1 Wednesday, 2 November 2011
2 (10.00 am)
3 MR MACAULAY: Good morning, my Lord. Before I call my next
4 witness, can I just draw your Lordship's attention to
5 the fact that Mr Wood appears for the Medical Protection
6 Society on behalf of Dr Akhter.
7 My Lord, my next witness is Henry John Woodford.
8 DR HENRY JOHN WOODFORD (sworn)
9 Examination by MR MACAULAY
10 MR MACAULAY: Are you Henry John Woodford?
11 A. I am.
12 Q. Could you tell the Inquiry what position you hold at
13 present?
14 A. I'm a consultant physician who specialises in geriatrics
15 with a subspecialty interest in stroke at
16 Cumberland Infirmary in Carlisle.
17 Q. It is very important that you speak quite slowly, so
18 that the transcribers can hear what you say, and I think
19 we may also have to adjust the microphone.
20 A. Sorry.
21 Q. If I could ask you to have your CV in front of you and
22 put on the screen, it is at INQ02740001. Can we see
23 that you obtained your medical qualification, Bachelor
24 of Medicine, Bachelor of Surgery, at King's College,
25 London, in 1996?
1
1 A. That's correct.
2 Q. As part of that, you also had an intercalated BSc
3 degree; is that right?
4 A. That's right.
5 Q. I think we see, if we read on, that you became a Fellow
6 of the RoyalCollege of Physicians in July 2010.
7 A. That's correct.
8 Q. If we go on to page 2 of the CV, starting at page 3, in
9 fact, working backwards, do you set out, beginning
10 in August 1996, your employment history?
11 A. Yes, that's when I started as a junior doctor, yes.
12 Q. If we move on, then, to page 2, to look at the more
13 recent employment history, can we see that,
14 from February 2006 to July 2006, you were a specialist
15 registrar in geriatric and general medicine at
16 Cumberland Infirmary in Carlisle?
17 A. Yes.
18 Q. When, then, did you take up your current position?
19 A. I started acting up as a consultant from July 2006, and
20 then became a formal substantive post when I obtained my
21 certificate of completion of specialist training
22 in October 2006. So, pretty much, I've been doing the
23 same job since July 2006.
24 Q. That's at Cumberland Infirmary in Carlisle?
25 A. That's correct.
2
1 Q. What sort of hospital is that? Can you give us a feel
2 for --
3 A. It's a district general hospital in a mixed sort of
4 urban and rural population. It has slightly more
5 subspecialty interests than most district generals,
6 because it's fairly isolated, so it has some things like
7 dermatology, neurology, cancer treatment, the type of --
8 renal dialysis, that you don't have in every DGH, but
9 essentially it is a district general hospital.
10 Q. Can you give us a feel for the size of the hospital?
11 How many beds, would you say?
12 A. I'm sorry, I don't have the figure off the top of my
13 head. There's approximately 100 medical beds in total.
14 There must be, at a guess, about 200 beds in the
15 hospital.
16 Q. So quite a small hospital?
17 A. It serves a population of about 220,000.
18 LORD MACLEAN: There is another hospital in Carlisle, isn't
19 there? Isn't there?
20 A. Not another in Carlisle. There is another in north
21 Cumbria. There is one in Whitehaven. Is that what you
22 mean?
23 LORD MACLEAN: No, it is the infirmary I'm thinking of. You
24 are talking about the hospital which is in Carlisle?
25 A. That's right.
3
1 LORD MACLEAN: I'm only saying that because I have been
2 there. I have visited it, so I know it.
3 A. Are you saying there is another hospital?
4 LORD MACLEAN: No. We keep on being at odds with each
5 other. There is only one, and that is the one you were
6 talking about?
7 A. Yes.
8 MR MACAULAY: Can we go back to page 1 of the document and
9 look briefly at your publications and perhaps focus on
10 the first reference there to a book with the title
11 "Essential Geriatrics". Is that a textbook?
12 A. It is.
13 Q. Can we see it is now in its second edition; is that
14 correct?
15 A. It is.
16 Q. For whose benefit is the textbook?
17 A. It was mainly written to target specialist registrars in
18 geriatrics, but hopefully it has some wider appeal.
19 Q. We can look for ourselves at the other references you
20 give us on page 1. On page 2, if we look at page 2, the
21 first entry, you make reference to the NICE guidelines
22 on urinary incontinence in women. Was that some input
23 you had into that particular aspect of the guidelines?
