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1 (10.00 am)
2 Monday, 7 June 2010
3 THE CHAIRMAN: Welcome to the start of the oral hearings for
4 the Vale of Leven Hospital Inquiry. My name is
5 Lord MacLean, and I am the chairman of the Inquiry.
6 I want to begin by making a few remarks about the
7 Inquiry and its forthcoming stages. Can I ask that
8 everyone present ensures that their mobile phones are
9 turned off or set to silent mode.
10 Since the start of our Inquiry in October, we have
11 been engaged in gathering documentary evidence from
12 a wide range of sources and taking statements from key
13 witnesses -- indeed, that process is still ongoing. We
14 are currently taking statements from staff at the
15 Vale of Leven Hospital and will be moving on to
16 Health Board managers and experts in infection control.
17 We held a preliminary hearing on 1 February, and
18 have now reached the stage where our oral hearings can
19 begin.
20 We will sit here, at Maryhill Community Central
21 Halls, from Mondays to Thursdays, starting at 10 am,
22 breaking mid-morning, usually at 11.30 am. Lunch will
23 be between 1 pm and 2 pm and we will try to fish by 4 pm
24 each day.
25 This is, of course, a public Inquiry and members of
1
1 the public who wish to attend are encouraged to do so.
2 If anyone wishes to follow the evidence but cannot be
3 here in person, they will be able to do so each day by
4 viewing a transcript of the day's proceedings on the
5 Inquiry website.
6 Our hearings start today and we expect to conclude
7 the patient and family evidence early next week.
8 Assuming that we have a sufficient number of witnesses
9 available, I would hope to reconvene the hearings on
10 Monday, 30 August for approximately six weeks. We will
11 have a two-week break from 11 October, resuming on
12 25 October, and continue until all the oral evidence is
13 complete, hopefully by mid-December. The hearings stage
14 will end with closing submissions by core participants
15 in late January 2011.
16 My team and I will then consider all of the evidence
17 and I will lead the writing of the Inquiry's report,
18 which I expect to provide to Scottish ministers and core
19 participants some time in May 2011, with publication at
20 the end of that month.
21 This, at least, is our plan. However, I will urge
22 you to regularly check the Inquiry website,
23 www.ValeofLevenHospitalInquiry.org, because if there are
24 any variations to the schedule, you will be able to keep
25 up to date with these.
2
1 Over the coming days, we will hear from surviving
2 patients and relatives of those affected by the tragic
3 outbreak of C. difficile at the Vale of Leven Hospital.
4 The process of recalling events will, inevitably, bring
5 back painful memories for relatives who lost someone
6 close to them, but this is a vital part of the evidence
7 to the Inquiry.
8 Before turning to the formal business of today,
9 I would invite you to stand, if you feel that is
10 comfortable, and join me, please, in a moment of
11 reflection to remember those who died.
12 (One minute's silence observed)
13 I would now invite Colin MacAulay QC, senior counsel
14 to the Inquiry, to say a few words about how the
15 proceedings will work.
16 MR MACAULAY: As your Lordship has already said, this first
17 phase of the Inquiry is dedicated to the evidence of
18 patients who suffered from C. difficile while in the
19 Vale of Leven Hospital, and relatives of patients who
20 died and also suffered C. difficile during their stay in
21 the hospital.
22 Former patients and many relatives have provided the
23 Inquiry team with signed statements. These signed
24 statements have already been circulated to the core
25 participants.
3
1 The evidence during this first phase will be of two
2 kinds. Firstly, oral evidence will be led from a number
3 of witnesses in the course of the next two weeks. Each
4 witness will be placed on oath or asked to affirm and
5 provided with a copy of his or her statement.
6 Thereafter, I shall lead that witness through the
7 statement, in the main by reference to the statement,
8 but also seeking some elaboration and clarification of
9 that witness's evidence.
10 That then is the oral evidence, and the core
11 participants have been provided with a list of
12 the proposed witnesses in this first phase.
13 Secondly, and additionally, the Inquiry does accept
14 as relevant evidence the signed statements of all those
15 who have provided and assisted the Inquiry with such
16 statements, and in the course of this first phase, all
17 of the core participants will be provided with a list of
18 those witnesses. Their statements have already been
19 provided to them.
20 Witnesses have been programmed to attend this week
21 and into next week. Every effort will be made to ensure
22 that any prospective witness will suffer as little
23 inconvenience as possible by giving evidence.
24 That is all I propose to say at this stage, my Lord,
25 and I am prepared and ready to start with the first
4
1 witness.
2 THE CHAIRMAN: Well, I know we haven't sat here very long so
3 far, and we will be sitting here a great deal longer in
4 the future, but I think we should take a break now.
5 Could we start again at quarter to 11?
6 MR MACAULAY: Very well, my Lord.
7 THE CHAIRMAN: We might then go straight through to lunch
8 from there.
9 MR MACAULAY: I think so, my Lord.
10 THE CHAIRMAN: I should perhaps invite those with cameras
11 now to leave. We will use this break for them to leave.
12 Thank you very much.
13 (10.09 am)
14 (A short break)
15 (10.45 am)
16 THE CHAIRMAN: Mr MacAulay, your first witness?
17 MR MACAULAY: I think your Lordship has been provided with
18 a list of witnesses.
19 THE CHAIRMAN: I have.
20 MR MACAULAY: The first witness is number 1 in the list, and
21 that's Mrs Brenda Bowes.
22 MRS BRENDA BOWES (sworn)
23 Examination by MR MACAULAY
24 MR MACAULAY: Good morning, Mrs Bowes. Are you Brenda
25 Margaret Bowes?
5
1 A. Yes, I am.
2 Q. I think you are employed as a primary school teacher; is
3 that correct?
4 A. Yes.
5 Q. Do you have your witness statement in front of you?
6 A. I do, yes.
7 Q. I think that you are the daughter of Margaret Ellis
8 Dalton; is that correct?
9 A. Yes, I am.
10 Q. Your mother died in the Vale of Leven Hospital on
11 31 December 2007?
12 A. Yes, she did.
13 Q. She was 74 at that time; is that correct?
14 A. Yes.
15 Q. I think I'm right in saying that your mother lived with
16 you?
17 A. She did, yes.
18 Q. For how long had she lived with you?
19 A. About nine years.
20 Q. You and your family.
21 A. Yes.
22 Q. Do you live in the catchment area of
23 the Vale of Leven Hospital?
24 A. Yes, I do.
25 Q. I want to ask you about the morning of 18 November 2007.
6
1 I think that morning you had taken your children
2 swimming; is that correct?
3 A. Yes, I had, yes.
4 Q. Did something happen then that morning?
5 A. Yes. When I returned, my mum had fallen out of bed.
6 She had been suffering from sweats, night sweats, for a
7 period a couple of months prior to that. She had fallen
8 out of bed and she was so weak she couldn't get herself
9 back into bed. She'd also suffered -- she'd also gone
10 to the toilet and she was really embarrassed about this.
11 She was a very private person and really don't want help
12 from myself or my husband, but we managed to get her
13 back into bed, but we had to call the -- I don't know --
14 I can't remember whether we actually called the
15 out-of-hours service, you know the service, or whether
16 we directly called the Vale of Leven, but we called and
17 we were sent an ambulance in the afternoon.
18 Q. I think you arrived home and you found that your mother
19 had this problem; is that right?
20 A. Yes.
21 Q. I think in your statement --
22 MR PEOPLES: I'm sorry to interrupt. I have been passed
23 a message that the families who are sitting in the
24 gallery are having some difficulty hearing the witness.
25 THE CHAIRMAN: Thank you, Mr Peoples. It may be because the
7
1 windows are open.
2 MR PEOPLES: I'm not sure. It may be that the microphone is
3 not positioned at an ideal spot.
4 MR MACAULAY: Perhaps Mrs Bowes could come a bit closer to
5 the microphone.
6 A. Is that better?
7 MR MACAULAY: We are having nodding heads.
8 THE CHAIRMAN: If you ever have a difficulty, raise your
9 hand for me to see, all right?
10 Yes, Mr MacAulay.
11 MR MACAULAY: If you look at your statement, which I think
12 you have in front of you, I think what you say there is
13 it was NHS24 that you contacted.
14 A. That's what it was, yes.
15 Q. In any event, was your mother admitted to the
16 Vale of Leven Hospital?
17 A. Yes, she was admitted.
18 Q. Was that on that same day, then, 18 November?
19 A. Yes, I believe it to be that date, yes.
20 Q. Perhaps, if only just to test the technology, could
21 I ask you to look at GGC00140010. That will go on the
22 screen, so if you could look at the screen in a moment.
23 We are looking there at a document from the medical
24 assessment unit from the Vale of Leven. Can you see, if
25 you look to the top right, that the admission date --
8
1 this can be highlighted -- is 18 November 2007?
2 A. Yes.
3 Q. And the time that has been noted there is 15:30?
4 A. Yes.
5 Q. Does that accord with your own recollection?
6 A. Yes.
7 Q. If you look briefly into the text, which is under the
8 heading "Initial Assessment", if we can highlight that,
9 we read:
10 "Patient got up this morning 11 am, states she felt
11 weak."
12 So some history was given. Was that by your mother
13 or by you to the hospital?
14 A. Probably my mother.
15 Q. Once your mother had been in the medical assessment
16 unit, was she then moved to one of the wards within the
17 hospital?
18 A. Yes, she was moved to ward 4, as I recollect.
19 Q. I think in the past you have been shown a plan of ward
20 4; is that right?
21 A. Yes.
22 Q. Could you now look, please, at GGC00670001. I know it
23 is a bit of a mouthful, but we need that for the
24 technology. Can we just try to orientate you here,
25 Mrs Bowes. If we look towards the bottom, it is said to
9
1 be a plan of ward 4, and we see in brackets "Original"
2 has been written in. Can you tell me, under reference
3 to this plan, which room your mother was taken into in
4 ward 4?
5 A. I'm trying to orientate myself. I believe it to be the
6 one numbered 16, but I'm sure there was only one bed,
7 but I'm not 100 per cent sure. Is 01 the entrance?
8 Q. Yes. If you imagine 01 to be the entrance, and
9 certainly in your statement at paragraph 6 you said your
10 mother was placed in room 16, in the right-hand bay --
11 A. Yes, I believe it to be there, but if you look at the
12 bottom of that, it says two bed, but I believe, if
13 I recall correctly, it was one bed.
14 Q. In room 16?
15 A. Yes.
16 Q. Indeed, that's what you say in your statement, that it
17 was a single bed on the right of the bay that she was
18 put into; is that correct?
19 A. Yes.
20 Q. Thereafter, did you get a call to tell you that your
21 mother had been moved to the high-dependency unit?
22 A. Yes, in the early hours of the following morning.
23 Q. On the 19th?
24 A. Yes.
25 Q. If you could look at GGC00140214. Again, if we can
10
1 highlight the text, and we see the date at the top --
2 A. Yes.
3 Q. -- do we see that it is suggesting that following
4 a discussion with Dr Black, the decision was taken to
5 transfer your mother to the HDU; does that accord with
6 your recollection?
7 A. Yes.
8 Q. Indeed, it goes on to say that her daughter has been
9 informed by telephone.
10 A. Yes.
11 Q. So that's the telephone call you made reference to?
12 A. Certainly, yes.
13 Q. Did you then go to visit your mother in the HDU?
14 A. Yes.
15 Q. Was that the same day, 19 November?
16 A. Yes. We went -- when they called, we went to visit her.
17 Q. There and then?
18 A. Yes.
19 Q. What time was that?
20 A. I can't recall but it was very early in the morning,
21 probably 1, midnight -- after midnight, I believe.
22 I called my brother and both of us went.
23 Q. She spent some time in the high-dependency unit; is that
24 correct?
25 A. Yes.
11
1 Q. And, thereafter, where was she moved to?
2 A. Because the high-dependency unit was being closed, as
3 far as we were aware it was being closed around about
4 10 December, and she was moved -- I'm not 100 per cent
5 on the time -- but 7 or 8 December she was moved to ward
6 6.
7 Q. Again, if I could ask you to look at the medical
8 records, and this is GGC00140009. You will see that is
9 an admission form, and if we look at the date to the
10 left-hand side and highlight the date, the date is
11 3 December, and below that "ward 6". Might it be that
12 the transfer from the high-dependency unit to ward 6
13 occurred on 3 December?
14 A. It could possibly have been. I wasn't clear about that
15 at all. I could not remember. I knew that it was being
16 closed on the 10th, and I knew prior to that she had
17 been moved, but I honestly couldn't have recalled that
18 at the time. I guessed at the 7th or 8th.
19 Q. And it may be the case in your statement, and indeed in
20 other statements, that we will find dates that do not
21 coincide with the medical records. If the medical
22 records say a particular date, then you are prepared to
23 accept that as being the correct date?
24 A. Yes, I'm prepared to accept that. There are times when
25 I know exactly dates, but I couldn't recall that one.
12
1 Q. But once your mother had been moved to ward 6, did you
2 then visit her in ward 6?
3 A. Yes.
4 Q. Perhaps you could look, then, at a plan, GGC0070001.
5 You will see in the bottom left this is described as
6 "ward 6". Can you tell us what room in ward 6 your
7 mother was moved to?
8 A. 02 being the entrance again, yes?
9 Q. Yes.
10 A. She was moved to room 15, where she was the nearest to
11 the window on the left-hand side, top left.
12 Q. Yes. Now, if we go to your statement, I think your
13 recollection at the time of the statement was that your
14 mother was placed in room 14. You will see that in
15 paragraph 8.
16 A. It's maybe not as clear a diagram, but it's certainly
17 room 15.
18 Q. You think it was room 15?
19 A. Yes, I'm sure.
20 Q. How many beds were in that room?
21 A. Four.
22 Q. Did you say a moment ago which bed your mother was in?
23 A. Top left.
24 Q. Top left?
25 A. Top left.
13
1 Q. We know there were four beds. Can you say in relation
2 to each other how close the beds were?
3 A. If you take that the beds were -- obviously the bottoms
4 of the beds, it's quite spacious between the bottoms of
5 the beds, and the four were pointing -- the bottoms of
6 the beds were pointing towards each other. The cabinets
7 were to the right and the left of the beds, so that in
8 between there wasn't a cabinet and the beds were quite
9 close together, enough so that you couldn't get one of
10 those plastic bucket style chairs, which are quite wide,
11 but you couldn't get that between the two beds.
12 Q. That's effectively what you're saying in paragraph 8 of
13 your statement, isn't it?
14 A. Yes.
15 Q. You couldn't get a chair --
16 A. You couldn't get a chair in without nudging beds,
17 basically.
18 Q. What you say in your statement is that the beds were so
19 close that your mother could have held hands with the
20 patient next to her?
21 A. Yes, I remember my mother and the patient next to her
22 having a joke about that, "We could hold hands", so
23 that's why it's clear in my mind about that.
24 Q. At this time, when your mother first went to ward 6 on
25 about 3 December, were all the beds occupied?
14
1 A. As far as I can recall, yes. It was very busy.
2 Q. I think you've told us that your mother was 74 when she
3 died. The other patients in ward 6, can you give us
4 some feel as to whether they were elderly or --
5 A. There were a number of elderly patients, but the patient
6 directly opposite my mother was a young girl, maybe in
7 her 20s.
