1 Monday, 12 September 2011
2 (10.00 am)
3 LORD MACLEAN: Something has been brought to my attention
4 about which I wish now to make a statement. Nurses who
5 may yet give evidence have received letters from the
6 board which set out the position of the board in
7 relation to certain matters. That letter is dated
8 2 September. It says this, and this is sent to a series
9 of nurses:
10 "You will recall that I wrote to you on 31 March,
11 24 May and 20 June 2011 about the public Inquiry looking
12 at the incidence of C. difficile at the Vale of Leven
13 Hospital between January 2007 and June 2008. You will
14 also recall that conflict of interest issues have
15 prevented the NHS Board from giving individual members
16 of staff advice on how to prepare to give evidence to
17 the Inquiry. That remains the position.
18 "The NHS Board, as ever, is greatly concerned to
19 secure fair treatment for its employees. It has come to
20 the attention of the NHS Board that some staff members
21 may not realise that they may be criticised publicly in
22 the Inquiry's report. Senior Counsel for the Inquiry
23 has expressly declined to rule out the possibility that
24 any nurse may be criticised in this way. This applies
25 regardless of the nurse's grade and even if the nurse is
1
1 not represented by a lawyer when giving evidence to the
2 Inquiry.
3 "In particular, nurses may be asked questions to see
4 whether or not they complied with the NMC code of
5 conduct and the NMC guidance on record keeping.
6 "If you have not realised this before, you may wish
7 to take this into account when deciding whether to
8 consult a solicitor to get your own individual legal
9 advice about giving evidence to the Inquiry. The
10 Inquiry has the power to pay for such advice and may do
11 so if you apply to it for that.
12 "If you decide to consult a solicitor or the Royal
13 College of Nursing about this, you should do so urgently
14 and you should also notify the Inquiry urgently that you
15 are doing so."
16 The letter is signed by the chief executive of
17 the board, Robert Calderwood.
18 One nurse who had given evidence received this
19 letter and she couldn't understand why she had received
20 it. The others have been confused and anxious on
21 receipt of the letters. As a result, Lynne Allan, our
22 witness liaison officer, has been beset with enquiries.
23 It would appear that several nurses received their
24 letters before the Inquiry received their copy, seven
25 days after the first letter was sent out.
2
1 It should be understood that, following upon the
2 board's decision, very belatedly reached, not to
3 represent any of their employees, the Inquiry itself
4 liaised immediately with the Royal College of Nursing.
5 I received a full report from Mr Dickson of
6 Anderson Strathern, representing the Royal College of
7 Nursing, about the steps taken to inform the nurses
8 fully about their position, both as to the form of
9 examination they would have to undergo and the need to
10 seek legal representation.
11 As I understand it, all the nurses who received the
12 board's recent letter have received the induction course
13 provided by Anderson Strathern on behalf of the Royal
14 College of Nursing.
15 It can never be said in an Inquiry like this that
16 a witness will not be blamed or criticised, because that
17 depends on how the evidence turns out. What I can say
18 is that it is highly unlikely that anyone will be blamed
19 or criticised personally who has not received a written
20 warning of that in advance from the Inquiry.
21 Might I suggest, Mr Kinroy, that if you have any
22 doubt about anything, you should seek clarification of
23 that informally from Mr MacAulay, Senior Counsel to the
24 Inquiry.
25 Mrs Searle's experience exemplifies that. When she
3
1 came to give evidence, you objected on the ground,
2 I think, that she might not have had the proper advice.
3 Actually, she had. Forty minutes later, she returned to
4 give evidence, but she had been very anxious in the
5 interim, in light of what you had to say.
6 I immediately took steps to ensure that all the
7 nurses who have been cited to give evidence did receive
8 the induction course, as I have called it, from the
9 Royal College of Nursing.
10 Of course, Mrs Searle, who gave evidence,
11 subsequently received the letter; couldn't understand
12 why. It must always be remembered that we are not here
13 involved in adversarial proceedings, with parties in
14 standoff positions. What I urge you, Mr Kinroy, is to
15 confer. Confer.
