1 Monday, 17 October 2011
2 (10.00 am)
3 MRS LYNNE PHAIR (sworn)
4 Examination by MR MACAULAY
5 MR MACAULAY: Good morning, Mrs Phair.
6 A. Good morning.
7 Q. I think, of the 12 cases that you looked at, you have
8 three that I think you are still to give evidence in
9 connection with; is that right?
10 A. Yes.
11 Q. You have also, I think, to speak to your overview report
12 that you produced some time ago?
13 A. Yes.
14 Q. If you look at the first of the three remaining cases,
15 that is the case of Anne Agnew, if perhaps you could
16 have your report, first of all, before you, and that is
17 at EXP00070001. If you turn to page 3 of the report,
18 section 3 deals with Mrs Agnew's medical history.
19 I think you tell us that she was 93 when she was
20 admitted to the Vale of Leven.
21 A. Yes.
22 Q. What was the reason for her admission at that time?
23 A. She was admitted on 15 April 2008 with a fractured ulna,
24 which is the long bone in the forearm, following a fall,
25 and she was transferred from the Royal Alexandra
1
1 Hospital. She'd had many falls before she'd admitted to
2 the hospital.
3 Q. Are you able to tell us to what ward she was admitted on
4 admission to the Vale of Leven?
5 A. To ward 14.
6 Q. If we look at some of the extracts you have taken from
7 the nursing notes, first of all, and that begins,
8 I think, on page 15, the first entry is for 15 April,
9 where you say, "Admitted to RAH". Was she then
10 transferred from the RAH to the Vale of Leven?
11 A. Yes.
12 Q. When she was in the Vale of Leven in ward 14, did she
13 have any further falls?
14 A. Yes, I believe she did.
15 Q. If you turn to page 16 of the report, have you noted
16 that, on 23 April, she had a fall, I think in the
17 toilet; is that right?
18 A. Yes, she did, at 7.15 in the evening, and she sustained
19 a large bump on the back of her head.
20 Q. But focusing on C. diff, did she develop loose stools in
21 ward 14?
22 A. Yes, she did, on 8/5 she vomited a large amount and had
23 a lot of loose stools, reported at 5 pm.
24 Q. At that time, was a specimen taken which proved to be
25 negative for C. diff?
2
1 A. Yes, I believe it was.
2 Q. But subsequently, if you turn to page 17 of your report,
3 did she continue to have loose stools?
4 A. Yes, she did. An example is recorded on 15 May, that at
5 7 o'clock in the morning she had two episodes of loose
6 stool.
7 Q. If we read the extract we have taken for the 16th, you
8 say, "incontinent of large watery stool. Specimen sent
9 for C&S and C. diff. Infection control nurse in ward
10 aware of diarrhoea. Will need single room if result
11 returns as C. diff."
12 A. Yes.
13 Q. Again, that was a negative result, I think; is that
14 right?
15 A. Yes, I understand so.
16 Q. But do we understand from this that Mrs Agnew wasn't
17 isolated at this point in time?
18 A. The records indicate that she wasn't.
19 Q. If we turn then to page 18 of the report, have you noted
20 on the 19th that she had another fall?
21 A. Yes, she was found in the shower.
22 Q. Then, if we move on to the extract for the 23rd, again,
23 have you noted that Mrs Agnew continued to have loose
24 stools, a specimen was taken, and this proved to be
25 a positive result?
3
1 A. Yes.
2 Q. At 1647, have you taken from the records that there
3 was a:
4 "Message from microbiology, C. diff positive from
5 today's specimen. Infection control notified. Moved to
6 an isolation room."
7 So it would appear that, once the diagnosis had been
8 confirmed, Mrs Agnew was isolated?
9 A. Yes.
10 Q. That, I think, is a result that came through on 23 May.
11 Was she again positive for C. diff in June?
12 A. I believe she was. I have identified the microbiology
13 records.
14 Q. Well, we can put the result on the screen. In fact,
15 that is probably the easiest way to do it.
