1 Thursday, 26 January 2012
2 (10.00 am)
3 DR DOUGLAS CAMPBELL MCCRUDEN (continued)
4 Examination by MR MACAULAY (continued)
5 MR MACAULAY: Yesterday, we had some discussion about
6 staffing at the Vale of Leven Hospital. One of
7 the points that was raised, I think, by Dr Al-Shamma was
8 the position in relation to staffing at the weekends.
9 I think he suggested that at the weekend you had one
10 middle grade, one FY1 covering the whole hospital, and
11 I think he also said that he may have expressed concerns
12 to you about that position. Can you comment on that?
13 A. It is true that there was one FY1 and one middle grade
14 above the level of FY2 during the day covering the
15 hospital. At night, there would be an FY2 and a GP
16 covering the hospital.
17 Q. So that is two doctors --
18 A. Yes.
19 Q. -- day and night?
20 A. Yes.
21 Q. What about concerns being expressed to you in your role
22 as the lead clinician about that?
23 A. I don't recognise that as the process. The process was
24 that we discussed the problems at the medical division
25 meeting as a group of consultants. We were all
1
1 experiencing the same conditions. It is undoubtedly
2 true that we discussed all aspects of the rota on
3 a number of occasions. It is true that staffing at the
4 weekend was recognised as being at a level that was
5 desirable to be increased.
6 The level of cover at weekends was long-standing,
7 there had been no change, no deterioration. I remember
8 that when accident and emergency left the Vale of Leven,
9 the level of weekend cover by medical juniors was one of
10 the aspects that led to the creation of the medical
11 admissions unit and the response to the level of cover
12 by medical juniors was that specialist nursing posts
13 were created in medical advisory -- in medical
14 assessment unit. So that was a response at that time to
15 that level of cover.
16 At the time that Dr Al-Shamma is referring to, these
17 clinical nurse specialists in medical assessment unit
18 were still in post and there was a Hospital at Night
19 team that also involved clinical nurse specialists.
20 So these factors were aiding the junior medical
21 staff. Another response to this level of staffing was
22 to examine all the freedoms we had in the rota --
23 I referred to that before -- taking advice from those
24 with greater experience in rotas and aiming to deploy
25 additional members of the middle grade during the day at
2
1 the weekends.
2 I can't think now what the limiting factor there
3 was. It is likely to have been the absolute numbers in
4 the rota and availability of locums. The locum
5 dimension there is that Dr Khan's locum post in
6 geriatrics, care of the elderly, was basically 9 to 5
7 locum, and I remember it being looked at as to whether
8 he could be offered the opportunity to do extra time at
9 the weekends to contribute to the middle grade rota.
10 I don't think that ever happened. I don't think that he
11 was deployed in that way. I'm not sure how to say that
12 the definite evidence on that could be looked out.
13 In summary, our concerns were concerns as a body of
14 consultants, and they were discussed with a number of
15 people to look for ways of improving the situation.
16 These people included the clinical services manager for
17 emergency medical services, the general manager for
18 general medical services and Mr Tracey as the expert in
19 junior rotas within the HR department for advice, it was
20 not his role to take a decision on the matter.
21 Q. You began that answer, Dr McCruden, by saying that it
22 was recognised that it was desirable to increase
23 staffing at weekends?
24 A. Yes. Yes, I recognised it.
25 Q. I think you have also said that your concerns were
3
1 escalated upwards to management; is that correct?
2 A. Yes.
3 Q. We have discussed some of the committees that were in
4 place in the Vale of Leven yesterday, and I think you
5 mentioned that you, as the acting site clinical lead,
6 chaired the executive clinical governance meeting, which
7 sat, I think, monthly or six-weekly; is that right?
8 A. I don't recall ever chairing that meeting.
9 Q. Who chaired that meeting?
10 A. I do not remember.
11 Q. The other meeting I think you mentioned was the clinical
12 governance meeting which met locally on a fortnightly
13 basis, and that was chaired by Dr Carmichael.
14 A. Yes.
15 Q. Would it be at that meeting that you would have these
16 discussions about staffing?
17 A. No.
18 Q. At what meetings, then, did you have these discussions?
19 A. When I met the clinical services manager weekly, and
20 sometimes the general manager was involved in those
21 meetings.
