1
Monday, 12 September 2011
2
(10.00 am)
3
LORD MACLEAN:
Something has been brought to my attention
4
about which I wish now to make a statement.
5
may yet give evidence have received letters from the
6
board which set out the position of the board in
7
relation to certain matters.
8
2 September.
9
of nurses:
10
Nurses who
That letter is dated
It says this, and this is sent to a series
"You will recall that I wrote to you on 31 March,
11
24 May and 20 June 2011 about the public Inquiry looking
12
at the incidence of C. difficile at the Vale of Leven
13
Hospital between January 2007 and June 2008.
14
also recall that conflict of interest issues have
15
prevented the NHS Board from giving individual members
16
of staff advice on how to prepare to give evidence to
17
the Inquiry.
18
You will
That remains the position.
"The NHS Board, as ever, is greatly concerned to
19
secure fair treatment for its employees.
It has come to
20
the attention of the NHS Board that some staff members
21
may not realise that they may be criticised publicly in
22
the Inquiry's report.
23
has expressly declined to rule out the possibility that
24
any nurse may be criticised in this way.
25
regardless of the nurse's grade and even if the nurse is
Senior Counsel for the Inquiry
1
This applies
1
not represented by a lawyer when giving evidence to the
2
Inquiry.
3
"In particular, nurses may be asked questions to see
4
whether or not they complied with the NMC code of
5
conduct and the NMC guidance on record keeping.
6
"If you have not realised this before, you may wish
7
to take this into account when deciding whether to
8
consult a solicitor to get your own individual legal
9
advice about giving evidence to the Inquiry.
The
10
Inquiry has the power to pay for such advice and may do
11
so if you apply to it for that.
12
"If you decide to consult a solicitor or the Royal
13
College of Nursing about this, you should do so urgently
14
and you should also notify the Inquiry urgently that you
15
are doing so."
16
17
The letter is signed by the chief executive of
the board, Robert Calderwood.
18
One nurse who had given evidence received this
19
letter and she couldn't understand why she had received
20
it.
21
receipt of the letters.
22
witness liaison officer, has been beset with enquiries.
23
It would appear that several nurses received their
24
letters before the Inquiry received their copy, seven
25
days after the first letter was sent out.
The others have been confused and anxious on
As a result, Lynne Allan, our
2
1
It should be understood that, following upon the
2
board's decision, very belatedly reached, not to
3
represent any of their employees, the Inquiry itself
4
liaised immediately with the Royal College of Nursing.
5
I received a full report from Mr Dickson of
6
Anderson Strathern, representing the Royal College of
7
Nursing, about the steps taken to inform the nurses
8
fully about their position, both as to the form of
9
examination they would have to undergo and the need to
10
11
seek legal representation.
As I understand it, all the nurses who received the
12
board's recent letter have received the induction course
13
provided by Anderson Strathern on behalf of the Royal
14
College of Nursing.
15
It can never be said in an Inquiry like this that
16
a witness will not be blamed or criticised, because that
17
depends on how the evidence turns out.
18
is that it is highly unlikely that anyone will be blamed
19
or criticised personally who has not received a written
20
warning of that in advance from the Inquiry.
21
What I can say
Might I suggest, Mr Kinroy, that if you have any
22
doubt about anything, you should seek clarification of
23
that informally from Mr MacAulay, Senior Counsel to the
24
Inquiry.
25
Mrs Searle's experience exemplifies that.
3
When she
1
came to give evidence, you objected on the ground,
2
I think, that she might not have had the proper advice.
3
Actually, she had.
4
give evidence, but she had been very anxious in the
5
interim, in light of what you had to say.
Forty minutes later, she returned to
6
I immediately took steps to ensure that all the
7
nurses who have been cited to give evidence did receive
8
the induction course, as I have called it, from the
9
Royal College of Nursing.
10
Of course, Mrs Searle, who gave evidence,
11
subsequently received the letter; couldn't understand
12
why.
13
involved in adversarial proceedings, with parties in
14
standoff positions.
15
confer.
It must always be remembered that we are not here
What I urge you, Mr Kinroy, is to
Confer.
16
You see, if you take Mrs Searle's case as an
17
illustration, you will recall you didn't mention that
18
you were going to make this objection to anyone, and it
19
caught Counsel to the Inquiry off balance, actually.
20
But if you had mentioned it to him in advance, you could
21
have discussed it, and it might not have been necessary
22
to lose the time we did.
23
I suggest that if you had conferred in relation to
24
this letter and what it is said Senior Counsel had said
25
on a previous occasion, it would not have been necessary
4
1
for the board to write their letter and I wouldn't have
2
had to address the subject as I do today.
3
I have to say also that I remain critical of
4
the board's decision not to represent any of their
5
employees, but I will not stop you, Mr Kinroy, from
6
making interventions as the evidence is led.
7
thing, it keeps me on my toes.
8
9
For one
Can you please, however, show some discrimination in
judgment?
We had, in the case of the last witness, the
10
farcical position of your making an objection when it
11
should have come from the person sitting beside you, who
12
was engaged by the Inquiry to represent her.
13
that doesn't happen again.
14
an objective bystander that the board is having its cake
15
and eating it.
16
objections, why should the Inquiry go to the bother and
17
expense of providing separate representation?
18
Otherwise, it will appear to
If the board is to continue to make such
Now, that is a question of balance for you to decide
19
on in any situation.
20
stop you from making objections.
21
As I have said, I am not going to
Do you have anything you wish to say?
22
MR KINROY:
23
LORD MACLEAN:
24
MR MACAULAY:
25
I hope
No, my Lord.
Very well.
Next witness?
My Lord, the next witness I would like to call
is Mrs Janine Hart.
5
1
MRS JANINE MARGARET HART (sworn)
2
Examination by MR MACAULAY
3
MR MACAULAY:
4
Good morning, Mrs Hart.
Are you
Janine Margaret Hart?
5
A.
Yes, I am.
6
Q.
What position do you hold at present?
7
A.
I am the deputy ward manager in ward 15 at the
8
Vale of Leven Hospital.
9
Q.
For how long have you held that particular post?
10
A.
Approximately six years.
11
Q.
Can you tell me when you qualified as a registered
12
nurse?
13
A.
1984.
14
Q.
What did you do thereafter?
15
A.
After I qualified, I moved to Scotland and I worked in
16
private nursing homes until the year 2000, when I was
17
employed with the Vale of Leven Hospital.
18
Q.
19
When you went to work in the Vale of Leven Hospital,
what grade were you at that time?
20
A.
It is what is now a 5, a band 5.
21
Q.
Did you work in a particular ward at that time?
22
A.
I went to ward 16.
23
Q.
I think you have said you worked in ward 15 for some six
24
25
years or so; is that correct?
A.
No, actually, eight.
6
1
Q.
Eight years?
2
A.
Yes.
3
4
I joined them as a band 5 and then became what is
a deputy for six years now.
Q.
I propose to put a job description on the screen to see
5
whether or not this would fit in with your job
6
description.
7
best of copies, as you can see, but you will see the job
8
title is "Deputy ward manager", the department is
9
assessment and rehabilitation and it is
If you look at GGC13110001.
10
dated December 2004.
11
description or not?
Is this the same as your job
12
A.
It is very difficult to read, but --
13
Q.
It is.
14
15
Can I ask you this: do you have a job
description?
A.
16
17
It is not the
I will have, but obviously it has changed since Agenda
For Change came into play.
Q.
18
Did you have a job description during the relevant time,
the relevant time being from January 2007 to June 2008?
19
A.
Yes.
20
Q.
If we just look at this particular document to see
21
whether or not it contains information that would be
22
relevant to you, if you turn to page 2 of the document,
23
again it is not easy to read, but about a third or so
24
away from the top of the page there is a paragraph that
25
reads:
7
1
"Ensure that all written documentation within the
2
ward/department area is clear, concise, timely and
3
complies with NMC standards for records and record
4
keeping."
5
Did you have such a provision in your job
6
7
description at the relevant time?
A.
8
9
10
I couldn't be certain, but if this is, you know, a copy
of what would have been in place, then I would say yes.
Q.
About halfway down that same page --
MR KINROY:
My Lord, I do regret this, but how can it be
11
acceptable for the witness to be questioned on the basis
12
of what was in her job description and we elicit an
13
answer:
14
"Answer:
I couldn't be certain, but if this is, you
15
know, a copy of what would have been in place, then
16
I would say yes."
17
That, in my submission, is worthless.
If it is to
18
be construed as some kind of admission that this was
19
part of the job description, it is wrong.
20
21
MR MACAULAY:
I will explore that a little bit further,
my Lord, if that would assist.
22
LORD MACLEAN:
23
MR MACAULAY:
All right.
The provision we looked at focusing upon the
24
NMC standards for records and record keeping, first of
25
all, I think you know about those standards?
8
1
A.
Yes.
2
Q.
Would these be standards that you would seek to comply
3
with, in any event?
4
A.
Yes.
5
Q.
The next section in the job description that I want to
6
draw your attention to is about halfway down the page
7
where there is a provision which says:
8
"Works within the NMC code of practice and
9
professional guidelines."
10
Would the NMC code of practice and professional
11
guidelines be something you would wish to comply with in
12
any event?
13
A.
Yes, they would.
14
Q.
In relation to the code of practice, I think, if you
15
have been following the Inquiry, you will have seen that
16
other witnesses have been asked some questions about the
17
provisions of the code; is that right?
18
A.
Yes.
19
Q.
Have you been following the Inquiry?
20
A.
I have.
21
Q.
Have you seen transcripts of the evidence of some of
22
the nurses who have already given evidence to the
23
Inquiry?
24
A.
Yes, I have.
25
Q.
You will recognise, I think, that you have a duty of
9
1
care to your patients under the code?
2
A.
Yes, that's correct.
3
Q.
Similarly, in relation to record keeping, you will
4
understand, I think, that record keeping forms an
5
important part of nursing care?
6
A.
Yes.
7
Q.
Would you agree that the code of practice and the code
8
relating to the standards of record keeping, that these
9
are important guidelines for nurses to follow?
10
A.
Yes, important guidelines.
11
Q.
Can I just understand, Mrs Hart, what your duties were
12
13
at the relevant time as the deputy ward sister?
A.
Well, my duties -- obviously, I was part of the team
14
that actually did -- had a group of patients to look
15
after during my shift time.
16
when Sister Madden was on holiday, but that was more to
17
do with managing staffing issues.
18
do with any other of the issues that she took part in,
19
so I would do rotas, manage sickness absence and the
20
day-to-day running of the ward.
21
Q.
I was obviously in place
I had very little to
Just looking, then, to the nature of the ward itself,
22
I think we heard from Sister Madden that, generally, the
23
ward was full of patients; is that right?
24
A.
Yes, that's correct.
25
Q.
The patient profile -- perhaps you can give us your
10
1
description of how you would describe the patient
2
profile of the ward?
3
A.
Obviously, being a rehab and assessment ward, we took in
4
patients from medical and orthopaedic and some surgical,
5
but it was quite a varied group of patients, some of
6
them very mobile, some very immobile.
7
a few patients who suffered with dementia and,
8
therefore, we had to manage the problems that came with
9
patients with dementia; but very, very busy on
We had quite
10
a day-to-day basis, and obviously, when that -- patients
11
with complicated problems, that demanded more of our
12
time.
13
Q.
14
Would you say that the majority of the patients that you
had would be frail, elderly patients?
15
A.
Yes, you could say the majority of them were.
16
Q.
What knowledge did you have at the relevant time of
17
the contents of the infection control manual?
18
A.
I was aware of the infection control manual.
19
Q.
Did you have cause to look at it from time to time?
20
A.
Yes, as a reference.
21
Q.
Can you give me an example as to how you'd look to it
22
23
for a reference?
A.
Well, if there was something that occurred on the ward
24
that we were not familiar with, something that a patient
25
may have that needed to be looked up and give us
11
1
a guideline as to how to treat the patient, whether they
2
required to be isolated or not.
3
Q.
One of the policies that you will have seen that we have
4
looked at in the course of the Inquiry is the loose
5
stools policy.
6
connection with that?
You will have seen some evidence in
7
A.
Yes.
8
Q.
Were you aware of the contents of the loose stool policy
9
at the time that we are interested in, from January 2007
10
to June 2008?
11
A.
I was aware that it was in the infection control manual.
12
Q.
Do you remember if you had ever had any cause to look at
13
it?
14
A.
I don't remember whether I looked at it.
15
Q.
I'm sorry?
16
A.
I don't recall whether I looked at it --
17
Q.
You don't?
18
A.
-- during that time.
19
Q.
What about the C. diff policy that, again, you will have
20
seen referenced in the evidence?
21
you had cause to look at that?
Can you remember if
22
A.
I don't remember having cause to look at it.
23
Q.
In relation to patients with loose stools then, are you
24
able to tell the Inquiry what you saw the practice of
25
the ward to be in relation to isolation of such
12
1
2
patients?
A.
3
4
stools if there were side rooms available.
Q.
5
6
We would always attempt to isolate in the event of loose
Were there occasions when there were no side rooms
available and you did not isolate such patients?
A.
Yes.
During the norovirus outbreak, we did not have
7
enough side rooms to isolate the number of patients who
8
had the symptoms.
9
Q.
What then happened?
10
A.
In that case, then obviously we put in measures to
11
prevent cross-infection, such as the patient having
12
their own commode, using the PPE equipment, the signs on
13
the door and yellow bins -- orange bins in the room and
14
obviously making everyone aware that the patient had
15
symptoms.
16
Q.
At the relevant time, did you consider that patients
17
with loose stools might have been at a greater risk to
18
pressure damage?
19
A.
Everyone that has loose stools is at a risk of pressure
20
damage.
21
with all patients, but particularly with anyone who is
22
incontinent.
23
Q.
24
25
Obviously, good personal hygiene is paramount
In relation to assessing the risk of pressure damage,
were you using the Waterlow tool at that time?
A.
Yes, we were.
13
1
Q.
2
Did you, yourself, personally assess patients using the
Waterlow tool?
3
A.
Yes, I did.
4
Q.
What about nutrition, then, another aspect that might be
5
relevant in particular to C. diff?
Were you engaged in
6
assessing the nutritional status of patients?
7
A.
Yes, I was.
8
Q.
Did you have a tool, a screening tool, to assist you in
9
that operation?
10
A.
Yes, we had an adapted tool.
11
Q.
In relation to pressure management, I think I'm right in
12
saying that you didn't use turning charts in ward 15; is
13
that right?
14
A.
They weren't available to us.
We did sometimes use
15
blank pieces of paper to write down when we turned
16
patients.
17
Q.
18
19
Do you know why turning charts, as a document, weren't
available to you at that time?
A.
20
They just weren't available.
I don't know any reason
why.
21
Q.
Are they available to you now?
22
A.
Yes, they are.
23
Q.
What about the use of pressure mattresses?
24
25
What was
your experience in the use of those?
A.
Well, all the mattresses in the ward do have a degree of
14
1
pressure-relieving application, but there were
2
pressure-relieving mattresses -- they hired air flow,
3
alternating flow mattresses -- available within the
4
directorate, and we were able to hire them whenever we
5
needed them.
6
Q.
If a patient were to be nursed on a special mattress
7
that was seeking to assist with pressure management,
8
would you expect that to be recorded in the nursing
9
records?
10
A.
It should have been, but I believe it was not.
11
Q.
I think we heard from Sister Madden last week -- and
12
I don't propose to go over old ground with you -- that
13
after the event, sometime perhaps later on in 2008, she
14
became aware that things were not being recorded as they
15
should have been.
16
in her transcript?
Do you remember reading that evidence
17
A.
Yes, I do.
18
Q.
What about your position?
Were you aware at the
19
relevant time that matters that should have been
20
recorded in the nursing records were not being recorded?
21
A.
I don't believe I was aware.
22
Q.
Did you become aware then?
23
A.
When Sister Madden brought it to our attention, yes.
24
Q.
What --
25
A.
At some later point.
15
1
Q.
Can you say when that was?
2
A.
No, I can't.
3
Q.
You will have seen that with Sister Madden I took her to
4
a number of individual patients and put a number of
5
propositions to her once we had looked at the records,
6
and you will have seen that, in particular, we looked in
7
some detail at patients such as Mary Broadley,
8
John Boyle, Margaret Gaughan and, to a lesser extent,
9
Elizabeth Rainey.
10
the transcripts?
I think you will have seen that from
11
A.
Yes, I did.
12
Q.
If you just look at these patients in turn, I mean,
13
Mary Broadley was not isolated when she had developed
14
loose stools until the C. diff diagnosis was confirmed,
15
although she had been previously isolated because she
16
had MRSA.
You may remember that from what you read?
17
A.
Yes, I remember she was MRSA positive.
18
Q.
There was no care plan in place for her C. difficile
19
infection?
20
A.
No, I believe there was not.
21
Q.
Can you explain why that might be?
22
A.
No, I can't recall why that would have happened.
23
Q.
Similarly, there was no stool chart for her?
24
A.
No, we didn't have stool chart, at that time, available.
25
Q.
What do you mean by that?
You weren't using the Bristol
16
1
stool chart?
2
A.
No, we were not using the Bristol stool chart.
3
Q.
But if you had a patient with loose stools, particularly
4
if that patient developed C. diff, would it be your
5
expectation that a stool chart would be completed by the
6
nurse caring for the patient?
7
A.
I believe we should have formulated one.
However, we
8
did use a bowel chart and try to document in the
9
narrative, as best we could, about the episodes of bowel
10
11
movements.
Q.
I think Sister Madden's expectation was that there
12
should have been stool charts.
13
far as you can recollect, complete a stool chart for any
14
patient with loose stools?
15
A.
Did you, yourself, so
I remember completing a stool chart, but it was not
16
a pro forma, it was one that we had made up ourselves on
17
a piece of paper.
18
Q.
Indeed.
That sort of document, if you dated the time of
19
the stool and described the stool, would give you an
20
easy history of the patient's stools.
21
purpose of it?
That would be the
22
A.
Yes, it would.
23
Q.
You would be able to assess the progress of whatever
24
25
infection the patient had?
A.
Obviously, if we had put that in place for every
17
1
patient, we would have had a better idea of how the
2
infection was progressing.
3
Q.
We also looked at Mr Boyle, John Boyle, who also wasn't
4
isolated, on the face of it at least, until the C. diff
5
infection was confirmed.
6
whether it really was a matter of practice within the
7
ward not to isolate patients until the C. diff infection
8
was confirmed?
9
A.
Are you able to say, Mrs Hart,
No, I would not, because, obviously, at this time, there
10
was norovirus, which meant there were probably other
11
patients within those isolation rooms.
12
have a confirmation one way or another, you are dealing
13
with several patients with symptoms that you place into
14
isolation as you can.
15
Q.
So until you
Do I take it from that answer, then, if the isolation
16
rooms aren't available, then you really have to take
17
other steps to see what you can do?
18
A.
Yes, exactly.
19
Q.
Also, in relation to Mr Boyle, there was no care plan in
20
place for C. diff?
21
A.
No, but there should have been.
22
Q.
Similarly, there was no stool chart for him?
23
A.
Yes, I accept that.
24
Q.
Margaret Gaughan was one of the other patients we looked
25
at.
Again, she wasn't isolated until C. diff was
18
1
confirmed.
Also, there was no care plan for her.
Can
2
you explain -- this is the third patient we have been
3
looking at with C. diff.
4
of these patients, there was no care plan put in place
5
for C. diff?
Can you explain why, in each
6
A.
No, I can't.
7
Q.
Again, I don't think there was a stool chart either.
8
Might it be said that the lack of care planning for
9
patients with C. diff was simply a practice that was
10
being adopted in ward 15 at the relevant time?
11
A.
No, I would not agree with that.
12
Q.
The other patient that we touched upon last week was
13
Elizabeth Rainey.
Again, she wasn't isolated until the
14
C. diff was confirmed, but furthermore, there was no
15
care plan for C. diff in her case either.
16
have four patients out of a handful, in fact, who were
17
positive for C. diff in ward 15.
So there you
18
Can I put it to you again that, might it be the case
19
that, at the time, it just simply wasn't the practice to
20
put in place care plans for C. diff?
21
A.
No, that isn't the case.
I think the heightened
22
activity on the ward may have been partly to blame for
23
the reason that they weren't put in place.
24
Q.
What do you mean by that?
25
A.
That we were busy dealing with the patients, delivering
19
1
hands-on care at the bedside.
2
deal with the patients.
3
Q.
4
It became a priority to
So, effectively, you are saying, because you were so
busy, the care planning wasn't put in place; is that --
5
A.
Well, that's the explanation I am offering to you.
6
Q.
Can I ask you again, do you, yourself, recollect putting
7
in place a care plan for a patient suffering from
8
C. diff?
9
A.
10
11
I do, but later on within this period.
I believe it was
another patient.
Q.
12
When you say "later on", how much later on are you
talking about?
13
A.
Later on in 2008, after --
14
Q.
After June 2008?
15
A.
I'm trying to recollect, because obviously I'm thinking
16
17
of a specific patient.
Q.
If we look at the chart that sets out the patients who
18
tested positive for C. diff in ward 15, that is
19
INQ02700001, and we will have that on the screen, I have
20
mentioned to you over the last little while
21
Mrs Broadley, and perhaps if you just orientate yourself
22
by looking towards -- to the right of the middle section
23
of the chart.
24
Mrs Broadley with a positive result associated with her
25
name.
You are see there is reference to
There is also reference to Elizabeth Rainey.
20
1
There is reference to John Boyle and there is reference
2
to Margaret Gaughan.
3
discussed with you in relation to whom there was no care
4
plan or, indeed, stool charts put in place.
5
These are the four patients I have
As we move on into the year, we see reference --
6
beyond that, we see reference to a particular patient,
7
Mr Somerville, who tests positive for C. diff on
8
a number of occasions all the way through, really,
9
until -- certainly until November 2008.
10
you have in mind mentioned on the chart?
11
A.
Yes.
12
Q.
Who is the patient?
13
A.
It is Mr Somerville.
14
Q.
Mr Somerville.
Is the patient
He was positive first of all, then, it
15
would appear, in March, and he tested positive on
16
a number of occasions.
17
were involved in the nursing of Mr Somerville?
Do I take it, then, that you
18
A.
Yes, I was.
19
Q.
Is it your recollection that you put in place a care
20
21
plan for C. diff?
A.
22
I believe there was a care plan put in place for C. diff
for Mr Somerville.
23
Q.
By yourself?
24
A.
I'm not sure whether it was myself or whether it was
25
a colleague, actually.
21
1
Q.
Can you tell me whether it was on the first occasion he
2
tested positive or on one of the other occasions that he
3
was positive?
4
A.
I can't recollect without the notes in front of me.
5
Q.
The other issue that arose from the records that
6
I looked at with Sister Madden -- there were a number of
7
issues.
8
charts, on many occasions these weren't adequately
9
completed and, indeed, not in place at all in some cases
10
For example, in relation to fluid balance
when they should have been.