8 Q. I see.
9 A. That was when she initially went into that ward, and
10 then diagonally opposite was an elderly lady, probably
11 in her late 70s, and next to my mother a woman in her
12 late 60s. But I couldn't recall as to other bays
13 because obviously I wasn't interested in other bays, if
14 you like.
15 Q. By this time, during your mother's admission in the
16 hospital, what information had you been given by the
17 staff as to her condition?
18 A. We were kept quite closely up to date by Dr Clark, who
19 was the oncologist. Again, we didn't ask a lot of
20 questions, we just listened to what Dr Clark had to say
21 and knew that my mum had an uphill struggle and that she
22 was soon going for chemotherapy, and that was the
23 decision made.
24 Q. What diagnosis had been made, can you help us with that?
25 A. She had severe arthritis, and at a point, I couldn't
15
1 honestly tell you when she was diagnosed, but it was
2 non-Hodgkin's lymphoma was what she was eventually
3 diagnosed with. When, I'm not sure of that. But she
4 had severe arthritis for around ten years, hence the
5 reason she came to live with us. But she went onto
6 a programme with Gartnavel, I believe, and became very
7 mobile after having been quite immobile and lived a full
8 life and was on holiday regularly.
9 Q. When you tell us in paragraph 9 of your statement about
10 discussions with Dr Clark; I think you say you were kept
11 well informed by Dr Clark as to what the position was?
12 A. Yes, certainly. Well informed by Dr Clark; excellent,
13 yes.
14 Q. When your mother was moved into ward 6, how would you
15 describe her condition by then?
16 A. She was able to walk, able to get to the toilet by
17 herself. She was using a frame initially, because she
18 felt quite weak still, but then she was able to walk
19 unaided and she was quite buoyant and waiting for a care
20 package, as she'd been told, and that I would have
21 received a call -- Monday, 10 December I was waiting for
22 a call to take my mum -- someone from, I don't know who,
23 but at the care package, someone would have contacted me
24 to assess my home and ensure my mother could come home,
25 and we were expecting her home more or less that week.
16
1 I had made preparations for that: we'd moved her bed to
2 a room downstairs, and we had a downstairs toilet,
3 et cetera. So we were just waiting on being assessed,
4 if you like.
5 Q. If we go back to ward 6 and room 15 where you say your
6 mother was.
7 A. Yes.
8 Q. You have told us about the four beds. Can you tell me
9 if there is a wash hand basin in that particular room?
10 A. I don't recall there being one.
11 Q. Do you --
12 A. I remember a wash hand basin located at 05, the black
13 dot.
14 Q. Yes.
15 A. See exactly where the black circle is over the 05,
16 I remember a wash hand basin roughly there.
17 Q. You have cottoned on. I think the black dots are
18 designed to indicate a wash basin. You are confirming
19 that the absence of a black dot in room 15 coincides
20 with your own recollection?
21 A. Yes. I don't recall at all, there wasn't room enough
22 for one.
23 Q. Did your mother remain in room 15 while in ward 6, or
24 was she moved into any other rooms within the ward?
25 A. She was moved again.
17
1 Q. How long do you think elapsed from being in ward 15 to
2 being moved again?
3 A. I am definite that she was not moved until after Monday,
4 10 December, either -- it could have been the evening of
5 Tuesday the 11th, the morning of Wednesday the 12th, it
6 could even have went into the Thursday, but I think the
7 Tuesday or the Wednesday she was moved.
8 Q. The date roughly for that?
9 A. Roughly 11, 12 December.
10 Q. Where was she moved to?
11 A. She was moved to room 13.
12 Q. Did you say room?
13 A. 13.
14 Q. 13, yes. We can see that on the plan that's still on
15 the screen. How many beds would you say were in that
16 room?
17 A. There were two beds, one located -- the headboard was
18 touching the wall of room 14, and my mother's bed, the
19 headboard was touching the wall of room 12.
20 Q. In relation to wash hand basin, can you remember --
21 A. No, there certainly wasn't one.
22 Q. Was there somebody else in that room when your mother --
23 A. Yes, an elderly lady.
24 Q. Were you given any explanation as to why your mother was
25 moved then from room 15 to room 13?
18
1 A. I asked, I think, upon entering and discovering she
2 wasn't in the bed where she was, and someone said, "Oh,
3 just --", I can't recall whether it was prior to
4 chemotherapy or after chemotherapy, that it was either,
5 "Oh, she's going to be in chemotherapy so we just want
6 to keep an eye on her and move her nearer to the nurse's
7 station", or whether it was post.
8 Q. Perhaps you can help me on that. Where was the nurses'
9 station, if you look at the plan on the screen?
10 A. It's difficult to look at. Either in front of 10 or 9.
11 Q. Right.
12 A. Around about in front of 9.
13 Q. So from the nurses' station they would have a good view
14 of your mother in room 13?
15 A. Yes.
16 Q. We've been talking about wash hand basins and you
17 mentioned the wash hand basin at 05. So far as you can
18 remember, was that the closest wash hand basin to wards
19 15 and 13?
20 A. It's the one I did use at one point when my mum was in
21 13, but only when she was later moved again did I notice
22 one outside room 11.
23 Q. Outside where, sorry?
24 A. Room 11.
25 Q. Yes.
19
1 A. I don't recall it being where the black dot is, if
2 that's what the wash hand basins are. I would --
3 Q. You would have --
4 A. And the door doesn't open -- I don't recall.
5 Q. Are you saying the wash hand basin that's the black dot
6 at 10 is outside rather than --
7 A. It was -- yes, it was outside room 11.
8 Q. Okay.
9 A. Yes. 10 isn't a room. I don't kind of recall that
10 shape, but certainly outside room 11, when I opened my
11 door, slightly to the right was a wash hand basin on the
12 wall opposite.
13 Q. If you look at paragraph 11 of your statement, on
14 page 3, you give an account there about a recollection
15 of someone being taken to room 12, which was an
16 isolation room?
17 A. Yes.
18 Q. I think we can see that right next to room 13 on the
19 plan. And that her family went with her and they were
20 all wearing gloves and aprons. Can you just tell me
21 about that. First of all, when was that, can you tell
22 me?
23 A. Again, I can't recall, but my mother was still in room
24 15 and she had -- I would reckon it was the week of
25 10 December. I think a doctor had come to speak to my
20
1 mum and pulled the curtain around, and myself and my
2 family moved back and we were standing in the corridor
3 about 05, and we went to go out and at that a bed came
4 past with a woman in it and was taken directly to room
5 12. We looked and all the family were asked to put on
6 gloves and aprons, and I remember my brother and
7 I making a comment along the lines of, "Oh, that looks
8 quite serious", and -- just because we hadn't seen that
9 before, people being gloved up, et cetera, and an
10 elderly lady, I believe, to be taken into room 12. And
11 then we saw them after that with the gloves and aprons
12 on and remember thinking, "Oh, must be something
13 serious", but other than that, it was just a memory,
14 a recall.
15 Q. In the next section of your statement, you draw
16 a comparison between the number of visitors that were
17 permitted into the high-dependency unit --
18 A. Yes.
19 Q. -- and the visitors into ward 6. What is the point you
20 are making there?
21 A. I just -- high dependency -- obviously being
22 a high-dependency unit visiting was very strict, and we
23 were used to that, very strict, and we were quite
24 shocked when we went to ward 6, about how relaxed the
25 visiting was and that -- at one point, I think the first
21
1 day, the patient next to my mother had grandchildren and
2 there were about four grandchildren on the bed with her
3 crawling about, and we were -- I just think because we
4 had been so used to the high dependency strict
5 regulations, if you like, that we were quite concerned
6 about that, and we kept to minimum numbers ourselves, as
7 a family. We were concerned about the number of
8 visitors being allowed in.
9 Q. The other point you raised there is in relation to hand
10 washing. What instructions were you given in relation
11 to hand washing when your mother was in ward 6?
12 A. When she was first admitted I was given no information
13 whatsoever, but because, again, how I'd been used to
14 washing my hands -- using the alcohol gel on my hands as
15 I entered the high-dependency unit, we kept that up and
16 in fact I actually said to some visitors, "Here, you can
17 actually use this".
18 Q. Perhaps I should ask you: where were the washing gels,
19 the hand gels?
20 A. I only recall one, which was on your left-hand side
21 around about -- it could have -- in the corridor 02 on
22 your left-hand side after room 04.
23 Q. So on the wall?
24 A. On the wall.
25 Q. I think the pencil is in the wrong place. The pencil is
22
1 pointing to that general area?
2 A. Yes, yes, further up, past entrance to 04.
3 Q. Coming back to room 13, you make some mention in
4 paragraph 13 about the fact that it was also used as
5 a storage area; is that right? Can you just elaborate
6 upon that?
7 A. When -- on entering room 13 there was, on the right-hand
8 side, a wooden long unit that regularly nursing staff
9 came to access stuff. I couldn't recall whether it was
10 cupboards or drawers, but it certainly seemed to have
11 things like, I don't know, medical supplies within.
12 I didn't look closely, but they accessed that quite
13 regularly.
14 There was, on your left-hand side -- and there's
15 a door there which I can't recall being there -- there
16 was a metal unit which did have some sort of covering,
17 possible covering, but that was either pulled up or tied
18 back, and that was bed linen, linen for the ward, or
19 that half of the ward, which was accessed regularly --
20 not personally when I was there, but my mum said
21 regularly the nurses accessed bed linen from that unit.
22 Then one day, again I couldn't recall when -- or
23 maybe I did in my statement but I can't recall now --
24 I was sitting, and what I believe to be an auxiliary
25 passed with a little kind of parcel truck, and she had
23
1 stacked about three, four high cardboard boxes, and
2 I actually offered to help, and I said, "Oh, what's
3 this?" And she proceeded to take them down and she
4 said, "Well, it's the stores. If we don't take what we
5 need, we will -- it will be gone, so we have to access
6 as much as we can", and she said, "so we just store it
7 here".
8 Q. So were the cardboard boxes that you've mentioned then
9 stored in room 13?
10 A. They were stored against the wall in room 13 -- on the
11 wall of room 12, in that corner, and along beside, that
12 whole area was cardboard boxes. So I would say between,
13 I don't know, four to -- it could be, no, it was much
14 more than that, ten cardboard boxes of various sizes and
15 shapes.
16 Q. I think you also mentioned there was an old Christmas
17 tree in that room?
18 A. Yes. I can't recall if it was actually up, but I just
19 remember a forlorn-looking Christmas tree. Perhaps
20 a television on the table in the corner opposite the
21 entrance. There was a table, there was stuff stored
22 underneath, there was a Christmas tree and a television,
23 I believe.
24 Q. We will look at this later when we come to the point in
25 time when your mother I think is given a weekend pass.
24
1 A. Yes.
2 Q. But did your mother say anything to you about the impact
3 of this traffic on her, for example, ability to sleep?
4 A. Yes, she said she was woken throughout the Thursday
5 night and the Friday night, and when I went to collect
6 her on the Saturday she said she had a terrible night
7 and hadn't slept most of the night due to constant
8 traffic in collecting supplies.
9 Q. I think we will come to the point -- I think it was
10 the Saturday -- when your mother got a weekend pass; is
11 that correct?
12 A. Yes, certainly.
13 Q. What date would you say that was?
14 A. It was Saturday, 15 December.
15 Q. If you look at the medical records again, it is
16 GGC00140245. If we move down towards the bottom third
17 of the page, and this is against the date 13 December at
18 about 19:10, do you see there is an entry:
19 "Settled evening, no complaints, for weekend pass as
20 from AM".
21 Do you see that?
22 A. Yes.
23 Q. If you go to the next page, 246, just turn the page. If
24 we look against the date, 17 December, 11.20 I think
25 that may be, if we highlight that entry:
25
1 "Returned from weekend pass. Unwell."
2 It looks like 11 o'clock, rather than 11.20. Can
3 you tell me what day of the week it was that your mother
4 returned with her weekend pass?
5 A. Monday, 17 December.
6 Q. So you are saying it was then on the Saturday, the 15th,
7 that she actually got it?
8 A. Saturday, the 15th, yes.
9 Q. On the Friday, the 14th, I think you went to visit your
10 mother, and you tell us about that in paragraph 14 of
11 your statement. I think she had some difficulty in
12 getting to the bathroom, is that correct? Can you just
13 elaborate upon that?
14 A. Quite regularly she had said to me in that week that
15 there had been times when going to the toilet -- she was
16 a very, very proud person. She would never complain.
17 Much to her annoyance sometimes she would wait until we
18 arrived so we could ask for the commode, because she'd
19 get up to go to the bathroom and it was maybe occupied
20 with people showering, and she said she believed there
21 to be -- she said there was a lot of diarrhoea and
22 people were unwell on the ward, and there seemed to be
23 a lot of use of the shower, et cetera.
24 I'm unaware of if both -- I think there were two
25 toilets in the ward, I'm unsure. I just remember my mum
26
1 saying there was definitely a shower in one, but I don't
2 know if that to be true. It was my mum that said that,
3 and that she couldn't get in because the shower was
4 being used regularly, and she'd asked for a commode
5 I think several times.
6 Q. Can we just get the plan up again, it is GGC00670001.
7 Can you help me, Mrs Bowes, as to where the toilets
8 and shower facilities were then on the --
9 A. I'm sorry, I can't, because --
10 Q. You can't.
11 A. -- again, my mum would never have -- you know, she just
12 was such a -- a quite annoying person at times. She
13 really wouldn't have let me accompany her to the toilet
14 so therefore I really couldn't tell you. I guess when
15 she was in room 14 -- or is that a different plan? Is
16 that --
17 Q. No, this is ward 4. It should be ward 6.
18 A. Yeah. She was room 15.
19 Q. We had it up before.
20 A. Yes, that's a different ward. When she was room 15,
21 I would recall her disappearing out to go to the toilet
22 around about 22, 21, 20, somewhere there, but I honestly
23 couldn't tell you of any other locations of toilets.
24 Q. But on this Friday we were talking about then, there was
25 a problem because the showers were so busy and you
27
1 said -- were you told by your mother there was
2 a diarrhoea problem in the ward?
3 A. Yes, she told me that, that had obviously been something
4 she'd heard, that a lot of people had diarrhoea. There
5 was a lot of changing of sheets and things.
6 Q. And she had to use the commode; is that correct?
7 A. Yes. And, again, this is -- she told me that she found
8 the commode to be quite -- very old and she was quite
9 upset in using it.
10 Q. I think what you said in your statement is that the
11 commode was rusty, dirty and quite disgusting?
12 A. That's what my mum had said to me.
13 Q. You yourself never saw the commode?
14 A. No.
15 Q. At the time of that visit, on 14 December, the day
16 before your mother was going to come home for the
17 weekend, how was she?
18 A. On the 14th she was in quite good spirits, tired, but on
19 the Saturday morning she was very tired and very quiet,
20 and had said to us -- again, much was said in the car
21 rather than in the hospital. You know, it was after
22 she'd been out and she said, "Oh, I didn't want to say
23 anything." In fact, it was home before she actually
24 said, "I didn't really want to say anything", because
25 I thought she was very quiet, and she said, "I was
28
1 tired".
2 She would never have made this known to the staff.
3 She thought the staff were wonderful and didn't want to
4 annoy them, and she felt she was always -- she was --
5 she just felt that, you know, she was an annoyance to
6 the staff and didn't want to be that. She felt they
7 were run off their feet and didn't want to ask the staff
8 anything, and she just wanted to go home for the weekend
9 and was scared to say, "I'm not feeling very well", and
10 she didn't really tell us that until the afternoon at
11 some point.
