1 Monday, 4 July 2011
2 (2.00 pm)
3 MR MACAULAY: Good afternoon, my Lord. My next witness is
4 Professor Anthony Michael Palmer.
5 PROFESSOR ANTHONY MICHAEL PALMER (sworn)
6 Examination by MR MACAULAY
7 MR MACAULAY: I think you are Anthony Michael Palmer; is
8 that correct.
9 A. That's correct.
10 Q. What position do you hold at present, Professor?
11 A. Well, I am currently, as from February this year, an
12 independent nursing consultant and expert witness.
13 Q. Could I then ask, what was the last position you held?
14 A. The last position I held was chief nurse and director of
15 clinical services at the Luton & Dunstable Hospital
16 Foundation Trust.
17 Q. For how long did you hold that particular post?
18 A. I was in that post for approximately four years.
19 Q. Could you have your curriculum vitae in front of you?
20 The database number is INQ01790001. We have that on the
21 screen. If you could turn to page 2 of the document, do
22 you set out, towards the top of page 2, your
23 professional qualifications?
24 A. That's correct.
25 Q. Can we see that you became a registered general nurse in
1
1 1983?
2 A. That's correct.
3 Q. Then we see that you have a number of academic
4 qualifications, and we then see your university
5 appointments; is that right? You are a Visiting
6 Professor of the University of Bedfordshire?
7 A. That's correct.
8 Q. And that's in nursing?
9 A. That's correct.
10 Q. You give some details about your recent publications and
11 the books that you have had some involvement in
12 publication; is that correct?
13 A. That's correct.
14 Q. If we now go on to the third page of the CV, do you set
15 out there your track record from the time that you
16 registered as a nurse?
17 A. Yes, very briefly, yes.
18 Q. Do we see that you were a senior -- I think you
19 registered as a nurse, in fact, in 1983 and that you
20 were a senior nurse in medicine from July 1988
21 to August 1990?
22 A. That's correct.
23 Q. Can you take us briefly through your career path since
24 then?
25 A. Okay. So from July 1988 to 1990, I was a senior nurse
2
1 in a medical unit in Scarborough. That was very much
2 a clinically-based role working in and around the wards
3 on a daily basis, so very active in clinical care.
4 Then I moved to Oxfordshire in a community hospital
5 in Oxfordshire, where I became a lecturer practitioner.
6 So at that stage, I was actually a senior charge nurse
7 on one of the wards, but I was a senior charge nurse
8 actually for the three wards that were based at what was
9 Abingdon Community Hospital. It is still there.
10 I was also part time. As part of that role as
11 a lecturer practitioner, I taught nursing, fundamental
12 nursing, as part of that role within the Oxford Brookes
13 University, previously Oxford Polytechnic.
14 I then spent several years entirely as a general
15 manager, which you can see, in City Hospitals,
16 Sunderland, between 1993 and 1995. Following that move
17 into general management, I returned to a senior nursing
18 role. Again, you can see that, between December 1995
19 and March 1998, I was a directorate head of nursing for
20 medicine and elderly at the RVI in Newcastle.
21 Q. Would that involve you being present on the wards?
22 A. One point I would stress throughout my evidence is that,
23 throughout my career, even in my last month as a chief
24 nurse at Luton & Dunstable, I spent a day on the wards
25 on a very regular basis and was on the wards every day
3
1 that I was at work because that's how a chief nurse
2 ensures the quality of care is adequate.
3 As the head of nursing however, back to the
4 Royal Victorian Infirmary, I was very much involved with
5 supervising the senior ward managers, the senior
6 clinical nurses, in ensuring the quality of care was of
7 the highest standard in medicine and in elderly.
8 Q. If I take you to your last post, which I think we see at
9 the top was from May 2007 to, I think you said, February
10 of this year?
11 A. That's correct.
12 Q. Executive director of nursing and deputy chief
13 executive. In that post, would you spend time on the
14 wards?
15 A. Yes, I was spending regular time on the ward. Just to
16 be absolutely clear, I programmed in days on the wards
17 where I would supervise and assess the quality of
18 nursing in the acute wards.
