1 Thursday, 1 March 2012
2 (10.00 am)
3 MR MACAULAY: Good morning, my Lord --
4 MR KINROY: My Lord, I wonder if I should just explain about
5 the documents from yesterday?
6 LORD MACLEAN: Yes, of course.
7 Discussion re documents
8 MR KINROY: In the time available, my Lord, the position is
9 this: the board staff have spent very many hours on the
10 task of searching for all documents conceivably relevant
11 and handing them over to the Inquiry, but despite that,
12 obviously this audit document turned up yesterday in the
13 hands of Judy Taylor.
14 Clearly, my Lord, if the board had known that this
15 document existed and that the Inquiry wished it, that
16 would have been handed over.
17 Now, the explanation appears to be this, that --
18 I should put this in context. There have been 116
19 requests for documents from the Inquiry to the board
20 since 24 September 2010 until 25 February 2011.
21 LORD MACLEAN: What was the second date?
22 MR KINROY: 25 February 2011. The board, overnight, has
23 done what it can to check to see if there was a specific
24 request for documents in a category which would include
25 audit of nursing records. Insofar as it has been able
1
1 to find out overnight, there has been no such request
2 for documents falling within that category.
3 LORD MACLEAN: That is looking at it, if I might say so,
4 a little too specifically.
5 MR KINROY: My Lord, I'm not finished yet.
6 LORD MACLEAN: I beg your pardon.
7 MR KINROY: As it happens, quite spontaneously,
8 in June 2011, the director of nursing for the acute
9 division had a meeting with the senior charge nurse,
10 including Judy Taylor, and one of the issues which was
11 discussed was the state of care planning and documents
12 pertinent to that, and specifically asked of the group
13 was the question, "Do you have any record of audit of
14 nursing records?", and that was a negative.
15 LORD MACLEAN: That was an item?
16 MR KINROY: No-one apparently had any documents to hand
17 over. But furthermore, my Lord, as I understand it, on
18 6 September, the director of the rehabilitation and
19 assessment directorate, because she was aware of
20 the evidence given by Anne Madden, communicated directly
21 with Judy Taylor to ask if she in fact had any documents
22 concerning the audit of nursing records, and the answer
23 to that was no.
24 My Lord, I can't understand why that should have
25 happened or why Ms Taylor should have turned up
2
1 yesterday with this document, but it came as a complete
2 surprise to the board. That is all I can find out at
3 the moment. This has arisen quite suddenly, but the
4 board, of course, takes the matter very seriously
5 indeed.
6 LORD MACLEAN: That is very helpful.
7 My assumption, I think, from what you have just
8 said, is that the board realised from Mr Orr's letter --
9 actually, the decision I made which was communicated in
10 the letter, I think it is 11 May, where the interest
11 lay, especially in a nursing sense, for the Inquiry, and
12 one of them was, of course, care planning.
13 MR KINROY: Yes, care planning.
14 LORD MACLEAN: So I see that. Thank you very much. As long
15 as they keep it under their attention, I don't suppose
16 there is much more you can do.
17 MR KINROY: My Lord, they very much do. In fact, I have
18 a bundle of documents which has brought home to me quite
19 vividly how much effort is put in week by week by the
20 board and, further, I think, vouching of the seriousness
21 with which the board takes it, I have with me the head
22 of board administration and the director of nursing for
23 the acute division. So, my Lord, I don't think there
24 can be any suggestion that anything other than zeal has
25 been applied to this task.
3
1 LORD MACLEAN: I'm glad to hear that and I hope that will
2 continue, and I hope that nothing starts to --
3 MR KINROY: My Lord, having met these officers, I have no
4 doubt it will.
5 LORD MACLEAN: It probably will. I think something will
6 surface unexpectedly, as with yesterday's document.
7 Thank you very much indeed.
8 MR MACAULAY: My Lord, the next witness I would like to call
9 is Craig Nixon.
10 MR CRAIG DAVID NIXON (sworn)
11 Examination by MR MACAULAY
12 MR MACAULAY: Are you Craig Nixon?
13 A. I am.
14 Q. Can you tell the Inquiry what position you hold at
15 present?
