Download Day 55 - 3 November 2011 - The Vale of Leven Hospital Inquiry

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Thursday, 3 November 2011
(10.00 am)
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DR HENRY JOHN WOODFORD (continued)
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Examination by MR MACAULAY (continued)
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MR MACAULAY:
Good morning, my Lord.
Good morning,
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Dr Woodford.
I want to begin this morning by looking at
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the case of Irene Harnett.
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at your report, please, that's at EXP01260001.
If I could ask you to look
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We have on the screen the front page of that report.
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Have you noted there that Ms Harnett's date of birth was
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24 June 1930?
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A.
Yes.
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Q.
Indeed, you have also noted her date of death as
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7 May 2008; is that correct?
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A.
Yes.
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Q.
If we look at the death certificate, it is at
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SPF00180001.
We can see that Ms Harnett was 77 at her
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date of death on 7 May 2008, and she died in the
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Vale of Leven Hospital.
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section II, in relation to the cause of death,
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Clostridium difficile does appear on the death
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certificate?
Can we also see that in
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A.
Yes.
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Q.
If we then turn to your report, Dr Woodford, and in
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particular if we turn to page 4 of the report, can you
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perhaps give us some insight into Ms Harnett's medical
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history?
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A.
She was recorded as having type 2 diabetes,
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osteoarthritis, duodenal ulcer, vulval carcinoma,
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hypertension, depression, alcohol excess with possible
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Korsakoff's syndrome in her past history.
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Q.
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Again, just to remind you to speak a little bit slower
so that the stenographers can transcribe your language.
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In relation to the events leading up to her
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admission to the Vale of Leven, I think you tell us in
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the third paragraph of page 4 that she had surgery at
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Gartnavel General Hospital; is that right?
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A.
That's my understanding, yes.
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Q.
What did you understand that was for?
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A.
A resection of a vulval carcinoma.
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Q.
Do you then tell us that she was admitted to the
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Vale of Leven on 22 October 2008 under the care of
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Dr McCruden?
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A.
I do, yes.
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Q.
What was the basis for her admission then as at that
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time?
A.
Apparently, she'd had a recent history of nausea and
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vomiting blood and she'd had some swelling of her lips
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recently, following the administration of an antibiotic.
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There was also evidence of some degree of cognitive
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impairment and self-neglect.
Q.
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In relation to her initial assessment, what line were
they taking with her in the Vale of Leven?
A.
The assessing doctors thought that she'd either
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developed a urinary tract infection or an infection of
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her surgical wounds.
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Q.
At that time, was she prescribed any medication?
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A.
She was commenced on some antibiotics.
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she went on to an antibiotic called co-amoxiclav,
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So initially,
orally, from 22 October.
Q.
If we move on to page 5 of your report, do you tell us
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in the first main paragraph that she was transferred to
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ward 14 in the course of this admission and that was
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under the care of Dr Akhter?
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A.
That's my understanding, yes.
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Q.
Did you understand that was for rehabilitation?
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A.
Yes.
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Q.
Was she positive for MRSA at around this time?
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A.
The wound swabs obtained on 25 October grew MRSA.
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Q.
Did they attempt to keep her in isolation because of
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that?
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A.
They did attempt to, yes.
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MR MACAULAY:
My learned friend has pointed out to me,
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my Lord, that Mr Wood is not here today, and he
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represents, I think, as I indicated, MBS, but in
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particular Dr Akhter.
It may be that there has been
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a delay, and it would be unfortunate if he weren't
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present for some of the evidence.
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we could have a very short adjournment just simply to
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check?
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LORD MACLEAN:
I wonder, my Lord, if
I did wonder about that, but just made the
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assumption that this was a day he wasn't going to be in
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attendance.
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MR MACAULAY:
I certainly hadn't noticed he wasn't here, and
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he certainly didn't let me know whether or not he would
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be here or not.
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LORD MACLEAN:
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case?
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MR MACAULAY:
Did he know that you were dealing with this
I don't know if he would know that.
But in
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any event, a number of the cases would touch upon
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Dr Akhter, in any event.
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I am informed, my Lord, that he is in the building
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now, so perhaps if we can maybe chase him up, and we
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needn't adjourn, if we just give it a couple of minutes.
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LORD MACLEAN:
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MR WOOD:
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LORD MACLEAN:
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Here he is.
Apologies, my Lord.
There was great concern, Mr Wood.
We haven't
got very far.
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MR WOOD:
I will catch up, my Lord.
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LORD MACLEAN:
We are dealing with Ms Harnett's case, and it
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is one in which you will be interested.
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MR WOOD:
I see that, my Lord.
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MR MACAULAY:
Thank you.
I had taken you, Dr Woodford, to page 5 of
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your report where, in the second paragraph, you do
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indicate that Ms Harnett was transferred to ward 14
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under the care of Dr Akhter, and that was for
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rehabilitation.
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A.
Yes.
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Q.
We had moved on, and I think you had indicated that she
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had contracted MRSA, and the staff were at least
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attempting to nurse her in a side room because of that
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particular infection; is that right?
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A.
Yes.
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Q.
Did that prove problematic for them?
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A.
She apparently tended to wander around the corridor.
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Q.
Did she improve sufficiently that she was discharged
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home on 23 November 2007?
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A.
Apparently so, yes.
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Q.
But shortly after that, as you tell us on page 5 of your
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report, was she referred back to the Vale of Leven by
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her GP, on 30 November 2007?
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A.
That's correct.
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Q.
What was the basis for that?
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A.
The GP had noted that she'd been found wandering naked
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around her home, she didn't seem to be eating well, she
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was pulling off her wound dressing and seemed to be
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sticking her fingers into the wound.
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Q.
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So far as you could tell from the records, was she
admitted, once again, to ward 14 in the Vale of Leven?
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A.
I believe so, yes.
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Q.
If you turn to page 6 of your report, in the course of
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this admission, was she admitted to the Beatson Oncology
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Centre for some radiotherapy for her cancer?
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A.
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She was.
I believe that was between the dates of
18 December and 30 January.
Q.
Did you tell us on page 6 that she was back in ward 14
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at the Vale of Leven under the care of Dr Akhter on
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30 January?
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A.
Yes.
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Q.
In the following paragraph, you make some observations
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as to what you have taken from the records on
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18 February.
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A.
What was the position at that time?
Well, what was recorded, that she was found to be
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frightened and confused and, for that reason, she'd been
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commenced on an antipsychotic drug called haloperidol.
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Q.
Was she complaining of some abdominal pain at that time?
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A.
That was some time later.
On 29 February, there was
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some abdominal pain.
An abdominal X-ray was performed,
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which appeared to be normal.
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have constipation and she was commenced on laxative
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It was felt that she may
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medication.
Q.
Do you go on to tell us that, on 2 March, she had a fall
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and that, following upon that, she had a CT scan on
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4 March?
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A.
What did that indicate?
It suggested a degree of brain atrophy, but I presume
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the scan was done to look for any intracranial injury
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following her fall, which it didn't demonstrate.
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Q.
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If you turn to page 7, have you noted that the
orthopaedic team did note that there was an impacted
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fracture of her right humerus, although that hadn't been
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seen on the initial X-ray?
Is that correct?
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A.
Yes.
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Q.
The point you make in, not the next, but the next
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paragraph after that, under reference to 19 March, can
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you explain that, as to what the findings were and what
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they indicated?
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A.
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So a sputum sample had been sent to the laboratory, and
it had grown the bacteria Haemophilus influenzae.
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Q.
What does that mean?
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A.
It's a bacteria that's often present in the respiratory
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tract.
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be a normal finding.
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Q.
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It can be a source of pneumonia, but it can also
So far as Ms Harnett was concerned, what was the
response?
A.
She was commenced on an antibiotic called co-amoxiclav,
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presumably on the basis that this was causing
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a pneumonia or chest infection, although the clinical
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assessment at the time had noted she didn't have
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a temperature and, although there were some crepitations
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or crackles heard on listening to her chest, those
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seemed to clear on coughing, which suggests there is no
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area of consolidation, which would be consistent with
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chest infection.
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Q.
Did the staff decide that she should be psychiatrically
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assessed, and did that happen in the course of the month
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of March?
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A.
I'm not sure the exact date it happened.
She was
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referred to Dr Coulter on 23 March and she ended up on
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Fruin ward under the care of Dr Coulter on 2 April, so
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without checking the notes, I'd have to see the exact
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date that she was seen, but obviously, some form of
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psychiatric assessment and transfer to the psychiatric
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unit occurred around the end of March.
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Q.
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So by 2 April, then, she's been transferred to the Fruin
ward within the Vale of Leven Hospital?
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A.
That's correct.
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Q.
If we move on to page 8 of the report, I think you tell
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us in the first main paragraph that there was a urine
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culture obtained on 9 April.
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that?
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What was the result of
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A.
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That had grown a coliform organism, which is a type of
bacteria often found in the bowel.
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Q.
Did the medical staff respond to that in any way?
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A.
She was commenced on the antibiotic co-amoxiclav on
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11 April for what was suspected to be a urinary tract
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infection.
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Q.
Do you then tell us, in concluding this general history,
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that, as we have already noted, she, I think,
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deteriorated and she died on 7 May 2008?
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A.
Yes.
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Q.
Is it right to say, when we look at the position in
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relation to C. diff, and you look at that on page 9 of
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your report, that Ms Harnett didn't really report loose
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stools until shortly after her transfer to Fruin ward?
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A.
Yes.
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Q.
I think what you tell us there, under the heading
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"C. diff diarrhoea", is that loose stools were first
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reported on 4 April 2008.
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transfer to Fruin?
That's two days after the
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A.
Yes.
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Q.
You list for us some further episodes of loose stools --
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7 April, and you give some further dates.
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correct?
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A.
Is that
Yes, those are the references I could find within the
notes to loose stools being found.
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Q.
Then, if we look at the microbiology result that was
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eventually obtained, if we could have on the screen,
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please, GGC00270325, can we see that a specimen was
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eventually obtained from Ms Harnett on 30 April and
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received by the lab on the same day, and that was
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a positive result?
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A.
Yes.
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Q.
As you point out on page 9, if we go back to your
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report, in that particular paragraph dealing with
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C. diff, Ms Harnett had had loose stools for a period of
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time leading up to the obtaining of that particular
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specimen?
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A.
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Yes, multiple episodes that are recorded within the
notes.
Q.
Can I then turn on to that section of your report where
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you look at the antibiotic treatment that was given to
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Ms Harnett for conditions other than C. diff.
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at section 4 of the report on page 10.
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take us through that, as to what you were able to take
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from the medical records?
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A.
That is
Can you just
So the initial antibiotics, she was commenced on
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co-amoxiclav for what was, at that time, thought to
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possibly be urinary tract infection or an infection of
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her surgical wounds.
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denied having any urinary tract symptoms.
When specifically asked, she
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She did have
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a mild temperature.
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a marker of inflammation within the blood, was a little
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elevated at 14 and her white cell count was markedly
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raised at 22.7, which are both consistent with an
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infective process.
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Her C-reactive protein, which is
Her urine culture was subsequently negative and the
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wound swabs did not grow any organisms, so it makes me
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think that a urinary tract infection was probably
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unlikely on the basis of a lack of urinary symptoms and
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the negative urine culture.
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Q.
The prescription was for co-amoxiclav; is that correct?
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A.
That's right, yes.
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Q.
If she did have a urinary tract infection, would
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co-amoxiclav be an appropriate choice?
A.
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The recommended first-line antibiotic would have been
trimethoprim.
Q.
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Is that why you say, then, the choice of antibiotic was
suboptimal?
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A.
Yes.
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Q.
If you move on, then, in relation to what else you say
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towards the latter part of that paragraph.
A.
So the other suspected differential diagnosis was a skin
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infection, cellulitis, which, typically, the recommended
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first-line drug would be flucloxacillin, so also
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co-amoxiclav wouldn't be the first-line drug you would
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have chosen if that was the suspected source of
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infection.
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Q.
Co-amoxiclav would have been?
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A.
Would not have been.
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Q.
Would not have been?
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A.
Flucloxacillin was the recommended first-line drug for
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skin infections.
Q.
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Was the co-amoxiclav then prescribed before the culture
results were available?
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A.
That's right.
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Q.
Then, when the culture results came through, what did
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they show?
A.
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So when there was no organism identified in the urine or
the skin, the same antibiotic was continued.
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Q.
Should that have happened?
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A.
Probably not.
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Q.
Can you tell me how long the co-amoxiclav was actually
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then given to Ms Harnett at this time?
A.
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From 22 October to 29 October, so that makes eight days,
I make it.
Q.
I think we are looking here at the first admission; is
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that correct?
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she was discharged and she came back shortly after that.
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This is the first admission?
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A.
As we noted, there was an admission and
Yes, that is the first admission, yes.
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Q.
As you tell us in the next paragraph in relation to the
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second admission, on 30 November, she was admitted with
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confusion, and so on.
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she again prescribed antibiotics at the time of this
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admission?
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A.
She was.
If you move on to page 11, was
She again had -- sorry, no, she had
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ciprofloxacin and co-amoxiclav prescribed at the time
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that she came in, on 30 November.
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Q.
Can you tell us what the reasoning behind that was?
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A.
Well, the initial assessment concluded query UTI, query
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confusion, query cause.
Q.
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What was the thinking, then, behind the prescription of
these two antibiotics?
A.
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Presumably, the suspected diagnosis was urinary tract
infection, although it wasn't clear.
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Q.
Were there clinical signs of a urinary tract infection?
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A.
There were no urinary symptoms reported by the patient.
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I think there's a minor typo there: no urinary symptoms
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or temperature recorded.
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pyrexial at that time.
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which can sometimes happen with infection, and her CRP
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was elevated, so those blood tests could be consistent
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with infection.
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She doesn't seem to have been
Her white cell count was low,
But a subsequent urine culture showed no growth and
had no white cells within it, so it suggests that it
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wasn't simply an infection that had partially been
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treated by antibiotics by the time the culture was sent.
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The absence of white cells suggests that she didn't have
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a urinary tract infection.
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Q.
Are you able to say whether or not it was appropriate,
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first of all, to prescribe an antibiotic in the
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circumstances?
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A.
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Sometimes antibiotics are given empirically, when people
are ill and you are not sure why and it is thought, you
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know, that the risk of broad-spectrum antibiotics is
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justified.
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clear whether a septic process was going on.
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I think it is hard to comment just based on what's
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recorded in the notes.
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Q.
However, on this occasion, it is not really
You know,
If antibiotics were appropriate, what about the
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combination of antibiotics that were prescribed here,
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the ciprofloxacin and the co-amoxiclav?
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appropriate choice?
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A.
Was that an
You know, it's two broad-spectrum agents in combination
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that would have covered most infections.
It is not
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a very common combination used.
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be a great combination for a urinary tract infection,
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for instance.
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diagnosis wasn't clear, the treating doctors thought
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they should give very broad-spectrum treatment initially
You know, it wouldn't
The assumption is that, because the
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and then perhaps revise when some investigations and
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more information came to light.
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from that.
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Q.
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That is my assumption
Well, on that assumption, might this course of action be
looked upon as a reasonable approach?
A.
I think it is hard to say definitely not, so I think the
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best I can say is possibly.
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evidence of a severe sepsis when she came into hospital,
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but that is just based on what I have seen in the notes.
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There is not overwhelming
It may have been appropriate.
Q.
I think we have seen, and you have told us, that
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generally trimethoprim would be the first port of call
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for a suspected urinary tract infection?
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A.
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So if that was the primary diagnosis, then this would
not be following guidelines for the treatment of that.
Q.
Are you inferring from the approach that was taken that
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the thinking might have been there may have been another
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cause or causes and, therefore, a broader-spectrum
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approach was being adopted?
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A.
That's the way I would interpret it, yes.
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Q.
Should the records disclose what the thinking was?
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A.
Ideally, there would be a bit more information there so
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as, you know, the next doctor coming along would have
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been able to follow the thought processes.
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live in an ideal world.
We don't
There was some information
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recorded, but it is hard for us, in retrospect, having
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just seen the notes, to know for sure whether that was
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the right action at that time.
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Q.
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But, in any event, do you tell us at the top of page 11
that this prescription was for a short period?
A.
Yes.
These antibiotics seemed to be stopped, I think it
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is just two days later, and that seems to be before the
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results of cultures were known.
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Q.
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As far as the culture results were concerned, were they
normal?
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A.
At that stage, I don't think so.
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Q.
Is this where you have a --
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A.
So the --
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Q.
The CRP is raised; is that right?
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A.
The CRP was raised, yes.
The urine culture was
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collected on 1 December, but recorded as received by the
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laboratory on 3 December, but her antibiotics were
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discontinued on 1 December.
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Q.
Let's move on, then, to what you tell us in the
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following paragraph.
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Haemophilus influenzae that you mentioned before to have
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been noted in her sputum.
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apyrexial and she had chest crepitations that cleared
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with coughing.
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A.
This is in relation to the
She said she was noted to be
Is that what's in the records?
Yes, that is what is written.
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Q.
What happened here in relation to medication?
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A.
She was commenced on an antibiotic, I believe it was
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co-amoxiclav orally, from 19 November to 25 March.
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Q.
Was that an appropriate response?
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A.
I don't think so.
There doesn't seem to be
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justification in terms of recording of a septic process
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within the notes.
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Q.
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to indicate that -- why they thought that co-amoxiclav
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might have been an appropriate course of action?
A.
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This is presumably predominantly in response to finding
Haemophilus influenzae in the sputum.
Q.
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Are you able to infer what the thinking might have been
Why do you not think it was appropriate, then, to
prescribe this particular antibiotic?
A.
Because Haemophilus influenzae can just be a normal
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organism found within the respiratory tract.
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need more than just the culture result to justify the
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use of antibiotics.
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evidence of a septic process.
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does not diagnose a chest infection.
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Q.
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You would
It would need to be that along with
The culture result itself
Would co-amoxiclav be an appropriate antibiotic for
a hospital-acquired pneumonia?
A.
Yes, and in light of the sensitivities of
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the Haemophilus influenzae that was isolated,
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co-amoxiclav would seem to have been a good choice of
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antibiotic, if this had been part of a chest infection
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and not just a commensal organism.
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Q.
Your position is that if the diagnosis was
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a hospital-acquired infection, such as pneumonia, then
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that would have been an appropriate approach?
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A.
Yes.
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Q.
But you are saying that you don't see evidence of that
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in the records?
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A.
Not from the notes I have seen, no.
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Q.
How long was this particular course of antibiotics
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given?
A.
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This was from 19 March to 25 March, so is that seven
days in total?
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Q.
Again, this is a broad-spectrum antibiotic?
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A.
It is, yes.
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Q.
If we move on, then, to the following paragraph, I think
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you tell us that a urine culture obtained on 9 April had
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grown a coliform, and you give a reference for that.
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Can you just take it on from there?
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did matters proceed from there?
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A.
What, then -- how
So she went on to further antibiotics for a suspected
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urinary tract infection based on the finding of
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a coliform bacteria within her urine.
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indication said frequency in micturition, but I didn't
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find documentation of an assessment of the patient
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The form for the
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performed at that stage.
Q.