22 Q. Could I just look at a couple of documents with you? If
23 you look at GGC21260001, we will see this minutes of
24 the meeting of the Vale of Leven clinical governance
25 group, and this meeting, as we see from the date, took
4
1 place on 12 May 2008; do you see that?
2 A. Yes.
3 Q. Would this meeting then be held in the Vale of Leven?
4 A. Yes.
5 Q. Is this the meeting chaired by Dr Carmichael?
6 A. I'm looking for ways of distinguishing this meeting
7 between the meeting that I referred to as the executive
8 clinical governance meeting, and my conclusion is that
9 this is the fortnightly meeting and that it was at least
10 usually chaired by Dr Carmichael. I can't tell from
11 what I see on the screen whether this was an example of
12 a meeting, an individual meeting, of this group which he
13 chaired.
14 LORD MACLEAN: Can you tell me, Dr McCruden, who was the
15 clinical services manager?
16 A. Melanie McColgan. Her name is there. So that indicates
17 that, as her presence would have been as clinical
18 services manager, it was her, it was she. I don't see
19 her predecessor listed there, so this must be during the
20 time that Melanie McColgan was the clinical services
21 manager.
22 LORD MACLEAN: Who was her predecessor?
23 A. Anne Paterson.
24 MR MACAULAY: I think you had come to the conclusion,
25 Dr McCruden, that this would be a minute of a meeting of
5
1 the fortnightly meetings chaired by Dr Carmichael; is
2 that correct?
3 A. Yes.
4 Q. We see your name listed as one of the persons in
5 attendance, along, I think, with some of the nurse
6 managers -- Liz Rawle and Sue Wilson, for example; is
7 that correct?
8 A. Yes. I see Dr Carmichael, colleague consultant;
9 Nick Dunn, GP, who was central to the organisation of
10 the GP cover of the hospital; Jim Kelly, who was
11 a clinical nurse specialist; Liz Rawle, the clinical
12 services manager for RAD, or at least the lead nurse for
13 RAD, one of the two; Judy Taylor, who was the senior
14 nurse dealing with professional matters for the nurses;
15 Adrian Tully, an anaesthetist; Paul Turner, the
16 resuscitation officer; Sue Wilson, the lead nurse for
17 medicine.
18 Q. Since we have this minute in front of us, would it be at
19 this kind of meeting, just to be clear, that you would
20 discuss staffing, or would that be at one of the other
21 meetings that you held in the Vale of Leven?
22 A. If our staffing was a matter of concern expressed by the
23 nonphysicians at this meeting, it would be discussed
24 there, but it would not be where staffing issues would
25 ordinarily be discussed. That would be the medical
6
1 division meeting.
2 Q. Another minute I want to put to you as an example is at
3 GGC21610001. We are now looking at a minute of
4 the clinical governance group for unscheduled medicine,
5 and these minutes that we have here are for
6 17 March 2008. We see that, again, you are mentioned
7 there, along with, for example, Dr Carmichael. What was
8 the purpose of this particular group?
9 A. I think it's the same group as the last one.
10 Q. I'm sorry?
11 A. I think it's the same group as the last one.
12 Q. Is it just a different name?
13 A. It was a group that perhaps went through several changes
14 of name. The other name that I recall was issues group.
15 Q. I think we have minutes of that as well. So these are
16 the same group, are they, but under different guises?
17 A. I don't see anything there that leads me to think that
18 it was a different group.
19 LORD MACLEAN: What is unscheduled medicine?
20 A. Emergency medicine.
21 MR MACAULAY: If we look, then, at GGC21580001, here we have
22 minutes of what's described as the issues group, and we
23 see similar names to what we'd seen before. Is this,
24 then, the same group under a different name?
25 A. I believe so.
7
1 Q. Do I take it from what you said that this would not then
2 be the umbrella under which staffing issues would be
3 discussed?
4 A. No. I can't give an absolute "no" to that, in that any
5 staffing issues that arose might well be initially
6 discussed at that meeting. Any concerns raised by any
7 member at the meeting in general would be discussed.
