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1 2 Thursday, 3 November 2011 (10.00 am) 3 DR HENRY JOHN WOODFORD (continued) 4 Examination by MR MACAULAY (continued) 5 MR MACAULAY: Good morning, my Lord. Good morning, 6 Dr Woodford. I want to begin this morning by looking at 7 the case of Irene Harnett. 8 at your report, please, that's at EXP01260001. If I could ask you to look 9 We have on the screen the front page of that report. 10 Have you noted there that Ms Harnett's date of birth was 11 24 June 1930? 12 A. Yes. 13 Q. Indeed, you have also noted her date of death as 14 7 May 2008; is that correct? 15 A. Yes. 16 Q. If we look at the death certificate, it is at 17 SPF00180001. We can see that Ms Harnett was 77 at her 18 date of death on 7 May 2008, and she died in the 19 Vale of Leven Hospital. 20 section II, in relation to the cause of death, 21 Clostridium difficile does appear on the death 22 certificate? Can we also see that in 23 A. Yes. 24 Q. If we then turn to your report, Dr Woodford, and in 25 particular if we turn to page 4 of the report, can you 1 1 perhaps give us some insight into Ms Harnett's medical 2 history? 3 A. She was recorded as having type 2 diabetes, 4 osteoarthritis, duodenal ulcer, vulval carcinoma, 5 hypertension, depression, alcohol excess with possible 6 Korsakoff's syndrome in her past history. 7 Q. 8 Again, just to remind you to speak a little bit slower so that the stenographers can transcribe your language. 9 In relation to the events leading up to her 10 admission to the Vale of Leven, I think you tell us in 11 the third paragraph of page 4 that she had surgery at 12 Gartnavel General Hospital; is that right? 13 A. That's my understanding, yes. 14 Q. What did you understand that was for? 15 A. A resection of a vulval carcinoma. 16 Q. Do you then tell us that she was admitted to the 17 Vale of Leven on 22 October 2008 under the care of 18 Dr McCruden? 19 A. I do, yes. 20 Q. What was the basis for her admission then as at that 21 22 time? A. Apparently, she'd had a recent history of nausea and 23 vomiting blood and she'd had some swelling of her lips 24 recently, following the administration of an antibiotic. 25 There was also evidence of some degree of cognitive 2 1 2 impairment and self-neglect. Q. 3 4 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 5 developed a urinary tract infection or an infection of 6 her surgical wounds. 7 Q. At that time, was she prescribed any medication? 8 A. She was commenced on some antibiotics. 9 she went on to an antibiotic called co-amoxiclav, 10 11 So initially, orally, from 22 October. Q. If we move on to page 5 of your report, do you tell us 12 in the first main paragraph that she was transferred to 13 ward 14 in the course of this admission and that was 14 under the care of Dr Akhter? 15 A. That's my understanding, yes. 16 Q. Did you understand that was for rehabilitation? 17 A. Yes. 18 Q. Was she positive for MRSA at around this time? 19 A. The wound swabs obtained on 25 October grew MRSA. 20 Q. Did they attempt to keep her in isolation because of 21 that? 22 A. They did attempt to, yes. 23 MR MACAULAY: My learned friend has pointed out to me, 24 my Lord, that Mr Wood is not here today, and he 25 represents, I think, as I indicated, MBS, but in 3 1 particular Dr Akhter. It may be that there has been 2 a delay, and it would be unfortunate if he weren't 3 present for some of the evidence. 4 we could have a very short adjournment just simply to 5 check? 6 LORD MACLEAN: I wonder, my Lord, if I did wonder about that, but just made the 7 assumption that this was a day he wasn't going to be in 8 attendance. 9 MR MACAULAY: I certainly hadn't noticed he wasn't here, and 10 he certainly didn't let me know whether or not he would 11 be here or not. 12 LORD MACLEAN: 13 case? 14 MR MACAULAY: Did he know that you were dealing with this I don't know if he would know that. But in 15 any event, a number of the cases would touch upon 16 Dr Akhter, in any event. 17 I am informed, my Lord, that he is in the building 18 now, so perhaps if we can maybe chase him up, and we 19 needn't adjourn, if we just give it a couple of minutes. 20 LORD MACLEAN: 21 MR WOOD: 22 LORD MACLEAN: 23 Here he is. Apologies, my Lord. There was great concern, Mr Wood. We haven't got very far. 24 MR WOOD: I will catch up, my Lord. 25 LORD MACLEAN: We are dealing with Ms Harnett's case, and it 4 1 is one in which you will be interested. 