on staffing.
20
Q.
Did you have a job description?
21
A.
I didn't have a job description, because my job
22
basically evolved over the years, so I was never
23
actually given a formal job description.
24
25
Q.
Can I ask you a little bit about the prescription of
antibiotics, and I take it that was one of the tasks
9
1
that you had to carry out; is that right?
2
A.
Yes.
3
Q.
What did you use to guide you in prescribing
4
5
antibiotics?
A.
Well, I was aware of the Greater Glasgow and Clyde
6
formulary, because that was used in general practice as
7
well, although I can't remember how readily available
8
that was on the ward.
9
The empirical antibiotic prescribing guideline
10
became readily available latterly, but I can't remember
11
at what stage in this -- in the period that we are
12
looking at that became available, but certainly I think
13
it's described as the EAT guideline, the empirical
14
antibiotic therapy guideline.
15
Q.
16
We will put it on the screen for you to look at, it is
GGC22180001.
17
A.
That's the guideline I'm talking about.
18
Q.
I think what you are unclear about is when this actually
19
became available?
20
A.
When it came into use, yes.
21
Q.
Was there a change to this guideline post June 2008?
22
A.
Was there a change?
23
Q.
Yes.
24
A.
I think there was, yes.
25
Q.
The other document you mentioned, if I can just see if
10
1
I can understand what it was, if you look at
2
GGC18270001.
3
A.
That's the document I'm talking about, yes.
4
Q.
Is that what you used?
5
A.
Yes.
6
Q.
This is the August 2007 edition?
7
A.
As well as the British National Formulary as well.
8
Q.
So you used the BNF as well?
9
A.
Yes.
10
Q.
The other document that we have focused on with some of
11
the witnesses in the Inquiry, if I can put that on the
12
screen for you, is GGC21790001.
13
this to be the Argyll and Clyde drug formulary for 2006?
I think we understand
14
A.
Yes.
15
Q.
Did you use this?
16
A.
It's not something that I was aware of, no.
17
Q.
Do I take it, then, that it's the British National
18
Formulary, the Greater Glasgow, the one I put on the
19
screen, which is --
20
A.
Yes.
21
Q.
Yes, the Greater Glasgow and Clyde formulary and, when
22
it came in, the empirical guidelines?
23
A.
24
LORD MACLEAN:
25
Yes.
Dr Herd, you worked on the mornings of Monday
to Friday in the hospital?
11
1
A.
Primarily, yes.
2
LORD MACLEAN:
3
A.
Primarily?
What do you mean "primarily"?
Well, I arrived at 11 o'clock -- I suppose, in fact, it
4
was more into the afternoon, because, as I say, it was
5
roughly about three hours.
6
11.00 until 2.00, approximately, except for Tuesdays and
7
Thursdays.
8
LORD MACLEAN:
9
Sometimes you arrived at 8.00, you said, in
the morning.
10
A.
11
LORD MACLEAN:
12
13
So I arrived about 11.00, so
Sorry?
You said sometimes you arrived at 8.00 in the
morning.
A.
Yes, that was in the morning of the ward round.
I would
14
often come in early just to make sure there was nothing
15
needing done prior to the ward round.
16
LORD MACLEAN:
17
A.
18
LORD MACLEAN:
19
A.
20
LORD MACLEAN:
21
A.
How did you fit in your general practice?
I just fitted it.
It was in the afternoon, was it?
Sorry?
In the afternoon?
Well, I had a ward round -- I had surgery in the
22
morning, between 9.00 and 11.00, and then I would come
23
to the hospital after that, and then I would have
24
a surgery later on in the afternoon.
25
LORD MACLEAN:
Pretty active?
12
1
A.
2
LORD MACLEAN:
3
MR MACAULAY:
4
Yes.
Thanks.
You indicated that you didn't have a job
description, Dr Herd --
5
A.
Mmm-hmm.
6
Q.
-- and that, what, the post evolved over a period of
7
time; is that right?
8
A.
Yes.
9
Q.
But who provided you with guidance as to what the post
10
11
would involve?
A.
I'm not quite sure how to answer that.
I mean, when
12
I first started doing the job -- I don't know whether --
13
how far -- when I first started doing the job, the
14
practice looked after two wards, wards 15 and 16, which
15
were both long-stay wards, and then, over time, these
16
wards -- ward 16 closed and ward 15 was initially partly
17
rehabilitation and partly long stay, and then gradually
18
ward 15 became completely rehabilitation, so it was just
19
like ward 14.
20
So it was a case of that's how things evolved over
21
the years, and so it might seem like, having one ward,
22
there would be less work than looking after two bigger
23
wards.
24
long-stay wards was 32 beds, whereas ward 15 I think is
25
24 beds.
In fact, I think the number of beds in the two
So we were looking after 64 long-stay beds and
13
1
latterly we'd been looking after 24 acute beds, but in
2
fact there was more work generated by that than the 64
3
long-stay beds.
4
Q.
5
6
When you finished your stint, then, in the ward, who
took over from you?
A.
Well, the nurses -- there was -- the nurses knew that
7
there were junior hospital staff that they could call on
8
if patients became ill during the time that I was not
9
there.
10
Q.
Did you hand over, then, to a particular doctor or not?
11
A.
I didn't hand over to a particular doctor, but if there
12
were particular issues that I felt needed dealt with,
13
I would leave a message for whichever doctor was
14
available, on a rota basis.
15
Q.
16
17
What was your understanding as to how the ward was
covered medically at the weekend?
A.
I didn't have a very thorough understanding of that.
18
I knew that there were doctors available to be called
19
over the weekend.
20
Q.
21
Do I take it from what you said to me earlier that you
never worked at weekends?
22
A.
I never worked at weekends, no.
23
Q.
If you had a situation where a patient became unwell on
24
25
the Friday, then how would you manage that?
A.
It would depend on what the situation was.
14
If I felt
1
that the patient needed, for example, a blood sample
2
taken at the weekend, I would make arrangements for
3
that.
4
a doctor over the weekend, I could make arrangements for
5
that, either directly or through the nurses.
6
If I felt that they needed to be reviewed by
There was also provision -- it didn't often happen,
7
but sometimes patients could be transferred back from
8
ward 15 to the acute medical wards, if we felt they
9
needed more intense monitoring, but that rarely was
10
11
necessary.
Q.
12
Ward 15, I think you have indicated already, was
a rehabilitation ward; is that right?
13
A.
Yes, that's right.
14
Q.
Can you give us a general understanding as to the
15
16
profile, then, of the patients in the ward?
A.
Well, as I say, there was a tendency for ward 15 to
17
specialise in orthopaedic rehabilitation, so a lot of
18
the patients that were admitted had orthopaedic
19
conditions and had been transferred from Paisley.
20
Many of these patients had fractured necks of femur.
21
Some of the patients -- the other main source of
22
the patients was from the acute medical wards, and, say,
23
for example, a patient had a chest infection and poor
24
mobility, for example, they would be transferred to
25
ward 15 for rehabilitation, primarily
15
1
physiotherapy/occupational therapy.
2
groups.
3
Q.
They were the main
Can I just ask you some questions about your knowledge
4
in the period that we are concerned about in relation to
5
the antibiotics that were known to precipitate C. diff?
6
A.
Yes.
7
Q.
What was your state of knowledge at that time?
8
A.
I think most people would have known at that stage that
9
clindamycin and the newer-generation cephalosporins were
10
highly likely to produce C. diff.
11
raised already, the question of how well known it was
12
that co-amoxiclav would be likely to select out C. diff,
13
and my impression at the time was that it wasn't well
14
known that that was a particularly dangerous antibiotic
15
to use and it was still being used relatively
16
frequently, certainly in primary care, and to some
17
extent in the hospital as well.
18
I think this has been
As far as 5-aminoquinolones like ciprofloxacin is
19
concerned, I think there is still a wee bit of
20
controversy.
21
is likely to select out C. diff, and other papers which
22
draw that into question, but I have never been in the
23
habit of using these drugs very readily anyway, I always
24
felt that they should be reserved for resistant
25
infections, and I have never been in the habit of using
I have read papers which suggest that it
16
1
2
cephalosporins either.
Q.
So at the time, then, if you are just looking at what
3
your state of knowledge was at the time, you did have an
4
awareness that cephalosporins and clindamycin --
5
A.
Yes.
6
Q.
-- were risk antibiotics for C. diff?
7
A.
Yes.
8
Q.
But in relation to the other antibiotics you mentioned,
9
10
you may not have had that awareness?
A.
As I say, specifically for co-amoxiclav I wasn't aware
11
at that time that it was a sort of high-risk drug, and
12
ciprofloxacin, I probably wouldn't have known that was
13
a particularly high-risk drug for C. diff, but I would
14
have tended to have avoided using it anyway because
15
of -- you know, I felt these drugs should be kept back
16
for resistant organisms.
17
Q.
18
19
What was your awareness in relation to asymptomatic
bacteriuria?
A.
I was well aware of the fact that we shouldn't be giving
20
antibiotics to patients with asymptomatic bacteriuria,
21
and I can remember instances in the past where nurses
22
have taken blood samples -- not blood samples, urine
23
samples, on a sort of routine basis, and I always --
24
I can distinctly remember telling them not to do that,
25
because if these samples are taken and you get a result
17
1
back, there's always the temptation on the part of
2
the doctor that receives these specimens to treat, and
3
I think it is better not to take these, because they
4
were inappropriate specimens, I think.
5
specimens should only be taken if it is appropriate.
6
MR KINROY:
7
I think urine
My Lord, I wonder if we can clarify when in the
past this practice was going on?
8
A.
That was quite a long --
9
LORD MACLEAN:
10
A.
11
LORD MACLEAN:
12
Sorry, just a minute --
Where is that coming from?
Don't just answer.
It has to come through me
or through Counsel to the Inquiry.
13
A.
14
LORD MACLEAN:
15
Oh, right.
You have been talking about what was known
and what there was a controversy about, and so on.
16
A.
Yes.
17
LORD MACLEAN:
18
A.
Which period are you talking about?
I'm not talking about recently.
Obviously I worked in
19
the unit for a long, long time and I'm talking about
20
distant past; you know, long before the period that we
21
are looking at.
22
LORD MACLEAN:
Long before January 2007 to June 2008?
23
A.
I think -- I can't remember exactly when, but
Yes, yes.
24
I can distinctly remember, you know, a few episodes
25
where nurses have taken urine specimens and I have asked
18
1
them, you know, "Why have you taken this?", and they
2
have been taken on fairly flimsy grounds.
3
that lesson has actually been learned by the nurses.
4
I don't think they tend to do that now and didn't tend
5
to do it at the time in question.
6
you know, before that.
7
LORD MACLEAN:
8
MR MACAULAY:
9
10
But I think
I'm talking about,
Thank you.
What antibiotic was generally prescribed,
then, for a non-severe urinary tract infection?
A.
Well, for a lower urinary tract infection, the
11
antibiotic you'd generally use would be trimethoprim for
12
three days in females.
13
Q.
But if you suspected there was an infective process, but
14
you couldn't decide what the source was, how, at that
15
time, did you approach that?
16
A.
Well, I think the appropriate response to that would be
17
to take as many specimens as possible -- urine sample,
18
blood cultures, perhaps, and sputum samples -- if they
19
were available, to try to identify the organism.
20
I think it's -- obviously you should try and be treating
21
a specific bacterium, rather than using broad-spectrum
22
antibiotics unnecessarily.
23
Q.
Could there be instances where you would use
24
broad-spectrum antibiotics until you had the results
25
available to you?
19
1
A.
There might be -- this situation wouldn't often arise,
2
I would have to say, in the patients that I was dealing
3
with.
4
antibiotics or having been treated with antibiotics, but
5
I didn't often -- I wasn't often in the situation where
6
there was, for example, a pyrexial unknown origin and,
7
you know, I was having to use a broad-spectrum
8
antibiotic.
9
guidelines.
10
Q.
A lot of patients arrived in the ward already on
If there was, I would look to the
Can I just ask you some questions about infection
11
control?
12
time that there was an infection control manual in the
13
ward?
14
A.
First of all, were you aware at the relevant
I think I was aware of it and I think there was a hard
15
copy kept in the ward, but it wasn't something that
16
I remember referring to.
17
Q.
If I can take you to a number of the policies in it, if
18
we look at GGC00780252, we are looking at a policy
19
that's described as "C. difficile associated diarrhoea
20
and pseudomembranous colitis policy".
21
this particular policy?
Were you aware of
22
A.
I wasn't aware of that policy, no.
23
Q.
If we look at another document, it is at page 258, this
24
is described as a "Loose stools policy", were you aware
25
of the policy for loose stools at the time?
20
1
A.
I wasn't, no.
2
Q.
The other one to perhaps take you to is at page 145.
3
This is said to be an outbreak policy.
Were you aware
4
that there was an outbreak policy in place at the time?
5
A.
No, I wasn't, no.
6
Q.
Did you have any understanding as to what might
7
8
constitute an outbreak for C. difficile at the time?
A.
9
I don't know what the technical definition of an
outbreak would be of C. diff.
10
Q.
So you didn't know that at the time?
11
A.
No.
12
Q.
So if you had a number of patients in the ward with
13
C. diff, you would not have been aware of whether or not
14
that would constitute an outbreak?
15
A.
I think if there were a number of patients in the ward
16
at the same time, I would be suspicious that there was
17
a problem.
18
sure.
19
Q.
20
Whether I would term it an outbreak, I'm not
What training, if any, had you had in C. difficile prior
to the time we are concerned with?
21
A.
Prior to the term we were concerned with?
22
Q.
Yes.
23
A.
The only training I'd had prior to the time we're
24
concerned with would have been as an undergraduate
25
training in microbiology and pathology.
21
1
Q.
In the time we are looking at, from January 2007
2
to June 2008, did you have any training in relation to
3
C. difficile during that period?
4
A.
I don't remember any training being provided by the
5
hospital, but in fact, I did go to a course at the Royal
6
College of Physicians and Surgeons of Glasgow and part
7
of the course was to do with resistant infections and
8
part of that was do with C. diff, and that was --
9
I can't remember the exact timing of that, but it was
10
11
during the period that we are concerned with.
Q.
12
13
After June 2008, did you receive training in relation to
C. diff?
A.
I remember going to a course that was chaired by the
14
infection control nurse -- is it Helen O'Neill, I think
15
her name is?
16
and to do with careful hand washing, et cetera.
That was to do with how C. diff spreads
17
Q.
Did you find that helpful?
18
A.
I found it -- I mean, a lot of the principles were
19
familiar to me, but I think it did reinforce the
20
importance of, you know, washing your hands properly,
21
which I think perhaps had not been emphasised enough.
22
Q.
23
Did you consider C. difficile at the time to be an
important clinical diagnosis in its own right?
24
A.
I did, yes.
25
Q.
Did you consider the infection to have potentially
22
1
serious consequences, particularly in the elderly?
2
A.
I did, yes.
3
Q.
You mentioned Helen O'Neill.
What understanding did you
4
have at the time as to the involvement or presence of
5
the infection control team in the hospital?
6
A.
I don't think I had any direct dealings with the
7
infection control team myself.
8
existed, but I wasn't quite sure what their job
9
entailed.
10
I knew that they
The contact with the infection control team, in my
11
experience, was primarily -- came from the nurses.
12
I don't remember having much of an interaction with them
13
at the time.
14
Q.
I think you have mentioned Helen O'Neill as someone who
15
at least was involved in the training programme that you
16
had post June 2008.
17
A.
Yes.
18
Q.
Did you have any recollection of her being present in
19
the ward over the relevant period that we are looking
20
at?
21
A.
22
23
period.
Q.
24
25
I think she was present at various times during that
Do you recollect at any time discussing patients with
her, or anyone else in the infection control team?
A.
I may have done.
I can't say I distinctly recollect.
23
1
Q.
2
Do you know if there was an infection control doctor
allocated to the Vale of Leven Hospital?
3
A.
I don't know.
4
Q.
You were, I think, working in the hospital when
5
Dr Stephanie Dancer was the microbiologist there; is
6
that right?
7
A.
Yes.
8
Q.
Did she have a presence on the ward?
9
A.
She was a very enthusiastic -- I think probably everyone
10
uses that term about Stephanie Dancer, but she was
11
a very enthusiastic doctor, and she basically made her
12
presence known wherever she went, I think, so -- but
13
whether I -- I don't remember seeing her on ward 15 at
14
the time that she was active at the Vale.
15
Q.
But I think at the time we are concerned with, there
16
wasn't a resident microbiologist in the hospital; is
17
that correct?
18
A.
At the time that we are looking at?
19
Q.
Yes.
20
A.
I don't know.
I think Stephanie Dancer had left quite
21
some time before that, so we were using -- we were using
22
the services of the microbiologists at Inverclyde and
23
Paisley.
24
25
Q.
Were you ever aware of any of them being present in the
ward?
24
1
A.
I don't remember seeing -- well, I remember Dr Bagrade
2
being in ward 15, but I can't remember at what stage
3
that was.
4
remember actually seeing in ward 15, but I can't recall,
5
you know, at what point that was, whether it was within
6
the period we are talking about.
7
Q.
8
So she's the only microbiologist that I can
On occasions, did you require to consult
a microbiologist?
9
A.
On occasion, yes.
10
Q.
How would you set about doing that?
11
A.
By telephone.
12
Q.
Did you seek to make contact with a particular
13
14
microbiologist, or can you just explain how it worked?
A.
Well, the way that it worked was that there would be
15
a microbiologist who was, on a rota basis, available for
16
the Vale of Leven on a particular day, and you would
17
phone either RAH or Inverclyde and ideally speak to them
18
directly or leave a message with their secretary.
19
Q.
What would cause you to contact the microbiologist?
20
A.
Well, if there were -- say, for example, a patient was
21
allergic to penicillin and they were intolerant of
22
erythromycin and these were the only two antibiotics
23
that the bacterium was sensitive to, I would contact the
24
microbiologist to find out what -- because often the
25
bacterium would be tested against other antibiotics, but
25
1
they wouldn't be reported on the form that we got, so
2
I would ask them what antibiotic they would recommend in
3
that situation, or if someone wasn't responding to the
4
antibiotic regime that we were prescribing for them,
5
I would tend to ask their advice about that.
6
Q.
Do you know if microbiologists from another hospital,
7
like the Royal Alexandra Hospital, would come to the
8
laboratory at the Vale of Leven?
9
A.
I don't know.
I don't know.
10
Q.
Just looking to the management of a patient who has
11
contracted C. diff, at the time, did you consider that
12
a clinical assessment of the patient to assess the
13
severity of the C. diff was important?
14
A.
I think it's important in general to assess the severity
15
of the disease, particularly if you think someone is at
16
risk of developing toxic megacolon, for example, but my
17
understanding -- later, a scoring system became
18
available, but I can't -- my recollection is that became
19
available quite late in this.
20
became available during the year and a half that we are
21
considering, or whether that was later that that became
22
available.
23
I'm not sure whether that
So what I'm saying is, my recollection is that,
24
during the 18-month period that we are talking about,
25
there wasn't a formal scoring system for C. diff.
26
That
1
may be wrong, but that's my recollection.
2
appreciate that it is important to get a feeling for how
3
serious the infection is, because, you know, the most
4
important effect of C. diff would be toxic dilatation of
5
the colon, which is a surgical emergency.
6
Q.
7
8
But I do
The clinical assessment, would that involve, for
example, an abdominal examination of the patient?
A.
9
I think it would, particularly -- generally, if somebody
had toxic dilatation of the colon, they would also have
10
abdominal pain, so I think abdominal examination is
11
important, especially if someone has abdominal pain.
12
I think it is less important if someone has mild
13
diarrhoea and no abdominal pain and no abdominal
14
distension.
15
Q.
16
What about isolation?
Let's just start with a patient
who has developed diarrhoea, which may be infectious.
17
A.
Yes.
18
Q.
Did you have any view at the time as to whether or not
19
20
such a patient should be isolated?
A.
I think the controversial area here is whether someone
21
should be isolated while we were awaiting the results of
22
their stool sample, or whether we should wait until the
23
stool sample came back.
24
the actual policy was, to be honest, which of those two
25
options was the one that was recommended at the time.
I think -- I'm not sure what
27
1
I think, ideally, someone -- if there are facilities
2
to isolate someone, they should be isolated prior to
3
getting the result back if you think they have an
4
infectious diarrhoea, because that is potentially
5
transmissible to the other patients in, for example,
6
a four-bedded area.
7
Q.
8
I think you said already that you had not, for example,
seen the loose stools policy to see what that said?
9
A.
That's correct.
10
Q.
In relation to the diagnosis being made, did you see
11
isolation at least being important --
12
A.
Yes.
13
Q.
-- once the patient was diagnosed with C. diff?
14
A.
Well, it's obviously -- yes, it's clearly important once
15
the patient has been diagnosed as having C. diff.
16
Q.
Why did you think it was important?
17
A.
Because C. diff is a spore-forming organism and it can
18
19
be transmitted from one person to another.
Q.
Now, in relation to medication, if you suspected
20
a patient may have C. diff but the diagnosis has not
21
come through from the laboratory, in the sense of
22
a positive report, would you consider, nevertheless,
23
starting the patient on medication or not?
24
25
A.
I think at the time I would probably not have started.
I'm not sure what the current recommendation is, but at
28
1
the time, I think I wouldn't have started them on
2
metronidazole usually -- that was the usual drug that
3
was used -- until we had a positive result.
4
Q.
But then, once you had a positive result, I think, as
5
you have indicated, metronidazole would generally be the
6
first line of therapy?
7
A.
Yes.
8
Q.
Was it your practice to review, on an ongoing basis, the
9
antibiotic treatment; for example, whether or not it was
10
successfully dealing with the diarrhoea?
11
A.
Yes.
12
Q.
What about fluid management?
Did you, at the time,
13
consider whether or not fluid management was an
14
important part of managing a patient with C. difficile?
15
A.
I think fluid management is important in any patient
16
with -- well, obviously important in any patient in
17
general, but particularly in patients who have
18
diarrhoea, because they can lose a lot of fluid in the
19
diarrhoea, a lot more fluid than they would normally
20
lose.
21
Q.
22
23
What was your approach, then, to that aspect of
management?
A.
Well, assessment of patients with C. diff includes an
24
assessment of their hydration clinically, and by means
25
of fluid balance chart.
29
1
Q.
2
You mentioned fluid balance charts.
Would you look at
the fluid balance charts?
3
A.
I would look at the fluid balance charts, yes.
4
Q.
What was your impression at the time as to how fluid
5
6
balance charts were being kept?
A.
I think they were being kept, you know, reasonably well,
7
but it's often difficult in people with diarrhoea to
8
monitor their fluids accurately.
9
being kept reasonably well.
10
Q.
11
12
What about stool charts?
But I think they were
Did you see stool charts as an
aspect of management for such a patient?
A.
I think -- I don't recall stool charts being used
13
certainly at the beginning of the period that we are
14
looking at.
15
it, and I think they probably are used now, but my
16
recollection was that the nurses kept a narrative record
17
of whether or not a patient had loose stools, and an
18
estimate of how frequent they were, but formal stool
19
charts I don't think were kept on a routine basis.
20
Q.
They may have been used towards the end of
At the relevant time, what was your knowledge about the
21
possibility of a false negative result for a C. diff
22
patient?
23
A.