I think you say there was no recorded temperature, no
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blood tests were performed around this time, that the
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culture had shown the organism to be resistant to
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trimethoprim but was sensitive to nitrofurantoin.
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that right?
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A.
Nitrofurantoin.
Is
But the notes suggested she may have
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had some lip swelling in response to an antibiotic
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before that was prescribed by the gynaecologist prior to
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coming into the Vale of Leven, which -- the records seem
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to suggest that was nitrofurantoin.
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Q.
Your position, I think, reading this, is that you
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thought it was unlikely that she had a significant
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urinary tract infection; is that correct?
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A.
Based on what's recorded, there doesn't seem to be any
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recording of patient symptoms or assessment or abnormal
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signs on examination at that stage.
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Q.
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Are you saying, based on what's recorded, there wasn't
a basis for prescribing an antibiotic?
A.
My suspicion is that this is another case of
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asymptomatic bacteriuria which would not usually be
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treated with antibiotics.
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Q.
If she did have a urinary tract infection, and standing
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the fact that the organism was resistant to trimethoprim
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and she had a previous allergic reaction to the
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alternative, then would co-amoxiclav be an appropriate
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course of action?
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A.
It would.
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Q.
How long, then, was she prescribed the co-amoxiclav on
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this particular occasion?
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A.
This time it went from 11 April to 16 April.
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Q.
Looking at the duration, again on the hypothesis that it
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was an appropriate route to take, was that duration an
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appropriate duration?
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A.
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No, the recommended duration of treatment in this
situation would be just three days.
Q.
Now, then, if we move on to page 12 of your report -- we
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are still dealing with antibiotic treatment -- I think
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you tell us there that, on 21 April, she was prescribed
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a further seven-day course of co-amoxiclav; is that
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correct?
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A.
Yes.
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Q.
What was the basis for that?
19
A.
It's hard to decipher from the notes alone, given there
20
was no recording of any patient assessment at that
21
stage.
22
Q.
23
24
25
Is there any basis, then, from the notes for that
particular prescription?
A.
Let me just check what was written down at the time.
No.
Presumably in response to another urine culture.
20
1
Q.
2
3
prescription?
A.
4
5
Did you see any basis in the records for that
Not that I have recorded here, so, no, presumably not,
no.
Q.
What you have recorded -- perhaps we can look at what
6
you have recorded.
It is at GGC00270372.
I think what
7
you have referenced is the prescription record; is that
8
correct?
9
A.
That's right.
10
Q.
I'm looking for 21 April 2008.
11
A.
About halfway down the page, there is a co-amoxiclav
Is that perhaps just --
12
that has now got a line through it, presumably to show
13
that the course had finished at that stage.
14
Q.
If we then go back to your report at page 12, I think
15
you also tell us that, by this time, Ms Harnett has been
16
having regular episodes of diarrhoea; is that correct?
17
A.
Yes.
18
Q.
If we go back to that section of your report where you
19
deal with her C. diff diarrhoea, on page 6 --
20
A.
Page 9, I think.
21
Q.
Sorry, page 9.
You have indicated to us the references
22
in the records where there is reference to diarrhoea and
23
particularly from 17 April, I think, through towards the
24
end of April and into May, we have quite a number of
25
references indicating diarrhoea; is that the position?
21
1
A.
Yes.
2
Q.
Now, what I haven't taken from you before, and this
3
might be the time to do it, is, was there, in fact,
4
a previous specimen sent before the one that actually
5
tested positive?
6
at GGC00270326.
If I can put this on the screen, it is
7
Can we see that there is a specimen that was
8
collected on 17 April 2008, and that is at a point in
9
time where you have noted that she may have had loose
10
stools, it was received by the lab on 17 April also, but
11
would it appear that this was not tested for C. diff?
12
A.
That is how it looks to me.
13
Q.
You can't say why that is, but do you consider that
14
there should have been, at about this time, a sample
15
sent for testing for C. diff, because we know that the
16
sample that was sent ultimately wasn't until 30 April?
17
A.
Yes, if not sooner, yes.
18
Q.
I'm sorry?
19
A.
If not even sooner, given that she'd had diarrhoea
20
21
before that.
Q.
Just to be clear, are you saying that, although this one
22
wasn't tested for C. diff, there should have been
23
a specimen sent around this time to test for C. diff?
24
A.
Yes.
25
Q.
If we go back to page 12, I think, of your report, you
22
1
have indicated that she was prescribed with the
2
co-amoxiclav at a time when she was having episodes of
3
diarrhoea.
4
A.
Should that happen?
There may be situations where you have got -- you know,
5
if she'd got evidence of a very severe infection other
6
than Clostridium difficile, then she may well have had
7
to have antibiotics for another reason, but I think, in
8
the light of the clinical context, the suspicion of
9
everything else that was going on around, you would want
10
to be as sure as possible that you were giving
11
antibiotics for a really good reason, and that just
12
doesn't seem to be documented within the notes.
13
is no clear evidence that she had a significant septic
14
illness that would justify the use of these antibiotics
15
at this stage.
16
Q.
There
I think that's what you say towards the top of page 12.
17
Do you go on to say it is highly likely that her
18
repeated course of co-amoxiclav led to her development
19
of C. diff diarrhoea?
20
A.
Yes.
21
Q.
You go on to say there that there does not appear to
22
have been any consultation with microbiology at any
23
stage.
24
involvement with the microbiologists?
25
A.
Do you think that there should have been
I think, in retrospect, there should have been.
23
I think
1
at the time, perhaps not.
If the clinicians felt they
2
were simply dealing with a urinary tract infection, they
3
wouldn't necessarily call for a microbiologist advice on
4
how to do that.
5
Clostridium difficile -- so the management of any
6
illness that requires broad-spectrum antibiotics at the
7
same time you are trying to eradicate
8
Clostridium difficile would be a complex process, and
9
you may have -- so in retrospect, a microbiologist may
But given that she subsequently had
10
have been able to help, but I'm not sure at the time
11
that they necessarily would -- you know, should have.
12
Q.
You then move on to look at medical management.
I think
13
you remind us, as you did yesterday, that doctors have
14
a duty to abide with the GMC code of conduct.
15
right?
Is that
16
A.
Yes.
17
Q.
In particular, you tell us that the standards for
18
medical record keeping should be adhered to, as set out
19
in the code?
20
A.
Yes.
21
Q.
If we look, then, at record keeping generally, and in
22
particular, if you focus on the position in Fruin,
23
I think what you say is it's hard to tell which doctor
24
was present and who recorded the notes, but in Fruin, is
25
the position in relation to record keeping a bit
24
1
different to the Vale of Leven, and do the nursing notes
2
and the clinical notes go together?
3
A.
I believe so, yes.
4
Q.
Whereas, I think, in the other part of
5
the Vale of Leven, you have the nursing notes separate
6
from the clinical notes.
7
A.
Yes.
8
Q.
Does the fact that they are together make it more
9
difficult to tell who has written what?
10
A.
It shouldn't.
11
Q.
But did it?
12
A.
I don't think that is the sole reason.
The problem was
13
that entries weren't legibly marked, rather than that
14
the notes were combined together.
15
Q.
If we move on to page 13, again, as you discussed
16
yesterday, with the onset of diarrhoea in a susceptible
17
individual, that should always raise suspicion?
18
A.
Yes.
19
Q.
The patient should be moved to a side room as soon as
20
the diarrhoea develops; is that right?
21
A.
Yes.
22
Q.
You say then, after that, that it wasn't clear at what
23
stage Mrs Harnett was moved into isolation.
24
had noted that she had been isolated for the MRSA?
25
A.
She had.
25
I think we
1
Q.
2
3
What about for the C. difficile?
What was the position
there?
A.
I couldn't find that recorded within the notes.
But, in
4
any case, she tended to wander, so it's unlikely that
5
she was kept in a side room throughout the duration of
6
the time she had Clostridium difficile anyway.
7
Q.
Looking to the last paragraph on that page, page 13, you
8
express the view that Mrs Harnett's C. diff diarrhoea
9
was contracted whilst in hospital, it was the result of
10
exposure to broad-spectrum antibiotics and C. difficile
11
spores, and, in particular, I think you are focusing on
12
the co-amoxiclav there; is that correct?
13
A.
Yes.
14
Q.
When you say the diagnosis was very delayed, can you
15
16
just elaborate on that, what you mean by that?
A.
Well, the recorded first loose stools were on 4 April,
17
yet the first positive sample was 30 April.
So that's,
18
what, 26 days from first symptoms to diagnosis.
19
Q.
Are you telling us that that really is too long a delay?
20
A.
Yes.
21
Q.
When do you consider a stool specimen ought to have been
22
23
taken to be tested for C. diff in these circumstances?
A.
The difficulty from, you know, trying to look back
24
through the notes is the recording of the episodes of
25
loose stools is very poor.
26
By reading through the notes
1
I have managed to find reference to a number of
2
episodes, but that doesn't necessarily mean that that is
3
all of the episodes.
4
She seemed to have at least had episodes on 4 April
5
and 7 April, but then, from the 17th onwards, the
6
episodes seemed to be more frequent.
7
if there were -- if those were isolated episodes on
8
4 and 7 April, then perhaps, you know, if there were
9
formed stools in between times, you wouldn't have sent
So, you know, even
10
a sample then, but certainly, after 17 April, this seems
11
to be a regular occurrence.
12
was obtained on the 17th.
13
know why that wasn't tested for Clostridium difficile.
14
There certainly seems to have been at least a two-week
15
opportunity of regular episodes of diarrhoea where
16
a stool sample wasn't sent and tested for
17
Clostridium difficile.
18
Q.
So certainly a stool sample
As we said before, we don't
Moving on to page 14, you narrate there some information
19
that you have obtained from the records in relation to
20
her oral intake, nutritional state, and I think her
21
state of hydration.
22
What conclusions were you able to come to in
23
24
25
relation to that from the records?
A.
The blood tests seemed to suggest that she'd become
malnourished and dehydrated.
27
Albumin is not a perfect
1
marker of state of nutrition, but it's certainly fallen
2
from a reasonable level of 29 in November down to a very
3
low level of 14 on 28 April.
4
Q.
Yes.
5
A.
Urea had risen from a normal value of 5.8 up to a high
6
value of 12.4 over that same time period, which suggests
7
that she'd become dehydrated.
8
Q.
Did you see any steps taken to address that?
9
A.
She did receive some intravenous fluids, although it
10
only seems to have been for a short period, from 29 to
11
30 April.
12
that she was in hospital, although it did appear stable
13
throughout the period of April.
14
Q.
She'd also lost some weight during the time
I think what you say there is that, on 16 March, she was
15
reported to have lost 5kg of weight since 6 March.
16
that is, what, in ten days?
17
A.
So
Is that correct?
Yes, the difficulty with these sort of things is
18
people's weight can fluctuate, and it depends on the
19
time of day they are weighed, and sometimes the
20
technique that is used.
21
variability.
22
could be consistent with dehydration.
23
lose fluid a lot quicker than you can lose fat and
24
muscle, say.
25
Q.
So there can be some
But that sort of degree of weight loss
You know, you can
But you also tell us that her weight appears to have
28
1
been relatively stable between 6 April and 20 April?
2
A.
Yes.
3
Q.
That was at a period after she had been admitted to the
4
Fruin ward in the Vale of Leven?
5
A.
It was, yes.
6
Q.
The point you make in the next paragraph about taking
7
Senna and lactulose up until 28 April, what is the point
8
you are seeking to make there?
9
A.
10
On the surface, it seems illogical to be giving
pro-diarrhoea agents to someone who has diarrhoea.
11
Q.
Could you see a basis for these agents being given?
12
A.
No.
13
Q.
You also tell us that, on 28 April, she was prescribed
14
15
loperamide.
A.
Can you --
This is a type of treatment that people can buy over the
16
counter to treat diarrhoea.
17
in people with cases of infectious diarrhoea, the
18
thought process being that it is better to let the
19
infection pass out of your body rather than plug up your
20
bowel so that it remains within your body.
21
Q.
It is usually not indicated
Certainly this appears to have been at a time after
22
which Ms Harnett had been having diarrhoea for a number
23
of weeks; is that right?
24
A.
Yes.
25
Q.
Was this an appropriate approach to that?
29
1
A.
No.
A diagnosis of Clostridium difficile should have
2
been made prior to this date, in my opinion, and she
3
should have been treated on the appropriate treatment
4
that would have prevented her diarrhoea, ie, a specific
5
treatment to treat Clostridium difficile, not
6
a treatment for diarrhoea.
7
Q.
Now, in that final paragraph under this section, you say
8
that, during her time in hospital, she acquired
9
a diagnosis of dementia, and you go on to say the
10
clinical justification for this is not recorded.
11
Can you just elaborate upon what would you expect to
12
13
see in the records?
A.
A diagnosis of dementia is based on a holistic clinical
14
assessment that takes into account the patient's
15
cognitive progress over a period of time, and the way
16
that that has affected their functional status.
17
At the time that someone is acutely unwell, they are
18
prone to developing things like delirium, an acute
19
confusional state.
20
diagnose dementia at this time, to be able to
21
distinguish it from, simply, delirium, which could be
22
reversible.
23
Q.
So it would be very difficult to
Although it would appear, looking to the history you
24
have looked at, that there was evidence of some
25
cognitive impairment, looking to the reasons why she was
30
1
2
admitted.
A.
Yes, of course.
There was some evidence of cognitive
3
impairment.
4
simply acute because she was unwell for other reasons or
5
whether this was a chronic background process.
6
is -- delirium usually occurs in people who do have
7
background dementia, but not always, but to be able to
8
judge the degree of cognitive impairment would be very
9
difficult, very unreliable, I think, given the other
10
What we don't know is whether this was
There
things that were going on.
11
The notes draw reference to this Korsakoff's
12
psychosis which could cause a chronic memory impairment,
13
but it is, you know, trying to untangle what is acute
14
and potentially reversible from what is a chronic
15
progressive global impairment of function suggested by
16
the term "dementia" would be very difficult.
17
Q.
18
Who would carry out the assessment, then?
Would it be
the geriatrician who would do this or the psychiatrist?
19
A.
It could have been either.
20
Q.
Would this be something you, yourself, would do, as
21
a geriatrician?
22
A.
Yes.
23
Q.
You then, in the next section, look at the do not
24
attempt resuscitation order.
25
completed by Dr Khan on 3 March.
31
You tell us that that was
We can put that on the
1
screen, in fact; it is at GGC00270065.
Perhaps I can
2
just say to you -- and I think we see this on occasion
3
in your reports -- you sometimes refer to a Dr Khan with
4
a K and sometimes a Dr Chan with a C.
5
probably the Dr Khan with a K that we have here.
6
that the way you read the signature on the DNAR order?
I think this is
Is
7
A.
That is the way I read it, yes.
8
Q.
But there is also a Dr Chan, and I think you may have,
9
on occasions, confused one or the other.
10
We will look
at that in due course.
11
In this particular case, it appears to be Dr Khan
12
and the DNAR order is dated 3 March 2008 with the
13
consultant's name also entered was Dr Akhter.
14
that?
Do we see
15
A.
Yes.
16
Q.
I think the point you make is there is no indication
17
that it's been discussed with the family on the
18
document, but insofar as reasons why CPR would be
19
unlikely to be successful, is that under reference to
20
her cancer that we see some reference there?
21
A.
Yes, I mean, it is -- the entry says "valvular malignant
22
carcinoma (vagina)".
23
meaning was "vulvular" carcinoma.
24
25
Q.
I think what the doctor was
In the circumstances, do you consider that it was an
appropriate course of action?
32
1
A.
It seems to be that the vulvular carcinoma was
2
considered a non-curative condition that would
3
eventually kill her.
4
referenced at some point in the report with Dr Reed,
5
I believe, the oncologist, had suggested that her
6
prognosis was good.
7
you know, I can't tell any more than what that meant.
8
But on the basis that she has what is a progressive,
9
non-curative condition, then this may be a justified
10
11
Although a telephone conversation
But I don't know exactly what --
decision.
Q.
Moving on then to the next section of your report, at
12
page 15, that is the section headed "Cause of death and
13
death certification", perhaps we can put the death
14
certificate back up on the screen, SPF00180001.
15
discuss this on page 15.
16
views are in relation to the cause of death that's been
17
certified here?
18
A.
You
Can you just tell us what your
From the clinical records, it's hard to say that she
19
died of vulval neoplasia.
20
seemed to have an active problem, being
21
Clostridium difficile.
22
thing to have put down under section I, rather than
23
section II.
24
25
At the time of her death, she
I think that is a more likely
As we'd said, Dr Reed had said over the telephone,
on 1 March, that a prognosis with that condition was
33
1
good, but I don't know what the word "good" meant in
2
Dr Reed's mind.
3
would have been from that condition.
4
So we are not sure what her survival
The term "infection" in II, I can't tell you any
5
more about that.
6
be to justify, you know, certainly some source of
7
infection in that case.
8
Q.
It would seem that good practice would
Are you drawing attention to head II where the first
9
reference is to "infection", which seems to have been
10
separated from Clostridium difficile, because there is
11
a semicolon between the two?
12
A.
Is that the point?
I presume that's meant to be a separate condition, yes,
13
but it is obviously not specified what the source of
14
that infection is.
15
Q.
16
17
have been if she had not contracted C. diff?
A.
18
19
Are you able to say what her expected survival might
I'm not, because I don't understand what the term "good"
means in terms of the prognosis of vulval carcinoma.
Q.
Can we then look at your conclusion for Ms Harnett's
20
case and, if we focus in particular on the final
21
paragraph of your report, can you perhaps just take us
22
through that and tell us what your final views are?
23
A.
I obviously think it was suboptimal in some areas.
As
24
we discussed, the antibiotics she received, namely, the
25
co-amoxiclav, seemed hard to justify on what was
34
1
recorded in the clinical notes.
2
Clostridium difficile seemed to be delayed by what would
3
seem to be a period of weeks, rather than just the odd
4
day or two.
5
Q.
The diagnosis of
Before you move on from that, can I just ask you this:
6
are you able to say what impact, if any, the delay may
7
have had on the course of her infection?
8
A.
9
I think having a couple of weeks of ongoing diarrhoea is
going to affect both your state of hydration and
10
nutrition and increase your probability of death, not
11
also to mention the fact she may well have been
12
spreading spores around the unit that may have
13
implicated other patients during that time period.
14
Q.
The treatment that she ultimately received for C. diff,
15
and you tell us what that was on page 9 of your report,
16
namely, the metronidazole, was that an appropriate
17
course of treatment?
18
A.
19
20
It
ultimately seems to have been ineffective.
Q.
21
22
It was appropriate to put her on metronidazole.
But do you consider that the treatment should have been
changed before her death, or not?
A.
Possibly.
I think there were difficulties giving her
23
the medication, weren't there?
24
been some consideration to alternative strategies.
25
Q.
So there should have
If we go back, then, to your conclusions, you have
35
1
talked about your opinion, that the diagnosis of C. diff
2
was delayed by almost two weeks and, if we move on from
3
there, I think you say the treatment she received did
4
not eradicate the infection.
