1 Wednesday, 30 May 2012
2 (10.00 am)
3 MR MACAULAY: Good morning, my Lord. The next witness, and
4 this is a witness I would like to recall, is
5 Dr Linda Bagrade.
6 DR LINDA BAGRADE (affirmed)
7 Examination by MR MACAULAY
8 MR MACAULAY: Good morning, Dr Bagrade.
9 A. Good morning.
10 Q. I imagine you have been told the principal reason you
11 have been recalled to give evidence. Before I come to
12 that, there are two other points I want to explore with
13 you very briefly.
14 Just to remind us, you became infection control
15 doctor covering the Vale of Leven Hospital
16 in February 2008; is that correct?
17 A. Yes.
18 Q. Was that from 1 February?
19 A. I think that was the first Monday of February -- maybe
20 the 4th.
21 Q. 4 February?
22 A. Yes.
23 Q. Just to confirm the hospitals that you were responsible
24 for once you took up that particular post as infection
25 control doctor, which hospitals were you responsible
1
1 for?
2 A. That was Royal Alexandra Hospital and
3 Vale of Leven Hospital initially, and then Dr Biggs
4 wanted to keep responsibility for infection control for
5 Inverclyde Hospital, and she gave up this responsibility
6 sometime later in the year, but I can't remember exactly
7 when that was -- June/July.
8 Q. At that point in time, then, did you become responsible
9 as infection control doctor for the three hospitals?
10 A. Yes.
11 Q. Just to be clear, that was the position that Dr Biggs
12 herself had prior to you taking up your position?
13 A. Yes. She was responsible for all three hospitals in
14 Clyde.
15 Q. The other point I want to ask you about -- this is
16 something that came out of the evidence from Mr Ahmed
17 yesterday relating to the Royal Alexandra Hospital;
18 I don't know if you can help us or not -- there was some
19 discussion in connection with ward 7, which was referred
20 to in one of the minutes. Is ward 7 a care of
21 the elderly ward, or not, or can you tell me?
22 A. The numbers of the wards have changed since, and I can't
23 really remember, but I think it was care of the elderly,
24 but I can't be 100 per cent sure about that.
25 Q. The main reason, as I indicated, that you have been
2
1 called back, Dr Bagrade, is so I can put to you some of
2 the evidence that was given to the Inquiry by Mr Mallon.
3 Mr Mallon, just to remind you, was the chief biomedical
4 scientist at the Royal Alexandra Hospital certainly up
5 until September 2009, I think. But he was primarily the
6 IT manager.
7 A. Yes.
8 Q. Did you know Mr Mallon?
9 A. Yes.
10 Q. He gave evidence in connection with the reports that
11 were produced at the Royal Alexandra Hospital for onward
12 transmission to Health Protection Scotland. You're
13 aware of that?
14 A. Yes.
15 Q. Have you seen his evidence?
16 A. Yes, I read the transcript.
17 Q. Just to remind you of the nature of these reports, if
18 I can put one of these on the screen, it is GGC29720006.
19 We are looking at a weekly report that was sent by
20 Mr Kinloch from the Vale of Leven Hospital to HPS, and
21 this is for the week ending 25 January 2008. Do you see
22 that?
23 A. Yes.
24 Q. That would have predated your appointment?
25 A. Yes. I was already at that time doing microbiology, but
3
1 I wasn't infection control doctor.
2 Q. He said, first of all, that on a weekly basis, usually
3 on the Friday, two reports would be printed out for the
4 Vale of Leven and Vale Highland, I think is how he put
5 it.
6 A. Yes.
7 Q. Ultimately, including the Royal Alexandra Hospital,
8 there would be four reports produced.
9 A. Yes.
10 Q. His understanding was that these reports went to the
11 microbiologist's office and the microbiologist looked
12 through them. That is what he understood and that is
13 what he said in evidence. Indeed, he said at one
14 point -- the way he put it was that "We put them to the
15 microbiologists so that they had sight, not just of what
16 was happening at the Royal Alexandra Hospital, but what
17 was happening at the Vale of Leven Hospital". Do you
18 remember reading that in his transcript?