I think this is something -- this is an area of which we
24
were completely unaware at the time and there was no
25
indication on the reports from the microbiology lab that
30
1
we should be aware of the possibility, which I think
2
would have been useful.
3
Q.
4
5
If you had a patient who had a recurrence or a relapse
of C. diff, what was your approach at the time?
A.
I think the approach at the time would have been, in
6
patients who seemed relatively mildly affected, in
7
general to give a further course of metronidazole, but
8
in people who were more severely affected, they would
9
tend to be given vancomycin orally.
10
Q.
11
12
Would you do that yourself, without consulting
a microbiologist?
A.
It would depend on the situation.
If I was unclear
13
which was the appropriate antibiotic to use, I would
14
certainly consult the microbiologist.
15
Q.
If you had a patient in relation to whom C. diff was
16
confirmed, but that patient was on other antibiotics for
17
other conditions, what was your practice in relation to
18
managing the other antibiotic treatment?
19
A.
I mean, in general, obviously you would like to think
20
that patients are on antibiotics for a good reason, and
21
that good reason may be life threatening, but having
22
said that, the general principle is to stop all other
23
antibiotics, if possible, for patients who have been
24
diagnosed to have C. diff.
25
in the patient's best interests to carry on with the
31
So unless I felt that it was
1
2
antibiotics, I would stop them as soon as possible.
Q.
3
You would require, then, in the first instance, to
review the position --
4
A.
Yes.
5
Q.
-- and then make a decision.
6
7
Would that be your own
decision, or would you consult the consultant?
A.
It would, again, depend on the situation.
If I was not
8
sure what would be the best thing to do, I would
9
certainly speak to Dr Johnston or whichever other
10
11
consultant was available.
Q.
What was the position at the relevant time in relation
12
to ward 15 and, in particular, the presence of
13
a pharmacist in the ward?
14
A.
Again, this is another thing which is difficult to
15
remember, but certainly, latterly, there has often been
16
a pharmacist on the ward rounds, which is actually
17
extremely useful, but I can't remember if there was
18
a pharmacist available to go on the ward rounds at that
19
time.
20
Q.
Looking to your knowledge at the time, Dr Herd, did you
21
consider whether lactulose and Senna should be given to
22
patients who had C. diff, or indeed diarrhoea?
23
A.
24
25
I would say they shouldn't be given to a patient who has
C. diff.
Q.
Should loperamide be given to patients with C. diff?
32
1
A.
No.
2
Q.
Did you become aware at a point in time that there may
3
have been a problem in the Vale of Leven with C. diff
4
infection?
5
A.
Sorry?
6
Q.
Did you become aware at a point in time that there may
7
have been a problem with C. diff infection in the
8
Vale of Leven?
9
A.
I wasn't aware that there was a big enough problem to
10
constitute an outbreak, if that is what you are asking,
11
but certainly -- I mean, in my previous experience of
12
C. diff, I hadn't seen very many cases -- I'm not sure
13
whether I'd seen any cases prior to the ones in the
14
indexed period, but there were a number of patients in
15
ward 15 who had C. diff, but I wasn't aware that there
16
were patients in other wards in the hospital, which
17
might have made me more suspicious that there was
18
a general problem, because my duties were purely in
19
ward 15.
20
Q.
21
Did you not receive any anecdotal information about what
might have been happening in other wards at that time?
22
A.
No.
23
Q.
Did there come a point in time when you were aware that
24
25
there may have been a problem?
A.
I think I became aware towards the end of the period in
33
1
question that there was a large problem, if you like,
2
and certainly I was -- there are minutes of a clinical
3
governance meeting which was held, I think,
4
in June 2008, and I was present, and this was -- it was
5
discussed that there seemed to be a problem with, you
6
know, a much larger than expected number of cases of
7
C. diff in the Vale of Leven Hospital in general.
8
I was certainly aware at that point, but I'm not sure at
9
what stage prior to that I was aware.
10
Q.
So
I think you indicated that you may not have had any
11
cases of C. diff patients prior to the period we are
12
looking at.
13
A.
Did I understand you correctly there?
I can't distinctly remember, but if I had come across
14
C. diff before, it would only be a small number of
15
patients.
16
Q.
But in the period we are concerned with, and
17
particularly if we look at the period from December 2007
18
through to about May 2008, did you become aware that
19
there may have been more patients than you might have
20
expected with C. diff?
21
A.
Yes -- well, certainly, as I say, it was a rare
22
diagnosis in my previous experience and there were
23
a number of cases in the ward, so that was unusual.
24
25
Q.
Was that a matter you discussed with the consultant,
with Dr Johnston?
34
1
A.
I don't remember discussing it, no.
2
Q.
Why not, if this was unusual, in the sense that it was
3
not within your general experience to have that number
4
of patients with C. difficile?
5
A.
6
7
I don't really know why it wasn't sort of generally
discussed.
Q.
8
I think you have said that you did consider C. diff to
be an important illness at the time?
9
A.
Yes.
10
Q.
So far as you were able to see from what was happening
11
in ward 15, if a patient was diagnosed with C. diff,
12
generally, was such a patient isolated, at least at that
13
time?
14
A.
Yes.
15
Q.
Remind me, how many isolation rooms did you have
16
17
available in ward 15?
A.
We had four, four single rooms available.
But I don't
18
think they were ever -- I don't think there was ever
19
a situation where all four were occupied with patients
20
with C. diff.
21
Q.
I think perhaps two would be the maximum.
Coming back to the issue of fluid management, would you
22
agree that when you're looking at frail, elderly
23
patients, fluid management is particularly important for
24
them?
25
A.
Yes.
35
1
Q.
2
If someone has diarrhoea, then such a patient can become
dehydrated very, very quickly?
3
A.
Yes, that's correct.
4
Q.
Looking to the keeping of fluid balance charts, did you
5
see that as an important aspect of management for such
6
patients?
7
A.
8
DAME ELISH:
9
Yes.
My Lord, I wonder if my learned friend could
clarify -- earlier, the witness referred to clinical
10
examination and fluid balance charts as part of
11
the management of hydration -- what weight he placed on
12
physiological features of hydration and what weight he
13
attached to the fluid balance charts, given the caveat
14
that he mentioned earlier?
15
LORD MACLEAN:
16
17
That is quite a lot, isn't it?
Can you
answer that?
A.
I think one can assess to some degree the degree of
18
hydration of an individual by looking at how moist their
19
mucous membranes are, for example, and looking at -- if
20
one holds a fold of skin, the rate at which it flattens,
21
so to some extent on physical examination you can get
22
a degree of hydration, a measure of the degree of
23
hydration, but, like other clinical methods of
24
assessment, it has its limitations.
25
So fluid balance charts would be a useful adjunct.
36
1
MR KINROY:
My Lord, I wonder, for lay people, can we
2
clarify if perhaps the holding of a fold of skin to see
3
the rate at which it flattens concerns skin turgor?
4
A.
5
MR MACAULAY:
6
Yes.
I think you agreed with that.
Is that
a method of checking for dehydration, is it?
7
A.
It has some use.
8
Q.
In elderly patients, is it of particular use?
9
A.
Yes -- well, I think it is of use in most patients.
10
11
But
it has its limitations.
LORD MACLEAN:
If I follow what you are saying, the
12
combination of the physical examination, appearance,
13
together with the chart --
14
A.
15
LORD MACLEAN:
16
As well as blood tests as well.
As well as blood tests, too?
That is
important?
17
A.
Yes.
18
MR MACAULAY:
So, as a matter of practice -- we have touched
19
upon this already -- to what extent would you, during
20
this period, review the fluid balance charts that were
21
being kept by the nursing staff?
22
A.
Well, obviously on the ward rounds that's something that
23
we would look at, but on a day-to-day basis, I quite
24
often would be the person who was writing up fluids for
25
an individual that was on subcutaneous or intravenous
37
1
fluids, so at the point of doing that, I would look at
2
the fluid balance charts as well.
3
Q.
4
Did you have occasion to raise with the nurses whether
or not the charts were being properly kept?
5
A.
I don't remember whether I did or not.
6
Q.
When the consultant was carrying out her ward round,
7
that's Dr Johnston, would you or would you not be
8
present?
9
A.
I would generally not be present.
10
Q.
Would that be because you would not be there at the
11
12
time?
A.
13
No, I would be there at the time, but seeing other -seeing new admissions, for example.
14
Q.
So --
15
A.
Also, I should say that I think Dr Johnston's ward round
16
started at -- it was on Mondays, generally, and started
17
at 9 o'clock, so that a lot of the ward round would be
18
completed by, you know, around about 11.00, when
19
I arrived, so ...
20
Q.
You dropped your voice there.
You say that by the time
21
you would be there, are you saying the ward round would
22
be completed?
23
A.
Well, it depended on how long the ward round took, but
24
obviously the ward round would have been running for
25
about two hours or so by the time that I would generally
38
1
arrive on a Monday.
2
Q.
So would Dr Johnston then be relying on nursing input --
3
A.
Yes.
4
Q.
-- rather than clinical input from yourself as to the
5
management --
6
A.
Yes, on that ward round, yes.
7
Q.
Was there any ward round that Dr Johnston carried out
8
9
that you would be able to give clinical input?
A.
No, the arrangement that we had was that Dr Johnston
10
would do her ward round on Monday, on her own, and
11
I would do the ward round on Thursday, on my own, but
12
then I would meet her at the multidisciplinary meeting
13
immediately after the ward round, so anything that had
14
come up on the ward round that I conducted myself,
15
I could raise with her immediately after the ward round.
16
Q.
Of course, because of your presence, your regular
17
presence, on the ward, would you say that you would have
18
a better understanding of the patients generally than
19
Dr Johnston?
20
A.
Well, I think the nurses valued the continuity provided
21
by having the same doctor coming in on a daily basis, so
22
I would certainly -- because Dr Johnston wasn't able to
23
come into the ward every single day, in a sense, I would
24
have more knowledge of the day-to-day happenings with
25
the patient.
But if I felt there was anything that she
39
1
needed to be informed of, then I would clearly inform
2
her, in between her ward rounds.
3
Q.
If you saw a patient to carry out an assessment or an
4
aspect of management, would you record that in the
5
clinical notes?
6
A.
Yes.
7
Q.
If you considered a patient to be becoming unwell, would
8
you review that patient more often than you might
9
otherwise do?
10
A.
In general, yes.
11
Q.
Are you able to say generally, when you were dealing
12
with a patient who was relatively stable, how often you
13
would review such a patient?
14
A.
If someone was stable, I would generally see them on the
15
weekly ward round, unless the nurses raised issues in
16
between times, knowing that, in general, Dr Johnston
17
would see them sort of in between my ward round on her
18
ward round.
19
Q.
To be clear, then, if the patient was stable, then,
20
really, you would be seeing the patient, what, on your
21
ward round on a Thursday; is that right?
22
A.
23
24
25
Well, I would see them once a week and Dr Johnston would
see them once a week.
Q.
Would you then be relying on the nurses to involve you
more if a patient became unstable or unwell?
40
1
A.
In general, yes, although, clearly, if there was
2
a patient who I knew to be less stable than completely
3
stable, you know, I was coming into the ward on a daily
4
basis, my office was in the centre of the ward very
5
close to the four single rooms and, in general, the more
6
unwell patients were looked after in the single rooms,
7
so that I would often be aware that patients were less
8
well than others and, you know, I would possibly see
9
them when I was in the ward anyway, and the sicker
10
patients would tend to be in rooms close to where I was
11
working.
12
DAME ELISH:
I wonder if my learned friend could clarify
13
with the witness, my Lord, whether or not he recorded
14
those types of visitations, in an informal context?
15
LORD MACLEAN:
16
A.
Can you answer that, Doctor?
I think it is possible -- I think it is likely that
17
there were a number of occasions where I sort of saw
18
patients informally in these situations, where,
19
unfortunately, I didn't record it in the notes.
20
MR MACAULAY:
If you had a patient who was suffering from
21
C. difficile, would that be the sort of patient that
22
would demand more regular review?
23
A.
Yes.
24
Q.
When you carried out your ward round on the Thursday,
25
what about Dr Johnston?
Would she be on call at that
41
1
2
time?
A.
I'm not sure what her timetable was.
She was certainly
3
available for the multidisciplinary meeting at
4
11 o'clock, so -- but, as I say, I don't know what her
5
timetable was on a Thursday.
6
Q.
7
If, for any reason, she wasn't able to carry out her
ward round on a Monday, what would happen then?
8
A.
There wouldn't be a ward round on the Monday.
9
Q.
You, yourself, wouldn't then do it if you knew she
10
wasn't to be available?
11
A.
I wouldn't have the time to do it.
12
Q.
If you, yourself, weren't available for whatever reason
13
14
on the Thursday, how would that be managed?
A.
I'm not sure.
Certainly the -- when I was on holiday,
15
my partners, to some extent, filled in on my behalf, but
16
they didn't have sufficient time to do a ward round on
17
the Thursday, in general, I don't think.
18
obviously visit the ward, but I don't think they would
19
have time to do a ward round.
20
Q.
They would
So if you were on holiday, then, are we to assume that
21
the ward round would not be done, or what would the
22
position be?
23
A.
I don't think it would be done.
There was an increased
24
reliance on the junior doctors on call when I was on
25
holiday, as well as, as I say, some involvement of my
42
1
2
partners, particularly Dr Garthwaite.
MR KINROY:
My Lord, I wonder if we could clarify from an
3
earlier answer if, in general, the time required for the
4
ward round was something over two hours?
5
A.
Sorry?
6
LORD MACLEAN:
7
A.
What was the average time for ward rounds?
I think the ward round -- we were actually sort of
8
constrained to have the ward round more or less in
9
a two-hour period because the nurses would often have
10
difficulty -- I would often have difficulty getting the
11
nurses available at 9 o'clock to start the ward round
12
because they would have drug rounds, and so on, at that
13
time.
14
But, in general, we tried to start as near 9.00 as
15
possible, and we were constrained at the other end by
16
the fact that the MDT meeting was at 11 o'clock and
17
people, like social workers, for example, were coming to
18
that meeting, and occupational therapists, so there was
19
a bit of a sort of constriction in terms of when the
20
ward round could take place on a Thursday.
21
squeezed at one end by the nursing commitments and at
22
the other end by the MDT meeting.
23
24
25
We were
So, in general, to answer your question, the ward
round would take approximately two hours.
MR KINROY:
My Lord, just to dot the I and cross the T, that
43
1
would be, in general, the ward round, even on a Monday?
2
A.
I don't know how long the ward round on Monday took.
3
LORD MACLEAN:
4
A.
You are talking about your own?
Yes, I'm talking about my own ward round on Thursday.
5
I think the ward round on Monday often would last a bit
6
longer than two hours, because quite often it was still
7
taking place when I arrived at around about 11.00 or
8
11.15, or thereabouts.
9
MR MACAULAY:
10
11
But for your Thursday ward round that you
did -- sorry, when would you start that ward round?
A.
We would try and start at 9 o'clock and finish -- we
12
would try and finish around about 11 o'clock, but it
13
often ran on to maybe 11.15.
14
Q.
15
So that is a day when your presence in the ward was
earlier than the normal day?
16
A.
Yes.
17
Q.
So far as ward 15 is concerned, and you have indicated
18
that was a rehabilitation ward, but if a patient became
19
acutely ill -- well, did that happen during the time we
20
are interested in?
21
became ill?
Were there occasions when patients
22
A.
Yes.
23
Q.
But the patients would stay in that ward, would they,
24
25
generally, or what would the position be?
A.
It would depend on the degree of nursing and medical
44
1
supervision that was felt to be required.
If it was
2
felt that they could be safely maintained in ward 15,
3
then they would be kept there.
4
Q.
Even though it was primarily for rehabilitation?
5
A.
Well, as I say, if it was felt that it was safe to keep
6
them there, then they would be kept there, but there was
7
always the facility to transfer the patients back to the
8
acute medical ward, where, you know, the staffing would
9
allow more intense supervision.
10
There was also certain specific things, for example,
11
haematemesis, for example, where they might need to be
12
transferred to Paisley for specific management of that.
13
So there was that facility as well.
14
Q.
Who would make the decision for a patient to be
15
transferred from ward 15 to, let's say, ward 6 or ward 3
16
within the Vale of Leven because of that patient's
17
deterioration?
18
A.
That would be something I would discuss with
19
Dr Johnston.
20
myself.
I'm not sure whether I ever made that decision
21
myself.
Ideally, that would be something I would
22
discuss with the consultant.
23
Q.
24
25
I wouldn't often make that decision
Looking back over this period, did you find that this
was something that did occur from time to time?
A.
It did occur from time to time, because elderly people
45
1
2
obviously can become acutely unwell unexpectedly.
LORD MACLEAN:
Was the transfer to the RAH for haematemesis
3
because of internal bleeding that might require
4
operative treatment?
5
A.
Yes.
6
MR PEOPLES:
My Lord, I wonder if I could ask a question
7
about the inability to do a ward round on Monday in
8
place of Dr Johnston?
9
If the ward round could take two hours on a Thursday
10
and Dr Herd worked three hours on a Monday, what would
11
be to stop him doing a ward round between 11.00 and 2.00
12
on a Monday if Dr Johnston was unavailable?
13
LORD MACLEAN:
14
A.
What is the answer to that?
My work on a Monday primarily was seeing new admissions.
15
I actually collected statistics at the time in terms of
16
the number of admissions, so the average number of
17
admissions to the ward was 28 a month, but sometimes
18
there could be considerably more than that, for
19
example -- I think the maximum number of admissions to
20
the ward, I think I'm right in saying, was 46 admissions
21
in a month, so that, although it may seem to learned
22
counsel that I would have had plenty of time to do
23
a ward round on Monday, in fact, there were a lot of new
24
admissions to be seen and other things to be done.
25
I was also not asked to do a ward round on Monday
46
1
when Dr Johnston was on holiday.
2
MR MACAULAY:
You weren't asked?
3
A.
I wasn't asked.
4
Q.
As you have told us, you didn't have a job description?
5
A.
Precisely, yes.
6
Q.
Perhaps I should have asked you this before, because you
7
have indicated, in fact, that you had quite a commitment
8
then to manage new admissions.
9
A.
Yes.
10
Q.
Can you give us a feel for the practicalities involved
11
in that?
First of all, if a patient was a new
12
admission, where would you see the patient?
13
A.
I would see them in the ward, in their bed in the ward.
14
Q.
Yes.
15
A.
But one of the annoying things was that patients who
16
were transferred from Paisley would almost never arrive
17
with a transfer letter, despite -- in the past, I had
18
tried to make efforts to produce a sort of form so that
19
we could at least have some basic information about what
20
had happened to a patient when they were transferred
21
from Paisley, but that had never been taken up.
22
So that, quite often, patients would arrive with
23
very thick Paisley notes, having had a very complex
24
admission to Paisley, but without a transfer letter, so
25
prior to seeing the patient, I would quite often have to
47
1
spend quite a lot of time -- I should say also that
2
these patients often had very thick Vale of Leven notes,
3
so prior to seeing the patient, I would tend to go
4
through the Paisley admission details -- admission notes
5
in quite a lot of detail to make sure that I knew about
6
everything that had happened to them in Paisley, and
7
also I would then take the time to go through their
8
previous Vale of Leven notes, because, quite often,
9
something that's happened in the past is very relevant
10
to what happens to the patient in the ward at the time.
11
So once I had done that, I would then go and see the
12
patient and examine them, and so it was quite
13
a time-consuming process, especially, you know, if they
14
had had a long, complicated admission to Paisley, which
15
was not uncommon.
16
It was made more onerous because of the fact that,
17
for some reason or other, it was not felt necessary to
18
encourage the doctors in Paisley to provide a transfer
19
letter.
20
Q.
21
22
We had focused on Monday, I think, but was this an issue
that you had on a daily basis in relation to admissions?
A.
Yes, it was an issue with -- it was an issue on a daily
23
basis.
The other thing I would say that -- you know,
24
I haven't made reference to the number of admissions
25
there were to ward 15, and I think Dr Johnston in her
48
1
evidence did mention the fact that the number of
2
admissions under her jurisdiction, if you like, had
3
increased quite dramatically.
4
average lengths of stay compared to RAH and Inverclyde
5
and our average length of stay was considerably shorter
6
than other hospitals.
7
workload in the ward.
8
Q.
9
She gave figures for
That obviously added to the
Correct me if I am wrong, but the impression you seem to
be giving, Dr Herd, is that, because of your commitment
10
to new admissions, which involved looking at records
11
more than you might have liked --
12
A.
Yes.
13
Q.
-- that would detract you from your duties on the ward?
14
A.
I think that is true.
It made it harder to monitor
15
and/or document the monitoring of patients who were
16
already in the ward.
17
Q.
Did you raise this particular matter with anybody?
18
A.
I didn't raise it -- perhaps I should have raised it
19
with Dr Johnston, but certainly -- I think the nurses,
20
as well, were aware of the fact that the throughput in
21
the ward had increased.
22
of, in a way, proud of the fact that our ability to
23
rehabilitate the patients meant that, you know, we were
24
doing well from that point of view.
25
hand, there was no doubt that this added -- you know,
I mean, they think we were sort
49
But, on the other
1
there was more work involved in this, and I'm not sure
2
if that was fully recognised.
3
DAME ELISH:
My Lord, I wonder, given my learned friend
4
earlier established with the witness about the adequacy
5
of the medical staff on the ward, whether or not the
6
witness could be asked whether or not this evidence he's
7
just given, if he wishes to reflect on what he said
8
earlier, or whether or not he still maintains that there
9
was adequate medical staffing on that ward?
10
LORD MACLEAN:
11
12
How does that sit with what you said at
the outset of your evidence about medical staffing?
A.
13
14
Yes.
I suppose, in retrospect, you know, I would maybe argue
that there should have been increased staffing.
MR MACAULAY:
I think what you are saying, Dr Herd, is, if
15
you had this busy commitment to managing new admissions,
16
then you wouldn't be able to be managing the patients on
17
the ward in the way that you might otherwise do?
18
A.
I think that would be the case, yes.
19
Q.
Just to finish my line of thought, I think you indicated
20
that you -- you can correct me if I am wrong -- didn't
21
raise this issue?
22
A.
I didn't raise the issue with Dr Johnston.
23
Q.
Or anybody else?
24
A.
Or anybody else, and perhaps, in retrospect, I should
25
have.
50
1
Q.
Can you explain why you didn't?
Because, from what you
2
have said so far, it seems to have been a bit of
3
a problem, so why didn't you raise it?
4
A.
I think there is a bit of a tendency in medicine in
5
general to basically get on with things and not
6
complain, so I think that's probably as much as I would
7
say.
8
MR PEOPLES:
9
In retrospect, perhaps, I should have raised it.
My Lord, I'm just a little puzzled by why new
admissions would be a particular problem on a Monday for
10
a rehabilitation ward unless there was a clear-out in
11
Paisley at the weekend or a clear-out of the acute
12
medical wards on the Vale of Leven?
13
pattern was?
14
LORD MACLEAN:
15
A.
Is that what the
Could you answer that?
I wasn't arguing that there was a particular problem on
16
Monday, but it was a problem throughout the week,
17
although some patients were transferred from Paisley on
18
Friday, for example, or over the weekend, but I'm not
19
arguing that this was a particular problem on Monday,
20
but it was a problem generally.
21
LORD MACLEAN:
I'm not quite sure what is meant by "new
22
admissions", at least so far as the work that you were
23
carrying out on a Monday is concerned.
