1 Tuesday, 17 January 2012
2 (10.00 am)
3 DR JAVED AKHTER (continued)
4 Examination by MR MACAULAY (continued)
5 MR MACAULAY: Good morning, Dr Akhter. I propose in
6 a moment to look at some of the cases that you had some
7 involvement with over the relevant period. Before I do
8 that, I just want to raise two points with you.
9 If I can put on the screen this document,
10 INQ00270001, you are looking at a document produced --
11 it is "Guidance for Doctors" produced by the General
12 Medical Council, and it is said to be good medical
13 practice. Would this be something that you were aware
14 of in 2007/2008?
15 A. Yes.
16 Q. If we turn to page 3 of the document, can we see that
17 this particular version came into effect on
18 13 November 2006?
19 A. Yes.
20 Q. If we turn to page 9, there is a section here headed
21 "Providing good clinical care", and can we read here:
22 "Good clinical care must include.
23 "(a) adequately assessing the patient's conditions,
24 taking account of the history (including the symptoms,
25 and psychological and social factors), the patient's
1
1 views and, where necessary, examining the patient."
2 And we see some further advice. Was that advice
3 that you were aware of at the time?
4 A. Yes.
5 Q. On page 10, can we see here that there is some further
6 guidance given, and at (f), we can read that in
7 providing care you must:
8 "... keep clear, accurate and legible records,
9 reporting the relevant clinical findings, the decisions
10 made, the information given to patients, and any drugs
11 prescribed or other investigation or treatment."
12 Again, were you aware of that advice?
13 A. Yes.
14 Q. Perhaps finally, in relation to this particular
15 document, on page 11, at section 6 there is a section
16 dealing with raising concerns about patient safety, and
17 can we read there:
18 "If you have good reason to think that patient
19 safety is or may be seriously compromised by inadequate
20 premises, equipment, or other resources, policies or
21 systems, you should put the matter right if that is
22 possible. In all other cases, you should draw the
23 matter to the attention of your employing or contracting
24 body."
25 Just looking to what you said to us yesterday,
2
1 Dr Akhter, did you consider, particularly if you focus
2 on the weekend periods, that there were adequate
3 resources in the Vale of Leven Hospital for managing all
4 the patients that would be there at that time?
5 A. I think from the medical cover, from the junior doctor
6 point of view, I probably thought not, and, as I said,
7 I raised that concern to my lead physician, but I don't
8 feel that that has put the patient in danger, because,
9 although there was not enough support, the junior
10 doctors have full authority to contact the senior doctor
11 and then they can contact the consultants even and, if
12 the need arises, then the consultants need to come to
13 the hospital to see those patients and help all the
14 juniors, so ...
15 Q. I think you told us yesterday that the lead physician
16 was Dr McCruden?
17 A. Yes.
18 Q. Did you expect that Dr McCruden would take the matter
19 further?
20 A. Yes.
21 Q. Did you get any further feedback from Dr McCruden as to
22 whether or not he did?
23 A. There was concern from the other physicians as well, who
24 were doing oncalls on the weekend, but, again, we were
25 told that these are the doctors numbers and we cannot
3
1 have more and we have to arrange our rota according to
2 the number of the doctors provided.
3 Q. Who told you that?
4 A. That was Dr McCruden.
5 Q. So that is what he reported back to you, was it?
6 A. Yes.
7 Q. Can I then move on to look at some patients' records
8 with you? I want to begin with the records of
9 the patient [Patient C]. The medical records are at
10 GGC26340001. Perhaps just before we look at the records
11 in detail, I understand, in fact, from yesterday --
12 I have been informed there is a point you want to
13 clarify in connection with the use of curtains in the
14 context of isolation?
15 A. Yes.
16 Q. What is the point you would like to make?
17 A. Maybe there was a slight confusion from my part. It was
18 a bit late in the afternoon, and I get confused, but
19 I was thinking of doing my ward round of the new
20 patients on the medical ward, and there are -- you asked
21 me whether somebody with a loose motion and diarrhoea
22 should always be kept in a side room, so my answer was
23 yes, but I was also thinking of the patients who are
24 transferred from the other hospitals to our hospital and
25 they did not have diarrhoea and they had no other
4
1 illness, but because they are from other hospital, we
2 need -- the policy was to keep them in the side room as
3 well and screen them for MRSA, although they are not
4 suffering from the disease, but it is the policy to
5 screen them first.
6 If those patients have no side room, then they can
7 be kept isolated around their bed, so they do not have
8 any symptoms of diarrhoea, they do not have any other
9 symptoms. They may have come to our hospital for
10 different reason, but because they are new to our
11 hospital, they are kept in a side room initially for
12 24 hours until we have screened them for MRSA, and if it
13 is negative, they can come out. But if there is no side
14 rooms, they can be kept around their bed and we isolate
15 them around their bed, and then we need to take
16 precautions like wearing gloves and the gowns when we
17 are examining those patients.
18 So that was my intention to say yesterday, but I may
19 get confused with the patients with the diarrhoea. We
20 never used those curtains for a patient with the
21 diarrhoea to isolate them in the bed.
22 Q. So the point you made yesterday about putting patients
23 in what you described as isolation, by which you meant
24 putting them in a bed in a bay with a screen --
25 A. Yes.
5
1 Q. -- is only relevant to patients who may be suffering
2 from --
3 A. It is just for screening, who may or may not be
4 suffering. It is after 24 hours, if the screening is
5 negative, then that can be -- that barrier can be
6 stopped, barrier nursing.