19 The Luton & Dunstable is not a huge hospital, it is
20 on one site. The Luton & Dunstable Hospital is very
21 keen on patient safety and this concept of being the
22 board to the ward, it was very important, not only to
23 me, but to our hospital board. So, yes, I was very
24 active in clinical care and, not only that, having been
25 an expert witness for 15 years, I have been constantly
4
1 reviewing standards and quality of nursing care.
2 Q. If we turn to the first page of the CV, you have
3 a little box towards the middle of the page and you
4 indicate what your areas of expertise are. Are these
5 areas that you have developed expertise through your
6 experience as a nurse?
7 A. Entirely. As you can see, a number of those areas of
8 expertise are general and specific. They are the
9 current areas where I offer advice on nursing aspects,
10 quality of care.
11 Q. We see, for example, reference to pressure sore
12 development and prevention. We have heard already quite
13 a bit of evidence on that. Is that a core element of
14 nursing care?
15 A. I would say, without doubt, that pressure sore
16 development is a fundamental element of care.
17 Q. In relation to the work that you have done for this
18 Inquiry, I think you have looked at a number of patient
19 records and prepared reports; is that correct?
20 A. That's correct.
21 Q. How many patients have you looked at in some detail?
22 A. I have examined ten patients.
23 Q. Have you prepared a report in relation to each patient?
24 A. On each patient, yes.
25 Q. Have you also prepared an overview report, having
5
1 completed your ten cases?
2 A. I have produced an overview report.
3 Q. We can perhaps look at one of your reports, just to see
4 what you were asked to do. If you could look at the
5 report, EXP00450001, this is the report that you have
6 carried out into the case of [Patient C].
7 If you turn to page 2 of the report, do you set out
8 there the terms of your instruction: namely, that you
9 were to focus on the medical case notes of the patient?
10 A. That is correct.
11 Q. Do you confirm in the second paragraph that you haven't
12 interviewed the patient, relatives or members of staff
13 in providing your opinion?
14 A. That's correct.
15 Q. Nor have you reviewed any statements or reviewed
16 transcripts of evidence?
17 A. That's correct.
18 Q. So essentially, as with the other nursing experts, you
19 have focused entirely on the patient records?
20 A. That is correct.
21 Q. In support of that, were you also provided with some
22 materials that were believed to be local policies
23 relevant at the relevant time?
24 A. I have looked at them as well; that's correct.
25 Q. Can I just ask you, have you ever been to the
6
1 Vale of Leven Hospital?
2 A. No, I haven't.
3 Q. Were you supplied with some information to give you some
4 sort of background as to what sort of hospital it was?
5 A. I think we've had fairly minimal information regarding
6 the hospital.
7 Q. One of the things I think you were given was the Junior
8 Doctors' Handbook; is that correct?
9 A. That's correct.
10 Q. If we look at that, GGC21720001, we see the first page
11 of that document on the right-hand side of the screen.
12 Did this at least give you an idea as to what size of
13 hospital you were looking at -- about 180 beds or so --
14 and what services might have been available there?
15 A. I did. That's correct.
16 Q. Apart from never having been to the
17 Vale of Leven Hospital, have you ever worked in
18 Scotland?
19 A. I haven't.
20 Q. Is it right to say that all registered nurses have to
21 register with the regulatory body, the
22 Nursing & Midwifery Council?
23 A. That is correct.
24 Q. Could you look, please, at INQ01970001. You will see
25 this is a document with the title "The NMC Code of
7
1 Professional Conduct: Standards for Conduct, Performance
2 and Ethics", and you will see this is the 2004 version.
3 Is this an important document to registered nurses?
4 A. Quite right: it is an extremely important document. It
5 is a document that every nurse registered at that time
6 would be familiar with.
7 Q. We have gone through it in detail before. There are
8 just a couple of points I want to take you to. If you
9 turn to page 3 of the document, looking to the
10 right-hand side, does the text set out there summarise
11 the standards expected of the registered nurse?
12 A. Yes, it does. It does summarise.
13 Q. As we see towards the very end, these are the shared
14 values of all the United Kingdom healthcare regulatory
15 bodies?