24
patients who arrived at the Monday?
25
A.
Are these
Yes -- well, there were patients arriving every day.
51
1
LORD MACLEAN:
Oh, I know that.
But, I mean, so far as
2
Monday was concerned -- after all, the weekend has
3
preceded that.
4
A.
Yes, I see what you mean.
The patients who were new
5
patients on Monday would have been patients who had
6
arrived either on Friday late on or over the weekend.
7
LORD MACLEAN:
8
9
So that might result in an increase in the
number of admissions -A.
Yes.
10
LORD MACLEAN:
11
A.
12
MR MACAULAY:
13
-- that you were dealing with on an Monday?
Mmm, yes.
My Lord, that might be an appropriate point to
have a break.
14
LORD MACLEAN:
15
(11.20 am)
Yes, thank you very much.
16
(A short break)
17
(11.45 am)
18
MR MACAULAY:
Before the break, Dr Herd, you had been giving
19
some evidence about, in particular, interhospital
20
transfers from the Royal Alexandra Hospital to the
21
Vale of Leven.
22
not have been transfer documentation, you would have to
23
spend more time making yourself familiar with the case;
24
is that right?
25
A.
You pointed out that, because there may
That's correct, yes.
52
1
Q.
When a patient was sent from the Vale of Leven either
2
back into the community or to the Royal Alexandra
3
Hospital, would there be a transfer document to indicate
4
what the treatment had been?
5
A.
6
So if I was sending a patient from the Vale to Paisley,
for example?
7
Q.
Yes.
8
A.
Yes, I would always do a letter telling -- basically,
9
detailing what had happened to the patient and, you
10
11
know, the circumstances leading to the referral.
Q.
If you are transferring a patient, for example, to
12
a nursing home or back into the community, would you
13
send a letter to the nursing home or the general
14
practitioner?
15
A.
Yes, for patients who were being discharged to the
16
community or to a nursing home or residential home,
17
there was a standard -- there's a separate form for the
18
drugs they were being prescribed and another form for
19
the brief details of what had happened to them during
20
their hospital stay, and there would subsequently be,
21
obviously, a typed discharge letter done.
22
LORD MACLEAN:
Could I ask you about that: if there was
23
a typed discharge letter, wherever the patient was
24
going, was a copy kept in the hospital records?
25
A.
Yes, but the typed discharge letter wouldn't be done for
53
1
a while after the patient was discharged.
2
have completed would have been what is called an
3
immediate discharge letter, which was handwritten.
4
consultant would do the typed discharge letter later.
5
LORD MACLEAN:
6
A.
What I would
The
Would there be a difference between the two?
Well, the consultant's letter would be more detailed.
7
The one that I was writing, the immediate discharge
8
letter, would just be a brief summary of what had
9
happened.
The consultant's letter, which would come
10
later, would be more detailed.
11
would be kept in the notes.
12
LORD MACLEAN:
13
A.
14
LORD MACLEAN:
15
A.
16
LORD MACLEAN:
17
MR MACAULAY:
But in both cases a copy
In all cases?
In all cases.
Both cases?
Yes.
Thank you.
You have been telling us in particular about
18
your own commitments to the Vale of Leven Hospital.
19
I just want to be clear about Dr Garthwaite's role.
20
A.
Yes.
21
Q.
He, as you have indicated, was one of your partners; is
22
that right?
23
A.
Yes.
24
Q.
Just to be clear, was he the only other partner from
25
your partnership that had a commitment to the
54
1
2
Vale of Leven Hospital?
A.
He was the only partner who had a formal commitment,
3
although, in some cases, when I was on holiday,
4
Dr MacRae would become involved as well, but that was
5
uncommon.
6
Q.
7
8
It was usually Dr Garthwaite.
So I can just understand, then, what his commitment was,
can you help me on that?
A.
9
Yes.
Dr Garthwaite had a regular commitment on Tuesday
mornings, so he would go to the hospital on Tuesday
10
mornings, roughly between 9.00 and 11.00, but he also
11
was paid a session to participate in the cover when
12
I was on holiday.
13
Q.
The Tuesday morning session, was that in ward 15?
14
A.
In ward 15, yes.
15
Q.
You weren't there then on the Tuesday morning?
16
A.
No, I came later on Tuesday.
17
Q.
Apart from covering for you on holiday, was that then
18
the extent of his commitment?
19
A.
Yes.
20
Q.
So he had no weekend commitment?
21
A.
No.
22
Q.
Why was Dr Garthwaite brought in to cover for the
23
24
25
Tuesday morning?
A.
It was an historical thing.
I can't remember how that
arose, but that was just the way that things were.
55
1
2
I can't remember how that was arrived at.
Q.
Focusing on the relevant time, and we'll leave Dr MacRae
3
out of it, the only two GP practitioners who were
4
engaged at the Vale of Leven were yourself and
5
Dr Garthwaite?
6
A.
From our practice, yes.
7
Q.
From your practice.
8
A.
Yes.
9
Q.
What about other practices?
10
A.
Other practices provided -- I mean, the practice that we
11
merged with eventually had two partners who participated
12
in the geriatric unit.
13
partner of the practice we merged with, and he did
14
a similar job to myself in ward 14; Dr Robertson, who
15
was the partner that retired just before the practices
16
merged, did his sessions in the day hospital in the Vale
17
and I actually took over his sessions, so I now work in
18
the day hospital, but I've only been doing that
19
since March.
20
LORD MACLEAN:
21
There was cover at night, wasn't there, too,
from other GPs?
22
A.
23
LORD MACLEAN:
24
A.
25
Dr Stevenson was a former
That's a separate arrangement.
Yes.
There are other GPs involved in the cover at night as
well, but we didn't have anything to do with that.
56
1
DAME ELISH:
My Lord, I wonder if my learned friend could
2
clarify if this witness recollects when Dr Stevenson
3
resigned from that post and whether he was present
4
during the focus period of the Inquiry?
5
A.
6
7
I don't know.
MR KINROY:
8
9
I can't remember when Gordon Stevenson retired, so
My Lord, it might help us all if I suggest that
Dr Khan became a replacement for Dr Stevenson.
A.
I think that's correct, yes.
10
LORD MACLEAN:
11
MR MACAULAY:
12
I think that's right.
Can I ask you a little bit about the DNAR
orders?
13
A.
Yes.
14
Q.
Would that be a procedure that you would become involved
15
in with particular patients?
16
A.
Yes.
17
Q.
Can you just elaborate upon that?
18
19
How would you become
involved in that?
A.
Well, it would often -- sometimes it would occur to me,
20
as a doctor seeing the patients on a day-to-day basis,
21
that someone would be probably inappropriate for
22
resuscitation, but quite often it would be the nurses
23
who would prompt the question of whether someone, you
24
know, would or would not be suitable for resuscitation.
25
Q.
If you were prompted by the nurses, would you, yourself,
57
1
be then involved in assessing the patient?
2
A.
Yes.
3
Q.
With what purpose?
4
A.
Well, if I agreed that I felt it would be inappropriate
5
for someone to be resuscitated, I would either discuss
6
it with the patient or the relatives in general.
7
Q.
8
What about the consultant?
Would you involve the
consultant?
9
A.
The consultant would often be involved as well, yes.
10
Q.
But, as a matter of practice, would you, if you were
11
involved in this process, discuss it with the
12
consultant?
13
A.
I sometimes would, yes.
14
Q.
Do we take it not always?
15
A.
Not always.
16
Q.
Was it your practice to write in the clinical notes if
17
such a decision had been made?
18
A.
In general, I would write in the notes, yes.
19
Q.
If the decision were to be that the patient was to
20
receive palliative care, I don't think at the relevant
21
time you were using the Liverpool pathway; is that
22
right?
23
A.
24
25
That's correct.
We weren't using the Liverpool care
pathway at the time.
Q.
What was the position that was adopted at the time if
58
1
you had a situation where the patient was really just
2
simply for palliative care?
3
A.
That decision should be documented in the notes, so that
4
other doctors who were involved in the care of
5
the patient would know that that was the policy being
6
adopted by the team looking after them.
7
Q.
8
9
decision?
A.
10
11
What should we see in the records, then, if that was the
It should be recorded in the notes that the patient was
being managed palliatively.
Q.
Did you have any experience of that being the situation
12
with a patient who was, at the time, suffering from
13
C. difficile?
14
A.
Yes.
15
Q.
What about the treatment for C. difficile?
What would
16
happen in relation to that, if you had a patient who was
17
for palliative care?
18
A.
I think if the patient were being managed palliatively,
19
we would still in general carry on with the treatment
20
for C. difficile.
21
Q.
Death certification is another topic I want to discuss
22
with you.
Did you become involved in certifying the
23
deaths of patients?
24
A.
I was involved quite often in certificating patients.
25
Q.
On a separate topic, was there a computer system,
59
1
a hospital intranet system in place at the relevant
2
time?
3
A.
I think there was, yes.
4
Q.
Did you make use of it?
5
A.
I did, yes, although I can't remember whether, at the
6
time, I had my own log-in details.
7
information via the intranet, I would generally ask the
8
nurses to log on on my behalf.
9
Q.
10
11
If I wanted
What sort of information would you be looking for, then,
off the system?
A.
Things like lab results, which might be available at an
12
earlier stage rather than waiting for them to come
13
through in hard copy.
14
results, for example.
15
Q.
That was the main -- or X-ray
We discussed earlier the policies contained in the
16
infection control manual.
17
not, so far as you can say?
18
A.
19
20
Were they on the system or
I don't know if they were.
I suspect they were, but
I don't know.
Q.
Are you able to say what the facilities were like in the
21
Vale of Leven during this particular time, looking in
22
particular at things like hand washing facilities and
23
toilets?
24
25
MR PEOPLES:
My Lord, before leaving the matter of
the intranet, Dr Herd said he was interested in this
60
1
side of things, and we have heard of something called --
2
something known as the SCi system.
3
whether he could explain whether that was different from
4
the intranet or the same as the intranet and what its
5
function was.
6
A.
I just wonder
SCi Store is -- I'm not sure whether that's on --
7
I think it is on the intranet, because it can be
8
accessed from general practice as well as from the
9
hospital.
10
Lab results -- for example, biochemistry and
haematology -- would be uploaded to SCi Store.
11
From the practice in Alexandria, I can access data
12
on SCi Store, but only for my practice patients.
13
LORD MACLEAN:
14
A.
Yes.
That is just as well.
But in the hospital, if I had had log-in details
15
at the time, I could theoretically have accessed, you
16
know, all patients; anyone who might be admitted to the
17
Vale.
18
MR MACAULAY:
19
For the benefit of the transcribers, it is
intranet we are talking about, not internet.
20
A.
Intranet, yes.
21
Q.
I've been moving on to ask you about facilities, then,
22
at the time, because I think we understand there have
23
been changes, but at the relevant time, did you have any
24
views on that topic?
25
A.
Are we talking about the interior of the building?
61
1
Q.
2
3
Let's look at facilities such as wash-hand basins and
toilets.
A.
I think there were sufficient wash-hand basins and
4
toilets, but the fittings, for example, on the wash-hand
5
basins were often -- looked as if they needed replacing,
6
the taps were dripping, for example, and it seemed to be
7
impossible to repair them and stop them dripping, so
8
that tended to make one feel as if there was a lack of
9
investment in that area.
10
But, having said that, I felt that in the -- in
11
ward 15, there was an adequate number of wash-hand
12
basins, it didn't discourage me from washing my hands,
13
for example.
14
Q.
Was there any change in that after June 2008?
15
A.
Well, the hospital -- the care of the elderly block has
16
been extensively refurbished and there are now new
17
wash-hand basins and new taps, and so on.
18
of these is still the same, as far as I'm aware, but
19
they are new and fully functional.
20
Q.
21
22
So the number
Is the design of the taps different to what it was
before?
A.
The taps now have handles which can be operated with
23
your elbows, as I recall, rather than standard taps.
24
Yes, I think that is different from the previous.
25
Q.
Can I ask you about the staff morale at the time?
62
Did
1
you have any views as to what that was like, standing
2
the fact that the Vale of Leven might have been under
3
a degree of threat?
4
A.
Yes.
I think there was a perception that the hospital
5
was under threat at the time and there was a perception
6
that there was a lack of commitment of the health board
7
to the long-term future of the hospital, whether that
8
was well founded or not.
9
But certainly, the fact -- I mean, I think the thing
10
that was a constant reminder was the lack of maintenance
11
to the external fabric of the building.
12
large areas where the rough cast hadn't been replaced
13
and the windows were in a poor condition, and I think
14
that every time one came to the building, one had
15
a feeling that there was a lack of commitment to the
16
building, just by these appearances.
17
LORD MACLEAN:
18
19
Dr Herd, are you still engaged as a hospital
practitioner?
A.
20
21
There were
I am, yes, but I now work in the day hospital, rather
than in ward 15.
LORD MACLEAN:
How much were you aware of the possible
22
change in the running of the hospital by -- if GPs were
23
prepared to manage it or run it?
24
A.
I'm not sure what you mean, my Lord.
25
LORD MACLEAN:
No, I'm not surprised you're not sure.
63
We
1
were told that there was a proposal for general
2
practitioners in the area to take the hospital over so
3
that the central services would go elsewhere, but it
4
would become a smaller hospital but run on the basis --
5
on that basis by general practitioners.
6
of that?
7
A.
I think I was aware of that.
Were you aware
I mean, in my previous
8
practices, or in my previous practice and in my trainee
9
job in Crieff, both practices had GP community
10
hospitals, so what you are describing is like a sort of
11
larger GP community hospital.
12
there was a proposal that that might happen.
13
LORD MACLEAN:
14
A.
15
MR MACAULAY:
16
I think I was aware that
You weren't involved in that, though?
I was not involved in that.
What's the position now on the ground?
have a GP commitment to the hospital?
17
A.
Yes.
18
Q.
What about the rest of the hospital?
19
20
You
Is there a GP
involvement?
A.
There is.
The medical assessment unit is partly
21
staffed -- staffed in the evenings and overnight, and at
22
weekends it's partly staffed by what are called
23
integrated care practitioners, and Dr Garthwaite has
24
actually become one of those, and they all do sessions
25
seeing -- patients are carefully selected for admission
64
1
to the Vale of Leven, and if they are considered
2
suitable to be kept there, part of their care is carried
3
out by doctors who are general practitioners mainly, but
4
they also have specific training, for example, on
5
advanced resuscitation techniques, to allow them to
6
carry out the job.
7
Q.
I just want to pick up some points from your statement
8
that you provided earlier to the Inquiry, Dr Herd, and
9
if we put that on the screen for you, it's WTS01430001.
10
I think you have clarified this point already, but in
11
paragraph 10 on page 2, it is where you say:
12
"If there was a particular problem, I would speak to
13
Dr Fiona Johnston who was the consultant at the time and
14
my line manager."
15
I think you have qualified that.
16
A.
That's the wrong term to use.
17
Q.
If I take you to paragraph 44 and just ask you what you
18
mean by this, you say there on page 9 of the statement:
19
"In relation to infection control, I would say from
20
my experience that it is everyone's responsibility and
21
we all have a part to play."
22
What did you mean by that when you made that
23
24
25
statement?
A.
Well, I think obviously an important area of infection
control is hand washing, and I think an enormous amount
65
1
of publicity has gone into proper care as regards hand
2
washing, and that obviously has to be an individual
3
responsibility: anyone who is involved in contact with
4
patients should be washing their hands often enough and
5
in the proper way to make sure that they don't pass
6
infections from one patient to another.
7
Q.
At the time we are interested in, and before matters
8
came to a head in about June 2008, did you see that
9
everyone had a responsibility for infection control?
10
A.
Yes.
11
Q.
You have mentioned hand washing.
Any other aspects of
12
infection control that you consider you had
13
a responsibility for at that time?
14
A.
Well, there were recommendations in terms of doctors
15
have to have their sleeves rolled up, for example, and
16
not wear ties in the ward.
17
these recommendations came in after the period in
18
question or whether they came at some point during the
19
period in question.
20
infection control like that.
21
Q.
I can't remember whether
But there are other aspects to
If you were dealing with a patient who you suspected
22
might have C. diff, or at least infectious diarrhoea,
23
then what steps would you take if you were to go and see
24
such a patient?
25
A.
Well, I would wash my hands thoroughly and put on
66
1
2
a plastic apron and wear gloves.
Q.
Just in washing hands, if you turn to page 14 of
3
the statement, you have a section dealing with hand
4
hygiene.
5
I think, what notices were displayed regarding hand
6
hygiene at the time; is that right?
At paragraph 71, you are not able to say,
7
A.
That's right.
8
Q.
Then you say:
9
"My view is that we did not wash our hands as often
10
at that time because there was less awareness about
11
infections."
12
13
Can you just explain what you mean by that?
A.
I think it is probably true that we -- I think we washed
14
our hands as often as any other doctor in the health
15
board area at the time, but I think since -- probably
16
largely in the light of the outbreak, there has been
17
much more attention focused on this, but I think it is
18
true to say at the time that we were perhaps not as
19
careful about washing our hands as we are now, but
20
I think we were as careful as any other doctors at the
21
time.
22
Q.
I now want to move on to look at some individual
23
patients with you that you had some involvement with,
24
Dr Herd.
25
Mary Broadley.
The first patient I want to look at is
Do you have a copy of the medical
67
1
records to hand?
2
A.
No.
3
Q.
It may be easier for you to work off a hard copy.
4
I will put the records onto the screen, GGC00050001.
5
I don't know what you recall about this patient,
6
Dr Herd, but this was a patient who was initially
7
admitted to the Royal Alexandra Hospital on
8
21 September 2007 because she'd had a fall and she broke
9
the neck of her right femur.
She was transferred to the
10
Vale of Leven on 29 September and she also suffered
11
falls in the Vale of Leven as a consequence of which she
12
was transferred back to the Royal Alexandra Hospital.
13
A.
Yes.
14
Q.
She eventually comes back to the Vale of Leven on
15
23 November 2007 to ward 15.
16
A.
Yes, I can see that relevantly.
17
Q.
Once she's in ward 15, she'd come under the care of
18
Dr Johnston, and you would have some involvement with
19
her; is that correct?
20
A.
21
22
That's correct.
The first -- the note from 23 November
is by Dr Garthwaite.
Q.
Then, if we turn to page 28 of the records, is that the
23
note on the 23rd that you are identifying as
24
Dr Garthwaite?
25
A.
That's correct, yes.
68
1
Q.
This is when Mrs Broadley comes back?
2
A.
Yes.
3
Q.
If we look below that, for the 26th, can we see that
4
that's when she's first seen by Dr Johnston?
5
A.
Yes.
6
Q.
Then she's seen again by Dr Johnston on 3 December; is
7
that right?
8
A.
Yes.
9
Q.
We have heard from Dr Johnston about this, and there is
10
clearly a gap of a number of days between the entry that
11
she made on 26 November and the one she made on
12
3 December, and I think she thought that the patient
13
should have been seen by you in that period?
14
A.
Yes, I am surprised by the gap.
I don't understand why
15
there isn't a note from me.
16
been a note from me during that time.
17
Q.
18
I think there should have
If we turn to page 30 of the records, we have an entry
by yourself, I think, on 5 December; is that right?
19
A.
Yes.
20
Q.
The background here is that a specimen had been taken
21
for analysis, and I will put that on the screen for you,
22
it is page 80 of the records.
23
collected on 4 December, received by the lab on the 5th
24
and that was a positive result?
25
A.
Yes.
69
You can see that it was
1
Q.
2
If we go back to the clinical notes on page 30, we see
your note for the 5th.
3
"C. diff confirmed.
4
Is that right?
It reads:
Already on metronidazole."
5
A.
Yes.
6
Q.
Again, would you have carried out a clinical examination
7
of the patient, standing the fact that there was
8
a positive C. diff result?
9
A.
I may have done, but I have not noted it.
10
Q.
I think, again, Dr Johnston expected that you would have
11
carried out such an examination?
12
A.
Right.
13
Q.
Should you have done so?
14
A.
I should have done.
15
Q.
We touched upon this earlier.
16
17
I don't know whether I did or not.
What would that have
involved, then?
A.
That would have involved an assessment of, for example,
18
whether the patient was fevered or not, their degree of
19
hydration and whether there was any evidence of
20
abdominal distension or abdominal pain and possibly an
21
examination of the abdomen.
22
23
24
25
Q.
The patient tests positive again, and I will put the
report on the screen --
DAME ELISH:
My Lord, I wonder, given the answer that the
witness gave, that he should have, although it is not
70
1
noted, from his experience, would it have been likely in
2
such a situation as that that he would have carried out
3
an abdominal examination, or can he assist?
4
LORD MACLEAN:
5
out an examination".
6
He can't remember.
Is that right?
7
A.
8
LORD MACLEAN:
9
10
Well, we have his answer: "I may have carried
I can't remember.
5 December --
To take up Dame Elish's question, how likely
is it that you would have or would not have?
A.
11
Can I just say that 5 December, I think, was
a Wednesday.
12
LORD MACLEAN:
13
A.
It was.
I was wondering about that.
Yes, so -- whereas 6 December, where I again made
14
a note, was Thursday.
15
I examined the patient on the 6th.
16
examine her on the 5th.
17
MR MACAULAY:
18
So I think it's more likely that
I think I didn't
Although your note for the 6th is extremely
brief.
19
A.
I know that, yes.
20
LORD MACLEAN:
21
A.
How likely is it that you examined or --
I think it is extremely likely that I assessed her
22
degree of hydration clinically, in the ways that I have
23
already described.
24
abdominal examination.
25
MR MACAULAY:
I am not sure whether I performed an
What day are you focusing on now, Dr Herd; is
71
1
2
it the 5th or the 6th?
A.
3
My recollection is that I didn't examine her on the 5th.
I think I probably examined her on the 6th.
4
Q.
Why didn't you examine her on the 5th?
5
A.
I don't know.
6
Q.
Was C. diff at the time -- this is the important thing
7
we are looking at here -- considered to be a serious
8
infection?
9
A.
We considered it to be a serious infection, yes.
10
Q.
Moving on, then, to see when she tested positive again,
11
if we look at the lab report on page 73 of the records,
12
we are looking now, Dr Herd, at a specimen being
13
collected on 17 December, received by the lab on the
14
18th, and, again, we see that is a positive result.
15
A.
Yes.
16
Q.
If we look at the clinical records, on page 31, we have
17
a note by Dr Johnston for 17 December where she says,
18
"Has had MRSA, C. diff and norovirus.
19
her own currently".
20
it may be, of course -- I think the specimen was only
21
collected on the 17th.
Not mobilising on
So there is no mention there, but
22
A.
Mmm.
23
Q.
Then we have a note by yourself on the 18th, which
24
I think recounts a conversation you had with family
25
members; is that right?
72
1
A.
Yes.
2
Q.
There is no mention there of C. diff in particular?
3
A.
No.
4
Q.
Then if we move to page 32, again, I think we can now
5
understand that's your handwriting for 20 December?
6
A.
Yes.
7
Q.
Can you read that for us?
8
A.
It says "Referral" and then there is an arrow
9
10
"Consultant psychiatrist".
Q.
11
Then there is a further entry for the 20th by someone
else, and we are dealing with a plaster; is that right?
12
A.
Yes.
13
Q.
And again on the 21st.