11
Can you explain that to the Inquiry as to why that
12
could have arisen?
13
A.
Which part of that question are you asking me to answer?
14
Q.
Well, I am asking you generally in relation to fluid
15
balance charts.
16
evidence, you will have seen that when I looked through
17
the detail of some of the records with Sister Madden,
18
fluid balance charts were not being adequately
19
completed, or not put in place at all in some cases.
20
A.
If you have been following the
There is -- was a problem with fluid balance charts, and
21
it can still be a problem today, because, obviously,
22
giving patients fluids, we're not always there when they
23
complete the drink, or if the drink is taken properly,
24
and it isn't always charted immediately, so it does
25
cause us some problems in making sure they are
22
1
2
accurately completed.
Q.
So you are saying that, if you are not there, then you
3
don't get information that a drink has been taken; is
4
that --
5
A.
Not in every case, no.
It is sometimes quite difficult,
6
especially if a relative is giving someone a drink.
7
They do not always tell us that they have, so it isn't
8
on the chart.
9
Q.
There does appear to have been a real problem in
10
relation to keeping proper fluid balance charts, looking
11
at ward 15.
12
A.
13
14
Were you aware of that at the time?
I think it is something that had been addressed on more
than one occasion, yes.
Q.
I also, I think, discussed with Sister Madden days when
15
no nursing entries were made on the records, and you
16
will have seen that discussion if you have looked at the
17
transcript.
18
Are you, yourself, able to put forward any
19
explanation as to why there would be days when nursing
20
records would not be made in relation to patients?
21
A.
No, I haven't, unless it was due to the height of
22
activity in the ward, that they just weren't able to go
23
back and complete the documentation.
24
25
Q.
There also appear to have been failures in relation to
pressure management.
Can you explain why that may be?
23
1
A.
Failures in pressure management?
2
Q.
Yes, in relation to managing patients who go on to
3
4
develop pressure damage, not being properly assessed.
A.
Patients are assessed every day by the nurses who look
5
after them.
6
course.
7
Q.
It is something we do as a matter of
I think I also put to Sister Madden some points raised
8
by family members.
For example, it was being suggested
9
that appropriate advice on hand washing was not given.
10
If you were faced with a family member and your patient
11
had C. diff, what advice would you give on hand washing?
12
A.
To use soap and water.
13
Q.
Did you give that advice at the relevant time?
14
A.
I have given that advice, yes.
15
Q.
Would you always anticipate that a notice would be put
16
on the door of a single room that accommodated a patient
17
with C. diff?
18
A.
It was put on the door.
19
Q.
Again, there is a suggestion from one witness that there
20
21
was no notice on a door.
A.
Could that have happened?
It is possible, but in my experience, there was a notice
22
on the door of every patient that I nursed who had an
23
infection.
24
25
Q.
In relation to the laundry of a patient with C. diff,
were you involved in giving advice to any patient -- to
24
1
any family member, rather, in relation to the patient's
2
laundry?
3
A.
4
I'm not sure during this time, but I have given advice
to patients' relatives about laundry, yes.
5
Q.
What advice did you give?
6
A.
At that time, we had alginate bags, which were rather
7
large, and clothing would be placed inside that and then
8
inside a patient clothing bag.
9
that the laundry go in separately into the washing
I would always advise
10
machine on a high temperature, and in some cases
11
I actually advocated that if they were happy to use
12
a pair of Marigold gloves to handle the laundry before
13
it was washed and then wash those.
14
Q.
Would it surprise you that it has been suggested by some
15
family members that no advice on laundry was given in
16
relation to patients who had laundry and who were
17
suffering from C. diff?
18
A.
19
20
It would surprise me and it would disappoint me that
that dialogue did not take place.
Q.
If I could ask you, please, to have in front of you the
21
statement that you have given to the Inquiry, Mrs Hart,
22
and we can have that put on the screen -- you may have
23
a copy in front of you -- WTS00970001.
24
25
In paragraph 3 you discuss the setup with facilities
at the Vale of Leven and you say:
25
1
"During this time period, I felt that externally the
2
Vale of Leven was in a state of disrepair.
Some of
3
the facilities were poor, such as wash-hand basins
4
without elbow taps, shower rooms that needed attention
5
and flooring which was of a poor standard."
6
I think you say:
7
"In my opinion, this was largely due to funding not
8
being provided for refurbishment."
9
Are you there discussing facilities in particular in
10
ward 15?
11
A.
Yes.
12
Q.
What were the problems, then, just looking at shower
13
rooms that needed attention?
14
upon that for us?
15
A.
Can you just elaborate
Well, some of the shower rooms, it was the flooring, the
16
way it sloped.
17
of water when we showered a patient, which would come
18
out and encroach into the room itself.
19
the drainage wasn't really very good at the time.
20
Q.
21
22
It meant that we were getting a flowback
So it meant that
Wash-hand basins without elbow taps; was that something
that you were aware of at the relevant time?
A.
23
Yes, and I believe it had been highlighted on -- at
several times during my period in the Vale of Leven.
24
Q.
Since June 2008, has that been changed?
25
A.
Yes, most definitely.
26
1
Q.
If we turn to page 4 of your statement, you have
2
a section there at paragraph 15 dealing with morale.
3
Can I ask you about that?
4
at the relevant time?
5
A.
How do you think morale was
As I said, we were all uncertain as to the future of
6
the Vale of Leven, but I still don't believe it ever
7
affected how we did our jobs.
8
Q.
The uncertainty was down to what?
9
A.
The threat of closure of the Vale of Leven at that time.
10
Q.
In relation to training for C. diff, prior
11
to January 2007, had you had specific training in
12
relation to C. diff as an infection?
13
A.
Yes, I had.
14
Q.
Was that as part of your general training?
15
A.
No.
I did the Cleanliness Champions in 2006, actually.
16
I believe I gave the wrong date of completion when
17
I gave my statement.
18
Q.
So you completed that course in 2006?
19
A.
Yes, I had.
20
Q.
Part of that included looking at C. diff?
21
A.
Yes, it did.
22
Q.
What about since June 2008?
23
Have you had some further
education in relation to C. diff?
24
A.
Yes.
We have yearly updates.
25
Q.
If we turn to paragraph 21 on page 5, you say there:
27
1
"Whenever I have had a patient where I suspected
2
there may be a risk of infection, I would use my
3
clinical judgment and immediately implement isolation
4
procedures."
5
I think we have had a discussion over that and we
6
have certainly seen a number of C. diff patients who
7
were not isolated until the diagnosis was made.
8
I take it that, really, you qualified this by saying
9
that you would isolate if you were able to do so,
10
Do
I suppose; is that what you are saying, effectively?
11
A.
Yes, exactly.
Yes, that's true.
12
Q.
Your contact with the infection control team, can I just
13
understand that?
14
isolate the patient and then you contact the infection
15
control team, but can you tell me, in practice, how did
16
it work?
17
you suspected may have an infection, what happened in
18
practice in the relevant time?
19
A.
The suggestion here is that you
If you had a patient who had loose stools and
In practice, we would obviously obtain a sample and
20
inform the infection control nurse by telephone, if she
21
wasn't on the ward, and discuss with her the patient,
22
and we would go through any relevant information, such
23
as drug therapy or antibiotic therapy, so that she could
24
risk assess.
25
Q.
Would you then get advice from the infection control
28
1
2
nurse on what to do?
A.
Yes, because, obviously, that would be a part of her
3
risk assessment.
4
isolation rooms at that time, then obviously she would
5
be aware that there would be a patient being nursed in
6
a shared room.
7
Q.
8
If there were other patients in
Then on page 6 of your statement, at paragraph 24, what
you say is:
9
"Stool samples would be obtained if a patient had an
10
unexpected, which is more than one episode, of loose
11
stools.
12
ward 15 from admission to discharge."
We used stool charts for all patients in
13
We have had a discussion about that, Mrs Hart.
14
Certainly in relation to the patients we looked at, who
15
suffered from C. diff, there was no stool chart?
16
A.
I believe I meant bowel chart, not stool chart.
17
Q.
I see.
18
A.
Yes.
19
Q.
If we look at paragraph 28, you say there:
20
So we should qualify that by that?
"We would isolate symptomatic patients immediately
21
as a matter of course and they would be placed in
22
a single room.
23
was not a single room that could be used for isolation
24
purposes."
25
I cannot recall any instance where there
If we just pause there, looking to what you have
29
1
said to me this morning, that is not absolutely correct,
2
is it?
3
A.
No, that would appear so.
4
Q.
I think the explanation you are giving for patients who
5
may have loose stools and are not isolated until the
6
C. diff is confirmed is that there may not have been
7
a room available?
8
A.
Yes.
9
Q.
So to say that you would isolate symptomatic patients
10
immediately as a matter of course and you couldn't
11
recall any instances where there was not a single room,
12
that is overstating the position?
13
A.
Obviously in hindsight, looking back at all the
14
information that was given to me after I made the
15
statement, then obviously that would be correct.
16
Q.
17
paragraph 29.
18
You mention that in
You say:
"I am not aware that at any time in ward 15 patients
19
were cohorted."
20
21
What about cohorting then?
But are you aware of that happening?
A.
Obviously, during the norovirus outbreak, we were aware
22
that some patients were cohorted due to the lack of side
23
rooms, but I think I was thinking of C. diff patients
24
being cohorted together when I answered this question.
25
Q.
And you are not aware of any instance where C. diff
30
1
2
patients were cohorted together?
A.
Not knowingly.
Obviously, you have made me aware that
3
there were patients in four-bedded areas that became
4
C. diff positive and then that we moved into isolation.
5
Q.
I now have some questions, Mrs Hart, that I have been
6
asked to put to you; first of all, on behalf of families
7
and patients.
8
The first question I want to put to you is this: was
9
there anything in the way of ward practice at the
10
relevant time that you were uncomfortable with or
11
considered was less than best nursing practice?
12
A.
13
14
No, I believe that the care given to every patient on
ward 15 was of a very good standard.
Q.
15
Were there any practices that you considered might be
putting a patient's safety at risk?
16
The example I have been given is: practices that
17
increased the risk of cross-infection or potentially
18
compromised the safe and effective treatment of
19
patients.
20
A.
21
22
Every attempt was put in place to reduce the risk of
cross-infection during this period.
Q.
Just looking to the question I have been asked to put to
23
you, were there any practices that you considered might
24
be putting patients' safety at risk?
25
A.
Not that I'm aware of.
31
1
Q.
To what extent do you consider that management above
2
ward level was responsible for the deficiencies which
3
have been identified in the records by the nursing
4
reports?
5
A.
I'm sorry, I think you need to repeat that.
6
Q.
Will I put that to you again?
7
A.
Yes, please.
8
Q.
To what extent do you consider that management above
9
ward level was responsible for the deficiencies which
10
have been identified in the records by the nursing
11
reports?
12
A.
I believe that if we had had a standardised system of
13
paperwork, it may -- well, it would have helped at the
14
time of the incidents.
15
Q.
16
17
Could you elaborate upon that?
What sort of paperwork
do you have in mind?
A.
Well, the whole hospital now has a standard set of
18
paperwork and, as we have seen, the Royal Alexandra had
19
different paperwork at that time, which we probably
20
would have benefited from, if we had had it.
21
Q.
Since the relevant time, for example, have you been
22
supplied with new documentation to assist you to deal
23
with C. difficile?
24
A.
Yes, we have.
25
Q.
Is that helpful?
32
1
A.
It is very helpful now.
2
Q.
Perhaps, then, I can put this question to you that
3
I have been asked to put to you: what, in your view, has
4
been the most significant improvement since June 2008 in
5
relation to the prevention of C. diff infection and the
6
minimisation of the risk of cross-infection?
7
A.
I believe that the prescribing policies that are now in
8
effect have made a very big difference to the outcomes
9
for the patients in the incidence of C. diff.
10
Again, I would say, basically, there is a greater
11
understanding amongst all of the staff in the
12
Vale of Leven about C. difficile infection and its
13
transference and survival.
14
Q.
I have also been asked to put some questions to you on
15
behalf of the families in connection with communication
16
with families.
17
As regard communication with the patient's family,
18
did you see it as part of your function to impart
19
information to the family without waiting to be
20
approached or asked for information?
21
A.
Yes, I did.
22
Q.
As a matter of course, did you?
23
A.
With at least two of these families I remember very good
24
dialogue that I personally had with them throughout
25
their stay with us.
33
1
Q.
2
3
had from a family member?
A.
4
5
Would you personally record any communication that you
I did not record every conversation that I had with
a family member.
Q.
6
Was it a disadvantage that visiting times coincided with
the handover period in the evening?
7
A.
It could be, yes.
8
Q.
In what way?
9
A.
It meant that, obviously, there was less time to spend
10
giving over information with the families.
11
handover had finished, it was basically coming towards
12
the end of visiting hour.
13
Q.
Once the
If family members wanted to see nursing staff at
14
visiting times, would that, in practice, have been
15
difficult?
16
A.
17
18
No, unless, obviously, we were involved in other tasks
with other patients.
Q.
I have also been asked to put some questions to you on
19
behalf of the board.
20
recent years, there has been a reallocation of
21
the duties of doctors and nurses, with nurses taking on
22
some work formerly done by doctors, and on occasions
23
this has resulted in staff taking on responsibilities
24
which they were ill-equipped to do.
25
Can I put this to you: that, in
Do you agree with that proposition?
34
1
A.
I would not have said "ill-equipped to do".
I would
2
have just said that, obviously, the reallocation of
3
duties has added to the nurses' workload.
4
Q.
5
So that meant, what, that you would be busier than you
might otherwise have been; is that --
6
A.
Yes.
7
Q.
But capable of doing the additional work?
8
A.
No nurse should ever carry out anything that she does
9
10
not feel she has adequate training to do.
Q.
Well, it has been suggested that this problem of staff
11
taking on responsibilities which they were ill-equipped
12
to do was a problem in Scotland for a period
13
including January 2007 to June 2008.
14
Did you see that as a problem in your ward in the
15
16
Vale of Leven?
A.
17
18
I don't see it as a particular problem.
As I said
before, it just added to the nurses' workload.
Q.
The Leading Better Care Review, has that made
19
a difference to the way in which the nurses now work on
20
the ward?
21
A.
Yes, it has.
As I said, we now have quite robust
22
auditing taking place, and it takes place on a monthly
23
basis, so that we can identify any areas where we may be
24
lacking and put it right as we see it ongoing.
25
Q.
Who does the auditing, the weekly auditing?
35
1
A.
2
3
Various members of staff are allocated to each one of
the CQIs, which I believe Sister Madden addressed.
Q.
Would you accept that hospitals have sometimes
4
engendered a culture of recording, administration and
5
meeting targets which has taken nurses away from direct
6
or hands-on care of patients?
7
A.
Sorry, I didn't hear the first part.
8
Q.
Would you accept that hospitals have sometimes
9
engendered a culture of recording, administration and
10
meeting targets which has taken nurses away from direct
11
or hands-on care of patients?
12
A.
I believe that, yes, the amount of paperwork that
13
accompanies each patient has impacted on how we divide
14
up care, as in how we prioritise care.
15
obviously -- nurses prefer to -- not "prefer" --
16
prioritise that the patient in front of them is who we
17
should be dealing with and prioritising our time
18
towards.
19
quite time-consuming.
20
Q.
We're
Paperwork is important, and obviously it is
Is there a balance to be struck between nurses spending
21
too much time on documentation and too little on direct
22
or hands-on patient care?
23
A.
There is a balance to be struck, yes.
24
Q.
Would you accept that, in addition to what we see in the
25
notes, there are other things that nurses are required
36
1
to document and record for the purpose of audits, and
2
all of this takes time away from the patient?
3
A.
Yes, it does.
4
Q.
Do you accept that the priority for most nurses is
5
6
direct patient care and not administration?
A.
7
8
It is our priority, but obviously documentation does
evidence what has been put in place and it is important.
Q.
9
Would you agree that it is understandable that a nurse
committed to direct or hands-on care of the patient
10
would make that patient care a priority over completing
11
inessential paperwork?
12
A.
As I have said before, hand-on care is the priority.
13
Q.
Are you aware that the records have been criticised for
14
the absence of documents such as stool charts, fluid
15
balance charts, assessments and care plans, such as
16
falls risk assessments, Waterlow score charts, manual
17
handling assessments and nutrition scoring?
18
Do you accept that much of this information, where
19
20
appropriate, is found in the nursing notes?
A.
I believe that, during the narrative, we do make point
21
on some of these, but the nurse assesses a patient at
22
every intervention, as to whether they are changing --
23
as in whether their Waterlow, whether their pressure
24
areas are more at risk, whether they are at more risk of
25
falling, and obviously it is not always documented
37
1
2
formally in the tools.
Q.
For example, in general, although there may not be
3
a stool chart for a particular patient, the nursing
4
evaluation notes do carefully record the patients'
5
stools; is that correct?
6
A.
7
8
in the evaluation.
Q.
9
10
We make every attempt to make sure that it is recorded
Would you accept that some of the nurses devise their
own paperwork?
A.
I'm not aware of that.
Obviously, I have already
11
intimated that we devised our own stool chart on
12
occasion and a turning chart.
13
Q.
14
But sometimes staff write the details one would find in
a care plan in the narrative notes?
15
A.
On occasion, yes.
16
Q.
Would you accept that there is evidence in some of
17
the notes of goals being set for patients as one would
18
expect in a care plan and that this, too, is often in
19
the narrative contained in the notes?
20
A.
I have found that from time to time.
21
Q.
Would you accept that in some patients' notes there is
22
no form for the assessment of the risk of pressure
23
ulcers, but the actual score is often documented?
24
25
A.
It has been seen that there is documentation of
the score in the narrative, but I don't recall seeing it
38
1
2
that often in ward 15's notes.
Q.
3
Would you accept that there is recording of abdominal
pain or discomfort in the nursing notes?
4
A.
In the narrative, yes.
5
Q.
Would you accept that special mattresses were readily
6
available in ward 15?
7
A.
Yes.
8
Q.
Were they well used?
9
A.
Very much so.
10
Q.
Would you accept that if a patient had a special
11
mattress, it would not necessarily have been recorded in
12
the notes?
13
A.
Yes.
14
Q.
On the basis of the records alone, it has been suggested
15
that Helen O'Neill and Jean Murray attended the wards
16
infrequently.
17
A.
18
19
Was that your own experience?
I often contacted the infection control nurses via
telephone, in my experience.
Q.
The question here that I have been asked to put to you
20
is whether it was your experience that Helen O'Neill and
21
Jean Murray attended the ward on an infrequent basis?
22
A.
23
24
25
I can only -- yes, you would probably be right because,
as I said, most of my contact was via telephone.
Q.
Generally, would you agree that in your evidence, when
you have referred to "isolation", you have meant putting
39
1
the patient in a single room for the purpose of
2
isolating the patient?
3
A.
Yes, that's correct.
4
Q.
If it was not possible to isolate a patient, were other
5
precautions against cross-infection taken?
6
A.
Yes.
7
Q.
If so, what were these?
8
A.
Patients had their own commode, a wash basin of their
9
own, we used PPE whenever we attended to the patient,
10
there was an orange bin placed in the room which also
11
highlighted to everybody else that there was a patient
12
in isolation, and there would still be a sign on the
13
outside of the door, even if they were in a shared
14
accommodation.
15
Q.
So far as you are aware, then, was there ever a case in
16
ward 15 when no precautions against cross-infection were
17
taken in regard to a patient suffering from loose stools
18
or who had tested positive for C. diff?
19
A.
No, I'm not aware of any.
20
Q.
Would you agree that the proper nursing care of
21
a patient who has contracted C. diff infection is not
22
a very specialised skill?
23
A.
Yes, I would agree with that.
24
Q.
But would you agree that proper nursing care of
25
a patient who has contracted C. diff infection is
40
1
time-consuming?
2
A.
I would not agree that it is time-consuming.
3
Q.
But fundamentally, as far as actual nursing care of
4
the patient is concerned, leaving aside medical
5
treatment and infection control issues, the patient
6
should, through the course of the illness, be kept
7
properly hydrated and given proper nutrition?
8
A.
Yes, I would agree.
9
Q.
Is the currency of the illness judged very much by lab
10
tests for C. diff infection and for how long the patient
11
has or has not had loose stools?
12
A.
13
Yes, there are severity markers that are completed by
the medical staff.
14
Q.
Was that the position at the relevant time?
15
A.
I remember them being completed, but I cannot remember
16
17
at what point during this outbreak.
Q.
In regard to stools as a measure of a patient being
18
infectious, the criterion is whether they are loose or
19
not, it is not crucial to gauge degrees of looseness.
20
Would you agree with that?
21
A.
Unfortunately, without a proper guidance tool, it is
22
quite subjective when a nurse assesses the looseness of
23
a stool.
24
25
Q.
That is the problem.
In ward 15, it was possible, was it, for staff to
communicate amongst themselves without reference to the
41
1
written records which patients were suffering from
2
C. diff infection?
3
A.
Yes.
4
Q.
In ward 15 it was possible for staff to know without
5
reference to written records which patients were
6
suffering from C. diff and to know for how long these
7
patients had been suffering from loose stools?
8
A.
Yes.
9
Q.
Was there a general practice at keeping patients
10
suffering from C. diff infection adequately hydrated?
11
A.
Yes, there was.
12
Q.
What was it?
13
A.
Patients had nurses allocated to them who would
14
obviously try to monitor how much fluid they were taking
15
and would report back to the trained nurses.
16
Q.
Are you able to agree whether medical staff can acquire
17
all the information they need about the hydration of
18
a patient suffering from C. diff infection without that
19
necessarily being in the records?
20
A.
Obviously, medical staff would be monitoring blood
21
results, which would give a true picture of how well
22
hydrated a patient is.
23
Q.
Would you agree it is not easy to keep proper fluid
24
balance charts in the case of elderly patients suffering
25
from C. diff infection?
42
1
A.
Yes.
2
Q.
Is that because fluid loss by vomiting and diarrhoea is
3
very difficult to gauge?
4
A.
Exactly.
5
Q.
Information about the state of health and needs of
6
individual patients would be communicated to staff
7
during handovers or by general word of mouth and on the
8
notice board on the ward; is that correct?
9
A.
Sorry?
Notice board?
10
Q.
This is the question I have been asked to put to you:
11
would you agree that information about the state of
12
health and needs of individual patients would be
13
communicated to staff during handovers or by general
14
word of mouth and on the notice board on the ward?
15
A.
It would be in handovers, and during the shift we would
16
update each other on what was happening with that
17
patient.
18
Q.
19
What about the reference to the notice board?
Is that
not part of --
20
A.
No, that does not apply to ward 15.
21
Q.
Would you agree that there may have been good
22
communication between and among the nursing staff and
23
others caring for the patients -- for example, at ward
24
rounds, multidisciplinary team meetings and shift
25
handovers -- without that necessarily being recorded in
43
1
the nursing records?
2
A.
Yes.
3
Q.
Would you accept that in ward 15, where the staff knew
4
the patients, that may have been an effective way of
5
communicating significant issues?