5
I think, looking at the chronology, she died on
6
5 May, and the diagnosis wasn't actually made until
7
under reference to a specimen that was collected on
8
30 April.
9
from metronidazole to another form of treatment.
10
So it is quite a tight timeframe to move on
Is
that fair?
11
A.
Yes.
The opportunity to intervene may have been missed.
12
Q.
Because of the delay?
13
A.
Yes.
14
Q.
Moving on, then, to the degree of senior medical review,
15
you consider that that was poor; is that your
16
conclusion?
17
A.
That is my reading from the notes, yes.
18
Q.
You make mention of her fall.
You also say -- I think
19
we saw this part of your discussion in your report --
20
that her state of nutrition and hydration was poor?
21
A.
22
23
weight, rising urea.
Q.
24
25
Yes, on the basis of her falling albumin, falling
So there was quite clear evidence of that in the
records?
A.
I think so, yes.
36
1
Q.
Thank you.
2
LORD MACLEAN:
Before we leave the case, Mr MacAulay, could
3
I ask you to put on screen the first microbiological
4
examination of the sample that was given to see what the
5
date was?
6
MR MACAULAY:
7
A.
17 April, I think, wasn't it?
8
Q.
Yes, GGC00270326.
9
10
Yes.
That is GGC -- sorry, the first.
So 17 April it was collected and
received on the same date.
LORD MACLEAN:
So it is the 17th.
If I could ask you,
11
Dr Woodford, to look at page 9 of your report, where you
12
list in the first paragraph all the episodes of loose
13
stools.
14
A.
Yes.
15
LORD MACLEAN:
So far as I can see, on this admission,
16
I think, the only prior one was on 7 April; is that
17
right?
It looks like it.
18
A.
There was one on 8 April also.
19
MR MACAULAY:
20
A.
21
LORD MACLEAN:
Was that a different --
There is one on 4 April.
4 April, 7 April and the 17th.
Yes, and then the 17th.
Given the
22
description of two episodes of very loose stools, does
23
it surprise you that the sample wasn't also tested for
24
C. diff?
25
A.
Yes, it does.
37
1
MR MACAULAY:
I don't know whether you are aware of this or
2
not, but unless the request is made, then it may have
3
been policy not to test.
4
perhaps not within your knowledge.
5
LORD MACLEAN:
6
MR MACAULAY:
7
LORD MACLEAN:
That is something that is
I'm coming to that.
Very well.
Because it is obvious that it hasn't been,
8
presumably because that wasn't a request that was made.
9
If that is right -- if it is right; I don't know whether
10
it is or isn't -- whose responsibility would it be to
11
ask for it to be tested for a particular purpose?
12
A.
I don't know what the policy was at this particular
13
hospital.
14
inpatient who had diarrhoea was sent to the lab, it
15
would be tested for Clostridium difficile as a routine.
16
LORD MACLEAN:
17
A.
Yes.
In my own hospital, if a sample with an
As a routine?
The finding of -- the things that were tested are
18
things that you get with food poisoning, so unless
19
everybody in the hospital has suddenly come down with
20
food poisoning from the food that's been provided within
21
the hospital, it is unlikely that any of those would be
22
positive.
23
to do on someone at the time of admission, to see if
24
they have got food poisoning.
25
diarrhoea within hospital, Clostridium difficile is the
It is the kind of things that are more useful
38
When someone develops
1
most likely cause, compared to these other bacteria
2
listed on the stool form.
3
LORD MACLEAN:
Going back to your paragraph, though, on
4
page 9, looking at the fact that the sample here on the
5
17th was not tested for C. diff, how many more periods
6
or episodes did she have of loose stools which were not
7
tested?
8
A.
9
Well, from what's recorded in the notes, numerous, but
we don't even know if that is an accurate reflection of
10
exactly what happened.
11
within her notes, so I'm reliant mainly on the nursing
12
notes there for when someone had written "loose stools",
13
which may not be 100 per cent accurate in any case, but
14
even from what was recorded, it seemed to be an almost
15
daily occurrence throughout the majority of April.
16
LORD MACLEAN:
There is no accurate bowel chart
Is there any explanation in the notes that
17
you have looked at to account for the failure to have
18
that tested?
19
A.
I didn't find any reasoning recorded that would justify
20
that.
21
LORD MACLEAN:
22
MR MACAULAY:
Thank you.
If I can just follow through one of
23
his Lordship's points, if it be the policy -- if it had
24
been the policy in the Vale of Leven that a test for
25
C. diff would not be done unless the request was made,
39
1
then it would be for the person sending the stool to
2
consider the position and make the request; would that
3
be --
4
A.
I can make the assumption, but, you know, you're asking
5
me to comment on what the policy at the hospital was,
6
and I simply don't know.
7
Q.
The other point is this, that we note, as his Lordship
8
pointed out, that the clinical details in the document
9
on the screen, if we look to the screen, is two times
10
episodes of loose stools, of very loose stools, but in
11
relation to the specimen that's been sent, it's
12
described as "semi-formed faeces".
13
on that at all, as to whether or not the nature of
14
the faeces, semi-formed, might have impacted upon the
15
lab's ability to test for C. diff?
16
A.
Are you able to help
I think that's a question to ask the lab, isn't it?
17
"Semi-formed" doesn't tell us exactly what the stool
18
looked like.
19
Q.
Very well.
20
A.
I think it is hard to know from that test, isn't it?
21
They obviously thought it was worth testing for other
22
causes of diarrhoea, but you'd have to ask the lab if
23
that was the reasoning behind it.
24
that, when this sample was sent, on the 17th, she then
25
had further episodes of diarrhoea which weren't
40
But, you know, beyond
1
explained by that sample, so it seems odd, if she was
2
having further loose stools, that a further sample
3
wasn't taken for a whole -- what was it, 13, 14 days,
4
between then and the sample that did test positive for
5
Clostridium difficile?
6
Q.
If we look at that sample again, just to look at the
7
details of it, it is at GGC00270325, here we see that
8
the clinical details tell us "loose watery stool
9
10 days", and I think your position is that within that
10
period there must have been an opportunity to send
11
a specimen?
12
A.
Yes.
13
Q.
The specimen itself is described as "liquid faeces"?
14
A.
So we can speculate that that may be why the lab tested
15
that sample differently than the other, but we don't
16
know, do we?
17
the preceding ten days has been missed.
18
19
20
21
MR MACAULAY:
My Lord, that might be an appropriate point to have
a break.
LORD MACLEAN:
23
MR MACAULAY:
25
I think that then brings us to the end of
Ms Harnett's report.
22
24
But it looks like an opportunity within
Yes, we will have a break.
I can say that the next case I propose to look
at is that of John Boyle.
(11.10 am)
41
1
(A short break)
2
(11.40 am)
3
MR MACAULAY:
Dr Woodford, I now want, then, to look at the
4
case of John Boyle.
Your report is at EXP00830001.
As
5
you point out on the first page of the report, can we
6
see that Mr Boyle's date of birth was 8 January 1918?
7
A.
Yes.
8
Q.
You have noted that he died on 6 February 2008?
9
A.
Yes.
10
Q.
If we look at the death certificate, SPF00020001, can we
11
see that, when he died on 6 February 2008, Mr Boyle was
12
90 years of age?
13
A.
Yes.
14
Q.
He died in the Vale of Leven Hospital and
15
Clostridium difficile enteritis does appear at
16
section I of the death certificate?
17
A.
Yes.
18
Q.
Now, then, if we look at your report, and turn to page 4
19
of the report, can you give us some insight into
20
Mr Boyle's medical history?
21
A.
His past history is brief for a gentleman of his years.
22
He had a history of Paget's disease and a single episode
23
of recorded urinary tract infection in 2001.
24
no medications.
25
Q.
What is Paget's disease?
42
He was on
1
A.
2
3
It is a chronic disease of the bone, not life
threatening.
Q.
Do you note, though, that he was first admitted to the
4
Royal Alexandra Hospital on 3 January 2008, and he was
5
89 at that time?
Is that right?
6
A.
Yes.
7
Q.
What was the reason behind his admission to the Royal
8
9
Alexandra Hospital?
A.
He'd been found on the floor on that morning by his
10
warden at his sheltered accommodation, apparently fallen
11
over when he'd tried to get -- and was unable to get up
12
off the floor, although he didn't know the exact time
13
that he'd fallen down, and he complained of some right
14
hip pain.
15
Q.
16
17
particular, was he X-rayed?
A.
18
19
Yes, he had an X-ray of his hip and they found there was
no fracture.
Q.
20
21
In the Royal Alexandra Hospital, was he assessed and, in
Before he was transferred to the Vale of Leven, did he
suffer some deterioration?
A.
He did.
The notes report he seemed to be drowsy and
22
have difficulty with both his swallowing and speech on
23
9 January.
24
weakness, although the nursing notes suggest this may
25
have been longstanding, but there is nothing in his past
Examination showed some mild left arm
43
1
history to suggest why that would be.
2
have some crepitations in his light lung base.
3
scan of his head was performed which showed some
4
generalised atrophy, but no obvious reason for his acute
5
deterioration and he was prescribed some antibiotics for
6
what was suspected to be a chest infection, although he
7
didn't actually seem to get any doses.
8
Q.
9
He was found to
A CT
So the prescription was made, but he didn't actually get
any?
10
A.
Yes.
11
Q.
This was all in the Royal Alexandra Hospital before he
12
was moved to the Vale of Leven Hospital?
13
A.
That's right.
14
Q.
In relation to that, then, was he transferred to the
15
Vale of Leven on 10 January, I think that should be,
16
2008?
17
A.
Sorry, my mistake, yes, that should be January.
18
Q.
At this time, so far as you could see, was he under the
19
care of Dr Johnston?
20
A.
Yes.
21
Q.
I think you have noted that this transfer was to ward 15
22
in the Vale of Leven?
23
A.
I believe so.
24
Q.
If we just perhaps read on in this section of
25
the report, I think you tell us that, on the 12th, he
44
1
was unsettled and he was found on the floor beside his
2
bed, although the cot sides were still raised and there
3
was a bump on the side of his head; is that right?
4
A.
Yes.
5
Q.
You have taken that, I think, from the nursing notes; is
6
that correct?
7
A.
That's correct, yes.
8
Q.
If we move on to page 5, I think you tell us there was
9
no corresponding entry in the medical records?
10
A.
Yes.
11
Q.
Do you think there should have been some medical
12
13
assessment at this point?
A.
I do.
In an elderly gentleman who has fallen from
14
a distance of bed height plus the height of the cot
15
rails and was noted to have an injury to his head, there
16
would be a risk of serious trauma.
17
would be the appropriate thing, for him to have been
18
seen by a doctor.
19
Q.
20
21
I suspect -- that
Then reading on, how did he progress, and, in
particular, what treatment did he receive and why?
A.
On 14 January, he was assessed by Dr Herd and felt to
22
have cellulitis of his left leg and a chest infection.
23
We will come to the reasoning behind that later,
24
I guess.
25
Q.
Yes.
45
1
A.
He was commenced on some intravenous antibiotics, all
2
those were discontinued on 17 January, when he pulled
3
out his intravenous line.
4
Q.
Do we take from that that the intravenous antibiotics
5
were given for, what, perhaps two or three days, in
6
total?
7
A.
Yes.
So they were prescribed on the 16th.
8
at some point on the 17th.
9
each.
10
11
They stopped
So he had just two doses of
But then these were changed to oral formulations
of the same drugs from 18 January.
Q.
Again, we will look at that in a moment, but you tell us
12
that he was diagnosed with C. diff diarrhoea on
13
25 January.
14
report, and that's at GGC00030025.
15
Perhaps if we can look at the microbiology
Can we just see here that the specimen that was
16
tested was collected on 22 January and received by the
17
lab on 25 January; is that right?
18
A.
That's what it says.
It seems slightly strange that it
19
would take three days to get across a hospital from
20
a ward to a microbiology department.
21
Q.
If we look at the specimen, can we see that it was, as
22
indeed was the last one we looked at in the last case,
23
semi-formed faeces, but this was a positive result?
24
25
A.
Yes, so in light of the previous case, that's
interesting, isn't it, that this stool described as
46
1
2
"semi-formed" was tested for Clostridium difficile.
Q.
3
But that may be because the request was made.
You don't
know?
4
A.
Yes.
5
Q.
But, on the face of it, there appears to have been
6
a delay between the date of collection, then, and the
7
date of receipt, of two or three days?
8
A.
Yes.
I'm not sure why that is.
9
Q.
If we look at the nursing notes -- I will just put this
10
on the screen for you -- at GGC00030042, I am looking at
11
a page where the first date, which I think is in the
12
column "Problem No" is 18 January, and then the next
13
date is 20 January.
14
of days.
15
so, again, there is a gap in the nursing notes.
16
note says:
17
There seems to be a gap of a couple
Then the next date after the 20th is the 22nd,
That
"John has been up on several occasions overnight.
18
Taking risks."
19
Can we take it that the sample -- if the laboratory
20
report is accurate, then the sample that was tested must
21
have been taken on or about the 22nd, albeit that
22
there's no reference there to that?
23
A.
Yes.
24
Q.
Then we come to the 23rd, and the record is:
25
"Fairly settled.
Continues to take" -- I can't read
47
1
the next bit -- "antibiotics":
2
"Continues to take antibiotics.
3
Then moving on to the 25th, can we see the note at
4
Little diet taken."
1450 is:
5
"Received notification that Jake is C. diff
6
positive."
7
So does it appear that, although we are not told in
8
the nursing notes when the specimen was taken, looking
9
to the microbiology report, it was on the 22nd, but that
10
the ward did not know that he was positive until the
11
25th, the date of receipt of the specimen?
12
A.
Yes.
13
Q.
If we move on to the entry at 1700, can we note that the
14
entry then is:
15
"Now in side room."
16
A.
Yes.
17
Q.
So it seems that, once they were aware of the positive
18
result, Mr Boyle was then isolated?
19
A.
Yes.
20
Q.
In relation to the treatment that Mr Boyle was
21
prescribed for the C. diff diarrhoea -- I think you
22
discuss that at the bottom of page 5 and on to page 6 --
23
what was the treatment?
24
A.
Metronidazole orally from 25 January until 4 February.
25
Q.
Was that an appropriate response?
48
1
A.
Yes.
2
Q.
Now, then, you give us some information that you have
3
taken from the records about Mr Boyle's state of
4
independence and dependence prior to this admission; is
5
that correct?
6
front?
7
A.
What were you able to ascertain on that
So he had managed to live alone, to some degree he had
8
his independence, although he was in a warden-controlled
9
sheltered flat.
He was usually mobile with two sticks,
10
he managed to be independent with self-care but did have
11
some support from his family for other activities.
12
had some impairment of his hearing.
13
He
When he first came into hospital, the comments say
14
he was a bit confused but scored 9 out of 10 on a brief
15
cognitive test, the abbreviated mental test score, at
16
that time.
17
Q.
18
For his age -- he was 89, I think, when he was
admitted -- he seems to have been relatively fit?
19
A.
Yes.
20
Q.
Looking at the next section of your report on page 6,
21
that is your review of antibiotic treatment for
22
conditions other than C. diff, can you just explain to
23
the Inquiry what the position was here?
24
25
A.
So he went on the flucloxacillin and amoxicillin on
14 January for what was recorded as a suspected
49
1
cellulitis and chest infection, although the entry
2
doesn't describe the appearance of his leg, and there
3
was no chest examination recorded in the notes for that
4
entry.
5
the reason why chest examination was not performed.
It says "Refuses to take deep breaths", that was
6
Q.
I see.
7
A.
Which is unusual, given he -- you know, he must
8
9
obviously have been breathing.
Q.
Yes.
Just on the point you make about -- you say there
10
are no comments in the notes on either the appearance of
11
his leg or chest examination at that time.
12
at what is in the notes on page 15, that is GGC00030015,
13
can we see there is an entry on 14 January which
14
certainly describes that there is cellulitis of the left
15
leg?
16
A.
17
18
Q.
Would you have anticipated seeing some sort of
description, then, as to --
A.
21
22
Those are the words said, yes, but there is no
description of what the leg looked like.
19
20
If we look
It then aids assessment at a later date to see whether
things are getting better or worse, doesn't it?
Q.
23
So that is the purpose of having some sort of
information there?
24
A.
Yes.
25
Q.
In relation to the chest infection that you say was
50
1
mentioned, if we are looking at the records we are
2
looking at, is there reference to the chest infection
3
here as at the 14th?
4
A.
5
"Also 'chesty' but refuses to take deep breaths for
6
7
Yes, so it reads, as I read it:
that exam."
Q.
Then looking to the response to what one takes from this
8
examination, namely, the prescription of
9
the flucloxacillin and amoxicillin, was that on
10
11
appropriate response?
A.
12
13
If he had cellulitis of his leg and a chest infection,
then those would be reasonable antibiotics to use.
Q.
14
Let's assume he had the cellulitis, because it has been
mentioned --
15
A.
Yes.
16
Q.
-- although, as you have indicated, there is no
17
description of it, which of the antibiotics mentioned
18
there would be more appropriate for that?
19
A.
20
21
Typically, flucloxacillin would be a first-line
antibiotic for a skin infection.
Q.
22
Then would the amoxicillin be prescribed for the chest
infection?
23
A.
That's my assumption.
24
Q.
In relation to that, are you able to take from the
25
information here whether or not he had a chest
51
1
2
infection?
A.
Well, the entire basis for the diagnosis of a chest
3
infection seems to be the description of him as
4
"chesty".
5
Q.
What do you take from that?
6
A.
It is not convincing evidence of a chest infection.
7
Q.
Let's assume it can be said that he did have a chest
8
infection.
Would amoxicillin be an appropriate
9
antibiotic for that?
10
A.
Yes.
11
Q.
When you say there is no recording of his temperature,
12
would you have expected his temperature to have been
13
recorded within the context of assessing whether or not
14
he had an infection?
15
A.
Yes, that would seem to be a basic simple test to do.
16
Q.
What about the blood tests, then, that were obtained on
17
18
15 January?
A.
What did they show?
They did show he had a raised white cell count and
19
C-reactive protein, which are both suggestive of,
20
although not diagnostic of, infection.
21
X-ray was performed.
22
Q.
23
24
25
But no chest
But would the raised white cell count and the CRP
justify the antibiotic that was given?
A.
In medicine, you treat a patient, not a blood result, so
it is part of the clinical assessment, but if -- you
52
1
know, if someone who is otherwise well had a high white
2
cell count and CRP, you wouldn't start on antibiotics.
3
They are just one part of the assessment.
4
Q.
The point you make of the fact that the chest X-ray was
5
not performed, how would that have helped in this whole
6
diagnostic process?
7
A.
Well, it would be usual practice for a patient in
8
hospital with a diagnosis of pneumonia to have a chest
9
X-ray performed to see if there was indeed signs of
10
consolidation, any subsequent complications of that,
11
such as the development of empyema, and also it can be
12
used to monitor if the patient didn't respond as
13
expected to antibiotics.
14
Q.
You go on to say towards the very bottom of page 6, and
15
moving on to page 7, that the antibiotics selected are
16
reasonable for the indication recorded?
17
A.
Yes.
18
Q.
I think you also, on that hypothesis, say that the dose
19
and duration chosen, these were also reasonable choices?
