1 Monday, 16 May 2011
2 (10.00 am )
3 LORD MACLEAN: Welcome to the third session of the oral
4 hearings for the Vale of Leven Hospital Inquiry.
5 Following a request made to me last week on behalf of
6 Greater Glasgow Health Board, the timetable for the next
7 few weeks of the third session has been changed, as
8 I hope you all know anyway.
9 The Inquiry will sit for only one day this week,
10 today, and then resume hearings on Tuesday, 31 May. We
11 will hear today from two expert witnesses, with
12 presentations and context-setting reports. From 31 May,
13 we will hear from more experts in relation to reports
14 they have prepared on the care of individual patients
15 before proceeding to hear at length the evidence of
16 the nursing staff at the hospital.
17 We will conclude this session in the summer, with
18 further expert evidence on nursing care.
19 The Royal College of Nursing recently applied to be
20 a core participant to the Inquiry, and I have been
21 pleased to grant their application and their
22 representative is here today.
23 I would invite Mr Dickson, therefore, as the senior
24 of the two representatives present, to make
25 a submission, if he wishes to do so.
1
1 Submissions by MR DICKSON
2 MR DICKSON: Thank you, my Lord. I am here on behalf of
3 the Royal College of Nursing in Scotland, who I will
4 refer to as the RCN.
5 My Lord, I propose to make a brief statement on
6 behalf of the RCN. I have spoken the statement into the
7 following three parts: firstly, the role of the RCN in
8 Scotland; secondly, the RCN's area of interest in this
9 Inquiry; and, thirdly, the proposed approach by the RCN
10 to assist the Inquiry.
11 Turning to part 1, which is the role of the RCN in
12 Scotland, the RCN represents nurses and nursing,
13 promotes excellence in practice and shapes health
14 policies. It aims to support and protect the value of
15 nurses and nursing staff in all their diversity. It
16 seeks to develop and educate nurses professionally and
17 academically and constantly strives to improve the
18 quality of patient care. The RCN has over 38,500
19 nursing members in Scotland. These members cover the
20 full spectrum of nursing professional practice in
21 Scotland.
22 My Lord, turning to part 2, which is the RCN's area
23 of interest in the Inquiry, the RCN welcomes the Inquiry
24 and has a significant interest in all aspects of
25 the Inquiry. They have two interrelated areas of
2
1 particular interest: firstly, ensuring that their
2 members, who are due to give evidence, are fully
3 prepared to give evidence so that the Inquiry can gain
4 maximum assistance from their evidence; and, secondly --
5 and this follows on from the first point -- that the
6 Inquiry is provided with the fullest information
7 possible in order to enable it to make recommendations
8 regarding the best possible practice in this area of
9 patient care. This second point is of critical
10 importance to the RCN as they will play a major role in
11 ensuring that its members are advised of and follow the
12 best practice recommended by the Inquiry.
13 My Lord, turning to part 3, which is the proposed
14 approach by the RCN to assist the Inquiry, the RCN has
15 recently been advised that a number of RCN members are
16 due to give factual evidence to the Inquiry in the
17 coming months. These members performed a variety of
18 different nursing roles at the Vale of Leven Hospital,
19 including ward staff, ward managers, infection control
20 nurses and senior managers. Their evidence will
21 therefore cover the full range of nursing care in the
22 hospital. Each nurse witness will, of course, give
23 evidence from their own particular experience and
24 perspective, and one would therefore expect different
25 nurses and, in particular, nurses working in different
3
1 nursing areas, to approach matters from slightly
2 different viewpoints. In those circumstances, the RCN
3 does not think it would be possible to singularly
4 represent all of their members due to give evidence.
5 In any event, the RCN has full confidence that
6 Counsel to the Inquiry and the other represented
7 parties, including counsel for the Greater Glasgow
8 Health Board, will satisfactorily explore all issues
9 with the RCN members giving factual evidence in order to
10 find out what happened and why it happened.