16 You see, if you take Mrs Searle's case as an
17 illustration, you will recall you didn't mention that
18 you were going to make this objection to anyone, and it
19 caught Counsel to the Inquiry off balance, actually.
20 But if you had mentioned it to him in advance, you could
21 have discussed it, and it might not have been necessary
22 to lose the time we did.
23 I suggest that if you had conferred in relation to
24 this letter and what it is said Senior Counsel had said
25 on a previous occasion, it would not have been necessary
4
1 for the board to write their letter and I wouldn't have
2 had to address the subject as I do today.
3 I have to say also that I remain critical of
4 the board's decision not to represent any of their
5 employees, but I will not stop you, Mr Kinroy, from
6 making interventions as the evidence is led. For one
7 thing, it keeps me on my toes.
8 Can you please, however, show some discrimination in
9 judgment? We had, in the case of the last witness, the
10 farcical position of your making an objection when it
11 should have come from the person sitting beside you, who
12 was engaged by the Inquiry to represent her. I hope
13 that doesn't happen again. Otherwise, it will appear to
14 an objective bystander that the board is having its cake
15 and eating it. If the board is to continue to make such
16 objections, why should the Inquiry go to the bother and
17 expense of providing separate representation?
18 Now, that is a question of balance for you to decide
19 on in any situation. As I have said, I am not going to
20 stop you from making objections.
21 Do you have anything you wish to say?
22 MR KINROY: No, my Lord.
23 LORD MACLEAN: Very well. Next witness?
24 MR MACAULAY: My Lord, the next witness I would like to call
25 is Mrs Janine Hart.
5
1 MRS JANINE MARGARET HART (sworn)
2 Examination by MR MACAULAY
3 MR MACAULAY: Good morning, Mrs Hart. Are you
4 Janine Margaret Hart?
5 A. Yes, I am.
6 Q. What position do you hold at present?
7 A. I am the deputy ward manager in ward 15 at the
8 Vale of Leven Hospital.
9 Q. For how long have you held that particular post?
10 A. Approximately six years.
11 Q. Can you tell me when you qualified as a registered
12 nurse?
13 A. 1984.
14 Q. What did you do thereafter?
15 A. After I qualified, I moved to Scotland and I worked in
16 private nursing homes until the year 2000, when I was
17 employed with the Vale of Leven Hospital.
18 Q. When you went to work in the Vale of Leven Hospital,
19 what grade were you at that time?
20 A. It is what is now a 5, a band 5.
21 Q. Did you work in a particular ward at that time?
22 A. I went to ward 16.
23 Q. I think you have said you worked in ward 15 for some six
24 years or so; is that correct?
25 A. No, actually, eight.
6
1 Q. Eight years?
2 A. Yes. I joined them as a band 5 and then became what is
3 a deputy for six years now.
4 Q. I propose to put a job description on the screen to see
5 whether or not this would fit in with your job
6 description. If you look at GGC13110001. It is not the
7 best of copies, as you can see, but you will see the job
8 title is "Deputy ward manager", the department is
9 assessment and rehabilitation and it is
10 dated December 2004. Is this the same as your job
11 description or not?
12 A. It is very difficult to read, but --
13 Q. It is. Can I ask you this: do you have a job
14 description?
15 A. I will have, but obviously it has changed since Agenda
16 For Change came into play.
17 Q. Did you have a job description during the relevant time,
18 the relevant time being from January 2007 to June 2008?
19 A. Yes.
20 Q. If we just look at this particular document to see
21 whether or not it contains information that would be
22 relevant to you, if you turn to page 2 of the document,
23 again it is not easy to read, but about a third or so
24 away from the top of the page there is a paragraph that
25 reads:
7
1 "Ensure that all written documentation within the
2 ward/department area is clear, concise, timely and
3 complies with NMC standards for records and record
4 keeping."
5 Did you have such a provision in your job
6 description at the relevant time?
7 A. I couldn't be certain, but if this is, you know, a copy
8 of what would have been in place, then I would say yes.