24 A. No, that was just a letter in response to them.
25 A synopsis of it was I didn't think they well
4
1 represented the needs of elderly people.
2 Q. So you were giving them some views on that?
3 A. If you like, yes.
4 Q. The penultimate reference, "Diagnosis and management of
5 urinary tract infection in hospitalised older people",
6 was that an article or what sort of publication?
7 A. Yes, that's right. It was based on a review of people
8 with a diagnosis of urinary tract infection within our
9 trust.
10 Q. Finally, if we look at page 4 of the CV, do you tell us
11 that you also have some teaching commitments?
12 A. Yes. This CV is now a year old, and, you know,
13 I probably would word it slightly differently, depending
14 on the audience the CV is for. I think that is the way
15 people play their CV, isn't it? I have since then
16 become the training programme director for geriatrics in
17 the Northern Deanery in England.
18 Q. Moving on, then, to look at your involvement in this
19 Inquiry, have you looked at the case records of
20 17 patients who attended the Vale of Leven Hospital
21 between 2007 and 2008?
22 A. Yes, I believe that's correct.
23 Q. I think you have prepared reports in relation to each of
24 these?
25 A. Yes, I have.
5
1 Q. I think you have also prepared an overview report
2 summarising what you saw to be the position in relation
3 to the cases you looked at?
4 A. Yes.
5 Q. In relation to the way you approach your task, was your
6 primary focus on the medical records of the patients
7 that you were provided with by the Inquiry team?
8 A. Yes, of course, yes.
9 Q. In particular, you weren't asked to look at statements
10 by members of the families --
11 A. No.
12 Q. -- or, indeed, any of those who might have been working
13 in the Vale of Leven at the relevant time?
14 A. No.
15 Q. But I think you were provided with other materials, and,
16 in particular, material relating to what the prescribing
17 policies might have been at the relevant time?
18 A. I was.
19 Q. I think also you may have had some materials provided to
20 you in relation to matters such as infection control?
21 A. Yes.
22 Q. Insofar as the Vale of Leven Hospital is concerned, have
23 you ever worked there?
24 A. No.
25 Q. Have you ever been to the Vale of Leven Hospital?
6
1 A. No.
2 Q. But were you provided with an introductory booklet that
3 would give you some information as to the nature of
4 the hospital?
5 A. There was the handbook for junior doctors from 2007 and
6 2008, I believe, within all the information provided by
7 the Inquiry.
8 Q. Perhaps if we can look at that, then, it is at
9 GGC21720001. Is this one of the documents that you
10 looked at to try to develop some sort of insight into
11 the nature of the hospital? We have it on the screen.
12 A. I can't really tell from just that one page, but
13 I presume so. Yes, it was.
14 Q. As we see, then, the information that you have been
15 provided with at the time was that there were
16 approximately 180 patient beds on site, and you were
17 given some information about the services provided; is
18 that correct?
19 A. Yes.
20 Q. Were you able to compare and contrast the Vale of Leven
21 in any way with your own hospital -- size and services?
22 A. Yes, it is obviously quite a lot smaller. I might have
23 been inaccurate with my judgment of 200 beds. We have
24 perhaps got slightly more. There seem to be six medical
25 consultants at the Vale of Leven, whereas there would be
7
1 approximately 25, if you include specialties such as
2 cancer therapy, and so on, at my hospital. So four
3 times as many medical consultants.
4 Q. If we look at page 3 of this document -- we now have it
5 on the screen -- can we see that a number of consultants
6 is listed there?
7 A. Yes.
8 Q. For example, Dr Carmichael, Dr McCruden and
9 Dr Al-Shamma. Do you see that?
10 A. Yes.
11 Q. Were these names that you came across in the medical
12 records that you looked at?
13 A. Yes.
14 Q. Similarly, if you on to page 4, there is reference to
15 Dr Johnston and Dr Akhter. Again, did you come across
16 these names in the course of your examination of
17 the records?
18 A. I did, yes.
19 Q. I think you understand that you were supposed to be the
20 first witness to give evidence in relation to geriatric
21 matters last week in particular, but because we ran out
22 of time, you weren't able to come and do that, but
23 I think you had prepared an introductory presentation on
24 elderly medicine with a view to presenting that to us,
25 to give us some general insight into that area of
8
1 medicine; is that correct?