19 A. Yes.
20 Q. Just to perhaps complete the picture, he said that in
21 early February 2008 there was an electronic system
22 introduced which was used to transmit the information to
23 the HPS, and that was the ECOSS system, which we
24 understand means Electronic Communication of
25 Surveillance Scotland system?
4
1 A. Mmm-hmm.
2 Q. Notwithstanding that, these reports continued to be sent
3 to the microbiologists?
4 A. That's correct, yes.
5 Q. At one point, he said that he understood that they were
6 being sent to the consultant so that the consultant
7 could look at them and have a clinical view of them;
8 that's what he said at one point in his evidence.
9 Under reference to some questions put to him by
10 his Lordship, his Lordship asked him:
11 "Lord MacLean: Each of these reports should have
12 been seen by a microbiologist?
13 "Answer: Yes.
14 "Lord MacLean: Which is the object of putting them
15 on the desk?
16 "Answer: Yes."
17 Can you perhaps, under reference to what I have put
18 to you, explain your position, what your understanding
19 of the position was?
20 A. Well, I don't remember signing Vale of Leven reports.
21 I definitely remember signing reports for
22 Royal Alexandra Hospital, for Greater Glasgow and Clyde
23 area and for Highlands, but not particularly
24 Vale of Leven reports.
25 I understand that the agreement for these reports to
5
1 be signed was put in place before I joined
2 Greater Glasgow and Clyde, because Dr Weinhardt was the
3 head of department, but all clinical work was done by
4 consultants based in Inverclyde Hospital.
5 So Vale of Leven reports were going to
6 Charlie Kinloch for checking, and I don't really know
7 what was the agreement before I joined -- that was done
8 before I joined Greater Glasgow and Clyde -- who would
9 sign these reports. I understand that Charlie Kinloch
10 was signing these reports. Because there is not really
11 a requirement in any of the official documents from HPS
12 for consultant microbiologists to sign these reports
13 and, when they are reported electronically, there is
14 nobody to sign these reports because it's an electronic
15 record of the isolates isolated in the lab. So I am not
16 aware that there is any requirement specifically for
17 a consultant microbiologist to sign these reports.
18 The arrangement, when I joined -- when I started my
19 work in Clyde was that we are signing reports for
20 Royal Alexandra Hospital for both areas, Greater Glasgow
21 and Clyde area and Highland area.
22 Q. You are focusing there on the signing of reports, and
23 that, in a sense, is perhaps not the issue. First of
24 all, in relation to the Royal Alexandra Hospital
25 reports, which you say you did sign --
6
1 A. Yes.
2 Q. -- do I take it that you would have looked at the
3 reports?
4 A. Well, obviously, yes.
5 Q. Why were you signing the reports?
6 A. Well, I suppose the signature shows that somebody has
7 seen these reports in the lab and this is an accurate
8 reflection of what has been isolated for that particular
9 week in our lab. So, basically, that means that
10 somebody has seen and it is agreed that this is an
11 accurate reflection of the true situation.
12 Q. First of all, is it the case, as Mr Mallon said, that
13 the Vale of Leven reports were also sent to the
14 microbiologist, along with the Royal Alexandra reports?
15 A. I don't remember seeing them. What usually happened --
16 and that's my recollection, that these reports were
17 taken to the office and usually secretaries brought them
18 to our office, those copies which needed to be signed by
19 us, and my understanding is that they were separated at
20 the office: Vale of Leven copies were sent to
21 Charlie Kinloch at the Vale of Leven and RAH ones came
22 to us for signing.
23 Q. Are you saying, then, that the separation was carried
24 out by a secretary?
25 A. Well, I don't think there was exact protocol how to do
7
1 this. Sometimes it was brought in by John Mallon or
2 somebody else to the office, but most of the times -- at
3 least most of the times when I was signing these reports
4 they were brought in by a secretary.
5 Q. Certainly Mr Mallon said that he, himself --
6 A. Sometimes he did, yes.
7 Q. -- would bring in the reports and put them on the desk?
8 A. Sometimes I'd just come to my office and find them on my
9 desk, so I can't really tell you who exactly brought
10 them in.
11 Q. Are you saying that when you went to look at these
12 reports, the Vale of Leven reports were not there in the
13 bundle?