20
A.
Yes.
21
Q.
We have noted already that, certainly as at 25 January,
22
the ward staff knew that Mr Boyle had contracted
23
C. diff.
24
antibiotics that he was prescribed for these, on the
25
basis of what we have been discussing?
What was the position in relation to these
53
Were they
1
continued?
2
A.
They were.
3
Q.
For how long?
4
A.
Just up to the 25th.
At the time that he was
5
actually -- the sample was sent on the 22nd, wasn't it?
6
So they continued beyond the time he developed
7
diarrhoea, but discontinued at the time the diagnosis of
8
C. difficile was made.
9
Q.
10
The point you make in your report, if we go back to
page 7, is that -- what you say is:
11
"After the onset of C. difficile, the antibiotics
12
were continued, no consideration of their
13
discontinuation is recorded in the notes."
14
What seems to have happened is, once they had the
15
diagnosis of C. diff, then the antibiotics were
16
discontinued?
17
A.
Yes, but I guess the thing to perhaps clarify at that
18
stage is he'd then received them for some seven or eight
19
days, hadn't he?
20
he'd had almost ten days of treatment.
21
been the natural end to the course of treatment anyway.
22
Q.
In fact, he'd started on the 15th, so
So that may have
Do you consider, when the specimen was taken and the
23
suspicion was there that he may have C. diff, that this
24
is something that should have been addressed?
25
A.
I think that would have been the ideal, yes, that, once
54
1
he was known to have diarrhoea, a sample was sent.
2
obviously there was some suspicion he had
3
Clostridium difficile.
4
reasonable to carefully consider whether he should
5
continue those antibiotics whilst awaiting the result.
6
Q.
So
Then it would have been
That consideration and the result of that consideration
7
then would depend on what?
8
clinical signs were in relation to the basis upon which
9
they had been prescribed?
10
A.
Exactly.
Would it depend on what his
So a further assessment of the patient would
11
have been appropriate, at that stage, to see whether
12
their, you know, justification was still present.
13
Q.
14
Did you see any evidence of such a consideration in the
records?
15
A.
I did not.
16
Q.
Then, if we move on to the next section of your report
17
on page 7 -- and we have already, I think, this morning,
18
touched upon the doctors' duties under the Good Medical
19
Practice code -- you then tell us in the next paragraph
20
that, according to what you have taken from the records,
21
Dr Johnston had the primary responsibility for the care
22
of Mr Boyle on ward 15; is that how you saw it?
23
A.
Yes.
24
Q.
What about, then, the extent of consultant review, so
25
far as you could tell from the records?
55
1
A.
So there was, I think, a scheduled, once-a-week
2
consultant ward round with some medical review in
3
between these times.
4
ad hoc.
5
it.
6
Q.
That seemed to be rather sort of
It didn't seem to have a very planned nature to
Again, if we go back to page 15 of the records, we
7
looked at the entry for the 14th.
I think that probably
8
again is Dr Herd.
9
a further entry in the same sort of handwriting.
Again, I think, on the 16th, we see
10
I think we assume that is Dr Herd.
So it would appear
11
that Dr Herd has been having some input over that
12
period; is that right?
13
A.
Yes.
14
Q.
Then, if we move on to page 16 of the clinical notes,
15
can we see again that there appears to be an entry by
16
Dr Herd on 18 January, which I think is narrating the
17
fact that he had spoken to Mr Boyle's two daughters; is
18
that right?
19
A.
Yes.
20
Q.
Then there is a gap to 21 January, and then a further
21
gap of about four days to 25 January.
22
there is some reference to the fact that Mr Boyle is now
23
C. diff positive and he's been started on metronidazole?
24
25
A.
Is that where
Yes, that seems to be the oncall doctor who has seen the
patient on that day.
56
1
MR KINROY:
My Lord, I notice an entry on 21 January 2008,
2
"Swallow much better.
3
that is relevant to what we already know about
4
Mr Boyle's difficulties?
5
MR MACAULAY:
6
Eating normal diet".
Well, you have seen that entry.
I wonder if
This is the
one for 21 January:
7
"Swallow much better.
8
Eating normal diet.
Not for
CPR or ventilation."
9
A.
I see that, yes.
10
Q.
Can you work out -- can you see what the signature is
11
there, or not?
12
A.
I think, from prior knowledge, that that is Dr Johnston.
13
Q.
I think the consultant.
14
A.
But if this was the first time I'd ever seen that,
15
16
I would not be able to read it.
Q.
No.
If we move on to page 17, then, we have noted that
17
a doctor, the FY1 on call on the 25th, has noted
18
the C. diff diagnosis.
19
is not until 28 January?
20
A.
Yes.
21
Q.
Where the note is:
Then can we see the next entry
22
"C. diff improving.
23
Do you consider that is appropriate review to have,
24
25
Diarrhoea lessened."
particularly when the patient has contracted C. diff?
A.
No, there is no -- like we've found in previous records,
57
1
we don't know how the patient was feeling or any idea
2
that the patient had a physical examination on that day.
3
Q.
What about the gap?
There is a gap, on the face of it,
4
between the 25th and the 28th where there doesn't appear
5
to be any review in the clinical records?
6
A.
Yes, and the entry on the 25th is the oncall foundation
7
year 1 doctor, who is simply commenting that they have
8
seen the Clostridium difficile result and started on
9
metronidazole.
It doesn't say if the patient was
10
actually seen, other than his drug chart was written on.
11
So, essentially, it looks like there was a week between
12
any kind of review of the patient.
13
Q.
14
LORD MACLEAN:
15
Is that -I notice that there are no notes between
21 and 25 January as well.
16
A.
Yes.
17
LORD MACLEAN:
18
A.
Is that normal?
In a rehabilitation setting, a patient might be seen by
19
a consultant once a week, but you would expect more
20
regular junior doctor review.
21
patient was symptomatic, weren't they?
22
they developed diarrhoea on 22 January, to the point
23
that a stool sample was sent, but they didn't seem to
24
have been seen by a doctor at that stage.
25
MR PEOPLES:
Particularly, this
We know that
My Lord, I wonder, on the point of the entry on
58
1
the 25th, it seems to have been made at 3.45 by an
2
oncall doctor.
3
arrangement at 3.45 in the afternoon?
4
A.
5
MR PEOPLES:
6
Is that normal, to have an oncall
Is that a question to me?
Sorry, I was asking it through his Lordship,
but I wonder if it could be picked up.
7
LORD MACLEAN:
8
MR PEOPLES:
9
LORD MACLEAN:
10
MR PEOPLES:
11
A.
I can't answer that question.
No, I am hoping that the witness can.
Yes, I know.
It just seems a bit strange.
I get the point of the question.
It would be nice to
12
see a calendar to know what day of the week 25 January
13
was.
14
MR PEOPLES:
15
16
I don't know, off the top of my head.
I'm told it is a Friday.
If we assume it was
a Friday, 3.45.
A.
Yes, so 3.45 on a Friday, it wouldn't usually be the
17
oncall team, would it?
18
whom you would expect to be present 9.00 to 5.00 on all
19
working days.
20
MR MACAULAY:
It would usually be the day team
We have a situation here, I think, where
21
Mr Boyle now has been -- it has been confirmed that he
22
has contracted C. diff, and he is an elderly gentleman,
23
of 89 or 90.
24
about this time?
25
A.
Yes.
Should there have been consultant input at
I mean, this was clearly a high-risk patient for
59
1
deterioration and, as it sadly proved, death from
2
Clostridium difficile.
3
health of this gentleman.
4
Q.
This was a major setback in the
We do see, if we assume it is Dr Johnston who has seen
5
Mr Boyle on 21 January, a few days before that, and has
6
carried out a form of review, do you consider that is an
7
appropriate review for a consultant?
8
A.
9
That is the kind of information you would probably get
from speaking to the nurse, rather than examining or
10
speaking to the patient.
11
that Dr Johnston had a face-to-face interaction that
12
included a physical examination with this patient.
13
Q.
14
There is nothing there to say
Do you consider that she should have had such an
interaction with the patient?
15
A.
That should be a routine part of every ward round.
16
Q.
Then, if we move on to page 17 of the notes, the entry
17
that we touched upon on the 28th is that the C. diff was
18
improving, but then we have another entry, I think it
19
looks like the 29th.
20
is Dr Herd.
I think we can now focus on his thicker and
21
darker pen.
But can you --
22
A.
23
I believe that says:
"Daughters agree that he is candidate for
24
25
Are you able to read -- I think it
institutional care."
Q.
That doesn't tell us whether or not Dr Herd has examined
60
1
Mr Boyle?
2
A.
No.
3
Q.
The next entry, this is perhaps a couple of days later,
4
would also appear to be Dr Herd.
5
us?
Can you read that for
6
A.
"Still [something] diarrhoea despite metronidazole".
7
Q.
Then do we see there is a gap until we get to the next
8
entry, of 3 February, and this is the junior doctor on
9
call, I think; is that how we interpret that?
10
A.
Yes.
11
Q.
What does he or she discover?
12
A.
So the entry reads:
13
"Patient is not swallowing.
Diarrhoea not improved.
14
On metronidazole for C. diff.
15
subcutaneous fluids" -- "SC" presumably stands for
16
subcutaneous -- "six-hourly".
17
Q.
I have started patient on
In your opinion, Dr Woodford, do you consider there
18
should have been consultant review, let's say, between
19
31 January and 3 February, particularly when we have
20
this picture where there doesn't appear to be
21
improvement?
22
A.
Yes.
Yes, I do.
23
Q.
Then the next entry we see on 4 February is:
24
"Patient slowly dying."
25
Is that correct?
61
1
A.
That's how I read it, yes.
2
Q.
Then, on 6 February, the doctor has been asked to
3
certify Mr Boyle's death; is that correct?
4
A.
Yes.
5
Q.
Would it appear, insofar as the consultant's involvement
6
is concerned, the last time prior to 6 February at the
7
time when Mr Boyle died that he had been seen by the
8
consultant, on the face of it, was 21 January?
9
A.
10
11
I think that is incorrect, isn't it?
It looks like it
is Dr Johnston on 4 February.
Q.
Ah, yes, so that is Dr Johnston's note for 4 February,
12
yes.
13
period of time during which he was not seen by the
14
consultant?
15
A.
16
From the 21st, then, to the 4th, we have the
The 28th.
The 21st -- I presume that entry on the top
of the page of 28 January --
17
Q.
You think that is Dr Johnston as well?
18
A.
It looks like it is signed by "TT", but the handwriting
19
looks like it is Dr Johnston's, and it is a week after
20
the last entry, so it would seem to coincide with the
21
weekly ward round pattern, and that is my assumption.
22
Q.
You are assuming that the entry -- you may be right --
23
at the top of page 17, for 28 January, is by
24
Dr Johnston?
25
A.
I can only guess.
62
1
Q.
Okay.
2
A.
It looks like it is signed "TT", but conceivably that
3
4
could be a bad "FJ", I suppose.
Q.
5
6
If that is Dr Johnston, is that an adequate review of
the patient?
A.
No.
I mean, it is almost the same as the one from
7
21 January, isn't it?
8
the patient was actually spoken to or physically
9
examined.
10
Q.
There is nothing there to suggest
Let's assume Dr Johnston has seen Mr Boyle on
11
28 January, and I think we can take it that she doesn't
12
see him again until 4 February.
13
he had C. diff, is that appropriate review by the
14
consultant?
Standing the fact that
15
A.
I would say not.
16
Q.
What would you envisage?
17
A.
Well, it would seem a strange situation, to have gone
18
from apparently improving on 28 January to "Patient
19
slowly dying" on 4 February.
20
mind-set shift, doesn't it, from a patient who is
21
improving and being actively treated to a patient who is
22
to be treated palliatively, with no clear justification
23
within the notes as to why that change in approach has
24
occurred.
25
Q.
It seems a complete
Would you have expected that the consultant would have
63
1
had greater involvement, then, with the patient recorded
2
in the records?
3
A.
4
5
Greater and more thorough involvement, I would have
expected.
Q.
Now, then -- we digressed, I think, from your report --
6
if we go back to the section we were looking at on
7
page 7, if you look at the final section, beginning
8
"Note entries are brief", can you take us through that
9
final part of your report which moves from there through
10
11
to page 8 of it?
A.
That is what we have just been talking about, that the
12
entries are two to three lines and very little for us to
13
know what the patient was feeling or what they looked
14
like at the time.
15
The 27-day period from first being seen on ward 15
16
to the time of the patient's death on 6 February
17
occupies three size of clinical paper.
18
quality isn't very good.
19
name on the top of the sheet of paper.
20
practice would be to add at least the age or date of
21
birth or unit number, or possibly all three of those.
22
If these notes had fallen out of the file, there must be
23
plenty of other John Boyles in the world.
24
25
The record
There is only the patient's
Standard
There doesn't seem to be any increase in frequency
or quality of assessment following the diagnosis of
64
1
the C. difficile.
As we have just commented on, the
2
senior involvement was minimal, in my opinion.
3
one recorded entry of a conversation with the daughters
4
on 18 January, although I note this doesn't include
5
a CPR decision, although this was the inference on the
6
DNAR form, that this had occurred.
There is
7
There doesn't seem to have been any direct
8
conversation between Dr Johnston, the consultant in
9
charge, and the patient's family.
10
Q.
You then move on to give some insight into how
11
C. difficile might be diagnosed, and that is by the
12
accommodation of diarrhoea and a stool sample positive
13
for C. diff toxin.
14
I think your own practice would be that you might start
15
treatment on suspicion without waiting for the diagnosis
16
to be confirmed; is that correct?
We have discussed this already, but
17
A.
Yes.
18
Q.
But in any event, it appeared from the records that
19
Mr Boyle was not isolated until the positive diagnosis
20
had been made?
21
A.
Yes.
22
Q.
Does that then produce a possible risk of contaminating
23
24
25
other patients with the infection?
A.
Yes.
I think, you know, optimal practice would be to
isolate any patient on the point that they developed -65
1
2
first developed symptoms.
Q.
3
4
If we look at the final paragraph on page 8, what is the
point you are seeking to make there?
A.
I think it is simply that he wasn't improving with the
5
metronidazole, and it may have been worthy of getting
6
a microbiology opinion to see if there were any other
7
things that they should be doing at that time.
8
There was, what, an 11- 12-day period that he had
9
diarrhoea up to his death?
In fact, it was from the
10
22nd, wasn't it?
11
the 25th.
12
treatment prior to his death.
13
Q.
14
Although the antibiotics started on
That gives us approximately two weeks of
Indeed, had it been noted in the notes we looked at that
it was recognised that his diarrhoea was not improving?
15
A.
Yes.
16
Q.
Do you consider that it would have been appropriate,
17
then, to have had microbiology input into this, into his
18
position?
19
A.
Yes.
20
Q.
Are you able to say what, if any, difference that might
21
22
have made?
A.
It may have made no difference, but they may have chosen
23
to change him, at that stage, from metronidazole to
24
vancomycin, for instance.
25
Q.
The point you make in relation to infection control
66
1
card -- I think you have given the wrong reference
2
there, but we know the reference begins with an SPF, so
3
it's SPF00410001.
4
see this for ourselves on the document -- is that, for
5
1 February, the note is "asymptomatic".
6
have noted that there was still evidence of diarrhoea at
7
that time; is that right?
I think what you have noted -- we can
But I think you
8
A.
That's what's written in the nursing records, yes.
9
Q.
You conclude that his C. diff diarrhoea was acquired in
10
the Vale of Leven Hospital; is that right?
11
A.
I think so, yes.
12
Q.
Can I just perhaps correct something?
13
If I said this,
then I shouldn't have said it.
14
If we go back to the clinical notes on page 17,
15
I thought I put to you that there would have been
16
a realisation at some point that his diarrhoea was not
17
improving, and I had in mind the entry particularly on
18
3 February.
19
not improved"?
Do you see that, where it says "diarrhoea
20
A.
Yes, and the entry prior to that, 31 January.
21
Q.
Yes.
But there was an entry previous to that, of
22
course, that we did touch upon on the 28th, we think
23
possibly by Dr Johnston, where there was a suggestion
24
that the C. diff was improving?
25
A.
Yes.
67
1
Q.
And diarrhoea lessened?
2
A.
Yes.
3
Q.
So it would appear there may have been an improvement,
4
but between then and the 31st and the 3rd, that position
5
changed?
6
A.
Without an accurate record of a stool chart, it is hard
7
for us to comment, isn't it?
8
what Dr Johnston felt on 28 January, but then things
9
would seem to have subsequently deteriorated after that.
10
Q.
But obviously, that is
If we go back, then, to your report on page 8, you say
11
his diarrhoea was acquired in the hospital, C. diff
12
diarrhoea was the result of exposure to spores in
13
a susceptible patient, that is a frail elderly patient,
14
who had recently received broad-spectrum antibiotics; is
15
that right?
16
A.
Yes.
17
Q.
So far as the antibiotics are concerned, then, you are
18
I think there -- do you have in mind the antibiotics we
19
discussed earlier, namely, the co-amoxiclav, and I think
20
also the amoxicillin -- sorry, it was the amoxicillin,
21
flucloxacillin?
22
antibiotics?
Is that correct?
Were these the
23
A.
Yes.
24
Q.
We discussed whether or not they were necessary or not
25
already.
68
1
Moving on, you say that, despite the patient being
2
known to have poor swallow, parenteral fluids were only
3
sporadically given."
4
5
Can you explain what you mean by that?
A.
This is a patient at risk of dehydration because they
6
are not swallowing normally.
7
reason why they might be losing fluid, in that they are
8
having diarrhoea.
9
Q.
10
11
What are you suggesting here?
They also have an obvious
Do you think there should
have been some different approach?
A.
They are likely to have become dehydrated, and it is
12
likely that, during the period of reduced swallow and
13
diarrhoea, they would have needed supplementary fluids,
14
given either subcutaneously or intravenously.
15
Q.
Did that happen in this case?
16
A.
It is hard for us to assess because there is very little
17
information regarding the patient's state of health
18
recorded in the notes and no blood tests after
19
15 January to give us any clues as to state of
20
hydration.
21
that this patient was dehydrated.
22
MR KINROY:
But, logically, it would seem very likely
My Lord, it takes me back to ask if the Inquiry
23
might relate this to the entry on 21 January, "Swallow
24
improving".
25
reckoning of the situation?
I wonder how this fits into the doctor's
69
If that question is
1
2
permissible to be asked through the Inquiry.
MR MACAULAY:
Yes, you heard that.
There is evidence that
3
there was -- I will take you back to the entry on
4
page 16 of the clinical notes.
5
21 January:
It is the entry for
6
"Swallow much better."
7
Do you feed that into your views you express in your
8
9
report?
A.
Well, that is a step in the right direction, isn't it?
10
But it doesn't tell us what the patient's intake
11
actually was at that time.
12
about the oral intake, you would expect some other kind
13
of assessment; ie, a food diary, a fluid balance chart,
14
some bloods to look at the state of hydration.
15
I don't think that entry in itself was enough to
16
17
Given there were concerns
reassure us that this man was not dehydrated.
Q.
I was going through the records to see if I could focus
18
on the fluid balance charts, and particularly for this
19
period.