2 A. That's correct.
3 Q. Before we look at it, can you just give us some insight
4 as to what it tells us?
5 A. Well, my brief was to give a sort of introduction into
6 elderly medicine, much like we do to sort of doctors
7 arriving to our unit, so it is a little bit of
8 a background about ageing and some of the aspects of
9 care of older people that are a bit different to caring
10 for people of different ages.
11 Q. I think it is a fairly short presentation?
12 A. It is, yes.
13 Q. Perhaps we could get you to simply go through that for
14 us. I might interrupt you from time to time, but
15 I think we can do it on the screen, and I think you can
16 organise that from where you are over there; is that
17 right?
18 A. I think so.
19 Q. Technology allows that.
20 A. We will soon see.
21 Q. Just proceed, then.
22 A. Briefly, the aims were to sort of define old age, talk
23 a bit about geriatric medicine, talk a bit about the
24 hazards of hospitalisation, aspects of infection in the
25 old -- obviously, we are most concerned with Clostridium
9
1 difficile today; a little bit about medical doctors and
2 what constitutes good medical practice.
3 Q. Again, if I could ask you to slow down a little bit so
4 we can make sure we get everything transcribed.
5 A. I would like to start with a quote:
6 "What do you want to treat all those old people for?
7 Everyone has to die sometime."
8 Perhaps it is notable just because the chap,
9 Edward Tallis, was the father of Raymond Tallis, who was
10 a Professor of Geriatric Medicine at Manchester. It is
11 true, life is 100 per cent fatal. Does that make all
12 medicine futile? I think not. We can lengthen life,
13 but also shorten suffering. The population is getting
14 older. We are not just seeing that we're having longer
15 periods of people living with disability, but longer
16 periods of healthy life and, you know, we see reduced
17 rates of age-adjusted disability in the population.
18 Old age is a pretty new thing. Life expectancy in
19 Britain, we only have to go back just over 100 years, it
20 was just 46 in the census in the 1880s, but a lot of
21 people died because of infectious diseases and it is
22 still ongoing in many parts of the third world:
23 Sierra Leone and Malawi. If you believe the press, in
24 some parts of Glasgow, people don't live that long.
25 But, overall, life expectancy has been gradually
10
1 increasing, and this is a sort of linear increase that
2 is showing no signs of slowing down. Approximately
3 a quarter of a year, every year, the national average
4 age increases.
5 The oldest person who has lived that we know of
6 worldwide was a lady called Jeanne Louise Calment,
7 a French lady who lived to over 122 years.
8 Old people are often seen in a fairly negative light
9 in the media, and so on, but a lot of cultures consider
10 elderly people to be the elders of the tribe. In
11 Vanuatu, the older people are considered the most
12 important people that you go to for advice. There are
13 examples of people who are still considered worthwhile
14 and, some would say, attractive members of society.
15 I must say, Sean Connery now 81, Brucie, still on the
16 TV, aged 83.
17 Q. I understand he puts his good health down to three
18 portions of broccoli a day. I don't know whether that
19 would help or not.
20 A. Worth a try, maybe. If you want to turn out like
21 Brucie, obviously. Nelson Mandela, I think that picture
22 is a little bit old. He looks more frail these days,
23 but, still, at 93, considered a very respectable
24 international statesperson.
25 So what is ageing? It is defined by a biologist
11
1 John Maynard Smith as "A progressive, generalised
2 impairment of function resulting in an increased
3 probability of death". We all see that as having
4 aspects that are both chronological, the years on the
5 clock, and biological. A sort of tough paper-round
6 scenario.
7 There are obvious changes, as all of us get older.
8 Our hair tends to go grey, we tend to lose our teeth,
9 our skin becomes more wrinkled, we lose senses: hearing,
10 smell, taste, and so on.
11 What makes a patient elderly? Is there a specific
12 age from which we go from being youthful to becoming
13 old? Obviously not. Traditionally, people used to look
14 at the age of over 65, which used to be the common
15 retirement age, but more recently we think of elderly
16 people really beyond 75.
17 Is it specific illnesses? Well, sometimes. Someone
18 who is a bit younger with dementia may be more like an
19 elderly person than an otherwise healthy 70-year-old.
20 A lot relates to functional ability. Nursing home
21 residents would tend to be classified as elderly, even
22 if they were a bit younger than someone who was
23 independent in the community. It is probably
24 a combination of all of those things.