12 Q. On the Saturday?
13 A. On the Saturday.
14 Q. In relation to being tired, did she explain why she was
15 tired?
16 A. Yes, she said she'd been kept awake most of the night
17 due to staff coming back and forwards collecting linen,
18 et cetera.
19 Q. At this point, the point when your mother came home
20 early on for the weekend pass, did she say to you
21 whether she was suffering from any diarrhoea?
22 A. No, certainly didn't. And she didn't -- I mean, not
23 only did she not, but we have a downstairs toilet, and
24 she certainly didn't access that regularly. I mean, I'm
25 not saying I would know, because of the type of person
29
1 my mother was, but there certainly was no rush to the
2 toilet at any point during that day.
3 Q. Did she give you any information, either in the car or
4 when she got home, as to what the position was in the
5 ward, as to whether there was anything wrong at all?
6 A. Oh, she said several times that she -- there was
7 certainly something going on in the ward. There was an
8 excess of diarrhoea and she just knew there was
9 something going on. I can't recall her exact words, but
10 I remember her telling me, you know, that that certainly
11 was the case, "There's something happening in the ward".
12 It's like she felt it was highly unusual, the amount of
13 linen that was being changed, and she felt that people
14 were ill on the ward.
15 Q. In paragraph 17 in your statement, you say at the bottom
16 of the page that she told you she thought there was some
17 kind of bug in the ward?
18 A. Yes. She said something like a kind of bug, you know,
19 and she had no idea. She obviously felt there was some
20 sort of bug. At that point, there was no mention of
21 what kind of bug or anything, but she felt there was
22 something going on in the ward.
23 Q. In the period of the weekend, then, when she was at home
24 with you, how was she?
25 A. That evening she sat with her grandchildren, my three
30
1 daughters, on her knee. Sorry.
2 She was very happy, but she said, due to her
3 tiredness, after the girls had gone to bed, that she
4 felt she wanted to go to bed also, so she got herself
5 off to bed, and I think my husband and I sat up watching
6 a film, or whatever, and I popped in and said good night
7 about half 11 or something like that. I think my mum
8 had retired. My daughters would have been in bed by
9 half 8 at the latest, at that time, so probably, you
10 know, about half 9 or something like that my mum had
11 gone to bed.
12 Then my husband had woke early and had heard my
13 mother going up and down to the toilet, and probably
14 about 6 that morning, 7 it could be, rough timing that
15 morning, when I awoke my husband had said, "I didn't
16 want to go down myself, but would you like to go down
17 and check on your mother". She was directly -- her room
18 was directly below ours. Because she had, he felt,
19 moved an inordinate amount of times during the night and
20 he just felt that she needed checking. And when I went
21 down, in the last few -- 10, 20 minutes, she'd actually
22 soiled herself and said that she'd been constantly in
23 the toilet.
24 Q. With diarrhoea?
25 A. With diarrhoea.
31
1 Q. So this is the Sunday morning that you were made aware
2 of this?
3 A. Yes.
4 Q. And in the course of the Sunday, did she suffer from
5 very bad bouts of diarrhoea?
6 A. Yes, throughout. And she didn't get out of bed.
7 I managed to get her to take her sips of water, and the
8 kind of strength-building powder drinks they give her,
9 I managed to get her to take some of that, but other
10 than that she hadn't eaten anything on the Sunday.
11 Q. Then was she taken back to the Vale of Leven on the
12 Monday, the 17th of December?
13 A. She'd asked us repeatedly on the Saturday -- the Sunday,
14 sorry, not to take her, and then on the Sunday evening
15 late she said she didn't want to be a burden to me, and
16 that she felt with the girls in the house she didn't
17 feel she should lay that upon me, and that yes, she
18 would go back. But prior to that she had said she would
19 rather stay with us. And we took her back on the Sunday
20 morning -- sorry, the Monday morning, 17 December.
21 Q. When you got back to the Vale of Leven then, where did
22 you go initially?
23 A. Straight to ward 6.
24 Q. What was the position then when you got to ward 6?
25 A. When I arrived at ward 6, we entered and we were told it
32
1 had been closed due to a bug. I don't recall being told
2 what the bug was, I could have been but I don't recall.
3 I didn't see any notices or anything and, to my
4 knowledge, the two main doors were kind of opened and
5 I'd walked in unawares, and was told by -- I believe
6 greeted by Sister Fox who said, "The ward is closed, but
7 since your mother is -- we will find her a bed somewhere
8 else in the hospital", and we were asked to go into the
9 TV room.
10 At this point I said that my mum hadn't been quite
11 well, and we waited in the TV room and my mother grew
12 progressively worse, and it was difficult to rouse her,
13 and she looked very sweaty and -- the way she had been
14 on the Sunday for periods.
15 Q. Can I just bring you back a little.
16 A. Yes, sorry.
17 Q. You said you were met by Sister Fox.
18 A. I believe, yes.
19 Q. Had you met Sister Fox before?
20 A. Yes, she was the sister in the ward.
21 Q. Did you get the impression that she was in charge of
22 the ward?
23 A. Yes, yes, I had that impression, yes.
24 Q. Now, you mentioned then that because of what you were
25 told your mother was taken to the TV room; is that
33
1 correct?
2 A. Yes.
3 Q. Is that shown in the plan, or is that in a different
4 location from the plan?
5 A. No, I believe it to be 23, room 23.
6 Q. So it's really to the right as you enter?
7 A. To the right as you enter, yes.
8 Q. And at that time was there anybody else in the TV room?
9 A. Yes, there was. Either at the -- already arrived or
10 just shortly after us, there was a lady who had
11 I believe liver cancer or something like that, and she
12 was with her neighbour, and she'd also been told they
13 would have to find her -- she'd been on a day pass also.
14 Q. Was there anything that struck you about the setup in
15 the TV room when you got there?
16 A. There was a lot of old-fashioned chairs, different
17 sizes, et cetera, and there was a table in the top
18 left-hand corner, and I remember a nurse coming in and
19 lifting her bag and saying she was going for something.
20 I remember saying something like, "Oh, do you not have
21 a locker?" You know, I was quite surprised that her bag
22 was lying -- jackets and coats and things, belonging to
23 the nursing staff, were on the table there quite openly.
24 I was worried about security rather than -- at the time.
25 Q. What did the nurse say when you asked if she had
34
1 a locker?
2 A. I don't recall her comment, but it was something like --
3 I don't recall, I honestly can't recall. I did recall
4 at the time, but ...
5 Q. Can you say how long your mother spent in the TV room,
6 then, on the Monday?
7 A. I don't recall exactly when we arrived. I know you said
8 earlier in the notes it was 11 o'clock. I couldn't tell
9 you. I thought it was slightly earlier than that,
10 nearer 10, but again I don't -- I'm unsure of that. But
11 certainly we were still in the room, I would say, at
12 2 o'clock I think, I believe.
13 Q. I think you said a moment ago --
14 A. And the nurses offered us sandwiches for lunch, so we
15 were definitely there over the lunch period.
16 Q. When you say "we", yourself and your mother. Was your
17 husband with you?
18 A. No, my husband was at work, but my brother had dropped
19 us off and brought us out and did return at one point at
20 lunchtime, but he had business elsewhere and said he
21 would be back later. I can't honestly recall -- neither
22 of us can recall whether he did or not. Quite strange,
23 but we can't recall.
24 Q. Did you have some further dealings then with Sister Fox?
25 A. Yes, sister had come in to check on my mum, and then
35
1 I felt my mum had grown worse and I opened the door
2 knowing I wasn't allowed on the ward and caught
3 someone's attention to get sister, and sister came back.
4 She took her temperature and said "We will take a stool
5 sample from her", but I can't recall whether that was
6 prior to lunch or after.
7 Q. You do recall Sister Fox asking for the stool sample?
8 A. Yes.
9 Q. If we look at your statement at paragraph 24, you said
10 there that you thought that was at about 1 o'clock. Is
11 that your best recollection?
12 A. That could be -- yes. It was -- I was trying to put
13 a time to it, I couldn't be absolute 100 per cent.
14 Q. Did Sister Fox then obtain a stool sample from your
15 mother?
16 A. Yes.
17 Q. Thereafter, were you given some information by
18 Sister Fox as to what had been discovered?
19 A. I was told she had C. diff.
20 Q. Can you say when that was, in the course of the day?
21 A. Definitely before half 2 at the very latest, but
22 I couldn't tell you.
23 Q. So do I take it your mother was still in the TV room
24 when you obtained that information?
25 A. Yes.
36
1 Q. Can I just ask you to tell the Inquiry what did
2 Sister Fox say to you about C. diff?
3 A. I was told it was a bug that a lot of people get if
4 their immune system is low and that it can be created
5 within yourself.
6 Q. Anything else that you can remember?
7 A. Not that I recall.
8 Q. Were you given any information at that time as to how
9 serious it might be?
10 A. No.
11 Q. Were you given any leaflets or documents that might
12 explain what C. diff was about?
13 A. No.
14 Q. I think you left the hospital to go to work; is that
15 correct?
16 A. Yes.
17 Q. When you left, was your mother still in the TV room or
18 had she been moved?
19 A. She could have either just been taken out as I was
20 leaving or had just been taken out slightly previous to
21 that. I have -- I don't recall.
22 Q. At that point in time, do you know where she went?
23 A. Yes, because I came back up after.
24 Q. So were you told where she was going to be then, at that
25 stage?
37
1 A. I was told she would be within that ward. She was being
2 admitted to the ward.
3 Q. Ward 6?
4 A. Yes.
5 Q. I think you went back to the hospital?
6 A. Yes.
7 Q. What time was that?
8 A. Again, I'm not 100 per cent sure. I believe it to be
9 before visiting, or whatever. I don't know what --
10 I think I was probably pressed to say a time, but
11 I wasn't 100 per cent sure. It was definitely after
12 half 3, 4 o'clock.
13 Q. Okay. I perhaps should have asked you this before: can
14 you help me with this, what were the official visiting
15 hours at the Vale of Leven?
16 A. I can't recall, I really can't recall now. I felt as if
17 I lived there, but I honestly can't recall.
18 Q. Did you go in outwith visiting hours on occasions?
19 A. When she was in high dependency, and then when she was
20 eventually in the isolation room, but prior to that
21 I always stopped at visiting hours.
22 Q. Let's, then, go back to when you returned to the
23 hospital in the afternoon.
24 A. I think that was about the first time that I was allowed
25 in, because the ward was closed and it was outwith
38
1 visiting hours. It could have been visiting hours, I'm
2 not 100 per cent sure.
3 Q. Can you tell me where your mother was now, which room in
4 ward 6? We have the plan on the screen.
5 A. It wasn't a bed as such, it wasn't a room as such, so
6 I can't recall now looking at it. I would probably say
7 one bed where 18 is just now.
8 Q. I think that's --
9 A. That's if 19 is a room, just looking at it. 19 looks to
10 be a room, so she wasn't in a room, she was in a bay, so
11 I would assume 18 with her headboard to 17.
12 Q. I think that's what you say in your statement,
13 certainly, that she was placed in number 18 on the plan,
14 but you say it was just one bed there and not the two?
15 A. Yes, I recall only one.
16 Q. Pardon?
17 A. I recall only one.
18 Q. At that time, the ward itself, did you form any
19 impression as to whether it was busy, by that I mean
20 with patients, or not?
21 A. I would consider it to be quite empty prior -- you know,
22 having the previous experience, but, again, because
23 I was so interested in my mother, I couldn't tell you
24 how many patients were in it, but certainly almost
25 empty, as far as I remember.
39
1 Q. And the previous experience when your mother was there
2 before, was it busy then?
3 A. I can't recall a bay being empty. It was full.
4 Q. Did you at that point then take some of your mother's
5 clothing away with you when you left?
6 A. Yes, when I arrived her slippers were on the floor and
7 her dressing gown, that was across the bottom of
8 the bed, and the cord of the dressing gown had obviously
9 trailed through and there was faeces on the cord of her
10 dressing gown, and then when I went to lift her
11 slippers, they also had faeces on them, and I had
12 a shopper bag with me so I placed them in that and tied
13 it and took it home. I later binned the slippers and
14 went to a local shop and bought her a new pair before
15 coming back up later for visiting.
16 Q. Did you raise with the nursing staff at all that you'd
17 found faeces on your mother's dressing gown and on her
18 slippers?
19 A. No. I just felt that they were busy and it was an
20 oversight that I could understand in those
21 circumstances.
22 Q. And you don't know how long then the faeces was on the
23 slippers or on the dressing gown?
24 A. No.
25 Q. Did you then go back to the hospital that same evening?
40
1 A. Yes.
2 Q. Was your mother still in ward 6?
3 A. No -- yes, sorry, she was in ward 6, yes, but she was
4 not in that bed.
5 Q. Where was she now then?
6 A. She had been moved to the isolation room, room 11,
7 left-hand side in your diagram.
8 Q. You call it the isolation room?
9 A. I called it that, yes. That's what I knew it as, yes.
10 Q. Was there a sign to say "Isolation Room"?
11 A. No, but it was just a room rather than a bay, so it was
12 isolated.
13 Q. It has been highlighted on the plan. Can you tell me if
14 there is a wash hand basin in that room or not?
15 A. There was a wash hand -- I believe, because I did not
16 enter it, but I'm now looking at the plan and I realise
17 that 10 is the toilet for that room.
18 Q. Yes.
19 A. So, yes. I imagine that it would have been -- I don't
20 know if there was a shower in that room, but there was
21 a toilet and I'm assuming a wash hand basin.
22 Q. If we look at the plan, we get the impression that
23 there's a door from room 11 into 10?
24 A. Yes, that was her toilet.
25 Q. And there is an indication in the plan that there was
41
1 a wash hand basin in that toilet?
2 A. Yes, that was her personal toilet.
3 Q. Now --
4 A. I just notice, there was another wash hand basin which
5 is not marked, now that I see that that is -- prior, you
6 asked me if there was another, and there was one -- as
7 you open the door in room 11 and you look straight
8 ahead, there was one located somewhere on the corner of
9 09. There was definitely a wash hand basin there.
10 Q. Let me see if we can get the pencil to indicate. Could
11 you give us that description again, Mrs Bowes?
12 A. If you go to the corner of 10 and 9, where 8 and 9
13 sticks out slightly, I believe -- the nurses' station
14 was somewhere there, I'm assuming 9 and 8 are rooms
15 behind the nurses' station but I'm not 100 per cent
16 sure. Outside, an external angle between 9 and 10,
17 I think there to be a wash hand basin there. There
18 certainly was some sort of washing facility before the
19 nurses' station, as I came out that door.
20 Q. So roughly where the pencil is placed there?
21 A. Roughly, yes.
22 Q. On this occasion this evening when you went to visit
23 your mother when she was in the isolation room, were you
24 given any instructions as to how to equip yourself when
25 you visited your mother?
42
1 A. I was asked to wear an apron and gloves.
2 Q. And can you remember the nurse who asked you to do that?
3 A. No, I can't recall. It could have been Sister Fox.
4 Q. Yes.
5 A. It could have been Sister Fox.
6 Q. Was Sister Fox quite prominent in the ward?
7 A. Yes, certainly. I think she had a very good hand on the
8 ward and was kept very busy.
9 Q. And generally was it Sister Fox that you discussed
10 matters with when you visited?
