1 Wednesday, 1 February 2012
2 (10.00 am)
3 DR HUGH CARMICHAEL (continued)
4 Examination by MR MACAULAY
5 MR MACAULAY: Good morning, my Lord.
6 Good morning, Dr Carmichael.
7 A. Good morning.
8 Q. Yesterday, you gave us some information about your
9 commitments to the Vale of Leven Hospital. Can I just
10 explore one or two points with you in that connection.
11 So far as wards are concerned, were there particular
12 wards that you would be in attendance at?
13 A. The acute medical wards, as you know, were 3, 4 and 6,
14 so these would be the primary wards I would be involved
15 in.
16 Obviously, we often had boarders elsewhere,
17 particularly ward 5, the surgical ward, and
18 occasionally, of course, elsewhere.
19 Q. So if you focus on ward 6, for example, how frequently,
20 then, do you consider in a week you would be in
21 attendance in ward 6?
22 A. My routine ward rounds would be twice a week and, if
23 I was receiving at weekends, it would obviously be
24 another three days as well -- Friday, Saturday, Sunday.
25 Q. So far as your acute receiving duties were concerned,
1
1 would you attend ward 6 for that, or would you perhaps
2 attend MAU? How did it work in practice?
3 A. The MAU purely worked as a place where patients were
4 brought in by ambulance or came in on their own and were
5 assessed with a view to admission. We would not
6 normally go down there unless requested to do so by the
7 receiving middle grade staff, which sometimes happened.
8 Sometimes they were under a lot of pressure, and we went
9 down to help get through the numbers. As time went on,
10 that was becoming an increasingly frequent request, to
11 help them out.
12 Q. During the week, are you able to tell the Inquiry how
13 many medical staff would be based in the MAU?
14 A. Usually, there would be one, perhaps two, middle grade
15 and I think an FY1 would be helping out as well down
16 there during the daytime. There was a variation. But
17 during the weekdays, I think there could have been two
18 middle grade staff there at certain times, anyway.
19 Q. And at weekends?
20 A. At weekends, mostly one. There would be one middle
21 grade and one FY1 covering the hospital at weekends.
22 Q. Did you have any views on the adequacy of that cover for
23 the whole hospital?
24 A. We had concerns about that number. When things were not
25 busy, it was perfectly manageable, but when things got
2
1 busy, it proved difficult for relatively inexperienced
2 junior staff to cope, and that was a cause of concern.
3 We had attempted -- and I'm not sure of the timeframe of
4 this -- to get extra staff for the weekend, particularly
5 for the Saturday, when things were busier and an extra
6 pair of hands would have been very useful, for a number
7 of hours, anyway. But we were unable to get
8 accreditation for an extra junior member of staff.
9 Q. Can you just elaborate upon that: why was that? If you
10 needed the manpower, why did you not get it?
11 A. I suspect a number of reasons. In terms of
12 accreditation, it is looked on as whether there's
13 sufficient educational material to support an extra
14 post, and it was judged by those in charge of that that
15 that was not the case.
16 MR KINROY: My Lord, I wonder if I could ask if that was to
17 do with the deanery?
18 A. That's the deanery, yes. It's a deanery decision, that.
19 MR MACAULAY: I think you were responsible for the rota, and
20 I propose to ask you some questions about that.
21 A. The senior rota, yes, the consultant rota.
22 Q. That will perhaps put you in a position to give us some
23 indication as to medical staffing generally.
24 First of all, is it right to say that there were no
25 registrars or specialist registrars in the Vale of Leven
3
1 at the relevant time?
2 A. No, there were not. We had -- occasionally, had one or
3 two of them in the past, when staffing was a bit more --
4 there was more staffing available generally in the
5 deanery, but not for a number of years up to that point.
6 Q. Why was that the situation, then, Dr Carmichael?
7 A. Largely because there were fewer of the senior trainees
8 to go around anyway and, also, because of the departure
9 of the other specialties from the Vale, the Vale was
10 being regarded less and less as a potential source of
11 senior education.
12 Q. Did you have any views, from your perspective as
13 a consultant, on the fact that you didn't have this
14 middle grade level of medical expertise?
15 A. It would obviously have helped to have more experienced
16 middle grade staff in the hospital, yes, it would have,
17 and it did in the past. But as time went on, well, that
18 level of experience became less available.
19 Q. Would that have any impact on the training of the junior
20 doctors?
21 A. Not in the training of the junior doctors, just in how
22 things were managed, basically, the service was managed,
23 yes.
24 Q. Did you see this as an important gap in the medical
25 services at the Vale of Leven?
4
1 A. I think it would have been ideal to have had more senior
2 middle grade staff available, but we realised that was
3 just not going to happen.
4 Q. Did I understand from what you said a moment ago that
5 some of your patients would, in fact, be accommodated in
6 wards 14 and 15, as well as the acute wards?
7 A. It was not very common to be boarded out to 14 and 15.
8 Occasionally, if patients had to go there, they would
9 usually be those in whom we were expecting to transfer
10 them to care of the elderly anyway, at some stage, and
11 so a decision would be made to send them there, rather
12 than to, well, say, ward 5, but mostly they would go
13 through to the surgical ward.
14 Q. Are these patients who would be acutely ill and
15 otherwise would be accommodated in the acute medical
16 wards?
17 A. We would try to avoid sending patients with significant
18 ongoing acute problems to 14 and 15, largely because
19 of -- well, they were not really looked on as acute
20 wards. That was predominantly why. We tried to keep
21 the acute patients -- the ongoing issues within the
22 environment of the main hospital.