2 MR WOOD: I see that, my Lord. 3 MR MACAULAY: Thank you. I had taken you, Dr Woodford, to page 5 of 4 your report where, in the second paragraph, you do 5 indicate that Ms Harnett was transferred to ward 14 6 under the care of Dr Akhter, and that was for 7 rehabilitation. 8 A. Yes. 9 Q. We had moved on, and I think you had indicated that she 10 had contracted MRSA, and the staff were at least 11 attempting to nurse her in a side room because of that 12 particular infection; is that right? 13 A. Yes. 14 Q. Did that prove problematic for them? 15 A. She apparently tended to wander around the corridor. 16 Q. Did she improve sufficiently that she was discharged 17 home on 23 November 2007? 18 A. Apparently so, yes. 19 Q. But shortly after that, as you tell us on page 5 of your 20 report, was she referred back to the Vale of Leven by 21 her GP, on 30 November 2007? 22 A. That's correct. 23 Q. What was the basis for that? 24 A. The GP had noted that she'd been found wandering naked 25 around her home, she didn't seem to be eating well, she 5 1 was pulling off her wound dressing and seemed to be 2 sticking her fingers into the wound. 3 Q. 4 So far as you could tell from the records, was she admitted, once again, to ward 14 in the Vale of Leven? 5 A. I believe so, yes. 6 Q. If you turn to page 6 of your report, in the course of 7 this admission, was she admitted to the Beatson Oncology 8 Centre for some radiotherapy for her cancer? 9 A. 10 11 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 12 at the Vale of Leven under the care of Dr Akhter on 13 30 January? 14 A. Yes. 15 Q. In the following paragraph, you make some observations 16 as to what you have taken from the records on 17 18 February. 18 A. What was the position at that time? Well, what was recorded, that she was found to be 19 frightened and confused and, for that reason, she'd been 20 commenced on an antipsychotic drug called haloperidol. 21 Q. Was she complaining of some abdominal pain at that time? 22 A. That was some time later. On 29 February, there was 23 some abdominal pain. An abdominal X-ray was performed, 24 which appeared to be normal. 25 have constipation and she was commenced on laxative 6 It was felt that she may 1 2 medication. Q. Do you go on to tell us that, on 2 March, she had a fall 3 and that, following upon that, she had a CT scan on 4 4 March? 5 A. What did that indicate? It suggested a degree of brain atrophy, but I presume 6 the scan was done to look for any intracranial injury 7 following her fall, which it didn't demonstrate. 8 Q. 9 If you turn to page 7, have you noted that the orthopaedic team did note that there was an impacted 10 fracture of her right humerus, although that hadn't been 11 seen on the initial X-ray? Is that correct? 12 A. Yes. 13 Q. The point you make in, not the next, but the next 14 paragraph after that, under reference to 19 March, can 15 you explain that, as to what the findings were and what 16 they indicated? 17 A. 18 So a sputum sample had been sent to the laboratory, and it had grown the bacteria Haemophilus influenzae. 19 Q. What does that mean? 20 A. It's a bacteria that's often present in the respiratory 21 tract. 22 be a normal finding. 23 Q. 24 25 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, 7 1 presumably on the basis that this was causing 2 a pneumonia or chest infection, although the clinical 3 assessment at the time had noted she didn't have 4 a temperature and, although there were some crepitations 5 or crackles heard on listening to her chest, those 6 seemed to clear on coughing, which suggests there is no 7 area of consolidation, which would be consistent with 8 chest infection. 9 Q. Did the staff decide that she should be psychiatrically 10 assessed, and did that happen in the course of the month 11 of March? 12 A. I'm not sure the exact date it happened. She was 13 referred to Dr Coulter on 23 March and she ended up on 14 Fruin ward under the care of Dr Coulter on 2 April, so 15 without checking the notes, I'd have to see the exact 16 date that she was seen, but obviously, some form of 17 psychiatric assessment and transfer to the psychiatric 18 unit occurred around the end of March. 19 Q. 20 So by 2 April, then, she's been transferred to the Fruin ward within the Vale of Leven Hospital? 21 A. That's correct. 22 Q. If we move on to page 8 of the report, I think you tell 23 us in the first main paragraph that there was a urine 24 culture obtained on 9 April. 