So we don't see, following upon
14
the diagnosis that had occurred on or about 17 December,
15
or thereabouts, any reference in the clinical notes to
16
that particular diagnosis; is that correct?
17
A.
I would have to agree, yes.
18
Q.
Why is that?
19
A.
We were aware that she had the infection, clearly, but
20
we were giving her what should be appropriate treatment,
21
and she seemed to be stable at that point.
22
Q.
23
24
25
Should there have been a clinical examination of
the patient at this time?
A.
I think there may have been one or more clinical
examinations, but they haven't been documented.
73
1
Q.
What we see, if we go back to page 32, after your entry
2
on the 20th, which is really dealing with referral to
3
a consultant psychiatrist, and the entries dealing with
4
the plaster, there is no medical involvement again until
5
27 December?
6
A.
I think that's clearly the way that it looks from the
7
record, but I don't think that's true.
8
being reviewed.
I think she was
9
Q.
By yourself?
10
A.
Well, by myself and by Dr Johnston when she was in the
11
12
ward.
Q.
13
Are you saying, then, that the true position is that
there would have been a review --
14
A.
Yes.
15
Q.
-- and that simply has not been recorded in the records?
16
A.
Yes.
17
LORD MACLEAN:
I take it, looking at the entry for
18
27 December, that there must have been some kind of
19
review, because there's a reference to her being on oral
20
vancomycin?
21
A.
Yes.
22
LORD MACLEAN:
23
point?
24
A.
25
LORD MACLEAN:
So that the drug had been changed at some
That's correct.
This is something which I really feel I have
74
1
to put to you: do you think that the absence of notes
2
about examination and the results of that examination
3
give rise to the inference that the illness was not
4
really regarded all that seriously?
5
A.
6
LORD MACLEAN:
7
A.
8
LORD MACLEAN:
9
I don't think that's the case.
You don't think that is fair?
No, I don't think that is fair.
What is the reason why, if there were
assessments -- if there were; and you think there
10
were -- there is no record?
11
A.
I agree that the record should be more complete.
12
MR MACAULAY:
I think it was yourself who prescribed the
13
vancomycin, and we can perhaps get that from the Kardex,
14
if we turn to GGC27170007.
15
I think, on the 20th.
The vancomycin is started,
That's the second reference.
16
A.
Yes.
17
Q.
If we are looking to a specimen that was collected on
18
17 December, there is a bit of a gap before the
19
vancomycin treatment has commenced?
20
A.
Yes.
21
Q.
Should the gap be as large?
22
23
I suppose it depends on
when the result comes back?
A.
It depends on obviously -- as soon as I became aware of
24
the result -- I obviously changed the medication as soon
25
as I became aware of the need to change it.
75
1
Q.
2
I think, if we look at the nursing notes on page 127,
this is on the 19th, for 1900 hours:
3
"Written in retrospect due to busyness of ward -
4
Mary's stool specimen is positive for C. diff.
5
discussion with microbiologist, Mary commenced on oral
6
vancomycin."
7
8
After
Would that discussion have been with yourself?
A.
9
10
It may have been.
It probably was, but, again, it's not
been written down.
It would quite often be left for me
to speak to the microbiologist.
11
Q.
I'm sorry?
12
A.
Sorry?
13
Q.
You say it would be quite often left for you to speak to
14
15
It would be left to you to do it?
the microbiologist?
A.
I think probably the discussion was between me and the
16
microbiologist.
17
the drug, so it would be likely that I was the one that
18
discussed it.
19
Q.
Certainly I was the one that prescribed
So the discussion has taken place sometime on the 19th,
20
but the prescription doesn't get put in place until the
21
20th; is that how we read this?
22
A.
I agree that does seem odd.
23
Q.
Your hours of attendance, I think you have told us,
24
25
generally would be in the morning; is that right?
A.
Usually, yes, between 11.00 and 2.00, 2.30.
76
1
Q.
So if this note is written in retrospect, are we to
2
assume that the discussion you had with the
3
microbiologist would have been in the morning of
4
the 19th?
5
A.
That seems likely, yes.
I can't understand why the
6
prescription was on the 20th if this discussion took
7
place on the 19th.
8
is.
I don't know what the explanation
9
Q.
There is an apparent delay there.
10
A.
Yes.
11
DAME ELISH:
My Lord, I wonder if my learned friend could
12
confirm where the Kardex itself would have been stored
13
and, if it was stored at the end of the bed, if that is
14
correct, would this be an indication that Dr Herd was at
15
the bed of the patient?
16
LORD MACLEAN:
17
A.
18
Could you answer that?
The Kardex is where -- kept in a folder, which was on
the drug trolley.
19
MR MACAULAY:
The drug trolley, is that out in the corridor?
20
A.
It's out in the corridor, yes.
21
Q.
The third occasion I think Mrs Broadley tests positive
22
is in January, and if we just look at the lab report for
23
that, GGC00050067.
24
collected on 12 January, apparently not received until
25
the 5th, and we can again see that this is a positive
Here we see that a specimen has been
77
1
result; is that correct?
2
A.
Yes.
3
Q.
If we look at the clinical notes for this period, if we
4
go to page 34, perhaps go back to page 33, we have an
5
entry at the top of the page by yourself, I think; is
6
that correct?
7
A.
Yes, that's my note.
8
Q.
Then we have a note by Dr Johnston for the 10th?
9
A.
Yes.
10
Q.
Should the gap be as long as that, if the inference is
11
that she wasn't seen?
12
A.
The 7th was --
13
DAME ELISH:
Sorry, my Lord, I wonder if it could be
14
established -- I had understood that my Lord had
15
established that that inference, although put to the
16
witness, wasn't accepted by the witness, that if there
17
wasn't a review recorded in the medical notes, it did
18
not thereby imply that there hadn't been any
19
examination.
20
21
LORD MACLEAN:
I didn't say that.
I put to him, actually.
22
DAME ELISH:
23
LORD MACLEAN:
That wasn't the question
You should look at the notes.
Unfortunately, it is outwith the screen -You should be able to operate that.
24
find that that wasn't what I put to him.
25
would confirm that.
78
You will
I think he
1
I am not suggesting there wasn't an examination.
2
What I am saying is, if there was an examination, and
3
there are no notes of that, no assessment, does it give
4
rise to the inference that C. diff was not regarded
5
really seriously, and he said no, that wasn't the case.
6
That is his answer.
7
I think it is right I should put it to him, and that is
8
what I put.
9
DAME ELISH:
10
MR MACAULAY:
I think he is probably right.
But
I'm obliged, my Lord.
I had moved on to ask you, in relation to the
11
two entries we have towards the top of page 33, whether
12
the inference can be drawn that the patient wasn't seen
13
or, indeed, whether or not the patient should have been
14
seen at all?
15
A.
Between the 7th and the 10th?
16
Q.
Yes.
17
A.
There is certainly no note of an assessment between the
18
19
7th and the 10th, I would have to agree.
Q.
I think we have heard with some patients there may not
20
be a need to review a patient on a daily basis.
21
this patient in that category?
22
23
24
25
A.
Was
Well, this patient had recurrent C. diff, so they
required to be assessed more often.
DAME ELISH:
My Lord, I wonder if my learned friend could
refer the witness, regarding this, to the entry on the
79
1
nursing notes on GGC00050130 for 8 January, the entry
2
there?
3
MR MACAULAY:
Page 130, I think, of the notes.
4
LORD MACLEAN:
5
DAME ELISH:
6
MR MACAULAY:
These are the nursing notes?
Yes, my Lord.
I think that is the entry that begins, "Trying
7
to get out of bed last night".
8
Then there is one at 1600 hours:
9
"Mary has positive [something] spec."
10
Can you read that?
11
12
13
14
15
16
That's the first entry.
It is very difficult to read
that handwriting.
A.
"Positive urine spec"?
No?
I don't know.
with Dr Herd".
MR MACAULAY:
If there is a particular point my learned
friend wishes to pick up -DAME ELISH:
I think it is the next sentence, which reads,
17
my Lord, "Not symptomatic at the moment.
18
keen to treat as previously had C. diff."
19
"Discussed
MR MACAULAY:
Would not be
Is this indicating there is to be no treatment
20
for a suspected urinary tract infection because she's
21
not symptomatic; is that ...
22
LORD MACLEAN:
23
point is.
24
25
DAME ELISH:
I'm not at all sure, Dame Elish, what your
I wonder if my learned friend could put whether
or not it is indicative that Dr Herd was involved with
80
1
2
this patient's care on that date?
LORD MACLEAN:
3
4
urinary tract infection.
DAME ELISH:
It is a reference to the discussion with
5
Dr Herd.
6
MR MACAULAY:
7
LORD MACLEAN:
8
DAME ELISH:
9
LORD MACLEAN:
10
11
But "not symptomatic" is in relation to the
Would you be in the ward at 1600 hours?
Is there a reference to that in the note?
"Discussed with Dr Herd at 1600".
I'm missing that.
Oh, yes, there it is, in
the fourth line.
A.
It would be unusual for me to be in the ward at that
12
time.
It is not impossible, but it would be unusual for
13
me.
14
MR MACAULAY:
On the face of it, the nurses have had
15
a discussion with you about whether or not there should
16
be treatment for a suspected urinary tract infection?
17
A.
Occasionally, the nurses, rather than contacting the
18
oncall doctor, would phone me in the practice, so it is
19
possible that they discussed it with me on the telephone
20
at 1600.
21
Q.
22
23
be your time for being in the hospital?
A.
24
25
From what you have said to us, this would not normally
It would be very uncommon for me to be there at
4 o'clock.
Q.
But then, if we go back to the clinical notes at
81
1
page 33, do we see here that, on the 15th, there is
2
a note?
Do you recognise the handwriting?
3
A.
That is Dr Garthwaite's note.
4
Q.
Are you able to read the first line of that for us?
5
A.
I think it says, "Further C. diff.
Discussed with
6
Dr De Villiers".
7
"Further vancomycin" -- do you want me to read it all
8
out? -- "orally 125mg QDS".
9
Q.
Then there is an arrow saying,
So this is confirming that, at this point, the doctor is
10
aware that there has been a further diagnosis of
11
C. difficile?
12
A.
And that vancomycin is to be given initially at 125mg
13
four times a day and doubled in 48 hours if there is no
14
improvement.
15
Q.
16
17
Do we see from that note by Dr Garthwaite whether or not
he has carried out a clinical examination?
A.
Can I also say that she's to have IV immunoglobulin as
18
well?
There is no indication from that note that he
19
carried out a clinical examination.
20
Q.
But should he have done so, in the circumstances?
21
A.
I think he probably should have done.
22
Q.
If we look at about this time, if we look at the Kardex
23
at page 94, I want to focus on the second entry, which
24
is dealing with the lactulose, which seems to have been
25
prescribed for a lengthy period of time during
82
1
Mrs Broadley's admission.
2
that she was in receipt of lactulose when she was
3
testing positive for C. diff?
4
A.
In particular, does it seem
It does appear as if she was still being prescribed it.
5
I think "14" means that the nurses didn't give it; is
6
that correct?
7
Q.
8
9
Yes.
I think "14" means there is some explanation in
the nursing notes as to why it wasn't given.
A.
I'm very surprised that the nurses -- admittedly,
10
Dr Johnston or myself should have noticed this, but I'm
11
very surprised that the nurses didn't draw it to our
12
attention.
13
Q.
14
I think the point you're making is she shouldn't have
been in receipt of lactulose when she was positive?
15
A.
That's correct.
16
Q.
I think this is a patient, Dr Herd, in relation to whom
17
you had some involvement with the death certificate; is
18
that right?
19
A.
I think that's correct.
20
Q.
Perhaps before I come to that, I think also with the
21
DNAR position, if you look at page 10 of the records, we
22
have here a DNAR order that has been completed by
23
yourself, I think we see that, on 10 December?
24
A.
Yes.
25
Q.
In relation to the discussions in connection with the
83
1
document, can you say, was this a discussion you had
2
with the family?
3
A.
4
5
It doesn't appear that there was a discussion with the
family on this occasion.
Q.
If you go back to page 30 of the clinical notes, we are
6
looking at the entries we looked at earlier covering the
7
period from 4 December through to 12 December.
8
certainly nothing recorded there about a discussion with
9
the family?
There is
10
A.
No.
11
Q.
The discussion I think you had was on 18 December, if
12
you look at page 31 of the records --
13
A.
Yes.
14
Q.
-- which is, I think, dealing with the need of care and
15
also the psychiatric review; is that right?
16
A.
That's correct.
17
Q.
Can you help me with this: there is also a DNAR order on
18
page 4 of the records.
19
has been reviewed by Dr Johnston on 21 January.
20
know why there were the two?
21
A.
This is dated 15 January and it
I have no idea how that occurred.
I think it happened
22
with another patient that you may come to.
23
don't know how that happened.
24
25
Q.
Do we
I really
But so far as you are concerned, when you completed the
DNAR order that you have signed on 10 December, are you
84
1
able to say whether you had any discussion with the
2
family or not?
3
A.
I'm not able to say, but I don't think I did.
4
Q.
What was the general policy?
Would you discuss these
5
matters with family members, or with the patient, if
6
possible?
7
A.
Yes, that was the general policy, yes.
8
Q.
Are you able to say now why such a discussion didn't
9
take place in this case?
10
A.
I'm not able to say.
11
Q.
The other point I want to raise with you is that I think
12
you also dealt with the death certificate in this case,
13
and if we look at that, it is at SPF00030001.
14
that Mrs Broadley died on 22 January 2008, and that you
15
have put Clostridium difficile enteritis as the primary
16
cause of death?
Do we see
17
A.
Yes.
18
Q.
If we look at the clinical notes on page 34, just so
19
I can understand, and perhaps you can help me here, it
20
would appear that on the 22nd it is Dr Dunn who I think
21
sees the patient, and you are then involved; is that --
22
A.
Yes, Dr Dunn is one of the integrated care general
23
practitioners, so he saw her at 0345.
24
these doctors saw a patient who had died out of hours,
25
they wouldn't issue a death certificate, they would
85
In general, if
1
leave it to the doctors who were usually looking after
2
the patient.
3
Q.
4
Do I take it, then, that when you came on duty in the
morning, this was something you would attend to?
5
A.
Yes.
6
Q.
Looking to your note, does that begin by reading,
7
"Discussed with the fiscal"?
8
A.
Yes.
9
Q.
Did you telephone the procurator fiscal, then, to
10
11
discuss the case with?
A.
It was mainly to do with the fact that C. diff was being
12
put as the cause of death.
13
of, if patients had fractured necks of femur, I would
14
tend to discuss it with the fiscal anyway, because
15
sometimes -- not so much with a patient who was in the
16
ward for quite a long time, but sometimes the Fiscals
17
wanted to look into the circumstances of the fall that
18
had caused the fractured neck of femur.
19
I always made it a practice
So basically, I would discuss patients with
20
fractured necks of femur quite often with the fiscal, no
21
matter what the cause of death, but in this particular
22
instance I think it was because of the fact that I was
23
going to put C. diff as the cause of death.
24
25
Q.
Was there some form of protocol that you required to
follow as to when you would contact the
86
1
2
procurator fiscal with a hospital death?
A.
Well, there are certain deaths which are notifiable --
3
diseases which are notifiable.
4
was any history of falls, for example, that is something
5
I would tend to discuss with the fiscal.
6
Q.
Also, as I say, if there
While I'm looking at this patient, can I just see if
7
I have to pick up any points that have been raised by
8
other parties.
9
I'm putting some questions to you that I have been
10
asked to put on behalf of the Medical and Dental Defence
11
Union of Scotland.
12
Dr Woodford, who was one of the geriatricians who
13
gave evidence, said that, with regard to the clinical
14
notes -- I think we have been looking at these on
15
pages 29 through to 31 of the records, and you can cast
16
your eye over them again -- he considered they were
17
inadequate.
18
19
Do you have any comments to make on that?
A.
I think, in retrospect, I should have written more
20
detailed notes.
21
writing what the outcome of my thinking was and not
22
writing the background which had led me to come to that
23
outcome.
24
25
You know, I was, I think, guilty of
For example, in the entry on 6 December, clearly
I concluded that her fluid intake was inadequate, but
87
1
I haven't documented my reasons for thinking that, so in
2
retrospect I should have written more complete notes.
3
I also think there may have been assessments of
4
the patient which have not been recorded at all, which
5
is not as good as it should have been.
6
Q.
I think that was one of the other points I was asked to
7
raise with you, that Dr Woodford did talk about the lack
8
of regular review, and I think you probably accept that.
9
A.
10
Well, the records suggest that, but I don't think it is
an accurate reflection of the care.
11
Q.
Indeed.
12
A.
Obviously, yes.
13
Q.
I think you may have dealt with this already, but I will
14
Well, he was going on the basis of the records.
put it to you again, just to make sure that you have.
15
The question is: can you recollect if you discussed
16
the DNAR form of 10 December?
17
saying is you didn't discuss it.
18
A.
19
20
I don't remember discussing it.
I think it is something
I would have documented if I had done.
LORD MACLEAN:
Could I ask you about the entry for the 6th,
21
so that I understand it?
22
fluids?
23
A.
24
LORD MACLEAN:
25
But I think what you are
Is that for subcutaneous
Subcutaneous fluids, yes.
Yes, so you must have made an assessment of
some kind -88
1
A.
2
LORD MACLEAN:
3
A.
4
MR MACAULAY:
5
6
A.
Exactly.
The assessment would be in relation to the
Yes, I must have concluded that their hydration wasn't
being adequately maintained by their oral intake.
Q.
9
10
-- before you could write that?
patient's state of hydration?
7
8
Yes.
To make that assessment, what would you do?
Would you
carry out a clinical assessment?
A.
I would have carried out a clinical assessment and
11
assessed the fluid chart that was available and gone on
12
any biochemical results that were available.
13
Q.
14
Did you, or can you say whether or not you would have,
take blood samples to assess hydration at that point?
15
A.
I might have done at that point, yes.
16
Q.
Would that be the practice?
17
A.
It would be common practice, yes.
18
Q.
We would want to look to see if there were any reports,
19
then, of that in the records?
20
A.
Right.
21
Q.
Now, then, the next patient I want to discuss with you
22
23
is Mr Boyle.
DAME ELISH:
Sorry, my Lord, before moving on, I wonder if
24
my learned friend could perhaps pose the second question
25
for MDDUS?
89
1
MR MACAULAY:
2
DAME ELISH:
3
Sorry?
The first question and the third have been
dealt with.
4
MR MACAULAY:
5
DAME ELISH:
Is that question 9?
It is question 9.
The first part has been
6
dealt with, regarding the issue of regular review, but
7
it is the conclusion that Dr Woodford comes to
8
specifically, that the appearance of the absence of
9
regular review from the records suggests that the care
10
of her C. difficile appears to have been suboptimal,
11
whether this witness agrees with that?
12
MR MACAULAY:
I will just put that specifically to you,
13
then, Dr Herd: do you agree with Dr Woodford's
14
suggestion that the care of Mrs Broadley's C. difficile
15
appears to have been suboptimal?
16
A.
I think it could be regarded as suboptimal in terms of
17
the documentation of the monitoring of her C. diff, but
18
I think the actual treatment of her C. diff was
19
appropriate, and also involved communication with the
20
microbiologist.
21
of her C. diff, I think it was -- it was optimal, but
22
from the point of view of documentation of
23
the monitoring, it was possibly suboptimal.
24
25
Q.
So from the point of view of treatment
Although just a couple of points we have picked up,
I think: namely, the apparent delay in prescribing, in
90
1
particular vancomycin, and the continued prescription of
2
the lactulose.
3
A.
Yes, I would concede that.
Although I don't think the
4
delay that you mentioned would have made a difference to
5
the prognosis, but the lactulose, I agree, was an
6
oversight.
7
Q.
I think another point that Dr Woodford made, and
8
I haven't taken you to this, is there were no blood
9
results after 19 December.
10
A.
Right.
11
Q.
Should there have been?
12
A.
Probably there should have been, yes.
13
Q.
Are you able to express to the Inquiry as to how you,
14
yourself, feel this patient was managed in the period
15
that she had C. diff and up to her death?
16
A.
I think the patient was managed fairly well.
I would
17
agree that the documentation is not as good as it should
18
have been.
19
DAME ELISH:
My Lord, on the point which my learned friend
20
has raised regarding the continued prescription of
21
lactulose, I wonder if he could ascertain from this
22
witness whether or not that would have made any material
23
difference, in his opinion, to the prognosis and outcome
24
for Mrs Broadley?
25
A.
I think it would be difficult to comment on that.
91
It
1
looks to me as if, although it was being prescribed,
2
she -- on quite a number of occasions, she wasn't
3
actually getting it, so I think it would be difficult to
4
comment on that.
5
MR MACAULAY:
6
Lactulose, theoretically, would increase the
diarrhoea; is that right?
7
A.
Possibly.
8
Q.
I am moving on, then, to look at Mr Boyle.
9
The medical
records for Mr Boyle are at GGC00030001.
10
Mr Boyle was, first of all, admitted to the
11
Royal Alexandra Hospital on 3 January.
He'd had a fall,
12
although there wasn't evidence of a fracture.
13
transferred to the Vale of Leven on 10 January, under
14
the care of Dr Johnston.
15
GGC00030011, can we see here -- this is your
16
handwriting, isn't it, Dr Herd?
He was
If we look at the records, at
17
A.
That's right.
18
Q.
We did puzzle earlier on about the date, but it is a 10,
19
and not an 18, I think?
20
A.
It is a 10.
21
Q.
We see it is 10 January 2008 and Dr Johnston is the
22
consultant.
So you saw the patient, then, when he was
23
admitted to the Vale of Leven?
24
A.
Yes.
25
Q.
If we turn to page 15, can we see here that you have
92
1
seen Mr Boyle again on 14 January?
2
A.
Yes.
3
Q.
The first line makes reference to cellulitis, is that
4
right, of the left leg?
5
A.
Cellulitis, yes.
6
Q.
"Also chesty".
7
A.
"But refuses to take deep breaths for chest
8
9
examination".
Q.
10
11
You have prescribed some antibiotic therapy for him; is
that correct?
A.
12
13
Can you read the rest of that for us?
Yes, the amoxicillin was for the chest infection and the
flucloxacillin was for the cellulitis.
DAME ELISH:
My Lord, I wonder if my learned friend, on that
14
particular issue, could clarify with this witness
15
whether or not the comment "Refuses to take deep
16
breaths" for that examination is an indication of
17
whether or not a physical examination took place?
18
A.
Yes, I can remember that a physical examination -- or an
19
attempt at a physical examination took place, but if you
20
are using a stethoscope, it is very difficult to come to
21
a conclusion if the patient won't take deep breaths.
22
You can't decide whether there are any crepitations or
23
bronchi.
24
examination is of limited use.
25
If they won't take deep breaths, then the
But I had noted that, when he was admitted, there
93
1
were crepitations in his chest, and I think he'd been
2
thought to have a chest infection in Paisley as well.
3
So I was really -- I did examine him, or attempt to
4
examine him, on that occasion, but I felt it was of
5
limited use, the clinical examination.
6
basically basing my decision to treat him on the fact
7
that he was at risk of aspiration because of swallowing
8
problems, which we'll later come on to, and the
9
examination that I made of him a few days before, when
10
11
So I was
he was admitted.
MR MACAULAY:
Before we move on, if we look towards the
12
entry before your entry, we can see that on the same day
13
as you have seen Mr Boyle, he's also been seen by
14
Dr Johnston; is that correct?