14 A. I don't remember seeing them.
15 Q. If we focus on the period when you became infection
16 control doctor, I assume, at least from the perspective
17 of infection prevention and control, you would have
18 a particular interest in what was happening in the
19 Vale of Leven?
20 A. Yes, but these reports were not the only way to find out
21 what's happening. The same information was reported to
22 infection control teams on a daily basis, so the
23 infection control team would have known about these
24 reports.
25 This Friday report, basically, it was never
8
1 designed, or it wasn't used as a surveillance tool. It
2 was basically a reflection of what has happened in the
3 lab for that particular week and what are we reporting
4 to Health Protection Scotland.
5 So it was never, ever designed to be a surveillance
6 tool. That would be just one of the many ways to find
7 out how many C. diff isolates have been isolated for
8 that week. But it wouldn't be the main document where
9 I or anybody else would see the numbers or the
10 information about the C. diff isolates.
11 Q. As you have just said, it would be one of the ways in
12 which you could see how many C. diff cases there had
13 been in a particular ward in that week?
14 A. If I was seeing these reports. The arrangement was that
15 the consultant who is covering hospitals,
16 Royal Alexandra and Vale of Leven Hospitals, on Friday
17 for that week would see these reports and sign them. So
18 not all consultants would see those reports.
19 So if I am not rotad on Friday to do hospital work,
20 I wouldn't see those reports. So for me to say that
21 this was the way to see how many C. diffs are isolated
22 for that particular week, I would need to see them
23 regularly, every week, and do some analysis on those
24 data, or something like that, but these reports were not
25 designed -- not ever used for that reason.
9
1 MR PEOPLES: My Lord, I wonder if I could ask the witness to
2 clarify an earlier answer? She's explained the purpose
3 of the reports and what they were designed to do. She
4 also said the same information was reported to the
5 infection control team on a daily basis. If she was
6 a member of the team from the Vale of Leven, do we take
7 it that she would have the information on a daily basis
8 after she became the doctor for that hospital?
9 A. No, I wouldn't. This information was reported to the
10 infection control nurses.
11 LORD MACLEAN: So it did go to them?
12 A. I wouldn't be told about every single isolate --
13 LORD MACLEAN: No, I didn't ask you that. The information
14 would go to them, would it, the infection control
15 nurses?
16 A. Yes.
17 LORD MACLEAN: The question that occurs to me to ask is
18 this: before you became infection control doctor and you
19 were attached to the RAH as a microbiologist, looking at
20 that period, it is relatively short, isn't it?
21 A. It is a week or two weeks, yes.
22 LORD MACLEAN: That is all, isn't it?
23 A. Mmm-hmm.
24 LORD MACLEAN: So what did actually happen to the reports
25 for the Vale of Leven Hospital? Who saw them?
10
1 A. Obviously, when they were printed out at the RAH, then
2 they went to the office for secretaries to send them to
3 Charlie Kinloch, to Vale of Leven.
4 LORD MACLEAN: So did anyone actually look at the
5 Vale of Leven reports before they went to the lab and
6 Mr Kinloch?
7 A. I don't think so.
8 MR MACAULAY: If you looked at an RAH report, which you say
9 you did, and you would sign it before it was sent to
10 HPS, and you saw in a particular ward in the RAH there
11 were a number of C. diff cases, would you do anything
12 about that?
13 A. Well, all work would already be done. When I see these
14 reports, what I am looking for is if I know about these
15 isolates -- for example, if I know these blood cultures,
16 if I know these C. diffs, MRSAs. So it's basically,
17 like, a summary of the week, what has happened and, for
18 me, I would already know about these isolates when they
19 become positive on that day.
20 So I'm just looking if there is any surprise or
21 anything we didn't know or anything has been missed, but
22 we already would know about these isolates as soon as
23 they become positive and all work that's necessary
24 already would be done.
25 Q. What about the Vale of Leven, particularly when you
11
1 became infection control doctor? As I understood your
2 evidence earlier, you were not aware of there being
3 a problem with C. difficile in the Vale of Leven
4 until April or May 2008; is that correct?
5 A. Yes.
6 Q. In light of what you say, that you would know about what
7 was in the Royal Alexandra Hospital and about these
8 isolates before you saw the report, why wouldn't you
9 know what was happening in the Vale of Leven Hospital?