25 that? 8 What was the result of 1 A. 2 That had grown a coliform organism, which is a type of bacteria often found in the bowel. 3 Q. Did the medical staff respond to that in any way? 4 A. She was commenced on the antibiotic co-amoxiclav on 5 11 April for what was suspected to be a urinary tract 6 infection. 7 Q. Do you then tell us, in concluding this general history, 8 that, as we have already noted, she, I think, 9 deteriorated and she died on 7 May 2008? 10 A. Yes. 11 Q. Is it right to say, when we look at the position in 12 relation to C. diff, and you look at that on page 9 of 13 your report, that Ms Harnett didn't really report loose 14 stools until shortly after her transfer to Fruin ward? 15 A. Yes. 16 Q. I think what you tell us there, under the heading 17 "C. diff diarrhoea", is that loose stools were first 18 reported on 4 April 2008. 19 transfer to Fruin? That's two days after the 20 A. Yes. 21 Q. You list for us some further episodes of loose stools -- 22 7 April, and you give some further dates. 23 correct? 24 25 A. Is that Yes, those are the references I could find within the notes to loose stools being found. 9 1 Q. Then, if we look at the microbiology result that was 2 eventually obtained, if we could have on the screen, 3 please, GGC00270325, can we see that a specimen was 4 eventually obtained from Ms Harnett on 30 April and 5 received by the lab on the same day, and that was 6 a positive result? 7 A. Yes. 8 Q. As you point out on page 9, if we go back to your 9 report, in that particular paragraph dealing with 10 C. diff, Ms Harnett had had loose stools for a period of 11 time leading up to the obtaining of that particular 12 specimen? 13 A. 14 15 Yes, multiple episodes that are recorded within the notes. Q. Can I then turn on to that section of your report where 16 you look at the antibiotic treatment that was given to 17 Ms Harnett for conditions other than C. diff. 18 at section 4 of the report on page 10. 19 take us through that, as to what you were able to take 20 from the medical records? 21 A. That is Can you just So the initial antibiotics, she was commenced on 22 co-amoxiclav for what was, at that time, thought to 23 possibly be urinary tract infection or an infection of 24 her surgical wounds. 25 denied having any urinary tract symptoms. When specifically asked, she 10 She did have 1 a mild temperature. 2 a marker of inflammation within the blood, was a little 3 elevated at 14 and her white cell count was markedly 4 raised at 22.7, which are both consistent with an 5 infective process. 6 Her C-reactive protein, which is Her urine culture was subsequently negative and the 7 wound swabs did not grow any organisms, so it makes me 8 think that a urinary tract infection was probably 9 unlikely on the basis of a lack of urinary symptoms and 10 the negative urine culture. 11 Q. The prescription was for co-amoxiclav; is that correct? 12 A. That's right, yes. 13 Q. If she did have a urinary tract infection, would 14 15 co-amoxiclav be an appropriate choice? A. 16 17 The recommended first-line antibiotic would have been trimethoprim. Q. 18 Is that why you say, then, the choice of antibiotic was suboptimal? 19 A. Yes. 20 Q. If you move on, then, in relation to what else you say 21 22 towards the latter part of that paragraph. A. So the other suspected differential diagnosis was a skin 23 infection, cellulitis, which, typically, the recommended 24 first-line drug would be flucloxacillin, so also 25 co-amoxiclav wouldn't be the first-line drug you would 11 1 have chosen if that was the suspected source of 2 infection. 3 Q. Co-amoxiclav would have been? 4 A. Would not have been. 5 Q. Would not have been? 6 A. Flucloxacillin was the recommended first-line drug for 7 8 skin infections. Q. 9 Was the co-amoxiclav then prescribed before the culture results were available? 10 A. That's right. 11 Q. Then, when the culture results came through, what did 12 13 they show? A. 14 So when there was no organism identified in the urine or the skin, the same antibiotic was continued. 15 Q. Should that have happened? 16 A. Probably not. 17 Q. Can you tell me how long the co-amoxiclav was actually 18 19 then given to Ms Harnett at this time? A. 20 21 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 22 that correct? 23 she was discharged and she came back shortly after that. 24 This is the first admission? 