15
A.
Yes.
16
Q.
Can you help with this: your examination has resulted in
17
a particular form of therapy, antibiotic therapy.
18
about Dr Johnston?
19
mentioned, that would have been present, I assume, when
20
seen by Dr Johnston?
21
A.
Yeah.
What
The cellulitis that you have
I don't know -- it looks to me as if the nurses
22
were sufficiently concerned about Mr Boyle to ask me to
23
see him on the same day as he'd been seen by Dr Johnston
24
on the ward round.
25
attention wasn't drawn to the area of cellulitis, but
I don't know why -- perhaps her
94
1
I don't know why she hasn't made a note about it.
2
Presumably she would have done if it had been brought to
3
her attention.
4
Q.
If I just put to you the point made by Dr Woodford, who
5
looked at this case as well, he said there was no
6
comment on the appearance of the leg.
7
said more about the leg appearance?
8
A.
9
10
I think it may have been better to make a more detailed
note.
Q.
11
12
Should you have
But the other point he made was whether or not you
should have remitted this patient for a chest X-ray?
A.
Yeah.
I think this is an example where you have to look
13
at the decision that was made in context.
14
it's -- if you look at this patient as someone who you
15
know later developed C. diff and who you know was in
16
a situation where we regard there as being a C. diff
17
outbreak, it may alter your decision in terms of
18
prescribing a broad-spectrum antibiotic.
19
I think
But our position, at that point, was that we weren't
20
aware that we were in the middle of a C. diff outbreak,
21
and we didn't know that he was going to develop C. diff,
22
possibly partly because he was given this antibiotic.
23
So that I think, bearing that in mind, my decision
24
wasn't unreasonable, and I am not sure -- I think the
25
question of a chest X-ray is up for debate.
95
You know,
1
I think if you took 100 doctors and asked them what they
2
would do in this situation, it's not a case of
3
99 per cent would say, "I would do a chest X-ray", and
4
1 per cent wouldn't.
5
different.
6
I think the proportions would be
I don't know what they would be.
I can certainly say that there are hundreds of
7
prescriptions, probably, for amoxicillin every day in
8
primary care made on the basis of far less, you know --
9
on a shakier ground than this decision was made.
10
Q.
Just a couple of points on that.
I think you are saying
11
that, if you had had a heightened awareness about the
12
presence of C. diff in the hospital at the time, then
13
you might have been more cautious; is that --
14
A.
I think that is probably true, yes.
15
Q.
But because you didn't have that awareness, then you
16
17
didn't have the concern -A.
It's still obviously a serious decision to decide to
18
prescribe an antibiotic for someone, but I think that
19
was the context I described; you know, that was the
20
situation.
21
Q.
So far as a chest X-ray was concerned, I think
22
Dr Johnston also expected that there should have been
23
a chest X-ray, but you say, as the clinician who saw the
24
patient, you didn't see the need at the time?
25
A.
I felt that the background -- I mean, he had dysarthria
96
1
when he was admitted.
2
stem stroke, and I think that was the basis of his
3
difficulty swallowing.
4
risk if he develops a proper, ongoing lower respiratory
5
tract infection.
6
He appeared to have had a brain
So he is a patient who is at
So I felt that, you know, the balance of risks and
7
benefits was in favour of prescribing, and I decided
8
that I didn't need to have a chest X-ray to confirm
9
that.
10
LORD MACLEAN:
Notwithstanding that you couldn't examine his
11
chest properly, and he had creps when he came in and you
12
wrote down "chesty"?
13
A.
Yes, even allowing for that.
14
LORD MACLEAN:
15
A.
16
DAME ELISH:
Even allowing for that?
Even allowing for that.
My Lord, I wonder, in the context the witness
17
has described, if my learned friend could clarify what
18
probably we assume, that of the patients in primary care
19
who are prescribed amoxicillin -- and there may be many
20
thousands across Scotland -- they are not all sent for
21
chest X-rays before the prescription?
22
LORD MACLEAN:
23
DAME ELISH:
24
LORD MACLEAN:
25
That --
It may seem trite, my Lord -It is not only trite, it is unnecessary,
because the important point here was that the doctor
97
1
made his clinical decision -- didn't you? -- in the
2
circumstances, so the general experience of amoxicillin
3
in Scotland is neither here nor there.
4
prescription on that occasion without a chest X-ray.
5
DAME ELISH:
6
LORD MACLEAN:
7
Certainly, my Lord.
My difficulty --
I'm not going to let the question go, sorry.
Do you understand that?
8
DAME ELISH:
9
LORD MACLEAN:
10
He justifies the
DAME ELISH:
I understand, my Lord.
Right.
But I do have a concern, my Lord, that there
11
was a criticism made about that particular prescription
12
by the witness which has not focused on the context of
13
the general picture, but rather on this particular
14
patient.
15
LORD MACLEAN:
16
DAME ELISH:
I'm sorry, I don't follow that.
Dr Woodford criticises the basis of this
17
diagnosis when, in fact, he did not look at the wider
18
picture of the prescription of amoxicillin in primary
19
care where X-rays would not be taking place.
20
LORD MACLEAN:
21
I'm sorry, I don't follow that at all.
Do you follow that?
It is a question that is
22
intended for you.
23
your decision that this was the right drug in all the
24
circumstances of this particular case.
25
A.
Do you follow that?
Yes.
98
I mean, you made
1
LORD MACLEAN:
2
think so.
3
MR MACAULAY:
4
A.
So do we need to go anywhere else?
I don't
Pass on.
Did you arrange for blood samples to be taken?
I think there were blood samples taken around about that
5
time and, if I'm right in -- my recollection is that
6
there was a raised white cell count, which could be
7
consistent either with a cellulitis or with a lower
8
respiratory tract infection.
9
Q.
Just to understand the rationale, then, for the
10
amoxicillin, you say, I think, you have a recollection
11
that you had a difficulty in examining the patient.
12
A.
Yes.
13
Q.
So how did you conclude that he was chesty?
14
A.
That was how the nurses had described him --
15
Q.
Yes.
16
A.
-- and, as I say, I think the fact that he was -- that
17
I was asked to see him later on in the day, when
18
Dr Johnston had already seen him earlier in that day,
19
indicates that the nurses felt that he was
20
deteriorating, presumably from the chest point of view.
21
Q.
If we look at the note in the nursing records, page 40,
22
it is at 1815.
Just looking at the time, would that be
23
outwith your normal time?
24
A.
Well, that was 6.15, I think, wasn't it?
25
Q.
Yes.
99
1
A.
That would be -- I wouldn't be in the ward at that time.
2
Q.
It reads:
3
"Commenced on antibiotics today by Dr Herd to help
4
the laceration on his left shin as it is quite inflamed.
5
That should also help his chest, according to Dr Herd,
6
as he sounds quite chesty."
7
Is that where the "chesty" reference -- I'm trying
8
9
to put this together.
A.
I think he was obviously prescribed two different
10
antibiotics: one which would be expected to help his
11
chest and one which would be expected to help his
12
cellulitis.
13
MR MACAULAY:
14
My Lord, that might be an appropriate point to
adjourn for lunch.
15
LORD MACLEAN:
16
(1.00 pm)
17
2 o'clock.
(The short adjournment)
18
(2.00 pm)
19
MR MACAULAY:
20
Good afternoon, my Lord.
Good afternoon, Dr Herd.
21
A.
Good afternoon.
22
Q.
Before the break, we were looking at the case notes for
23
Mr Boyle, if we can return to that.
24
we focus on when he developed C. diff, and if we look at
25
page 25 of the records, at GGC00030025, can we see that
100
In particular, if
1
a sample was collected on 22 January, received by the
2
lab, according to the document, on the 25th, and that
3
was a positive result?
4
A.
Yes.
5
Q.
If we look at the clinical notes on page 16, on the 21st
6
there's an entry by Dr Johnston, I think we can see
7
that, "Swallow much better.
8
then, on the 25th, the next entry, the junior doctor has
9
noted that Mr Boyle has been started on metronidazole
10
Eating normal diet", and
for ten days for his C. diff diarrhoea?
11
A.
Yes.
12
Q.
We see it is an FY1 doctor on call who has done this.
13
Obviously, at this time of the day, you would not be in
14
the hospital: 1545?
15
A.
I think that was on a Friday as well, was it not?
16
I think that was a Friday, 25 January.
17
I wouldn't be in the hospital.
18
Q.
Yes.
So
If we then turn to page 17, there are two entries for
19
you in the month of January.
There is one on the 29th,
20
I think that is; is that correct?
21
A.
Yes.
22
Q.
Which I think is dealing with a conversation you may
23
have had with Mr Boyle's daughters; is that right?
24
A.
Yes.
25
Q.
Then on the 31st -- can you read that for us,
101
1
31 January?
2
A.
"Still severe diarrhoea despite metronidazole".
3
Q.
Do we then have a gap to 3 February when the junior
4
doctor on call has seen Mr Boyle?
5
A.
Yes.
6
Q.
The note is, "Diarrhoea not improved".
The gap from the
7
31st to the 3rd in connection with a patient who appears
8
not to be recovering from the C. diff infection, do you
9
consider you would have seen the patient in that time or
10
11
not?
A.
I think what happened on the 31st was -- I think the
12
31st was a Thursday, and I think that was my -- is that
13
right, 31 January?
14
written on my ward round, and that was followed by the
15
multidisciplinary meeting.
16
decided at that meeting, but hasn't been documented, was
17
that we felt his prognosis was so poor that we were
18
basically switching from a treating situation to
19
a palliative situation, but that has not been
20
documented.
21
It was a Thursday.
I think that was
Now, I think what was
As I pointed out earlier on, after the -- one thing
22
that was the practice at the time was that we didn't
23
take notes into the multidisciplinary meeting, so no
24
notes -- nothing was entered in the notes at the MDT
25
meeting, and I left to go back to the practice just
102
1
after the meeting on a Thursday.
2
So I think, unfortunately, at that -- I'm going --
3
this is what I think happened, but I agree it's not
4
written down, is that the decision was taken at that
5
point that his prognosis was poor and that we were
6
switching to a palliative situation.
7
Q.
I think the point that has been raised is whether there
8
should have been a medical review between 31 January and
9
the date he's seen by the junior doctor on call on
10
11
3 February?
A.
The only opportunity I would have had to see him --
12
3 February was a Sunday, I think.
13
Dr Johnston saw him on the 4th.
14
opportunity I would have had to see him after 31 January
15
would have been the Friday, the next day.
16
argued that I should have seen him on the Friday, but
17
I wouldn't have had any other opportunity to see him
18
myself.
19
Q.
Yes.
And then
So the only other
It could be
Certainly Dr Johnston, I think, seemed to suggest that
20
the patient should have been seen between those two
21
dates, whether by yourself or by another doctor, looking
22
to the fact that the patient is not improving on
23
metronidazole?
24
25
A.
I think that can be argued, but, as I say, my
understanding of what happened at the time was that, you
103
1
know, his prognosis was regarded as very poor at that
2
stage, but I agree that he probably should have been
3
reviewed on the Friday.
4
Q.
It would appear he has been on metronidazole from the
5
25th -- we can look at the Kardex, in fact.
That is
6
probably how best to do this.
7
we see the entry for the metronidazole beginning on
8
25 January.
9
up until certainly 3 or 4 February.
If we look at page 65, so
We can see that he remains on metronidazole
10
A.
Yes.
11
Q.
I think we discussed this earlier today, but if you have
12
a patient that has C. diff diarrhoea and you start that
13
patient on metronidazole and there does not appear,
14
after a period of time, to be improvement, should there
15
be a review of the antibiotic treatment?
16
A.
I think, in general, that is true, but this patient also
17
had problems with recurrent swallowing difficulty and
18
aspiration, so his illness wasn't purely due to his
19
C. diff, and the fact he had difficulty swallowing and
20
was pulling out intravenous and subcutaneous lines meant
21
that there were severe practical difficulties in
22
treating his chest, as well as in treating his C. diff.
23
Q.
But in relation to a review of his antibiotic treatment,
24
do you consider there should have been a review prior to
25
3 February?
104
1
A.
You could argue that.
2
Q.
If you look at the nursing notes for this period, on
3
page 43, if we look at the entry for 31 January, there
4
is reference to the ward round.
5
round -- is that right? -- on the 31st?
6
LORD MACLEAN:
7
A.
8
MR MACAULAY:
9
meeting?
That would be your ward
The 31st was a Thursday, not a Friday.
That's right, yes.
Then "MDTM", that's the multidisciplinary team
10
A.
Multidisciplinary team meeting.
11
Q.
Then we read to continue present treatment seems to have
12
been the decision at that time?
13
A.
Yes.
14
Q.
I think you said your recollection was that it may have
15
been it was more a palliative approach that was to be
16
taken?
17
A.
18
19
been documented as such.
Q.
20
21
A.
I don't think it contradicts it, but it doesn't confirm
it either.
Q.
24
25
Certainly the nursing note seems to -- well, does the
nursing note contradict that?
22
23
That's what I think was the decision, but it should have
If the decision was to continue present treatment, what
would that mean for this patient?
A.
It's obviously somewhat ambiguous, but -- because, in
105
1
terms of drug treatment, he'd already, I think, been on
2
metronidazole for -- is it ten days or more at that
3
stage?
4
Q.
Yes.
5
A.
So it wouldn't be standard practice to carry on with the
6
7
drug treatment with metronidazole at that point.
Q.
8
9
The metronidazole didn't appear to be working at that
point.
A.
Yes, yes.
But I think -- I don't think that note refers
10
to the metronidazole.
11
management of the patient, in terms of, you know,
12
nursing care and general medical care.
13
ambiguous note.
14
Q.
I think it just means the general
But it is an
If we look at the previous entry, for the 29th -- there
15
doesn't appear to be an entry for the 30th, but the
16
previous entry seems to be fairly positive, in that
17
there's a note which says:
18
"Jake has had a very good day today."
19
A.
Mmm.
20
Q.
The reference to "Choice letter and pack", what is that?
21
A.
The choice letter was a letter which was given to
22
patients who were considered to be rehabilitated to the
23
optimum level and were being considered for residential
24
or nursing home care.
25
Q.
This, on the face of it, looks quite positive at this
106
1
2
point?
A.
Yes.
I agree it is -- I agree it does look incongruous,
3
but, you know, on 4 February, Dr Johnston has written,
4
"Patient slowly dying", which wasn't long after the
5
event either.
6
Q.
As at 4 February, as has been noted by yourself on the
7
31st and on the 3rd by the junior doctor, the diarrhoea
8
is not improving?
9
A.
Mmm.
10
Q.
Then, on the 4th, Dr Johnston has written, "Patient
11
slowly dying".
Would you normally record in the
12
clinical notes that a decision not to continue
13
treatment --
14
A.
That would normally be recorded, yes.
15
Q.
So we don't have that in this case?
16
A.
No, we don't.
I think, as I say, it would have been
17
better if we had taken notes into the multidisciplinary
18
team meeting so that if these decisions are made at
19
these meetings, you know, they can be documented at the
20
time.
21
Q.
22
So what we have is the nursing note for the 31st which
is "to continue present treatment"?
23
A.
Yes.
24
Q.
It seems also to be the case here, Dr Herd, that there
25
were no blood tests carried out on Mr Boyle after
107
1
15 January.
Can we go back to that?
If we go back to
2
page 15 of the clinical notes, I think we'd noted your
3
entry on the 14th where you'd prescribed the
4
antibiotics, and I think you had indicated that you
5
would have requested blood samples?
6
A.
Yes.
7
Q.
Should you have had further blood sampling done after
8
9
the 15th?
A.
10
11
There should have been further blood sampling done
after.
Q.
12
Can you explain to the Inquiry why that didn't happen
here?
13
A.
I can't explain that, I'm afraid.
14
Q.
What would the purpose for the blood sampling be?
15
A.
To continue to monitor his hydration particularly, his
16
17
white cell count, that sort of thing.
Q.
This is another case, I think, Dr Herd, where we have
18
two DNAR orders, if I can just look at that.
19
turn to page 4 of the records, we are looking at a DNAR
20
order dated the 18th, I think, and then redated the
21
24th.
22
yourself, first of all; is that right?
Perhaps you can look at that.
If you
It is signed by
23
A.
Yes.
24
Q.
Should we see an entry, then, for the 18th, to indicate
25
that you have spoken to the family?
108
1
A.
Yes.
2
Q.
That is on page 16; is that correct?
3
A.
Yes.
4
Q.
That was the entry we saw where you have noted, "Spoken
5
to two daughters"?
6
A.
Yes.
7
Q.
Did you raise with the daughters the fact of a do not
8
9
attempt resuscitation order?
A.
10
I can't remember the details of the conversation, but my
memory at the time was that I did discuss it with them.
11
Q.
Have you recorded that in the notes?
12
A.
I haven't recorded it in the notes.
13
LORD MACLEAN:
14
It is on the form, though, according to the
form: "Discussed with daughter".
15
MR MACAULAY:
16
A.
17
Yes.
Indeed.
I would agree that I wouldn't have written that if
I hadn't been under the impression.
18
Q.
Okay.
19
A.
And I think the reason for the date being changed on
20
that form must have been that I wrote the date that
21
I discussed it with the family and then I sort of went
22
to -- I think that was probably written on the 24th,
23
that form, but when I first wrote the date, I wrote the
24
date that I discussed it with the family, and then
25
I realised that the two dates were different, so that's
109
1
2
why it's been changed.
Q.
The other form is at page 10.
This one is dated --
3
well, the date we have on it is 21 January.
4
a different style of form.
5
A.
6
7
It is
Again, I don't know why there was a second form.
That's
strange.
Q.
8
Did you also complete the death certificate for this
patient, if we look at SPF00020001?
9
A.
Yes, I did.
10
Q.
Can we see that Mr Boyle died on 6 February, and we have
11
Clostridium difficile enteritis at section I of
12
the death certificate, and dementia at section II.
13
A.
Yes.
14
Q.
In relation to that, the reference to dementia, which we
15
also see on the second of the DNAR orders we looked at,
16
what was the basis for that?
17
A.
When I admitted Mr Boyle, his abbreviated mental test
18
score was 2 out of 10, and in my list, my summary list
19
of diagnoses, I listed severe dementia.
20
I shouldn't have put that.
21
did have a degree of dementia, but it was impossible to
22
say at that stage the extent to which it was severe.
23
In retrospect,
I still think that Mr Boyle
There could well have been an element of delirium at
24
that stage because he was still generally unwell,
25
although I think it is unlikely that his degree of
110
1
delirium was enough to explain an abbreviated mental
2
test score of 2 out of 10.
3
So I think there was -- I mean, the commonest risk
4
factor for delirium is dementia, and dementia would be
5
very common in a patient of this age group anyway.
6
I would still contend he was likely to have had a degree
7
of dementia, but it was wrong to write "severe dementia"
8
at that stage.
9
Q.
10
11
So
Was it right or not to put dementia on the death
certificate?
A.
I think it's debatable.
I'm not sure whether it was the
12
right thing to do or not.
I decided to put it on
13
because I thought it contributed to his death.
14
As I say, I still feel that there was a degree of
15
dementia there, although the main factor in his death
16
was the Clostridium difficile, I think.
17
Q.
I think you mentioned the score of 2 out of 10.
18
A.
Yes.
19
Q.
Were you aware that there had been a previous score in
20
21
the Royal Alexandra Hospital of 9 out of 10?
A.
22
23
think I was aware at the time.
Q.
24
25
I don't think -- I'm now aware of that, but I don't
Might that have impacted upon your thinking, then, if
you had been made aware of that?
A.
Yes.
The other thing I should say is that his CT scan
111
1
in RAH was said to show cerebral atrophy, which can
2
often be associated with a degree of dementia, although
3
not always.
4
Q.
5
6
dementia; is that correct?
A.
7
8
Here, clearly, the diagnosis had not been made of
No, it was wrong to write "severe dementia" at the time
he was admitted; I would agree.
Q.
9
Looking to the management of Mr Boyle in the
Vale of Leven, particularly in relation to his
10
C. difficile, which, as you have indicated, was the
11
primary cause of death, do you have any observations to
12
make as to how this patient was managed?
13
A.
As I say, I think, although I have only listed -- I have
14
listed that as a major cause of death, I think there was
15
a degree of a lower respiratory tract infection as well,
16
which was caused by his tendency to aspiration, so
17
that -- you know, I think it could be argued that we
18
should have sought further advice in terms of changing
19
from metronidazole on to vancomycin, but the C. diff was
20
not the only factor in his illness, and also there were
21
substantial difficulties in treating him with
22
antibiotics because of his difficulty swallowing and the
23
fact that he couldn't tolerate intravenous lines or
24
subcutaneous lines.
25
Q.
Putting that aside for the moment, just looking
112
1
generally to his management, do you think he was
2
appropriately managed or not, looking at the whole
3
picture?
4
A.
5
6
perhaps have been considered at an earlier stage.
Q.
7
8
I think it could be argued that vancomycin should
I'm just going to move on to see what questions I have
been asked to put to you --
DAME ELISH:
9
regarding the vancomycin, Dr Herd is referring here to
10
oral vancomycin, I assume.
11
A.
12
DAME ELISH:
13
14
A.
If that is the case, could his swallow issue
Certainly, you know, he may not have been able to take
oral vancomycin because of his swallowing difficulties.
LORD MACLEAN:
17
18
Yes.
have affected any clinical judgment at that time?
15
16
Sorry, my Lord, on that particular point
Remind me, can you give vancomycin
intravenously?
A.
19
Vancomycin can be given intravenously for other
indications, but for C. diff it's always given orally.
20
LORD MACLEAN:
21
A.
22
LORD MACLEAN:
Always?
Yes, always given orally.
That is what I thought.
So maybe, as
23
Dame Elish has pointed out, that was a contraindicator
24
of the change.
25
A.
Yes.
113
1
LORD MACLEAN:
2
MR MACAULAY:
There was a problem here.
If we look at the Kardex for the patient at
3
page 65, he receives the metronidazole orally from
4
25 January through to 4 February; is that right?
5
A.
Yes.
6
Q.
Just focusing on what you have been discussing, if he's
7
receiving metronidazole orally up until two days before
8
his death, then, on the face of it, might he have been
9
able to take oral vancomycin?
10
A.
Possibly.
11
DAME ELISH:
My Lord, I wonder if my learned friend can
12
confirm whether or not metronidazole can be given in
13
a syrup form and whether that is the same case for
14
vancomycin?
15
LORD MACLEAN:
16
17
Can you look at the Kardex and tell us in
what form he was receiving it?
A.
It doesn't actually specify.
It just specifies the dose
18
and that it was to be given orally.
19
whether either can be given in a liquid form.
20
MR MACAULAY:
21
I'm not sure
On the point of the swallow, his swallow had
been improving at a point in time in the Vale of Leven?
22
A.
I think his swallowing had been variable.
23
Q.
Is this the point, really that, although we could
24
discuss whether or not he could have taken the
25
vancomycin, it was never looked at, it would appear from
114
1
the records?
2
A.
It would appear from the records.
3
Q.
So the opportunity wasn't taken up; is that fair?
4
A.
I think that's fair, yes.
5
DAME ELISH:
My Lord, on that particular point, I wonder if
6
my learned friend could refer back to the Kardex and
7
whether or not the designation of "11"s over that period
8
on the metronidazole prescription correspond with the
9
note of 11 saying that there was difficulty swallowing
10
11
metronidazole.