9 Q. About halfway down that same page --
10 MR KINROY: My Lord, I do regret this, but how can it be
11 acceptable for the witness to be questioned on the basis
12 of what was in her job description and we elicit an
13 answer:
14 "Answer: I couldn't be certain, but if this is, you
15 know, a copy of what would have been in place, then
16 I would say yes."
17 That, in my submission, is worthless. If it is to
18 be construed as some kind of admission that this was
19 part of the job description, it is wrong.
20 MR MACAULAY: I will explore that a little bit further,
21 my Lord, if that would assist.
22 LORD MACLEAN: All right.
23 MR MACAULAY: The provision we looked at focusing upon the
24 NMC standards for records and record keeping, first of
25 all, I think you know about those standards?
8
1 A. Yes.
2 Q. Would these be standards that you would seek to comply
3 with, in any event?
4 A. Yes.
5 Q. The next section in the job description that I want to
6 draw your attention to is about halfway down the page
7 where there is a provision which says:
8 "Works within the NMC code of practice and
9 professional guidelines."
10 Would the NMC code of practice and professional
11 guidelines be something you would wish to comply with in
12 any event?
13 A. Yes, they would.
14 Q. In relation to the code of practice, I think, if you
15 have been following the Inquiry, you will have seen that
16 other witnesses have been asked some questions about the
17 provisions of the code; is that right?
18 A. Yes.
19 Q. Have you been following the Inquiry?
20 A. I have.
21 Q. Have you seen transcripts of the evidence of some of
22 the nurses who have already given evidence to the
23 Inquiry?
24 A. Yes, I have.
25 Q. You will recognise, I think, that you have a duty of
9
1 care to your patients under the code?
2 A. Yes, that's correct.
3 Q. Similarly, in relation to record keeping, you will
4 understand, I think, that record keeping forms an
5 important part of nursing care?
6 A. Yes.
7 Q. Would you agree that the code of practice and the code
8 relating to the standards of record keeping, that these
9 are important guidelines for nurses to follow?
10 A. Yes, important guidelines.
11 Q. Can I just understand, Mrs Hart, what your duties were
12 at the relevant time as the deputy ward sister?
13 A. Well, my duties -- obviously, I was part of the team
14 that actually did -- had a group of patients to look
15 after during my shift time. I was obviously in place
16 when Sister Madden was on holiday, but that was more to
17 do with managing staffing issues. I had very little to
18 do with any other of the issues that she took part in,
19 so I would do rotas, manage sickness absence and the
20 day-to-day running of the ward.
21 Q. Just looking, then, to the nature of the ward itself,
22 I think we heard from Sister Madden that, generally, the
23 ward was full of patients; is that right?
24 A. Yes, that's correct.
25 Q. The patient profile -- perhaps you can give us your
10
1 description of how you would describe the patient
2 profile of the ward?
3 A. Obviously, being a rehab and assessment ward, we took in
4 patients from medical and orthopaedic and some surgical,
5 but it was quite a varied group of patients, some of
6 them very mobile, some very immobile. We had quite
7 a few patients who suffered with dementia and,
8 therefore, we had to manage the problems that came with
9 patients with dementia; but very, very busy on
10 a day-to-day basis, and obviously, when that -- patients
11 with complicated problems, that demanded more of our
12 time.
13 Q. Would you say that the majority of the patients that you
14 had would be frail, elderly patients?
15 A. Yes, you could say the majority of them were.
16 Q. What knowledge did you have at the relevant time of
17 the contents of the infection control manual?
18 A. I was aware of the infection control manual.
19 Q. Did you have cause to look at it from time to time?
20 A. Yes, as a reference.
21 Q. Can you give me an example as to how you'd look to it
22 for a reference?
23 A. Well, if there was something that occurred on the ward
24 that we were not familiar with, something that a patient
25 may have that needed to be looked up and give us
11
1 a guideline as to how to treat the patient, whether they
2 required to be isolated or not.
3 Q. One of the policies that you will have seen that we have
4 looked at in the course of the Inquiry is the loose
5 stools policy. You will have seen some evidence in
6 connection with that?