25 A. As we noted, there was an admission and Yes, that is the first admission, yes. 12 1 Q. As you tell us in the next paragraph in relation to the 2 second admission, on 30 November, she was admitted with 3 confusion, and so on. 4 she again prescribed antibiotics at the time of this 5 admission? 6 A. She was. If you move on to page 11, was She again had -- sorry, no, she had 7 ciprofloxacin and co-amoxiclav prescribed at the time 8 that she came in, on 30 November. 9 Q. Can you tell us what the reasoning behind that was? 10 A. Well, the initial assessment concluded query UTI, query 11 12 confusion, query cause. Q. 13 14 What was the thinking, then, behind the prescription of these two antibiotics? A. 15 Presumably, the suspected diagnosis was urinary tract infection, although it wasn't clear. 16 Q. Were there clinical signs of a urinary tract infection? 17 A. There were no urinary symptoms reported by the patient. 18 I think there's a minor typo there: no urinary symptoms 19 or temperature recorded. 20 pyrexial at that time. 21 which can sometimes happen with infection, and her CRP 22 was elevated, so those blood tests could be consistent 23 with infection. 24 25 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 13 1 wasn't simply an infection that had partially been 2 treated by antibiotics by the time the culture was sent. 3 The absence of white cells suggests that she didn't have 4 a urinary tract infection. 5 Q. Are you able to say whether or not it was appropriate, 6 first of all, to prescribe an antibiotic in the 7 circumstances? 8 A. 9 Sometimes antibiotics are given empirically, when people are ill and you are not sure why and it is thought, you 10 know, that the risk of broad-spectrum antibiotics is 11 justified. 12 clear whether a septic process was going on. 13 I think it is hard to comment just based on what's 14 recorded in the notes. 15 Q. However, on this occasion, it is not really You know, If antibiotics were appropriate, what about the 16 combination of antibiotics that were prescribed here, 17 the ciprofloxacin and the co-amoxiclav? 18 appropriate choice? 19 A. Was that an You know, it's two broad-spectrum agents in combination 20 that would have covered most infections. It is not 21 a very common combination used. 22 be a great combination for a urinary tract infection, 23 for instance. 24 diagnosis wasn't clear, the treating doctors thought 25 they should give very broad-spectrum treatment initially You know, it wouldn't The assumption is that, because the 14 1 and then perhaps revise when some investigations and 2 more information came to light. 3 from that. 4 Q. 5 6 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 7 best I can say is possibly. 8 evidence of a severe sepsis when she came into hospital, 9 but that is just based on what I have seen in the notes. 10 11 There is not overwhelming It may have been appropriate. Q. I think we have seen, and you have told us, that 12 generally trimethoprim would be the first port of call 13 for a suspected urinary tract infection? 14 A. 15 16 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 17 the thinking might have been there may have been another 18 cause or causes and, therefore, a broader-spectrum 19 approach was being adopted? 20 A. That's the way I would interpret it, yes. 21 Q. Should the records disclose what the thinking was? 22 A. Ideally, there would be a bit more information there so 23 as, you know, the next doctor coming along would have 24 been able to follow the thought processes. 25 live in an ideal world. We don't There was some information 15 1 recorded, but it is hard for us, in retrospect, having 2 just seen the notes, to know for sure whether that was 3 the right action at that time. 4 Q. 5 6 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 7 is just two days later, and that seems to be before the 8 results of cultures were known. 9 Q. 10 As far as the culture results were concerned, were they normal? 11 A. At that stage, I don't think so. 12 Q. Is this where you have a -- 13 A. So the -- 14 Q. The CRP is raised; is that right? 15 A. The CRP was raised, yes. The urine culture was 16 collected on 1 December, but recorded as received by the 17 laboratory on 3 December, but her antibiotics were 18 discontinued on 1 December. 19 Q. Let's move on, then, to what you tell us in the 20 following paragraph. 