16 A. At present, I am a BI data analyst for Scottish Sea
17 Farms.
18 Q. For how long have you held that particular position?
19 A. Since May last year.
20 Q. Before that?
21 A. Before that with Capita.
22 Q. There was a time, I think, when you were working in the
23 Vale of Leven Hospital; is that right?
24 A. Yes.
25 Q. When was that?
4
1 A. It was before Capita. 2006/2007, I think it was.
2 Q. What is your background? I think you have some
3 involvement with computers; is that right?
4 A. Yes.
5 Q. Can you just give us some understanding as to what your
6 background is?
7 A. My background is in spreadsheets, SQL, and a little bit
8 of programming.
9 Q. When you were working in the Vale of Leven Hospital,
10 what position did you hold there?
11 A. It was quality effectiveness facilitator.
12 Q. Were you connected to the infection control team?
13 A. Yes.
14 Q. I can put your job description on the screen, and that
15 is at GGC30310001. We are looking at a job description.
16 It doesn't have your name, but we can see the job title
17 is "Divisional quality and effectiveness facilitator".
18 Is that the post you held in 2006/2007?
19 A. I don't recall the word "Divisional" on it.
20 Q. But the rest of it fits?
21 A. It certainly looks like it, yes.
22 Q. If we just look at the section dealing with job purpose
23 and dimensions, what we read is:
24 "To contribute to, and support the implementation
25 of, appropriate quality and effectiveness systems to
5
1 enable the organisation to deliver evidence-based, safe
2 care and high-quality services."
3 Did that form part of your job plan?
4 A. In terms of the spreadsheets and the databases, I would
5 take that from that, yes.
6 Q. Was that within the context of infection control?
7 A. Yes.
8 Q. If you look at the last paragraph in this section, we
9 read:
10 "The post holder may specialise in one project area,
11 such as infection control surveillance audit and
12 programmes ..."
13 Really, was that what you did specialise in when you
14 were in the Vale of Leven?
15 A. "Infection control surveillance audit and programmes
16 guidelines implementation". I'm not sure I specialised
17 in that, no.
18 Q. In any event, Mr Nixon, you really worked with the
19 infection control team over this period that you were
20 employed at the Vale of Leven?
21 A. Yes.
22 Q. You said up to 2007. Was it in December 2007 that you
23 left the Vale of Leven?
24 A. Yes.
25 Q. Although you have indicated you were working in the
6
1 Vale of Leven, did your commitments also mean that you
2 went to Gartnavel to do work?
3 A. Yes, that was a separate contract.
4 Q. How many days a week would you spend at the
5 Vale of Leven?
6 A. Three days, three days at the Vale and two days at
7 Gartnavel, but I wasn't based at Gartnavel. I was doing
8 audits on GP clinics, opticians, that kind of thing.
9 Q. Not to do with infection control?
10 A. No.
11 Q. Can you just give the Inquiry a general understanding as
12 to what your job involved, then, in the Vale of Leven?
13 A. I would say general administration. I could be doing
14 something silly like pasting spreadsheets into a report
15 or I could be actually doing some number crunching on
16 a spreadsheet or creating a database to capture
17 information.
18 Q. All within the context of infection control?
19 A. Yes.
20 Q. So far as producing spreadsheets, and so on, did you do
21 that on a regular basis?
22 A. That was on a regular basis, yes.
23 Q. For example, were you also involved in preparing
24 quarterly reports for the infection control team?
25 A. Yes, the quarterly reports were the main ones.
7
1 Q. Does the fact that they were quarterly mean they were
2 reports that were designed to cover a particular period
3 within the year; is that right?
4 A. Yes.
5 Q. How often would you have to produce these reports?
6 A. Every quarter.
7 Q. So it wouldn't be on a running basis, then?
8 A. Every three months.
9 Q. Can you just indicate where you were located when you
10 were based at the Vale of Leven?
11 A. Next to the infection control office.
12 Q. Did you have your own office there then?
13 A. I shared with Isobelle, yes.
14 Q. Is that Isobelle McIntyre?
15 A. Yes.
16 Q. Was she the secretary to the infection control team?
17 A. Yes.
18 Q. So far as the infection control office was concerned,
19 then, was that used by the infection control nurses?
20 A. Yes.
21 Q. At that time, were they Jean Murray and Helen O'Neill?
22 A. Yes, they were.
23 Q. Did you, yourself, ever get involved in visiting the
24 wards in the hospital?
25 A. No.
8
1 Q. Who was your line manager at this time?
2 A. Jean Murray.
3 Q. Did you know who the infection control doctor was at the
4 time?