7 Q. If we come to patients who have diarrhoea, what I think
8 you said yesterday is that such patients should be
9 isolated. Do you mean by that --
10 A. I mean, I have seen patients straight away from the
11 community with a history of diarrhoea, they always kept
12 in the side rooms until we have got more information
13 from the stool culture and sensitivity.
14 Q. Yes, but we have seen in the records patients who
15 developed diarrhoea in the hospital, and it appears that
16 the general practice was not to isolate such patients
17 until a diagnosis for C. diff was made?
18 A. I will still apply the same condition that those
19 patients who would all have diarrhoea, then they should
20 be isolated in a side room.
21 Q. I think we looked at this yesterday, because in your
22 statement you seemed to suggest that patients would be
23 isolated before diagnosis.
24 A. Yes.
25 Q. In your examination of the records, have you seen that,
6
1 in fact, generally speaking, patients were not isolated
2 before the diagnosis was made?
3 A. I think it is difficult to see from the notes where the
4 patients were located at that time, so I cannot say with
5 100 per cent whether at the time I examined the patient,
6 whether that patient was in the side room or not.
7 Q. I think we pick this up in your statement, if I perhaps
8 go back to it. It is at WTS1880001. At page 7, at
9 paragraph 44, you say:
10 "If the patient was suspected of C. diff, I would
11 reassess the patient condition, consider their
12 medications, start treatment if they were not already
13 started on treatment and make sure they were isolated."
14 That's what you say there?
15 A. Yes.
16 Q. Then, on the next page, on page 8, paragraph 45:
17 "A patient would normally be allocated to a single
18 room based on their symptoms, before a positive result
19 is obtained from the lab."
20 A. Yes.
21 Q. From your perusal of the records, and you have had an
22 opportunity of looking at the records of a number of
23 cases, does it appear to be the case that, generally,
24 patients were not isolated until the diagnosis was made
25 by the lab?
7
1 A. Yeah, that may be true, but my opinion and my
2 inclination is that those patients should be in a side
3 room, and that also be the decision of the ward sister
4 and the bed manager if they can find the side room, if
5 not in that ward, then in some other place.
6 Q. I understand that that is your opinion, that these
7 patients should be isolated, but does it seem, from
8 looking at the records, that, as a matter of fact, such
9 patients generally were not isolated until the positive
10 result was made?
11 A. Yes.
12 Q. Can we then move to look at [Patient C]'s records, and
13 I will give the reference for that again: GGC26340001.
14 I think we know that this is Patient C, for the
15 transcribers.
16 I think [Patient C] was admitted to the
17 Vale of Leven Hospital on 9 December 2007. At that
18 time, according to the records, Dr Al-Shamma was the
19 admitting consultant, but you subsequently became
20 involved in about the middle of December. If we look at
21 page 25 of the case records, is there a note there for
22 18 December that begins "MDT", which means
23 multidisciplinary team; is that right?
24 A. Yes.
25 Q. Is that your handwriting?
8
1 A. Yes.
2 Q. At this point, then, did you take over the care of
3 the patient?
4 A. Yes.
5 Q. Can you tell me this: who would be present at the
6 multidisciplinary team meeting?
7 A. Multidisciplinary team meeting happens once a week, on
8 Thursday -- Tuesday afternoon, about half past one.
9 Apart from me, there is a ward sister. If the ward
10 sister is not there, then the main nurse in charge who
11 is responsible for the patients, they are there.
12 The senior physiotherapist also attends, the senior
13 occupational therapist, the speech and language
14 therapist, as well as the social worker are there.
15 Sometimes there is a dietician may be there, but not
16 always, and myself, and sometimes my junior doctors are
17 there. If not, if they are busy somewhere else, then it
18 is only me.
19 Q. So at this time, then, you had such a meeting. If we
20 then look at the next note in the records, can we see
21 that the date is not clear, if we just focus on that for
22 the moment. We can see the "1", it begins with a "1".
23 The next figure has been blanked out, and then we see
24 the "2/07". Do we take from this that this is a date
25 some time before 20 December 2007?
9
1 A. Yes.
2 Q. It would appear to be a note by a junior doctor; is that
3 correct, an FY1 doctor?
4 A. Yes.
5 Q. Then do we see that the next entry in the records is not
6 until 8 January 2008?
7 A. Yes.
8 Q. So there appears to be a period from, let's say, about
9 the 20th, because we know it is shortly before that,
10 20 December 2007 to 8 January 2008, when there doesn't
11 appear to have been medical review; is that correct?
12 A. Yes. I can explain that.
13 Q. Sorry?
14 A. I can explain that.
15 Q. Before we come to that, can I just take you to this: if
16 we can look at page 46 of the records, do we see here
17 a report from the lab in relation to a faecal sample
18 which was received by the lab on 24 December? The
19 clinical details is "Episode diarrhoea infection
20 outbreak in ward". It is addressed to yourself, we see
21 that in the top right, and can we see that this patient
22 tested positive for C. diff as at about
23 24 December 2007?
24 A. Yes.
25 Q. If we look at the infection control card, at
10
1 SPF01390001, can we note that it has been noted here
2 that the infection control nurse was aware that the
3 patient was positive on 24 December, when there's a note
4 to the effect, "Informed by lab staff". Do you see
5 that?
6 A. Yes.
7 Q. Does it appear, as we look to the records, that the
8 patient was not reviewed between about 20 December
9 and -- if we go back to page 25 of the records, does it
10 appear that the patient was not reviewed medically from
11 about 20 December 2007 to 8 January 2008, during
12 a period in which she tested positive for C. diff?