16 A. That's correct.
17 Q. The only other point I want to take you to in this
18 document, if you turn to page 4, if you look at
19 paragraph 1.4, you will see that that reads:
20 "You have a duty of care to your patients and
21 clients, who are entitled to receive safe and competent
22 care."
23 A. That's correct.
24 Q. Did you have that firmly in your mind when you were
25 looking at the medical records of the patients you
8
1 looked at?
2 A. I did. I had the whole of the NMC code of conduct in
3 mind when I was reviewing.
4 Q. Another document I want you to look at as a preliminary
5 is INQ02090001. You will see that this is an NMC
6 document relating to record keeping. Again, this is
7 a document that nurses are well aware of?
8 A. That's correct.
9 Q. Again, we have looked at this in detail, but if you turn
10 to page 4 of the document, this is something we have
11 looked at before, and the second main paragraph after
12 the bullet points, does it read:
13 "The approach to record keeping that courts of law
14 adopt tends to be that, if it is not recorded, it has
15 not been done."
16 Do you see that?
17 A. Yes, I do see that.
18 Q. Is that the approach that is taken?
19 A. I certainly think that is the approach that courts of
20 law adopt. I think it is quite reasonable to assume
21 that every element of contact between a nurse and
22 a patient, every interaction, cannot be documented.
23 So of course, in reality, the documentation can be
24 supported by nursing statements and nursing recollection
25 of events, et cetera. So the nursing records will never
9
1 contain every element of care between a nurse and
2 a patient, but that is quite right, that the courts of
3 law do adopt that if it has not been recorded, it has
4 not been done.
5 Q. Similarly, if we look to the first page of the document,
6 after the bullet points, the third sentence in that next
7 paragraph:
8 "Good record keeping is a mark of a skilled and safe
9 practitioner, while careless or incomplete record
10 keeping often highlights wider problems with that
11 individual's practice."
12 Is that within your experience?
13 A. That is within my experience.
14 Q. Looking to some of the other materials that you were
15 supplied with, were you also supplied with the infection
16 control manual that it was believed was in place at the
17 time we are concerned with?
18 A. I was, yes.
19 Q. If we could have, please, GGC00780001. I think we see
20 that is the first page of the manual, and if you could
21 turn to page 252, do we have on the board now the
22 C. diff policy that we see was effective
23 from October 2004?
24 A. Correct.
25 Q. Did you have regard to that document --
10
1 A. Yes, I did.
2 Q. -- in preparing your report?
3 A. I did.
4 Q. Could you look also, please, at page 258 of the manual.
5 You will see this is the loose stools policy. Again,
6 did you have regard to that when --
7 A. I did.
8 Q. -- you prepared your reports?
9 A. I did.
10 Q. Do these policies, the C. diff policy and the loose
11 stool policy, set out important principles relevant to
12 the management of diarrhoea and C. diff?
13 A. They do.
14 Q. For example, without looking at the detail, do they
15 envisage risk assessments being carried out by the
16 infection control team?
17 A. Correct.
18 Q. Care planning in respect of loose stools and C. diff?
19 A. Correct.
20 Q. And the recording of loose stools?
21 A. Correct.
22 Q. Is it important, from a nursing perspective, that there
23 is some response to unexplained diarrhoea?
24 A. Sorry, could you repeat that?
25 Q. Yes. Is it an important nursing matter that there is
11
1 some response to unexplained diarrhoea in a patient?
2 A. Clearly, yes, on two levels: one, because the
3 unexplained diarrhoea may be an infective diarrhoea,
4 which clearly could place the patient at risk and other
5 patients at risk if that infection was spread to other
6 patients; secondly, for that individual patient,
7 particularly if they are elderly, infirm, frail and
8 suffering with other underlying medical conditions, then
9 a significant episode of diarrhoea lasting for days or
10 more could compromise that patient really quite
11 severely, leading to quite serious consequences.
12 Q. I think there are two other policies I want you to look
13 at before we move on to the cases. If you look, please,
14 at GGC26540001. You will see this document is dated
15 21 December 2006. It is NHS Greater Glasgow and Clyde
16 Acute Services Division and it is the management of
17 inpatient falls.
18 Did you have regard to this document when you were
19 preparing your reports?