5 A. At the time, I probably did, but I couldn't tell you
6 whose name it was. The name I do recall was Tom Walsh.
7 I know there was a microbiologist based over at
8 Inverclyde but, again, I can't remember names.
9 Q. Did the infection control doctor, so far as you could
10 see, ever visit the Vale of Leven Hospital when you were
11 there?
12 A. They may well have done, but they might not have come
13 into my office.
14 Q. So you didn't see the infection control doctor?
15 A. Yeah, exactly.
16 Q. Apart from the staff you have mentioned, because I think
17 another name you mention in your statement is
18 Adrienne Morgan?
19 A. Yes.
20 Q. Was she working there as well?
21 A. She was.
22 Q. Was she in your office?
23 A. She was in the infection control nurses' office.
24 Q. What was her function?
25 A. She was an infection control nurse. I think she was an
9
1 infection control nurse specialist.
2 Q. Had she left the Vale of Leven before you left there
3 yourself?
4 A. Yes.
5 Q. Can I then just focus on the database that was being
6 used in infection control. As I understand it, one of
7 your responsibilities was to manage the database; is
8 that right?
9 A. Yes.
10 Q. Can you tell us a little bit about that? What sort of
11 system was it?
12 A. It was an access database with forms to allow the user
13 to key in information and reports that could be run in
14 the background, and the reports were the quarterly
15 reports. I would also add fields, or dropdown lists, to
16 the database as required.
17 Q. Apart from yourself, who else operated the database?
18 A. Jean Murray and Helen O'Neill could operate it. They
19 certainly keyed information in.
20 Q. Insofar as the information that was input into the
21 database would be concerned, would that then be done by
22 Mrs Murray and Mrs O'Neill?
23 A. That would have been, yes.
24 Q. Did you, yourself, input data?
25 A. No.
10
1 Q. So far as you know, did Mrs McIntyre input data into the
2 database?
3 A. Not so far as I'm aware, no.
4 Q. What sort of data would the infection control nurses
5 input into the database?
6 A. It would have been the basic patient details, the
7 patient's name, their address, which ward they're in.
8 I think what the symptoms were and, if the results from
9 the lab came back as C. diff positive or if it was
10 norovirus, that type of thing, what date they came back
11 on.
12 Q. So if we are focusing on C. diff, they would enter the
13 patient's details, the ward the patient was in; is that
14 correct?
15 A. Yes.
16 Q. The fact there was a positive result?
17 A. Yes.
18 Q. The date of that result?
19 A. Yes.
20 Q. So that sort of information could be input?
21 A. Correct.
22 Q. Would that be the information then that you would be
23 focusing upon when you came to produce your quarterly
24 report for C. difficile?
25 A. Yes.
11
1 Q. What did you understand the reasons to be for producing
2 quarterly reports?
3 A. To see an historical -- to see a trend and to see what
4 the historical basis of it was.
5 Q. Do you know what use was made of these reports?
6 A. I do not, no. I know they were taken to the quarterly
7 meetings, but I don't know what was done after that.
8 Q. Insofar as the production of the reports would be
9 concerned, do I take it that that was your function and
10 the infection control nurses did not do that themselves?
11 A. That's correct.
12 Q. Were they able to do that themselves if they so wished?
13 A. I don't know. I would assume they could, because it's
14 just clicking a button.
15 Q. Apart from producing reports, did you also produce
16 graphs to indicate what the trends might be?
17 A. Yes, that was from the spreadsheets, yes.
18 Q. That comes under the heading spreadsheets?
19 A. Yes.
20 Q. Perhaps we can look at some of this material, then. If
21 we could have on the screen GGC13260006, we, ourselves,
22 have looked at this before, but this is a minute of
23 a meeting of the Clyde acute infection control support
24 group, and what I want you to look at is what is
25 attached to that and, if you could look at page 17, do
12
1 we see here -- if we look at the bottom table, for
2 example, it is headed "Clostridium difficile positive,
3 symptomatic patients for period 1/7/06-18/4/07". At the
4 bottom, we can read it is a quarterly report
5 for May 2007. Do you see that towards the very bottom
6 on the right?
7 A. Yes.
8 Q. Would this be the sort of material that you would
9 produce?