23 Q. But I think you just said you tried to do that, but did
24 it happen that patients --
25 A. I would imagine occasionally it did happen that patients
5
1 went to 14 and 15 that we would prefer not to, that we
2 would have preferred to have kept under a closer
3 scrutiny.
4 Q. That's the next point I was going to come to. Looking
5 to the experience of the staff in the different wards,
6 the staff in the rehabilitation wards, did you consider
7 that they were sufficiently experienced to deal with
8 patients who may be acutely ill and should have been in
9 another ward?
10 A. They were also used to dealing with elderly patients
11 with many comorbidities, and the answer to that would
12 be, yes, they did have these skills, but their staffing
13 was mainly geared to rehabilitation, of course, and not
14 to looking after acutely ill patients.
15 Q. We have heard evidence, Dr Carmichael, and you may have
16 seen this in the transcript yourself, that, at weekends,
17 indeed, as you said, you only really had two doctors
18 covering the whole hospital; is that correct?
19 A. At the weekends, yes, at any one time.
20 Q. I'm sorry?
21 A. At any one time, yes.
22 Q. Did you, yourself, consider whether this situation
23 compromised patient care?
24 A. Well, it's always been the situation at the Vale. It's
25 never been any different, really, so I suppose, if
6
1 I felt it did compromise patient care, I would feel it
2 was an untenable situation, so the answer to that must
3 be, no, I didn't feel it compromised it unduly.
4 Obviously, as time has gone on, as with most
5 other -- well, all other acute medical units throughout
6 the country, the pressure has increased inexorably over
7 the years. When I took up my post in '79, I think we
8 were roughly between 1,200 and 1,500 admissions per
9 annum and, when I retired -- I think we had peaked at
10 4,000 within the year or two before I retired. So that
11 is almost a threefold increase in admissions, and these
12 admissions were becoming more elderly, more complicated,
13 more comorbidities, more interventions had developed
14 over the years. So, all in all, the workload for
15 medical and nursing staff had steadily increased, and
16 I have to accept that the staffing, to some extent, had
17 not kept up with that increased need.
18 So the answer to your question must be, to some
19 extent, it would have been preferable if staffing levels
20 were higher than they were, but that's the reality we
21 have to live with, and certainly district hospitals
22 throughout the country, especially small ones, have
23 limited staffing.
24 Q. Could I just ask you to slow down a little bit, for the
25 benefit of the transcribers?
7
1 A. Sorry, yes.
2 MR PEOPLES: My Lord, I wonder, before we go on about
3 weekend cover, I had understood Dr Carmichael yesterday
4 to say that he would attend on a Saturday and Sunday in
5 person. Would that be in addition to the two doctors
6 during the day?
7 A. When I --
8 MR PEOPLES: If so, for what purpose?
9 A. When I was receiving? On receiving duties?
10 MR PEOPLES: When you were on call for the weekends.
11 A. On call, yes, the consultant on call, we'd go in on
12 a Saturday and a Sunday morning as well.
13 MR MACAULAY: Would that be to respond to a call from the
14 doctor who was there to come and see a patient who was
15 ill?
16 A. No -- well, we would go in as a routine when we were on
17 call to see all the new patients that had arrived in
18 from the Friday to the Saturday and then from the
19 Saturday to the Sunday, so they had at least one
20 consultant assessment following admission.
21 Q. That's for new patients?
22 A. For new patients, and also any other patients flagged up
23 for us to see who were a cause of concern, either by the
24 junior staff, the junior medical staff, or by the
25 sisters in the various wards. We would go around all of
8
1 the medical wards and see what problems there were and
2 ask the sisters, or ask the nurse in charge, what issues
3 there were.
4 Q. Can I then ask you a little bit about the organisation
5 of the rota. When did you take on that responsibility,
6 Dr Carmichael?
7 A. Well, when I took up my post at the Vale, I was the only
8 full-time consultant. There was another part-timer.
9 So, really, from day one.
10 Q. Can you just give me some understanding as to what the
11 task involved, then? For example, when you were making
12 up the rotas, would you have a list of the days when the
13 consultants that were to participate in the rota would
14 have had ward rounds?
15 A. The rota was primarily based on days when the individual
16 consultants were best placed to undertake receiving. Of
17 course, that was not always possible. There were six
18 consultants to be accommodated, and the weekday rota was
19 from Monday to Thursday. That's four days. And the
20 oncall weekend rota was Friday, Saturday, Sunday. So
21 Friday, Saturday, Sunday was kept out of the weekday
22 rota.
23 To fill four days with six people does require
24 a fair degree of flexibility. Nonetheless, I tried to
25 maintain certain days for certain people.
9
1 Q. When you say four people, sorry, can you just remind
2 me -- not six people, then?
3 A. There were six people.
4 Q. Sorry, I thought --
5 A. Four days and six people.
6 Q. Four days and six people, yes.
7 A. Yes, six consultants. So on a Monday, that was my
8 preferred day; on a Tuesday, that was Dr Al-Shamma's
9 preferred day; I think in the early part of the period
10 in question Wednesday was Dr Forbat's preferred day; and
11 then, when he left, I think Dr McCruden preferred the
12 Wednesday -- I may be wrong about that. I'm not
13 100 per cent sure.
14 Thursday, the preference was for Dr Johnston and
15 I think Dr Akhter -- that's five, isn't it? Who have
16 I missed out?
17 DAME ELISH: My Lord, I wonder if my learned friend --
18 MR MACAULAY: Yourself, I think.
19 A. No, I was Monday. I think that more or less covers it,
20 in fact.
21 DAME ELISH: My Lord, I wonder if my learned friend could --
22 LORD MACLEAN: You were going to say?
23 A. Sorry.
24 DAME ELISH: I wonder if my learned friend could clarify,
25 when the doctor refers to composing a rota for six