11 The RCN does not, therefore, at this stage, propose
12 to be represented at the oral hearings. Rather, the RCN
13 takes the view that it can most productively assist the
14 Inquiry by making sure that its members who are due to
15 give evidence, firstly, fully understand the process for
16 giving evidence to the Inquiry; secondly, are given
17 a fair opportunity prior to giving evidence to consider
18 and respond to any information or expert report that
19 comments upon their area of professional practice; and,
20 thirdly, are fully prepared to give evidence in order
21 that the Inquiry can obtain the maximum amount of
22 assistance from their evidence.
23 To achieve that end, the RCN has arranged to
24 disclose, with the authority of your Lordship, Inquiry
25 documents relevant to the individual RCN members who are
4
1 due to give evidence and to hold group information
2 sessions with RCN members in order to ensure, insofar as
3 possible, that they are fully prepared to give evidence
4 to the Inquiry.
5 Finally, my Lord, I would simply record that the RCN
6 are committed to providing any further assistance to the
7 Inquiry that your Lordship considers would be helpful in
8 fulfilling the Inquiry's terms of reference.
9 Unless I can assist any further, that concludes the
10 statement for the RCN.
11 LORD MACLEAN: Thank you very much. I think we understand
12 your position here. Of course, you are very welcome to
13 stay on here for the rest of today, and to come and go
14 as you wish, because you are a core participant. You
15 understand that. Your desk may be empty, but you are
16 very welcome to return to it at any time.
17 I am glad that the RCN did decide to make an
18 appearance and, therefore, I grant it a core participant
19 status.
20 Mr Kinroy, we welcome you, of course, in place of
21 Ms Grahame, as leading senior for the Health Board; is
22 that right?
23 MR KINROY: Yes, my Lord, I am obliged for that. I have the
24 honour and responsibility of following in the shoes,
25 with respect -- not literally, I may say -- of
5
1 Ms Grahame.
2 LORD MACLEAN: Does anyone want to raise any matter at all
3 before we hear from Professor Poxton?
4 PROFESSOR IAN RAYMOND POXTON (sworn)
5 Examination by MR MACAULAY
6 MR MACAULAY: Are you Ian Raymond Poxton?
7 A. Yes.
8 Q. What position do you presently hold?
9 A. I am Professor of Microbial Infection and Immunity at
10 the University of Edinburgh.
11 Q. Could I ask you, first of all, to look at your CV; that
12 is INQ01760001. Do you have a hard copy of the CV in
13 front of you?
14 A. I don't, no.
15 Q. We will have it on the screen shortly. This is
16 a somewhat detailed curriculum vitae, Professor, and
17 I don't propose to spend a lot of time on it, but if we
18 look at your university background, we see that you have
19 a BSc in microbiology from the University of Edinburgh;
20 is that correct?
21 A. That's correct.
22 Q. You also have a Doctor of Philosophy degree, again in
23 microbiology, from the University of Edinburgh?
24 A. Yes.
25 Q. Essentially, Professor, has your career been an academic
6
1 one?
2 A. Yes, absolutely: teaching and research.
3 Q. If we look under the heading "Career", we see that from
4 1999 to date, you have been Professor of Microbial
5 Infection and Immunity?
6 A. Yes.
7 Q. We are interested, in particular, here in the infection
8 Clostridium difficile. Is that something you have had
9 a lot of experience with over the years?
10 A. Yes, absolutely. I think it was probably 1979 I was
11 first introduced to it by my then head of department,
12 and I have been interested in it ever since.
13 Q. In relation to that, have you delivered presentations on
14 this particular infection?
15 A. A few, yes. I think probably in the hundreds by now.
16 Q. Yes, and not just in this country, but in other
17 countries as well; is that right?
18 A. Yes, in the US, Australia, all over Europe.
19 Q. In relation to your contribution to the literature, have
20 you contributed to textbooks?
21 A. Yes.
22 Q. Perhaps turn to page 11 of the CV to get a feel for what
23 your contribution has been. Towards the bottom, we see
24 a list of publications. First of all, books, then books
25 and journal and special issues edited. That goes on for
7
1 several pages.
2 A. It is very out of date, I suppose, because it was 2010
3 it was done.
4 Q. In relation to the Inquiry, I think you have produced
5 a report; is that right?