11 A. You very rarely get a chance because she was so busy,
12 and there were a couple of times I remember my brothers
13 and I and my sister quite regularly kind of hanging
14 about and you felt that she just didn't have the time.
15 I felt, you know, that she didn't get a breath, if you
16 like, so the odd occasion I did get a chance to speak,
17 she was on the go, if you like.
18 Q. What about your mother on this evening? How was she
19 then when you saw her?
20 A. She was quite unwell. She was very, very low. She was
21 very drowsy. Just very similar to the way she had been.
22 Q. Was she suffering still from diarrhoea?
23 A. Oh, yes. Yes. As far as I recall, yes. It was --
24 I mean, for that whole period it was just loose stools
25 and she was very embarrassed by it. I remember at some
43
1 point in that time, in room 11, that she had wanted --
2 she kept asking for just me, and then when my brothers
3 left she said that she'd kind of soiled herself and
4 asked for nurses and things.
5 She just wasn't the type of person that would ever
6 let anyone know that that had happened. She was -- and
7 I'm, to be honest, very surprised that she asked for the
8 nurses, because that's the type of person, and I knew
9 then that she was really ill if she couldn't get up
10 herself and ...
11 Q. Did she improve then in the course of that week?
12 A. I saw some improvement, I felt that at times there was
13 an improvement. It's very difficult to recall back now,
14 but certainly come -- as we came towards 22,
15 23 December, I started to feel there was a possibility
16 she could -- she might get home for Christmas. But then
17 Sister Fox, I can't recall whether it was 23 or 24th
18 now, but Sister Fox -- we had been hopeful, and then
19 Sister Fox discussed it with us and felt that as a joint
20 decision perhaps it would not be the best thing for her
21 to come home, due to the age of my children and how my
22 mum was.
23 Q. We'll come to that. If you could go back to the medical
24 records, GGC00140252, you will see some entries there
25 for 22 December. Just before 17:00, there is an entry:
44
1 "May be able to get home Monday over holiday
2 period."
3 Does that accord with your recollection?
4 A. Yes, around about there. I remember having that
5 discussion, and then probably the 23rd she wasn't as
6 good, the 24th maybe even, and the joint decision was
7 made that perhaps it would be best for her not to come
8 home.
9 Q. Although I think the note on the 23rd at least, early
10 hours of the morning, 6.30, if you look at the bottom of
11 the page, is "Much improved".
12 A. Yes, that could be possible. I definitely noticed an
13 improvement in her, and she didn't have loose stools
14 over that period, but I couldn't give you exact times.
15 Q. If you go on to the next page in the records, for the
16 24th, Christmas Eve, you will see that there is a note
17 that she was incontinent in her faeces. So that seems
18 to accord with your recollection --
19 A. Yes.
20 Q. -- that there was an improvement but then there was
21 a decision that she wouldn't get home; is that right?
22 A. Yes, mmm-hmm.
23 Q. What did Sister Fox explain to you then about her
24 condition at this time when you had this discussion with
25 Sister Fox?
45
1 A. I can't recall her exact words, but, again, it was just
2 that, you know, her condition hadn't -- you know, she
3 was having loose stools, et cetera, but there was no
4 in-depth discussion.
5 Q. Were you told she was still suffering from C. diff?
6 A. I don't recall. I could have asked that, probably did,
7 because I remember at some point asking it, but
8 I couldn't recall if it was that particular time.
9 Q. Were you told by Sister Fox or by anybody that your
10 mother was being treated for C. diff with antibiotics?
11 A. Yes. Oh, yes, I knew that.
12 Q. You knew that?
13 A. Yes.
14 Q. I think you narrate in paragraph 29 of your statement
15 that your mother had a fall at some point when she was
16 trying to get to the toilet?
17 A. Yes, again through her own -- certainly not the nurses,
18 I couldn't fault them in any way. It was my mother who
19 would have probably been trying to get out of bed and
20 wouldn't have wanted to bother them.
21 Q. That's obviously the sort of person -- you have
22 mentioned this on a number of occasions.
23 A. Yes.
24 Q. That's the sort of person she was.
25 A. Yes, she didn't want to be a nuisance.
46
1 Q. But you do say, I think, in your statement that you were
2 told by Sister Fox at some stage that you needed to wash
3 your hands with soap and water and not just the gel?
4 A. Yes. I recall I had some sort of reaction and I went to
5 the pharmacist prior to Christmas Eve, I know that, and
6 the pharmacist said that she thought -- I thought it was
7 alcohol gel perhaps causing it, and I said I'd been to
8 the hospital and I had kind of like spots and just
9 a horrible feeling in my hands, and the pharmacist said
10 that she thought it was perhaps the latex gloves, and
11 she gave me white cotton gloves to wear under the latex
12 gloves when I returned to the hospital, but, again, I'm
13 not 100 per cent sure on the timing. Sister Fox saw
14 what I was doing and I said "I don't know whether it's
15 the alcohol gel or the gloves", and she said "Oh, no,
16 you should be washing your hands with soap and water
17 because that alcohol gel is not sufficient for C. diff".
18 Q. I see. And I know time and dates are difficult but,
19 first of all, was this before Christmas?
20 A. It was before Christmas but certainly not too much
21 before.
22 Q. The impression I get from you, and you can correct me if
23 I am wrong, is that at least in relation to your
24 dealings with Sister Fox, she was giving you clear
25 information about C. diff and what you should be doing?
47
1 A. Yes, at that -- yes, I felt that -- not -- I wasn't
2 given detailed information, but I've probably shared
3 with you the information that I was given in that
4 respect. And I couldn't fault Sister Fox, she was
5 a very busy lady and seemed to run a tight ship.
6 Q. I think when you saw her on Christmas Day she was quite
7 poorly; is that right?
8 A. Yes.
9 Q. The following day, 26 December, you took her some
10 yogurt?
11 A. Yes. I had been told, and I don't recall if it was
12 Sister Fox, or there was another sister, I can't recall
13 her name, or whether it was a nurse who said -- in fact,
14 I think it was Sister Fox -- that probiotic yogurt has
15 been shown in some respects to help and it might be
16 worth. So my brother stayed and I went out to a local
17 shop and bought it there and then I came back with it
18 and they kept it in the fridge for her, and tried to get
19 my mum to eat it. She was eating very little.
20 Q. You make a point in paragraph 31 that you remember
21 returning to visit later on the 26th and you noticed
22 that her lunch was still there, uneaten and cold. Was
23 that the lunch that had been provided at the hospital?
24 A. Yes.
25 Q. What time of day was this that you saw her --
48
1 A. It was outwith visiting hours, but it couldn't be too
2 much before visiting hours, so again I'm not
3 100 per cent sure. 2-ish, something like that, it could
4 have been earlier, but not much earlier. I just felt
5 that the staff were very busy and obviously hadn't had
6 time, and I don't know whether my mother had been roused
7 or tried to be roused or whether it had just been left.
8 I have no idea.
9 Q. On a number of occasions, you have said that it was your
10 impression that the staff in this ward were very busy,
11 is that correct?
12 A. Yes.
13 Q. At a given time, can you tell me how many nurses would
14 be on the ward, at least from your perspective?
15 A. It wasn't until later I became -- I think the family
16 became quite concerned about how much stress the staff
17 were under, so certainly when my mum was in better
18 spirits prior to the, you know, 17 December, I couldn't
19 recall, but I remember the staff being up and down.
20 There was never any time where they were standing at the
21 nurses' station. They were about, they were moving,
22 they were always on the move.
23 But certainly after that we came to become more
24 aware that the staff were few and far between, and
25 I recall one day in particular I'd only seen three
49
1 people including Sister Fox on; there could have been
2 others on tea breaks and things, but I remember
3 wondering where the rest of the staff were, given the
4 outbreak of whatever.
5 I wasn't aware at that time whether there was anyone
6 else suffering from C. diff, either on the ward or
7 anywhere else.
8 Q. So far as the presence of a ward sister such as
9 Sister Fox, so far as you can recollect, generally was
10 the ward sister present when you visited?
11 A. Yes.
12 Q. Did you have any dealings with a specialist nurse, such
13 as an infection control nurse, during --
14 A. No, at no time.
15 Q. Now, on 27 December, you tell us in your statement that
16 you went to visit your mother again and that she was in
17 quite a poor way; is that right?
18 A. Yes.
19 Q. And you had some contact with Dr Clark, who I think had
20 been involved with your mother in the high-dependency
21 unit?
22 A. Yes, she was her oncologist. She came back, and to me,
23 looking at her, she was quite visibly shocked at my
24 mother's condition, and said she wanted my mother moved
25 immediately to high dependency, and my statement to that
50
1 was that there is no high dependency, the unit has been
2 closed. She said, "Your mother needs one to one and
3 they will need to find her a bed in this hospital".
4 Q. Did you have any discussions with Dr Clark at that point
5 as to what the problems with your mother were?
6 A. Again, we are not the type of family that would have
7 asked, so I didn't go -- delve in. I just put my mother
8 in their hands and didn't want to delve too deeply.
9 Q. We have already touched upon the fact that you were told
10 to wear an apron and gloves when you went to see your
11 mother in the isolation ward.
12 A. Yes.
13 Q. Did that remain the position during the time she was in
14 room 11?
15 A. Yes.
16 Q. Would that also apply to other members of your family
17 who visited?
18 A. Yes, everyone.
19 Q. What about the numbers of your family who would visit at
20 a given time? Was that limited to a particular number?
21 A. We were never limited in that sense that we would have
22 known, because we kept to two only ever in the room.
23 But nobody told us that, we just continued that process
24 ourselves.
25 Q. And --
51
1 A. I mean, probably -- maybe if we had tried we would have
2 been told no. I couldn't tell you that because we
3 didn't.
4 Q. Generally speaking, how many of your family would visit?
5 A. Two. Others would wait outside and then we would go.
6 Q. Yes.
7 A. Yes.
8 Q. You have told us about your experience in relation to
9 washing with soap and water. The rest of your family,
10 did they follow suit? Did they also wash --
11 A. I told them -- as soon as I was told, anybody that was
12 there, I told them, and anyone who was going to visit,
13 and it was only close family that visited. I called
14 them and said, "Are you aware that alcohol gel doesn't
15 work?" They didn't know that, and I told them to use
16 alcohol gel on entering and then wash their hands with
17 soap and water at the sink opposite 11.
18 Q. That was the sink you used?
19 A. Yes.
20 Q. It was the sink in room 11 itself that you used?
21 A. No, not inside room 11. I never entered that.
22 I considered that was my mum's personal toilet and would
23 never have used that. It was opposite room 11.
24 Q. I think you tell us in your statement that when your
25 mother was in room 11, her door was always kept open?
52
1 A. As far as I recall, the ward was always open.
2 Q. I suppose that would mean that the nurses at their
3 station would be able to --
4 A. Yes, have a clear view.
5 Q. -- see her?
6 A. Yes.
7 Q. You also give us some insight into a telephone
8 conversation I think that you overheard --
9 A. Yes.
10 Q. -- involving Sister Fox. Can you just give us some
11 background to that? What was that about?
12 A. At that point, my mother was awake and we were having
13 a conversation, and we were just generally talking about
14 different things, about Christmas, et cetera, and she
15 was saying how she felt terrible that she'd missed it
16 and maybe things would get better, but she felt
17 dreadful, et cetera.
18 At that point the phone rang and Sister Fox answered
19 it. I can't recall her exact words but it was a very
20 heated conversation. I remember my mother and I at the
21 same time going "Ooh", and my mother saying "Someone is
22 not happy", or words to that effect. She seemed to
23 certainly fight her case and stand her ground. The
24 words were to the effect that she wasn't taking any
25 more, that her ward was closed, and at one point the
53
1 phone was slammed down. I can't recall now, I don't
2 know whether I said in my statement whether the phone
3 rang again or whether it was the one conversation. And
4 she then called I believe to be two members of staff,
5 I didn't want to turn around, but I believe there were
6 two members of staff called to the nurses' station, and
7 she told them that two patients were coming from Paisley
8 and that we'd better get ready for them, and that she
9 wasn't happy. She didn't actually say, "I'm not happy
10 about it" to the staff, but she showed she was not
11 happy.
12 Q. Was it your impression at this point in time, which I
13 think was shortly after Christmas --
14 A. It was Thursday, 27 December.
15 Q. -- that the ward was full?
16 A. No, it was not full, no. It was still closed, as far as
17 I was aware. It was quite empty.
18 Q. So we have your mother --
19 A. Again, because I'm only concentrating on my mum
20 I couldn't tell you how many beds were occupied.
21 Certainly on one of the days walking in, room 15, the
22 original room she was in, the beds had been out of that
23 one of the days and it was being cleaned by a big
24 machine.
25 Q. Was that before or after Christmas?
54
1 A. Before Christmas. Just prior to Christmas.
2 Q. I think, in any event, your mother was moved back to the
3 high-dependency unit?
4 A. No. The high-dependency unit had been closed, so she
5 was moved on Thursday, 27 December. Shortly after that
6 phone call, in fact, Dr Elizabeth Clark came to tell us
7 that they had found her a bed in what is now -- within
8 ward 4 they had made an area and called it I believe
9 critical care.
10 Q. Very well. Perhaps you could look at the --
11 A. I'm not 100 per cent sure on the new name, the
12 terminology.
13 Q. If you look at the plan, it is GGC00670001, we see at
14 the bottom it is described as ward 4.
15 A. Yes. I was very hazy on -- when presented with this at
16 the time, I was very unclear where the actual nurses'
17 station was in relation -- as you can imagine, it was
18 a very emotional time.
19 Q. But you were shown this plan --
20 A. I was shown this plan, and I couldn't recall where the
21 nurses' station was.
22 Q. But can you recall where your mother --
23 A. She was on the left-hand side as you went in, but the
24 plan just threw me off a bit.
25 Q. So if we imagine ourselves going along the passageway,
55
1 1, 4, 7, are you turning left at 7?
2 A. I could have been. It could have been earlier than
3 that. It doesn't bear resemblance, as I said at the
4 time. I couldn't quite pick out where I was in it.
5 Q. I think you said in your statement that your mother was
6 placed in room 15?
7 A. We worked out that perhaps -- the nurses' station --
8 if -- yes, I think -- yes, room 15, and there were two
9 beds, yes, because we couldn't recall coming out and
10 turning -- yes, I'm pretty sure it was room 15 now, and
11 that became the critical care.
12 Q. But your recollection is that there were two beds in the
13 room that your mother was?
14 A. There were only two beds, yes.
15 Q. Was the other bed occupied?
16 A. Yes.
17 Q. Was it an elderly patient or not?
18 A. I can't recall whether there were two or three patients
19 in the time my mother was there. All certainly were
20 elderly. I believe it to be a gentleman in the latter
21 stages and a woman who subsequently died to be there
22 when my mother arrived, but they could have changed at
23 one point because, again, I wasn't paying much
24 attention.
25 Q. I think you tell us in your statement that on the
56
1 morning of Friday, 28 December, you visited your mother
2 and she told you she had had a bad night that night?
3 A. Yes.
4 Q. I think she also told you that she thought the patient
5 in the bed opposite had died; is that correct?
6 A. Looking back, I can't recall whether -- it could have
7 been the Saturday, but I believe it to be the Friday,
8 and my mother had said that the relatives would have
9 been quite upset, they had been there all night, and
10 that a female relative had been quite hysterical. My
11 mum had been there all night and she felt terrible for
12 the family, she felt there was no privacy for them, and
13 that a patient had died.