8 Anything that was relevant to clinical practice,
9 particularly, as I have said before, focused on the
10 triage and transfer of patients and, indeed, on our ways
11 of assessing the physiological stability of patients.
12 Q. We have been looking at minutes of the same group, which
13 met locally, I think, and, as you told us yesterday, you
14 thought that was fortnightly; is that right?
15 A. Yes. There were periods where it was weekly and there
16 were periods where it was fortnightly.
17 Q. Yesterday, just so I can be clear, you mentioned also
18 the executive clinical governance meeting, which met
19 monthly. Now, just so I can understand the position in
20 relation to that particular group, was that meeting at
21 the Vale of Leven?
22 A. It was at the Vale of Leven.
23 Q. Just, again, who did you say chaired this meeting?
24 A. I do not recall, simply that. I can remember the
25 intention behind the meeting, which was contact between
8
1 executives who had clinical responsibility and
2 clinicians and managers at the Vale of Leven. I don't
3 have a clearer recollection than that.
4 Q. But at management level, for example, would
5 Melanie McColgan attend that meeting?
6 A. Possibly not.
7 Q. So who would attend at management level?
8 A. I would really need to see an agenda or minutes, I'm
9 afraid.
10 Q. What I'm trying to establish, then, where would concerns
11 about staffing levels be discussed?
12 A. I haven't got a fuller answer than I've given. Medical
13 division and then by contact with the clinical service
14 manager and the general manager for emergency medical
15 services. If there had been any overriding urgent
16 matter that justified taking it higher in the clinical
17 management structure, then that would be by discussion
18 with Graham Curry, the clinical director, or
19 John Dickson, the associate medical director.
20 Q. Looking to the groups that you were, yourself, involved
21 in, and we have certainly seen evidence of that from
22 these minutes, do you have an opinion as to how clinical
23 governance was functioning?
24 A. I think it was functioning reasonably well.
25 Q. Do you know if issues raised at these meetings would be
9
1 reported upwards, as it were, to the appropriate board
2 level?
3 A. By circulation of minutes.
4 Q. Was that the mechanism? That would be the mechanism,
5 would it?
6 A. I beg your pardon?
7 Q. That would be the method of escalating matters further
8 upwards?
9 A. Yes.
10 Q. Yesterday, we looked at the --
11 MR KINROY: My Lord, I wonder if we might ask if that would
12 be the only method and if there might not be a different
13 method if there was an issue sufficiently grave?
14 A. Yes, unusual steps outside the structure would always be
15 possible. There was no bar to individuals speaking to
16 whomsoever they chose in the structure.
17 LORD MACLEAN: But in terms of the structure, formally,
18 communication would be by way of the minutes?
19 A. Yes. This meeting, the issues group and the other names
20 under which it served, was formed up as -- was formed as
21 part of the Lomond integrated care pilot, and,
22 therefore, was not a routine part of the structure set
23 up by management. It was set up within the Lomond
24 integrated care pilot. What I'm trying to indicate is
25 that the means of communication outwith the group are
10
1 less clear to me now. It was mainly a group that was
2 focused on dealing with problems onsite as they were
3 identified to the group.
4 It may be possible from these minutes to see who the
5 minutes were circulated to. They were certainly
6 circulated to regular attenders. But it may be true to
7 say there wasn't a settled route of upwards referral of
8 issues.
9 I think it would be more correct of me to say that
10 I don't recall what the methods of communication outside
11 the group were.
12 Q. Yesterday, we looked at some minutes of the infection
13 control working group meeting. You will remember I took
14 you through a number of these yesterday.
15 A. Yes, I was rather puzzled, and I have checked what
16 I have in my possession. I did, when I retired, take
17 some of the files that were appropriate to me and
18 relevant to matters still to be determined with me, and
19 I find that I have a file which I have labelled --
20 LORD MACLEAN: "Do not remove", does it say?
21 A. Well, it is my own copy, so it actually says, "Infection
22 control committee". In it I do find the agenda for the
23 5 April 2007 meeting, and it is headed
24 "Vale of Leven Hospital Prevention and Control of
25 Infection Working Group Meeting", which was a title
11
1 I didn't recall. This is the meeting which I remembered
2 being unable to find a clinician who could attend and
3 having made apologies, so that explains my presence on
4 the minutes of the 5 April meeting, as having given
5 apologies. I don't have any minutes of that meeting.