20
the period from about 21 January through to the date of
21
death?
22
A.
Did you focus on fluid balance charts to cover
I found it very difficult to put together a coherent
23
summary of exactly the fluids in and out that he had,
24
based on the records that were received.
25
Q.
If we look at page 28 of the records, we have a fluid
70
1
balance chart for the period 16 to 17 January.
2
pre-dates the period we have actually been looking at,
3
but we can see that there are some -- is that
4
intravenous fluids?
5
this for us?
6
A.
Is that correct?
That
Can you interpret
I think it was intravenous fluid.
He was known to have
7
an intravenous line at that time.
You know, he's
8
basically getting a litre of fluid over an eight-hour
9
period, isn't he?
400ml every four hours.
That is at
10
a rate faster than you would probably give fluids -- be
11
able to give fluids subcutaneously.
12
is incomplete.
13
or the total amount out.
14
Q.
15
But the fluid chart
It doesn't tell us the total amount in
No, I understand that.
There is no oral intake or any
output given at all?
16
A.
Yes.
17
Q.
The other one is actually on page 31 of the records.
So
18
we have looked at the one for the 16th to the 17th, and
19
then we will go to the 17th to the 18th.
20
now on the screen.
21
A.
We have that
So it simply seems to be the prescription of
22
the intravenous fluids that he's had at that time.
23
doesn't tell us anything about his total fluid intake or
24
his fluid output.
25
Q.
It
I can be corrected if I am wrong, but that is what we
71
1
have in relation to fluid balance charts, so that
2
doesn't really assist us in relation to the period after
3
the 21st?
4
A.
5
There is a subcutaneous fluids one, isn't there, again
relating to the same date, the page before, page 30?
6
Q.
Sorry, what was the page for that?
7
A.
GGC00030030.
8
Q.
As you indicated, that is the same information that's on
9
10
Is that page 29?
the fluid chart?
A.
I think that's slightly different, isn't it?
At the top
11
it says "Subcutaneous fluids", so that might relate to
12
what was prescribed after the intravenous line came out.
13
Q.
14
On page 31, we see "SC fluids" at the top.
Is that
indicative of the fact that this may be --
15
A.
Sorry, my mistake.
They may actually be the same, yes.
16
Q.
If that is what we have, and what we have is all there
17
was, does it seem that, from the 21st through to the
18
date of death, fluid management has not been charted?
19
That is what the position is?
20
A.
That is how it seems, yes.
21
Q.
What do you make of that?
22
A.
Well, you know, a patient who is at risk of dehydration,
23
that is suboptimal assessment of his current state of
24
fluid balance.
25
Q.
This little chapter was triggered by that sentence in
72
1
your report that you read out, that, despite the patient
2
being known to have poor swallow, parenteral fluids were
3
only sporadically given.
4
Now, are you envisaging that such fluids should
5
still have been given, notwithstanding the improvement
6
that may have been taking place in his ability to
7
swallow?
8
A.
9
By that stage, he could have been profoundly dehydrated.
There is no quantification as to what extent his swallow
10
improved.
11
of liquid over 24 hours or had he gone to normal diet?
12
We simply don't know.
13
Q.
Had he gone from no swallow to two teaspoons
You see, if we read on, page 8 into page 9, that blood
14
tests were not performed after 15 January to assess
15
hydration.
16
to why there were no blood tests?
Did you find in the notes any explanation as
17
A.
No.
18
Q.
Should there have been blood testing after that time?
19
A.
I believe so.
I mean, this is a gentleman who was
20
diagnosed with infection on 15 January, and then was
21
prescribed intravenous fluids, was known to have a poor
22
oral intake, so was known to be at risk of dehydration,
23
plus, also, things like salt imbalances, such as low
24
potassium related to his diarrhoea, so I think it would
25
be impossible to monitor this man optimally without
73
1
2
doing further blood tests.
Q.
You go on to say, if we look at what you tell us in your
3
report, towards the top of page 9, that dehydration is
4
likely to have contributed to the patient's
5
deterioration.
6
A.
Why do you say that?
Because he's actively losing fluid in excess through his
7
diarrhoea, and our knowledge is that his oral intake has
8
been poor.
9
Q.
10
11
Does that allow you to make that conclusion, then, that
the dehydration did play a part in his deterioration?
A.
My conclusion is that it is likely.
Without the
12
relevant information, I can't be more specific than that
13
or more definitive than that.
14
DAME ELISH:
My Lord, I wonder, on this particular point, if
15
Mr MacAulay could clarify the role of physiological
16
testing of hydration, the primacy of that, in regard to
17
dehydration.
18
19
20
21
22
MR MACAULAY:
I think my learned friend means physiological
testing such as blood sampling; is that correct?
DAME ELISH:
No, physical examination -- turgor, et cetera,
and other examinations.
MR MACAULAY:
Can you deal with that?
I think what is being
23
put to you is whether physical examination, testing for
24
hydration, would disclose dehydration?
25
skin, eyes, and so on?
74
For example,
1
A.
None of these tests are perfect.
Skin turgor, and
2
things like sunken eyes, are known to be poor tests in
3
elderly people because of changes in the makeup of
4
the skin, compared to younger people.
5
Some assessments, such as the presence of peripheral
6
oedema or the measurement of the jugular venous pressure
7
would be better indicators, or things like tachycardia,
8
hypotension, postural drop in blood pressure, but none
9
of these are recorded so we can't use these as the basis
10
11
to know.
Q.
You have indicated what your views are on that approach,
12
but in any event, is there any evidence of that sort of
13
approach being taken --
14
A.
No.
15
Q.
-- particularly over this latter period?
16
A.
No.
Also, you know, these wouldn't tell us other things
17
that blood tests may do, such as, you know, the amount
18
of potassium in the patient's body, which would be at
19
risk of being low, given the ongoing diarrhoea.
20
Q.
What is your overall conclusion, then, that you set out
21
under this particular section of your report in that
22
main paragraph towards the top of page 9?
23
A.
24
25
What, that we just said, that dehydration was likely to
have occurred?
Q.
Then the next paragraph.
I think you are trying to give
75
1
us a broad overview.
What do you say?
You begin by
2
saying that the overall quality of Mr Boyle's medical
3
care at the Vale of Leven appears to be poor.
4
A.
Yes.
5
Q.
We have been discussing some of that in the last few
6
7
moments.
A.
So he seemed to have had some form of transient
8
neurological event when he was at the Royal Alexandra
9
Hospital, but neurological assessment was very brief
10
when he came to VOL.
His death certificate stated
11
a diagnosis of dementia, but this isn't recorded in his
12
notes prior to his death.
13
assessment done at the Royal Alexandra Hospital scored 9
14
out of 10, although this subsequently seems to have
15
fallen to 2 out of 10 when he got to the Vale of Leven.
16
But this suggests he may have had an acute confusional
17
state and, therefore, this could have been a partially
18
reversible process rather than an irreversible dementia
19
process.
His initial cognitive
20
We talked about the occasion when he fell out of bed
21
and had no medical review, and we have also talked about
22
the fact that he had a poor swallow and diarrhoea, but
23
not getting a lot of supplementary fluids or blood tests
24
to monitor his state of hydration.
25
Q.
You then go on to look at the DNAR order position, and
76
1
you, I think, point out that this was signed by Dr Herd.
2
Perhaps we can just put the document on the screen, it's
3
at GGC00030004.
4
screen as well, if we can put page 10 beside that.
5
We can put another document on the
If we are looking at the document on the right-hand
6
side, and I think -- is this the document that you
7
particularly reference in your report, page 4?
8
on the right-hand side.
The one
9
A.
Yes.
10
Q.
There is no indication as to why the DNAR order is being
11
put in place, but can we see that it's been signed by
12
Dr Herd, he's printed his name, and the date for this is
13
18 January -- sorry, his date is 24 January --
14
A.
Yes, the 24th is the date there.
15
Q.
The suggestion is it was discussed with the daughter on
16
17
18 January.
A.
There is a discussion with the daughter in the medical
18
records on 18 January, although this doesn't seem to
19
discuss the issue of resuscitation.
20
Q.
Is that the note we looked at earlier?
I will put it
21
back on the screen.
22
can move the document on the left off for the moment.
23
24
25
It is page 16 of the records.
We
I think we look at this to some extent before, but
it is 18 January:
"Spoke to 2 daughters."
77
1
Is that how it begins?
2
3
Are you able to read the
handwriting for us?
A.
4
I would read that as saying:
"Spoke to 2 daughters.
Mentioned about fact he is
5
pulling out IVI and subcut fluids.
6
swallowing [something] better today.
7
that NG or PEG is inappropriate."
8
Q.
9
Yesterday, his
She seems to agree
I think the point you make is that it doesn't -- the
note doesn't disclose whether the discussion included
10
that there would not be CPR?
11
A.
That's correct.
12
Q.
If we can put the other document back on the screen,
13
please, that we had a moment ago, that's page 10, this
14
appears to be another document, which is headed "Do not
15
attempt resuscitation".
16
when you were looking at the records?
17
A.
Did you look at this at all
I don't recall if I came across that, but it seems to be
18
a duplication of the other, doesn't it?
19
what the justification was.
20
forms?
21
Q.
I don't know
Why would there be two
I don't know.
We don't know.
But this one seems to be dated
22
21 January.
It looks like Dr Herd's writing.
This one
23
does indicate that the basis may be dementia.
That has
24
certainly been written on it.
25
A.
Yes.
78
1
Q.
Do you consider, in any event, whether or not a DNAR
2
order being put in place on, let's say, 18 or 21 January
3
was appropriate for this patient?
4
A.
Well, he was about 90 years old at this stage.
He may
5
not have survived resuscitation.
It may not have been
6
beneficial to him.
7
because there is no clear irreversible diagnosis well
8
documented within the notes.
9
already.
I think it is hard to know for sure,
We have discussed dementia
But if this was a 90-year-old gentleman with
10
dementia, then I think most people would agree not to
11
perform CPR in this situation.
12
Q.
Looking to cause of death and death certification, if
13
you just look at that -- and we can put the death
14
certificate back on the screen; that's SPF00020001 -- we
15
did, I think, observe earlier that C. diff does appear
16
on the death certificate, as does dementia.
17
You discuss this in section 7 of your report.
What
18
conclusions do you come to in relation to the
19
appropriateness of the death certification and the cause
20
of death?
21
A.
I think it is right that Clostridium difficile was the
22
primary cause of his death.
23
prognosis had he not had Clostridium difficile.
24
have mentioned, he was old, so, you know, he was
25
unlikely to have lived for more than a few years
79
It is hard to know his
As we
1
irrespective of this.
2
that his swallowing and memory problems were a chronic
3
part of an irreversible process such as, for instance,
4
dementia, or whether they were an acute process related
5
to the fact he was acutely ill with things like
6
cellulitis.
7
It is hard to know the extent
Whether he could have survived if his
8
Clostridium difficile was more actively treated, you
9
know, I think that is certainly a possibility.
The fact
10
that dementia is on his death certificate and his -- one
11
of his DNAR certificates is a little odd, in that it is
12
not recorded actually in his notes at other times.
13
Q.
I did propose to ask you about that.
I think you
14
touched upon this in your previous section, that in the
15
RAH he was seen as being generally independent
16
pre-admission and you say he scored 9 out of 10 on the
17
AMTS.
18
that involve?
19
A.
Can you explain that analysis to us?
What does
The abbreviated mental test score is just a very simple,
20
very quick, 10-question brief screening tool to look for
21
the presence of cognitive impairment.
22
would be within normal limits.
23
would suggest there may be a problem.
24
best, it is a very limited, very brief screening tool.
25
That alone would be insufficient to diagnose dementia.
80
A score of 9
A score of 8 or less
But, at the very
1
Q.
Looking to what you have taken from the medical records,
2
did you see any clinical assessment to allow the
3
clinician to come to the conclusion that Mr Boyle did
4
have dementia?
5
A.
He subsequently had -- when he arrived at VOL, he had
6
a score of 2 out of 10 on the same test, which
7
presumably is the basis that he was labelled as having
8
dementia.
9
add up, in that, as you already said, it is only,
But, you know, that in itself doesn't seem to
10
at best, a very brief screening tool.
11
dementia is based on a holistic assessment of
12
a patient's cognitive and functional ability, and it is
13
something that slowly progresses over time.
14
A diagnosis of
We have seen here the records seem to suggest his
15
cognition was roughly normal when he went to Royal
16
Alexandra, yet, when he arrived at the Vale of Leven
17
some, I don't know, days or a week later, he seemed to
18
have, you know, been confused at that stage, which
19
suggests an acute confusional process, ie, delirium,
20
which is a potentially reversible, non-dementia
21
condition.
22
DAME ELISH:
My Lord, could Mr MacAulay perhaps clarify
23
whether or not a CT scan showing global atrophy would
24
have assisted in that diagnosis?
25
MR MACAULAY:
I think you did touch upon that before, but
81
1
2
can you help us on that: does the CT scan help at all?
A.
Yes.
The simple answer is, no.
Brain atrophy is common
3
with advancing age and does not correlate well to
4
cognitive function.
5
Q.
If we remind ourselves, and go back to page 6 of your
6
report, if I can take you back to that, have you taken
7
from the history that, prior to his admission, Mr Boyle
8
lived alone in a warden-controlled sheltered flat and
9
was mobile with the aid of two sticks and independent of
10
self-care?
So that was the background before he went to
11
the Royal Alexandra Hospital.
12
A.
Yes.
13
Q.
So far as you are able to tell us, then, are you able to
14
say whether or not there was an appropriate basis for
15
the conclusion that we see in the death certificate,
16
that Mr Boyle was suffering from dementia as at the time
17
of his death?
18
A.
I don't think you can summarise that from what's been
19
recorded in the notes, no.
20
adequate assessment to know whether he did or did not
21
have dementia.
22
Q.
I don't think he's had an
Just two points out of this part of your discussion,
23
first of all, if we assume that Mr Boyle had not
24
contracted C. difficile in the Vale of Leven -- so he
25
went there from the Royal Alexandra Hospital to be
82
1
rehabilitated and had not contracted C. difficile -- in
2
your opinion, what would his prognosis have been?
3
A.
Well, it seems likely that he would have survived
4
hospital admission and, you know, the aim would be to
5
return him to his previous functional status, ie, living
6
independently with some support from a warden control
7
and his family.
8
Q.
9
10
It is hard to say for how long he might have lived after
that?
A.
Yes.
I mean, you can get all the tables that can
11
predict people's life expectancy, can't you, that things
12
like insurance companies use?
13
they would say, but obviously, life is a bit of
14
a lottery.
15
you know, at the age of 90, it was unlikely he would
16
have lived on a great -- you know, a great number of
17
years more, but he may have lived another year or two.
18
Who knows?
19
Q.
I don't know exactly what
Who knows what would have happened?
But,
The other point is this, that I think you envisage that
20
the C. diff might have been managed differently,
21
particularly when the diarrhoea wasn't improving.
22
you think that, if there had been a change in
23
management, that might have made a difference?
24
25
A.
Do
I think there's certainly a reasonable probability to
think that, yes.
83
1
Q.
2
I think we know that C. diff is a debilitating illness,
particularly in elderly people; is that right?
3
A.
Yes.
4
Q.
Indeed, as we see from the death certificate, that seems
5
to have been accepted, that that was the primary cause
6
of death?
7
A.
Yes.
8
Q.
Can we then look to your conclusion for Mr Boyle on
9
page 11 of your report, and it is the main paragraph on
10
that page.
11
thoughts there insofar as Mr Boyle is concerned?
12
A.
Can you just take us through your final
As we talked, at the time, the basis of the diagnosis of
13
cellulitis and chest infection aren't really well
14
documented.
15
for sure what his leg looked like at the time.
There was no chest X-ray and we don't know
16
Generally, after that, there is very little
17
documentation of examination and few investigations
18
done, including no apparent medical assessment when he
19
was found on the floor with an injury to his head.
20
We have already discussed the issue about the
21
labelling of "dementia", and we also talked about the
22
fact that he seemed to have diarrhoea and impaired
23
swallow for at least part of the time he was in
24
hospital, yet wasn't on supplementary fluids.
25
blood tests done after the 15th.
84
He had no
1
Then, when he didn't seem to get better with the
2
metronidazole, there was no change in tack.
3
think the family were consulted, from what I can tell in
4
the records, about his DNAR decision and, overall, the
5
documentation of assessment is brief and there is very
6
little to tell us what he was feeling or any physical
7
signs he had at that time.
8
Q.
9
Thank you.
I don't
That then concludes our examination of
Mr Boyle's case.
10
The next case I want to look at with you is that of
11
Sarah McGinty.
Your report for Mrs McGinty is at
12
EXP00880001.
13
the report that we now have on the screen, have you
14
noted that Mrs McGinty's date of birth was
15
1 October 1940?
If we look first at the first page of
16
A.
Yes.
17
Q.
I think she was one of the younger patients that you
18
looked at?
19
A.
Yes.
20
Q.
Her date of death was 1 February 2008?
21
A.
Yes.
22
Q.
If we look at the death certificate, at SPF00250001, can
23
we note that Mrs McGinty was 67 years of age when she
24
died on 1 February 2008, and that she died in the
25
Vale of Leven Hospital?
Looking to the death
85
1
certificate, the cause of death, there is a number of
2
entries there, but there is also an entry, the third
3
entry in part II, which reads "secondary
4
Clostridium difficile enteritis".
Do we see that?
5
A.
Yes.
6
Q.
Again, we will return to that in due course.
If we then
7
look to the body of your report, can we look at page 4
8
and start there.
9
medical history is concerned, that there is no note of
I think what you tell us, insofar as
10
any significant medical history for Mrs McGinty; is that
11
right?
12
A.
Yes, and she was on no medications at that time.
13
Q.
Was she, then, on 3 December 2008, admitted to the
14
Vale of Leven Hospital under the care of Dr Carmichael?
15
A.
2007.
16
Q.
I'm sorry, yes, 3 December 2007.
17
A.
She was, yes, with a left-sided weakness, and it was
18
noted after she was found on the floor of her own home
19
by her daughter.
20
Q.
What investigations, then, were carried out thereafter?
21
A.
The investigations included a CT scan of her brain that
22
showed a right-sided infarct consistent with her having
23
had a stroke to cause a left-sided weakness.
24
25
Q.
Have you also noted that, on admission, a urinary
catheter was inserted?
86
1
A.
2
I have, and the reason for this isn't clear in the
notes.
3
Q.
What might the reasons be, though?
4
A.
Well, my assumption is, because it's not recorded that
5
she had something like urinary retention, that this was
6
a reflex reaction to someone who's had a stroke and,
7
therefore, may be incontinent of urine for a while, on
8
the basis that they can't get to the toilet as they
9
would normally.
10
Q.
You say the reason is not recorded but the catheter is
11
still in situ up until the time of her death on
12
1 February 2008?
13
A.
Yes.
14
Q.
Does it seem that the catheter then seems to have been
15
in place from about 3 December, the date of admission,
16
2007, up to 1 February 2008?
17
A.
Yes.
18
Q.
Then, was she, on 11 December -- that's just over a week
19
after admission -- transferred to ward F under the care
20
of Dr Akhter?