6 A. That's correct, yes.
7 Q. If you could look at EXP00600001.
8 A. Yes.
9 Q. Is that the report that you have produced?
10 A. Yes.
11 Q. Can we see that the declaration on page 9, you signed
12 that?
13 A. Yes.
14 Q. Is it right to say that the report has largely been
15 superseded by the presentation that you are about to
16 give us this morning?
17 A. Yes. I think this report was done several months ago,
18 so things have moved on and we have refined one or two
19 bits. So, yes, the presentation is the latest.
20 Q. So far as the presentation is concerned, that is
21 EXP00690001. If I can invite you, Professor, to take us
22 through the presentation, and I think you can use the
23 mouse to point to any particular aspects of
24 the presentation that you might find to be of interest
25 to us.
8
1 A. Okay. So starting now, I think the plan will be to ask
2 questions at the end. Is that correct?
3 Q. I may ask some questions --
4 A. I was going to say, if anybody has any -- if it is
5 permissible, if anybody has any questions about
6 something that they don't understand, they don't follow,
7 please interrupt.
8 What I plan to do is to introduce the organism,
9 Clostridium difficile -- in fact, if we could go back
10 one, could I -- it seems to have moved on from the
11 title.
12 Q. Yes, page 1.
13 A. I think my original remit was to say what
14 Clostridium difficile is, how it is transmitted and what
15 it causes, the disease we know is Clostridium difficile
16 infection.
17 Then, more recently, which probably isn't in the
18 written report in the detail it will be here, is a brief
19 introduction about how it is diagnosed in the laboratory
20 from the early days up to the present. I want to give
21 a very brief overview of the various treatment options.
22 Again, that brings us right up to date.
23 If you look at the plan of the talk, I will
24 introduce the organism and the disease first. I will
25 talk a little bit about the natural history of
9
1 Clostridium difficile, because I think this is crucial
2 to infection from the organism. I will say something
3 about the infections it causes, the actual mechanisms of
4 how the disease is caused, and this is referred to as
5 pathogenesis, the causing of disease. We have all heard
6 about the hypervirulent strains, the 027, whatever you
7 want to call it, I will say something about that and how
8 there have been changes in the disease and epidemiology
9 since that came on the scene, but that is by no means
10 the whole story. I will say a little bit about the
11 changes in incidence over the past 40 years and then
12 a little bit about lab diagnosis and, finally,
13 a treatment overview.
14 I think I start off with a slide I use in some of my
15 teaching, so this is to undergraduate science,
16 veterinary and medical students, just to say what
17 Clostridium is. Clostridium is a sort of bacterium. It
18 is Gram-positive, and I don't think that means anything
19 to anybody. It is rod shaped -- you all understand what
20 that is, shaped like a rod.
21 The next thing is probably the first important fact:
22 it is anaerobic. That means it can only survive --
23 well, sorry, it can only grow in conditions where there
24 is no oxygen present. So it cannot grow on surfaces
25 where air is around.
10
1 The crucial thing about it is that it forms spores.
2 Those spores are a dormant form of the organism, in that
3 they are highly resistant to all sorts of physical and
4 chemical conditions. So they can survive very, very
5 well in the environment in a dormant form. They are not
6 causing any problems there until they get ingested by
7 a sufferer, or a potential sufferer.
8 Clostridia generally -- and I am not talking about
9 Clostridium difficile here -- the whole genus of
10 bacteria, tend to be what is referred to as
11 "saprophytic" in the environment. That means most
12 Clostridia are living on things that were once dead. So
13 they are involved in decay and putrefaction. You come
14 across them in everyday life, in compost heaps and
15 soils, in decomposing bodies, decomposing plant
16 material. That is what most Clostridia do. They are
17 there to break down and recycle elements.
18 A lot of them live in the gastrointestinal tract,
19 that is the GI tract. "Commensal" means they live there
20 doing no harm, they are just part of our normal gut
21 microbiota. A few of them are pathogenic for man and
22 animals. So there are probably over 100, maybe 200,
23 different species of Clostridium, but only very, very
24 few cause disease. The way most of them cause disease
25 is they produce these exotoxins, these extracellular
11
1 products that are very, very toxic, and I will describe
2 how toxic these are very soon.