MR MACAULAY:
I'm not sure I can see where the 11s are.
12
There is one on the 3rd, I think -- there are three 11s
13
on the 3rd.
14
DAME ELISH:
15
I think.
16
MR MACAULAY:
17
18
And I think there's one on the 4th, at the top,
So on the 3rd and 4th -- 11, I think, means
difficult to swallow.
A.
19
I don't know.
There is a coding system that the
nurses --
20
Q.
Page 68 gives us the code.
21
A.
I don't have access to that.
22
LORD MACLEAN:
23
MR MACAULAY:
24
25
It will come.
You will see it.
I will put it on the screen for you, yes.
11, you will see -A.
Unable to swallow.
115
So
1
Q.
2
On the 3rd and the 4th, certainly there is evidence that
he was unable to swallow?
3
A.
Yes.
4
Q.
I have been asked to ask questions, first of all, on
5
behalf of the patients and families.
6
learned friend might just indicate if there are
7
questions on his list he no longer would wish me to ask
8
in connection with this particular patient?
9
MR PEOPLES:
I wonder if my
My Lord, I think my learned friend Mr MacAulay
10
has dealt with the issue of DNAR, although I'm not sure
11
he put specifically Mrs McMurdo's position in evidence,
12
that she did not have a discussion on the 18th about
13
DNAR.
14
Dr Herd, for completeness on that issue?
15
MR MACAULAY:
16
17
I wonder if that could be perhaps raised with
Again, if my learned friend would just
indicate which numbers -MR PEOPLES:
That is 1(e).
I don't think he's dealt with
18
(h), (i), (j), (k), (l), (o), (p), (q), (r), (s), (t),
19
(u), (v), (w) and (x).
20
MR MACAULAY:
The first point, then, is in relation to your
21
clinical note of 18 January.
22
to that, it is on page 16 of the records.
23
one where you refer to a discussion with Mr Boyle's two
24
daughters.
25
A.
Yes.
116
Dr Herd, if we can go back
That is the
1
Q.
That is on the 18th.
2
A.
Yes.
3
Q.
You don't mention in that note that the patient is not
4
for CPR and that a DNAR order has been discussed with
5
the patient's daughters.
6
Now, Mrs McMurdo, who gave evidence, said that the
7
DNAR itself was not discussed with her and her sister.
8
A.
9
Well, clearly I thought we had discussed it, because
that's -- I completed a form stating that we had
10
discussed it.
11
a discussion like that, it wouldn't come up, because
12
it's an ideal opportunity to bring it up.
13
that I have not documented that.
14
Q.
15
16
But I agree
I think, as his Lordship pointed out, you did document
it in the form itself?
A.
17
18
It would also seem surprising that, in
Yes.
I should have written it down on that note,
I would agree.
Q.
I have also been asked to put to you whether you can
19
explain the delay between the collection of the stool
20
sample on 22 January and its receipt by the laboratory
21
on 25 January.
22
document on the screen.
23
A.
Yes.
You will remember, I think, I put the
I don't know what the explanation for that is.
24
These samples were collected by the nurses and processed
25
by the nurses.
I wasn't involved in the process at all.
117
1
2
So I don't know why that was.
Q.
3
The consequence of a delay of that kind would be to
delay the commencement of treatment?
4
A.
I realise that, yes.
5
Q.
Do you know where, between the collection of samples and
6
transportation to the laboratory, the samples would be
7
kept?
8
A.
9
At the time there was a small tray at the end of
the ward near the door where samples were placed for
10
collection on a regular basis by the porters.
11
as I'm aware, the nurses would take the sample -- or
12
would acquire the sample from the patient and more or
13
less immediately take it to that collection point.
14
I don't know what happened to the sample between the
15
patient and the collection point, assuming that is where
16
the delay occurred.
17
Q.
So as far
So
I have also been asked to ask you this: when did you
18
first see Mr Boyle after he'd been diagnosed with
19
C. diff infection on 25 January?
20
back to the records for that.
21
on the screen, we see the entry for 25 January, and then
22
move on to page 17.
23
A.
I think we need to go
At page 16, which we have
Well, 25 January, there's a time attached to that, which
24
was a Friday, and the time attached to that is 1545,
25
which is after I would have left on the Friday.
118
1
I certainly saw him on 31 January, but I'm not sure --
2
I suspect I would have seen him at some point before
3
then, but I don't know when I saw him between those
4
dates.
5
Q.
6
7
There is an entry by you on the 29th, where you're
dealing with a discussion.
A.
Yes, I know that there's an entry from me on the 29th,
8
but I'm not sure whether I saw him at that time.
9
Obviously, Dr Johnston saw him on the Monday, which
10
11
I presume was her ward round.
Q.
12
13
Did you, at any stage, assess and record the severity of
Mr Boyle's C. diff infection?
A.
Only in general terms; for example, recording that he
14
had severe diarrhoea on 31 January.
15
question, I don't think -- later there was a C. diff
16
scoring system, which was brought into use, which at
17
that time I don't think we were using the standard
18
scoring system, so in terms of assessing the severity of
19
his C. diff, it was purely in descriptive terms, such as
20
the note on 31 January, where I mentioned that he had
21
severe diarrhoea, which would imply severe infection in
22
general terms.
23
Q.
At the stage in
Having reviewed Mr Boyle's notes, do you consider that
24
management of his fluid balance was optimal or
25
suboptimal?
119
1
A.
I think, bearing in mind the difficulty in dealing with
2
a patient who not only has severe diarrhoea, but also
3
has difficulty maintaining subcutaneous/intravenous
4
lines, I think overall his fluid balance was managed
5
reasonably well.
6
Q.
We can put the documentation on the screen, it's page 28
7
for the period 16 to 17 January and page 31 for 17 to
8
18 January.
9
screen together?
10
Can we have, perhaps, both documents on the
I think -- I may be wrong -- that is all we have for
11
fluid balance charting.
12
that that was adequate?
Do you think, if that is right,
13
A.
I'm surprised that there aren't more charts.
14
Q.
Would you have expected, particularly, charts to be in
15
place at the time that he was C. diff positive?
16
A.
Yes.
17
Q.
If there weren't, then coming back to the question
18
I have been asked to put to you, having reviewed
19
Mr Boyle's notes, do you consider that management of his
20
fluid balance was optimal or suboptimal?
21
A.
Well, in retrospect, it may have been suboptimal.
22
Q.
On the 14th, if we go back to the clinical notes, this
23
is the note on page 15 dealing with the cellulitis.
24
you carry out a physical examination of Mr Boyle on that
25
date?
120
Did
1
A.
On the 14th?
2
Q.
Yes.
3
A.
Yes.
4
Q.
Have you recorded your findings of that physical
5
6
examination?
A.
I have recorded my findings in terms of the fact he had
7
cellulitis of his left leg.
8
in the leg it was and what the appearances were, and
9
I agree that that perhaps should have been more
10
I have not described where
detailed.
11
In terms of the examination of his chest, that was
12
limited by the fact that, at the time, he wouldn't take
13
deep breaths, as I have previously described.
14
Q.
15
16
What was the patient's clinical condition, then, on the
14th when you saw him?
A.
He was obviously quite unwell, and that is confirmed by
17
the fact that the nurses had asked me to see him.
18
the second.
19
I was being asked to review him in the afternoon.
20
Q.
21
22
25
Dr Johnston had seen him in the morning and
Have you recorded the nature of his condition at that
time?
A.
23
24
I was
Well, I have recorded some findings.
I'm not sure what
the question means, to be honest.
Q.
If you thought he was unwell, is that something you
might note?
121
1
A.
2
3
Well, I would have thought that the note itself suggests
that he was unwell.
Q.
Was it the practice in ward 15 at the relevant time only
4
to isolate a patient with suspected C. diff after
5
a positive stool result?
6
A.
I don't know the answer to that.
I'm not sure if the
7
policy was to isolate patients when they developed
8
diarrhoea which you thought was infectious or whether to
9
wait until you had a positive bacteriological result.
10
MR PEOPLES:
My Lord, the question was directed to the
11
practice, not policy.
12
recollection of practice, rather than policy.
13
he answered the policy question earlier on.
14
LORD MACLEAN:
15
A.
I just wanted Dr Herd's
I think
What was the practice, Dr Herd, in ward 15?
I can't recall, but my opinion is that it would be
16
better to isolate patients if they have got infectious
17
diarrhoea while you're waiting for the result, but
18
I can't remember what the practice was at the time.
19
LORD MACLEAN:
20
A.
21
MR MACAULAY:
You have said that already, actually.
Yes.
Just a point I have been asked to raise,
22
although I may have covered it, but I will just confirm
23
it with you: in order to properly manage the risk of
24
dehydration, particularly during the period when
25
Mr Boyle was suffering from C. diff diarrhoea, was it
122
1
2
not necessary to carry out blood tests after 15 January?
A.
3
4
Yes, I think there should have been more blood tests
after the 15th.
Q.
Moving on then to look at questions I have been asked to
5
put to you on behalf of the Medical and Dental Defence
6
Union of Scotland --
7
DAME ELISH:
8
9
My Lord, all of those questions have been posed
and covered.
MR MACAULAY:
10
Thank you.
The last patient that I propose to look at in any
11
detail with you, Dr Herd, is Mrs Pirog.
12
Vale of Leven records for Mrs Pirog are at GGC21690001.
13
You may remember that Mrs Pirog had been admitted to the
14
Royal Alexandra Hospital after a fall, on 8 June 2007,
15
and she had suffered fractures to her lower limbs.
16
The
Do you remember Mrs Pirog as a patient?
17
A.
Yes.
I'm just trying to find the admission notes.
18
Q.
She was transferred to the Vale of Leven Hospital,
19
ward 15, on 9 July 2007.
20
with Mrs Pirog when she was in ward 15; is that right?
21
A.
22
23
Yes.
I think you had some contact
I was actually on holiday when she was admitted,
though.
Q.
If we look at the care of the elderly documentation on
24
page 31, do we see that the admission was on 9 July?
25
this time, Dr Akhter seemed to be designated the
123
At
1
2
consultant in charge of the case.
A.
3
4
Yes.
I'm just trying to find the hard copy of this.
seems to be out of sequence.
Q.
It
Yes, okay.
There are a couple of points I want to ask you about.
5
If you turn to page 86 of the records, the nursing
6
notes, there's an entry for 9 August which reads:
7
"Ward round - commenced on co-amoxiclav for a UTI."
8
Do you see that?
9
A.
Yes.
10
Q.
Whose ward round would that be?
11
A.
9 August?
12
Q.
Yes.
13
A.
That was a Thursday ward round, so I presume it was my
14
This is in 2007, isn't it?
ward round.
15
Q.
This, of course, is the nursing notes we are looking at.
16
A.
Although, having said that, I think at this point
17
Dr Johnston was off sick.
18
I think, from June to October 2007.
19
Dr Akhter is mentioned as the consultant.
20
Dr Johnston was off sick,
That is why
So I can't remember the arrangement.
I mean, when
21
Dr Johnston was off sick, I can't remember what
22
provision was made in terms of consultant cover at the
23
time.
24
recollection is that he would sometimes come on the ward
25
rounds on Thursdays.
I think Dr Akhter was the consultant, and my
I think there was some reason why,
124
1
if I remember correctly, he couldn't do a ward round on
2
Mondays.
3
Q.
Certainly the suggestion there is that Mrs Pirog was to
4
be started on an antibiotic for a urinary tract
5
infection.
6
A.
Yes.
7
Q.
If we look at the clinical notes on page 11, towards the
8
bottom, at this time there's reference to, for 7 August,
9
"For the fracture clinic", for 9 August, "For the
10
fracture clinic today", and then over on page 12,
11
I think there's a record of the attendance at the
12
fracture clinic; is that right?
13
A.
Yes.
14
Q.
No.
15
16
There's no mention of a prescription.
Can you help with that?
Do you have any
recollection as to what the background to that was?
A.
Is there a drug Kardex that corresponds?
I have
17
a feeling that there's a drug Kardex which lists
18
co-amoxiclav, but it's actually scored out.
19
Q.
Yes.
If we look at page 62.
20
A.
That's my writing, yes.
Is that your handwriting?
I think I considered
21
prescribing co-amoxiclav on 9 August, but for reasons
22
which aren't recorded, I decided against prescribing it.
23
But the nursing Kardex suggests that it was prescribed.
24
But I think it wasn't actually prescribed.
25
conclude that I presumed she had asymptomatic
125
I can only
1
bacteriuria and that she didn't have a genuine urinary
2
tract infection.
3
LORD MACLEAN:
4
That should have been documented.
Does that indicate that you were on duty on
the 9th?
5
A.
Yes.
6
MR MACAULAY:
If we go back to the clinical notes, then, for
7
this time, we have looked at the entries for the 7th and
8
the 9th.
9
period; is that right?
10
A.
11
There is no entry by yourself over that
Well, the brief note on 9 August is my writing, about
the fracture clinic.
12
Q.
That is your handwriting, is it?
13
A.
Yes.
14
Q.
If you look at page 12, then, have you made any
15
I don't know why it is not signed.
contribution to the notes on page 12?
16
A.
That is my note on 22 August.
17
Q.
I think you begin by saying you'd had a long discussion
18
with the daughters; is that right?
19
A.
Yes.
20
Q.
I think you also have a note, if you turn over to
21
page 13, on 30 August; is that right?
22
A.
Yes.
23
Q.
If we move on to the next page, page 14, are there any
24
25
entries there by yourself?
A.
No, there aren't.
The thing that strikes me as odd
126
1
about this page of the record is the fact that the note
2
on 18 September, 20 September and 25 September -- sorry,
3
not the 18th.
4
25 September are both signed by Dr Malcolm MacRae, who
5
was my other partner, and the only situation in which
6
Malcolm MacRae would have been writing in the notes
7
would have been if I wasn't available.
The one on 20 September and the one on
8
So for some reason or other, I was obviously not
9
available around about that time, but I am unable to
10
explain why I wasn't available.
11
having had any holidays at that time.
12
if I was off sick, or whatever.
13
probably significant that Malcolm MacRae has written,
14
you know, these notes.
15
So I don't know
But I think it is
But I think the one on the 18th -- the one on the
16
17
I am not aware of
18th, the 20th and 25th are all by Malcolm MacRae.
Q.
18
If we just focus, then, on the one on the 25th, and then
look to the next entry, which is for 3 October --
19
A.
Yes.
20
Q.
-- can we see that between Dr MacRae's note on
21
25 September and 3 October, there doesn't appear to have
22
been any medical input into her care?
23
A.
Yes.
24
Q.
Should there have been some medical input into this
25
patient's care at this time in her stay?
127
1
A.
2
3
I would have thought so, yes, but I can't explain why
there was that gap.
Q.
Were you aware, when Mrs Pirog was admitted to the
4
Vale of Leven, that she had had C. difficile
5
diarrhoea --
6
A.
I was aware, yes.
7
Q.
-- in the Royal Alexandra Hospital?
8
A.
Yes, it is documented in the admission note.
9
Q.
Did you at any stage consider whether or not specimens
10
should have been taken from her during her stay in the
11
Vale of Leven?
12
specimens taken for C. diff testing.
13
A.
Because we know there weren't any
I don't think any of the doctors and nurses who were
14
looking after her thought that her symptoms were
15
suggestive of recurrence.
16
samples.
17
threshold for sending samples because we knew she had
18
had C. diff in Paisley.
19
Q.
Otherwise, we would have sent
I would have thought we would have had a low
There was certainly evidence, I think, when she was in
20
the Vale of Leven that she had loose stools.
21
seen that from the records?
22
A.
Have you
Yes, she had loose stools intermittently, but I think
23
even Dr Harrington, who was, I think, the expert in this
24
case, in her report I think I'm right in saying it
25
concedes that, in August, she seemed to predominantly
128
1
have constipation, so that -- I think, overall, the
2
doctors who had the patient in front of them, the
3
doctors and nurses, knowing that this patient had had
4
C. diff, didn't feel prompted to send further samples.
5
Q.
This was a patient, again, I think, that you were
6
involved in the certification of the death; is that
7
correct?
8
A.
Yes.
9
Q.
I will put the death certificate on the screen, it is at
10
INQ00960001.
11
3 October 2007, and the cause of death, I(a),
12
bronchopneumonia; (b), immobility; and (c), bilateral
13
fractured tibia and fibula.
14
We can see that Mrs Pirog died on
Can you explain what the basis for the reference to
15
bronchopneumonia is?
16
this time on page 14 -- perhaps keep the death
17
certificate on the screen.
18
A.
Yes.
If we go back to the records at
I think what has happened is obviously there is
19
a lack of notes in the medical record, as you have
20
alluded to, but I think probably I have taken
21
information from the nursing staff in terms of how she
22
had been in the few days prior to her death.
23
I'm right in saying that there is a mention of her
24
being -- having respiratory symptoms.
25
described as being "chesty" in the nursing notes.
129
I think
I think she's
1
Q.
2
Let's just see if we can find that.
Was it at about
this time?
3
A.
Yes, around about this time.
4
Q.
Let's look at the records, then.
If we turn to pages 90
5
and 91.
Page 90, towards the top, we are in September,
6
"Incontinent of soft faeces" is the entry.
7
page 91, on 1 October again there is reference to
8
"Incontinent of soft faeces.
9
frail".
Moving on to
Sounding chesty.
Very
10
A.
"Sounding chesty", is that not --
11
Q.
Is that the basis for it?
12
A.
I'm just saying that I think that suggests that the
13
nurses had observed some respiratory symptoms, and this
14
was a lady who had a history of COPD and had been very
15
immobile because of her fractures.
16
suddenly.
17
or a pulmonary embolus.
18
probability, that her bronchopneumonia was the most
19
likely cause of death.
20
Q.
21
22
She hadn't died
It didn't look like she'd had a heart attack
So I thought, on the balance of
Was the basis of that conclusion the entry we see for
1 October, "Sounding chesty"?
A.
It wasn't that entry, but it was -- that entry reflects
23
the opinions of the nurses I think they probably
24
expressed to me when I was deciding what I should enter
25
onto the death certificate.
130
1
Q.
2
3
call in the doctor to assess the patient?
A.
4
5
If a patient is sounding chesty, then should the nurses
I think it could be argued that they should have done,
yes.
Q.
6
Because that is something that could possibly be
treated?
7
A.
Yes.
8
Q.
I think we have looked at the clinical notes, and there
9
isn't a note between the 25th and 3 October.
10
A.
Yes.
11
Q.
Do you think, looking at it now, it was appropriate to
12
put bronchopneumonia as the primary cause of death for
13
this patient?
14
A.
Well, the only alternative would have been to have
15
a post-mortem examination, I suppose, but I think, in
16
the absence of a post-mortem examination, that was
17
a reasonable thing to put down as the cause of death.
18
Q.
Looking at it now, are you comfortable with the view
19
that you formed at the time, that this was the primary
20
cause of death?
21
A.
I think I am comfortable, yes.
I mean, bronchopneumonia
22
is a common cause of death in the elderly who are
23
immobile, especially if they have pre-existing pulmonary
24
disease.
25
Q.
What we seem to have, then, is a cause of death that had
131
1
2
materialised some days before death; is that right?
A.
3
Well, her symptoms had materialised some days before
death.
4
Q.
For which she was not treated?
5
A.
It would appear not.
6
Q.
Do you remember receiving a letter in July 2008 in
7
connection with Mrs Pirog's attendance at the
8
Vale of Leven from Mrs Squires?
9
A.
I remember there was a letter, yes.
10
Q.
If we put that on the screen, it is INQ01580001.
11
12
We can
perhaps just enlarge that a little bit.
This, I think, is a copy of the letter, which is
13
addressed to yourself, Dr Herd, in ward 15, with copies
14
to Sister Madden and to Ms Baillie.
15
letter was raising was a number of concerns in relation
16
to Mrs Pirog's management in ward 15.
17
18
19
I think what the
In particular, if we look at the second paragraph,
the second sentence begins:
"She spent three months recuperating after breaking
20
both her legs.
21
died of bronchial pneumonia/immobility.
22
we are asking is: what assurances can you give our
23
family that our mother's death was completely unrelated
24
to the current outbreak of this superbug?"
25
On her death certificate it says she
They go on to say:
132
The questions
1
"Can we please have more details of my mother's last
2
week in the Vale of Leven Hospital Ward 15?
3
please explain why large periods of time have no entries
4
in the evaluation sheets?"
5
Can you
Just on that point, can you explain that point?
6
A.
The gaps?
7
Q.
Yes.
8
A.
I have already said that I can't explain them.
9
Q.
"Why was it that our mother suffered from a breakdown on
10
her bottom?"
11
That is making reference to pressure damage,
12
I think, that Mrs Pirog suffered:
13
"Can you please detail for us what kind of pneumonia
14
it was that she died from?"
15
I think, following on that letter, do you recollect
16
having a meeting with Mrs Squires and other members of
17
her family?
18
A.
I remember having a meeting, yes.
19
Q.
If you could look at INQ01620001, this bears to be
20
a note of questions and answers at the meeting that took
21
place.
22
9 December 2008?
23
A.
24
25
Do you recollect having a meeting on
I remember there was a meeting.
I couldn't say what
date it was.
Q.
Does that ring a bell, in that it was towards the latter
133
1
part of the year?
2
A.
I think it probably was, yes.
3
Q.
I think, according to this, there was Anna Squires,
4
Tony Squires and Helen Wilson who were present, and you
5
were present with Anne Madden; is that right?
6
A.
I didn't realise there were so many other -- are these
7
relatives?
8
I think.
Mrs Squires is Mrs Pirog's daughter,
9
Q.
As far as you're concerned, was Sister Madden with you?
10
A.
Yes, from ward 15 it was Sister Madden and I.
11
12
I couldn't recall who else was present.
Q.
There's a heading on this first page about two-thirds of
13
the way down, "Circumstances of Mrs Pirog's death".
14
you see that note?
15
A.
Yes.
16
Q.
What has been transcribed is the question:
17
"Question:
18
Mrs Pirog's death?"
Did C. difficile play any part in
19
The answer has been noted:
20
"Answer:
21
25
It's
Do you remember that forming part of
23
24
People don't die of C. difficile.
because this has become politicised."
22
the conversation?
A.
I can't.
Do
I am aware that I am alleged to have said
this, but I cannot believe that I did say it, and
134
1
I think it really would make no sense for me to say it,
2
considering that I had, by this time, issued a number of
3
death certificates with Clostridium difficile as the
4
cause of death.
5
unusual language for me to use, especially to
6
a patient's relatives.
7
using those words.
8
Q.
9
It also seems a rather -- it seems
So I have no recollection of
If we move on to the second page, I think you were being
asked to confirm if you are the same person whose name
10
appeared in the death certificate, and you responded
11
"Yes" to that.
12
A.
Yes.
13
Q.
Then the question:
14
"Question:
How come the diagnosed bronchopneumonia,
15
cause of death, on death certificate, is not mentioned
16
in Mrs Pirog's notes prior to her death?"
17
What has been noted here is:
18
"Answer:
It was not a cause of death as such,
19
something needs to be put down on the death certificate.
20
Can't just say 'Died of old age' ..."
21
It is suggested that you were sniggering at this
22
point and Mrs Wilson became very upset.
23
that aside for the moment, do you recollect something
24
being said along the lines that it wasn't the cause of
25
death and something had to be put down?