14 Q. You say in your statement that you could see the body.
15 Were there curtains not around the bed?
16 A. If you look at the room I believe my mother to have been
17 in, I'm just a bit disorientated, but I believe that to
18 have been the room. It was like a bay so it didn't have
19 a door. If you went in, my mother's headboard was to
20 the right onto the two bed, and the lady's headboard,
21 the other patient, was -- her headboard was to 14. The
22 two beds were placed in such a way that in order for
23 equipment to be placed behind each bed, and the level of
24 equipment required for critical care or high dependency,
25 they were quite a bit out from the wall because there
57
1 was a lot of equipment around both beds.
2 When the curtains were pulled around the beds in
3 privacy, it was either the same curtain or two curtains
4 so close together at the bed that in order to get
5 around, the beds were so close and the spacing was so
6 poor between the ends of both beds due to the equipment
7 being placed there, that you had to go through the other
8 patient's curtain to get to the other side of the bed,
9 and that's when I inadvertently saw the covered body,
10 which I can understand that times and places, et cetera,
11 but my mum had been quite distressed at that.
12 Q. During this time when your mother was in the
13 high-dependency unit, what was the position with you
14 wearing gloves and aprons and so on?
15 A. I was told it was not necessary.
16 Q. Were you told why that was the case?
17 A. No. Again, we were very concerned for my mother. We
18 then became quite concerned for other patients, knowing
19 it was -- or believed it still to be the cardiac ward,
20 and we felt -- I remember a few raised eyebrows between
21 my brothers and I and my sister that this is the cardiac
22 ward and my mother has C. difficile, and we were quite
23 uneasy about it. I remember asking "Should we not be
24 wearing gloves?" and they said "No, it's okay, it's not
25 necessary at the moment".
58
1 Q. Did you understand around this time, 29 December, that
2 your mother was still suffering from C. difficile?
3 A. I totally understood that, yes. I was not told any
4 different.
5 Q. Were you told positively that she still had --
6 A. I asked on the Saturday. They were thinking of running
7 a catheter at some point -- it could have been the
8 Friday -- and they were thinking about that, but they
9 didn't want to because -- I remember asking why not, and
10 they said it could be another source of infection. And
11 I said, "So she still has C. difficile?" And I was told
12 yes. It could have been the Friday, but I think it was
13 the Saturday morning.
14 Q. Now--
15 A. But certainly in that room and in that place.
16 Q. You mentioned the catheter. What sort of catheter was
17 it? Was it a urinary catheter?
18 A. Sorry, I didn't ask. I think she certainly had -- at
19 one point she had both, but it could have been the
20 Sunday before both were in place or the Saturday later
21 on.
22 Q. I don't want to dwell on this for too much, but your
23 mother died on Monday, 31 December.
24 A. Yes.
25 Q. I think on the Sunday and into the Monday you and your
59
1 family visited your mother?
2 A. Yes, we were there the whole day. Nobody left her.
3 I got a fright on the Sunday morning and felt that she
4 wanted me, and when I arrived she said, "I told the
5 nurse -- I just panicked, and that I wanted you, and you
6 can go home now", and I said, "I'll do no such thing.
7 I'll stay here with you until you settle", and she
8 settled. But there were periods, I can't recall now
9 when, but there were certainly periods or points where
10 she was imagining things and she wasn't lucid, and then
11 later there were periods where she was quite lucid with
12 us, and that's the first that had happened.
13 Q. Can I pick up on one or two other points with you,
14 Mrs Bowes. The first is in relation to laundry
15 facilities.
16 A. Yes.
17 Q. From the point in time when you became aware that your
18 mother was suffering from C. difficile, and that was
19 from about 17 or 18 December, what was the position with
20 regard to her laundry?
21 A. It was either -- it was always tied at the bottom of her
22 bed in a white laundry bag with the writing "Patient's
23 Laundry" in red writing.
24 Q. Did you then take the bag home?
25 A. I took the bag home.
60
1 Q. Were you given any instructions in relation to how you
2 should deal with the washing?
3 A. Never.
4 Q. Generally speaking, what sort of washing was it?
5 A. Soiled garments.
6 Q. How often then, in the period over which your mother may
7 have been suffering from C. diff, did you take the bags
8 home to wash?
9 A. Every day almost. I can't recall a day I didn't.
10 Q. Throughout the whole period you were given no
11 instruction as to how the washing should be handled?
12 A. No instructions. Some were very heavily soiled.
13 Q. How did you do the washing?
14 A. I washed them in a normal wash at home. Now I would
15 have washed them in a boil wash, but to be honest it
16 didn't occur to me. I washed them separate from the
17 family's.
18 Q. Would you take the washing out of the bag, then, and put
19 it into the washing machine, is that --
20 A. I emptied it in.
21 Q. Emptied it in?
22 A. Yes.
23 Q. And disposed of the bag?
24 A. Yes.
25 Q. Can I ask you one or two questions about the state of
61
1 cleanliness in the wards, and if we look first to ward
2 6, have you any observations to make as to what your
3 view was of the state of cleanliness in that ward?
4 A. My view was that the ward was not unclean, and
5 I couldn't say at any point I noticed anything that was
6 unclean, but certainly the fixtures and fittings were
7 not -- they weren't as new as they should have been.
8 There was a lot of frayed bedding. In my mother's room
9 in room 11 there were vertical blinds and several of
10 the slats were missing and they looked as if they'd been
11 there a long time.
12 Q. Slats from the window, is it?
13 A. Slats from the vertical blinds.
14 Q. Yes.
15 A. The way the Vale is, the Vale of Leven Hospital is,
16 there was like an outside area and then the corridor, so
17 actually the corridor, you could see from the corridor
18 into my mum's room if you stopped and looked through,
19 although it was -- so the children had waved to her on
20 Christmas Day, and they'd had to be lifted, but an adult
21 could see through. So we did ask at one point if they
22 could be replaced and the comment was, "They'll never
23 give us money", I assume they were referring to the
24 Health Board, that we'll never get that replaced.
25 Q. The comment was from whom?
62
1 A. From a nurse. And a patient's laundry bag they cut and
2 placed it over to give my mum some privacy when she was
3 getting changed.
4 Q. So just so I can understand the layout, the blinds --
5 A. Are internal.
6 Q. And they look into the corridor?
7 A. They look into the room.
8 Q. But from the corridor, you could look through the hole
9 in the blinds and see your mother?
10 A. Yes. In the corridor, which wasn't blind -- there was
11 no blind in the corridor, you could look through the
12 gap, the outside gap, and through -- yes, you could have
13 seen through the gap. There were two or three slats
14 missing. It was quite a sufficient gap.
15 Q. Did you say there was a bag then put over the gap?
16 A. Yes, because at this point my mum had to be I think
17 given bed baths or whatever, and it was for a bit of
18 privacy.
19 Q. You have already mentioned the deep clean of the ward.
20 A. Mmm.
21 Q. What was the position after the deep clean? Was the bag
22 still there?
23 A. The bag was still in place after the deep clean, because
24 I remember my brother and I making the comment that we
25 thought, "Oh, certainly all material fixtures and
63
1 fittings would have been removed".
2 And to go back to the question about the general
3 cleanliness, again, I said that I didn't feel there were
4 any problems with cleanliness, but there were chipped
5 tiles, odd tiles missing, if I recall, plasterboard
6 chunks. That general state that was -- it hadn't been
7 kept up to date as I would have expected a hospital to
8 be.
9 Q. In paragraph 45, you give an account of an occasion when
10 a doctor was attempting to take blood from your mother?
11 A. Yes.
12 Q. And you give us a description of the doctor, a female,
13 tall and slim with reddish blonde hair. You don't know
14 the name of the doctor?
15 A. No. At that point I remember, my mum was very difficult
16 to get blood from, and I know that they had attempted
17 several times to get blood and I was asked on occasion
18 was there any time I remember specifically no gloves
19 were used, and I do remember that time, because they had
20 tried several times and she gave up and left, but
21 I don't recall her ever wearing gloves, no.
22 Q. Can you tell me when this was? In relation to
23 Christmas, was it before --
24 A. Before. She was still in bed -- the room -- the bay 15.
25 Q. Or was this after C. diff had been diagnosed?
64
1 A. No.
2 Q. This was before C. diff?
3 A. Yes.
4 Q. I think the point you make is that the doctor didn't
5 wear gloves when she was doing this; is that right?
6 A. Yes.
7 Q. You then give an account of an occasion when your mother
8 was in room 11 and had "an accident" and you were there
9 and you were asked to call the nurse in; is that
10 correct?
11 A. Yes.
12 Q. Can you remember when that was?
13 A. No. Certainly it was room 11.
14 Q. Was it after your mother had been diagnosed then with
15 C. diff?
16 A. Oh, yes, certainly.
17 Q. When you say "an accident", was that with faeces?
18 A. Yes.
19 Q. Did the staff come to clean her up?
20 A. Yes.
21 Q. Did they move pretty quickly? Did they come at your
22 call?
23 A. Oh, yes, yes.
24 Q. What then? I think you went in to see to your mother
25 after the staff had dealt with her?
65
1 A. Yes.
2 Q. What was the position then? What did you find?
3 A. She was -- I couldn't fault the staff at all. I mean,
4 at no point do I recall -- I mean, I'm pretty sure they
5 gloved up, any time I saw them in the room they were
6 wearing gloves, they were wearing aprons. The only
7 thing I felt with my mother was her fingernails were
8 long and she never let me ever cut her nails, and she
9 said, "Please, please, would you cut my nails?" And
10 when I cut her nails -- and again, I can't recall
11 whether that was slightly prior -- it was either
12 slightly prior to Christmas or the day after, and she
13 asked me to cut her nails, and I cut her nails back,
14 they were quite long, and -- because she usually managed
15 to do it herself, but she was too weak, and there were
16 faeces under her fingernails.
17 Q. Was this at a different date to the date that you --
18 A. It could possibly have been.
19 Q. You can't be clear, then, whether it was the same time
20 when the staff came in to clean her after she had the
21 accident or a different date?
22 A. Yes, I'm unclear about that, but certainly there was
23 faeces under her fingernails.
24 Q. Did you raise that with the staff?
25 A. No.
66
1 Q. Any reason why not?
2 A. I just think as a family we -- we felt -- you know, it
3 could have happened and it could have been missed
4 easily, and we just felt that she was -- I remember her
5 being given wet wipes to rub her hands, because she
6 couldn't get out of bed, and I brought in extra wet
7 wipes so she could regularly give her hands a rub, but
8 I can't fault the staff for that.
9 Q. You make some comments in paragraph 47 about the hand
10 washing facilities. Can you just elaborate upon that?
11 A. Sorry, what paragraph?
12 Q. You talk about --
13 A. Which paragraph, sorry?
14 Q. Well, you are talking about visiting your mother in ward
15 4 --
16 A. Yes, ward 4.
17 Q. And you were told to use a staff toilet which didn't
18 have a sink?
19 A. Yes. It was probably -- I think -- I believe it to be
20 on the Sunday night, and I was in the TV room, which was
21 the only waiting facility, sharing with cardiac
22 patients. I really needed to go to the toilet and I was
23 going on the way out of the ward, and this nurse asked
24 me where I was going and I said down to -- because
25 that's the toilet we used, which was the only one
67
1 I knew, which was down in the main building downstairs,
2 and she said, "Just use this one", and I went into the
3 right-hand side somewhere. I'm unsure whether I went
4 actually out of the ward or whether it was -- I was
5 still in the corridor of the ward at the entrance.
6 I can't recall. And I went in, and either there was no
7 sink or it wasn't working because I recall having to go
8 and find somewhere else to wash my hands.
9 Q. If you go back to that particular plan, which is
10 GGC00670001, that's the plan of ward 4, which we'll get
11 on the screen in a moment. We have looked at this plan
12 before, Mrs Bowes.
13 A. Yes.
14 Q. If you are coming out of the ward --
15 A. It could have been 02, but it could have been slightly
16 outside the ward. I'm not 100 per cent sure. I believe
17 I was in 05, the TV waiting room, what I would call the
18 TV room.
19 Q. If it is 02 certainly there is no wash basin indicated
20 in the plan.
21 A. I can't recall whether it was -- it wasn't -- I just
22 remember having to leave to wash my hands, but I can't
23 recall whether it was not working or just wasn't there.
24 Q. You give some impressions also in your statement about
25 the Vale of Leven Hospital. You have already mentioned
68
1 chipped tiles, and so on. What impression did you come
2 to in relation to the general state of the hospital?
3 A. I had been there previously. The last time I had
4 visited the Vale was on a maternity basis, when I had my
5 twin girls in 2001, and I just remember on entering, the
6 new entranceway looked quite impressive, and I can't
7 recall if that had been started building in 2001 or
8 whether -- because we entered from a different area, but
9 I remember being quite impressed that, yes, at last
10 money has been spent on this building. Then entered
11 through there, and once you're through and into the
12 stairwell, there didn't seem to be any further
13 upgrading, it seemed to be all on that kind of
14 curvature -- curved entrance. I didn't seem to see any
15 much of a difference within the actual fabric of
16 the building, and I still think it looked quite
17 neglected, certainly not a modern facility that I would
18 perhaps expect.
19 Q. Now, you have been complimentary of the nursing staff in
20 many respects.
21 A. Yes.
22 Q. Did you form any view as to the state of morale within
23 the hospital at this point in time when your mother was
24 a patient?
25 A. I would say, in general, the staff was -- the morale was
69
1 very low. In particular, when we first went to the
2 high-dependency unit and there was talk of it closing,
3 I think it would have been quite a shock to them.
4 I remember my mother saying to me several times, you
5 know, "That's a nurse" -- there were two leaving parties
6 for nurses or sister -- I don't know, because people --
7 because my mum had a little bit of cake, and she was
8 saying "That's a shame, that's really good staff that we
9 are losing to other hospitals because there's talk of
10 this ward being closed", and that was in November, and
11 morale was very low at that point within the staff.
12 Q. What makes you say that, though? What's your basis for
13 saying that morale was low?
14 A. General comments made to -- by my mother to me, and also
15 just the odd passing comments by staff that, you know,
16 "We'll not be here anyway". The general opinion from
17 staff was that they were being run down and that the
18 Vale was to close, the Vale of Leven would have been
19 lost as a facility in the area. And I genuinely believe
20 most of the staff felt that way, that they were being
21 run down.
22 Q. You also make a comment about the level of staffing, and
23 in your statement you describe that as "appalling"?
24 A. Certainly I felt that the staffing in ward 6 was poor
25 and that the staff were under stress, and when it came
70
1 to going to the critical care, I'm probably one of
2 the only families that experienced the high-dependency
3 unit, and then experienced what became critical care,
4 and I thought the level of staffing in there was
5 appalling. As far as I -- I have been told differently,
6 but I only ever saw one nurse or sister, I'm not quite
7 sure of the difference, at the time. I'm sure of
8 the difference, but I'm not aware of what they were --
9 how they were dressed differently in critical care, but
10 I only ever dealt with the one at that point.
11 And there was someone in the background who
12 occasionally came to help out a little bit, the one with
13 the knowledge and the expertise, on particularly the
14 Sunday evening and during the early hours right through
15 to the Monday, and she stayed on, this sister, the nurse
16 that was in charge, stayed on to be with my mum until
17 she died.