7 A. Yes.
8 Q. Were you aware of the contents of the loose stool policy
9 at the time that we are interested in, from January 2007
10 to June 2008?
11 A. I was aware that it was in the infection control manual.
12 Q. Do you remember if you had ever had any cause to look at
13 it?
14 A. I don't remember whether I looked at it.
15 Q. I'm sorry?
16 A. I don't recall whether I looked at it --
17 Q. You don't?
18 A. -- during that time.
19 Q. What about the C. diff policy that, again, you will have
20 seen referenced in the evidence? Can you remember if
21 you had cause to look at that?
22 A. I don't remember having cause to look at it.
23 Q. In relation to patients with loose stools then, are you
24 able to tell the Inquiry what you saw the practice of
25 the ward to be in relation to isolation of such
12
1 patients?
2 A. We would always attempt to isolate in the event of loose
3 stools if there were side rooms available.
4 Q. Were there occasions when there were no side rooms
5 available and you did not isolate such patients?
6 A. Yes. During the norovirus outbreak, we did not have
7 enough side rooms to isolate the number of patients who
8 had the symptoms.
9 Q. What then happened?
10 A. In that case, then obviously we put in measures to
11 prevent cross-infection, such as the patient having
12 their own commode, using the PPE equipment, the signs on
13 the door and yellow bins -- orange bins in the room and
14 obviously making everyone aware that the patient had
15 symptoms.
16 Q. At the relevant time, did you consider that patients
17 with loose stools might have been at a greater risk to
18 pressure damage?
19 A. Everyone that has loose stools is at a risk of pressure
20 damage. Obviously, good personal hygiene is paramount
21 with all patients, but particularly with anyone who is
22 incontinent.
23 Q. In relation to assessing the risk of pressure damage,
24 were you using the Waterlow tool at that time?
25 A. Yes, we were.
13
1 Q. Did you, yourself, personally assess patients using the
2 Waterlow tool?
3 A. Yes, I did.
4 Q. What about nutrition, then, another aspect that might be
5 relevant in particular to C. diff? Were you engaged in
6 assessing the nutritional status of patients?
7 A. Yes, I was.
8 Q. Did you have a tool, a screening tool, to assist you in
9 that operation?
10 A. Yes, we had an adapted tool.
11 Q. In relation to pressure management, I think I'm right in
12 saying that you didn't use turning charts in ward 15; is
13 that right?
14 A. They weren't available to us. We did sometimes use
15 blank pieces of paper to write down when we turned
16 patients.
17 Q. Do you know why turning charts, as a document, weren't
18 available to you at that time?
19 A. They just weren't available. I don't know any reason
20 why.
21 Q. Are they available to you now?
22 A. Yes, they are.
23 Q. What about the use of pressure mattresses? What was
24 your experience in the use of those?
25 A. Well, all the mattresses in the ward do have a degree of
14
1 pressure-relieving application, but there were
2 pressure-relieving mattresses -- they hired air flow,
3 alternating flow mattresses -- available within the
4 directorate, and we were able to hire them whenever we
5 needed them.
6 Q. If a patient were to be nursed on a special mattress
7 that was seeking to assist with pressure management,
8 would you expect that to be recorded in the nursing
9 records?
10 A. It should have been, but I believe it was not.
11 Q. I think we heard from Sister Madden last week -- and
12 I don't propose to go over old ground with you -- that
13 after the event, sometime perhaps later on in 2008, she
14 became aware that things were not being recorded as they
15 should have been. Do you remember reading that evidence
16 in her transcript?
17 A. Yes, I do.
18 Q. What about your position? Were you aware at the
19 relevant time that matters that should have been
20 recorded in the nursing records were not being recorded?
21 A. I don't believe I was aware.
22 Q. Did you become aware then?
23 A. When Sister Madden brought it to our attention, yes.
24 Q. What --
25 A. At some later point.
15
1 Q. Can you say when that was?
2 A. No, I can't.
3 Q. You will have seen that with Sister Madden I took her to
4 a number of individual patients and put a number of
5 propositions to her once we had looked at the records,