3 Q. Does "gram-positive" need any further elaboration,
4 Professor?
5 A. Absolutely not. All bacteria can be divided into two
6 forms by a stain that Christine Gram developed over
7 100 years ago. Some are Gram-positive and some are
8 Gram-negative. Whether they are purple or pink in the
9 microscope, that is the bottom line of it.
10 A little bit about spores. I have already said they
11 are survival stage. They are dormant stage, and then
12 the bit I have in bold here -- I see we have colour on
13 the screen now -- they are resistant to heat, dryness,
14 radiation, chemicals and they are resistant to many
15 commonly used disinfectants used in the household and in
16 the hospital, and they are resistant to alcohol. So
17 alcohol hand gels have no effect on the spores of
18 Clostridium difficile.
19 Q. How long can the spores survive in the atmosphere?
20 A. If they are not exposed to things like chlorine and so
21 on, I would say indefinitely. They can be found --
22 there are reports to say that they can exist for five
23 months on a hospital surface, but I would suggest they
24 can exist for years. Clostridial spores do hang around
25 for many, many years. There are rumours about them
12
1 being found in the pyramids and the tombs of pharaohs
2 and things. I have no evidence, but the rumours are out
3 there. They are very, very resistant.
4 I think an interesting thing about spores is that
5 when they germinate, that's when they come back to life
6 again. Not all of them do. Because it would be a very
7 poor survival strategy if they all came to life and then
8 conditions went bad very quickly and they all died. So
9 it is only a proportion of spores that actually
10 germinate when conditions become right. So there are
11 always going to be some spores remaining in any
12 environment.
13 Q. The graphics -- just before you move on, the graphics
14 you have on that slide, the pictures, what are we
15 looking at?
16 A. Again, this is a teaching slide. The top left-hand
17 corner here shows the cycle where you go from
18 a vegetative cell, the DNA does things, it forms -- it
19 starts to differentiate and then this is the spore
20 forming in the cell here and then that is released and
21 you get a fully formed spore, that is the survival
22 stage, and then, when the conditions become
23 favourable -- but, again, it can grow. I will mention
24 a little bit about this for Clostridium difficile as it
25 goes down the gut. These are just the different forms
13
1 of spores. This is typical of the organism that causes
2 tetanus, the bottom left, and these other ones --
3 I think the top right is supposedly
4 Clostridium difficile. It is fairly typical, as is the
5 one below.
6 Q. When you talk about "rod-shaped", is that what you mean?
7 A. That's the rod-shaped cell and this circular thing --
8 sometimes they are at the end of cells here, sometimes
9 they are in the middle of cells, sometimes they are
10 swollen, sometimes they are not swollen. These are all
11 the variations of spores. But the important thing is
12 they survive.
13 Just for the finish off about the pathogenic
14 Clostridia, they are divided into three main groups:
15 there are the enteropathogenic ones, these are the ones
16 that are pathogenic in the gut. There are really only
17 two species to note here: Clostridium perfringens which
18 causes food poisoning and Clostridium difficile, that
19 we'll hear a lot more about. There are also Clostridia
20 which cause wound infections, the most serious would be
21 gas gangrene. In humans, these tend to be
22 Clostridium perfringens almost entirely. Many of you
23 may have heard of the infamous Clostridium novyi. This
24 was the organism that killed, I think, 20-odd injecting
25 drug users in Glasgow a few years ago when they were
14
1 injecting heroin intramuscularly, so that is a nasty
2 organism but very rare. The others are more affecting
3 animals than humans.
4 The third group are Neurotoxic clostridia. Again,
5 two infamous species: Clostridium tetani, the organism
6 that causes tetanus and Clostridium botuli, the organism
7 that causes botulism. So really, on this slide here,
8 out of the 100 or 200 different species of Clostridia,
9 these are the only ones we worry about as pathogens. Of
10 course, Clostridium botulinum produces the most powerful
11 toxin known to man. Very, very toxic. A gram can kill
12 a million people. So very, very toxic organisms.
13 So this is the pathogen. The plate here on the top