18 Q. Just so I can understand it, you've come to the
19 conclusion that you've set out in your statement on the
20 basis that the nurses were just so busy in dealing with
21 patients?
22 A. Yes, and undue stress was put upon them, I believe.
23 Q. Because they were so busy?
24 A. Because they were so busy, and because I believe that
25 they didn't have the resources at hand that perhaps they
71
1 should have.
2 Q. What sort of resources do you have in mind?
3 A. I mean, new blinds, going as far as that; commodes.
4 That's just general. I believed they were being
5 short-changed, shall we say, in the resources they could
6 possibly have had.
7 Q. You have told us about the contact you had with
8 Sister Fox, and she gave you information about C. diff.
9 A. Mmm-hmm.
10 Q. But you had no contact with an infection control
11 specialist?
12 A. Not that I was made aware of, no.
13 Q. We know you had contact with Dr Clark --
14 A. Yes.
15 Q. -- but did you have contact with any other doctor who
16 gave you advice about C. diff?
17 A. No, certainly not.
18 Q. Were you given any information in relation to whether or
19 not your mother was at a higher risk of getting an
20 infection because of her lymphoma?
21 A. No, not because of lymphoma. I was not given any
22 information on that, but I was aware, due to -- my
23 father-in-law was involved in a course of chemotherapy
24 over that period, he also had non-Hodgkin's lymphoma,
25 he'd been diagnosed 15 years previously, and this was
72
1 his first bout of chemotherapy at the time. So I was
2 aware through him that he was told not to go into the
3 hospital basically, that once he'd had his dose to
4 leave, and he didn't visit my mother. He visited once
5 in high dependency and then he was told he'd be better
6 not to.
7 Q. Told by whom?
8 A. One of the nurses or someone in the oncology department
9 within the Vale of Leven.
10 Q. Are you inferring he was told that because of the high
11 risk of infection?
12 A. He was told separately, I don't think it was said at the
13 same actual time, but he said he was told to avoid risk
14 of infection, so it was better to avoid heavily public
15 places, doctors' waitings areas, et cetera, where people
16 could have infections.
17 So I was aware at that point after her chemotherapy
18 that she could be, but certainly not as lymphoma,
19 I wasn't aware of that.
20 Q. In the final section of your statement, Mrs Bowes, you
21 deal with death certification.
22 A. Yes.
23 Q. I think you express concern that C. diff did not appear
24 on your mother's death certificate.
25 A. Yes. When we received the death certificate our family
73
1 were quite concerned that C. diff did not appear on the
2 death certificate, because we feel it was a major factor
3 in my mother's death.
4 Q. Were you told by anybody in the hospital that in
5 relation to the final specimens that were taken from her
6 that C. diff had not been detected?
7 A. No.
8 Q. I think, finally, you give us some insight into
9 a discussion you had with your mother who had suffered
10 from diphtheria?
11 A. Yes.
12 Q. She was able to compare and contrast the care she had
13 then to what the Vale of Leven was like?
14 A. The conversation was when -- she mentioned it when she
15 was in room 15 and then s he mentioned it again in room
16 11 -- or bay 15, rather, and my mum, again, being a very
17 private person, rarely talked about her childhood,
18 rarely talked about anything really in her childhood
19 period, and she recalled the time when she had
20 diphtheria. I believe her to be about nine years old.
21 It's over 60 years ago. And she was in, again I don't
22 know where, but she was in the hospital for infectious
23 diseases in Glasgow. She and her cousin were in
24 separate rooms with glass partition and she remembers
25 her cousin dying and it was over a period of --
74
1 from November one year right through to her tenth
2 birthday in February, so she remembers that period of
3 about hour months being in infectious diseases, and
4 never having contact with her mother and father, they
5 only looked through the glass. Sorry.
6 And her doll and books that she had read were taken
7 from her and obviously, you know, later she discovered
8 from her mum, but as a child she didn't know, they were
9 burned, and she remembers it being scrupulously clean
10 and that nothing was ever contact, and she remembers
11 that being quite a scary period in her childhood, but
12 knew afterwards why, because a lot of people were dying
13 from it.
14 Q. Yes. It might be said it is a very contagious disease
15 and therefore one would have to have as many barriers as
16 possible --
17 A. Yes. She felt at that time, you know, going back to
18 what you hear in the press, et cetera, about matrons and
19 things, she felt that there was someone on the ward who
20 was a very firm hand and people were told very firmly,
21 and at that time probably visitors, et cetera, wouldn't
22 have argued back and people were of a different mind,
23 and times have changed, so I do agree with that.
24 Q. I want to ask you one or two other points that I have
25 been asked to raise with you, if you just bear with me,
75
1 Mrs Bowes.
2 A. Yes, certainly.
3 Q. I think you did agree with me earlier on that if there
4 is any difference between the dates you have given in
5 evidence and the dates in the medical records, you're
6 quite happy to accept that --
7 A. No, at times; some I'm quite definite about, but
8 others --
9 Q. Sometimes, yes. Were you aware of there being any
10 notices in the wards, or indeed any part of the hospital
11 that you had access to, to stipulate that there should
12 be no more than two visitors to a bed?
13 A. I believe there was one as you enter somewhere in ward
14 15, but it wasn't prominent, and I remember reading it
15 and thinking it wasn't enforced.
16 Q. Would you accept -- I'm putting this to you as
17 a proposition that I have been asked to put forward to
18 you -- that if people have travelled a long distance to
19 visit, you could perhaps relax the rule and have more
20 than two people at a bed?
21 A. Yes, I totally agree with that. My concern was the
22 number of visitors sitting on beds and, you know,
23 children crawling about on top of beds, et cetera.
24 Q. Just on that, I mean, so far as you could see, were the
25 nurses aware of what you have just described, more than
76
1 two visitors, and children crawling about beds?
2 A. I don't think they could possibly not be aware, it was
3 very prominent. A lot of visitors during visiting hours
4 were standing due to the lack of chairs, or sitting on
5 beds, and it was obvious that a lot of beds had a lot of
6 visitors. But to be honest they were probably so busy,
7 whether they actually felt able or, again, if there
8 isn't -- if there's that relaxed atmosphere, because
9 there is no-one seriously ill as such, because I think
10 ward 6 didn't cater for seriously ill patients, maybe
11 that's why there were the relaxed rules.
12 Q. In relation to the washing of hands, so far as nurses
13 washing their hands is concerned, did you see nurses
14 regularly washing their hands?
15 A. Again, it's not something I was paying much attention
16 to, to be honest, so -- definitely when my mum was in
17 room 11 they gloved up at every time that I recall.
18 Q. I think I asked you this before, but I just want to
19 confirm it, that when your mother left the hospital on
20 her weekend pass she wasn't suffering from diarrhoea at
21 that time?
22 A. No.
23 Q. So she developed the diarrhoea over the weekend and
24 suffered from the diarrhoea once she went back to the
25 hospital?
77
1 A. Yes. It was later that evening, on Saturday,
2 15 December.
3 Q. When you returned on 17 December, after the weekend
4 pass, were you told why the ward was closed?
5 A. I don't recall being told the exact nature, but I was
6 told there was a bug in the ward, but I don't remember
7 whether it was -- what was used to tell me, and whether
8 it was specifically named or not. But I do recall after
9 that, a couple of days later, there was a white notice
10 on the door. Usually when I arrived, the doors were
11 open, and this particular day I was slightly early and
12 the doors were closed and there was a white with black
13 writing, but I honestly don't know if it said "winter
14 vomiting" or "norovirus". I can't recall.
15 Q. When your mother returned from the weekend out, did you
16 yourself mention the diarrhoea to either Sister Fox or
17 one of the nurses?
18 A. Yes.
19 Q. Was it Sister Fox you discussed it with?
20 A. I believe so.
21 Q. Did you tell her that your mother had suffered quite
22 badly with diarrhoea over that weekend?
23 A. Yes.
24 Q. Was it after that that Sister Fox said she required to
25 have a stool sample?
78
1 A. It wasn't until I had -- she was really busy and had
2 been called away very quickly, so I can't recall whether
3 she was about to suggest that, but not long after I had
4 to go back out and ask her because my mum was quite
5 poorly, and she came back immediately and took her
6 temperature and asked for a stool sample to be taken.
7 Q. I think I've raised this with you, but just to confirm:
8 after your mother was diagnosed with C. diff, were you
9 aware that she was started on a broad spectrum of
10 antibiotics?
11 A. I can recall a lot of antibiotic talk nearer -- when she
12 was moved into room 11, but, I mean, being a lay person
13 I wasn't aware at any time, or really was -- not
14 uninterested, but I left that to the doctors. But I --
15 then, as it got nearer the time of her death, I was
16 aware of talk of different antibiotics being used. But
17 prior to that I could have been told, but I probably
18 didn't quite take it on board.
19 Q. So far as you were concerned, were you aware that the
20 nursing and medical staff were seeking to treat the
21 C. diff?
22 A. Yes. Oh, yes. Yes.
23 Q. I think you are a core participant to this Inquiry,
24 Mrs Bowes; is that correct?
25 A. Yes.
79
1 Q. Is there anything further you would like to say in order
2 to assist his Lordship in the Inquiry?
3 A. Just one of my concerns was that as a teacher, I have
4 been through several quite thorough inspections within
5 the school where I work, and as a layperson, and at many
6 times during my mother's stay in hospital, I felt that
7 perhaps there wasn't as robust an inspection system as
8 perhaps there should have been.
9 I began to be quite concerned about that after my
10 mother's death and felt, therefore, that, as a teacher,
11 I have that almost assurance that if there is something
12 wrong in the secondary level of management and,
13 therefore, where we are, we don't have the resources
14 perhaps we quite should, or the fabric of the building
15 isn't -- and if I go to my management and it's not
16 listened to we have then a thorough, robust system
17 whereby we have HMIE, who visit on a seven-year cycle,
18 if you like, and in between that there is constant
19 monitoring from your quality improvement officers within
20 your council.
21 And I just felt that, as a layperson walking into
22 the Vale of Leven, I could see that there appeared to be
23 areas, shall we say, that would have been picked up had
24 someone from an inspection process entered, without
25 going into any other medical detail, and that obviously
80
1 having spoken to some of the staff -- the remark about
2 the blind, that, you know, "We know we won't get it,
3 we're being run down", combined with low morale and
4 combined with that feeling that "We won't get the
5 resources", that they didn't have that almost assurance
6 that somebody would come round and say, "I'm sorry, they
7 need to have it".
8 So I began to look, and after a period I thought,
9 just what interests -- I took to the internet just to
10 see what was the public accountability within the health
11 service and what there was, and I just had a look, and
12 obviously I could print out an inspection report for the
13 local primary school, I could print out an inspection
14 report for Drumoak, which was a care of the elderly
15 within the area within West Dunbartonshire, I could
16 print out Robin House -- I don't know if you're aware,
17 it's children, I could print out a very detailed
18 inspection report from Robin House. I then went further
19 and I could print out a report on the supermarket, on
20 the leisure centre, and I could even go as far as
21 printing out -- and these are reports written in a very
22 public way, very easy to access on the internet; I could
23 even print out a report on the Vale of Leven tea bar,
24 and that the fridge hadn't been at the appropriate
25 temperature and they were asked to fix that.
81
1 I could not print out a report on the
2 Vale of Leven Hospital and I was quite concerned about
3 that. I then went into the government's website looking
4 for something to show public accountability: why could
5 we enter similar -- under the Care Commission -- Robin
6 House or, I'm not sure if it is Care Commission but
7 something like that, under Robin House and Drumoak,
8 which are similar care places, medical based. Very
9 detailed information, if you print one out you'll see
10 for yourself the amount of information you're given.
11 And I thought: why in this day and age do we not have
12 that for our hospitals?
13 So I then went into the government website and
14 looked for the last time that the Vale of Leven was
15 inspected in a HEI capacity, because I realise there are
16 many facets to the healthcare, and I felt that under
17 healthcare-associated infections, what was there? And
18 I located -- I actually brought the documents --
19 I located one from previous -- the last one I could find
20 was the Argyll & Clyde, when it belonged to Argyll &
21 Clyde, and it had been inspected in 2002, as were,
22 I think, I believe, most of the hospitals in Scotland,
23 and I don't think they did very well in general, and
24 I think that was mainly because of their newness to this
25 sort of inspection process with HEI in mind.
82
1 Then I started to look at other hospitals, and they
2 were -- Argyll & Clyde at that time, the Royal
3 Alexandra, the Vale and then I think Lorn & Islands and
4 Greenock Hospital, the four at the time in 2002, and
5 they scored 35 per cent -- there were 69 criteria and
6 they scored 35 per cent. I then went to look at other
7 hospitals, and Greater Glasgow at the time, I think it
8 was called the Greater Glasgow Primary Care Trust, had
9 scored 53 per cent on this HEI infection controls basis,
10 and there was a whole list of questions.
11 In 2004, Greater Glasgow had increased this to
12 88 per cent and Argyll & Clyde only scored a further 3
13 points and arrived at 39 per cent. When I read that
14 report, I actually was devastated that, and it goes
15 through quite thoroughly and says -- it has to be read
16 to be believed, to be honest. There is a lot about
17 monitoring infections, control systems, the detect
18 system. And it actually says at the beginning that no
19 report was actually submitted by the Vale of Leven.
20 I appreciate that when Argyll & Clyde then were
21 split and the Greater Glasgow inherited, I know there
22 was a millions deficit, but to my mind the QIS
23 documentation, the Quality Improvement Scotland, was
24 never, as far as I was concerned, broached. And I felt
25 that was something that, if it had been a school or for
83
1 any other in that matter, you would have been on
2 a six-week turnaround, and basically you would have been
3 inspected thoroughly and you would have had return visit
4 after return visit. And by the majority -- looking at
5 it, most of it was on a self-assessment basis, which
6 I don't think was good enough.
7 I hope that in the -- I did bring this point to
8 Nicola Sturgeon at one point, we did have a chance to
9 meet with Nicola Sturgeon, and I hope a more thorough
10 and robust inspection process is put in place. And
11 that's why I am here today, because I really feel that
12 something has to be done in the health service, and
13 I think in this day and age it is shocking that there is
14 not that same system in place.
15 MR MACAULAY: Thank you for that contribution, Mrs Bowes,
16 and, as his Lordship said at the beginning, this will be
17 an area of course that we will be looking at in
18 subsequent phases of this Inquiry. If you just bear
19 with me a moment or two. Thank you.
20 A. Thank you.
21 THE CHAIRMAN: Thank you very much, Mrs Bowes. You are free
22 to go. Thank you for coming, too.
23 MR PEOPLES: My Lord, I wonder if I could just ask a few
24 questions? I was advised that I could ask one or
25 two supplementary questions, if necessary. I don't
84
1 intend to be very long, but I just wanted to ask
2 Mrs Bowes just a few matters?
3 THE CHAIRMAN: Mr MacAulay?
4 MR MACAULAY: I don't have an objection.
5 MR PEOPLES: I don't think it will take long.
6 THE CHAIRMAN: Everybody says that.
7 MR PEOPLES: I will try to be as brief as I can. It is just
8 that since she did raise a --
9 THE CHAIRMAN: Do sit down.
10 MR MACAULAY: I think under the rules my learned friend
11 Mr Peoples probably can make an application at this
12 point.
13 THE CHAIRMAN: Because she is a core participant and he
14 represents her.