16 A. Yes.
17 Q. If we look at GGC00020094.
18 A. Yes. A sample was taken on 13 June and it was --
19 C. difficile was again detected.
20 Q. Had Mrs Agnew suffered from loose stools, then, leading
21 up to the taking of that sample?
22 A. Yes. They'd also had a sample taken on 23 May.
23 Q. That's the one that was positive?
24 A. Yes, and then a second sample -- so there were two
25 samples taken on that day. The reference 0091
4
1 identifies it wasn't isolated, and a second sample,
2 0092, identified that it was positive.
3 Q. So we have two positive results, one on 23 May and one
4 on 13 June?
5 A. Yes.
6 Q. If we go back to your report, so far as the 13 June
7 result is concerned, do you look at that on page 21?
8 Against the entry for 13 June, we see a stool sample
9 being sent, and then, at 12.20, the positive result has
10 been relayed to the ward?
11 A. Yes.
12 Q. What about isolation? Can you help with that at this
13 point?
14 A. I'm not aware whether she was removed from isolation
15 after the first positive episode -- the first positive
16 test and then placed back in isolation, or if she'd
17 remained in the side ward.
18 Q. If we look at the infection control card at SPF00390001,
19 certainly, as at 16 June, is the note there "Remains
20 isolated"?
21 A. Yes.
22 Q. Although she was described as being asymptomatic. Then
23 on 23 June, there's further reference to the loose
24 stools, and then, on the 27th, "Remains in single side
25 room".
5
1 A. Yes, so she did remain in isolation throughout that
2 time.
3 Q. Did Mrs Agnew survive these episodes of C. diff and was
4 she discharged to the nursing home on 15 July?
5 A. Yes, she was. She was discharged to the Bloomhill
6 Nursing Home on 15 July.
7 Q. If we just have page 21 in front of us again, and if you
8 look at the entry for 8 June, where there is some
9 reference to loose stools, then you have taken from the
10 records "Sacral area red and Triple Care applied". Do
11 you see that?
12 A. Yes.
13 Q. Reading that sort of entry, how do you read that as to
14 what the nature of the problem is in relation to the
15 sacral area being red?
16 A. The sacral area could be red due to excoriation due to
17 the loose stools damaging the skin; it could also be red
18 due to pressure damage; or a combination of both.
19 Q. I think you did see in the records there were a number
20 of entries dealing with this sort of problem?
21 A. Yes.
22 Q. For example, if we look at the records themselves, at
23 GGC00020121, on 29 June, can we see here that there is
24 a reference in the third-last line "No stools overnight.
25 Sacral area broken and extremely red"?
6
1 A. Yes.
2 Q. "Triple Care applied". What about that? Does that tell
3 us as to what the nature of the damage is, or not?
4 A. Well, it describes that the sacral area is broken, which
5 could be due to, as I say, the burning that you can --
6 that can occur due to urine and faeces on the skin. It
7 could also be due to pressure damage. So it gives an
8 indication that she has experienced pressure damage on
9 her sacrum, but it doesn't give a clear indication,
10 I would suggest, of the nature of the damage and whether
11 the wounds are responding to the treatment that is being
12 used.
13 Q. What about the treatment? Does that give us any insight
14 into the cause of the damage? It is "Triple Care
15 applied"?
16 A. No, my understanding is Triple Care is like
17 a barrier-type cream, so it doesn't indicate to me what
18 the treatment is, how large the wounds are, how
19 extensive the wounds are and whether they are responding
20 to the treatment that was put in place.
21 Q. Can I move on, then, to page 30 of your report, where
22 you have a section dealing with the position of nursing
23 care plans? I think you were able to see that there
24 were a number of care plans in the records; is that
25 correct?
7
1 A. Yes.
2 Q. So what you say there is that there were limited nursing
3 care plans covering only falls, her broken arm,
4 confusion, sore area on her left hip, which was never
5 revised to reflect it was an abscess, and C. difficile.