135
Just putting
1
A.
No.
I think what I was trying to say was -- I think
2
there are some doctors who are content to put down "Old
3
age" as a cause of death, but I feel that that's not
4
appropriate and not acceptable.
5
bronchopneumonia as the cause of death because
6
I thought, on the balance of probabilities, it was the
7
most likely cause of death.
So I put
8
I certainly would not be laughing at something like
9
this, and I'm not quite sure how that impression arose.
10
Q.
So if the inference from this is you put it down as the
11
cause of death simply because you couldn't put down
12
"died of old age", you are not accepting that, as
13
I understand your position?
14
A.
I'm not accepting that.
I put it down as the cause of
15
death because I thought, on the balance of
16
probabilities, it was the most likely cause of death.
17
Q.
Do you remember Mrs Wilson becoming upset?
18
A.
I don't remember that, I'm sorry.
19
Q.
I think there was also some discussion as to whether or
20
not Mrs Pirog had C. diff; is that correct?
21
in the --
I see that
22
A.
I think there was some discussion, yes.
23
Q.
I'm just going to move on to see what questions I may
24
have to put to you in connection with Mrs Pirog.
25
Perhaps I could invite my learned friend Mr Peoples to
136
1
indicate if there are any questions that have been
2
superseded before I launch forth into his list of
3
questions.
4
MR PEOPLES:
I think section 4 about the death certificate
5
has been dealt with, as has section 3.
6
are a couple of points about sections 2(a) and (c) that
7
may not have been covered, and then I think where there
8
was some evidence about frequency of review, I'm not
9
sure that the specific points were maybe put under
10
section 1 about the degree of review in the whole
11
period.
12
covered some of it, but it may be best if I leave those
13
questions in at this stage.
14
MR MACAULAY:
15
I think there
I would perhaps be grateful -- he may have
Sorry, just to confirm, did you say 4 in its
totality has been covered?
16
MR PEOPLES:
17
MR MACAULAY:
18
Yes.
It is really just 1, 2(a) and (c).
I'm putting these questions to you on behalf
of patients and families, Dr Herd.
19
Looking at Mrs Pirog, the patient we have been
20
looking at, and this is looking at generally the
21
frequency of medical review, was it your responsibility
22
to seek consultant involvement where appropriate?
23
A.
It was my responsibility to seek consultant involvement
24
in between regular reviews by the consultant.
25
was admitted at a time when I think Dr Johnston was off
137
Mrs Pirog
1
sick, and I can't recall what the arrangements were for
2
covering her illness.
3
an annual leave was that Dr Akhter would cover for her,
4
which was a reasonable arrangement, but if she was off
5
from, as I understand it, June 2007 to October 2007, I'm
6
not sure if any additional consultant cover was put in
7
place.
The usual situation when she was
8
I should also -- it may also be relevant the fact
9
that there were 46 admissions to ward 15, I think I'm
10
right in saying, in July 2007, and I was on annual leave
11
from 3 July to 22 July, so I think in July -- obviously,
12
Mrs Pirog was there -- wasn't just there in July, but at
13
the time that she was admitted, the ward was very busy
14
and the usual consultant was off sick.
15
As I say, I can't recall, since it's four years ago,
16
what the arrangements were for covering her workload.
17
But to come back to your original question, you
18
know, I am expected to bring things to the consultants'
19
attention in between their regular reviews.
20
MR KINROY:
My Lord, on the question of cover for when
21
Dr Johnston went off sick, I think there was some
22
evidence about Dr Yousif, and I wonder whether it is
23
worth trying to explore that, if that might jog the
24
witness's memory?
25
A.
I don't remember much involvement with Dr Yousif, to be
138
1
honest, so I don't think -- I don't know, is the answer,
2
whether he was involved in the cover.
3
MR MACAULAY:
4
My own recollection is that we don't see any
entries by Dr Yousif in the clinical notes.
5
A.
I don't think so.
Not as far as I'm aware.
6
Q.
The next two questions I think I can put together:
7
Mrs Pirog spent about 85 days in the
8
Vale of Leven Hospital.
9
A.
Mmm.
10
Q.
She was only seen by a consultant over that whole period
11
on two occasions.
Do you consider, having reviewed the
12
medical records, that Mrs Pirog had adequate consultant
13
medical review during her stay over that period?
14
A.
I don't think so.
15
Q.
Why was the review inadequate?
16
A.
Well, that just seems a remarkably small number of
17
consultant entries over a long period of time.
18
Q.
But what's the explanation for that?
19
A.
I don't know what the explanation is.
20
Q.
I'm now moving on to look at antibiotic prescription,
21
and I have touched upon some of this already.
Are you
22
able to say what medication she did receive after
23
6 August 2007?
24
A.
Is this in relation to the co-amoxiclav?
25
Q.
I think we have looked at the co-amoxiclav, which
139
1
I think we saw was not given.
Are you able to, under
2
reference to the records and your knowledge of
3
the case --
4
A.
I would need to look at the drug Kardex from that time.
5
Q.
Would you need to look at the drug Kardex?
6
A.
Yes.
7
Q.
Okay.
I think we probably begin looking at that on
8
page 57.
9
other medications there; is that right?
10
A.
11
12
So we see some references to aspirin and some
Yes, including salbutamol slow-release tablets, which
she was presumably on for her COPD.
Q.
I think if you look quickly at the entries, page 57,
13
page 58, page 59, page 60 and page 61, and we looked
14
earlier, I think, at page 62, so we can see there what
15
medications she was given, but there's no evidence of
16
any antibiotic treatment?
17
A.
Yes.
18
Q.
Do you accept the evidence given by Dr Akhter that the
19
microbiology specimen of urine that was collected from
20
Mrs Pirog on 7 August 2007 did not form a basis by
21
itself for a diagnosis of a UTI?
22
A.
Can I see the result?
23
Q.
Yes.
24
A.
Certainly there was a significant number of bacteria
25
That is page 45 of the records.
there, and there were numerous white blood cells, and
140
1
the infection was resistant to trimethoprim and
2
amoxicillin, which might explain why co-amoxiclav was
3
being considered, but --
4
Q.
But you cancelled it?
5
A.
Yes.
I think, at the end of the day, I concluded that
6
it didn't represent a genuine urinary tract infection.
7
But it should have been documented.
8
Q.
9
many times you saw Mrs Pirog under reference to the
10
11
records?
A.
12
13
Q.
Certainly on 9 August, and I think I saw her before
Would it be fair to say that you didn't see her very
much between then and the date of her death?
A.
16
17
Have we covered the times you did?
I had the discussion with her daughters on 22 August.
14
15
Looking to your own involvement, are you able to say how
I would agree.
I'm surprised that there are quite
a small number of entries.
DAME ELISH:
My Lord, just for the sake of clarification,
18
I understood that the witness said earlier he may have
19
visited and not recorded, so, again, is the emphasis on
20
recorded?
21
MR MACAULAY:
We will impose that caveat.
22
A.
Yes.
23
Q.
On 11 September, if we look at the records on page 14,
24
first of all, can you confirm this, is that your
25
handwriting?
141
1
A.
No, that is Dr Garthwaite.
2
Q.
The second-last line makes reference to "delayed
3
discharge"; do you see that?
4
A.
Yes.
5
Q.
Does that have any impact upon the infrequency of
6
7
medical review after that date?
A.
The term "delayed discharge" means that the patient was
8
at the stage where we felt there was no further
9
improvement that could be achieved medically, so they
10
were suitable for discharge to a nursing home if
11
a nursing home became available, but that doesn't mean
12
that they were ignored, because, obviously, elderly
13
people can develop other problems.
14
Q.
15
You would accept that she did require medical review
after that date?
16
A.
Yes.
17
Q.
The next series of questions I have been asked to put on
18
behalf of the Medical and Dental Defence Union of
19
Scotland --
20
DAME ELISH:
21
MR MACAULAY:
22
These don't require to be put, my Lord.
Thank you.
I have some further questions to put to the witness,
23
my Lord, but if your Lordship were contemplating having
24
a short break, this might be an appropriate point to
25
have it, or I can carry on, if you wish.
142
1
LORD MACLEAN:
2
take?
3
MR MACAULAY:
No, it is: how long do you think you will
I have questions to put on behalf of
4
the health board.
5
perhaps, if we are having a break, if there are to be
6
any questions excised, but certainly there are seven
7
pages of questions.
8
LORD MACLEAN:
9
MR MACAULAY:
10
LORD MACLEAN:
11
(3.15 pm)
Right.
My learned friend can indicate
We will have the break.
And I will have a word with my learned friend.
Yes.
12
(A short break)
13
(3.30 pm)
14
MR MACAULAY:
Dr Herd, I have now some questions to put to
15
you on behalf of the health board.
16
I have been asked to put to you is this: in the
17
Vale of Leven Hospital, what did the term "bed blocking"
18
mean in 2007/2008?
19
A.
The first question
Bed blocking, I think, was what I would prefer to call
20
delayed discharges, and these were patients who had been
21
rehabilitated to their maximum, as far as we were
22
concerned, and patients who were awaiting a place in
23
a nursing home or residential home.
24
25
I didn't really like to use the term "bed blocking",
personally, as I think it has a rather pejorative
143
1
2
flavour to it.
Q.
3
You haven't seen the GP records for the patients whose
care you were involved in; is that correct?
4
A.
That's correct.
5
Q.
Can you exclude the possibility that the patient may
6
have suffered from Clostridium difficile illness or
7
diarrhoea in the six months preceding the hospital
8
admission?
9
A.
No, I can't.
10
Q.
Can you exclude the possibility that, in such cases, the
11
patient was prescribed antibiotics in the three months
12
preceding the admission?
13
A.
No.
14
Q.
Now, is it possible that in some cases, at least, the
15
patient's susceptibility to contracting C. diff was
16
caused by antibiotic prescribing in the community?
17
A.
That's possible.
18
Q.
Is it the case that, quite often, elderly patients with
19
a urinary tract infection do not have the classic
20
symptoms of that?
21
A.
That's true.
22
Q.
Quite often, the most obvious clinical sign of that
23
infection in an elderly patient is confusion?
24
A.
Yes.
25
Q.
If you had encountered systematic and material delays in
144
1
the testing of samples, would you have done something
2
about that?
3
A.
Yes, I would.
4
Q.
Did you encounter such material delays in the testing of
5
samples?
6
A.
No, I didn't.
7
Q.
Where there was a common background rate of unexplained
8
diarrhoea for norovirus infection on wards at the same
9
time as C. diff, would that have the potential to make
10
it difficult to suspect a false negative on clinical
11
grounds?
12
MR KINROY:
My Lord, I don't need that question asked,
13
because we already know the evidence of the witness on
14
his unawareness of false negatives at the time.
15
LORD MACLEAN:
16
MR MACAULAY:
Yes, true.
Thank you.
It has been suggested that in February 2007
17
there was a talk given at the Vale of Leven Hospital by
18
the microbiologist Barbara Weinhardt and the infection
19
control nurse Jean Murray.
20
that?
21
22
23
A.
Do you know anything about
I have seen print-outs of the overheads from that talk,
but I wasn't -- I don't remember going to it.
MR KINROY:
My Lord, I wonder if I could clarify when the
24
witness saw the print-outs from the overheads of that
25
talk?
145
1
LORD MACLEAN:
2
A.
3
MR MACAULAY:
Do you remember when you saw them?
Within the last few months.
If you had been systematically hindered by the
4
quality of nursing of your patients, would you have done
5
something about that?
6
A.
Yes, I would.
7
Q.
Was the quality of the nursing care adequate?
8
A.
I think the quality of nursing care was good.
9
Q.
Do you consider that more single rooms would have
10
avoided the outbreak occurring?
11
A.
Is this purely applied to ward 15 or in general terms?
12
Q.
Whatever you feel comfortable with in answering the
13
14
question.
A.
As far as ward 15 was concerned, it seemed to me that
15
four single rooms appeared to be adequate for the number
16
of cases that we had, but I can't really comment on the
17
rest of the hospital.
18
Q.
Finally for these questions, you have been questioned
19
here in detail about decisions you made and the care you
20
provided.
21
evidence?
Have you prepared adequately for giving your
22
A.
I have prepared to the best of my ability.
23
Q.
Finally, if I can pick up the final questions that
24
I haven't already covered from the Medical and Dental
25
Defence Union of Scotland -146
1
DAME ELISH:
I can assist, my Lord, no questions require to
2
be put regarding Elizabeth Rainey, if that assists my
3
learned friend.
4
MR MACAULAY:
5
DAME ELISH:
6
7
That's questions 1, 2 and 3.
Yes.
No question requires to be put regarding
Coleman Conroy, that's 14 and 15.
MR MACAULAY:
That leaves me to ask you some questions
8
about, I think, two remaining patients, and the first of
9
these is Evelyn Scott-Adamson.
10
It is suggested that Dr Jones highlighted in his
11
evidence that there were no medical notes between
12
27 December and 9 January.
13
GGC27020018, so the dates that are focused upon are
14
27 December and 9 January.
15
for --
16
A.
If we look at the records at
If we look at the records
I think I noticed this, that the way the pages have been
17
photocopied, it makes it -- it takes them out of
18
sequence.
19
a more complete copy of GGC27020018, which shows these
20
dates.
21
Q.
I think the Inquiry has been provided with
I think that's right.
If we put this on the other
22
screen, I think we had some dates cut out previously; is
23
that right?
24
A.
Yes.
25
Q.
So we are looking at entries, then, for the -147
1
A.
The way the original photocopy goes, it looks as if
2
there is a large gap in the notes, when, in fact, it's
3
transposed in the wrong -- that sheet is in the wrong
4
place.
5
Q.
6
We can see dates on this sheet, for example, 3 January.
Now we can see 3 January, 7 January -- is that right?
7
A.
Yes, 3 January and 7 January.
8
Q.
3 January is an entry by yourself?
9
A.
Yes.
10
DAME ELISH:
11
I think, my Lord, there is also, 31 December,
an entry from Dr Johnston.
12
LORD MACLEAN:
13
MR MACAULAY:
14
Yes.
Thank you.
The previous entry, then, if we go back to page 17
15
on the screen, GGC27020017, that's where we have the
16
date for 27 December?
17
A.
Yes.
It is as if that page is sort of the wrong way
18
around.
19
got a new copy of and, in fact, it should be the other
20
way around, if you know what I mean.
21
Q.
The back of that page is the one that you have
Hopefully, that has clarified that.
22
I think you may have covered this, but I think from
23
what you said, you didn't work weekends; is that right?
24
A.
That's right.
25
Q.
Or, indeed, public holidays?
148
1
A.
Yes.
2
Q.
In relation to Ms Scott-Adamson, Dr Jones also suggested
3
that stool samples ought to have been sent for testing
4
after her fall on 25 January, although previously there
5
had been two negative samples sent on 5 and 8 January.
6
A.
Yes.
7
Q.
Are you able to comment on that?
8
A.
I think this comes back to the fact that we were not
9
aware of the significant possibility of false negatives
10
with C. diff testing, and I think, if we had been aware
11
of that at the time, we might have considered sending
12
further samples, but we weren't and, for that reason, we
13
felt we had excluded C. diff in this patient's case.
14
For that reason, we were looking for other causes of
15
diarrhoea, and I think arrangements were being made for
16
her to have a colonoscopy done to try to establish that.
17
So I think, again, looking at it from the point of
18
view -- from the perspective that we had at the time, we
19
felt we had excluded C. diff in her case, and that we
20
didn't need to look for it further.
21
we were able to go back in time, if you like, from now,
22
we would perhaps have behaved differently.
23
Q.
But if we now -- if
I think the final question here under this head is that,
24
having had regard to Dr Jones's evidence in this case,
25
do you consider that having the patient in front of
149
1
the treating clinician makes it easier for that
2
clinician to know what was going on with the patient?
3
A.
I think this comes back to the fact that the experts in
4
the Inquiry were having to make their reports on the
5
basis purely of the records, and I think some of
6
the experts seemed to admit that they recognised the
7
limitations of that, whereas others, I think, are less
8
prepared to admit that.
9
make a difference, having the patient in front of you as
10
11
But personally, I feel it does
well as having the written record.
Q.
The final patient I have been asked to ask some
12
questions about is Mr Somerville.
The first point is
13
this, that Dr Harrington said in her report that every
14
aspect of the management of his C. diff was substandard,
15
and in contrast, Dr Teare has said in evidence she
16
thinks he was managed well in respect of the treatment
17
for his C. diff.
18
A.
Yes.
19
Q.
I think you are being asked with whom do you agree, but
20
21
I suspect I know what the answer is.
A.
I would agree that his C. diff was managed well.
22
I mean, he had numerous courses of vancomycin, including
23
pulsed vancomycin, so I think the actual treatment of
24
his C. diff was appropriate and I think the
25
bacteriologist agrees with that.
150
I think any
1
deficiencies were possibly to do with monitoring his
2
C. diff, but I presume that's what Dr Harrington is
3
referring to.
4
Q.
Did you assess the severity of Mr Somerville's C. diff?
5
A.
Not in the terms of a formal scoring system, which
6
I think was introduced later, but the mere fact that he
7
had C. diff recurrently over a long period of time
8
I think suggests he had severe infection, which was very
9
difficult to eradicate.
10
11
So I'm not sure if that answers
your question.
Q.
12
I think Mr Somerville was a patient who had been in
hospital for a considerable period of time.
13
A.
Yes.
14
Q.
Dr Harrington also said in her report that there was
15
a delay in isolating him for the protection of others,
16
and, in evidence, that she could not identify
17
a rationale for some of the ward moves that
18
Mr Somerville was subjected to.
19
Would these aspects of Mr Somerville's management
20
be under your control?
21
A.
They wouldn't be under my control, no.
22
Q.
Given this patient's very complicated history, did you
23
consider that it was challenging to complete the death
24
certificate?
25
A.
I agree that he had a complex history, and it could be
151
1
argued that, in this case, I should perhaps have
2
discussed the certificate with a consultant before
3
issuing it.
4
DAME ELISH:
My Lord, I wonder if I could intervene here
5
that we have, since this was lodged, heard evidence from
6
Dr Johnston?
7
regarding Dr Johnston's position that she was consulted
8
in respect of this by Dr Herd.
9
learned friend could put that to the witness.
10
LORD MACLEAN:
11
DAME ELISH:
12
LORD MACLEAN:
13
A.
Sorry, my Lord, it is a communication
I'm not sure if my
Does he remember that?
I have no idea.
Do you remember that?
I don't remember.
I think Mr Somerville was a case in
14
which Dr Harrington proposed quite a different death
15
certificate from the one that I wrote for Mr Somerville,
16
but I think Professor Griffith, I think he actually
17
agreed with me that he died from an aspiration pneumonia
18
and not from cardiac failure, I think it was, secondary
19
to an arrhythmia, which is what Dr Harrington suggested.
20
MR MACAULAY:
I think the particular point my learned friend
21
has raised is, in fact, do you remember discussing the
22
patient with the consultant, who would be Dr Johnston?
23
A.
With regard to the death certificate?
24
Q.
Yes.
25
A.
I don't remember discussing it.
152
1
Q.
Dr Herd, then, I think that does conclude the questions
2
I have been asked to put to you and, indeed, the
3
questions I want to put to you myself.
4
Is there anything else you would like to say in
5
order to assist the Inquiry?
6
A.
7
MR MACAULAY:
8
LORD MACLEAN:
9
A.
10
I don't think so, no.
Thank you very much.
Thank you very much, indeed, for coming.
Thank you.
LORD MACLEAN:
I am sorry you waited such a long time
11
yesterday, but you will get back to -- tomorrow,
12
Wednesday, you are in practice?
13
A.
Yes.
14
LORD MACLEAN:
15
16
Good.
Thank you very much.
(The witness withdrew)
MR MACAULAY:
17
My Lord, the next witness I would like to call
is Dr Hugh Carmichael.
18
DR HUGH CARMICHAEL (affirmed)
19
Examination by MR MACAULAY
20
MR MACAULAY:
Dr Carmichael, are you Hugh Carmichael?
21
A.
Yes.
22
Q.
Could you tell us what your present status is?
23
A.
Retired.
24
Q.
When did you retire?
25
A.
May 2010.
153
1
Q.
What position did you hold prior to retirement?
2
A.
Consultant physician.
3
Q.
Was that in the Vale of Leven Hospital?
4
A.
Vale of Leven, yes.
5
Q.
Perhaps we could look at your CV.
It is at INQ03210001.
I will put it on the
6
screen.
Do we see that you
7
obtained your medical degree at the University of
8
Glasgow in 1970?
9
A.
Yes.
10
Q.
You became an MRCP in 1973 and an FRCP (Glasgow)
11
July 1987; is that correct?
12
A.
That's right.
13
Q.
If we look at your previous posts, you have listed these
14
against that particular heading, can we see, if we go to
15
the bottom of the list, that you were appointed
16
a consultant physician at the Vale of Leven Hospital
17
in June 1979?
18
A.
That's right.
19
Q.
So you were based there for a considerable period of
20
time?
21
A.
Indeed.
22
Q.
Did you have a particular speciality?
23
A.
Gastroenterology.
24
Q.
I think you give us some information about that under
25
the following headings.
If we turn through to page 2,
154
1
you have very helpfully set out what your job plan was.
2
Does this represent your job plan during the period that
3
we are particularly interested in, that's the period
4
from January 2007 through to June 2008?
5
A.
Yes.
6
Q.
Can you just take us through, then, what your
7
commitments were, since we have it here before us at
8
that point?
9
A.
On a Monday, usually I would be receiving four Mondays
10
out of six.
11
to divide up the receiving days to fit that number.
12
four days, normally, on a Monday, I would be receiving
13
and would come in about 8.30, between 8.00 and 8.30 and
14
start --
15
LORD MACLEAN:
16
17
There were six of us receiving, so we had
So
Could you bring the microphone closer to you?
You are not coming across all that well.
A.
Right.
I would come in at between 8.00 and 8.30 and
18
start the ward round shortly after 8.30, nearer
19
9 o'clock.
20
I would see all the patients that came in on the Sunday
21
after they were seen by whoever was on at the weekend.
22
So I would see everything -- well, I would see
23
everything after 5 o'clock on a Sunday, and whoever had
24
been on on the Sunday would see those who came in up
25
until 5.00 that morning.
That would be the post receiving round.
155
1
Q.
2
3
That would be between 8.30 and 12.00, in the morning; is
that right?
A.
That would normally take in -- uh-huh -- and that post
4
receiving ward round would be followed by my routine
5
ward round, so I would see all the other cases that were
6
still in hospital under my care.
7
Q.
I think also you have indicated that on a Monday you
8
would chair the hospital clinical governance meeting; is
9
that right?
10
A.
Yes.
11
Q.
We may return to that later.
12
13
Following through, your
weekly commitments?
A.
Tuesday would be all day endoscopies, two sessions of
14
that; Wednesday, I would be doing what I have called
15
"follow-up clinic", in inverted commas.
16
I had one outpatient clinic.
17
there was no space to fit me in, so what I -- my normal
18
practice was to receive more new patients than normal on
19
my clinic day and follow up the results in my office and
20
decide whether I needed to review them or what other
21
things should be done, should I contact the GP, the
22
patient, et cetera, rather than routinely follow
23
patients -- return as a return, I didn't bring all
24
patients back for the return visit, as is normal
25
practice.