6
A.
It was an effective way of communicating.
7
Q.
Would you agree that, in the case of patients, there may
8
have been liaison with medical staff and other
9
healthcare professionals and relatives which has gone
10
unrecorded?
11
A.
Yes.
12
Q.
If a contingency bed was added to any of the rooms, that
13
only took the room up to the complement of beds it was
14
designed for; is that correct?
15
A.
We never had contingency beds.
16
Q.
I will perhaps just ask you this final question: is it
17
the case that, generally, the cleaning staff did their
18
work outwith visiting hours?
19
A.
Yes, it is.
20
Q.
Mrs Hart, that is all I propose to ask you.
Is there
21
anything you would wish to say in order to assist the
22
Inquiry?
23
A.
I believe that during this period of time we had no less
24
than 241 admissions to ward 15 and were closed on three
25
separate occasions, and I would like to say that I work
44
1
with a highly professional and dedicated team of nurses
2
who did give, and still do give, a good quality and good
3
standard of care to every patient that comes into
4
ward 15.
5
MR MACAULAY:
6
LORD MACLEAN:
Very well.
Thank you very much indeed.
I am aware of what you said right at the
7
start of your evidence, and that was that you covered
8
for Sister Madden at weekends.
9
A.
10
11
It could be any
one of them.
LORD MACLEAN:
12
13
Yes, I worked three days out of seven.
Did you divide up the patients between you so
you took so many and she took so many?
A.
I was part of the ward team, so I always had
14
12 patients.
15
patients unless she was the only second trained on
16
the ward.
17
the week, one of the six, she did not necessarily have
18
a group of patients to look after because obviously she
19
had management areas that she needed to deal with, which
20
took her from the ward, so that meant that she could not
21
be included as part of the team looking after a group of
22
patients.
23
LORD MACLEAN:
24
full?
25
A.
Sister Madden wouldn't have a team of
So it meant that, although she was, during
What was the complement of the ward if it was
Sorry, 24 patients, do you mean?
45
1
LORD MACLEAN:
2
A.
3
LORD MACLEAN:
4
5
Twenty-four?
Yes.
Thank you very much indeed.
You are now free to go.
A.
Thank you.
6
7
(The witness withdrew)
MR MACAULAY:
8
9
That is all.
My Lord, that might be an appropriate point at
which to have a break.
(11.15 am)
10
(A short break)
11
(11.30 am)
12
MR MACAULAY:
13
My Lord, I would like to call next
Sister Gargaro.
14
MS LAURA JANE GARGARO (affirmed)
15
Examination by MR MACAULAY
16
MR MACAULAY:
17
A.
I am, yes.
18
Q.
Is your maiden name Shepherd?
19
A.
Yes.
20
Q.
What position do you hold at the moment, Sister Gargaro?
21
A.
I am a senior charge nurse now in ward 14 at the
22
Are you Laura Jane Gargaro?
Vale of Leven.
23
Q.
For how long have you held that position?
24
A.
Within ward 14, just since February.
25
was in ward F, since 1998.
46
Prior to that, it
1
Q.
Can you tell me when you qualified?
2
A.
I qualified in 1990.
3
Q.
Where did you go to work after you qualified as
4
5
a registered nurse?
A.
From 1990 to 1996, I worked in a private nursing home,
6
and then, 1996, I came to the Vale of Leven as a deputy
7
ward sister and took the post of ward sister in 1998.
8
Q.
Did you work as a deputy in ward F?
9
A.
Yes, I did.
10
Yes, it was actually previously ward 5,
but, yes, I came to ward F as a deputy, yes.
11
Q.
You worked in ward F then from February 1998 to 2011 --
12
A.
Yes.
13
Q.
-- as a ward sister?
14
A.
Yes.
15
Q.
Can I ask you to look at a job description, perhaps with
16
some fear and trepidation, but let's see if you
17
recognise this document at all.
18
INQ01160001.
19
description with the job title being that of ward
20
manager.
If you could look at
This is described as a generic job
I think that was your position?
21
A.
Yes.
22
Q.
Before we just look at the document, in the main, I will
23
be asking you questions that will focus on the period
24
January 2007 to June 2008.
25
evidence, that is usually referred to as "the relevant
47
Do you follow me?
In
1
time"; do you understand that?
2
A.
Yes, sure.
3
Q.
Just looking at this document, then, would this be the
4
job description that would be relevant to you or not?
5
A.
Yes, it would.
6
Q.
Did you actually have a job description that you signed?
7
A.
Yes, I have brought a copy with me.
8
It doesn't have
a signature on it.
9
Q.
It doesn't have a signature?
10
A.
It doesn't -- no, I believe that is just a copy.
11
But
I believe I signed it at the time.
12
Q.
And you kept your own copy?
13
A.
Yes.
14
Q.
Is it then dated November 2004?
15
A.
It is, yes.
16
Q.
Can you tell me, is it really identical to the document
17
that the hospital supplied us with?
18
A.
Yes, it appears to be, on the front page.
19
Q.
Then, if we look at the front page, so far as ward F was
20
concerned, can you just tell me -- and I will look at
21
this in a bit of detail later -- generally what the
22
profile of the patient in ward F was?
23
A.
It was mainly stroke rehabilitation.
The patient would
24
come into the medical ward, be referred up to ward F for
25
an ongoing period of rehabilitation.
48
We also had other
1
neurological conditions, including head injury, and
2
occasionally medical boarders, if there was pressure on
3
the hospital.
4
Q.
It was a mixed ward?
5
A.
It was a mixed ward, yes.
6
Q.
If we look at the job description then for a moment or
7
two, the organisational position, I think we see your
8
post identified just below the directorate manager; is
9
that right?
10
A.
Yes.
11
Q.
Who was the directorate manager, then, that was your
12
supervisor?
13
A.
That would be Liz Rawle, Elizabeth Rawle.
14
Q.
Then, if we look at some aspects of the job description,
15
the first section is headed "Clinical", and we see that
16
a number of issues are raised under that head; for
17
example, the fourth point down suggests that you have to
18
supervise and develop all staff to ensure efficient
19
management of a rapidly changing and developing nursing
20
service.
Did you see that as one of your functions?
21
A.
Yes.
22
Q.
Two beyond that:
23
24
25
"Ensure that all written communication complies with
NMC standards for records and record keeping."
You will have seen, if you have been looking at the
49
1
evidence that other nurses have given, that this is an
2
area that has been looked at.
3
duty at the relevant time to ensure that all written
4
communication did comply with NMC standards for records
5
and record keeping?
6
A.
Yes.
Did you see it as your
Every nurse has a responsibility to ensure that
7
they maintain records of that standard, and it was my
8
responsibility, as supervisor and leader of the area, to
9
ensure that was maintained.
10
Q.
11
entry from the top:
12
"Undertake clinical audit to measure/evaluate
13
efficacy of practice."
14
Just on that topic, did you see that as one of your
15
16
If we turn on to page 2 then of the document, the third
duties at the relevant time?
A.
At the relevant time, if the request was made of myself
17
to complete an audit, I would -- it would be myself that
18
would do that, yes.
19
Q.
Who, then, would require to make the request?
20
A.
Generally, it came down from the head of nursing, via
21
22
your lead nurse or directorate manager.
Q.
So let's just put some names on the labels, then.
So
23
far as the head nurse would be concerned, who would that
24
be at the relevant time?
25
A.
At the relevant time, I'm sure that would be
50
1
Catherine McGillivary.
2
Q.
Then you mentioned also the lead nurse?
3
A.
Elizabeth Rawle.
She had the combined role of lead
4
nurse and clinical services manager.
5
the request if they wanted pressure sore prevalence
6
audits done or record keeping audits.
7
Q.
8
So they would make
Looking to January 2007 to June 2008, was any such
request made of you?
9
A.
I can't remember during that period, sorry.
10
Q.
Can you remember, prior to that period, when you last
11
12
did carry out some form of audit of the record keeping?
A.
As part of my preparation, I have looked back at
13
previous audit that I have kept on the ward, and I could
14
only find back to 2009, so I would be unable to confirm
15
a date during the relevant period or just prior to that.
16
Q.
17
So are you saying that, in 2009, you did carry out some
sort of audit of the records?
18
A.
Yes, yes.
19
Q.
But you have no record of any audit prior to that?
20
A.
No.
21
Q.
Do you have any recollection of any audit prior to that?
22
A.
No, I do recall a peer review of record keeping at some
23
time in 2008, from memory, but I can't say if it was
24
during the relevant period or whether it was
25
after June 2008.
51
1
Q.
We will return to that.
But the next section then is
2
headed "Managerial".
3
items set out under that particular head.
4
fifth-last entry is:
5
You can see there is a number of
The
"Ensure all trained nurses work within NMC code of
6
professional conduct and code of practice."
7
That was to be a daily duty.
Did your see that as
8
your duty as the supervisor within the ward at the
9
relevant time?
10
A.
Yes, I would.
11
Q.
How did you comply with that duty?
12
A.
Through monitoring and observation of your staff's
13
practice to make sure it was maintained within the
14
principles that we all know in the code, and to address
15
any issues that may give you concern.
16
Q.
If you weren't checking on the records, could you still
17
comply with this particular duty to see that the nurses
18
worked within the code of conduct?
19
A.
My interpretation of that, the NMC code of professional
20
conduct, I didn't associate that with the record keeping
21
guidelines specifically, although it forms part of it,
22
but the ethics and the principles of the code, I was
23
able to have an overview of.
24
25
Q.
Although I think there is a section in the code that
does deal with healthcare records, is there not?
52
1
A.
There is a separate guideline certainly from 2002 and
2
a further advice sheet, I think, that came later, in
3
2007.
4
LORD MACLEAN:
5
benefit, that you speak a little more slowly?
6
A.
7
LORD MACLEAN:
8
9
10
Can I just suggest to you, for my own
Sorry, sure.
I think the transcriber is doing a wonderful
job, but it would be easier for her too, actually.
A.
Sure.
LORD MACLEAN:
I know it is not easy to slow down,
11
especially when you have not been in this position
12
before.
13
A.
Of course.
14
LORD MACLEAN:
15
MR MACAULAY:
But just take your time.
Thank you.
The provision of the code I had in mind, if we
16
perhaps put that on the screen for a moment or two, you
17
will find it at INQ01970001.
18
code for 2004, which I think you agree would be the
19
relevant standard at the time?
We are looking here at the
20
A.
Yes.
21
Q.
If we turn to page 6, paragraph 4.4, what we can read is
22
that healthcare records are a tool of communication
23
within the team:
24
25
"You must ensure that the healthcare record for the
patient or client is an accurate account of treatment,
53
1
care planning and delivery.
2
written with the involvement of the patient or client
3
wherever practicable and completed as soon as possible
4
after an event has occurred.
5
evidence of the care planned, the decisions made, the
6
care delivered and the information shared."
7
It should be consecutive,
It should provide clear
I think what I was seeking to explore with you,
8
Sister Gargaro, was how you could comply with the duty
9
in your job description of ensuring that all trained
10
nurses worked within the NMC code if you didn't check
11
nursing records from time to time?
12
A.
I did check nurses' records on a fairly regular basis,
13
when the day allowed me to do so.
14
of my structure and my workload to review care plans.
15
I think I said in my statement a timescale of roughly
16
every fortnight, but that would very much depend on the
17
pressure on the ward at the time and my availability to
18
do so.
19
It was very much part
I think, generally, working on the ward every day
20
with the patients I was able to see an overall standard
21
of the nursing narrative that was written every shift.
22
Q.
Then if you did check, did you see any difficulty with
23
the way in which the records were being kept by the
24
nurses in ward F?
25
A.
Yes.
Sometimes my checking would highlight some
54
1
2
problems that I had to address.
Q.
3
4
Can you give us an indication of what sort of problems
you came across?
A.
Sometimes I would, a few days after admission, discover
5
that a patient hadn't had a care plan initiated.
We
6
were going through a bit of a transition period at that
7
time, because we had just recently moved on to the
8
12-hour shift pattern in July of 2007, and prior to that
9
we worked on a named nurse philosophy, that the nurse
10
receiving the patient that day generated the care plan,
11
took responsibility for that that day and the subsequent
12
team would carry on that work.
13
But, when the 12-hour shifts started, the nurses
14
then only worked three days a week and, if they received
15
a patient on the Wednesday and they didn't manage to
16
complete the care plan, it might be some eight days
17
before they were back on duty again.
18
address how the team worked as a whole, and I -- and
19
find ways of improving that.
20
Q.
21
So I was having to
So if you were to have an eight-day gap, that wouldn't
be particularly helpful --
22
A.
No.
23
Q.
-- from the patient's perspective, from the point of
24
view of assessing the patient, and so on.
25
fair to say?
55
Would that be
1
A.
Yes.
I always made it the named nurse's responsibility
2
to generate the care plan.
3
responsibility to do what they could to maintain that
4
and to give evidence of evaluation.
5
Q.
6
7
It was in every nurse's
Did you have a system, then, in ward F where you did
have a named nurse for each patient?
A.
Yes, we did do that, yes.
Then it became quite obvious
8
over a period of months, once we settled into the
9
12-hour shift pattern, that that wasn't going to be
10
11
effective, so we then developed a team nursing approach.
Q.
12
You may have said this already, but can you tell us,
when did the 12-hour shift pattern came into play?
13
A.
It was July 2007.
14
Q.
Perhaps while we have the code on the screen, so I don't
15
have to go back to it, just go to the first section of
16
it, and this is on page 4.
17
a number of duties and indicates what the purpose of
18
the code is: namely, to set standards for conduct,
19
performance and ethics.
20
the provisions at 1.4 is:
21
The introduction sets out
You will see one of
"You have a duty of care to your patients and
22
clients, who are entitled to receive safe and competent
23
care."
24
25
Do you see that?
A.
Yes.
56
1
Q.
2
Did you understand that to be a fundamental duty on the
part of the nurse?
3
A.
Yes.
4
Q.
If you go back to your job description, then, on page 2,
5
and that is INQ01160002, we are in the section headed
6
"Managerial", and the last provision says:
7
"Communicate directly to directorate manager
8
advising and informing service-related data."
9
Is that with Ms Rawle?
10
A.
Yes, it would be.
11
Q.
Did you have regular communications with Ms Rawle?
12
A.
Yes, I would say so.
13
Q.
Can you give me a feel for how regularly you would meet
14
15
with her and discuss matters concerning the ward?
A.
I would see her every morning at the bed meeting, first
16
thing.
17
occasion to have a further dialogue that day, and she
18
would structure meetings every month within her own
19
directorate and also would attend the larger sister
20
meeting which happened monthly.
21
over a week, I would see her four out of the five days,
22
I would imagine.
23
Q.
She was present at most of those.
We may have
On an average period
Would she have a good -- from your perspective, would
24
she have a good understanding, then, of what was
25
happening on the ward?
57
1
A.
Yes, I would think so.
2
Q.
Perhaps just one further point to pick up out of your
3
job description, if you turn to page 4, there is
4
a section headed "Systems", and one of the provisions
5
relates to care planning.
6
read:
7
If we read across we can
"Manual individualised plan of care and daily
8
evaluation in negotiation with
9
patient/relatives/multidisciplinary team."
10
That is a daily duty.
11
What did you see your duty in relation to the care
12
13
planning of patients to be?
A.
To ensure that there was a care plan in place with
14
evidence of assessment and evaluation.
The ideal
15
template for that was a core care plan that we had
16
devised in the ward to address at least eight of
17
the common problems that we have in stroke, and then
18
further manual individualised care plans that were
19
initiated by the nurse on that team of that day.
20
But predominantly, the evaluation generally you can
21
evidence from the progress notes that we write on every
22
shift.
23
and certainly evidence of intervention.
24
25
Q.
I think you will find much more detail in that
I think you are still going a bit fast in your evidence,
if you can just try to slow down a bit.
58
1
I think when we look at some of the records for
2
ward F, we can see what appear to be pro forma type of
3
care plans?
4
A.
Yes.
5
Q.
So are these the care plans that were devised in
6
ward F --
7
A.
Yes.
8
Q.
-- for different issues?
9
But correct me if I am wrong,
you did not have a pro forma care plan for C. diff; is
10
that right?
11
A.
No, I didn't, no.
12
Q.
So if you are to be planning a plan of care for C. diff,
13
you would require to write up a written plan of care on
14
an individualised basis?
15
A.
Yes.
16
Q.
We can leave your job description, and I want now to
17
look at the floor plan of ward F, if we could have on
18
the screen GGC00760001.
19
us a bird's-eye view of ward F at the relevant time?
Do you recognise this as giving
20
A.
Yes.
21
Q.
Has the ward changed since this time?
22
23
By that I mean
since June 2008.
A.
It had, yes.
It is now no longer open, but
24
since June 2008, we reduced by one bed.
25
to 15.
59
We went from 16
1
Q.
Has the ward now closed as a ward?
2
A.
It has, yes.
3
Q.
When did that happen?
4
A.
February this year.
5
Q.
So that is then when you moved on to your present
6
position?
7
A.
Yes.
8
Q.
If we just get an understanding then of the layout of
9
the ward, if you were a visitor, how would you access
10
11
the ward?
A.
12
13
You would come into the right from the stairwell
numbered 46, I believe.
Q.
I see, yes.
14
the plan.
15
number 45?
We see that to the very far right of
That leads into an area that has got the
16
A.
Yes.
17
Q.
What was that area?
18
A.
That would represent, I believe, just the landing at the
19
20
top of the stairs.
Q.
21
It was quite a big area.
Is it from there, then, that you can get into the body
of the ward itself?
22
A.
Yes.
23
Q.
If we then look at the layout generally, if we move to
24
the left, can we see that there is an area, bottom left,
25
that is number 13, that is designated -- that someone
60
1
has written in handwriting "6-bed"?
2
A.
Yes.
3
Q.
Was that a six-bedded area?
4
A.
It was, yes.
5
Q.
That is 13.
6
Next to it, we have room 11, which is
described as a four-bedded area; is that right?
7
A.
Yes.
8
Q.
Then, if we move up to the left, we can see 15, which
9
would appear to be a stairway; is that correct?
10
A.
Yes, that was a fire escape.
11
Q.
Unfortunately, the room next to that has the black dot
12
13
over the number, but was that room 16?
A.
We didn't refer it as room 16.
That was an estates
14
plan.
15
room, which I think is known as room 16 on the plan,
16
yes.
17
Q.
18
19
But I believe that would represent a three-bedded
Someone has written "3-bed".
Was that then
a three-bedded area?
A.
It was.
On occasion, it would be a four-bedded area as
20
part of the winter contingency planning, but generally,
21
it was a three-bedded area.
22
Q.
23
I think some of the patients we looked at were
accommodated in that room; is that correct?
24
A.
Yes, yes.
25
Q.
We see it is described as if it had a door that would
61
1
open and shut.
2
A.
3
MR PEOPLES:
Was that the position?
It was a sliding door.
My Lord, before we go on, I wonder whether the
4
witness could tell us what the area that is described as
5
three-bedded was -- how it was referred to; was it bed
6
numbers or was it referred to in some other way?
7
A.
8
9
We generally would refer to it as a three-bedded area,
to be honest.
MR MACAULAY:
As a matter of interest, did the rooms, the
10
bays, have a number allocated to them, albeit not the
11
number that we see on the floor plan?
12
A.
From memory, we referred to it as -- we numbered the
13
beds as you walked in to the ward on the left.
The
14
first four-bedded would be beds 1 to 4; the six-bedded
15
would be beds 5 to 10.
16
Q.
Do we start, then, on the four-bedded, room 11?
17
A.
Room 11 would be beds 1 to 4, yeah, beds 5 to 10, 11 to
18
14, because it did used to be a four-bedded area, and
19
then further down to the single rooms were rooms 15, 16
20
and 17.
21
Q.
22
That was my next question for you: these are one-bedded
areas; is that right?
23
A.
Yes.
24
Q.
Let's just look at them.
25
If you take the one that is --
the first one-bedded area to the left, someone has
62
1
written "1-bed" at the top of it.
The black dot is
2
supposed to indicate a sink or a wash-hand basin.
3
there a sink in that?
Was
4
A.
Yes.
5
Q.
Was there a sink in each of the single rooms?
6
A.
There was, yes.
7
Q.
What about toilet facilities?
8
A.
There was toilet facilities in just rooms 16 and 17.
9
10
There was ensuite toilet in there.
Q.
11
So 16 is the three-bedded room we have mentioned
already?
12
A.
Sorry, I'm referring back to bed numbers.
13
Q.
Carry on then.
14
A.
The first single room had a sink with no ensuite toilet,
What room are we in for that?
15
and then the following two rooms had ensuite toilet and
16
wash-hand basin.
17
might be 25, is it?
18
Q.
19
So that would be rooms 23 and -- it
Sorry.
Again, it may not matter, but I think we know where you
are.
20
A.
Yes.
21
Q.
If you wanted to isolate a patient, then, it would be
22
one of the three single rooms that you required to use
23
for that purpose?
24
A.
Yes.
25
Q.
Does the ward continue, as then we move off to the
63
1
right -- if we look, for example, at room 51, if we look
2
towards the bottom towards the right, what was that
3
room, can you tell us?
4
A.
That might be the sitting room.
5
Q.
Another large area is area 42.
6
A.
I wonder if I could actually just rectify something that
What about that?
7
I have said earlier.
8
at the full plan of the floor, which included the
9
endoscopy suite.
10
Q.
11
That is fine.
I think I'm actually now looking
Sorry.
Do I take it, then, that the ward begins
at some point and then we move into the endoscopy suite?
12
A.
Yes.
13
Q.
Where is the dividing line between the endoscopy suite
14
15
and the ward?
A.
I think I have misled you earlier.
The stairwell that
16
is marked 01 in the middle of the floor plan is the
17
entry into ward F.
18
Q.
I see.
19
A.
So everything to the right of that would actually be
20
21
part of the endoscopy suite.
Q.
22
So, so far as ward F is concerned, we are really
focusing then on the left?
23
A.
On the left.
24
Q.
The main ward area then, is that the area we see "04"?
25
A.
Yes, that would be the corridor through the ward, yes.
64
1
Q.
2
Was there a nursing station, then, within the main ward
area?
3
A.
Yes, there was.
4
Q.
Where was that?
5
A.
That was in between the three-bedded area, which was
6
room 16, and the three single rooms.
7
Q.
Was there an office that the nurses could use?
8
A.
There was an office just outside the ward, which I think
9
10
would be room 29 on your plan.
Q.
11
What, then, about room 08 that we see on the plan?
Can
you tell us what that was?
12
A.
That would be the sitting room.
13
Q.
That's a sitting room?
14
A.
Yes.
15
Q.
Can we just put the plan aside for the moment?
Just
16
going back to the issue over record keeping, and I don't
17
propose to dwell on this with you for any period of
18
time, but you will know from the evidence you have seen
19
given by other witnesses that they have been asked
20
questions about the nursing and midwifery code relating
21
to record keeping.
22
A.
Yes.
23
Q.