6 If we just look at the C. difficile care plan on
7 page 109 of the records.
8 Here we have the care plan that I think you
9 mentioned in your report. The first date we see,
10 23 May 2008, that was the date, I think, that there was
11 the first positive result; is that right?
12 A. Yes.
13 Q. We see that there are a number of interventions
14 envisaged. Is this an appropriate care plan for the
15 problem?
16 A. Well, in my view, it's, as I described, a rudimentary
17 care plan. There is a care plan in place, which is
18 a positive, but the first item, for example, "Confirmed
19 C. diff positive". That is not an intervention. That
20 is a statement of fact.
21 The "Isolation procedures in place plus meticulous
22 hand washing" is an instruction.
23 "Administer antibiotics as prescribed" is an
24 instruction, but it doesn't actually ensure that the
25 nurses are identifying and checking for how the
8
1 antibiotics are affecting, how the person is responding
2 to the antibiotics.
3 "Liaise with infection control team", that doesn't
4 tell me about what. Does that mean just letting them
5 know? Does it mean that they are going to be coming
6 down to support, advise and guide?
7 "Liaise with family". Again, does it actually
8 identify that the family have been given information
9 about how to manage themselves, how to deal with the
10 laundry, et cetera, et cetera.
11 Q. It does say, for example, "Complete stool chart" at
12 intervention 6, which I assume would be an
13 appropriate --
14 A. That would have been appropriate, yes.
15 Q. And encouraging fluids, as well?
16 A. That would have been appropriate. However, it should
17 have indicated that, not only should fluids be
18 encouraged, but fluid intake should be monitored.
19 MR KINROY: My Lord, I wonder if I can just clarify if there
20 is any harm in including in the C. diff care plan the
21 fact that the patient was confirmed C. diff positive?
22 Is it actually harmful to put that in?
23 LORD MACLEAN: I think even I could answer that.
24 MR KINROY: It would appear to be a criticism, my Lord.
25 That was my interest.
9
1 LORD MACLEAN: Yes, I think the point -- but I will ask
2 Mrs Phair.
3 A. No, it is not harmful. The point that I'm making is
4 that the heading of the section says
5 "Actions/interventions", stating that the -- the fact
6 that someone has -- is C. diff positive is not an action
7 or intervention, it is a statement of fact, which has
8 also been listed as the problem.
9 MR MACAULAY: But I suppose, in contrast to other cases you
10 have looked at, we do have a C. diff care plan put in
11 place here on the day that the patient tested positive?
12 A. Yes, indeed, and that is a step forward.
13 Q. Now, the other point you make in this section of
14 the report, going back to the report at page 30, is that
15 you consider that there should have been other care
16 plans to cover other problems; is my understanding
17 correct?
18 A. Yes, there were a number of care plans. It's about not
19 necessarily having more documentation, it is about
20 having documentation that is smarter and meets the needs
21 of the patient.
22 So, for example, Mrs Agnew developed an abscess in
23 her hip. The care plan was never revised to reflect the
24 care that she would have needed to care for the abscess
25 in her hip, which might well have -- certainly, this is
10
1 outside my area of expertise, and I would have been
2 seeking advice from the doctors to establish the impact
3 that any infection that Mrs Agnew had in her hip and
4 the -- how that relationship bore with -- in terms of
5 antibiotic treatment with her C. difficile, for example.
6 Q. The care plan that was there is at page 108 of
7 the records. What it is is "Red sore area left hip"; is
8 that right?
9 A. Yes.
10 Q. I think the point you're making is that, once she
11 developed the abscess to her hip, this should have been
12 revised to deal with that? Is that --
13 A. Yes, it was updated on 26/5, as you can see, and it says
14 "Abscess left hip. Cleanse with Normosol. Allevyn
15 dressing applied. Monitor leakage. Surgical review".
16 But, again, we have no record that I could find of
17 the impact of the dressing that was being used and how
18 that wound and abscess was responding to the treatment.