156
Basically,
I really required two, but
1
Then midday, there was the weekly hospital clinical
2
meeting and, in the afternoon, my weekly outpatient
3
clinic.
4
of the month, these clinics were held elsewhere, in
5
Helensburgh and Dumbarton.
Now, two days out of the -- two Wednesdays out
6
Q.
Would you travel to these?
7
A.
I would have to travel to these.
So quite often,
8
I would miss either all or certainly the latter part of
9
the clinical meeting.
10
Q.
Moving on, then, to the Thursday.
11
A.
Thursday, my follow-up ward round, seeing all the
12
patients that still remained under my care.
13
was the unit medical meeting on a Thursday at lunchtime,
14
and then, in the afternoon, I had an extra endoscopy
15
session.
16
official sessions to cope with the demand.
17
Then there
This was one I started up in addition to my
Again, sometimes, if I was asked to do urgent
18
endoscopies, I would add them in to that list early on,
19
so sometimes I would miss the unit clinical meeting as
20
well, because of starting early in the endoscopy
21
sessions.
22
Then on the Friday, as with everybody else, I took
23
my turn being on call.
Although one in six, if you take
24
holidays into account, it usually ended up being between
25
one in four and one in five Fridays that I would end up
157
1
on call when I was working.
2
They were basically catching up on all the other
3
stuff that accumulates inevitably throughout the week.
4
During that time, and in the years preceding that,
5
I was heavily engaged in supervising the pilot of
6
the new way of working at the Vale and, in particular,
7
assessing, analysing, checking the figures that we were
8
trying to analyse to see if our system was working.
9
Q.
10
11
Is this the system for assessing whether or not patients
should be admitted or transferred?
A.
Yes.
We had devised a scoring system, and it was really
12
to check that that was robust.
13
that we used to analyse it had to be checked, and
14
sometimes there were some obviously faulty results and
15
some missing results, so I would have to get the case
16
notes out and correct these.
17
time.
18
MR KINROY:
Basically, the results
So that took a lot of
My Lord, I hope it is helpful and I hope I am
19
correct to suggest this may have been called the Lomond
20
care integrated pilot.
21
A.
22
MR MACAULAY:
23
A.
Yes.
24
Q.
The weekends, then, if we just complete this part of
25
Yes, that's right.
That's right.
So you were heavily involved in that project?
the discussion, you were on call, I think, one in six;
158
1
2
is that right?
A.
3
Along with the other consultants?
Again, when holidays were taken out of that, it's one in
four or five, one in five, nearer one in five, yes.
4
Q.
Can you help with that?
5
A.
That would involve coming in on a Saturday and Sunday
6
and going around the ward and seeing what new patients
7
had arrived in and any other patients flagged up to be
8
seen that weekend that caused concern.
9
involve going around the high dependency and
It would also
10
intensive -- the coronary care unit.
11
be seen every receiving ward round by whomever was on
12
call then.
13
Q.
All patients would
The next section of the CV where you have set out the
14
workload, then, was that relevant at the time that we
15
are looking at?
16
A.
Yes.
17
Q.
Can you just elaborate upon that for us?
18
A.
Because of my specialty, I got an awful lot of referrals
19
per week; 35 to 40 is what was my norm.
20
possible to see all of these as outpatients.
21
have required about four or five clinics to do that.
22
So, as most involved the likelihood of some form of
23
endoscopic examination, I would bring them up directly
24
to the endoscopy suite for either an upper or lower
25
endoscopy and, when I saw the patient, I would take
159
It was not
It would
1
a history and decide what other investigations,
2
et cetera, were required and discuss the findings with
3
the patient afterwards, of course.
4
Q.
If we then move on to page 3 of the CV, as you have
5
already mentioned, you chaired the hospital clinical
6
governance meeting, and you also tell us there that you
7
were in charge of organising the consultant oncall rota;
8
is that correct?
9
A.
That's right.
10
Q.
Then the Lomond integrated care project, that, you say,
11
12
was set up in 2004; is that right?
A.
13
14
Yes.
We started around about the end of -- towards the
end of 2004.
Q.
As you indicate here, you played a central role in
15
coordinating the team involved in the protocols that
16
were designed?
17
A.
Yes.
18
Q.
As far as research interests are concerned, I think you
19
give us some insight into that in the next section, and
20
you also, at least when this was prepared, had some
21
ongoing research activity; is that correct?
22
A.
With regard the pilot, you mean?
23
Q.
I'm just looking at your CV here.
24
A.
Right.
25
I see, right, I'm with you.
Sorry.
Yes,
basically, the initial tools that were devised I was
160
1
responsible for and, when the pilot was set up, we
2
gathered a prospective group of patients in whom we were
3
able to look at these tools again and see whether they
4
could be improved, but, basically, using more
5
sophisticated statistical methods that were not
6
available when I first did the assessment.
7
with the help of the Robertson Institute of
8
Biostatistics at Glasgow University.
9
Q.
10
11
That was
If you turn to page 4, can you give some information
about the Lomond integrated care project?
A.
This was set up really under the auspices of the Argyll
12
and Clyde Health Board, as it was then.
13
a steering group made up of general practitioners,
14
physicians, anaesthetists, managers, local authority and
15
the public representation, and this met, I think, once
16
every few months, as far as I can remember.
17
There was
Beneath that, there was the actual Lomond integrated
18
care implementation group, which was a fairly
19
broad-based group as well, that just kept a kind of
20
monthly eye on things as they were happening.
21
My recollection was that, below that, there was
22
a protocols group initially.
23
decided what kind of protocols were needed for
24
clinical -- for individual clinical decisions, and then,
25
of course, there was the issues group, which was set up
161
That really sort of
1
once the pilot started to look at things as they were
2
happening and making sure that things happened as they
3
should have done and, if not, then trying to correct
4
these things.
5
Q.
Then moving on, finally, to the section headed
6
"Publications", you indicate that you contributed
7
a chapter in a book in connection with that on diabetes;
8
is that correct?
9
A.
Yes, it was really dealing with the possibility of
10
essential fatty acids being used to treat or prevent
11
a neuropathy in diabetes.
12
Q.
Then finally, on pages 5 and 6 you set out some
13
information about the contributions you have made to
14
papers and articles.
15
A.
Yes.
16
DAME ELISH:
My Lord, just to draw my learned friend's
17
attention that Dr Carmichael has also provided to us
18
very recently a copy of an article that he wrote along
19
with others, including Dr McCruden, in the Scottish
20
Medical Journal on the Lomond initiative, and it may be
21
of some assistance to my learned friend.
22
included in the list.
23
MR MACAULAY:
24
25
I think that is a very recent article that has
been published.
A.
It is not
Yes.
162
1
Q.
What is it?
2
A.
It basically was describing how we came by the triaging
3
tools and how we improved them by the use of the pilot
4
data and the -- as I say, the statistical input, and we
5
compared them with, I think, seven or eight other
6
triaging tools that had been produced over the -- more
7
or less the same timeframe, the last ten-plus years, or
8
thereabouts, and -- well, in our view, our tools stood
9
up very well against these other ones.
10
Q.
That initiative involved the inclusion of GPs?
11
A.
The integrated bit basically means that.
It is
12
integrating primary and secondary care, the idea being
13
it wasn't just -- I should backtrack.
14
The reason for setting this up in the first place
15
was that, as you know, probably, when acute surgery left
16
in -- well, I think it was 2004 it did leave, A&E left
17
with it, because they felt they couldn't stay without
18
acute surgery on site.
19
went with that too.
20
obstetrics had moved away and so we were becoming
21
a stand-alone medicine.
22
Basically, most of anaesthetics
I think by that stage also
The impression we were given at the time was,
23
really, we would have gone as well, had there been room
24
for us at the inn, but there was no room at the inn, ie,
25
at RAH, so the health board asked if it was possible for
163
1
us to maintain acute medicine at the Vale pending a more
2
long-term decision.
3
Q.
Just to be clear, you say there that you would have
4
gone, in the sense that you and your consultant
5
colleagues would have left?
6
A.
We assumed acute medicine would follow the others, yes,
7
because, as anaesthetics were saying by that stage, it
8
was -- anaesthetics were unsustainable.
9
keep some form of acute cover for acute medicine,
They had had to
10
anaesthetic cover, so they could deal with resuscitation
11
requirements.
12
locum anaesthetists to just simply cover the acute
13
medicine, and obviously the workload for that was not
14
particularly high, so it was seen as unsustainable from
15
an economic point of view.
16
That was supplied, in fact, by employing
The plan had been that, if we could come up with
17
a way of managing medicine without onsite anaesthetic
18
cover, that was what we were being asked to do, and that
19
is what the pilot was really set up to try and check, to
20
see if it was safe to do so.
21
opposition to it, a lot of concern, including ourselves,
22
I must say.
23
well, but we tried to produce as robust a solution to
24
the problem as we could.
25
There was a lot of
We had our own concerns about doing it as
That involved, as I said earlier, the production of
164
1
these scoring tools, which we -- the plan was to use
2
them in the ambulance, first of all, a simple one in the
3
ambulance that would help divert patients away from the
4
Vale who were felt to be too unstable and, on arrival at
5
the Vale, a further, more sophisticated one that
6
involved arterial gases as well.
7
at the front door, to divert patients to Paisley or, if
8
patients went off in the ward, to apply the same and get
9
them out.
10
That would allow us,
These worked up to a point but you can never be
11
100 per cent certain that you have picked up everybody
12
in a specialty like acute medicine.
13
quickly.
14
then decide, in the absence -- once anaesthetics were
15
removed, what else had to be put in place.
16
decision was that there was a whole range of --
17
a tranche of conditions that it was felt untenable to
18
look after at the Vale in that situation, and that these
19
would all be diverted to Paisley as well as using these
20
triaging tools on the other patients that arrived at the
21
Vale.
22
Things happen very
So sometimes patients do go off and we had to
The final
That is really what has happened since then.
23
I think after I retired -- I think -- was it
24
September 2010? -- the plan was implemented, and so now
25
acute medicine at the Vale, as far as I'm aware -165
1
I don't have direct information of this, but as far as
2
I'm aware, they are admitting roughly two-thirds of what
3
we used to admit, and the other one-third are going
4
direct to Paisley, and the Paisley physicians are
5
looking after these patients in the Vale and the general
6
practitioners -- that is what you asked me earlier, and
7
my apologies for this rather long explanation.
8
The other part of this problem was the Vale was seen
9
to be too small to increase the number of juniors to
10
cover the out of hours and the only solution to this was
11
to involve the general practitioners.
12
occupied the primary care emergency centre just next
13
door to our medical assessment unit, so it seemed a very
14
practical solution to involve them in the out-of-hours
15
cover, and that is exactly what's happened.
16
They already
There was a long programme of upscaling the GPs so
17
they could cope with the pressures of acute medicine and
18
that was led by Dr Nick Dunn particularly, one of
19
the GPs in the Vale, and as far as I'm aware that's been
20
very successful.
21
general practicers are helping out; the juniors at the
22
Vale now are, in fact, GP trainees as opposed to
23
physician trainees, and the system appears to be working
24
as far as I can gather.
25
Q.
So that's how things are working: the
Did you say you retired in 2010?
166
1
A.
2010, yes.
2
Q.
Can you tell us the month?
3
A.
I think I retired in May.
4
Q.
So when you retired in May, how many consultants were
5
6
still -A.
There were still six posts there, and these six posts
7
were -- well, the six posts included two care of
8
the elderly, of course, Dr Johnston and the locum one
9
Dr Akhter was filling.
These four physician posts,
10
that's the other four physician posts, were transferred
11
to Paisley, and I think Paisley got also an extra six
12
posts funded from Edinburgh to run this expanded set up.
13
Q.
In the Royal Alexandra Hospital?
14
A.
In the Royal Alexandra Hospital, yes.
15
DAME ELISH:
On that particular point, I wonder if
16
Dr Carmichael and my learned friend could clarify, when
17
he said they got an additional six consultant posts at
18
the RAH, was that to deal with the sum total of the
19
patients which had been transferred from the Vale?
20
A.
It was a combination of that plus a longstanding feeling
21
in the RAH that they were undersupplied by consultants.
22
I think this was the deal that was done for them to take
23
on the Vale, basically.
24
25
MR MACAULAY:
Do you know, then, what the up-to-date
position is in the Vale of Leven in relation to medical
167
1
2
staff?
A.
The physicians -- as I say, there's a physician of
3
the week goes to the Vale and looks -- does the ward
4
rounds from 9.00 till 6.00, or whatever it is, looks
5
after the patients then.
6
junior doctors who are obviously there.
7
trainees who are doing -- part of their training is
8
acute medicine, so they are under the auspices of the
9
general practitioner -- general practice training.
After that, there is the
They are GP
The
10
overnight out of hours is the general practitioners in
11
the primary care centre who I think do the bulk of
12
the cover, but I'm now straying into areas that I'm not
13
quite sure how they are run now.
14
how it is supposed to happen, yes.
15
LORD MACLEAN:
16
A.
But that is roughly
So what has it become since you left?
It has become something that's not been tried anywhere
17
else before.
18
does not have out-of-hours anaesthetic cover.
19
just a community hospital which is usually run by GPs in
20
rural areas and which looks after roughly 20,
21
25 per cent of what would end up in acute medical wards.
22
It looks after three times that.
23
It is a hospital that is not requiring or
It is not
So it is looking after a group of patients that it
24
is felt to be reasonably safe to look after in that
25
environment, but, as I say, as far as I'm aware, it's
168
1
not been tried anywhere else.
2
it is an ongoing experiment.
3
MR MACAULAY:
4
A.
So as far as I'm aware,
It is unique?
It is fairly unique, as far as I'm aware.
There are
5
some who might have come up with another example, but
6
I am not aware of it.
7
LORD MACLEAN:
8
A.
9
There are some consultants left?
The consultants are based in Paisley, yes.
They come
and do ward rounds seven days a week.
10
LORD MACLEAN:
11
A.
12
MR MACAULAY:
13
DAME ELISH:
They come from Paisley?
They come from Paisley.
Is there -My Lord, on that particular point, it may be
14
obvious from what the doctor has said -- I apologise if
15
it is obtuse, but just for confirmation -- would it be
16
the case, then, that the profiling nature of
17
the patients at the time of the focus period of this
18
Inquiry was significantly different from the population
19
thereafter?
20
A.
Yes.
What we were doing then was as happens in normal
21
acute medical units: we had anaesthetic cover and we had
22
the full tranche of consultants at the Vale, based at
23
the Vale.
24
course, the consultants were based at the Vale.
25
an acute medical unit, as normal.
So during the time we are talking of, of
169
It was
1
DAME ELISH:
Further to that point, would it therefore be
2
the case that, if there was a comparison of the rates of
3
antibiotic prescription during the period and following
4
the period, as well as C. difficile infection, you would
5
not be considering like with like, in the context of
6
the Vale of Leven population?
7
A.
Before and after?
Obviously, things changed come
8
June 2008, and, yes, prescribing changed -- I think,
9
quite honestly, it changed throughout Scotland, not just
10
in the Vale.
11
happening elsewhere.
12
13
I think the Vale was the catalyst for it
So it did change, yes.
MR MACAULAY:
Just to be clear, then, as you understand the
14
position today, there are no consultants based in the
15
Vale of Leven?
16
17
18
A.
No acute physicians based at the Vale of Leven.
I think
care of the elderly still takes place there, yes.
MR MACAULAY:
I now want to move into some other areas with
19
you, Dr Carmichael, and it may be, my Lord, this is an
20
appropriate point to adjourn for the day.
21
LORD MACLEAN:
22
MR MACAULAY:
23
LORD MACLEAN:
24
MR MACAULAY:
25
You don't want to press ahead?
I can press ahead.
I think you should.
I will do that.
Can I just get a picture from you, Dr Carmichael, of
170
1
the state of the Vale in 2007/2008, before June 2008?
2
A.
In terms of its physical nature or --
3
Q.
Physical and facilities, in particular.
4
A.
Well, obviously I have described we were stand-alone
5
medicine, so we did not have the kind of setup that
6
other more fortunate medical units have, of having
7
close-by acute surgery, A&E and all the other services
8
that help one function safely.
9
Apart from that, in terms of the physical nature of
10
the building, there had been an assessment many years
11
before that that had looked at the fabric of all the
12
hospitals in Argyll and Clyde and had passed judgment on
13
various parts of the Vale as being poor.
14
My recollection is that I think the care of
15
the elderly building was thought to be irredeemable and
16
at some point should be written off, I think, and also
17
the acute wards, the medical and surgical wards, as they
18
were then, there were concerns about the need to upgrade
19
them.
20
things, like toilets and sinks, for example, and I think
21
bed spacing was mentioned, but I'm not 100 per cent sure
22
about that.
23
raised then, yes.
They were deficient in various areas, various
I think infection control issues were
24
Q.
What about wash-hand basins?
25
A.
Wash-hand basins, yes.
There was a deficiency.
171
There
1
2
was seen to be a deficiency such as that, yes.
Q.
Had concerns been expressed, for example, by yourself in
3
connection with the facilities and wash-hand basins in
4
particular?
5
A.
I think in the wards we were concerned and had expressed
6
concerns over the years, and occasionally I think the
7
odd extra sink was put in.
8
perspective of infection control, we didn't feel that we
9
had enough facilities to look after such patients,
10
certainly not in any significant numbers, anyway.
But I think from the
11
Q.
To whom had concerns been expressed?
12
A.
Oh, gosh!
I think local management back then and,
13
through that process, up into what was then the Argyll
14
and Clyde management tiers, I would imagine.
15
they were aware of issues, yes.
16
I think
But because the Vale was -- after acute surgery,
17
particularly, left and the uncertainty as to what the
18
future held for the Vale, I think there was, I suppose,
19
not surprisingly, a degree of unwillingness to pour too
20
much money into the Vale.
21
Q.
Post June 2008, then, did the position change?
22
A.
Oh, yes, incredibly so.
Yes, we ended up with an
23
extremely smart-looking ward, much smaller, but much
24
more space in between beds and with much better
25
facilities.
172
1
One of the reasons for not going down the road of
2
doing that earlier I think had been the feeling that to
3
run the resulting wards, which would be much reduced in
4
the number of beds, would be, from a nursing
5
perspective, relatively inefficient, so that was one of
6
the drawbacks of Argyll and Clyde grasping that
7
particular nettle, that they would end up having more
8
expensive wards to run at the Vale.
9
Q.
You have told us, I think, Dr Carmichael, that you have
10
been in the Vale of Leven since 1979 as a consultant; is
11
that correct?
12
A.
That's right.
13
Q.
In the relevant period that we are interested in, the
14
period January 2007 through June 2008, did you have
15
a line manager?
16
A.
Right.
Well, certainly, as I'm sure you've heard,
17
Douglas McCruden was our lead clinician for a number of
18
years, until that post I think was taken away, and above
19
him it would have been our CD, who I think during that
20
time was Graham Curry, in Inverclyde.
21
Q.
22
23
What was the setup?
Did you look upon Dr McCruden as
a line manager?
A.
Yes.
We would go through Douglas.
24
as the site lead clinician.
25
our link to further up the chain.
173
Douglas was acting
He would be the one that -Having said which, of
1
course, in my role with the integrated care and the
2
issues group, I was frequently meeting the non-medical
3
and sometimes medical managers in terms of how that was
4
working.
5
contact.
6
Q.
7
8
Did you, yourself, receive appraisals in that particular
period?
A.
9
10
So I did have contact with them, direct
Douglas did the appraising for all of us over that time,
yes.
Q.
11
Were you, yourself, responsible for conducting any
appraisals of staff?
12
A.
No.
13
Q.
I think I'm right in thinking, Dr Carmichael, that you
14
had been a member of the Vale of Leven infection control
15
committee in the past?
16
A.
That's right.
17
Q.
I take that from your statement, where you indicate --
18
this is in paragraph 2 -- that you were on the infection
19
control committee until 2003?
20
A.
21
I think that's about right, from my recollection,
anyway.
22
Q.
How active a committee was that at that time?
23
A.
It was -- yes, it was a very active committee, and I'm
24
thinking of it before Stephanie Dancer left.
25
Stephanie Dancer, as you presumably know, was our
174
1
microbiologist until 2002, when she moved to the
2
Scottish Surveillance for Infection Control in Glasgow,
3
SCIEH, I think it was called, and unfortunately couldn't
4
be replaced.
5
of why we're sitting here, I expect, that we didn't have
6
a replacement for her.
7
I think that was one of the first factors
When she was active -- when she was at the Vale and
8
obviously she took part in the infection control
9
committee -- she didn't chair it, I think it was
10
Lesley Murray, our pathologist that chaired it, but
11
Stephanie was really the person that provided, if you
12
like, the active involvement in infection control.
13
She was evangelical in terms of cleanliness and
14
avoiding hospital -- healthcare-acquired infections.
15
MRSA was the big thing back then.
16
managed to keep us either the lowest or certainly one of
17
the few lowest levels of MRSA in the country.
18
was not on the horizon then.
19
come through when she left.
I think Stephanie
C. diff
It was just starting to
20
Q.
She was a resident microbiologist based in the Vale?
21
A.
She was based in the Vale.
22
Q.
And not replaced?
23
A.
And not replaced.
24
DAME ELISH:
25
My Lord, on that particular point, my learned
friend elicited from this witness the fact that
175
1
Dr Dancer couldn't be, I think, replaced was the
2
phrased, couldn't be replaced.
3
be an explanation of why she couldn't be replaced and
4
how that position came about?
5
A.
I wonder if there could
Maybe others could answer it more accurately.
My
6
impression was that they tried to replace her but
7
couldn't get any interest in the post.
8
long and how hard they tried, but I think the end result
9
was that she was replaced by somebody based in Paisley.
I don't know how
10
That's my reading of it.
11
actual -- the post wasn't lost to Argyll and Clyde, as
12
far as I'm aware, it was just no longer at the Vale.
13
LORD MACLEAN:
14
right?
15
A.
16
17
So we didn't lose the
Well, you couldn't fill it there; is that
I think that might have been the case, but that's my
recollection, rather than a definite fact.
MR MACAULAY:
You were on the infection control committee,
18
then, at a time when Dr Dancer was on the same
19
committee; is that correct?
20
A.
Yes, and she left and then I stayed on it for another
21
year and I think there was some change in it then.
22
I could no longer -- I wasn't able to keep going to it.
23
I'm not sure if Douglas McCruden took over for a short
24
time.
25
Q.
I'm not clear about that.
Do you know what happened to that particular committee?
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1
A.
I think eventually -- Lesley retired and I think --
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Lesley Murray, the pathologist, the chairperson,
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retired, and I think around about that time the
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infection control committee was subsumed into the Clyde
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health control committee.
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recollection.
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That is my vague
My impression was it disappeared from the Vale.
It
was no longer sited at the Vale at that time, anyway.
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LORD MACLEAN:
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MR MACAULAY:
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LORD MACLEAN:
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(4.20 pm)
Do you want to stop there?
Yes, that is an appropriate point, my Lord.
Tomorrow morning, 10 o'clock, please.
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(The hearing was adjourned until
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Wednesday, 1 February 2012 at 10.00 am)
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I N D E X
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DR GORDON WILLIAM HERD (affirmed) ....................1
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5
Examination by MR MACAULAY ....................1
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DR HUGH CARMICHAEL (affirmed) ......................153
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Examination by MR MACAULAY ..................153
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178