25 A lot of age-related diseases, things that, if we
12
1 all live old enough, we probably would all develop:
2 osteoporosis, thinning of the bones, hypertension,
3 Alzheimer's disease, ischaemic heart disease, diabetes,
4 most cancers, almost everything outside postnatal
5 depression and mumps.
6 Alzheimer's disease is a classic example: virtually
7 no-one below the age of 60 has Alzheimer's disease,
8 fortunately. It almost exponentially rises to about
9 a third of people over the age of 90. If you want to
10 put a more positive spin on it, if you do live to the
11 age of 90, you have only a one in three chance you'll
12 have Alzheimer's disease.
13 "Frailty" is a term we often attached to older
14 people. Homeostasis is a normal physiological mechanism
15 by which we maintain our body parameters -- things like
16 blood pressure, body temperature, intracellular fluid
17 composition -- and we invest a lot of energy in doing
18 this, it is a very difficult process for our bodies to
19 maintain. But, as we get older, we just get less good
20 at that and our ability to compensate against insults
21 becomes impaired, so a more minor nudge from pathology
22 can knock the elderly off their perch, where it may have
23 a much lesser effect on a younger person.
24 Coupled to this concept of frailty is the loss of
25 muscle mass. The Greek term "sarcopenia", "poverty of
13
1 flesh". This results in a reduction of strength, slow
2 walking speed, tendency to fatigue.
3 Why do we age? Is it genetically programmed? Do
4 our cells die off? Well, animals don't age in the wild.
5 They die of predation, starvation, accidents.
6 Therefore, it is not an evolutionary mechanism, it
7 hasn't evolved. In no species that has ever been
8 studied by biology have we found a genetic mutation that
9 has resulted in the absence of ageing, so it doesn't
10 seem to be something encoded by genes.
11 The most plausible theory at the moment is the
12 disposable soma theory based on the fact animals don't
13 age in the wild, so you don't need to spend a lot of
14 energy maintaining a body that is going to ultimately
15 die of predation, starvation and accidents. It is
16 better to invest more energy in having offspring, so
17 ageing is really a compromise for the use of our energy
18 resources; they are not vesting too much in repairing
19 our body, investing more in producing more offspring.
20 The term "geriatric" is a term that some people
21 consider quite derogatory. It is not meant to be. It
22 is based on the Greek term "geron" for "old man" and
23 "iatros" for "healer", so it really stands for healer of
24 old men. So, in a geriatric doctor/patient
25 relationship, I'm really the geriatric one. It is
14
1 a young specialty really thought to be founded by
2 a doctor called Marjorie Warren in London in the 1940s.
3 She found a lot of elderly patients on long-term care
4 wards actually had treatable conditions and, if they
5 were given the right environment and the right
6 treatment, they could actually improve.
7 There are lots of difficulties in elderly medicine
8 that set it out from other general medicine: atypical
9 disease presentations, multiple co-morbidities because
10 of age-related diseases, polypharmacy really is
11 a knock-on from having lots of co-morbidities, adverse
12 drug reactions, complex social issues and a lack of
13 evidence.
14 Old people do present in some situations different
15 to younger people, and there are four things termed the
16 "geriatric giants" which are common pathways that old
17 people present: immobility, instability or falling over,
18 incontinence and intellectual impairment or confusion.
19 Where a young person with a chest infection may have
20 pleuritic chest pain, coughing up some sputum, a high
21 temperature, an old person with a chest infection may
22 present to healthcare by falling over.
23 Drug trials usually exclude older people, often for
24 good reasons. Drug companies want to look at a pure
25 sample of people that just have one illness so they can
15
1 test their drug in isolation, but this is, you know, to
2 say, well, there is no evidence for treating older
3 people may be to unfairly deny them access to treatments
4 that may work just as well, if not better. A lot of
5 people are on inappropriate medicines, ones that are
6 known to have unacceptable side effects where more
7 suitable alternatives exist.
8 Pharmacokinetics is a term for the way that the body
9 handles a drug. As we get older, the proportion of
10 different tissues in our body changes. We tend to have
11 more fat and less water, less muscle mass. We have
12 a liver mass that is involved in metabolising the drugs
13 and less renal blood flow, less excretion of drugs
14 through our kidneys.
15 People tend to accumulate a lot of drugs as they get
16 older and adverse drug reactions get more common. The