15 MR MACAULAY: Indeed; for whom he acts.
16 THE CHAIRMAN: Yes. You say he doesn't have to give you
17 notice of what questions he would like to ask.
18 MR MACAULAY: I think, preferably, one would always like to
19 have notice, but if it is only for clarification I don't
20 take any issue with that.
21 THE CHAIRMAN: Right. Is it only for clarification?
22 MR PEOPLES: Yes, it is only one or two matters arising out
23 of questions arising.
24 THE CHAIRMAN: I am pulling your leg, and I shouldn't do
25 that.
85
1 MR PEOPLES: I am grateful, my Lord.
2 Examination by MR PEOPLES
3 MR PEOPLES: Mrs Bowes, I won't detain you much longer,
4 I know you have had a long session this morning. Can
5 I just ask you one or two things: so far as ward 6 was
6 concerned, you told us your mother was in room 15 at one
7 point and then she moved to room 13, which was the --
8 A. Room 11.
9 Q. The plan is GC00700001, which I think will show ward 6.
10 A. Yes, she was 15 to room 11.
11 Q. She moved to 13 at some point and then she finally ended
12 up in room 11, I think, which is what --
13 A. Yes, sorry.
14 Q. The isolation room?
15 A. And at one point she was in 18, yes.
16 Q. So far as rooms 15 and 13 are concerned, I think you may
17 have implied this, but am I right in thinking that in
18 room 15 there would be no toilet or wash hand basin --
19 A. No, it wasn't a room, it was a bay.
20 Q. A bay?
21 A. And there was no door or anything. Yes, it was for beds
22 and for patients in moving trolleys, but there was
23 nothing else, to my knowledge.
24 Q. Would the same apply to room 13, that there were no
25 wash hand basins or washing or toileting facilities?
86
1 A. No.
2 Q. Can I just clarify one thing about your statement.
3 I think you mentioned that initially your mother went
4 into what you have described in I think paragraph 7 of
5 your statement as the high-dependency unit when she
6 first was admitted?
7 A. Yes.
8 Q. Then you referred to her going to the CCU --
9 A. Yes.
10 Q. -- later on, towards the end of her life?
11 A. Yes.
12 Q. Were these two different locations?
13 A. Yes, completely different locations. They had closed an
14 excellent facility downstairs, the high-dependency
15 unit -- I wasn't given a reason for the closure -- and
16 the staff were quite upset at this at the time, and then
17 later, when Dr Clark had said, "We need to get her a one
18 to one", I said, "But high dependency is not there now.
19 You know, where else is there?" I can't recall the
20 terminology, but I know it wasn't
21 "high-dependency unit", but I couldn't have told you it
22 was "critical care", or whatever, and it was based
23 within ward 4 of the cardiac ward.
24 Q. So the high-dependency unit you described at the
25 beginning of your statement was not in ward 4?
87
1 A. No.
2 Q. It was somewhere else?
3 A. No, the high-dependency unit was downstairs in
4 a dedicated high-dependency unit, which was -- had an
5 isolation room and very spacious beds and -- a very
6 open, very spacious unit that was closed.
7 Q. Can I just ask you briefly about the period that your
8 mother spent in the TV room when she came back from the
9 weekend visit feeling unwell.
10 A. Yes.
11 Q. You mentioned I think that she was there several hours.
12 I don't think you were precise, but she was certainly
13 there for a period of hours?
14 A. Yes.
15 Q. Was the other patient, the other -- was it a lady?
16 A. Yes, a lady.
17 Q. Did she remain for the same period of time?
18 A. Yes, I think she -- I believe she left after lunch.
19 So she wasn't quite there quite as long.
20 Q. And --
21 A. She was told that she had been found a bed somewhere
22 else.
23 Q. And your mother at some point was asked to provide
24 a specimen?
25 A. Yes.
88
1 Q. Did she have to leave the TV room to do that?
2 A. Yes.
3 Q. Do you know where she went?
4 A. There was some sort of mix-up, and one nurse had come to
5 take her and hadn't got a stool sample and hadn't taken
6 her where sister -- I'm not 100 per cent sure where, and
7 then she was taken -- I believe there was an argument
8 over whether it was going to be a staff toilet or
9 whether it was going to be into the ward and there
10 was -- and I don't know where she actually went.
11 Q. You have mentioned to counsel assisting the Inquiry
12 certain arrangements about laundry and what would happen
13 in your experience.
14 A. Yes.
15 Q. You were taking your mother's laundry away when she was
16 in ward 6?
17 A. Yes.
18 Q. When she moved to what has been now described as the
19 critical care unit or chronic care unit in ward 4, when
20 she moved there latterly, were you still taking laundry
21 home or was she wearing hospital gowns at that stage?
22 A. It was the same procedure. No, she was definitely still
23 wearing her own garments, and it was the same procedure,
24 although on I believe the second-last day or the last
25 day, because she had the catheter, I didn't have as much
89
1 as I had previously had, but certainly I took home bags
2 from that ward, from critical care.
3 MR PEOPLES: Thank you very much.
4 THE CHAIRMAN: Could I just ask you about the cardiac unit.
5 Was it upstairs?
6 A. Sorry? The?
7 THE CHAIRMAN: Was the cardiac unit upstairs?
8 A. Yes, in ward 4, yes.
9 THE CHAIRMAN: You see, CCU might stand for coronary care
10 unit?
11 A. No, it was definitely separate. It had separate -- it
12 was the staff from the high-dependency unit that were
13 manning it, and I was told it was specifically for
14 patients who were dedicated care one to one information.
15 THE CHAIRMAN: Dedicated care. No doubt we will have that
16 clarified in due course.
17 MS GRAHAME: My Lord, may I interrupt at this stage and ask
18 for clarification about one thing?
19 THE CHAIRMAN: Yes.
20 MS GRAHAME: I did have a number of supplementary questions
21 which I was wanting to ask this witness. I understood,
22 and perhaps your Lordship can clarify, that the core
23 participants were to be invited at the conclusion of
24 the examination-in-chief to make an application to
25 question a witness if they wished to do so, and that was
90
1 with all of the witnesses.
2 Obviously, there will be occasions where no
3 questions are asked, but does your Lordship anticipate
4 that we should interrupt at the end if we do have some
5 supplementary questions?
6 THE CHAIRMAN: I'm bound to say, I had thought that those
7 who had questions would frame them in advance, if it is
8 possible to do so, because I can't think that anything
9 has come out of Mrs Bowes' evidence that doesn't appear
10 from her statement. Am I wrong?
11 MS GRAHAME: Not at all, my Lord. I did provide lines of
12 questioning --
13 THE CHAIRMAN: I know you did.
14 MS GRAHAME: -- in relation to that. But there is one
15 particular issue which has arisen and I wonder if
16 I could clarify, because Mrs Bowes has indicated that
17 after the return from the weekend pass her mother was
18 kept in ward 6, but in the medical records -- and this
19 did form part of questioning I produced to counsel to
20 the Inquiry -- they do indicate that she was transferred
21 to ward 5, and I wondered if that was perhaps an
22 explanation why she didn't fully recognise the plan that
23 was shown to her of ward 6, and perhaps it was ward 5.
24 THE CHAIRMAN: Well, I am very keen, as you probably know,
25 to restrict any questions.
91
1 A. I'm quite happy to answer that one.
2 THE CHAIRMAN: No doubt, but I have another interest here:
3 It is so that we don't go around asking questions.
4 Otherwise, we would be back into a very different kind
5 of procedure. But in this case, by all means, ask the
6 question.
7 MS GRAHAME: I'm very much obliged.
8 Examination by MS GRAHAME
9 MS GRAHAME: Mrs Bowes, you have heard the matter I wish to
10 raise with you. I wonder if you would look for me,
11 please, at an entry in the medical records, which is
12 GGC00140246. Do you see that on the left-hand column
13 the date is given as 17 December 2007 --
14 A. Yes.
15 Q. -- which I understand is the day you returned with your
16 mother after the weekend pass?
17 A. Yes.
18 Q. If we could perhaps highlight that section, the first
19 line, 11 o'clock in the morning:
20 "Returned from weekend pass. Unwell ..."
21 Sorry, I'd like to see a bit more of that section,
22 please, if you'd perhaps go down to 13:40.
23 A. Yes, at that point I had left my mum.
24 Q. It's just to let the entry appear on the screen.
25 "Returned from weekend pass. Unwell -- lethargy
92
1 anorexia since Sunday."
2 Further down you will see that opposite 13:00 hours
3 it says "For transfer to ward 5", and then at 13:30 on
4 the second line:
5 "To remain on ward 5, due to x1 episode of loose
6 stools, specimen obtained."
7 A. I returned to the hospital -- I was gone at that point,
8 and I returned to the hospital, and my mother was
9 absolutely and totally in ward 6 when I returned later
10 that day. But I couldn't be 100 per cent when -- I know
11 I made shop opening hours and managed to get slippers
12 for her before returning, but I'm not 100 per cent sure,
13 but she 100 per cent -- I was not aware she had been
14 moved to ward 5.
15 THE CHAIRMAN: Are you sure it is a "5"? It looks awfully
16 like a --
17 MS GRAHAME: It says "For transfer to ward 5" on the line
18 above 13:30.
19 A. Yes, but that says to transfer, and then it says
20 "to remain on ward", and that actually does look like
21 a 6, "due to one episode".
22 MS GRAHAME: It may be we'll --
23 A. She definitely stayed on ward 6, as far as I was aware.
24 THE CHAIRMAN: Yes, it says:
25 "For transfer to ward 5."
93
1 MS GRAHAME: Yes.
2 A. I was told --
3 THE CHAIRMAN: Just a minute.
4 A. Yes, sorry.
5 THE CHAIRMAN: But "to remain on ward 6".
6 MS GRAHAME: Sorry, my Lord, I read that as "5".
7 THE CHAIRMAN: How do you transfer to a ward and then remain
8 in another ward?
9 MR MACAULAY: I think we need to look at this, my Lord.
10 This looks a little bit ambiguous, depending on whether
11 you read it as 5 or 6, but the other medical records,
12 and particularly the biochemistry, indicate that all the
13 results were sent to and from ward 6, so I think that
14 seems to be the position.
15 MS GRAHAME: Thank you, my Lord.
16 THE CHAIRMAN: Right. Ward 6 it is, I think.
17 A. Yes.
18 THE CHAIRMAN: Thank you very much indeed.
19 A. Thank you very much. Thank you.
20 (The witness withdrew)
21 THE CHAIRMAN: Mr MacAulay, what do you want to do? It is
22 10 to 1. Do you want to start the next witness?
23 MR MACAULAY: I would be inclined to say perhaps we should
24 adjourn a little bit earlier for lunch and come back
25 a little bit earlier, rather than starting a witness and
94
1 stopping.
2 THE CHAIRMAN: We will come back at 1.50 pm?
3 MR MACAULAY: Yes.
4 THE CHAIRMAN: 1.50 pm. We will rise now.
5 (12.48 pm)
6 (The short adjournment)
7 (1.50 pm)
8 (Brief interruption by member of public)
9 MR MACAULAY: My Lord, the next witness I would like to call
10 is number 2 on the list, Mrs Nancy Logan.
11 MRS NANCY LOGAN (sworn)
12 Examination by MR MACAULAY
13 MR MACAULAY: Good afternoon, Mrs Logan.
14 A. Good afternoon.
15 Q. I think you are Nancy Morrison Logan; is that correct?
16 A. Yes.
17 Q. I think you stay with your husband David Logan, who is
18 a co-participant in this Inquiry; is that right?
19 A. Yes.
20 Q. You are the daughter of Agnes Campbell?
21 A. Yes.
22 Q. And she was also known as Nancy Campbell?
23 A. That's correct.
24 Q. I think she died in the Vale of Leven Hospital on
25 13 January 2008?
95
1 A. Yes.
2 Q. Do you live in the catchment area of the Vale of Leven?
3 A. Yes, I do.
4 Q. And did your mother live in that area as well?
5 A. Yes.
6 Q. I think your mother lived with your father; is that
7 right?
8 A. Yes.
9 Q. Apart from yourself, you have a sister Christine?
10 A. Yes.
11 Q. We will come to look at when your mother went into the
12 Vale of Leven Hospital, and that was in December 2007.
13 A. Yes.
14 Q. But can you tell the Inquiry what her state of health
15 was before she went into hospital?
16 A. Before she went into hospital she had a very good state
17 of health. She went swimming regularly, she walked
18 regularly, she had a very good health record. She was
19 complaining of feeling tired latterly, and that was
20 really the only sort of thing that caused any concern.
21 She took not well walking home from the town the day
22 previous she was admitted, and she was admitted with
23 what they suspected was heart failure.
24 Q. Perhaps take from me that at the time of her death your
25 mother was 85?
96
1 A. She was, yes.
2 Q. But a fit 85 before she went into hospital?
3 A. Very fit, yes.
4 Q. What was the first you knew, then, that your mother had
5 become unwell?
6 A. My father phoned me the following morning to say that my
7 mother had taken not well on her way home from the town,
8 which I was quite concerned about, that he hadn't phoned
9 me the night previous, but she had told him not to phone
10 me because she thought she'd be all right. I went over,
11 straight over, to see her, and I felt there was
12 something not right. I phoned the doctor, who came to
13 see her and decided that my mother would be best to be
14 admitted because she was concerned over possible heart
15 failure.
16 Q. Do you have your statement in front of you there?
17 A. I do, yes, I have.
18 Q. I think you tell us in paragraph 6 that your father
19 phoned you on 17 December?
20 A. Yes.
21 Q. You went over to see your mother on the morning of
22 18 December?
23 A. That's right.
24 Q. Was it then, on 18 December, that your mother was
25 admitted to the Vale of Leven?
97
1 A. Yes.
2 Q. Perhaps I could ask you to look at the medical records.
3 If you could have in front of you GGC00080042?
4 A. There's nothing coming up on my screen.
5 Q. It will come up in a moment.
6 A. Oh, all right.
7 Q. You will see that is a document that is an admission
8 assessment or a case index.
9 A. Yes.
10 Q. If you look to the left, do you see the date admitted is
11 18 December 2007?
12 A. Yes.
13 Q. And that accords with your own recollection?
14 A. Yes.
15 Q. If you could turn, within the same record, to
16 GGC00080064, you will see this is a record from the
17 medical assessment unit, again the same date, and you
18 will see the admission time is 13:20?
19 A. Yes.
20 Q. Did you go to the hospital with your mother?
21 A. I did.
22 Q. The heading "Initial Assessment" is:
23 "Alert, orientated. Was out yesterday shopping,
24 fainted, had chest pain."
25 Was that your understanding as to what the problem
98
1 was?
2 A. Yes.
3 Q. I think I am right in saying that your mother didn't
4 spend very long in the Vale of Leven at this particular
5 time; is that right?
6 A. She was in the minor injuries unit. She was assessed in
7 the Vale of Leven that afternoon, and then she was
8 admitted up the stairs to a ward, where I was told at
9 the time there was no concern and she possibly would be
10 in for one night. She was taken up the stairs and
11 I went with her. I was told I would see her in a short
12 while, and an hour later I was very concerned and
13 I looked for medical staff and they said somebody would
14 be with me shortly.