If I can put that briefly on the screen, it is
24
INQ02090001.
Just to remind you of what has been
25
raised, you will see that the document begins by saying:
65
1
"Record keeping is an integral part of nursing,
2
midwifery and specialist community public health nursing
3
practice", and so on.
4
separate from the process.
In particular, that it is not
Would you agree with that?
5
A.
Yes.
6
Q.
What about the point in the next main paragraph, the
7
last sentence of that paragraph:
8
"Good record keeping is a mark of a skilled and safe
9
practitioner, while careless or incomplete record
10
keeping often highlights wider problems with that
11
individual's practice."
12
13
Does that accord with your own experience?
A.
Not necessarily.
You can have a nurse that will
14
maintain beautiful records but it's not always a true
15
reflection of how she practises.
16
a very hard-working, diligent nurse who works to a very
17
high standard but hasn't quite had the chance to
18
complete records to the full expectation.
19
have to say that I don't always agree with that
20
statement.
21
Q.
Equally, I can have
So I would
I suppose if you had a nurse who, on occasion, because
22
she was too busy, wasn't able to complete a document,
23
would you expect her to go back and do it at
24
a subsequent time?
25
A.
At her first opportunity, yes, I would.
66
1
Q.
2
3
Would it be your expectation that such occasions would
not be too frequent?
A.
You would hope it wouldn't be a significant gap until
4
she got back to doing that.
5
practices are able to be reflected within their daily
6
entry in the narrative notes.
7
LORD MACLEAN:
A lot of the nurses'
Could I ask you this in relation to an answer
8
you have just given?
The "very hard-working, diligent
9
nurse who works to a very high standard but hasn't quite
10
had the chance to complete records to the full
11
expectation", what did you mean by that?
12
A.
She will always complete an entry on her shift detailing
13
what she's done that day, which would include the
14
outcome of assessment and what interventions she's done,
15
but I would also like to see some review of the care
16
plan document --
17
LORD MACLEAN:
18
A.
19
LORD MACLEAN:
20
21
A.
"To the full expectation".
What do you mean
The expectation of myself and the standards that are set
by the record keeping guideline.
LORD MACLEAN:
24
25
-- and also the completion of charts.
by that?
22
23
What --
Would that be in general or would that be on
a particular occasion for other reasons?
A.
That would be in general.
67
1
LORD MACLEAN:
2
MR MACAULAY:
Thank you.
I think what I was exploring with you, if we
3
go back to this particular proposition that talks about
4
good record keeping is a mark of the skilled and safe
5
practitioner, if we just pause there, I take it you
6
agree with that?
7
A.
Yes.
8
Q.
It is the second bit, "careless or incomplete record
9
keeping often highlights wider problems with that
10
individual's practice".
11
that, on occasion, a nurse might be busy or distracted,
12
but would you expect that to happen on a regular basis
13
so that, on a regular basis, records were not being
14
promptly kept?
15
A.
I think you have made the point
No, I wouldn't like to see that done on a regular basis.
16
I can appreciate, during times of peak pressure, which
17
can be prolonged, that documents wouldn't always be
18
completed timeously, but it wouldn't necessarily reflect
19
her practice.
20
actually does with her patient at the bedside.
21
Q.
Her practice I would judge on what she
Would you expect the skilled and safe practitioner, if
22
she had not been able to complete a record, would go and
23
complete the record once the opportunity arose?
24
25
A.
I would like to think that she would, but there are so
many reasons on a day-to-day basis, especially when
68
1
there is a high pressure within the workload that day,
2
that might prevent her from doing that.
3
Q.
Could it be said, Sister Gargaro, that there are certain
4
aspects of record keeping that are more important than
5
others?
6
A.
7
Yes, I would agree that not every document has got the
same significance, no.
8
Q.
Care plans.
Are they important documents?
9
A.
A care plan would give good evidence that a nurse has
10
considered her assessment and planning and intervention,
11
but generally, from the progress notes that she writes
12
every day, would demonstrate her intervention.
13
Q.
I'm not sure if you answered my question, but are you
14
agreeing with me that the care plans are important
15
documents in the management of a patient's care?
16
A.
Yes.
17
Q.
Just looking then to the staff profile in ward F, can
18
I ask you some questions about that, and perhaps the
19
easiest way of dealing with this is to put the duty
20
sheets that we have on the screen, so if you could look
21
at GGC21710021.
22
duty sheets for ward F for January 2008.
23
that on the screen?
We are looking at the nursing staff and
Do you see
24
A.
Yes.
25
Q.
We see your name at the top of the list on the left-hand
69
1
side.
The next name, L Dannenberg, was she the deputy?
2
A.
She was, yes.
3
Q.
We then have a list, and if we move on to page 22, we
4
have some further names out there; that is right?
5
A.
Yes.
6
Q.
I had counted 22, but I'm not sure whether you would
7
agree with that or not.
8
complement was?
Can you remember what the
9
A.
That would have been right for the time, yes.
10
Q.
Can you tell me about the balance of qualified and
11
12
unqualified staff?
A.
13
On a 12-hour day shift there would be myself and two
12-hour trained staff and two 12-hour auxiliary staff.
14
Q.
That's on a 12-hour shift?
15
A.
Yes.
16
Q.
Are we looking at a duty sheet that was in place before
17
the 12-hour regime or not?
18
A.
No, this is a 12-hour regime.
19
Q.
This is 12 hours?
20
A.
Yes.
21
Q.
If we look at the names, then, can you tell me what the
22
proportion is per head?
23
were qualified and how many were unqualified?
24
25
A.
We have got 22 names.
How many
The eight names you are looking at just now are the
unqualified auxiliary staff.
70
1
Q.
If we go back to page 21?
2
A.
That's all the trained staff.
3
Q.
You mentioned in passing what your own shift was.
4
5
Can
you just remind me, what shift did you work?
A.
6
I worked a 30-hour week over four days, and the shift
generally started at 8 and finished at 4.
7
Q.
The four days, what days were these?
8
A.
Monday, Tuesday, Thursday, Friday.
9
Roughly every third
week I would be required to work an evening shift on
10
a Wednesday for site cover, page-holder duties, which
11
would mean I would be off on the Thursday of that week.
12
Q.
13
14
Can I just understand, then, your relationship with your
deputy, Ms Dannenberg.
A.
How did that work in practice?
She would be part of the -- she would be one of the two
15
12-hour trained nurses that were on, so it wouldn't
16
follow a certain pattern, it would just be as was
17
required on that month on the rota.
18
Q.
19
I take it -- I understand from what you have said that
you didn't work on a Wednesday or at the weekends?
20
A.
No.
21
Q.
Is that correct?
22
A.
Apart from every third Wednesday, I would be there.
23
Q.
I'm sorry?
24
A.
Apart from every third Wednesday, I would be there in
25
the evening.
71
1
Q.
2
3
weekends?
A.
4
5
Did Nurse Dannenberg work on the Wednesday and the
Not every week, but there would be occasion that she
would, yes.
Q.
6
How, then, did you divide the work of the ward up?
How
was it organised?
7
A.
Between myself and Sister Dannenberg?
8
Q.
And the nurses in general, yes.
9
A.
We had 16 patients at the time, so the two nurses that
10
were on the 12-hour shift pattern would take a team of
11
eight each and I would be there -- if we had a full
12
complement of staff that day, I wouldn't have a direct
13
caseload myself, but I would be involved clinically as
14
part of the working team, so I would have direct patient
15
care duties that day and I would generally step in to
16
deal with some of the more acutely unwell or any more
17
complex issues within the patient group that day, but
18
I didn't have a direct caseload unless it was required
19
of me.
20
I would quite often have to take a caseload.
If we were a member of staff down, for example,
21
Q.
Did you require to use bank and/or agency staff?
22
A.
Yes, we did.
23
Q.
If you could look at some of the information we have
24
been sent in connection with that, if you could look at
25
GGC13320004, this documentation, as I understand it,
72
1
indicates what requests were made for each ward for
2
either qualified or unqualified shifts, and gives an
3
indication as to how many of these shifts were filled or
4
remained unfilled.
Do you follow me?
5
A.
Yes.
6
Q.
If we look to ward F, that we see in the second section,
7
and this is requests in respect of the period 1 December
8
to 9 December 2007, can you see that there were, for the
9
qualified shifts, four requests and three of those were
10
bank filled.
Do you see that?
11
A.
Yes.
12
Q.
That meant that there was one such shift left unfilled
13
for that period?
14
A.
Yes.
15
Q.
So far as the supply by the bank was concerned, were
16
these nurses who were already working on the ward or did
17
they come from other wards or other hospitals, in the
18
main?
19
A.
It would be a combination.
We had a couple of our own
20
staff in substantive posts that would do work on the
21
bank, so they would quite often fill the gaps.
22
some occasions -- quite frequently, I would say -- it
23
would be just a member of the hospital bank, it wasn't
24
one of our own ward team.
25
Q.
Did you, yourself, do bank work?
73
But on
1
A.
No, I didn't.
2
Q.
What about Nurse Dannenberg?
3
A.
No, she didn't.
4
Q.
Then, moving on to the unqualified shifts for this
5
period, you will see there were 13 requests made, ten of
6
these were filled by the bank, which left three
7
unqualified shifts unfilled?
8
A.
Yes.
9
Q.
If you had a period -- this is about a period of a week
10
or so -- when you have, I think, a total of four
11
unfilled shifts, one qualified and three unqualified,
12
would that impact upon the work of the ward?
13
A.
Absolutely, yes.
14
Q.
In what way?
15
A.
You would be working with one member of the team less
16
than you should have, so it meant an increased workload
17
on the other members that were there, if you had been
18
unable to get some help from other areas.
19
Q.
If we move on to another period, this is at GGC13240002.
20
Again, if you focus on ward F, we see that five requests
21
have been made for bank or agency; no shifts filled by
22
the bank, one by the agency, which would leave four
23
unfilled qualified shifts?
24
A.
Yes.
25
Q.
Just following it through, if there were eight
74
1
unqualified shifts requested, five were filled by the
2
bank, one by the agency, which meant two unfilled.
3
there in a particular period you have a total of six,
4
four unfilled qualified shifts and two for unqualified
5
shifts.
6
A.
So
So, again, that would impact on --
Significantly.
That particular week, when only one
7
trained nurse was able to help out of the five requests,
8
that generally meant I would be the second trained
9
person working on the team that day.
10
Q.
How would it come about that you were required to make
11
such a number of requests?
12
illness?
13
A.
Would that be down to
It would generally be down to staff absence, yes, due to
14
sickness.
15
on a long-term sick period, you can generally plan
16
ahead, but as you can imagine, we do get the calls,
17
perhaps that morning, someone phoning in absent, or the
18
day before.
19
filled as readily as the longer, further-planned ones.
20
Q.
21
22
Some of that can be planned.
If they are off
So short-notice requests tend to not be
You said you would get help from other areas.
Do you
mean other wards within the hospital?
A.
Yes, if there was occasion that other areas were quieter
23
and perhaps didn't have full occupancy, you might be
24
able to get some help.
25
Q.
But that didn't always work.
Would that be outwith your own directorate?
75
1
A.
Yes, it would, on occasion.
2
Q.
Because we have on the screen that within your
3
directorate you have ward 15 and ward 14, but would you
4
get nurses from those wards to help?
5
A.
6
Generally, they were in the same position as myself, so
the help didn't tend to come from within RAD.
7
Q.
Where would the help come from then?
8
A.
The quieter areas in medicine, sometimes, if they are
9
not fully occupied or if -- at the front door, for
10
example, if they didn't have a lot of patients in.
11
tended to be sporadic.
12
a couple of hours of the shift rather than the full 12.
13
Q.
14
15
You would perhaps just get
So a nurse from ward 6, for example, could come to help
in ward F?
A.
Occasionally.
It didn't happen very often.
16
Particularly at that time.
17
under pressure.
18
Help
Q.
I think all the wards were
I have touched upon this already, but can I just be
19
clear in relation to the patient profile that you had in
20
ward F.
21
is described as a stroke ward?
As we have seen from your job description, it
22
A.
Yes.
23
Q.
Can you elaborate upon the nature of the patients you
24
25
had generally?
A.
The age range would generally be as young as 25 to 30,
76
1
up until -- we have had a few patients just over 100.
2
They would come in through the MAU and be admitted into
3
a medical ward, either ward 6 or what might have been
4
Lomond at the time.
5
on to stroke rehabilitation, they would be referred on
6
to ourselves.
7
in medicine for a week or sometimes longer before they
8
then came to ward F.
9
Q.
10
11
Once they met the criteria to move
So there would be occasion they would be
In relation to the percentage as to elderly against not
so elderly, can you give me a broad indication?
A.
It would be difficult to put an average on that.
Stroke
12
generally is more common in the elderly, so I would have
13
to say the client group would weight towards the
14
elderly.
15
be perhaps four or five of the younger group in the ward
16
at any one time.
17
Q.
18
19
But we could have occasion where there would
Looking at the generality of it, would you be dealing
with a number of patients who would lack mobility?
A.
20
Yes.
It was quite -- it was one of the most common
symptoms of stroke, yes.
21
Q.
And patients who would need significant levels of care?
22
A.
Yes.
23
Q.
And patients who would need encouragement in relation to
24
25
Varying levels of care, yes.
matters such as nutrition and fluid intake?
A.
Yes.
77
1
Q.
Turning to bed management, can we just look at the bed
2
state documentation and turn to GGC24180001?
If we
3
perhaps turn to page 2.
4
to ward F, just about a third of the way down from the
5
top of the page.
I think we see some reference
Can you find that in the bed state?
6
A.
Yes.
7
Q.
The number of beds, according to this, is 16; is that
8
right?
9
A.
Yes.
10
Q.
Can we see, if we read along, that at some point -- this
11
is 3 January -- you have had to increase the number to
12
17, according to what we see on the --
13
A.
Yes.
14
Q.
How would that come about?
15
A.
That would be -- we were the third stage of the winter
16
contingency planning when they were under pressure.
17
fourth bed would be put back into the bedded area,
18
room 16, to put the complement up to 17.
19
Q.
20
The
If the complement was up to 17, then the extra bed would
be going into room 16?
21
A.
Yes.
22
Q.
That is where it would go?
23
A.
Yes.
24
Q.
Was that the maximum, then, 17?
25
A.
It was, yes.
78
1
Q.
Generally, in relation to the period we are concerned
2
with, particularly if you are looking from December
3
through to, let's say, March/April -- December 2007
4
through to March/April 2008, what was the general state
5
of the ward in relation to how full you were?
6
A.
From memory, I would say we were full most of the time,
7
yep.
8
the patient numbers were lower than normal, but apart
9
from that, generally we filled up to 16 or 17 over that
10
We had an episode of closure for norovirus, and
period.
11
Q.
Was your norovirus episode in December 2007?
12
A.
It was, yes.
13
Q.
Can I just look briefly with you at some aspects of
14
policy, and if we look, first of all, to the assessment
15
of the risk of falls, did you have a tool that you used
16
in ward F to assess a patient's risk of falls?
17
A.
Yes.
There was a tool available.
My understanding was
18
it was to be used with someone with a history of
19
falls -- I have since seen a document, a policy
20
document, that wasn't available to me at the time, that
21
suggests that was the case -- or a suspected fall, but
22
the practice in ward F at the time would generally be
23
a subsequent fall.
24
25
Q.
Let's look at the tool first of all and let's take it
from there.
This is an example of, I think, what you
79
1
may have in mind.
If you look at GGC00190636, we are
2
looking here at a patient fall risk assessment chart for
3
a patient who was accommodated in ward 14.
4
can see, is to reduce incidence of patient falls.
5
there is an assessment criteria:
The aim, we
6
"Limited mobility, abnormal/unsteady gait."
7
That is the first one.
8
Then
If we move down the list,
one of the criteria is also:
9
"Known falls prior to attendance."
10
And another is:
11
"Known falls during attendance."
12
Did you use this form, this tool, in ward F at the
13
relevant time?
14
A.
Yes.
15
Q.
Let me just understand, then, what it is you are saying
16
as to when this assessment would be carried out in
17
relation to a patient.
18
of falls?
You said something about history
19
A.
Yes.
20
Q.
What was the position in ward F?
21
A.
I understood at the time that someone who had a history
22
of a fall would have a fall risk assessment tool
23
completed to evidence that we were putting in
24
intervention to prevent further falls.
25
The tool was a useful tool to give evidence of these
80
1
interventions, but the actions that we have to take to
2
prevent falls in stroke, the principles are embedded in
3
us, and we are quite often applying these interventions,
4
even before the patient comes into the ward, with
5
regards to bed positioning for optimum observation.
6
Quite a few of the interventions are taking place
7
without the tool being present.
8
Q.
9
Can we just understand, though, what you are saying
about what you understood the policy to be as to when
10
you would, as it were, use the tool?
11
Are you saying that it was your policy in ward F not
12
to use the tool unless you had information about the
13
patient that indicated the patient had had a history of
14
falls?
15
A.
Mmm-hmm.
16
Q.
Have I misunderstood you?
17
A.
Yeah, I understand that to be the definition from the
18
policy that I have subsequently seen during my
19
preparation.
20
me at the time.
21
that the staff implemented this tool following a history
22
of fall or if they were highly suspicious of having
23
a risk of falls.
24
25
Q.
That policy document wasn't available to
So my understanding in my own area was
Well, I'm still a bit puzzled.
Let's focus on the
relevant time and what the position was in ward F at the
81
1
relevant time.
2
Now, if you had a patient in ward F who was of
3
limited mobility, abnormal/unsteady gait, which is the
4
first assessment criteria, would you assess that patient
5
to assess that patient's risk of falls?
6
A.
Every patient is assessed for risk of falls.
We are not
7
always able to reflect that with a tool, as I have since
8
discovered during my preparation reading back on case
9
records, but the principles of fall prevention are
10
carried out with every patient that comes in, by the
11
very nature of their illness.
12
Q.
Would it have been your expectation, at the relevant
13
time, that if you had a patient who was of limited
14
mobility, as we see in the first criterion, that that
15
would be a patient who would be assessed under reference
16
to the tool for the risk of falls?
17
A.
Following the principles of the tool, yes, they would
18
be.
19
details of the patient that's coming to the ward, I can
20
tell sometimes from that information that they are going
21
to require a highly observable area in the ward, and we
22
are already putting an intervention without the presence
23
of the tool.
24
25
Q.
When I receive the referral information giving
So as a matter of course, then, are you saying that you
would not use the patient fall risk assessment chart in
82
1
2
ward F generally, as the chart we have on the screen?
A.
3
Yes, I would say the completion of the tool wasn't
routine with every patient that came into ward F, no.
4
Q.
Should it have been?
5
A.
My understanding from the policy that should have been
6
available at the time suggests that anyone with
7
a history of a fall or suspicion of falls would have one
8
completed, yes, but I didn't have that policy document
9
at the time certainly.
10
Q.
If we look at the document on the screen, certainly
11
"Known falls prior to attendance" and "Known falls
12
during attendance" do feature as part of the assessment
13
criteria, but they are not the only criteria.
14
A.
No.
15
Q.
There are other criteria that would impact upon the
16
assessment of risk?
17
A.
Yes.
18
Q.
This doesn't appear to envisage, on the face of it, that
19
you need to have had known falls prior to attendance or
20
falls during attendance before it would be triggered.
21
A.
No, I can see that.
Yes.
22
Q.
I'm still a bit confused.
At the relevant time, were
23
you working on the basis that you required to have
24
a history of falls before you would carry out this sort
25
of assessment?
83
1
A.
A history of a previous fall or highly susceptible to
2
being at risk of falls is, I believe, what we applied at
3
the time.
4
MR KINROY:
My Lord, the witness I think is trying to tell
5
us that, more recently, she has seen a policy of which
6
she was unaware of at the time which has a bearing on
7
this.
8
explore that with her?
9
I wonder if my learned friend would care to
MR MACAULAY:
10
I am happy to do that.
I was, in any event,
going to ask you about that.
11
The policy, then, that you have mentioned that you
12
have seen may have a bearing upon this whole assessment
13
of risk, can you give us some idea as to what it is?
14
might have it, you see.
15
A.
We
I believe it is dated 2006 perhaps with a title
16
"Prevention inpatient falls".
17
the title.
18
a policy that I might have had at the time, but I didn't
19
recognise it.
20
Q.
21
22
I certainly had it made available to me as
Is that, then, a policy that other nurses have been
asked about?
A.
I'm not too sure of
Is that how you have come to see it?
I came to see it because it got sent to me from the RCN
23
as perhaps a useful document in the preparation to come
24
today, and I hadn't seen it before.
25
Q.
Had you seen something before that would assist you in
84
1
how to approach the assessment of patients with falls?
2
A.
No, not that I can recall.
3
Q.
But you did have available to you in the ward the
4
screening tool that we have on the screen at the moment?
5
A.
Yes.
6
Q.
If you could turn to GGC26540001, we have on the screen
7
a document that is headed "NHS Greater Glasgow and Clyde
8
Acute Services Division" and it is dated
9
21 December 2006, and it is headed "Management of
10
inpatient falls".
11
mind?
Is this the document that you have in
12
A.
Yes, I think it is, yes.
13
Q.
Is there a provision in this document that says that you
14
15
would only assess if the patient had a previous fall?
A.
16
17
I'm sure I have read in that document that one of
the criteria was a history of falls.
Q.
Let's see if we can find that.
If we turn to page 4,
18
there is a provision at 3 which begins by saying "Aims
19
of the policy":
20
21
22
23
24
25
"To identify patients at risk of falling in
hospital.
"To reduce the risk of patients falling in
hospital."
So that isn't the particular provision.
Then, if we
turn to page 5, there is a provision headed "Key areas
85
1
of the falls prevention policy".
2
If I could read that:
"All inpatients presenting with a fall, or with
3
a condition which might render them susceptible to
4
a fall, will have the following documentation completed
5
within twenty-four hours of admission."
6
Then we have a list of issues.
7
8
Is this the position
you had in mind?
A.
9
I believe that is what I have read.
It looks as if they
have presented with a fall already or they have
10
a condition that will lead them to be more at risk of
11
having a fall.
12
Q.
I suppose someone who has had a stroke would have
13
a condition that might render them susceptible to
14
a fall?
15
A.
16
17
Q.
In any event, this is the provision that you had in
mind, is it, that you saw recently?
A.
Bearing in mind I have only read that during my
20
preparation.
21
period.
22
Not all of them have motor weakness,
but some of them do, yeah.
18
19
Not all of them.
Q.
It wasn't available to me at the relevant
What this says, then, is that all inpatients presenting
23
with a fall, or with a condition which might render them
24
susceptible to a fall, will have the documentation
25
completed.
But if you go back to the assessment
86
1
criteria at GGC00190636, would someone who presented
2
with limited mobility and an abnormal/unsteady gait not
3
be someone with a condition which might render them
4
susceptible to a fall?
5
A.
6
7
Yes, that would increase their risk of having a fall,
yes.
Q.