21
A.
Yes.
22
Q.
If you just look at the following paragraphs in your
23
24
25
report, how did she progress thereafter?
A.
So the next thing I commented on was she seemed to
develop a pressure sore during the time that she was in
87
1
hospital.
2
11 December, but by the time it got to 31 January, this
3
was described as a sacral pressure sore, so presumably
4
this has developed into a break in the skin at that
5
stage.
6
Q.
7
She had a sacral area -- it was red on
That is information I think you have taken from the
nursing notes; is that correct?
8
A.
Yes, I believe so, yes.
Yes.
9
Q.
In the next paragraph, you have some discussion as to
10
what has been entered in the medical notes in the period
11
from 18 December through to 8 January.
12
tell us what you say there in that part of
13
the discussion?
14
A.
Can you just
The only entries seem to be to write down what results
15
of urine cultures were and the antibiotics that were
16
then prescribed, but there is no actual mention of
17
the patient being asked how they feel or any clinical
18
evaluation being done.
19
Q.
Let's just see what we see when we look at the
20
documentation.
21
GGC00420005, we have an entry for 11 December which
22
I think you have told us was what you took from the
23
records to be the date when she was transferred to
24
ward F under the care of Dr Akhter; is that correct?
25
A.
If we look at the medical records at
Yes.
88
1
Q.
I think we see, if we read that entry for 11 December:
2
"Ward F.
Ward round Dr Akhter."
3
Then there is some information given in that entry?
4
A.
Yes.
5
Q.
The next entry for a different date is about a week
6
later, for 18 December:
7
"MDT."
8
Does that mean multidisciplinary team?
9
A.
I think so, yes.
10
Q.
So there is some discussion I think there, we can see
11
that in that entry.
Then there is a further entry,
12
I think, for the same date at 1612; is that correct?
13
I think it says -- is that:
14
"Helen, daughter.
She would like to take her home."
15
Or words to that effect?
Is that how it reads?
16
A.
I think so.
17
Q.
Then, if we turn over to page 6 --
18
A.
The pages are out of order.
19
Q.
Page 7 is the next one.
Page 7 is the next one.
The next entry we have is for
20
the following day, 19 December.
21
5 January and then there is another entry on 8 January.
22
So the period that you have taken is from 18 December to
23
8 January.
24
25
We have an entry for
I have looked at that period.
What is the point you are making in your report in
relation to the entries covered by that period?
89
1
A.
So there's just two entries in that time period, and
2
both of them are by F1 doctors, which are different
3
doctors, and they just simply document the result of
4
a urine culture and the antibiotic that they then
5
started.
6
seen or assessed to see if they had a septic process
7
going on.
8
Q.
9
10
There is no suggestion that the patient was
We may look at this later again, but do you consider
that this is appropriate medical review of this patient?
A.
No.
This patient had an indwelling urinary catheter,
11
and so it is almost certain that any urine sample you
12
had taken would have contained bacteria.
13
same thing as saying they have a urinary tract
14
infection.
15
Q.
16
17
It is not the
What nature of medical review would you have expected
from the consultant in charge?
A.
Well, you know, we don't know how the patient is during
18
this time, but I think the bare minimum assessment we
19
would expect would be at least a sort of weekly review.
20
But given the patient has been twice diagnosed with an
21
infection, although probably wrongly, you'd think
22
someone other than the most junior doctor on the ward
23
might have been involved in reviewing or helping with
24
the management of this patient.
25
Q.
But the point you make -90
1
A.
Incidentally, I should maybe add that it is two
2
different F1 doctors.
3
noted, but it would suggest that, unless there's two F1
4
doctors routinely working on the ward, it is probably at
5
least one if not both of them.
6
aren't usually involved in the care of the patient.
7
Q.
8
The time of the entries aren't
The doctors on call
There is no information given in the actual entry on
that point?
9
A.
No, that is just a guess.
10
Q.
What you say is what these entries we see on page 7 tell
11
us is they give the results of the samples, but there is
12
no mention of the patient's symptoms or any clinical
13
evaluation of the patient?
14
A.
Yes.
Doctors treat patients, not results.
15
Q.
I think you have told us that before.
16
A.
It seems quite simple, but it is often forgotten.
17
Q.
Moving on, then, to go back to your report, did she then
18
receive some antibiotics for suspected urinary tract
19
infections?
20
A.
So she did.
So on that page 7, the top entry, for
21
19 December, says she was commenced on trimethoprim, and
22
the next entry down, on 5 January, said she was started
23
on amoxicillin.
24
25
Q.
We will return to the antibiotic management very
shortly.
If we move on, do you tell us that the nursing
91
1
records report constipation on 25 December and that she
2
is treated with laxatives in connection with that?
3
A.
Yes.
4
Q.
Moving on, then, to page 5 of your report, we are now
5
into 15 January, so she's been in the hospital for over
6
a month, what has her progress been by this point?
7
looking at the top of page 5.
I'm
8
A.
You are simply asking me what happened next?
9
Q.
Yes.
10
A.
So she then had, on 15 January, an episode of increased
11
confusion.
She had some kind of cough that was thought
12
to be chesty and had developed a temperature, her body
13
temperature was raised at 37.9 degrees.
14
She was then seen by a doctor -- would it be
15
F Moroni? -- who had started her on co-amoxiclav for
16
a suspected chest infection, and blood tests taken at
17
that time did show that her white cell count was
18
elevated and her C-reactive protein was also a little
19
high, which could be consistent with a chest infection.
20
She also had a chest X-ray on the same date, which
21
the report suggested some signs suggestive of infection
22
in the right lung base, although the F1 doctor
23
interpreted it as change in the left lung base -- they
24
may have just documented that wrong -- and Dr Khan
25
interpreted it as not showing any changes, but in any
92
1
case, she was commenced on antibiotics for a suspected
2
chest infection.
3
Q.
Let me just understand this.
The chest X-ray itself of
4
15 January reported showing possible changes consistent
5
with infection in the right lung base; is that correct?
6
A.
Yes.
7
Q.
The junior doctor records an interpretation of changes
8
in the left lung base; is that right?
9
A.
Yes.
10
Q.
And Dr Khan does not detect any acute changes in the
11
X-ray at all.
Is that summary correct?
12
A.
That is what's written in the notes.
13
Q.
But you go on to say that, despite this, and a normal
14
chest examination, her antibiotics were continued; is
15
that right?
16
A.
That was based on Dr Khan's entry to say, though, that
17
the chest examination was normal and the chest X-ray
18
showed no abnormalities.
19
pyrexia, the symptoms, the abnormal blood tests and the
20
abnormal chest X-ray based on the radiology
21
interpretation would suggest it was appropriate she was
22
on antibiotics.
23
Q.
However, the evidence from the
Before we move on, then, and this might be an
24
appropriate point to take this point up, if you turn to
25
page 9 of the records, that's GGC00420009, the entry
93
1
that is noted for the 16th, is that the entry by Dr Khan
2
that you mentioned in your report?
3
A.
That's right, yes.
4
Q.
I think we can see -- the chest X-ray on the 15th, his
5
entry is:
6
"Nil acute changes."
7
Is that what you have mentioned in your report?
8
A.
Yes.
9
Q.
Then:
10
"On examination.
Normal chest.
11
Then the plan is set out.
No creps.
Wheeze."
Although there is
12
a reference to "Increased temperature today"; do we see
13
that?
14
A.
Yes, but the line below says "generally looks well".
15
Q.
Yes, but he does have a plan that in fact involves
16
17
continuing the co-amoxiclav; is that right?
A.
18
Which seems -- on the basis of the other information,
that seems appropriate.
19
Q.
Appropriate on the basis of the X-ray?
20
A.
And the blood tests and the high temperature and the
21
22
cough that was recorded previously.
Q.
23
24
25
But if you look at this entry in isolation, would the
continuing of the co-amoxiclav be appropriate?
A.
If that was the only entry, then it would look a bit odd
that this doctor has interpreted the chest X-ray as
94
1
being normal, the examination of the chest as being
2
normal and then the patient looking well and, although
3
they have got a high temperature, to diagnose a chest
4
infection on the basis of that would be odd.
5
MR KINROY:
I'm a little bit lost here.
Is it being
6
suggested Dr Khan got it wrong?
7
friend would care to clarify that after lunch?
8
LORD MACLEAN:
9
MR MACAULAY:
10
Perhaps my learned
Do you want to do that?
I can do it now.
Just to clarify, the prescription of
11
the co-amoxiclav I think you say was an appropriate
12
prescription.
13
A.
Yes.
14
Q.
But what you say is it doesn't fit in with the
15
16
description that we have in the note?
A.
There is a discrepancy, isn't there, particularly
17
between the report of the chest X-ray that the
18
radiologist made and the interpretation of the chest
19
X-ray that Dr Khan made.
20
Q.
Ultimately, Dr Khan got it right?
21
A.
He did.
22
MR MACAULAY:
23
LORD MACLEAN:
24
25
Thank you.
Hold on, Dr Khan got it right, but the
antibiotics were justified because ...?
A.
I think it was right that the patient remained on
95
1
antibiotics because there were signs of a chest
2
infection based on the radiologist's interpretation of
3
the chest X-ray, the previous reported symptoms, the
4
high temperature, the abnormal blood test results, and
5
Dr Khan seems to have interpreted the chest X-ray
6
differently to the radiologist, so I would tend to
7
suspect that the radiologist got that one right.
8
LORD MACLEAN:
9
A.
Yes.
10
LORD MACLEAN:
11
MR MACAULAY:
12
At all events, the treatment was appropriate?
Thank you.
My Lord, that might be an appropriate point to
adjourn for lunch.
13
LORD MACLEAN:
14
(1.05 pm)
15
1.45 pm, please.
(The short adjournment)
16
(1.45 pm)
17
MR MACAULAY:
Good afternoon, Dr Woodford.
We had been
18
looking at Mrs McGinty's case before we broke off for
19
lunch and, if we can go back to your report, and in
20
particular page 5 of the report.
21
If we look to the last paragraph on page 5, I think
22
there you draw attention to the fact that Mrs McGinty
23
was tested positive for C. diff; is that correct?
24
Towards the bottom of the page.
25
A.
Yes.
96
1
Q.
2
You say in fact that, from then onwards, her health
declined; is that what you see in the records?
3
A.
Yes.
4
Q.
If we look at the report from microbiology, just to get
5
the dates, it is GGC00420077.
6
Can we see that the date collected is 25 January and
7
it is received also by the lab on that same day, and
8
this is a positive result?
9
A.
Yes.
10
Q.
If we move on, then, to the next page of your report,
11
page 6, you make some comments there about her urine
12
output being noted as being low on 26 and 27 January,
13
and she's described as dehydrated; is that right?
14
A.
Yes.
15
Q.
Were steps taken then to manage that?
16
A.
Strange steps, in that she was prescribed diuretics,
17
which would remove water from the body, for which I can
18
find no justification within the record.
19
Q.
Before we come to the diuretics, I think what you have
20
noted is that her IV fluids were increased by Dr Hassan,
21
first of all; is that right?
22
A.
That's right, yes.
23
Q.
Would that be an appropriate response to dehydration?
24
A.
Yes, it would, yes.
25
Q.
Then you have noted that an assessment by Dr Khan on
97
1
28 January noted that she is not fluid overloaded.
2
explain that to us?
3
A.
Just
What does that tell us?
Not a great deal, I think.
Well, it tells us that --
4
presumably the basis of that is that she didn't have
5
peripheral oedema, which would be a sign of fluid
6
overload, but we'd heard just before that she was -- the
7
previous assessment was that she was dehydrated.
8
fact, Dr Khan even said that she appeared dehydrated.
9
But then she went on to have diuretics.
10
Q.
If we look at Dr Khan's note at GGC00420016, this is the
11
note for 28 January I think timed at 4 pm.
12
says, a few lines into the note, is:
13
"She is not looking fluid overload.
14
In
What he
Looks dry,
dehydrated."
15
Is that correct?
16
A.
Yes.
17
Q.
The diuretics that she is given, how is that triggered?
18
19
Is that by -A.
The start of that entry seems to suggest she'd had --
20
Lasix is an old trade name for a drug called furosemide,
21
which is a commonly used diuretic.
22
Q.
If we take it slowly, if we look at the entry on the
23
screen, we see the reference to "plan" and then there is
24
a number 1.
25
A.
Can you just explain that to us?
That says:
98
1
"Lasix.
2
[400mg] IV intravenously stat", which is
a term to mean to be given straight away.
3
Q.
What is that?
4
A.
Lasix is a trade name for a diuretic more commonly known
5
6
as furosemide.
Q.
7
So that is the basis, then, for what you say in your
report, that she's given diuretics; is that right?
8
A.
Yes.
9
Q.
What's the rationale behind that, as far as you can
10
11
understand from -A.
12
13
I don't understand it at all.
I can see no rationale
for that decision.
Q.
14
Is that contra-indicated in a patient who is said to be
dehydrated?
15
A.
Yes.
16
Q.
The next entry, 2, what does that tell us?
17
A.
That seems to suggest that intravenous fluid is being
18
given at the same time.
19
being increased.
20
with the other hand, it is being taken away.
21
Q.
In fact, the rate of that is
With one hand, fluid is being given;
I think, just to point something out to you that's been
22
pointed out to me, I don't know if you said a moment ago
23
that it was 400, but it is 40mg of the diuretic.
24
I think that is what you say in your report, actually.
25
A.
Yes.
Higher up in the same entry, it suggests that 60mg
99
1
2
of the diuretic had been given previously.
Q.
3
4
This was now -- it's been reduced to 40 intravenously,
according to this entry?
A.
I think it wasn't that -- it wasn't prescribed as
5
a regular dose, so it wasn't a reduction in a regular
6
dose --
7
Q.
I see.
8
A.
-- this was a further additional dose.
9
Q.
We are trying to understand the rationale behind this.
10
We're taking out and putting in, if I can put it that
11
way.
12
A.
Yes.
13
Q.
Can you think of any medical reason why that --
14
A.
It makes no sense to me.
15
Q.
If you have got a patient who is dehydrated, is there
16
any risk in prescribing that patient with a diuretic?
17
A.
You will make the dehydration worse.
18
Q.
Can that be counteracted by the introduction of 2 litres
19
of fluid, which seems to be the second part of
20
the entry?
21
A.
Well, it could be, but it's an illogical way to proceed.
22
It is like punching someone in the face and giving them
23
paracetamol, isn't it?
24
but it's just -- it makes no sense.
25
Q.
The net benefit may be the same,
You then go on to tell us in that part of your report
100
1
that she's recorded to have not passed any urine for two
2
days.
3
that, at this time, Dr Khan records renal failure but
4
just two lines below writes "renal function normal".
5
Can we look at that entry?
6
the records.
7
I think that is the next entry.
You then say
It is on page 17 of
It is the entry for 30 January, and, as you pointed
8
out, the first reference is to "No urine output in the
9
last two days".
10
Can you read the next line?
"Taking orally today"?
Is that
Is that what that says?
11
A.
It could be, yes.
12
Q.
But the point you have made in your report is that, if
13
we look towards the end of this entry, it says:
14
"Renal failure.
Continue oral fluid."
15
Then:
16
"Renal function normal."
17
Are these the entries you seem to question?
18
A.
Yes.
19
Q.
Can you understand this?
20
A.
No.
21
Q.
What was the position in relation to what could be
22
23
ascertained from her blood tests?
A.
She'd had a blood test done on 30 January, the day of
24
that entry, that showed her urea and creatinine were
25
elevated at 12.2 and 106 respectively, and then she had
101
1
blood tests the following day, on 31 January, that
2
showed that they'd got worse further, with urea rising
3
to 16.7 and creatinine rising to 161.
4
Q.
What does that tell us, then?
5
A.
That suggests that her renal function is not normal, and
6
the rapid decline would be consistent with dehydration,
7
although other causes are possible.
8
Q.
Do they take steps, then, to manage that?
9
A.
In terms of fluids?
10
Q.
It may be we can put the note on the screen, if that
11
12
would help you.
A.
It is page 17 of the notes.
There is nothing on that page that tells us what was
13
done.
14
the kidneys, but -- and continue oral fluid.
15
Q.
The plan seems to be to get an ultrasound scan of
This entry begins by:
16
"Asked to see patient re foot dusky and patient less
17
responsive than before."
18
Is that correct on the 31st, can we see that?
19
A.
Yes.
20
Q.
"Foot dusky", what can we infer from that, if anything?
21
A.
Well, it suggests there was some darkened discolouration
22
23
24
25
of the foot, but it doesn't tell us the cause of that.
Q.
We then look at -- there are a number of letters.
Letter E:
"Right foot last 3 toes discoloured.
102
Pulses felt in
1
foot.
2
Does that tell us anything about what the problem is
3
4
Rest of leg colour okay."
here?
A.
The implication is that the doctor is thinking this
5
could be due to reduced blood supply to the toes, and
6
the assessment there is to look at the vascularity of
7
the leg and, apart from the foot feeling cold, otherwise
8
circulation appears to be reasonable, from that
9
assessment.
10
Q.
But then we see some reference to hourly fluids, it says
11
"12-hourly intravenous fluids running" and it goes on
12
and says "urinary output".
13
indication as to what is happening in relation to her
14
hydration?
Does that give us some
15
A.
Yes, so -- well, she's getting some intravenous fluids.
16
Q.
Do you take from these entries and the results that you
17
18
mentioned that she was becoming, what, more dehydrated?
A.
Yes, that's what the blood tests show.
Presumably, the
19
second blood test would have come -- it was taken on
20
that day.
21
6 o'clock in the morning, so presumably that -- the
22
deterioration in the blood results wouldn't have been
23
known until later on that day.
24
25
Q.
Presumably that -- that entry was written at
If, then, we move on to go back to your report, you say
that she had developed oedema of her hand to the point
103
1
that her ring had to be cut off, and you have
2
referenced, I think, where that can be found in the
3
nursing notes.
4
5
Why has that happened?
A.
6
Probably because her albumin has fallen from 37 to 13.
People in a low albumin state tend to develop oedema.
7
Q.
Why has her albumin fallen?
8
A.
It's, you know, a non-specific marker of people being
9
unwell.
People with a severe infection or many other
10
medical conditions, such as cancer, would tend to
11
develop a low albumin.
12
Q.
But you tell us this is part of a more generalised
13
decline and only a limited neurological examination is
14
recorded.
15
31 January?
Is this the record that was made on
16
A.
Yes.
17
Q.
If we look at that on page 18 of the report, again, it
18
is Dr Khan, and I think it begins by saying:
19
"General condition worsening."
20
That is what I think you have recorded in your
21
report; is that right?
22
A.
Yes.
23
Q.
Then if we go down to the section headed "Impression",
24
25
can you read that for us?
A.
The first line seems to say:
104
1
"Recurrent episode of stroke."
2
The next line says:
3
"Renal" -- I'm not sure if that is a squiggle or
4
a cross-out after that, but it seems to read:
5
"Renal failure secondary to septicaemia or due to
6
C. diff positive."
7
8
And the final line says "Dehydration".
Q.
9
10
In relation to dehydration, can you ascertain from this
note what the basis for that assessment is?