10 A. It would be, yes.
11 Q. Who would ask you to produce this?
12 A. Jean.
13 Q. So far as you are concerned, were you someone who could
14 interpret trends, or were you simply just producing the
15 data?
16 A. I would just simply produce the data. I couldn't really
17 analyse why the trend was going up or why it was going
18 down, or anything like that.
19 Q. That would be down to the infection control nurse?
20 A. Yes.
21 Q. If you look at page 18, we are looking here at a graph
22 headed "C. diff trend from July '06 to April '07".
23 Again, was this the sort of material you could
24 produce --
25 A. That looks like the material, yes.
13
1 Q. Would this be under your spreadsheet?
2 A. It would.
3 DAME ELISH: Sorry, my Lord, to interrupt, just by way of
4 explanation, I wonder if it is the case that the jagged
5 line is the actual numbers and the straight line the
6 underlying trend?
7 A. Yes.
8 LORD MACLEAN: That's what I would have thought, yes.
9 DAME ELISH: I'm obliged.
10 LORD MACLEAN: When you agree it is the underlying trend,
11 what do you mean?
12 A. The direction of the number of C. diff patients is
13 increasing, so the heavy black line is climbing.
14 MR MACAULAY: We can all see, I think, that that is what is
15 happening, but insofar as the actual analysis of these
16 trends would be concerned, that was left to Mrs Murray?
17 A. That would have been Jean, yes.
18 Q. Perhaps we can leave that aside and look at another
19 document, GGC13340004. Here we have a document that's
20 headed "C. diff quarterly report", and the first section
21 is dealing with patients with Clostridium difficile
22 infection. Do you see that?
23 A. Yes.
24 Q. Again, as the document tells us, would this be the
25 quarterly report?
14
1 A. It is.
2 Q. Is this up to September 2007? There are no entries in
3 for December?
4 A. No, that's correct.
5 Q. So it covers a period up to September 2007?
6 A. Yes.
7 Q. Indeed, you left in December; is that correct?
8 A. That's correct.
9 Q. What about the box at the bottom? Would that be
10 something you would generate as well? It is headed
11 "Clostridium difficile across ward"?
12 A. That does look like something I would produce, yes.
13 Q. Would you be asked to produce that sort of presentation
14 by Mrs Murray or Mrs O'Neill?
15 A. Yes.
16 Q. Again, was this something that you were able to do on
17 your spreadsheet programme?
18 A. Quite easily, yes.
19 Q. Again, I understand your position to be that you can't
20 interpret the trends, but it was designed, in any event,
21 to produce, in a particular form, the presence of
22 C. difficile on a ward-to-ward basis?
23 A. Yes.
24 Q. Perhaps while we have this on the screen, if you turn to
25 page 5, we are looking again at another C. diff
15
1 quarterly report; is that correct?
2 A. Yes.
3 Q. I think it is fairly similar to what we have looked at,
4 but, again, do we see that, for the period October
5 to December it is blank, because it only covers up
6 to September?
7 A. Yes.
8 Q. I think what you have been saying so far is that the
9 material that you were being asked to produce from the
10 database was being produced on a quarterly basis?
11 A. Yes.
12 Q. Could the material have been produced on a more regular
13 basis?
14 A. It could, yes.
15 Q. For example, could you have produced this form of data
16 indicating the numbers of C. diff patients in each ward
17 in a week?
18 A. Yes. What it would rely on is the data being in the
19 database.
20 Q. I'm sorry?
21 A. It would rely on the data actually being in the database
22 each week.
23 Q. Yes, if the material was there, then you could produce
24 the material?
25 A. Yes.
16
1 Q. So far as the input of the data was concerned, can you
2 just tell me how that operated in practice? Would you
3 be there when either Mrs Murray or Mrs O'Neill input the
4 data?
5 A. No.
6 Q. Why not?
7 A. Well, there's a separate room, so they'd probably log
8 onto the database from their office and key the
9 information in.
10 Q. So they had their own outlet --
11 A. Yes.
12 Q. -- and they put the data in from there?
13 A. Yes.
14 Q. Do you know what sources they used to provide them with
15 the data?
16 A. The blue card system. They filled in the blue cards
17 based on what -- the patients in the ward: who was
18 symptomatic with C. difficile and had it been confirmed
19 by the lab?
20 Q. I think we know there was a T Card system in place?
21 A. Yes.