8
We see, in fact, that one of the assessment criteria is
four or five down, which also says:
9
"Recent CVA ..."
10
Is that a cerebral vascular accident?
11
That is
a stroke, is it?
12
A.
Yes.
13
Q.
"... within last month".
14
I think what you are saying, and you can correct me
15
if I am wrong, Sister Gargaro, is that you have gone
16
through the medical records that you have looked at in
17
preparation for giving evidence --
18
A.
Yes.
19
Q.
-- and have you noticed that, in relation to some
20
21
patients, there are no falls risk assessments?
A.
22
23
Yes, I have.
I have seen some that have and some that
don't, yes.
Q.
I imagine you have no doubt read reports by independent
24
nurses who have been critical of the absence of such
25
risk assessments for certain patients?
87
1
A.
Yes.
2
MR PEOPLES:
My Lord, I wonder if we could establish from
3
the witness in what circumstances a patient admitted to
4
ward F would not have a falls risk assessment carried
5
out if the majority were stroke patients?
6
help us to ascertain when they were likely to be
7
assessed.
8
MR MACAULAY:
9
That might
Let's just deal with that while we have it on
the screen, Sister Gargaro.
10
In what circumstances would a patient admitted to
11
ward F not have a falls risk assessment carried out, if
12
the majority were stroke patients?
13
A.
I would expect most of them with a motor weakness would
14
render them more susceptible to having a fall, so
15
ideally I would like to have seen some of the cases that
16
I looked at in my preparation with the risk assessment
17
tool completed, and I didn't see that.
18
What I have to give reassurance of is that the very
19
principles of the tool are followed with every stroke
20
patient because of the nature of the illness, and, like
21
I say, before the patient even comes into the ward, we
22
are thinking about where we are going to position them
23
just by the information that we have before we have even
24
seen the patient.
25
The principles are there in every nurse: we are
88
1
wanting to anticipate need and make sure they have
2
appropriate footwear and nurse call system handy without
3
necessarily completing the documentation.
4
Q.
Can I approach it with you in this way: would it have
5
been your expectation to have seen this sort of
6
assessment carried out in more of the patients than you
7
actually saw?
8
A.
Yes.
9
Q.
If we go on to the second page of the document, page 37,
10
you can see the way this works is that, if someone is
11
assessed as being at very high risk, then the
12
instruction is to place a red dot next to the patient's
13
name on the multidisciplinary care plan.
14
that?
Do you see
15
A.
Yes.
16
Q.
When you did use the falls risk assessment and the
17
patient was assessed at very high risk, did you follow
18
through this procedure or not?
19
A.
We didn't follow the procedure of the red dot because we
20
didn't actually have multidisciplinary care plans.
21
the disciplines within ward F have their own case
22
records, and we share information with each other at
23
quite a robust level of communication, I would say.
24
multidisciplinary team at that time on ward F were
25
funded members of the stroke team, they covered
89
All
The
1
exclusively that area.
It was a blanket referral.
They
2
saw every patient.
3
referring the patient to them, and at multidisciplinary
4
case discussion we would share information with each
5
other.
They didn't have to get a nurse
6
So at a very early stage from the physiotherapy
7
assessment, we would have it identified to us if someone
8
was at risk of falls because the physiotherapist
9
completes a moving and handling risk assessment and
10
subsequently then passes on mobility information to the
11
members of staff.
12
Q.
13
You are still going quite fast, if I may say so,
Sister Gargaro.
14
A.
Sorry.
15
Q.
This assessment tool anticipates that a care plan would
16
be put in place to manage the patient's risks of falls.
17
So far as you are able to say from the records you
18
looked at, were care plans put in place to manage falls,
19
as a matter of practice?
20
A.
21
22
I think in two of them, from memory.
Q.
23
24
25
Some of the care plans were evident, yes, for fall risk,
Were these pro forma care plans, or were they written
up, individualised?
A.
I believe they were pro forma, from memory.
I'm sure
it's certainly one of the core care plans that we
90
1
devised, reduced mobility and risk of falls, so it may
2
well have been.
3
Q.
It would be your expectation, then, first of all, if the
4
assessment was done, that there would be a care plan put
5
in place following upon the assessment, particularly if
6
it was at very high risk?
7
A.
Yes, your own assessment would identify the need for
8
a care plan without necessarily completing the tool.
9
Nurses can identify that from their own principles that
10
they have known in all the years they have been nursing.
11
They don't necessarily have to fill in the risk document
12
to initiate a care plan.
13
that in one case, that they had a care plan in place for
14
the prevention of falls, but they didn't actually have
15
a risk assessment tool completed.
16
Q.
Indeed.
And I think I saw evidence of
So there are two aspects to it and let's take
17
them one by one.
If a nurse did complete the falls risk
18
assessment using the tool and a patient was categorised
19
at a risk that should generate a care plan, then you
20
would expect to have a care plan in place?
21
A.
Yes.
22
Q.
Similarly, as you have said, even if the nurse didn't
23
follow the drill set out in the tool, but nevertheless
24
assessed that there was risk of falls, then you would
25
expect a care plan to be put in place?
91
1
A.
Yes.
2
Q.
I think what you have said is you have seen at least one
3
example where the tool is not in place but there is
4
a care plan?
5
A.
Yes.
6
Q.
If we look at what we have on the screen, it would
7
appear that the assessment involves initial assessment
8
and also regular review?
9
A.
Yes.
I don't think the tool actually dictates how often
10
the review should be, but it certainly has columns there
11
to suggest that you could put in further information,
12
perhaps, as their condition changed.
13
Q.
It seems to proceed upon the basis that there would be
14
an initial assessment and then the nurse would project
15
forward to see when the next evaluation would take
16
place.
17
it looks like 22 April, and then the next date -- that
18
doesn't appear to have been -- it doesn't appear to have
19
been completed -- is 13 June.
So if we look at the document, we have the date,
Do you see that?
20
A.
Yes.
21
Q.
It is pointed out to me, if you go back to page 36,
22
there is certainly an assessment provision --
23
reassessment when there is a known history of falls, do
24
you see that?
25
It says:
"Assess patients within one week of attendance when
92
1
there is a known history of falls."
2
That is at the very top.
3
A.
Yes.
4
Q.
In relation to nutrition, just looking at that aspect of
5
care, did you use a screening tool to assess a patient's
6
nutritional status in ward F?
7
A.
At that time, no, we didn't.
8
Q.
Was there a reason for that?
9
A.
We didn't actually have the request made of us, as
10
a unit, to complete the screening tool.
11
one point, the nutrition screening tool became available
12
for use elsewhere in the hospital, and I also can recall
13
a discussion with the dietetic service with regards to
14
considering implementing it in ward F.
15
look at it and decided that the outcome of that
16
screening tool ultimately would be referral to dietetic
17
service if it was required, and we already had a funded
18
dietetic service within the stroke team on ward F with
19
regular referrals made if necessary.
20
the tool would bring anything further to that service,
21
so I didn't implement it at that point.
22
I am aware, at
I had a good
So I didn't feel
I didn't receive any further instruction at
23
a directorate level to implement it within the RAD
24
wards, the three of them.
25
Q.
Let's just take that in stages, then.
93
If you just look
1
at the type of tool we are talking about, if we look at
2
GGC00030050, I think we are here looking at
3
a nutritional screening tool for a patient from another
4
ward, and it sets out various matters that require to be
5
assessed for the particular patient.
6
When was it that you gave consideration to using
7
8
this as a tool in ward F and decided not to do so?
A.
9
That is the date that I'm unclear of.
that accurately.
I can't recall
I do remember the dietician involved
10
that I had the discussion with, but I could -- I would
11
be guessing if I gave you a year.
12
prior, obviously, to this period, because we hadn't had
13
the implementation of MUST that we now use, which had
14
a mandatory rollout, so it would be any point between
15
2005 to 2007, I would imagine.
16
a guess.
17
Q.
It was certainly
But that is just
I'm sorry, I can't be any more definite.
What was the position after June 2008?
I understand
18
what you are saying is you didn't use this in what we
19
are looking at as the relevant period, mainly, but
20
after June 2008, was there some form of nutritional
21
screening tool introduced to ward F?
22
A.
Yes, there was.
23
Q.
What was it?
24
A.
No, it was the MUST tool.
25
Was it this tool or something different?
That had a mandatory rollout.
I think not just at the site level at the Vale of Leven,
94
1
I think it had more of a national rollout for those
2
areas that weren't already using it.
3
Q.
4
5
I suspect I ought to know what MUST means.
What does
MUST -A.
It is a malnutrition universal screening tool.
It had
6
a mandatory rollout, which was pre-empted with some
7
training and modules that everyone had to complete in
8
the ward team to understand the use of the tool, and it
9
is actually now a referral criteria to the dietician.
10
You can't refer a patient without this number.
11
before, I had an open service to dietetics without
12
restriction.
13
Q.
Whereas,
It was based on clinical judgment.
Just looking to nutrition generally, particularly if you
14
have a patient who is suffering from loose stools or,
15
indeed, C. diff, nutrition does become important in the
16
care of such a patient?
17
A.
It can do, yes, yes.
18
MR PEOPLES:
My Lord, before we go on, I wonder if my
19
learned friend would ask -- I think the witness said
20
earlier that in relation to falls risk the physio was
21
part of the stroke team and would see every patient on
22
admission to the ward.
23
A.
24
MR PEOPLES:
25
Yes.
Was the position the same with the dieticians
who were part of the team, or was that based on referral
95
1
2
only?
MR MACAULAY:
3
Well, you heard that question: would the
dietician see every patient --
4
A.
Not as a blanket referral, no.
5
Q.
Sorry?
6
A.
Not every single patient, no.
She would generally get
7
the referral from the nursing staff, but she was also
8
part of some of the multidisciplinary discussion and
9
would pick up her own referrals for observation.
She
10
wouldn't necessarily act on it at that point, but she
11
would be keen to know how it was progressing over
12
a period of weeks.
13
from referral from nursing staff.
14
Q.
But generally, I would say it came
The dieticians' department if that is the proper
15
description, how many dieticians were available to cover
16
the hospital as a whole?
17
A.
I'm not sure over the site as a whole, but we certainly
18
had a 0.2 sort of whole-time equivalent dietician for
19
the stroke team, which would suggest that she should be
20
available for one day out of the five just to
21
concentrate on the stroke team.
22
include visits after hospital within stroke, so it
23
wasn't necessarily just inpatient dietetic service.
24
she was part of the recognised stroke team.
25
Q.
I think that would also
You have mentioned the stroke team on a number of
96
But
1
occasions in giving your evidence.
2
elaborate upon what that included?
3
A.
Yes.
Can you just
It was basically all the multidisciplinary team
4
members that were designated to work on ward F with
5
regards to stroke exclusively.
6
a consultant physician with an interest in stroke --
It consisted of
7
Q.
Who was that in the Vale of Leven?
8
A.
At that time, that would have been Dr Akhtar.
9
Q.
Yes.
10
A.
Then we would have a senior physiotherapy, a half-grade,
11
lower-level physiotherapy and a physiotherapy
12
instructor.
13
therapist with an interest in stroke with an instructor
14
as well to support her.
15
social worker, speech and language therapist and
16
clinical psychology, and I'm not sure if I have left
17
anyone out here, and nursing obviously.
We would have a senior occupational
We would have a designated
18
Q.
How often would the stroke team meet as a team, then?
19
A.
On a multidisciplinary discussion basis, we met formally
20
every week, but we had a handover, if you like, in the
21
morning and sort of ongoing discussion through the day
22
of any relevant issues.
23
Q.
I now want to ask you some questions about the infection
24
control manual.
Did you have access to the infection
25
control manual in ward F?
97
1
A.
Yes.
2
Q.
Did you, in fact, access the manual from time to time?
3
A.
Yes.
4
Q.
For what reasons would you look at the manual?
5
A.
Generally, for information I didn't already have about
6
that particular condition.
7
would be transmission-based precautions specifically for
8
certain organisms.
9
Q.
10
11
What did you see your duties to be, if any, in relation
to infection control in ward F?
A.
12
13
More often than not, it
Just to ensure the implementation and adherence of any
policies that were available to guide us.
Q.
If we look at some aspects of policy, then, that we see
14
in the manual.
If you turn to GGC27390001, we are
15
looking at a policy that is described as an outbreak
16
policy, and it is said to be effective from July 2006
17
to July 2010.
Do you see that?
18
A.
Yes.
19
Q.
If you could also have on the screen GGC00780145, we are
20
now looking at a similar sort of policy, but this is
21
dated from December 2007 to December 2010.
22
that?
Do you see
23
A.
Yes.
24
Q.
Perhaps we'll just focus on this one, since we still
25
have it on the screen.
If you turn to page 147, can we
98
1
see that the first head of "Responsibilities" is that
2
"Healthcare workers must follow this policy", and so on?
3
Was this something that you focused on at the time,
4
assuming this policy came in in about December 2007 and
5
moving beyond that, that there was such a policy that
6
you, as a healthcare worker, required to follow?
7
A.
Yes.
8
Q.
If you turn to page 148, then, of this document, can we
9
see that section 3 is giving some outbreak definitions.
10
A generic one is:
11
"An outbreak is defined as either two or more linked
12
cases of the same illness (ie associated in person,
13
place or time) or as a situation when the observed
14
number of cases of an alert organism/communicable
15
disease which unaccountably exceeds the expected
16
number."
17
Then "Gastrointestinal":
18
"Three or more cases, with two or more episodes of
19
unexplained vomiting and/or diarrhoea, within a 24-hour
20
period in healthcare premises."
21
Were you, yourself, aware of these definitions of
22
"outbreak" let's say if we are looking beyond
23
December 2007 up to June 2008?
24
A.
Yes.
25
Q.
Can I ask you this: at the time -- let's look
99
1
beyond December 2007 -- did you, yourself, at any stage
2
consider that you had an outbreak of C. diff in ward F?
3
A.
Yes.
I recognised in January we had a level that
4
exceeded the amount in the gastrointestinal definition
5
of an outbreak, yes.
6
Q.
That would then be the diarrhoea definition?
7
A.
Yes.
8
Q.
At that time, just focusing on January and that
9
awareness, what did you do, if anything, at that time?
10
A.
I discussed it with infection control at that time.
11
Q.
Who was it within infection control that you discussed
12
it?
13
A.
It was Helen O'Neill.
14
Q.
Did she give you any advice at that point in time?
15
A.
I remember the discussion was around a point where
16
I felt I had four people that were all diagnosed with
17
C. diff at any one time.
18
Q.
You are talking about C. diff, are you?
19
A.
Yes.
20
Q.
That is, then, two or more linked cases of the same
21
22
illness; is that what you are talking about?
A.
My understanding of the definition was that because it
23
was a diarrhoeal illness, it would be the three or more
24
cases.
25
Q.
Okay.
Let's run with that then.
100
1
A.
That was my interpretation.
2
Q.
Be that as it may, you focused on the fact that you may
3
have had an outbreak, you say, in January 2008?
4
A.
Yes.
5
Q.
And you discussed that with Helen O'Neill?
6
A.
Yes.
I mean, the infection control department certainly
7
knew of every case as it happened.
It very often was
8
the case that they would be the ones who would phone us
9
and let us know of a positive result, certainly within
10
hours and within Monday to Friday.
11
that time, at the bed meeting and at ward level, was
12
daily, so I had rise to have a discussion when the
13
numbers I felt exceeded the definition of the policy.
14
MR MACAULAY:
15
16
Their presence, at
I will probably return to this, my Lord, and
maybe I should do that after lunch.
(1.00 pm)
17
(The short adjournment)
18
(2.00 pm)
19
MR MACAULAY:
Good afternoon, my Lord.
Perhaps I should
20
have mentioned that Mr Connolly appears here today on
21
behalf of Sister Gargaro.
22
Before lunch, Sister Gargaro, you had indicated that
23
in January 2008 you considered that you may have had an
24
outbreak in ward F; is that right?
25
A.
Yes, I knew I had an increased incidence of
101
1
2
C. difficile, yes.
Q.
3
4
So when we are using "outbreak", is it C. difficile
itself that you focused on in January 2008?
A.
I would say it was symptomatic patients of diarrhoea.
5
I can't remember accurately.
I'm sure I had confirmed
6
diagnosis at that point when I raised my concern, but
7
I certainly had four symptomatic patients.
8
Q.
Whom did you raise your concern with, remind me?
9
A.
I had the discussion with Helen O'Neill, the infection
10
11
control nurse.
Q.
12
13
Can you just perhaps tell the Inquiry what the nature of
the discussion was?
A.
It was prompted by the fourth patient that was brought
14
to our attention that day when Helen actually came to
15
the ward to tell me about it.
16
patient placement, because we already had three
17
symptomatic patients.
18
advice about cohorting the patients together and, at
19
that point, my words, to the best of my recollection,
20
were, "Cohorting?
We then had to discuss
She, at that point, offered the
Should we not be closing?"
21
Q.
What did Helen O'Neill say to that?
22
A.
Well, she said -- again, I wouldn't like to misquote her
23
words exactly, but her answer was along the lines of,
24
"These cases can be explained".
25
Q.
Did you use the word "outbreak" in your discussions with
102
1
Helen O'Neill?
2
A.
No, I didn't use the word "outbreak", no.
3
Q.
Did the term "outbreak" cross your mind as an
4
appropriate description as to what you had in the ward
5
at that time?
6
A.
7
8
qualify that it would be, yes.
Q.
9
Did you, yourself, know, under reference to the policy,
what steps someone in Helen O'Neill's position should
10
11
By the definition of "outbreak", then, yes, it would
have been considering?
A.
I believe, at that point, the responsibility of
12
infection control would be to close the ward to
13
transfers in and out, to admissions, and to put in
14
further measures.
15
Q.
What about communication with other people?
Did you
16
understand that the infection control nurse had a duty
17
to escalate the matter further up the ladder?
18
A.
Yeah, I think when -- it's infection control, my
19
understanding, that would declare the outbreak, and then
20
there's measures that need to follow on from that with
21
regards to an outbreak team, and there's quite a few
22
different responsibilities that they have within the
23
policy, I believe, once an outbreak has been recognised.
24
25
Q.
What about your own ward manager?
with her, that's Liz Rawle?
103
Did you discuss this
1
A.
I can't say directly that I told her every single time
2
I had a new episode of diarrhoeal illness in the ward,
3
but she was present at most of the bed meetings where we
4
discussed what infection we had in the ward at any one
5
time with all the wards in the hospital.
6
Q.
Well, if we are just focusing on this discussion you had
7
with Helen O'Neill and you'd focused on four patients,
8
was that at a bed meeting?
9
A.
No, it was at the ward I had that discussion with Helen.
10
Q.
Was Liz Rawle present for that discussion?
11
A.
No, she wasn't, no.
12
Q.
Did you make Liz Rawle aware of the position in relation
13
to the four patients at about this time that you are
14
talking about?
15
A.
I don't believe I did, no.
16
Q.
Why not?
17
A.
From memory, my best recollection at the time was
18
I accepted Helen O'Neill's explanation with regards to
19
the definition of "outbreak" and she reassured me that
20
it wasn't, because "These cases can be explained", and
21
I hope I haven't misquoted her, but certainly words
22
along those lines.
23
Q.
24
25
Did you ask for any explanation as to how the cases
could be explained?
A.
She suggested that because of the -- all the patients
104
1
had been on antibiotics, particularly the ones that are
2
C. diffogenic, as we refer to them.
3
was that these could be explained.
4
Her understanding
But the incidence of the fourth one happening was it
5
knew -- certainly infection control knew when every
6
single patient became symptomatic or confirmed positive,
7
so I didn't feel I had the responsibility to tell her
8
that we now had four; she brought the information to the
9
ward, to me, so --
10
Q.
There you are talking about infection control?
11
A.
Yes, sorry.
12
Q.
I understand what you are saying there, that it would
13
really be the duty of infection control to take matters
14
on.
15
A.
Mmm-hmm.
16
Q.
What I was asking you is --
17
MR KINROY:
My Lord, before we do that, I wonder if this is
18
in my discretion here, but I think there is an important
19
comma needing to be inserted.
20
odd, but it was the delivery of the witness which maybe
21
does make quite a big difference.
22
line 10.
23
page:
24
25
I appreciate that sounds
It is page 104,
It is quite ambiguous as it seems on the bare
"Answer:
... and she reassured me that it wasn't",
I expect there is a comma, "because these cases can be
105
1
explained [draft transcript]."
2
There was a moment of the delivery which in my
3
submission made it plain what that means, but it is not
4
evident from the bare text.
5
MR MACAULAY:
6
MR KINROY:
7
8
9
I'm not quite clear.
If I could assist my learned friend, at
page 104, line 9, read literally it would read:
"Answer:
... and she reassured me that it wasn't
because these cases could be explained [draft
10
transcript", but I think the evidence was "and she
11
reassured me that it wasn't, because these cases could
12
be explained".
13
in later.
14
MR MACAULAY:
It might be difficult to put the comma
Of course, you wouldn't be telling us where
15
the commas are, I think, Sister Gargaro, but just to go
16
back to that, I will read the sentence to you so that
17
you can understand it.
18
or two before that, I think you were asked by me:
19
"Question:
I think if we go back a question
Did you make Liz Rawle aware of
20
the position in relation to the four patients at about
21
this time that you are talking about?
22
"Answer:
23
"Question:
24
"Answer:
25
I don't believe I did, no.
Why not?
From memory, my best recollection at the
time was I accepted Helen O'Neill's explanation with
106
1
regard to the definition of 'outbreak' and she reassured
2
me that it wasn't, because 'These cases can be
3
explained' ..."
4
5
Is that the sense of what you are saying -A.
6
7
It wasn't an outbreak, because these cases could be
explained.
Q.
8
What you are saying is "She reassured me it wasn't an
outbreak, because these cases could be explained"?
9
A.
Yes.
10
Q.
Do we take from that then that the conversation did
11
12
contain within it reference to "outbreaks"?
A.
It was more, I would say, reference to ward closing,
13
discussing the possibility of the ward having to close,
14
which is the issue that I first raised.
15
the word "outbreak" would have been used.
16
Q.
At all?
17
A.
Certainly by myself.
I don't believe
I find it difficult to quote
18
accurately the content of what Helen said at that time,
19
given the fact it was so long ago, but -- I have thought
20
about it long and hard and can't bring anything further
21
to the conversation with regard to specific terms that
22
she used.
23
let me know that we now are dealing with four
24
symptomatic people and had advice to cohort them
25
together, or some of them together, that I raised the
I just know that when she came to the ward to
107
1
issue.
2
It might sound flippant now, but it was very much
3
along the lines of "Cohorting?"
4
"Don't you mean closing?"
5
say, "No, because these cases can be explained".
6
Q.
As a question mark,
That is when she went on to
So I can be clear, then, are you saying now that the
7
word "outbreak" was not used at all, either by yourself
8
or Helen O'Neill --
9
A.
Not that I can recollect.
10
Q.
-- in the course of the conversation?
11
A.
No.
12
Q.