20 A. I did.
21 Q. The other document I want you to look at, at this stage,
22 is GGC26440001. We are looking to the right-hand side
23 of the screen, where there is a document headed
24 "Inverclyde pressure ulcer protocol".
25 If you move on to page 2, we see some reference to
12
1 the prevention and management of pressure sores. Again,
2 did you have some regard to this document when you were
3 preparing your report?
4 A. Yes, I did.
5 Q. Before we look at the first of your reports, can we just
6 clarify with you what your approach to the cases was,
7 and, in particular, to what extent you sought to address
8 what you had to say under reference to the skills you'd
9 expect of the registered nurse? Do you follow me?
10 A. I'm not quite sure, no.
11 Q. We have seen from your CV, although you have had
12 significant experience in working on wards, you're at
13 a higher level to the registered nurse on the ward. But
14 when you came to examine the records and say what you
15 had to say, did you seek to put yourself in the shoes of
16 the registered nurse on the ward?
17 A. Absolutely, yes, I did. I was reviewing the
18 documentation in light of a registered nurse whom you
19 would deem as competent; ie, they have fulfilled
20 a course of study, they have qualified and they are now
21 practising as a registered nurse, no more than that,
22 because the programme of preparation for registered
23 nurses allows them to undertake assessments and care
24 plans and provide safe, reasonable care. So that was
25 the basis on which I reviewed the cases.
13
1 Q. We will look at the cases in detail in a moment, but for
2 example, if you take something like fluid balance, did
3 your find in cases that fluid balance documentation was
4 inadequate for a number of reasons?
5 A. Yes. I found many examples of inadequate or poor fluid
6 balance recording, some of which one can understand.
7 For example, if a patient has incontinence or has even
8 diarrhoea, for example, it is often quite difficult to
9 get a very accurate record of output in those
10 circumstances.
11 However, in some circumstances, I was finding
12 numerous examples of where even basic fluid intake was
13 inadequate. Consequently, I have drawn some conclusions
14 about fluid balance recording. Some was reasonable,
15 some of which was clearly not reasonable from a nursing
16 perspective.
17 Q. Ultimately, if you are looking at this within the
18 context of the ward, where you may have a number of
19 nurses and a ward sister in charge, who would bear
20 ultimate responsibility, then, for the inadequacies of
21 the records?
22 A. Well, I think, in the first instance, there would be
23 a registered nurse assigned to looking after a cohort of
24 patients. At this stage, I'm well aware of
25 the development in Scotland surrounding the charge
14
1 nurses and how their roles have been changing.
2 Putting that to one side for a second, there will be
3 a registered nurse assigned for each patient on
4 a shift-by-shift basis. Sometimes it may be the same
5 nurse shift after shift and sometimes it will change.
6 Some of those fundamental elements of care may be
7 provided by a healthcare assistant, of course, but the
8 registered nurse would be checking at the end of each
9 shift, when she completes her final documentation, that
10 the fluid balance chart, for example, is completed to an
11 adequate standard. Otherwise, they would backtrack and
12 make sure that it was completed.
13 After the registered nurse, of course, ideally you
14 would have a nursing sister who would be overseeing the
15 quality of all patient care, but I'm aware of
16 the context of the work that's been happening in
17 Scotland.
18 Q. If we're looking at the position at the time in
19 2007/2008, would ultimately the supervision lie with the
20 ward sister or nurse in charge of the ward?
21 A. That would be routinely seen as the accountable person
22 on the ward, the ward sister. But a registered nurse on
23 a shift-by-shift basis would be ensuring such
24 documentation is completed adequately.
25 Q. If the registered nurse were, for whatever reason,
15
1 herself to be involved in completing the documentation
2 and not doing it properly, then it would be the sister
3 on the ward --
4 A. Quite right.
5 Q. -- who would carry out the supervisory duties?
6 A. Quite right.
7 Q. The first case I want you to look at then is the case of
8 [Patient C], who has been designated "Patient C" for the
9 purposes of the transcript. I think you already have
10 this report. I will give the number again: EXP00450001.
11 The relevant records are GGC26340001.
12 If I take you to page 3 of your report, Professor,
13 you set out towards the bottom of the page the medical
14 history leading to [Patient C]'s admission to the