10 A. Because -- we would know about these isolates.
11 Infection control -- not necessarily myself, but the
12 infection control team would know about these isolates
13 and the work that's necessary would already be done.
14 I wasn't informed about the numbers of these
15 isolates, but the infection control team knew about
16 these patients. As you can see from the T Cards, they
17 were aware that these patients are in the ward and
18 infection control issues were being sorted out.
19 Q. If you had looked at the Vale of Leven reports in the
20 period after you became infection control doctor, and
21 you did see that in a week there were three or possibly
22 more cases in a particular ward, would you have done
23 anything about that?
24 A. Well, obviously we would investigate what's going on,
25 what's happening.
12
1 Q. It would be in the context of not having been told by
2 the infection control nurse; is that correct?
3 A. Yes. But we have to remember as well that the location
4 which is on this report is the location where the sample
5 has been taken, and sometimes it's not the ward or the
6 area where these patients actually are.
7 Q. Do I take it, notwithstanding that qualification, that
8 you would investigate to see what the situation was if
9 you had become aware under reference to the reports
10 there may have been three patients in a ward?
11 A. Yes. Absolutely, yes.
12 Q. The investigation would involve what?
13 A. Well, that really depends what the situation is. We
14 would definitely investigate, who are these patients, is
15 this hospital-acquired infection or is this
16 community-acquired infection, is there acute -- active
17 transmission, ongoing transmission, at this moment, do
18 we need to close the ward, can we isolate the patients,
19 do we need to call an outbreak meeting, and so on and so
20 on. So that would trigger a lot of work and a lot of
21 investigations.
22 Q. So an examination of these reports, and I appreciate
23 what you are saying is you didn't look at them, but an
24 examination of these reports could very likely, then,
25 have set in motion that sort of investigation?
13
1 A. Well, obviously, if you see that there are three or more
2 patients, especially in one particular area, we would
3 look at them, yes.
4 LORD MACLEAN: Let me just make sure I understand your roles
5 at the Vale of Leven Hospital. You took up post as
6 a consultant microbiologist there --
7 A. Yes.
8 LORD MACLEAN: -- on 4 February 2008?
9 A. Yes. That was the middle of January. It could have
10 been 21 January I became the microbiologist for Clyde.
11 LORD MACLEAN: I think you mentioned 4 February earlier?
12 A. That was infection control doctor duties.
13 LORD MACLEAN: Oh, was it?
14 A. Yes. So initially, I started my work as a medical
15 microbiologist responsible for the Royal Alexandra
16 Hospital and the Vale of Leven Hospital, and then
17 I think it was on 4 February I became the infection
18 control doctor.
19 LORD MACLEAN: And you remained infection control doctor
20 thereafter?
21 A. Yes.
22 LORD MACLEAN: And you still are, actually?
23 A. I still am, yes.
24 LORD MACLEAN: So if I have got it right now, that is that
25 you were appointed as consultant microbiologist in Clyde
14
1 and you were attached to the Royal Alexandra and the
2 Vale of Leven Hospitals?
3 A. Yes.
4 LORD MACLEAN: Then, a short time after that, namely, on
5 4 February 2008, you were appointed infection control
6 doctor?
7 A. Yes.
8 LORD MACLEAN: Thank you.
9 MR MACAULAY: Just so I can understand the full position,
10 once you were infection control doctor for the
11 Vale of Leven, you continued to look at the figures for
12 the Royal Alexandra Hospital; is that correct?
13 A. Figures, you mean these Friday reports?
14 Q. The reports, yes.
15 A. Yes.
16 Q. Although you were the infection control doctor for the
17 Vale of Leven, you never looked at the reports for the
18 Vale of Leven Hospital?
19 A. No, because they were not designed to be a surveillance
20 tool. That was just a reflection what has happened for
21 that week in the lab and what exactly we are reporting
22 to Health Protection Scotland. So, for us, it was more
23 or less to make sure that this report makes sense, that
24 there are no silly mistakes, for example, some mistakes
25 in the names of bacteria or somebody reported twice, or
15
1 something like that. We needed to make sure that this