In relation to Liz Rawle, was Liz Rawle aware that you
13
had four patients, as you have explained, who each had
14
C. diff in the ward at the same time?
15
A.
At that point, she probably didn't know that we had four
16
patients.
17
some point she would have known that I had three, but
18
I wouldn't be able to say about the fourth patient.
19
Q.
I would imagine that at the bed meeting at
At some point close to when you had the discussion with
20
Helen O'Neill, would Liz Rawle have been aware of
21
the position in the ward?
22
A.
I wouldn't be able to say for sure, I'm sorry, no.
23
Q.
Just looking to the nature of what you had in the ward,
24
would that be the sort of thing that you would discuss
25
with Liz Rawle?
108
1
A.
I would imagine, if Helen O'Neill hadn't satisfied me
2
with her explanation, or I felt it was appropriate to
3
get further advice, I would certainly have probably
4
involved her at that stage.
5
recall at what point I discussed the levels of C. diff
6
with Liz because she was present at the meetings where
7
we exchanged that information on a daily basis.
8
Q.
9
However, I can't accurately
Are you placing the conversation you had with
Helen O'Neill in January 2008?
Are you placing this
10
conversation that you had with Helen O'Neill that you
11
have been telling us about in January 2008?
12
A.
Uh-huh.
It happened in January 2008, January, yes.
13
Q.
Are you able to say if, in January 2008, Liz Rawle
14
became aware that you had four symptomatic patients in
15
ward F?
16
A.
I wouldn't be able to say at what point she became
17
aware, but she would have been at the meetings every day
18
when we discussed the levels that we have in any one
19
ward at any one time.
20
a specific conversation that I've had with her with
21
regards to those figures.
22
LORD MACLEAN:
23
right?
24
A.
25
LORD MACLEAN:
But I can't accurately recollect
You said they were symptomatic cases; is that
Yes.
Of C. diff?
109
1
A.
2
I believe the discussion was confirmation of the fourth
positive of C. diff, yes.
3
LORD MACLEAN:
4
patients?
5
A.
6
LORD MACLEAN:
7
A.
8
LORD MACLEAN:
9
Did that mean you had four confirmed
That's my recollection.
Four patients confirmed with C. diff?
That's my recollection, yes.
The explanation that was given to you by
Helen O'Neill related to the antibiotics that they were
10
on; is that right?
11
A.
Yes.
12
LORD MACLEAN:
13
A.
Yes.
In relation to C. diff?
When she offered the explanation that because
14
these cases could be explained, we went on to discuss
15
further and she referred to the antibiotic usage as
16
being relevant to that.
17
LORD MACLEAN:
18
19
Were these four patients in a room by
themselves?
A.
No, I don't believe they were.
No.
Her advice at that
20
time was to cohort them together when she came to the
21
ward.
22
LORD MACLEAN:
23
A.
24
25
So they couldn't have been together?
They couldn't have been, but there was -- yeah, that's
true.
MR MACAULAY:
Did you cohort these patients together?
110
1
A.
Yes, I think we cohorted three of the four.
We had to
2
cohort on two occasions, from memory, so I believe there
3
was one occasion when we cohorted three together and
4
another occasion, perhaps, we had four together.
5
Q.
Can we look at the floor plan again; GGC00760001?
6
Perhaps you can tell me this before we focus on the
7
plan.
8
and then you cohorted four.
9
a moment ago?
10
A.
11
You said you cohorted three together at one time
Is that what you said
Yes, that's the best of my memory.
I can't be more
specific about dates or patient names, unfortunately.
12
Q.
Which came first: the three cohorting or the four?
13
A.
I wouldn't be able to say for certain, sorry.
14
Q.
If we look at the floor plan, then, whether it be three
15
or four, are you able to tell us which room, or rooms,
16
was used for cohorting?
17
A.
It would be room 16.
18
Q.
So if you had four, you would have to put an extra bed
19
20
into the room.
A.
Yes.
Is that correct?
I can't remember exactly what dates I had the
21
contingency bed in place in ward F, because I think it
22
happened a couple of times over that winter period.
23
Q.
Logically, if you needed to cohort four patients in the
24
one area and it was room 16, you would require to
25
introduce the contingency bed?
111
1
A.
The contingency bed was never introduced to allow
2
cohorting to take place in that room.
The contingency
3
bed would have already been in place.
We wouldn't have
4
put in an extra bed at that point.
5
Q.
We can observe, I think, as we did this morning, that
6
you had available to you three single rooms that could
7
be used to isolate patients.
8
A.
Yes.
9
Q.
So if you had to resort to cohorting three or four
10
patients, what are we to assume in relation to the
11
single rooms?
12
A.
The single rooms -- at the time of cohorting three, I'm
13
not too sure exactly what would be in the single rooms
14
at that time.
15
out on discussion with Helen and Jean on some occasions,
16
I'm not too sure what patients were in the side rooms at
17
that time.
18
Q.
But the risk assessment that was carried
What would the options be for the side rooms if we are
19
looking to January 2008 in ward F?
I think you had your
20
norovirus outbreak in December; is that correct?
21
A.
Yes, 21 December, yes, we closed for seven days.
22
Q.
What, then, if we are looking into January, the period
23
you have in mind in January, would the options be for
24
who might be accommodated in the single rooms?
25
A.
I'm not too sure perhaps whether we had other -- another
112
1
episode of diarrhoeal illness that hadn't been confirmed
2
that we were putting in precautions for, or perhaps
3
whether we had -- we wouldn't have had norovirus at that
4
time, but we might have had someone perhaps with
5
a multiple site -- MRSA, for example.
6
accurately recall.
7
to the ward with the advice that the patients should be
8
cohorted together.
9
I really can't
I just know that Helen O'Neill came
It is very difficult to remember the exact
10
placements of patients at the time, and I have tried do
11
quite a lot of work on it in using the timeline
12
information that I have been given, and I do believe
13
that perhaps the first time would have been when the
14
room just had three beds in it.
15
Q.
I will come back to that.
16
A.
Yes.
17
Q.
Would you, yourself, as the ward manager, have any basis
18
for prioritising as to who would, as it were, be first
19
in the queue to get into one of the single rooms?
20
A.
Ideally, any unexplained sudden onset of diarrhoea that
21
requires precautions to be put in place and also
22
confirmed episodes of C. diff positive patients.
23
Q.
24
25
Well, you had three or four C. diff positive patients
confirmed, as I think you are telling us.
A.
Yes.
113
1
Q.
But notwithstanding that, three or possibly four of them
2
had to be cohorted, which would suggest that the single
3
rooms weren't available.
4
A.
Yes.
5
Q.
But you can't tell us why the single rooms were not
6
7
available?
A.
8
9
I'm unable to do that, actually, at this moment, sorry,
from memory.
Q.
Can we look at one of the charts that's been prepared,
10
then, that I think you have had sight of for ward F, and
11
this is INQ02540001.
12
chart available to you?
13
it might be easier to work off a hard copy.
14
that?
Do you have a hard copy of that
We have it on the screen, but
15
A.
Yes.
16
Q.
We are looking at ward F.
Do you have
I think this document has
17
been explained to you before coming to give your
18
evidence; is that right?
19
A.
Yes.
20
Q.
Before we come to the period we are looking at, can we
21
see that you did have some C. diff in the ward
22
from March 2007 through to about July 2007; is that
23
right?
There were a number of cases at that time?
24
A.
Oh, yes, in the earlier period, yes.
25
Q.
But then we see that certainly for August and September
114
1
there is no C. diff in the ward, according to this?
2
A.
No.
3
Q.
There is then one case in October; is that right?
If we
4
focus in particular into December, and we look towards
5
the top of the page, can we see that one of your
6
patients, [Patient C], who is, I think, Patient C, is
7
certainly diagnosed positive and the ward is aware of
8
that on 26 December?
9
A.
Yes.
10
Q.
This is a patient I think that was transferred to ward F
11
12
from ward 6; is that right?
A.
13
14
That would probably have been the case, yes.
Yes, she
was a female stroke patient, yes.
Q.
Then, if we look into January, which I think is the
15
period you have been looking at, can we see that
16
[Patient C] is again positive by 11 January?
17
that?
Do you see
18
A.
Yes.
19
Q.
Do we then see a number of patients -- there is
20
Rosa Rainey, Mary Hamilton, Alister Brand and
21
Sarah McGinty, who were all positive towards the latter
22
part of January?
Do you see that?
23
A.
Yes.
24
Q.
Can you help, now that you have looked at the chart,
25
whether or not you are able to identify the patients
115
1
that you have been telling us -- that you mentioned
2
before lunch and we have been discussing since after
3
lunch?
4
had your discussion with Helen O'Neill about and you got
5
the advice to cohort?
6
A.
Are you able to identify the patients that you
I wouldn't be able to say what definite patients that
7
were symptomatic or confirmed positive at any one time
8
that prompted that discussion.
9
fourth patient was when Helen came into the ward to
I don't know who the
10
inform us at that time, but I'm trying to -- it's been
11
very, very difficult remembering where everybody was at
12
any one time, unfortunately, and it's been quite
13
a challenge trying to confirm where everybody was in the
14
ward at any one time.
15
Q.
Of course --
16
A.
I have got a suggestion here -- sorry.
17
Q.
No, you carry on.
18
A.
From some of the detective work that I have had to try
19
to do over the last few weeks, I would suggest that
20
[Patient C], Rosa Rainey and perhaps Mary Hamilton were
21
cohorting together.
22
Q.
23
24
25
And you say cohorted together in room 16, the
three-bedded room; is that right?
A.
Yes.
At some point on 25 January, when Mrs McGinty was
symptomatic, we were able to move Mrs Rainey into a side
116
1
2
room at that point, on 25 January.
Q.
3
The fourth patient on this analysis, would that be
Mrs McGinty?
4
A.
Yes.
5
Q.
I think from what you are saying, you are leaving
6
7
Alister Brand out of this equation at the moment?
A.
Yes, Mr Brand, again from some of the research I have
8
done, looks as if he was able to be isolated in a side
9
room on 24 January.
10
Q.
11
He is a male patient.
Would you keep male and female
patients separately?
12
A.
Yes, absolutely.
13
Q.
If we are looking for the first three, you are looking
14
at [Patient C], Mary Hamilton and Rosa Rainey; is that
15
right?
16
A.
17
18
Yes, to the best of my memory, what I have been able to
look at, yeah.
Q.
Then Sarah McGinty becomes the fourth; is that right?
19
You are able, at that point in time, to isolate
20
Rosa Rainey; is that what you are saying?
21
A.
22
23
Yes, I believe Rosa Rainey moved into the side room on
the 25th, on or around that.
Q.
As we read on, can we see that, on 3 February,
24
a specimen is collected from Mary Millen and that was
25
also positive and the ward was aware on 4 February.
117
Do
1
you see that?
2
A.
Yes.
3
Q.
Can you help with Mrs Millen?
4
A.
I think by the time Mrs Millen became symptomatic, some
5
of the previously diagnosed ones were asymptomatic.
6
Mrs Millen, again, from the work I have been able to do,
7
moved into a side room on 2 February.
8
Q.
You say she moved --
9
A.
1 February, sorry.
10
11
I believe it would have been
1 February she moved in.
Q.
Then we see that [Patient C] is once again positive
12
on -- it would appear that the ward is aware of that on
13
6 February.
14
A.
Do you see that on the chart?
Yes, I can see that, yes.
I'm sure my previous chart
15
had indicated it was 11 February.
16
that one.
17
Q.
18
I might be wrong on
We certainly had [Patient C] diagnosed positive by
11 January, if you look towards the top of the chart?
19
A.
Yes.
20
Q.
She is positive again, it would seem, by 6 February, if
21
22
you look at this chart.
A.
The original timeline -- probably an abbreviated version
23
of what we are looking at now indicates [Patient C] was
24
11 February and not the 6th, I have got here.
25
Q.
I think you can take it that the -- well, if I can put
118
1
this on the screen; GGC26340042.
We can see that is
2
a report from microbiology.
3
the 11th came from.
4
was collected on 5 February, it was received by the lab
5
on the 6th and the report date on the document is
6
11 February.
I think I can see now where
But you will see that the sample
Do you see that?
7
A.
Yes.
8
Q.
But what the chart is now telling you is that the ward,
9
in fact, would have been aware before that, in
10
particular would have been aware on 6 February, of
11
the positive result?
12
A.
Right, okay.
I think I have perhaps misinterpreted the
13
date the lab reported it as the date that we were
14
informed of it when I was doing some work on that.
15
Q.
I think generally we find, in fact, that the ward is
16
probably aware of the result before the report date we
17
see on the document.
18
of six days from the collection of the specimen until
19
the report?
Certainly, you wouldn't want a gap
20
A.
No, no, absolutely not, no.
21
Q.
If we go then on the chart --
22
MR KINROY:
My Lord, before we go any further, it appears
23
this witness has done quite a lot of, as she says,
24
"detective work" over quite a period of time, possibly
25
on the basis of an erroneous chart.
119
I hope not, but can
1
we perhaps clarify that my fear is unjustified?
2
Because, of course, it would go to her ability now to
3
answer the questions if the benefits of her detective
4
work have been to some extent vitiated by looking at
5
a different chart than the one she is seeing now.
6
LORD MACLEAN:
7
MR KINROY:
Which is the erroneous chart?
My Lord, I believe INQ02540001 is the one we now
8
believe to be correct.
I think the witness spoke to
9
a previous chart which she thought, but could not be
10
certain, differed from that on the date of Rosa Rainey
11
becoming once again positive.
12
LORD MACLEAN:
I probably haven't grasped this correctly,
13
but I do think, Mr Kinroy, that she made the assumption
14
that [Patient C] was C. diff positive on the 11th, but
15
in fact, it would appear it was on the 6th, when it was
16
received by the lab.
17
MR KINROY:
That's correct, my Lord.
That appears to be the
18
true position according to the lab report.
19
is that the witness has seen an erroneous chart, which
20
now means that her detective work is to some extent
21
vitiated because she may have proceeded on a mistaken --
22
or a misapprehension engendered by the chart.
23
LORD MACLEAN:
24
MR KINROY:
25
My concern
So?
The question then is: how equipped is she now to
deal with questions about the chart, when the whole
120
1
point of this was to give her charts on which to reflect
2
and to prepare, now she has brought to our notice that
3
one of the charts was erroneous, but no time to reflect
4
on the consequences of that?
5
LORD MACLEAN:
6
MR KINROY:
7
MR MACAULAY:
Are there any consequences?
I don't know, my Lord.
There might be.
I think, first of all, it is not Rosa Rainey
8
we are looking at, it is [Patient C], just to be clear
9
on that.
10
A.
[Patient C], yes.
11
Q.
The chart I put on the screen, which is INQ02540001,
12
were you given a copy of that chart in preparation for
13
giving your evidence?
14
A.
No.
I believe I got a chart with all the positive
15
samples and also a chart with positive and negative
16
results.
17
Q.
We also have that chart.
But are you saying, then, that
18
the chart we have on the screen is not one you have seen
19
before giving your evidence?
20
A.
I will just take one moment, if you don't mind, just to
21
have a look at the chart that I have got.
The two
22
charts I had in advance of coming today both have
23
11 February on the chart for [Patient C] and not the
24
6th.
25
the chart with all samples sent, positive and negative,
The chart with all the positive results on it and
121
1
there is no reference to 6 February on that.
2
know, sorry, that she was symptomatic possibly on the
3
5th, going by her nursing records, but I don't have in
4
the nursing records confirmation of a positive sample.
5
Q.
But I do
Can I understand this, then, that the detective work
6
that you have undergone, does that have to be
7
reconsidered if, in fact, [Patient C] is positive by
8
6 February?
9
relation to where people might have been at different
10
11
points in time?
A.
12
13
Does that impact upon your conclusions in
No, because it doesn't appear that her location has
changed, so I don't imagine it does, no.
Q.
I think what I was trying to establish with you is where
14
people were, and I think we had got to the point where
15
you thought Rosa Rainey, [Patient C] and Mary Hamilton
16
were at one point cohorted in room 16; is that correct
17
so far?
18
A.
Could you repeat the three names back again?
19
Q.
[Patient C], Rosa Rainey and Mary Hamilton.
20
Now, did
you say earlier --
21
A.
That is one of the conclusions that I came to.
22
Q.
Whether [Patient C] was positive on 6 or 11 February
23
doesn't impact upon that?
24
A.
Not at that time in January.
25
Q.
I think you said that the fourth person that you had in
122
1
mind was Sarah McGinty; is that right?
2
A.
By 25 January, yes.
3
Q.
Was it Sarah McGinty, the positive result in respect of
4
Sarah McGinty, that prompted your discussion with
5
Helen O'Neill?
6
A.
The exact point in January, I'm not sure as to whether
7
it was when I was cohorting three or four.
8
Unfortunately, I don't have any more accurate
9
information on that one.
10
MR PEOPLES:
My Lord, just going back to [Patient C],
11
I think just for the avoidance of doubt -- because we
12
have heard a lot about a patient called [Patient C] and
13
we will no doubt hear more -- I think the witness said
14
she was known as [Patient C], but perhaps she can
15
confirm that.
16
infection control card for [Patient C], one does get
17
some information about the knowledge of infection
18
control on 6 February and it may be from that that the
19
witness can be assisted.
20
21
22
23
LORD MACLEAN:
Also, I think if one looks at the
For my part, Mr Peoples, she is well known as
[Patient C].
MR PEOPLES:
It is just I think we see her first name as
[Patient C], not [Patient C].
24
LORD MACLEAN:
25
MR PEOPLES:
We have encountered her before.
Yes, we have.
123
1
LORD MACLEAN:
2
MR PEOPLES:
3
Patient C, remember.
There are other [patients of the same name] who
have similar traits in other wards.
4
LORD MACLEAN:
5
MR PEOPLES:
6
LORD MACLEAN:
7
MR PEOPLES:
She came from ward 6, I think.
Yes, she did.
That is my recollection.
I was just saying that, in assisting on dates,
8
I think one gets some guidance perhaps from the
9
infection control card, or may get it, and it is
10
SPF01390001.
11
clarify on dates.
12
MR MACAULAY:
13
14
I think you did mention in passing -- you used
the name [Patient C] to describe [Patient C].
A.
15
16
It may be that this would at least help
I don't believe I mentioned it.
known as [Patient C].
Q.
But she was fondly
It was her preferred name, yeah.
If we look at the infection control card for
17
[Patient C], that's SPF01390001, can we see that
18
24 December there is reference to "Informed by lab
19
staff".
Do you see that?
20
A.
Yes.
21
Q.
That would then be the first occasion that [Patient C]
22
23
tested positive in ward F?
A.
24
25
Yes.
The ward was closed at that point with norovirus.
We were sampling quite a lot.
Q.
The next entry we see is for 4 January, where we are
124
1
told that "Flagyl due to be discontinued.
2
formed stool".
3
it is "Positive CDT spec today.
4
Metronidazole".
Has had
The next entry is for 10 January, where
Commenced on
Do you see that?
5
A.
Yes.
6
Q.
I think we had seen on the report on the screen that the
7
next positive sample -- sorry, we had seen on the
8
chart -- perhaps we can put the chart back on the
9
screen.
10
[Patient C] is again positive by 11 January; do
you see that towards the top of the page?
11
A.
Yes.
12
Q.
Then, if we move on into February, where we were,
13
I think, when we got a little bit bogged down, if you
14
turn to page 2 of the infection control card,
15
SPF01390002, is there an entry a few lines from the top
16
of the page for 6 February:
17
"Symptomatic again.
Positive result from specimen.
18
Has been commenced on vancomycin.
19
single rooms."
20
Cannot isolate.
No
Do you see that?
21
A.
Yes.
22
Q.
That would tend to suggest that, even at this point in
23
24
25
time, it wasn't possible to isolate [Patient C].
A.
Yes.
I unfortunately have no record in the nursing
notes that that sample was confirmed as positive on
125
1
2
6 February.
Q.
3
Indeed.
The infection control nurse was clearly aware
by 6 February.
4
A.
Yes.
5
Q.
The chart, as best as one has been able to do it, is
6
trying to work out when it might be the case that the
7
ward would be aware.
8
been told by the infection control nurse?
9
A.
Yes.
Would you expect the ward to have
Monday to Friday, the infection control nurse
10
would generally either come to the ward or phone us with
11
the result.
12
staff.
13
Q.
14
Out of hours and weekend would be the lab
It seems from the entry that the infection control nurse
had the information that it wasn't possible to isolate.
15
A.
Yes.
16
MR PEOPLES:
My Lord, I wonder, just on that entry, it
17
records that she's been commenced on vancomycin.
18
I presume that one can infer that the doctor on the ward
19
would have prescribed that and, therefore, one can
20
assume that the ward staff knew the position as at
21
6 February?
22
A.
Yes, she was there -- we have got acknowledgment in the
23
nursing records that she was symptomatic.
24
have confirmation of the positive result documented in
25
our own records.
126
We just don't
1
MR MACAULAY:
2
3
Should that have
been documented in your records?
A.
4
5
I will come to look at that.
I would have expected a ward member to write that down,
yes.
Q.
You mentioned a moment ago that you had also looked at
6
a chart that contained both positive and negative
7
results.
8
I ask you this: at the relevant time -- that's at about
9
this time, early January into February and March 2008 --
10
I don't propose to dwell on that, but can
were you aware of the potential of false negatives?
11
A.
No, I wasn't.
12
Q.
Is that something you have learned of since?
13
A.
It is.
14
Q.
Just looking to the discussion we have had, then, and we
15
have tried to focus on patients -- and can I say it may
16
be under reference to evidence we have had from family
17
members, it might be possible to focus on where patients
18
were at that point in time?
19
A.
Yes, that would be useful.
20
Q.
But did you, yourself, as the ward sister, consider that
21
you had a problem with C. diff at about this time
22
in January and into February 2008?
23
A.
24
25
Yes, I was -- the figures that I had at the time were
the highest I have ever had in ward F.
Q.
That being so, you have told us about the discussion you
127
1
had with Helen O'Neill.
2
considering that you thought you had a problem, or did
3
you take any further action?
4
A.
Was that the end of it,
No, I don't recall taking any further action.
We
5
continued to inform infection control with the new onset
6
of anyone else symptomatic.
7
the day they would have the current level of symptomatic
8
or positive people in the ward area.
9
Q.
10
So at any one point during
You have told us that you had your regular bed
management meetings on a daily basis?
11
A.
Yes.
12
Q.
Was this something that was raised at any of these
13
14
meetings?
A.
The bed meetings discussed quite a lot of things, but it
15
turns out, around about September 2007, we started to
16
introduce the concept of completing records to show what
17
everybody had isolated in their single rooms across the
18
hospital.
19
infection control, but the information was held with the
20
bed manager, and she completed a form with all the
21
symptomatic patients in isolation at that time.
22
Q.
23
I believe that might have been initiated by
Did you mention there September 2007?
Are you sure
about that date?
24
A.
If you've got reason to point out something, then --
25
Q.
As you can imagine, the Inquiry is particularly
128
1
interested in getting information as to where people
2
were.