21 Haemophilus influenzae that you mentioned before to have 22 been noted in her sputum. 23 apyrexial and she had chest crepitations that cleared 24 with coughing. 25 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. 16 1 Q. What happened here in relation to medication? 2 A. She was commenced on an antibiotic, I believe it was 3 co-amoxiclav orally, from 19 November to 25 March. 4 Q. Was that an appropriate response? 5 A. I don't think so. There doesn't seem to be 6 justification in terms of recording of a septic process 7 within the notes. 8 Q. 9 to indicate that -- why they thought that co-amoxiclav 10 11 might have been an appropriate course of action? A. 12 13 This is presumably predominantly in response to finding Haemophilus influenzae in the sputum. Q. 14 15 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 16 organism found within the respiratory tract. 17 need more than just the culture result to justify the 18 use of antibiotics. 19 evidence of a septic process. 20 does not diagnose a chest infection. 21 Q. 22 23 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 24 the Haemophilus influenzae that was isolated, 25 co-amoxiclav would seem to have been a good choice of 17 1 antibiotic, if this had been part of a chest infection 2 and not just a commensal organism. 3 Q. Your position is that if the diagnosis was 4 a hospital-acquired infection, such as pneumonia, then 5 that would have been an appropriate approach? 6 A. Yes. 7 Q. But you are saying that you don't see evidence of that 8 in the records? 9 A. Not from the notes I have seen, no. 10 Q. How long was this particular course of antibiotics 11 12 given? A. 13 This was from 19 March to 25 March, so is that seven days in total? 14 Q. Again, this is a broad-spectrum antibiotic? 15 A. It is, yes. 16 Q. If we move on, then, to the following paragraph, I think 17 you tell us that a urine culture obtained on 9 April had 18 grown a coliform, and you give a reference for that. 19 Can you just take it on from there? 20 did matters proceed from there? 21 A. What, then -- how So she went on to further antibiotics for a suspected 22 urinary tract infection based on the finding of 23 a coliform bacteria within her urine. 24 indication said frequency in micturition, but I didn't 25 find documentation of an assessment of the patient 18 The form for the 1 2 performed at that stage. Q. I think you say there was no recorded temperature, no 3 blood tests were performed around this time, that the 4 culture had shown the organism to be resistant to 5 trimethoprim but was sensitive to nitrofurantoin. 6 that right? 7 A. Nitrofurantoin. Is But the notes suggested she may have 8 had some lip swelling in response to an antibiotic 9 before that was prescribed by the gynaecologist prior to 10 coming into the Vale of Leven, which -- the records seem 11 to suggest that was nitrofurantoin. 12 Q. Your position, I think, reading this, is that you 13 thought it was unlikely that she had a significant 14 urinary tract infection; is that correct? 15 A. Based on what's recorded, there doesn't seem to be any 16 recording of patient symptoms or assessment or abnormal 17 signs on examination at that stage. 18 Q. 19 20 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 21 asymptomatic bacteriuria which would not usually be 22 treated with antibiotics. 23 Q. If she did have a urinary tract infection, and standing 24 the fact that the organism was resistant to trimethoprim 25 and she had a previous allergic reaction to the 19 1 alternative, then would co-amoxiclav be an appropriate 2 course of action? 3 A. It would. 4 Q. How long, then, was she prescribed the co-amoxiclav on 5 this particular occasion? 6 A. This time it went from 11 April to 16 April. 7 Q. Looking at the duration, again on the hypothesis that it 8 was an appropriate route to take, was that duration an 9 appropriate duration? 10 A. 11 12 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 13 are still dealing with antibiotic treatment -- I think 14 you tell us there that, on 21 April, she was prescribed 15 a further seven-day course of co-amoxiclav; is that 16 correct? 17 A. Yes. 18 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) 12 13 14 15 16 17 18 19 20 21 22 23 24 25 139 1 I N D E X 2 3 DR HENRY JOHN WOODFORD (continued) ...................1 4 5 Examination by MR MACAULAY (continued) ........1 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 140