A.
Higher up the entry, it says:
11
12
"100ml of urine output last 24 hours."
Q.
13
14
Does that allow the inference to be drawn, then, that
she's dehydrated?
A.
Not necessarily.
There are other possible causes of
15
lack of urine output.
16
a reasonable conclusion.
17
Q.
18
But in this case, it seems
We've seen, I think, from the results you looked at
earlier, that these results supported dehydration?
19
A.
They did.
20
Q.
The plan then, if we go to that, does it read:
21
"Discussed with Dr Akhter.
Not for CPR."
22
A.
Yes.
23
Q.
So that is on 31 January 2008 when that plan was put in
24
25
place; is that right?
A.
Look at the dates.
Yes.
105
1
Q.
The final entry, I think, is, "Not for any active
2
treatment".
3
correct?
That's been signed by Dr Khan; is that
4
A.
That's how I read it.
5
Q.
While we are on these aspects of the notes, if you turn
6
to page 19, there is an entry there for the 31st again:
7
"Discussed with family about prognosis and condition
8
of patient."
9
So there appears to have been a discussion with the
10
family at this time in connection with the prognosis of
11
Mrs McGinty?
12
A.
Yes.
13
Q.
If we then go back to your report, and just focusing on
14
the section in your report dealing with C. diff
15
diarrhoea, that's on page 7, you begin by saying:
16
"The doctor's records do not record diarrhoea at any
17
stage of her admission."
18
Would you have expected some reference in the
19
clinical notes, the notes made by the doctors, to her
20
diarrhoea?
21
A.
I would, yes.
22
Q.
Why would you expect that?
23
A.
Because this is a patient who, you know, is felt to be
24
dehydrated.
They're being given -- found to be
25
Clostridium difficile positive, as was recorded in the
106
1
medical record, but it seems strange that diarrhoea
2
wasn't mentioned at the same time.
3
Q.
In relation to the treatment for the C. difficile
4
infection, you tell us that she received metronidazole.
5
Was that an appropriate response to the infection?
6
A.
Yes.
7
Q.
If you turn to page 8 of your report, under the section
8
dealing with the state of her independence or dependence
9
before admission, what understanding did you glean from
10
11
the records as to what that was?
A.
12
She seemed to be living alone in a bungalow and was at
least independently mobile.
13
By 18 December, she's recorded as needing the
14
assistance of two people to transfer.
15
there'd been marginal progress with sitting balance, but
16
her neurological deficit was mostly persistent and she
17
was requiring full assistance with personal care.
18
Q.
On 8 January,
I think we saw from the records we had on the screen
19
a moment ago that she was considered not for active
20
treatment on 31 January 2008, and I think she died the
21
next day, 1 February 2008?
22
A.
Yes.
23
Q.
Can we then look at what you say about the review of her
24
antibiotic treatment for conditions other than C. diff?
25
You address this on page 8 of your report.
107
Can you just
1
2
take us through that part of your report?
A.
This is that period we were talking about in the notes
3
before, where she -- the documented entries in the notes
4
were just the results of the urinary cultures.
5
neither occasion was there any suggestion that she'd
6
been seen or assessed by a doctor prior to being
7
commenced on antibiotics.
8
of urine culture seems to be foul-smelling urine, with
9
or without positive urinalysis, which -- you know,
On
The reason for the requesting
10
foul-smelling urine is not a specific sign of urinary
11
tract infection.
12
Q.
So, then, first of all, do you consider whether it was
13
appropriate to prescribe antibiotics for a urinary tract
14
infection?
15
A.
In the absence of patient evaluation, no.
16
Q.
Just to remind ourselves, I think the records that we
17
looked at previously, is that what we have on page 7 of
18
the notes?
19
A.
Yes.
20
Q.
GGC00420007.
21
So we are looking at the entry towards the
top of the page for 19 December 2007; is that correct?
22
A.
Yes.
23
Q.
This discusses the urine sample that was taken, and
24
I think records what was in the microbiology report; is
25
that right?
108
1
A.
Yes.
2
Q.
Is there a basis there for prescribing an antibiotic?
3
A.
No.
4
Q.
Can you read the first line of that entry for us?
5
A.
"Urine sample taken 17/12/07.
6
7
negative.
Q.
8
Culture coagulase
Staph isolated greater than 100,000 per ml."
Just looking at that last reference, what do you take
from that?
9
A.
I'm just -- sorry, could you say that again?
10
Q.
The last reference to "Staph isolated greater than
11
12
100,000 per ml".
A.
13
14
talked about.
Q.
15
16
That is a staphylococcus bug, presumably, that is being
What does that mean, then, if you read that in a report
from microbiology?
A.
What does it tell us?
It tells us they found some bacteria within the urine,
17
but, as we talked about before, that is quite different
18
to saying this is a urinary tract infection,
19
asymptomatic bacteriuria being common in this patient
20
population.
21
Q.
But then, if we look at the rest of this entry, does it
22
also tell us that the lab have reported what the
23
sensitivities of various antibiotics might be to the
24
bacteria?
25
A.
Yes.
109
1
Q.
2
As we see, Mrs McGinty was commenced on the
trimethoprim; is that right?
3
A.
Yes.
4
Q.
In your opinion, are you saying that shouldn't have
5
happened?
6
A.
It's treating a test result, not treating a patient.
7
Q.
If we look at the next entry, there's a further
8
reference to the urine sample that was taken on the
9
31st, and the entry is on 5 January.
10
A.
What happens here?
So the entry says, "Urine sample from 31 December", so
11
we are now already six days down the line.
12
reports that they found a bacteria in the urine, this
13
time a bacteria of the family enterococcus, and, again,
14
there is a list of antibiotics that this is either
15
sensitive or resistant to.
16
Again, it
The doctor who has written this down -- I presume it
17
is a doctor because it is, as I say, foundation
18
year 1 -- has written that the patient finished the
19
course of trimethoprim on 27 December and was now
20
commenced on amoxicillin, 250mg three times a day.
21
Q.
22
Was there a basis to start the patient on the
amoxicillin?
23
A.
No.
24
Q.
Why not?
25
A.
Because, again, there is no patient evaluation.
110
This is
1
now even six days beyond the time of the symptoms --
2
sorry, beyond the time of the urine collection with no
3
recorded symptoms or observations how the patient was.
4
Again, the assumption is that this is asymptomatic
5
bacteriuria.
6
Q.
Let's assume for the moment that it might be said that,
7
although this is not recorded, there was a basis,
8
clinically, for concluding that the patient had
9
a urinary tract infection as at this time.
10
Would amoxicillin be an appropriate antibiotic,
11
standing the fact that the bug appears to have been, on
12
the face of it, resistant to trimethoprim?
13
A.
14
15
Yes, and it's recorded as sensitive to amoxicillin, so
the selection of antibiotic would be appropriate.
Q.
16
But I think your position is that there shouldn't be any
antibiotic at all?
17
A.
Yes.
18
Q.
So far as the doses prescribed on both occasions, on the
19
hypothesis that it was appropriate to go down that
20
route, were the doses reasonable?
21
A.
Yes.
22
Q.
You conclude this particular chapter by saying that the
23
real problem is the lack of any patient signs or
24
symptoms of infection, suggesting this was asymptomatic
25
bacteriuria which is present with most patients with
111
1
indwelling urinary catheters and should not be treated.
2
I think we can remind ourselves that, throughout her
3
whole stay in the Vale of Leven, Mrs McGinty did have an
4
in situ catheter?
5
A.
Yes.
6
Q.
If we move on, then, to the next paragraph of your
7
report, where you are looking at the position post
8
15 January 2008, where you tell us that she receives
9
co-amoxiclav from 18 January and also clarithromycin for
10
a chest infection, can you just tell us about that as we
11
move on to page 9 of your report?
12
A.
So that combination of antibiotics would not be
13
considered unreasonable.
14
a severe chest infection in a hospital setting,
15
although, obviously, the downside is that co-amoxiclav
16
is associated with the development of
17
Clostridium difficile, but clarithromycin is less
18
associated.
19
It seems fine for someone with
The doses and duration were appropriate for someone
20
with a severe infection, but multiple doses are not
21
given and it is not clear from the records why that was.
22
Q.
Was there clinical evidence of a chest infection?
23
A.
I believe so.
Let me just -- I'm sorry, I have all
24
sorts of patient details.
25
and look at the --
Can we just have a -- go back
112
1
Q.
I can put the records on the screen, if that would help.
2
This is page 9 of the clinical records, I think, or in
3
fact starting at page 8.
4
A.
If we go back to my report, for 15 January, she'd had
5
increased confusion, she was coughing and she was
6
chesty, she had a temperature of 37.9, blood tests
7
showed that she'd got blood evidence of infection and
8
her chest X-ray showed signs of infection.
9
looks like that was appropriate.
10
Q.
So, yes, it
I think you have summarised, in fact, what we may see on
11
the screen under reference to the final note for
12
15 January?
13
A.
Yes, we talked about this just before the lunchbreak,
14
didn't we?
15
antibiotics at that stage, yes.
16
Q.
I think it was appropriate that she had
If I can just go back, while I have the notes on the
17
screen, to page 7, we looked at the two entries that
18
resulted in antibiotics being prescribed for urinary
19
tract infection.
20
5 January, can we see that there is an entry for
21
8 January?
22
Dr Akhter's handwriting in a ward round.
23
that on the screen?
If you move on to the next entry after
I think we probably can work out that's
Do you see
24
A.
Yes.
25
Q.
Would you have expected Dr Akhter, as the consultant in
113
1
charge, to have reviewed the position in relation to the
2
medication being given for the urinary tract infection?
3
A.
Yes.
4
Q.
Do you see any evidence of that here?
5
A.
No.
6
Q.
Would it have been appropriate for him to have reviewed
7
8
the position up until that point?
A.
9
I would say so, yes.
Obviously, this is what's been
happening to his patient over the past -- what was
10
it? -- two weeks or so.
11
didn't at least comment on it at that time.
12
Q.
It's a bit strange that he
Just looking to the nature of the review itself, can you
13
help us with that?
14
medical review of this patient at this point in time in
15
her stay in the hospital?
16
A.
Do you see that as an appropriate
It's much like we've said before: there is no evidence
17
from that entry that Dr Akhter's spoken to the patient
18
or performed a physical examination.
19
Q.
If we go back to page 9 of your report, you tell us, in
20
relation to the two antibiotics that were prescribed and
21
given for the chest infection, that the doses
22
prescribed, and the duration, appear appropriate for the
23
severity of the infection; is that correct?
24
A.
Yes.
25
Q.
What is the point you make in the next sentence about
114
1
multiple doses not being given?
2
upon that for me, if you could, please?
3
A.
Well, I think this is based from what's written down in
4
the prescription charts.
5
documents there.
6
Q.
Can you just elaborate
Yes, very well.
I have referenced four
Shall we draw them up and we can -Shall we take them in turn, then?
7
first you have referenced is the medical records at
8
page 228.
9
which I think is the last entry on the Kardex?
10
11
The
Are we looking here for the amoxicillin,
Sorry,
the co-amoxiclav.
A.
Co-amoxiclav.
So there are two doses on that one.
We
12
may need to see a series of drug charts to be able to
13
piece together the gaps.
14
Q.
15
16
We have that.
So then we have 212 and the co-amoxiclav
is the third entry from the top; is that right?
A.
Yes.
So in there a lot of the boxes have the number 14
17
written, which I -- I'd have to check the drug -- the
18
coding of the drug chart to see what that means in this
19
particular instance.
If we can draw up --
20
Q.
Page 231?
21
A.
The back page of one of the drug charts, it tells us.
22
Q.
We have that on the screen, I think.
23
So 14 says:
"Other - record in nursing notes."
24
A.
Yes.
I couldn't find a record of why that was.
25
Q.
You couldn't find a record of why it would be saying the
115
1
record would be kept in the nursing notes as opposed to
2
the Kardex?
3
A.
No, that's fine.
It probably means it's a more lengthy
4
description than one of the more common ones which
5
should be recorded elsewhere, ie, in the nursing notes.
6
I couldn't find the justification within the nursing
7
notes for why that was.
8
Q.
9
That doesn't imply, or does it, that the dose wasn't
given at all?
10
A.
It does.
That's a code for non-administration.
11
Q.
You're right.
The heading there is "Codes for
12
non-administration".
We see 14, if we go back to the
13
Kardex, has been written in here on three occasions --
14
four occasions: on 25 January; twice on the 26th; and
15
once on the 27th.
16
A.
We have not got it on the screen at the moment.
17
Q.
I'm sorry, it is page 212.
18
19
Is it once or twice on the
25th?
A.
20
It looks to me like, on 25 January, the first three
doses of the day were labelled as 14.
21
Q.
Quite right.
22
A.
There is a signature after that to suggest it was given.
23
Then possibly a 7 and a 10.
24
I'm not sure, followed by another 14, then one or two
25
doses given after that, followed by a 14 on the morning
116
They could be signatures,
1
2
of 27 January.
Q.
The other references you have given are 227 -- this
3
I think is -- you are looking at the clarithromycin,
4
towards the bottom of the Kardex.
5
doses are given, but for one of the doses it's the
6
number 4 that has been written; is that the point you
7
are focusing on there?
Here we see that
8
A.
Yes.
9
Q.
That means drug not available -- I think we have seen
10
this before.
11
do you do?
If you don't have the drug available, what
12
A.
You ring up pharmacy and get them to provide it for you.
13
Q.
The other reference you gave was 213.
We now have that
14
on the screen for the clarithromycin.
We have a number
15
of 14s here; is that correct?
16
A.
Yes.
17
Q.
If we go back, then, just so I can understand this
18
myself, to page 231 of the records, the code for
19
non-administration that these numbers indicate is what's
20
happened here says "Other - record in nursing notes".
21
I'm still trying to understand what that means.
22
A.
It means there's some other reason, other than the
23
commonly given reasons there that are coded, the other
24
numbers, and that should have -- the nurse should write
25
in the nursing records what that reason was.
117
1
Q.
Did you look to see if there were reasons?
2
A.
You're asking me --
3
MR KINROY:
My Lord, I think the witness has already said he
4
did look and he couldn't find the reasons.
5
wrong about that.
6
MR MACAULAY:
7
I might be
You may be right, but I just, myself, hadn't
fully understood that.
8
Just to be clear, did you look at the nursing notes
9
to see whether or not there were reasons recorded for
10
why the drugs were not being administered?
11
A.
I did, and I couldn't find that information.
12
Q.
If the drugs were not administered, then should they
13
have been administered?
14
A.
We don't know why they weren't given, so ...
15
Q.
I'm sorry?
16
A.
We don't know the reason for not giving them, so I'm
17
18
left to speculate.
Q.
19
There could have been a good reason for not giving them
which we don't know?
20
A.
There could have been, yes.
21
Q.
In the absence of a good reason, should the medication
22
23
have been given?
A.
Well, it was prescribed, so someone thought it was
24
necessary.
If someone else is thinking it isn't
25
necessary, they should at least tell us why.
118
1
Q.
If we then go back to your report on page 9, you go on
2
to tell us that the prescription of these antibiotics
3
continues after the diagnosis of C. difficile diarrhoea
4
without any recorded consideration of change or
5
discontinuation.
6
Just to remind ourselves, the positive result for
7
C. diff was on about 25 January.
8
Kardexes that the drugs continued to be prescribed after
9
that?
10
A.
Yes.
Have you seen from the
The assumption, although it is not specifically
11
said, is that the nurses stopped giving the antibiotics
12
in the light of the diagnosis of Clostridium difficile,
13
but this doesn't seem to have been something that was
14
discussed with the doctors in terms of it's not recorded
15
in the doctors' entries to say that this was reviewed
16
and was a deliberate plan.
17
Q.
18
But then, might that be the reason why we have the 14
referenced in the Kardexes?
19
A.
That's the assumption I'm making, yes.
20
Q.
In any event, is it your opinion, as you set out in the
21
report, that this episode of C. difficile diarrhoea is
22
highly likely to have been triggered by the antibiotics
23
received by Mrs McGinty, especially the co-amoxiclav?
24
A.
Yes.
25
MR PEOPLES:
My Lord, I wonder, just on the question of
119
1
the explanation for the 14s, I may be wrong, but the
2
Kardex looked as if it had sometimes a 14 and then an
3
initial, as if the drug had not been given and then had
4
been given, and then another 14.
5
consistent with your assumption?
6
MR MACAULAY:
7
8
Would that be
I think we did say that the 14s are
intermittent in some -A.
9
Yes, I was just checking whether you want me to answer
that question.
Sometimes I do.
10
Q.
Yes, if you could answer the question.
11
A.
Yes, so it is inconsistent, isn't it?
It probably
12
springs from the fact that it doesn't seem to have been
13
a well-recorded carefully discussed decision with
14
doctors and nurses.
15
Q.
It seems a little ad hoc.
If we look at the clarithromycin, which is perhaps the
16
most clear-cut case, if you turn back to the records at
17
page 213, can we see that the clarithromycin has not
18
been given from 25 January, which coincides with the
19
time that Mrs McGinty was diagnosed with C. diff?
20
A.
Yes.
21
Q.
So your assumption might be borne out by what we see
22
there?
23
A.
Yes.
24
Q.
If we then go to page 227 that we looked at earlier,
25
where we have the prescription for clarithromycin, do we
120
1
see there that the 4 related to the fact that the drug
2
wasn't available, so that is a different situation, and
3
that was on 21 January?
4
A.
Yes.
5
Q.
Then, on page 212 of the Kardex, the co-amoxiclav is the
6
third entry, and can we see that the 14s do start on
7
25 January, but is there evidence also, after that, of
8
the drug being administered?
9
A.
It looks like it was given at least the evening dose of
10
25 January.
11
evening dose may have been signed for.
12
subsequently been crossed out.
A 14 is written in the
13
box below, by the looks of it.
I'm not exactly sure
14
what happened then.
15
Q.
It is not as clear on the 26th.
The
That may have
It may not be clear, but we should be able to know,
16
I suppose, from looking at the documentation, what the
17
real position was?
18
A.
Yes, it should be, yes.
19
Q.
On the face of it, if one is reading into it what one
20
can, it may be that, although it is not documented, the
21
decision was taken by someone to stop those antibiotics
22
once the diagnosis for C. diff had been made?
23
A.
Yes.
24
Q.
Can we then look at your section dealing with medical
25
management that is the next part of your report at
121
1
section 5 on page 9?
2
You remind us in the second paragraph that Dr Akhter
3
had responsibility for Mrs McGinty's care while she was
4
in ward F.
5
You make some points about medical review.
Have we covered these points in looking at the
6
records that we have looked at already: namely, the
7
dates when there was no review and the nature of
8
the reviews that were carried out?
9
A.
At least in part, haven't we?
10
Q.
Let's just look at it, then.
Can you just take us --
11
just remind us what your conclusions are in relation to
12
the nature of the medical review that was carried out on
13
Mrs McGinty?
14
A.
Well, there were gaps, weren't there?
They have
15
commented there between 18 December and 8 January, and
16
then no consultant review between 22 January and the
17
time of her death.
18
we saw weren't very thorough.
19
Q.
