1 Thursday, 3 November 2011
2 (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. If I could ask you to look
8 at your report, please, that's at EXP01260001.
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. Can we also see that in
20 section II, in relation to the cause of death,
21 Clostridium difficile does appear on the death
22 certificate?
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. Again, just to remind you to speak a little bit slower
8 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 time?
22 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 impairment and self-neglect.
2 Q. In relation to her initial assessment, what line were
3 they taking with her in the Vale of Leven?
4 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. So initially,
9 she went on to an antibiotic called co-amoxiclav,
10 orally, from 22 October.
11 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. I wonder, my Lord, if
4 we could have a very short adjournment just simply to
5 check?
6 LORD MACLEAN: 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: Did he know that you were dealing with this
13 case?
14 MR MACAULAY: 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: Here he is.
21 MR WOOD: Apologies, my Lord.
22 LORD MACLEAN: There was great concern, Mr Wood. We haven't
23 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. Thank you.
3 MR MACAULAY: 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. So far as you could tell from the records, was she
4 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. She was. I believe that was between the dates of
10 18 December and 30 January.
11 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. What was the position at that time?
18 A. 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. It was felt that she may
25 have constipation and she was commenced on laxative
6
1 medication.
2 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? What did that indicate?
5 A. 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. If you turn to page 7, have you noted that the
9 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. So a sputum sample had been sent to the laboratory, and
18 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. It can be a source of pneumonia, but it can also
22 be a normal finding.
23 Q. So far as Ms Harnett was concerned, what was the
24 response?
25 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. So by 2 April, then, she's been transferred to the Fruin
20 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. What was the result of
25 that?
8
1 A. That had grown a coliform organism, which is a type of
2 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. That's two days after the
19 transfer to Fruin?
20 A. Yes.
21 Q. You list for us some further episodes of loose stools --
22 7 April, and you give some further dates. Is that
23 correct?
24 A. Yes, those are the references I could find within the
25 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. Yes, multiple episodes that are recorded within the
14 notes.
15 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. That is
18 at section 4 of the report on page 10. Can you just
19 take us through that, as to what you were able to take
20 from the medical records?
21 A. 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. When specifically asked, she
25 denied having any urinary tract symptoms. She did have
10
1 a mild temperature. Her C-reactive protein, which is
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 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 co-amoxiclav be an appropriate choice?