3
information from February 2008 but not
4
from September 2007.
5
from September 2007?
6
A.
So far as we have been able to see, we have that
Do you think it exists
I'm sure some of the work that I've done in
7
preparation -- the infection control working group, it
8
might have been, minutes identified a date where
9
Jean Murray and Isobel Law had decided it would be
10
a good idea to fill in a form with all the information
11
of isolated patients.
12
Q.
13
14
from September 2007 through to January 2007 [sic]?
A.
15
16
Have you actually seen documentation covering the period
I have seen any of these documents.
I just knew they
were completing them at the bed meeting.
Q.
January 2008.
17
From the bed management meetings that you had at
18
about this time, did you get any information in relation
19
to whether or not there were any issues over C. diff in
20
any of the other wards in the hospital?
21
A.
I was aware that other areas had it, yes; to what
22
extent, I didn't know, but I certainly heard it
23
mentioned that other people with single rooms had
24
C. difficile at some points, yes.
25
Q.
We went down this route, I think, because we looked at
129
1
the definition of "outbreak" in the outbreak policy.
2
One policy I do want you to look at is the loose stools
3
policy.
4
were you aware of the contents of the loose stools
5
policy --
I may have asked you this this morning, but
6
A.
Yes.
7
Q.
-- in the infection control manual?
8
A.
Yes.
9
second presentation of loose stool within a 24-hour
10
11
I knew what prompted us to send samples on the
period, yes.
Q.
What about isolation?
If you had a patient who had
12
loose stools and you were to take a sample from such
13
a patient because you suspected the patient might be
14
infected, what was your attitude to isolating such
15
a patient pending confirmation of the results of
16
the specimen?
17
A.
If you are suspecting someone has infective diarrhoea,
18
then you are putting precautions in place at that point
19
of sampling, so when they present with their second
20
sample or second episode within 24 hours, we would be
21
looking at setting up precautions at that point, because
22
you are obviously strongly suspecting this could be
23
infective in nature.
24
If we had side rooms available, that would be our
25
first choice, would be to put that person in a single
130
1
room.
2
precautions at their bedded area, which is all the
3
transmission-based precautions in the absence of
4
actually having the single room to put them in.
5
Q.
Other than that, we have to set up the
If you had such a patient in either the four- or
6
six-bedded area, then do I take it from that answer
7
that, if you couldn't isolate the patient, the patient
8
would remain there in the four- or six-bedded area, but
9
you would take these additional precautions?
10
A.
Yes, if my ward is full and I have not got any remit to
11
move the ward around, that might have to be
12
a possibility we would consider, yes.
13
Q.
What was your state of knowledge in relation to the
14
risks of cross-infection at about this time, early 2008,
15
with patients who had diarrhoea who had not yet been
16
diagnosed with C. diff?
17
the four-bedded bay or in the six-bedded bay, was
18
cross-infection, in such circumstances, something you
19
gave any consideration to at all?
20
A.
Absolutely.
So if you had such a patient in
That is the main reason why we put
21
precautions in place.
In the absence of having a single
22
room, they would put in the single-use equipment and the
23
clinical waste bin, all the standard precautions we
24
would have in an isolation room, except we are unable to
25
actually have the walls around them to do it.
131
1
Q.
What about the mobility -- if you had a patient who was
2
mobile, what then?
3
diarrhoea, waiting for the result, but is inclined to
4
get up and move around the ward?
5
A.
If you had a patient who had
Well, you're looking to restrict them into that area as
6
much as you can to obviously reduce the risk of
7
cross-infection, yes.
8
Q.
9
Can I just understand the practice that you followed in
ward F with regard to the collection of specimens?
10
Can
you just help me with that?
11
If you had a patient who had diarrhoea and you
12
wanted to collect a specimen from that patient, what
13
would the procedure be?
14
A.
You would take the appropriate equipment to your
15
patient, obtain the sample -- well, you would
16
obviously -- I'll talk you through exact step by step,
17
sorry.
18
You would protect yourself with your PPE, your
19
gloves and your apron, and take the necessary sample
20
bottle and forms, et cetera, to the patient; obtain the
21
sample.
22
complete the relevant paperwork, putting the specimen
23
container in the bag and then be repeating the hand
24
hygiene and leaving the sample.
25
I would then take off my PPE and hand wash and
At that time, we had the ability to phone the porter
132
1
and get the sample straight over to the lab, so we could
2
fast-track it.
3
Q.
4
There, are you assuming that you have taken the sample
from the patient in the patient's own room?
5
A.
Yes.
6
Q.
If you had a mobile patient, could such a patient go to
7
8
the toilet and leave the specimen there?
A.
9
If we were expecting a specimen, we would forewarn
the patient in advance and generally use a commode with
10
11
No.
a bedpan.
Q.
Can you think of any occasions where the patient might
12
have gone to the toilet and left the specimen for
13
collection in the toilet?
14
A.
No.
We would have to set up the toilet to be able to
15
retrieve the sample, because, obviously, had they just
16
used the toilet, the sample wouldn't be able to be
17
retrieved, so that situation, to my knowledge, was never
18
set up, no.
19
Q.
20
21
the ward?
A.
22
23
There is a collection point at -- I might be able to
explain it better if --
Q.
24
25
Once the sample has been taken, where does it go within
Let's put the floor plan on the screen, then,
GGC00760001.
A.
So there was a recessed area in between room 10 and the
133
1
first single room.
It was a shelved area.
On the top
2
shelf of that it had a collection tray for samples.
3
Q.
So we see room 10 on the bottom section of the plan?
4
A.
Yes, that would be the kitchen.
5
Q.
It is outwith that area, is it?
6
A.
No, sorry, maybe I'm misreading the number.
7
is actually 19.
Maybe that
Sorry, on the other side of the ward.
8
Q.
So it is 19.
Did you see -- is that a kitchen?
9
A.
We have the three-bedded -- room 16, which is
10
three-bedded.
11
Then, room -- I think, if that says "19", that would be
12
the kitchen.
Then the next black dot would be the
13
sluice area.
Then between the sluice area and the first
14
single room, just outside the single room there would be
15
a -- there is a shelved area with a collection point.
16
Q.
17
18
Would the sample wait there for the porter to come and
collect it?
A.
19
20
Then we have a general bathroom area.
Yes, unless we'd fast-tracked it, and they would be
there within a few minutes.
Q.
21
Was the fast-tracking system in place at the relevant
time that we are interested in?
22
A.
Yes.
23
Q.
You are sure about that?
24
A.
I have seen confirmation in nursing records for one of
25
Yes, it was.
the samples in February that it's been fast-tracked,
134
1
2
I think.
Q.
3
Would you fast-track a sample that you suspected might
be C. diff?
4
A.
Yes.
5
Q.
Were all C. diff samples fast-tracked?
6
A.
Whenever the service became available -- that's the date
7
I'm unclear about -- or whenever we were given the
8
information that we could fast-track, if we had
9
suspicion of C. diff, we would get the porter to take it
10
11
there and then, yes.
Q.
Would the report from the lab then indicate that the
12
sample had been collected at a particular point and
13
received by the lab very shortly after that?
14
be able to ascertain from the report from the lab
15
whether or not it was a specimen that had been
16
fast-tracked?
Would you
17
A.
Yes, I would imagine, yes.
18
Q.
So far as the portering service was concerned, was that
19
20
service available at the weekend?
A.
Yes -- no, I think it was just -- I didn't work
21
weekends, so that is quite difficult to comment on, but
22
I believe there was specimen uplift on a Saturday
23
morning.
24
25
Q.
After that, I'm not sure, sorry.
If the result was negative -- and we have certainly
heard this from other evidence, that negative results
135
1
2
would not be communicated verbally to the ward.
A.
3
4
result, no.
Q.
5
6
No, I don't remember being phoned with a negative
So you would, in due course, get the report indicating
that the result was negative?
A.
Yes.
I have had occasion, if there's been a delay with
7
the lab contacting us, to contact them to find out
8
a result, but bearing in mind you have got your
9
precautions in place at this time anyway.
10
Q.
But if you are told -- once you have discovered that the
11
report is negative, and usually that would be by the
12
report being transmitted to the ward, would you then
13
remove the precautions you had put in place pending the
14
result?
15
A.
That would depend on if there is another explainable
16
cause for their diarrhoea.
17
a patient who had a very reasonable diagnosis when
18
infection was ruled out to explain her continued
19
symptoms, but if we didn't have that and the symptoms
20
continued, we would be looking to keep precautions in
21
place with further sampling at a later date.
22
Q.
I think we have got
As a matter of fact, looking to your more recent
23
examination of the records, do you know if any patient
24
in ward F was isolated pending the result of
25
the specimen?
136
1
A.
2
3
with precautions in place?
Q.
4
5
By "isolation", do you mean actually in a single room or
"Isolation" in the sense of being isolated in a single
room.
A.
In a single room, and having -- by looking at the
6
records, identified a suspected C. difficile in a single
7
room?
8
Q.
9
Is that what you're asking?
I will put the question again.
It wasn't particularly
clear.
10
A.
Sorry.
11
Q.
We have been discussing the approach to loose stools and
12
the desirability, at least, of isolating a patient who
13
has loose stools and may be infected with such as
14
C. diff.
15
tell us from your examination of the patients' records
16
if, in fact, any patient who had loose stools was
17
isolated prior to the C. diff result being confirmed?
18
A.
What I am asking you is whether you can now
Unfortunately, that -- where we place the patient and
19
the precautions that we start is not often documented in
20
the nursing records, so I wouldn't be able to get that
21
information, unfortunately.
22
We have not been very good at actually discussing at
23
what point we move a patient into a side room or at what
24
point we start precautions, because the principles of
25
standard precautions are there with any suspected
137
1
infected bodily fluid.
2
at the records, I have not been able to ascertain that
3
with certainty.
4
Q.
But I must admit, from looking
If we go back to the chart and put it on the screen,
5
INQ02540001, so far as [Patient C] is concerned, we take
6
from this chart that the sample was collected from her
7
on 23 December the first time, and the ward or infection
8
control were aware by 26 December.
9
Do you know if [Patient C] was isolated pending the
10
confirmation of the C. diff result?
11
isolated in a single room.
12
A.
13
In a single room, yes.
By that I mean
We moved [Patient C] into
a single room on 27 December.
14
Q.
So you have that information in front of you?
15
A.
Yeah, I managed to get that from the notes, when she was
16
actually moved into a single room.
17
prior to that, perhaps, that wasn't an option for us and
18
we had to just have the precautions in place in the room
19
where she was.
20
Q.
I understand your position on that.
I would imagine
What I am trying to
21
ascertain is whether, as a matter of fact, any patient
22
was isolated pending the confirmation of the result.
23
What about, then, Rosa Rainey?
If we -- perhaps go
24
back to [Patient C] again, because she is actually
25
diagnosed again, I think, by 11 January.
138
Are you able
1
to say whether she had been isolated pending the
2
confirmation of the result?
3
A.
4
5
I have got information on the chart that suggests she
was in a side room at that point.
Q.
Then Rosa Rainey is the next patient.
6
Mrs Rainey?
7
pending the result?
8
A.
9
Can you say whether or not she was isolated
I think, at that point, Mrs Rainey might have been one
of the cohorted patients who was moved into a side room,
10
11
What about
I believe from the records, on 25 January.
Q.
12
If we look at the infection control card, SPF00710001,
we can read that for 21 January:
13
"Informed by lab staff patient in shared bay."
14
Does that tell us, then, that she was not isolated
15
16
pending the confirmation of the C. diff result?
A.
Yes, that confirms that she wasn't in a single room at
17
that point.
18
place at the bed space.
19
MR KINROY:
20
She would just have had her precautions in
My Lord, can I clarify why it says "Informed by
lab staff that the patient was in a shared bay"?
21
MR MACAULAY:
22
A.
Sorry, can you ask that again?
23
Q.
If you look at the document, the date for
24
25
Could you help?
21 January 2008, it reads:
"Informed by lab staff patient in shared bay."
139
1
It depends on how you read that, whether there
2
3
should be -A.
I would imagine she means "Informed by lab staff", and
4
then "Patient in shared bay".
5
lab staff who told her that.
I don't think it is the
6
Q.
We probably could do with a full stop in there?
7
A.
Yes.
8
Q.
What I want you to look at next is Mr Brand --
9
LORD MACLEAN:
Before you do that, Mr MacAulay, I would like
10
to know a little bit more about the nursing care of
11
the person we know as [Patient C].
12
that?
13
MR MACAULAY:
14
Are you going to do
I am going to look at some of the records in
a little more detail.
15
LORD MACLEAN:
16
MR MACAULAY:
Thank you.
What about Mr Brand, Sister Gargaro?
Can you
17
help with him?
18
sample was collected on the 21st and she was certainly
19
positive by the 23rd.
20
earlier about Mr Brand being in a single room or did
21
I misunderstand?
22
A.
You will see on the chart that the
Did you say something to me
I believe when he first became symptomatic on
23
20 January, we weren't able to isolate him in a single
24
room.
25
up, and the bed space he had, if you understand the
I think, from memory, we had the precautions set
140
1
six-bedded room, as you walk in the door, had two beds
2
to the left, a very large area floor space and then four
3
beds on the other side.
4
left bed with precautions in place until we could move
5
him into the side room on -- if you bear with me --
6
I believe 24 January.
7
Q.
8
9
So that would be possibly the day or so after he had
been positively diagnosed with C. diff?
A.
10
11
So he was on the second on the
I do remember Mr Brand having precautions at a bed space
for a couple of days, yes.
Q.
You have perhaps anticipated one of the points I should
12
have raised with you.
If we can just put the floor plan
13
back on the screen, GGC00760001, do I take it from what
14
you said a moment ago that the six-bedded area, room 13,
15
was a male room?
16
A.
At that time it was, with Mr Brand in it, yes.
17
Q.
How was the rest of the hospital divided up, then, male
18
19
and female; or was it?
A.
20
21
It was just depending on the mix of the patient group at
the time.
Q.
It had no set definition each room, no.
Then, if we look at the next patient, we see it is
22
Mary Hamilton, where she's certainly diagnosed by about
23
22 January.
24
she was isolated before the diagnosis was confirmed?
25
A.
What can you tell us about whether or not
I'm not able to obtain from the records any point that
141
1
she was in a single room.
2
one of the cohorted group.
3
Q.
4
5
That would suggest, then, she was not in the single room
when the diagnosis --
A.
6
7
I believe Mrs Hamilton was
And at any point, I have not been able to get from the
records that she ever was in a single room.
Q.
Then, if we just stop in January and we come to
8
Sarah McGinty, what about Mrs McGinty pending the
9
result?
10
A.
11
12
Can you tell us what the position was?
Sarah McGinty wasn't moved into a single room until
1 February.
Q.
Would it appear, then, Sister Gargaro, in relation to
13
each of the patients we have looked at who were
14
diagnosed as positive, subject to [Patient C] on the
15
second occasion, that they were not isolated, for
16
whatever reason, pending the positive results of
17
the C. diff infection?
18
A.
19
20
It would suggest we have not been able to put them in
a single room, yes.
Q.
In relation to this aspect of a patient's care -- and by
21
that I mean isolation pending the results of
22
the specimen -- to what extent would you, as the ward
23
manager, be directly involved in that?
24
25
A.
It would vary from day to day.
I mean, I would
certainly be looking to make sure all the precautions
142
1
were in place that should have been, and if I was having
2
a caseload that day, I could be very much directly
3
involved in that person.
4
time, I would certainly want to know -- reassure that
5
all the suitable precautions were in place.
6
Q.
But outwith that demand of my
It would seem that over a period of several days you had
7
been sending specimens and obtaining positive results.
8
As the days went on, can you say, looking back to this
9
time, whether your suspicion that it may be a positive
10
C. diff result was heightened because you had C. diff in
11
the ward?
12
A.
Yes.
13
Q.
Did that impact at all upon your thinking as to whether
14
15
or not patients really should be isolated?
A.
Patients require isolation, or at least precautions in
16
place, if there is only one incident on the ward or four
17
or five.
18
regardless of the number.
19
Q.
You have to put in the same precautions
To what extent, if at all, would you involve bed
20
management in this exercise?
21
have seen, for a number of patients at this time you
22
were not, for whatever reason, able to isolate the
23
patient, would that be a matter that you would raise
24
with bed management to see whether or not there were
25
other areas of the hospital, for example, that could
143
Because if, in fact, as we
1
provide isolation?
2
A.
Yes.
3
Q.
Did you?
4
A.
Yes.
5
Q.
What was the response?
6
A.
I'm not -- I don't recall any patient moving out of
7
ward F to be able to be accommodated in a single room
8
elsewhere.
9
happening.
From memory, I can't remember that
10
Q.
Was it something that was explored with bed management?
11
A.
Yes, we would contact the bed manager and explain our
12
difficult -- well, alongside a discussion with infection
13
control, and explain our difficulty in being able to
14
isolate truly in a single room, and she would perhaps
15
consult this chart that she's already started getting
16
from the bed meeting and give us an answer directly or
17
have to phone around other areas and then report back to
18
us what she's been able to find out.
19
Q.
Just to understand fully the involvement of infection
20
control, if you had a patient who had loose stools and
21
you planned to take a specimen and send that for
22
analysis, would infection control be involved at that
23
point?
24
A.
Well, at the first point of taking the sample?
25
Q.
Yes.
144
1
A.
Yes -- would I contact infection control and tell her
2
I'd taken the sample?
3
one patient who had two episodes of loose stool in
4
24 hours, I wouldn't necessarily be prompted at that
5
point to let her know.
6
example, then, yes, I would.
7
Possibly not, no.
If I just had
If I had a couple of them, for
Incidentally, if she's at the bed meeting or in the
8
ward area, I would certainly let her know, but I don't
9
recall that I would actually phone her on that occasion,
10
no.
11
Q.
So you wouldn't phone with one patient, but --
12
A.
No, but if I had -- yes, if I had a couple, yes.
13
Q.
You would?
14
A.
Yes.
15
Q.
So if you had two or more patients with loose stools,
16
then infection control --
17
A.
Then I would let her know.
18
Q.
-- would be aware of that?
19
A.
Yes.
20
Q.
Can I then leave that aspect aside for the moment and
21
just touch on care planning.
22
model of care planning that you used in ward F at the
23
time we are looking at?
24
25
A.
Yes.
Was there a particular
The model that we used for our care planning was
based on the Roper Logan and Tierney approach.
145
1
I remember discussing it at reasonable length in one of
2
my statements, about that model.
3
we devised the core care plans that we developed for
4
ward F.
5
Q.
That is the basis that
You have mentioned the core care planning before.
Were
6
you, yourself, directly involved in putting together
7
that core care plan documentation?
8
A.
9
The nursing staff on the team were allocated certain
topics to work together with, and then I would ratify
10
the information at the end before it got put forward to
11
the records committee to put on the hospital forms'
12
drive on the computer.
13
Q.
When was this initiative put in place, can you remember?
14
A.
Gosh, quite some time ago, actually.
I think we
15
developed the first one -- I can't remember, to be
16
honest, but I would say at least five years ago now.
17
Q.
I think what you said is the information -- you would
18
ratify the information at the end before it got put
19
forward to the records committee?
20
A.
Mmm-hmm.
21
MR PEOPLES:
While we are on the records committee, my Lord,
22
lots of forms have reference to "Records committee" on
23
them.
24
for introducing a new form, if she is aware of it?
25
it have to go through a committee process before it
Can perhaps Sister Gargaro explain the procedure
146
Did
1
2
could be used?
A.
I don't believe the core care plans actually had to go
3
via the committee because they were solely for the use
4
of ward F staff who write care plans on a day-to-day
5
basis without ratification.
6
put forward that didn't exist at all, we put through the
7
practice development team, who I believe was part of
8
the records committee, and that would be -- my first
9
contact would be Judy Taylor in that instance.
10
MR MACAULAY:
But any other form that you
Was Judy Taylor somebody who provided you with
11
guidance in relation to how such core care plans should
12
be constructed?
13
A.
No, I don't believe she was involved at that stage, no.
14
Q.
So, really, the construction of the forms was done in
15
the ward?
16
A.
Yes.
17
Q.
And then you passed them on for any, what, input that
18
she may have?
19
A.
Yes.
20
Q.
If we focus again on C. difficile, so far as you're
21
concerned, what education, if any, had you had in
22
relation to C. diff prior to the period that we are
23
concerned with?
24
25
A.
That is prior to about January 2007?
I can't recall any formal training sessions on the
subject of C. diff prior to 2008.
147
Reference was made to
1
some information newsletters that we used to get sent to
2
us from infection control, and I believe the wider
3
aspect of infection control touched on it during my
4
general training, but certainly not any formal sessions
5
on the subject of C. diff separately.
6
Q.
7
What about the Cleanliness Champions programme?
Had you
completed that by June 2008?
8
A.
Yes, I had, by then, yes.
9
Q.
Can you remember when you had completed it?
10
A.
I registered for that initiative quite early on,
11
I think, in 2007, but I'm ashamed to admit that the
12
final module of the 11 I don't think I completed until
13
some time later, which would have been -- I certainly
14
refer to it in my statement, the exact date, which
15
I can't remember off the top of my head.
16
Q.
17
18
education on C. diff?
A.
19
20
Is there a section in that that does provide some
I believe so.
But I can't accurately remember that at
the moment, sorry.
Q.
In relation to the management of C. diff, and just
21
looking at your state of knowledge from January 2007
22
onwards, up to about June 2008, in relation to things
23
like hand washing, for example, were you fully aware as
24
to what was necessary?
25
A.
Yes, because your policy contains that information.
148
1
Q.
2
3
Was that your source, then, for finding out what sort of
hand washing was required?
A.
Yeah, the infection control manual and infection control
4
themselves, and also some of the information that the
5
link nurses for infection control would bring back from
6
the meeting would reinforce certain aspects of
7
the policy.
8
Q.
9
10
Since June 2008, have you had some training in relation
to C. diff?
A.
Yes.
I have had -- yes, I have had mandatory infection
11
control training sessions, and there's also been
12
a separate session, which I can't remember the date,
13
particularly for the management of C. diff, yes.
14
Q.
Has that improved your knowledge?
15
A.
It hasn't improved the knowledge of the basics of
16
managing someone with C. diff, but we are certainly much
17
more aware now of the severity markers indicating the
18
severity of the illness.
19
certain blood results, as members of nursing staff, and
20
medicine, we were keen to keep an eye on, but I have
21
since become much more informed about the input of the
22
parameters of recording white cells and creatinine,
23
et cetera.
24
the time.
25
MR MACAULAY:
There is always -- there were
That is certainly not something I knew at
If your Lordship were to have a short break,
149
1
2
this might be the appropriate point.
(3.15 pm)
3
(A short break)
4
(3.32 pm)
5
MR MACAULAY:
We saw, Sister Gargaro, that in relation to
6
patients in ward F in January and going
7
into February 2008, there were a number of patients who
8
ultimately tested positive for C. diff.
9
A.