6 MR MACAULAY: If we put the minutes back on the screen, just
7 to focus on that, that is GGC14750001. We looked at
8 this yesterday, but this is the minute of the meeting of
9 the infection control working group held on
10 5 April 2007. So that's the one where you now say that
11 your apologies may have been transmitted?
12 A. Yes. If you remember, I did recall that there was
13 a meeting during 2007 which I had been asked to attend
14 and couldn't do so. This turns out to be that meeting.
15 Q. I think, as we saw yesterday -- we needn't revisit this
16 in any detail again -- but there were some meetings of
17 this group in 2007, and I don't think, as it turned out,
18 you attended any of these meetings. I think the one
19 in December seems to have been cancelled, looking to
20 what you have in your diary. That seems to be the
21 position?
22 A. I checked my diary. It actually says when the meeting
23 was. It turns out that my diary doesn't say it was
24 cancelled, but I, from some other source, had the
25 knowledge that it was cancelled.
12
1 The other meeting that I know about is 27 June,
2 which I think you put up.
3 Q. Can we just get your assistance on that? That is
4 GGC14760001.
5 A. I have checked my diary on that. I was on leave for
6 a little over two weeks around that date, and I don't
7 have a copy of minutes.
8 Q. What I wanted to ask you about is this: there appears to
9 have been in place, at least for a period in 2007,
10 a local infection control working group designed to deal
11 with infection control issues within the
12 Vale of Leven Hospital.
13 Now, do you, yourself, know into what meeting
14 further up the chain this would feed into?
15 A. No.
16 Q. Are you able to say whether or not there was an
17 appropriate connection between the local infection
18 control meeting, at least during this period we are
19 looking at, and any other infection control group
20 further up the chain?
21 A. No.
22 MR PEOPLES: My Lord, I wonder, Dr McCruden referred to
23 historically a different setup, when there was
24 a hospital manager and a hospital management team, and
25 I think he also said there was an infection control
13
1 committee he could recall during that period. Could we
2 perhaps deal with the same point, whether that local
3 committee, if it then existed, was there a means of
4 communicating upwards to board level?
5 LORD MACLEAN: Do you follow that?
6 A. Yes, I follow it. As I think may be apparent, clear
7 recollections are very difficult to identify. There was
8 a more extensive committee structure on the site at that
9 time, and I would have really no doubt that the
10 infection control committee had a structure which
11 included a route of referral upwards to the board. It
12 would probably be through the hospital management
13 committee.
14 There were also clinical effectiveness committees --
15 there was a clinical effectiveness committee, there was
16 a clinical governance committee, there was a hospital
17 management committee I have referred to, and there was
18 a trust management group, which, when trusts were
19 abolished, became an acute services management group.
20 All of these groups, I think, were likely to have
21 had adequate communication, but it is not possible for
22 me to make a definitive response to that.
23 MR MACAULAY: The infection control committee that you
24 mentioned in that answer, is that then a different
25 committee from the infection control working group
14
1 committee that we have a minute of on the screen?
2 A. Yes, I believe so.
3 Q. Where did that sit? Where did it meet?
4 A. It was chaired by Dr Lesley Murray, who was
5 a pathologist at the Vale of Leven Hospital, and I was
6 never invited to contribute to that meeting, so I can't
7 answer by personal experience. It is likely to have
8 been at the Vale site, however. There would be no
9 reason for it to be at another site.
10 Q. Are we to take it that the infection control working
11 group meeting would feed into the infection control
12 committee?
13 A. No. No, I believe that the infection control committee
14 was succeeded by the infection control working group.
15 Q. Then that would be prior to -- I think the first minute
16 we looked at was 5 April 2007, so some time prior to
17 5 April 2007; is that what you're saying?
18 A. I have in my file something that contributes to my
19 answer to that, which is that in the invitation to
20 attend the 5 April 2007 meeting, addressed to me by
21 Jean Murray, senior infection control nurse, addressed
22 to me as consultant physician, she says:
23 "Since the disbandment of the Argyll and Clyde