You know, some of the entries that
What you go on to say is that whilst a once-a-weekly
20
consultant review may be appropriate for stable patients
21
in a rehabilitation setting, it is insufficient for
22
a patient who is clearly unwell and deteriorating?
23
A.
Yes.
24
Q.
If you take us through the rest of this section, then,
25
if you could read on there, from the report itself?
122
1
A.
So during the period of her deterioration with sepsis
2
from the evening of 15 January to her death on
3
1 February, there is just one recorded entry of
4
Dr Akhter's review on 22 January.
5
action taken was to increase her Ace inhibitor dose.
6
Q.
At that stage, the
If we look at the entry, it is on page 13 of
7
the records, is that the entry you have in mind for
8
22 January, towards the bottom of the page?
9
A.
Yes.
10
Q.
What does that tell us as to the nature of the review?
11
A.
It reads:
12
"Recovery from chest infection.
Chest right basal
13
creps.
Blood pressure 180 over 100.
14
X-ray.
Increase perindopril to 4mg."
15
Q.
16
Plan for chest
Does that indicate that Dr Akhter has carried out some
examination of the patient?
17
A.
It does on that occasion, yes.
18
Q.
Do you consider that to be an adequate review, assuming
19
that is the extent of it, in this patient at this stage
20
of her progress?
21
A.
22
At that point in time, the entries seem to suggest prior
to that that she's improving.
23
Q.
This is before she contracts C. diff?
24
A.
Yes.
25
Q.
So, as an entry, it is a reasonable entry in the
123
1
circumstances?
2
A.
I think so, yes.
3
Q.
But what you go on to say, if you go back to page 10 of
4
your report, is that there is no increase in review
5
frequency in response to her C. difficile diarrhoea
6
diagnosis.
Do you consider there should have been?
7
A.
Yes.
8
Q.
If we look at the next paragraph -- and you may have
9
mentioned this already -- do you say that Mrs McGinty's
10
C. difficile diarrhoea was contracted whilst in hospital
11
and it was due to the exposure to broad-spectrum
12
antibiotics and to C. diff spores?
13
A.
Yes.
14
Q.
What about the medical entries that we have been looking
15
at?
16
that final paragraph on page 10?
17
A.
You make some observations in relation to those in
So, generally, that the quality isn't great.
Some
18
sheets are only labelled with the patient's name, some
19
sheets have no label at all.
20
the date or the person who is writing the entry.
21
is little evidence of communication between senior
22
doctors and the patient and the relatives during her
23
decline in health.
24
that Dr Khan spoke to the family on 27 January, but the
25
content of that discussion is not recorded.
It is often hard to tell
There
Although the nursing notes do record
124
He did
1
speak again on 31 January, and on this occasion --
2
I think we have looked at that note before, haven't
3
we? -- the discussion was made about poor prognosis and
4
the DNAR decision.
5
Q.
You say in the next paragraph there is no recorded
6
involvement of a microbiologist.
7
a microbiologist should have been involved with
8
Mrs McGinty's care?
9
A.
I think so.
Do you consider that
I mean, this is someone who didn't recover
10
from the infection, so the treatment failed.
11
point in time, a microbiologist may have been able to
12
help.
13
Q.
So at that
Looking to the next paragraph, where you discuss
14
Mrs McGinty's oral intake, and I think you move on to
15
discuss dehydration in the next paragraph, what
16
conclusions do you come to here?
17
A.
Well, her overall state of nutrition seems to be poor.
18
Although albumin is not a brilliant marker of nutrition,
19
it does fall quite dramatically down to 13.
20
before about the state of hydration, her urine output
21
was low, she was noted to be dehydrated, she was on some
22
intravenous fluids, but there was also that strange
23
incident where she received 60mg and then 40mg of
24
furosemide for no obvious reason.
25
two days without passing urine by 30 January.
125
We talked
She'd gone a whole
1
There was that odd entry where she's recorded as
2
having normal renal function, but that's clearly not the
3
case, given she's not passing urine, her blood tests are
4
abnormal.
5
She was hypotensive, again, consistent with
6
dehydration.
She'd got ongoing diarrhoea, yet the
7
amount of fluid that she received parenterally was
8
small, just getting one litre of fluid per 24 hours.
9
Q.
Your concluding thoughts?
10
A.
That's inadequate, given she's hypotensive, has clinical
11
and biochemical signs of dehydration.
12
drinking much.
13
correct a potentially reversible problem.
14
Q.
She's not
She's not passing any urine.
It didn't
Just on that, if you just finish what you say, you say
15
at the very end of this section we have been looking at,
16
this part of it, that her fluid management can only be
17
described as extremely poor.
18
view?
Does that represent your
19
A.
Yes.
20
Q.
You go on to say that dehydration is certainly
21
a contributor to the decline in her health at the end of
22
her life?
23
A.
Yes.
24
Q.
I think the blood tests that you made reference to that
25
indicated dehydration were tests taken shortly before
126
1
she died; is that right?
On 30 January and 31 January?
2
A.
Yes.
3
Q.
Are you able to say whether this dehydration problem was
4
5
reversible?
A.
6
7
I mean, dehydration is a lack of fluid.
It is
possible to rehydrate people intravenously.
Q.
8
9
Yes.
What do we take from this as to why that didn't happen
with Mrs McGinty?
A.
I don't think I can answer that question for you.
10
I think you will have to ask those involved in her care
11
at that time.
12
Q.
If a decision is made for a patient not to be given
13
active management, would you still take steps to keep
14
such a patient hydrated?
15
A.
Not necessarily.
I mean, it is something -- we don't
16
know for sure.
The medical world doesn't really know.
17
Some people think that dehydration may cause discomfort,
18
and, therefore, you should give fluids up to the time of
19
death.
20
cause discomfort and possibly prolongs a death without
21
providing any quality of life, so it is something
22
that -- there is no clear-cut answer.
23
that would usually be discussed ideally with the
24
patient, if not with surrogate decision-makers, such as
25
the family.
Other people think that dehydration doesn't
127
It is something
1
Q.
2
But in this particular instance, there was evidence, you
say, from the testing that was taken, of dehydration?
3
A.
Yes.
4
Q.
The fluids that were being input were inadequate to
5
cater for that situation?
6
A.
Yes.
7
Q.
So if you wanted to improve that situation, you would
8
increase the amount of fluid that is being put in?
9
A.
Yes.
10
Q.
Now, the prescribing of lactulose between 12 January and
11
29 January you touch upon in the next paragraph.
12
I think you say it was prescribed but not actually
13
received after the 16th; is that correct?
14
A.
Yes.
15
Q.
Would it have been appropriate, particularly once she
16
had diarrhoea, for lactulose to have been given?
17
A.
No.
18
Q.
It wasn't, in fact, was it?
19
Was it given after she
developed diarrhoea?
20
A.
That's correct, yes.
21
Q.
Sorry, was it or was it not?
22
A.
No, she didn't receive it after 16 January.
I think her
23
diarrhoea started -- well, possibly then, sometime
24
shortly after then maybe.
25
Q.
You say the reasons for not receiving these medications
128
1
are not clearly documented, but you assume it was due to
2
the diarrhoea?
3
A.
Yes.
4
Q.
The point you make in the final paragraph here in
5
relation to the urinary catheter, can you just tell us
6
what point you are making there?
7
A.
Urinary catheters are known to cause harm.
They are
8
a source of infection and can lead to other problems,
9
such as an increased risk of delirium, and can lead to,
10
you know, worsening urinary incontinence.
11
something we try and avoid putting in.
12
situations in medicine where a catheter is necessitated.
13
But there didn't seem to be a documented necessary
14
reason in this lady's case.
15
Q.
That's
There are a few
You then move on to look at the DNAR order.
If we can
16
put that on the screen, it is probably useful to do
17
that.
18
of the doctor, do you take that to be Dr Khan?
It is GGC00420024.
If we look at the signature
19
A.
That's what I thought.
20
Q.
The date is 31 January 2008.
21
That is the day before
Mrs McGinty died?
22
A.
Yes.
23
Q.
There is no indication given in the document in relation
24
to discussion with the family.
25
look at the "CPR is unlikely to be successful due to",
129
But can we see, if we
1
what is listed there -- first of all, "Dense stroke".
2
Was there evidence of that in the records?
3
A.
That she had a stroke, yes.
4
Q.
What does "dense" mean in this context?
5
A.
I think it is a fairly colloquial way of saying
6
"severe".
7
Q.
The rest, can you read that next line for me?
8
A.
I think it says "Parietal and occipital infarct".
9
Again, that is relating to the stroke areas of the brain
10
that were damaged by this.
11
"C. difficile positive".
12
Q.
And below it says,
I think you point out in your report that the consultant
13
has not signed the document as the document seems to
14
envisage; is that correct?
15
A.
Yes.
16
Q.
But in relation to the appropriateness of the DNAR at
17
this point in time, do you consider that it was
18
appropriate to have a DNAR order in place?
19
A.
20
21
sure CPR wouldn't have reversed it.
Q.
22
23
Yes, if she'd had a cardiac arrest at that stage, I'm
If we turn to page 13, what is the final point, then,
you make under this section dealing with the DNAR order?
A.
Well, it's, you know, at that point in time, that seems
24
fine, but, you know, the risk is that a chance to
25
intervene earlier on, some ten days or so prior to that,
130
1
2
may have been missed.
Q.
We will then go to look at the cause of death and death
3
certification, and, again, if we just put the
4
certificate on the screen, it is SPF00250001.
5
at this earlier, and we can see there are a number of
6
different entries in relation to the cause of death.
7
We looked
What conclusions did you come to as to the
8
appropriate sequence of causes, having regard to the
9
medical records that you have looked at?
10
A.
My opinion was that the mechanism of her death was
11
related to her renal failure, secondary to both the
12
Clostridium difficile diarrhoea and to pneumonia, and
13
I would have put those in section I.
14
Q.
15
16
So renal failure, secondary to C. difficile and
pneumonia?
A.
Yes.
The evidence for a second stroke was on the basis
17
of a fairly brief entry in the notes, which wasn't
18
overly convincing, but certainly there was good evidence
19
of a stroke when she first came into hospital.
20
know, I certainly would have put that down under
21
section II.
22
Q.
Let me just look at this.
So, you
You say the evidence for the
23
second stroke was not compelling.
24
what it is, if you look at the notes on GGC00420018?
25
This is the entry we looked at before, by Dr Khan on
131
Can we look, then, at
1
31 January, the day before Mrs McGinty died.
2
we go to get evidence of the second stroke that features
3
in the death certificate?
4
A.
Sorry, was that a question to me?
5
Q.
Yes, please.
Where do
Can you take us to the information?
You
6
say the evidence for a second stroke was not compelling.
7
What evidence do we have here in this entry --
8
9
10
11
A.
Okay.
So, basically, this is -- Dr Khan's reviewed the
patient on the basis that she's had a general decline in
her condition.
I think it says:
"Orientation worse, speech worse, right side
12
movement decreased, more flaccid", which means more
13
floppy.
14
Then he goes on to talk about her urine output.
15
There is some examination of her abdomen, and then the
16
impression is she's had recurrent episode of stroke.
17
Then obviously he talks about renal failure and
18
dehydration after that.
19
So the basis for the diagnosis of stroke seems to be
20
that she's had a general decline, possibly with some
21
reduced movement on the right-hand side, which, you
22
know, stroke is a specific clinical diagnosis of a focal
23
neurological deficit, and that might be supported by CT
24
scan evidence, for instance, although a CT scan wasn't
25
done on this occasion, but that may have been
132
1
appropriate, given how close to death she was.
2
It is a general decline, rather than she's got new
3
right-sided weakness, and someone who is dehydrated, has
4
sepsis from the chest and Clostridium difficile
5
diarrhoea, their health may be expected to generally
6
decline and that wouldn't necessarily be an indicator
7
that she'd had further stroke.
8
Q.
If we look at the entry on page 19 by the junior doctor
9
who saw Mrs McGinty at the time after she died, we read:
10
"Patient passed away at 0600 on 1 February 2008.
11
Death certificate completed by myself.
12
cerebro-vascular event (b) cerebro-vascular infarct."
13
It would appear that these in particular are matters
14
15
I(a) recurrent
that have found their way into the death certificate?
A.
Yes, so this was written by the most junior doctor, the
16
foundation year 1 doctor.
17
this was discussed with a more senior doctor to decide
18
whether this was the right way to record the various
19
events.
20
Q.
21
22
It doesn't tell us whether
But in your opinion, having looked at the records,
should I(a) and I(b) appear on the death certificate?
A.
I would have changed the order, like I said before.
So
23
I would have put stroke, which is another way of saying
24
cerebro-vascular infarct or event, in section II rather
25
than section I.
133
1
Q.
2
3
Just so I can understand, what role do you consider,
then, that the stroke played in Mrs McGinty's death?
A.
4
It doesn't appear to have been the primary cause that
she died.
5
Q.
What was the primary cause, in your opinion?
6
A.
I think it was dehydration and renal failure secondary
7
to the chest infection and the Clostridium difficile
8
diarrhoea.
9
Q.
In relation to the suggestion of there being a second
10
stroke, do you consider there was a second stroke, on
11
the basis of the evidence you have seen?
12
A.
I think it is very hard to say, given what is recorded,
13
but, as I wrote in the notes, the evidence isn't
14
compelling.
15
know, it is hard to know, in hindsight, looking at what
16
someone's written down.
17
time.
18
Q.
I'm not convinced that happened.
But, you
I didn't see the patient at the
I'm not sure.
You say in the final paragraph, then, under this
19
particular section that, had she not contracted
20
C. difficile, her prognosis due to her stroke and
21
subsequent pneumonia would have been poor.
22
So that, even without the C. diff, the prognosis was
23
24
25
poor, you say?
A.
She'd had a severe stroke, and that carries with it
a degree of mortality and morbidity.
134
Later in that
1
paragraph, I talk about the sort of expected outcomes,
2
and the 30-day mortality rate is 39 per cent for this
3
type of stroke and a one-year mortality rate is
4
60 per cent.
5
Q.
So clearly she was unwell.
But you go on to say that, had she been given more
6
effective treatment for her C. difficile and hydration
7
status, she may have survived her hospital admission.
8
A.
9
10
Yes.
Most people, even with this type of stroke,
survive to leave hospital.
Q.
Just going back to this whole issue of hydration or
11
dehydration, and we touched upon this this morning, and,
12
in particular, clinical examination and clinical
13
examination of a patient in relation to skin turgor and
14
perhaps sunken eyes -- remember we touched on this this
15
morning?
16
you are seeking to assess a patient's hydration status,
17
particularly in elderly patients?
How reliable is that sort of examination when
18
A.
Like we have said before, they are not reliable tests.
19
Q.
But if you have a situation where the fluid balance
20
chart that you look at doesn't give you the information
21
that you want in relation to fluid management, could you
22
nevertheless carry out a clinical examination that would
23
give you some assistance?
24
25
A.
Yes, you would.
I would say that the best clinical
indicator, in the absence of, you know, a gross oedema,
135
1
or something, would be the jugular venous pressure,
2
which is one of the blood vessels in the neck that can
3
be examined to look for the state of intravascular fluid
4
volume, but there are other things, such as tachycardia
5
and hypotension, that may be better indicators of
6
dehydration than things like skin turgor or sunken eyes
7
in older people.
8
Q.
If we then look finally at your conclusion, and we look
9
at the second paragraph of that, can you just summarise
10
the position for us insofar as your opinion is concerned
11
in relation to the management of Mrs McGinty?
12
A.
So her Clostridium difficile wasn't adequately treated,
13
in that she continued to have symptoms up to her death.
14
It is not clear exactly when she developed diarrhoea,
15
and it may have pre-dated the finding of her
16
Clostridium difficile on a stool sample by several days.
17
Fluid management, as we have obviously talked about,
18
was poor.
19
to be dehydrated is strange.
20
The giving her diuretics when she was noted
The urinary catheter was inserted with, in my mind,
21
no clear indication or plan for removal.
22
best, have been a very temporary thing.
23
It should, at
She developed a sacral pressure sore, which may be
24
hard to avoid in someone who is not mobile, but it is
25
still not an indicator of great-quality care.
136
1
Medical records are generally poor.
The frequency
2
of consultant review, like we talked about, was poor,
3
and the consultant doesn't seem to have been involved
4
with the communications with family members.
5
She had the antibiotics for urinary tract infections
6
without evidence of a septic illness, and I think the
7
death certificate perhaps wasn't correct.
8
Q.
9
You made a point in passing there about the fact that
Mrs McGinty developed a sacral pressure sore whilst in
10
hospital.
11
the patient, have regard to that aspect of care?
12
A.
To what extent would the doctor, in managing
Well, I think the optimum -- the optimal situation would
13
be that a clinician would have a holistic view of their
14
patient and be interested and actively involved in the
15
management of all of their problems.
16
pressure sores is that it is often something that is
17
more considered in the nurses' role, but in my opinion,
18
doctors are every bit as involved in that as other
19
aspects of patients' care.
20
21
22
Q.
Thank you.
The reality with
That, I think, concludes our examination of
Mrs McGinty's case.
My Lord, I am looking at the time.
It is just past
23
3 o'clock.
I am quite happy to start another case, but
24
I think it would take us probably beyond 4 o'clock.
25
I think Dr Woodford has had quite a long session and he
137
1
has to come back, in any event, to deal with the
2
remaining cases, of which --
3
LORD MACLEAN:
4
You would want to complete the next case,
wouldn't you?
5
MR MACAULAY:
6
LORD MACLEAN:
7
MR MACAULAY:
I think so.
There is doubt about that; is that right?
There is a doubt about that.
I am inclined to
8
suggest, although it is earlier than one would have
9
liked, standing the fact Dr Woodford has to come back,
10
we might adjourn at this point.
11
LORD MACLEAN:
12
MR MACAULAY:
13
LORD MACLEAN:
14
15
MR MACAULAY:
We will do that.
Dr Woodford will come back
Not on Monday.
We will arrange a date for him
to come back.
17
A.
18
MR MACAULAY:
19
LORD MACLEAN:
20
MR MACAULAY:
Probably several.
Hopefully not, Dr Woodford.
I'm not sure.
There are 11 more cases to look at and an
overview as well.
22
LORD MACLEAN:
23
MR MACAULAY:
24
LORD MACLEAN:
25
Indeed, my Lord.
on another occasion?
16
21
Get out of school early.
You have done seven?
I have done six cases.
So the doctor is probably right.
be looking forward to returning, I'm sure.
138
But he will
1
MR MACAULAY:
No doubt.
2
LORD MACLEAN:
3
MR MACAULAY:
On Monday, I have Dr Sheridan to give
4
evidence.
5
LORD MACLEAN:
6
MR MACAULAY:
7
LORD MACLEAN:
8
9
So on Monday --
Dr Sheridan, right.
And on Wednesday, Dr Harrington.
So we will adjourn now until 10 o'clock on
Monday.
(3.04 pm)
10
(The hearing was adjourned until
11
Monday, 7 November 2011 at 10.00 am)
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I N D E X
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3
DR HENRY JOHN WOODFORD (continued) ...................1
4
5
Examination by MR MACAULAY (continued) ........1
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