Mmm-hmm.
10
Q.
What medical input would there be to the management of
11
12
such patients?
A.
Dr Akhtar, the consultant at the time, would have a ward
13
round once a week, MDT discussion once a week and any
14
review outwith that that was requested of him by his
15
junior medical staff, or by myself in some cases.
16
Q.
17
I think you indicated this morning that Dr Akhtar formed
part of the multidisciplinary team?
18
A.
Yes.
19
Q.
So would there be a meeting of the team, do you reckon
20
21
how often?
A.
He did a consultant ward round every Tuesday and the MDT
22
team discussion of all the patients on a Wednesday, and
23
he was available for -- he was available almost every
24
day for any junior member of staff to consult with him
25
or nursing staff in some cases.
150
1
Q.
Would Dr Akhtar and, indeed, the other members of
2
the team then be made aware of the number of patients
3
that you had on the ward with C. diff?
4
A.
5
6
Yes.
He would have that information when he was
reviewing the patients, yes.
Q.
Are you able to say whether he would be -- would he be
7
involved at all in the discussions as to what should
8
happen in relation to the ward, for example, whether the
9
ward should be closed or that sort of thing?
10
A.
11
12
No, he wouldn't be part of that discussion, unless he
raised it himself, I suppose.
Q.
Can I just understand from you how you managed handover
13
in ward F?
14
to an end and the new shift due to start, first of all,
15
can you tell me normally when that would be in the
16
course of the day?
17
A.
If you imagine that there is a shift coming
7.30 in the morning, the girls that were on overnight
18
would hand over to the day shift, and that would take
19
roughly half an hour, although sometimes, quite often,
20
it went over 8 o'clock in the morning, and then the same
21
again in the evening: the staff of that day, at 7.30,
22
would hand over to the oncoming shift at night.
23
Q.
24
25
Would the handover in the evening coincide with the
visiting hours to the ward?
A.
Yes, it did.
151
1
Q.
2
3
Could that impact upon staff being available to discuss
matters with family members who might be visiting?
A.
Yes, it would.
We split the handover into two separate
4
halves, so that one nurse that was looking after one
5
team would hand over to the night shift and then the
6
next nurse would take over.
7
availability of one trained nurse.
8
limited, yes.
9
Q.
So there should always be
But certainly it was
I now want to look at some individual patients with you.
10
What I propose to do is to look at the case records of
11
a number of patients who were accommodated in ward F,
12
and also to take you to some comments made by family
13
members.
14
observations that have been made from independent nurses
15
who have prepared reports in connection with each of
16
these patients.
17
I may also take you for your comments to
The first patient I want to look at with you is
18
indeed [Patient C].
19
the background to her, she was admitted to ward 6, first
20
of all, on 9 December 2007 and she was admitted to your
21
ward, ward F, on 14 December 2007.
22
records, in fact, to see the basis of the admission, if
23
we look at GGC26340169, you will see for
24
14 December 2007, at 2230, there is an entry that reads:
25
Just to remind you of
"Admitted to ward as boarder."
152
If we look at the
1
Do you see that?
2
A.
Yes.
3
Q.
I think this indicates when [Patient C] was admitted to
4
5
the ward.
A.
What does that mean?
I saw that when I was looking through the notes, and it
6
surprised me, because [Patient C], to my understanding,
7
came to the ward as a stroke patient.
8
be somebody moving from another specialty into an empty
9
bed on your ward to relieve some pressure at the front
10
11
A boarder would
doors of the hospital.
Q.
12
So not someone then -- well, would it be somebody who
would need some nursing care?
13
A.
Oh, absolutely, yes.
14
Q.
But not a stroke patient?
15
A.
No.
Anyone that transfers into a ward that has had
16
a stroke is one of ward F's patients.
17
moves from the medical wards that doesn't have
18
a diagnosis of stroke but they need to free up some
19
admission beds would come up to our ward as a medical
20
boarder, is the term.
21
Q.
Someone that
If we look at the next entry, just to perhaps get the
22
flavour of what the position was with [Patient C], it is
23
for 15 December at 1600 hours:
24
25
"Washed and dressed with assistance.
about ward.
Wandering
Interfering with other patients'
153
1
belongings.
2
Was this a picture that [Patient C] presented, that
3
4
Diet and fluids taken well."
she did wander about the ward?
A.
5
She had episodes, yes, where she would do that because
of her background of dementia.
6
Q.
Do you recollect this particular patient?
7
A.
Yes, I do remember [Patient C].
8
Q.
She was in the ward for quite some time?
9
A.
She was, yes.
10
Q.
If we look at the medical history, as set out in
11
Professor Palmer's report, EXP00450001, page 3 of this
12
report, towards the bottom, he's noted:
13
"[Patient C] was admitted to the Vale of Leven
14
Hospital on 9 December 2007 following a collapse at
15
home.
16
a noticeable facial droop and floppy left arm."
17
She was found by her carer ... and had
I think she had previously been in hospital because
18
she'd had a fall and fractured her right femur.
19
If we look at page 4, the middle paragraph:
20
"Over the following days and weeks it became
21
apparent that [Patient C] was significantly confused,
22
occasionally agitated and frequently tended to wander
23
around the ward.
24
falls, the nursing staff discussed the possibility of
25
hip protectors with the physiotherapists which were
As she presented a significant risk of
154
1
subsequently ordered.
2
transferred from ward 6 and boarded to ward F."
3
On 14 December she was
That is where we'd got to, I think, in your ward.
4
If you go back to the charts we looked at earlier,
5
INQ02540001, do we see that, really, [Patient C] is the
6
first patient to be positive for C. diff if we are
7
moving from December 2007 into January 2008?
8
A.
Yes.
9
Q.
Perhaps I could just get you to look at the reports, if
10
you turn to page 46 of the records, you will see there
11
there is a report from microbiology, and we don't,
12
unfortunately, have the date of collection, but you will
13
see it is received by microbiology on 24 December and it
14
is a positive result addressed to ward F.
15
that?
Do you see
16
A.
Yes.
17
Q.
The clinical details are given "Episode diarrhoea
18
infection outbreak in ward".
19
the point in time you still had your norovirus?
20
A.
21
Yes.
At this point, was this
The specimen was collected that morning,
incidentally, from the nursing record.
22
Q.
Do you think it was collected on the morning of the --
23
A.
The 24th.
24
Q.
Perhaps we can turn to page 172 of the records.
25
the entry we have for 0550?
155
Is that
1
A.
Yes.
2
Q.
"1 episode of diarrhoea at 9 pm - mucous present,
3
specimen obtained."
4
A.
Yes.
5
Q.
Do we read at 1630:
6
"Phone call from infection control - C. diff
7
positive.
Explained difficulty in isolating [Patient C]
8
due to dementia and wandersome behaviour."
9
A.
Yes.
10
Q.
The problem with [Patient C] at this point appears to be
11
the difficulty with her wandering, not so much the lack
12
or otherwise of an isolation room; is that correct?
13
A.
Like I have noted through some of the records, we
14
haven't indicated at what point someone has moved into
15
a side room, if, indeed, they have at all.
16
Q.
But she certainly hasn't by this point in time, has she?
17
A.
If I can just check.
18
No, sorry, she moved into the side
room on the 27th.
19
Q.
In fact, I think we see that in the records at page 173.
20
A.
It is on 172.
21
Q.
You are quite right.
22
23
24
25
On 27 December:
"Wandersome around ward until 11.30 pm.
slept thereafter.
Settled and
Continent at time of report."
That is for the 27th.
Does she still appear to be
wandering around the ward at this point?
156
1
A.
On the 27th?
2
Q.
Yes.
3
A.
Yes.
4
Q.
Then, at 1620:
5
"[Patient C] moved to side room today."
6
A.
Yes.
7
Q.
Was that the date upon which she was isolated?
8
A.
It was the date she was moved into a single room, yes.
9
10
She had precautions in place prior to that.
Q.
11
If you look at the entry for the 26th, the bottom of
page 172:
12
"Late to settled [I think that says].
13
about the room and ward."
14
Do you see that?
Wandering
15
A.
Yes.
16
Q.
If you move on, towards the top of the page:
17
"Continues to wander around ward.
18
Remains
symptomatic to infection."
19
Does it seem to be the case with this patient that,
20
although she was diagnosed with C. diff, she continued
21
to wander about the ward itself, not just her room, but
22
the ward?
23
A.
Yes.
During this period, of course, we were closed with
24
norovirus, and I remember we had to set up a few of our
25
own strategies to try and minimise [Patient C]'s
157
1
wandering, but of course, that's something that can
2
sometimes be -- well, it is challenging all the time,
3
but it sometimes can be impossible to do completely, and
4
it quite often involved a member of staff having to move
5
with her, because we can't physically restrain her in
6
a room or, indeed, chemically restrain her, so some of
7
the strategies we had to adopt were to observe
8
[Patient C] wandering and do what we could with
9
environmental cleaning and hand hygiene of [Patient C]
10
11
as well.
Q.
12
13
was in within the ward then at this point in time?
A.
14
15
Did your detective work disclose to you what room she
I came to the conclusion -- I'm not quite sure how
I did -- that she was in room 16.
Q.
Were you, yourself, aware, as the ward sister, that you
16
did have this patient who was C. diff positive and was
17
wandering around the ward?
18
A.
Yes.
At what point I became aware of that, I'm not sure
19
entirely, but I certainly did know, yes, at some point
20
in her stay, at the early part.
21
Q.
22
23
particular difficulty you had with her wandering or not?
A.
24
25
Placing her in a side room, did that cure this
It certainly helped, but she still made attempts to come
out of the ward.
Q.
We see that if we look on the 28th at 1925:
158
1
"Continues to wander around the ward."
2
Do you see that towards the bottom of page 172?
3
A.
Yes.
4
Q.
She is still symptomatic -- is that correct? -- at this
5
6
point?
A.
7
8
It does go on to say she's had a further one episode of
stools, so, yes, she is.
Q.
9
At this point, do you know what other patients, of
the patients we have looked at on the chart, had been
10
admitted to ward F?
11
A.
The admission date of -- what patient, sorry?
12
Q.
Perhaps I can put it to you in this way: we have
13
mentioned Rosa Rainey.
Now, were you aware if
14
Rosa Rainey was present in ward F by about 28 December?
15
A.
I'm not sure of that, sorry.
16
Q.
We will look at that later, then.
17
A.
There is information here on this other sheet of
18
19
No.
27 December being an admission date for Rosa Rainey.
Q.
20
That would tie in, then, with a time when [Patient C]
was wandering around the ward?
21
A.
[Patient C] was on the ward on the 27th, yes.
22
Q.
Does it seem that, after she was diagnosed with C. diff
23
for a period of days, [Patient C] was wandering around
24
the ward?
25
A.
It appears from the nursing records, and certainly from
159
1
my memory, that it was very difficult to maintain
2
[Patient C] within a single room, yes.
3
Q.
But at the time, did you apply yourself to the question
4
as to whether or not there was a risk of cross-infection
5
being caused by [Patient C]'s wandersome tendencies?
6
A.
At that time, [Patient C] was the only person that had
7
C. diff.
8
that was, in fact, Rosa Rainey on 19 January.
9
that point, I didn't have reason to consider, because
10
she was the only person presenting with C. diff at the
11
time.
12
LORD MACLEAN:
13
A.
14
LORD MACLEAN:
15
I think the first patient to come on after
So at
But I think if I'm -Is that an answer?
Sorry?
Is that an answer?
symptomatic.
16
A.
17
LORD MACLEAN:
18
A.
19
LORD MACLEAN:
I mean, she was
She had C. diff confirmed.
[Patient C]?
Yes.
Yes.
She was wandering, peripatetic.
Would it not
20
occur to you that there might be a risk of cross
21
infection?
22
A.
23
LORD MACLEAN:
24
A.
25
That's what I was going on to say -That is the question you have been asked.
I think he made reference to other patients
specifically, as if -- sorry, I have perhaps picked you
160
1
up wrong.
I thought you were referring to other
2
patients being positive at this time.
3
MR MACAULAY:
No, I don't think so.
4
A.
Sorry.
5
Q.
Perhaps we are at cross-purposes.
If you have a patient
6
who has C. diff and that patient is wandering about the
7
ward, does the risk of cross-infection arise?
8
A.
Yes.
9
Q.
I think we have focused on the fact that, by this point
10
11
in time, Rosa Rainey was admitted to the ward?
A.
12
13
She was admitted, sorry.
She wasn't -- sorry.
I think
I picked up the question -Q.
No, no, not at this point in time.
But I think also --
14
I think I can tell you that Mary Hamilton was admitted
15
to ward F on 28 December.
16
already there, in fact.
17
ward by this time?
18
A.
19
20
Yes.
I think Sarah McGinty was
Mrs McGinty was already in the
Not necessarily in the same room, but she was in
the ward, I believe.
Q.
I think the point you made was that [Patient C] was the
21
only patient you had positive at this point in time,
22
that's late December 2007.
23
A.
Yes.
24
Q.
Was she the next patient to be diagnosed positive again,
25
on 9 January, or thereabouts?
161
1
A.
Yes.
2
Q.
If we look at the microbiology report, it is
3
GGC26340045.
It is not particularly clear, but can we
4
see that a specimen was collected on 9 January, received
5
by the lab on the 9th and, according to this, reported
6
on 11 January?
7
A.
Yes.
8
Q.
We have seen -- and we have looked at this on the chart,
9
I think -- that [Patient C] was again positive at this
10
time.
11
investigations if she was or was not still in isolation
12
at this point?
13
A.
14
Were you able to work out from your detective
I have got reference on my chart to being in a side room
on, possibly, 8 January at this point.
15
Q.
On 8 January?
16
A.
Yes.
17
Q.
Do you know if she moved out of the isolation into the
18
19
main ward subsequently?
A.
She would have done at one point.
I just -- I'm unable
20
to ascertain exactly what date that was from the
21
records.
22
Q.
If we go to 177 of the records, can we see here, if we
23
start at 17 January, that [Patient C] continues to have
24
loose stools?
25
the page; is that right?
We see a reference towards the top of
162
1
A.
Yes.
I think that was her first presentation after
2
a week of being asymptomatic of the infection.
3
17th was her first presentation again.
4
Q.
5
So the
Do we see further references for the 18th, the 19th and
the 20th to loose stools?
6
A.
Yes.
7
Q.
On the 21st, is there an entry -- this is page 177 --
8
"Faecally incontinent prior to bed.
9
patient.
10
Bin emptied by
Faeces smeared over floor."
Do you have any recollection of this episode?
11
A.
No, I don't.
12
Q.
Are you able to tell us from the records if [Patient C]
13
is in isolation or not?
14
A.
On 22 January?
15
Q.
Yes.
16
A.
I wasn't able to note that information, no.
17
Q.
If you turn to page 178, there is an entry on the 23rd,
18
"Remains nursed in isolation".
So does that tend to
19
suggest that certainly then she's in isolation?
20
A.
Yes, it does.
21
Q.
Did [Patient C] prove troublesome to other patients,
22
Yes, it does, yes.
that you can recall?
23
A.
Yes, I do remember a couple of occasions, yes.
24
Q.
If we look on page 178, do we continue to -- if you look
25
to 29 January, again, do we see reference to "soft
163
1
faeces", 3 pm?
2
A.
Yes.
3
Q.
Then, on the 30th, "Incontinent of faeces.
4
Soft".
you see that?
5
A.
Yes.
6
Q.
Then, on the 31st, I think, at the top of page 179:
7
"Washed, dressed, maximum assistance.
8
stools today.
9
times."
10
Continues to wander into ward area at
in time?
A.
13
14
No loose
Do we still assume she's in isolation at this point
11
12
Do
We have to assume that, in the absence of any other
information, I think.
Q.
15
The entry on the 31st:
"Very late to settle despite getting prescribed
16
sedation.
Incontinent of greeny/black coloured stool",
17
and then there is reference to "Formed, loose"?
18
A.
I think it was "Formed, not loose".
19
Q.
"Formed, not loose".
20
Then, on 1 February:
21
"Totally disruptive last pm, continually annoying
22
other patients, going into their lockers causing them
23
distress.
24
phone her husband to take her home."
25
Mrs Millen very distressed, asking us to
Is that right?
164
1
A.
Yes.
2
Q.
Does it appear at this point that [Patient C] may not
3
4
now be in isolation?
A.
Unless she has -- thinking of the location of the side
5
room and room 16, perhaps she's come out of the side
6
room unnoticed and into Mrs Millen.
7
Q.
Can you recollect where Mrs Millen was at this point?
8
A.
It appears Mrs Millen's been in room 16 and was moved
9
10
into the side room on 1 February.
Q.
11
If you look at the entry for 3 February at page 179, we
can read:
12
"Continued to wander during early part of night,
13
disturbing patients in her room."
14
Does that imply that, by now, [Patient C] is no
15
longer in a side room?
16
A.
Yes, it seems that way.
17
Q.
If we look at the microbiology, if you turn to page 42
18
of the records, can we see that there was a specimen
19
collected on 5 February, received by the lab on
20
6 February -- we looked at this earlier on -- and this
21
is another positive result?
22
A.
Mmm.
23
Q.
So this is the third positive result for [Patient C]?
24
A.
Yes.
25
That was the third episode.
The chart reflected
11 February, but it turns out it was the 5th, yeah.
165
1
Q.
2
If we go back to the nursing records at page 180, is
there an entry there for the 5th?
3
It looks like:
"Washed and dressed with full assistance.
4
Seen by
Dr Akhtar for repeat stool specimen and bloods."
5
Then, at 10 o'clock, there is reference to smelling
6
loose stool, mucous.
Do you see that?
7
A.
Yes.
8
Q.
Then, on the 6th -- it seems to be on the 6th -- it says
9
"Stool specimen obtained".
That would appear to be, on
10
the face of it, the specimen that proved to be positive,
11
although the dates don't seem to quite tally?
12
A.
Yes.
13
Q.
At this point in time, then, are you able to tell us if
14
15
[Patient C] is in a single room or not?
A.
16
No.
I'm not sure how I got this information, but
I believe she's in room 16 at this point.
17
Q.
Is she?
18
A.
Yes.
19
Q.
I think, if we go to the infection control card, that is
20
SPF01390002, we read for 6 February:
21
"Symptomatic again.
22
We then see:
23
"Cannot isolate.
24
So that would indicate she's no longer in a single
25
Positive result from specimen."
No single rooms."
room?
166
1
A.
Yes.
2
Q.
By this time, of course, we know under reference to what
3
we have seen in the chart a number of other patients
4
have indeed tested positive for C. diff, and in
5
particular Rosa Rainey, Mary Hamilton and Sarah McGinty,
6
and indeed also, I think, Mary Millen, is that right, by
7
early February?
8
A.
Yes.
9
Q.
At the time, did you, yourself, consider how it came to
10
be that that number of patients had tested positive for
11
C. diff?
12
mind as to what source there might have been within the
13
ward for the infection?
14
A.
Yeah.
By that I mean, were you able to apply your
I mean, I think all of the patients that
15
subsequently became positive had been on recent
16
antibiotics within eight weeks, so they certainly were
17
a risk group for developing C. diff diarrhoea.
18
Q.
Did you give any consideration to whether or not there
19
was a source for cross-infection within the ward that
20
might have impacted upon the other patients?
21
A.
Yeah, I certainly was aware on a shift of around
22
about -- I think it was 10 January, when [Patient C] was
23
wandersome and, despite every effort with the
24
precautions in place, there was a possibility certainly
25
that she could be a risk of cross-infection.
167
1
Q.
What --
2
A.
I think at that point that's when I was prompted to --
3
sorry to interrupt you -- risk assess the situation,
4
because I think it was quite -- it was becoming apparent
5
that we could not contain [Patient C]'s behaviour within
6
the staffing that we had at that point and we were
7
obviously going to have to consider some kind of -- more
8
one-to-one over the 24-hour period observation.
9
risk assessment that I submitted to the Inquiry I think
The
10
corresponds with the entry on the 10th when I have
11
considered that as a possibility.
12
She then had a period of general malaise from her
13
second episode of loose stool -- sorry, C. diff and
14
actually her behaviour settled again.
15
a week where we have no recorded entries of wandering at
16
all during that period in January.
17
Q.
So we have over
Was infection control aware that you had a patient like
18
[Patient C], who had tested positive on more than one
19
occasion and had this tendency to wander within the
20
ward?
21
A.
Yes, I think the very first time she tested positive
22
in December we have acknowledged -- when infection
23
control actually phoned us with the positive result, we
24
have acknowledged a conversation that we had with them
25
telling them of our difficulty to keep her in isolation.
168
1
That would have been around about 26 December, I think.
2
Q.
Did they continue to be aware of that fact --
3
A.
Yes, absolutely, yes.
4
Q.
Because we know with [Patient C] she's been positive by
5
the beginning of February on two previous occasions --
6
that's in December and in January?
7
A.
Yes.
8
Q.
Perhaps we can look at the specimen report.
9
If we look
at page 89 of the records, can we see here a report from
10
the lab in relation to a specimen collected on
11
25 February 2008, received by the lab on the same day,
12
and this is another positive result?
13
A.
Yes.
14
Q.
So, again, [Patient C], this is the third I think -- or
15
this is the fourth, in fact, positive result.
She was
16
positive in December, in January, early February and now
17
we are into the latter part of February.
18
correct?
Is that
19
A.
Yes, it appears to be.
20
Q.
Do you know if she remained a problem from the point of
21
22
view of wandering about the ward?
A.
Her wandering was variable, I must admit.
With at least
23
the second episode of her C. diff, she did, like I say,
24
become quite unwell with it and was in bed and
25
restricted to bed.
So we have a long period of,
169
1
I think, about ten days where she is not wandersome at
2
all, but I think it becomes quite apparent to us by the
3
third episode, in February, that we weren't going to be
4
able to apply the level of observation to completely
5
reduce that risk that certainly had entered my mind.
6
At that point, we took steps to bring in an extra
7
member of staff over the 24-hour period, who,
8
incidentally, wouldn't be able to contain her in a room,
9
but certainly would be more aware of her attempts to
10
11
come out of the room.
Q.
But it would appear, then, that [Patient C] was positive
12
in ward F from about 26 December through to the latter
13
part of February 2008?
14
A.
Yes, not always symptomatic at those times, though.
15
Q.
No.
16
A.
No.
17
MR MACAULAY:
But she'd had three episodes by then, yes.
My Lord, I understand people are a little bit
18
concerned about the weather.
19
consider rising a bit early, this might be an
20
appropriate time to do it.
21
LORD MACLEAN:
22
(4.05 pm)
If your Lordship were to
Tomorrow morning at 10 o'clock, please.
23
(The hearing was adjourned until
24
Tuesday, 13 September 2011 at 10.00 am)
25
170
1
I N D E X
2
3
MRS JANINE MARGARET HART (sworn) .....................6
4
5
Examination by MR MACAULAY ....................6
6
7
MS LAURA JANE GARGARO (affirmed) ....................46
8
9
Examination by MR MACAULAY ...................46
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
171