15 As it transpired, they decided to do an examination
16 and discovered she'd had a heart attack. She was made
17 comfortable, and I stayed with her for quite a few
18 hours, and she was getting concerned because it was
19 getting dark and wanted me to get home. So I left the
20 hospital about 6 o'clock, went home to see my father to
21 tell him that my mum was staying in overnight, possibly
22 longer, because she'd had what I thought at the time was
23 a slight heart attack.
24 I phoned the hospital twice that night and they were
25 quite happy with her. Then the hospital phoned me later
99
1 on in the night to say they were concerned about her
2 breathing and her heart rhythm and I went back up to the
3 hospital that night. They were concerned about her
4 condition and I got to speak to the doctor who was on
5 duty who gave me a very good recollection of my mother's
6 health and what might happen if she didn't get
7 transferred to Royal Alexandra, because they had the
8 facilities to treat the type of heart problem she had.
9 Q. And is that what happened?
10 A. That's what happened.
11 Q. Was she discharged to the Royal Alexandra on --
12 A. I was told she'd get transferred that night.
13 Q. That was 19 December?
14 A. It was. I left the hospital about 3 o'clock in the
15 morning, because we were waiting on an ambulance, and my
16 mum was getting concerned because I was at the hospital
17 at such an early hour in the morning. I phoned the RAH
18 the following morning, about half 7, and they said she
19 had arrived but wasn't in a ward yet, and I called back
20 later and I was told she was in the cardiac care unit of
21 the RAH.
22 Q. Did you then go to visit her?
23 A. I went over that afternoon and she was in a room of own.
24 She looked very comfortable, had a mask on, had monitors
25 on, but she was very comfortable and relaxed because she
100
1 knew she was in good hands.
2 Q. If you could turn to your statement at page 4, you are
3 there talking about the position once your mother was in
4 the Royal Alexandra Hospital, and I think you say in
5 paragraph 16 you thought she was in ward 20?
6 A. Yes.
7 Q. In 17, you describe the nature of the ward, and in
8 particular you point out that the beds were wide apart
9 in that particular ward?
10 A. Yes. She was in the coronary care unit in a room of her
11 own for about maybe three or four days, and then
12 transferred to ward 20, and, yes, the beds were wide
13 apart.
14 Q. Your mother spent some time in the Royal Alexandra
15 Hospital; is that correct?
16 A. She was there until I think it was about 28 December.
17 Q. Was she then transferred back to the Vale of Leven?
18 A. While she was in the RAH, I was told they were really
19 pleased with how well she was doing, and considering how
20 ill she had been, they were delighted with her progress.
21 I was told at one point she would possibly be getting
22 home --
23 Q. In the Royal Alexandra?
24 A. Yes. A staff nurse told me she was doing really well
25 and would possibly be getting home, and I was quite
101
1 concerned because I'd ordered furniture, I wanted the
2 house just right for her coming home, we'd got new
3 furniture ordered, and I was concerned she was getting
4 home so quickly, because I thought the normal procedure
5 was when patients were transferred from the RAH after
6 having a heart attack they would go to the Vale of Leven
7 to be assessed on how they were able to cope at home.
8 I had an elderly father, so this was causing concern,
9 but the nurse had said, well, it wasn't actually written
10 in for definite yet, but it was being looked into that
11 she might be getting home.
12 Q. But that didn't happen?
13 A. What happened was, on the Friday, my sister went to
14 visit my mum with a friend, and my mum was walking out
15 of the reception area of the hospital and walked into
16 patient transport to take her to the
17 Vale of Leven Hospital. She was being transferred that
18 day. We weren't told that she was being transferred.
19 Nobody phoned to tell us. It seemed to be happening
20 very quickly. The night before she had been alert, she
21 had been quite bright, but we knew nothing of her being
22 transferred so soon, and she was transferred then to the
23 Vale of Leven.
24 Q. Did you then go and visit your mother that evening?
25 A. Yes.
102
1 Q. At the Vale of Leven?
2 A. Yes.
3 Q. If you could look at the medical records again, please,
4 Mrs Logan, and this is GGC00080051. You will see that
5 that is an admission form, and if you look to the left,
6 although it is not very clear, I think the date is
7 28 December 2007, and the admission is to ward 6. Do
8 you see that?
9 A. Yes.
10 Q. Was it then, at that time, that your mother was
11 readmitted to the Vale of Leven?
12 A. Yes, that was.
13 Q. Was it to ward 6 that she was admitted?
14 A. It was to ward 6.
15 Q. If I could just go back a bit and ask you about
16 yourself, Mrs Logan, because I think for a time you were
17 employed as a carer; is that right?
18 A. Yes.
19 Q. Just tell us a little bit about that. Where was that?
20 A. It was a convalescent retirement home for Sisters of
21 Notre Dame, and I worked there for a period of about
22 four years. I used to do their hair and I got to know
23 the sisters, and they were looking for carers. At the
24 time, I was unsettled in the job I was in, and I was
25 approached and asked would I consider applying for
103
1 a job. It was such a well-run convalescent home, it was
2 the best material. The sisters were so well looked
3 after and they had the best of attention staff-wise.
4 I got employment there -- as I said, I worked there for
5 five years.
6 Q. When was that, can I just interrupt? What period?
7 A. Sorry?
8 Q. When was that?
9 A. That would be about 2000, around about the year 2000, or
10 just before.
11 Q. From 2000 to 2005, was it, or --
12 A. Yes, I was there for the five years, almost. And it
13 made me very aware of the type of treatment that they
14 got. They were just so well looked after. Anything
15 that was needed, really, of medication, bandages,
16 towelling, was there. I often thought going into
17 hospital, that's the way it should be. They were so
18 well looked after, the nursing staff, which made me very
19 aware of the facilities in hospitals, and the few times
20 I visited hospitals I found I was always sort of
21 comparing to the environment I worked in.
22 Q. Let's go back, then, to the Vale of Leven, because
23 I think you said you went to visit your mother on the
24 evening of 28 December, and she was in ward 6 --
25 A. Ward 6.
104
1 Q. -- at that time. If I could ask you to look on the
2 screen to the plan, which is GGC00700001. Now, here we
3 have a floor plan for ward 6, Mrs Logan. Just take time
4 to orientate yourself.
5 A. Yes, I see it.
6 Q. Are you able to tell us what room in ward 6 your mother
7 was admitted to?
8 A. She was in bay 13, and she was in the bed right to the
9 left-hand side. There were two beds in the ward.
10 Q. You are pointing to the left. You go in the door, you
11 turn to your left?
12 A. Yes.
13 Q. The other bed, was that on the other side of the bed?
14 A. Yes, mmm-hmm.
15 Q. Was there somebody else in the room?
16 A. Yes, mmm-hmm.
17 Q. Can you tell me if that other person was an elderly
18 person or --
19 A. I would have said she was in her early 70s. She seemed
20 quite poorly. But, yes, I would have said about early
21 70s.
22 Q. How was your mother when you saw her?
23 A. Distressed. I was horrified when I went into the
24 hospital. It had been a long time since I had actually
25 visited the hospital, and I was shocked at the state of
105
1 it. The ward seemed to be in turmoil, chaos, and my mum
2 was actually quite distressed. She was very tired
3 looking, and I put it down to being transported, the
4 suddenness of it, coming from RAH. By the same token
5 she was glad to be in the Vale because she was nearer
6 home.
7 She was distressed by the fact that when she had
8 gotten into the ward she needed to visit the toilet and
9 she had asked someone where it was, a member of nursing
10 staff, and was told that they were very busy because
11 this was meal times, and it had upset her, and she felt
12 she was in the way, that they weren't prepared for
13 patients coming. But a domestic saw she was distressed
14 and assisted her and showed her where the toilet was.
15 But all I can describe is, to me, it was just chaos.
16 The staff were just -- they were short. It looked as
17 though there wasn't enough staff and the ward was
18 a mess.
19 Q. You said that on more than one occasion. You said the
20 ward was a mess.
21 A. Yes.
22 Q. Can you just elaborate upon that, Mrs Logan?
23 A. My mother's things that she had brought from the
24 hospital were still in the bag at the end of her bed.
25 She didn't have a trolley -- sorry, a cabinet beside her
106
1 bed. There were boxes opposite her bed, and beside the
2 fire escape there were boxes piled up. There was a vase
3 of flowers, stagnant water. Nothing looked fresh or
4 prepared.
5 My husband managed to find a cabinet that wasn't
6 being used and we emptied my mum's bag and we got her in
7 some sort of order. She hated a fuss being made. She
8 was very, very proud and she didn't want to cause
9 a fuss. She didn't want me to speak to any of
10 the nursing staff because she knew they were run off
11 their feet.
12 So we got her settled and she was fine by the time
13 we left. But I wasn't happy, I wasn't happy with the
14 way the ward was.
15 Q. You say the staff were busy.
16 A. Mmm-hmm.
17 Q. Can you elaborate upon that?
18 A. Beds seemed to be getting prepared -- they just seemed
19 to rush about the place. Beds were being moved about.
20 It seemed that they weren't prepared for other patients
21 coming into the ward, and it was as if they didn't have
22 the facilities or the staff or the time. It was just
23 chaos. That was my first vision of it when I went in,
24 I thought: there's something not right here. And
25 I wasn't happy. But I settled myself with the fact that
107
1 my mum was happy because she was nearer home.
2 Q. I think you said a moment ago, though, that you did
3 manage to get your mother settled --
4 A. I did get her settled, yes.
5 Q. -- in the bay. Did you return to see her the next day?
6 A. I did.
7 Q. Which would be 29 December?
8 A. I went up on the Saturday afternoon and she was sitting
9 at the side of her bed and she seemed quite content, and
10 she said, "I've been told I've got to drink plenty."
11 She said, "The girls here are very nice but they're so
12 busy," and she said, "I've got to drink plenty of
13 water," but she didn't have any water. So I went to go
14 and see if I could find some water for her.
15 I went looking for a nurse to see if I could find
16 out if there was any idea how long my mum would be in,
17 and I think at that point, it might have been that day
18 or the following day, I was told they only expected her
19 in the hospital for a couple of days as they thought
20 there was a good chance she would be home for the new
21 year.
22 Q. But in relation to the water point that you raised --
23 A. Yes.
24 Q. -- you say your mother said she needed to drink water
25 but there was no water in the ward?
108
1 A. Yes.
2 Q. In the bay?
3 A. Yes.
4 Q. Did you then get water from somewhere?
5 A. We went back up -- as I said, it was either the Saturday
6 or the Sunday, and we went back up, and I had noticed in
7 the afternoon there'd been a jug of water sitting on the
8 nurses' desk. I went back up on the Saturday night, or
9 possibly the Sunday, and I'd said about the water, and
10 the jug of water that had been sitting on the nurses'
11 desk was handed to me to give to my mum. And I went
12 back and I said to my mum, "I'm not happy, I don't think
13 this is fresh water," and my mum said, "Don't cause
14 a fuss." She just hated the idea -- the girls were
15 busy, the staff were run off their feet. So from then
16 on, I started to take small bottles of water up so that
17 I knew she was getting fresh water.
18 Q. So you saw on the nurses' desk the same jug that had
19 been there the day before?
20 A. Yes.
21 Q. But I suppose you don't really know whether it was the
22 same water or not?
23 A. No. No.
24 Q. Did there come a point in time, then, when your mother
25 was moved from ward 6?
109
1 A. Yes. She was moved a few days later. During that time,
2 I did get to speak to the ward sister again, and she
3 said my mum was doing well and they did think she would
4 get home. They'd possibly do an assessment on her in
5 a few days' time, which was a normal procedure, just to
6 check how fit she was for going home.
7 She was moved to ward 5, and that was just after the
8 new year. She was moved to ward 5. To start off with,
9 it was just herself and another patient.
10 Q. Were you told why she was being moved to ward 5?
11 A. No. No, I wasn't told. She just had got moved.
12 Q. Had your mother improved by the time she was moved to
13 ward 5?
14 A. When she was moved, that's when I started to think she
15 looked as though she was going down. She kept saying,
16 "When am I getting home?" There was never anybody to
17 ask for definite what was happening, but I felt she was
18 looking sort of peaky, she was getting tired, and I was
19 worried she was -- I was worried she was getting
20 depressed because she wasn't getting home quick enough.
21 Q. Well, just so we can put dates to this, can you look at
22 the medical records GGC00080051, and if you look towards
23 the bottom half, you will see a heading "Discharge
24 Summary", and the date is 5/1/2008, "Ward 5". Would
25 that be about the date that your mother was moved from
110
1 ward 6 to ward 5?
2 A. Yes.
3 Q. During the time that your mother was in ward 6, which
4 was for a number of days before she was transferred,
5 I think you've mentioned the ward sister. Did you have
6 discussions with the ward sister as to what the problem
7 was with your mother?
8 A. No, I was never told that her health was deteriorating,
9 or anything. The only thing I was actually told was
10 that the procedure would normally be she would get
11 assessed before she would go home. They were pleased
12 with her progress. She was feeling a bit nausea, and
13 I mentioned this, and we thought possibly it was
14 medication she was on. I didn't know what medication
15 she was on, but she didn't have a very good appetite,
16 and I started to take some fruit and the odd sandwich to
17 see if I could get her to eat, but --
18 Q. Do you know who you spoke to in ward 5?
19 A. No, I'm sorry, I can't remember the ward sister's name.
20 I'm sorry.
21 Q. We've had some reference already to a Sister Fox. Do
22 you know if you spoke to Sister Fox?
23 A. I'm sorry.
24 Q. You don't know?
25 A. I can't actually clarify for definite the names.
111
1 Q. Did you speak to any members of the medical staff, to
2 a doctor?
3 A. There was never any doctors about. I would say to my
4 mum, "Did you see the doctor today?", and she never
5 really seemed to see the doctor. The nurse did say, "We
6 still don't know for definite when she's getting home,"
7 but regarding medically, I wasn't told how she was doing
8 or what to expect when she did get home; no, I wasn't.
9 Q. Now, if you could go back to the plan for ward 6, so
10 that's GGC00700001, I think you said that your mother
11 was in bay 13; is that right?
12 A. Yes.
13 Q. Can you tell me if there was a wash hand basin in that
14 bay or not?
15 A. Do you know, honestly -- I honestly can't remember for
16 definite at the time. I honestly can't. I remember at
17 one point thinking there was possibly one on the
18 right-hand side as I went in, but I honestly can't say
19 100 per cent that there was.
20 Q. What was your approach to hand washing when you were
21 visiting at this time the Vale of Leven?
22 A. Our approach to hand washing was we always did wash our
23 hands when we went in, simply because when my mother was
24 in the RAH there was an outbreak of winter vomiting and
25 they emphasised to us that before you went into the ward
112
1 you had to wash your hands, use the gel.
2 So we were, as you could say possibly, really
3 educated that we wouldn't have thought of going onto the
4 ward without washing our hands.
5 Q. I may come back to that when we look at the difference
6 between the two, but if I could now just get you to look
7 at a plan for ward 5, and that's GGC00680001.
8 Now, if you just again orientate yourself,
9 Mrs Logan, this is a floor plan for ward 5. Does that
10 help you in indicating where your mother was at this
11 point? If it would help you by looking at your
12 statement, in paragraph 25, the suggestion at the time
13 of the statement was that she was in bay 9.
14 A. Yes. I remember she was next to a window, and as
15 I walked in it was on the left-hand side and there was
16 a bed opposite her. So, yes, that's as far as I can
17 remember, yes. That would have been about right.
18 Q. And how many beds were in the bay?
19 A. There was only one lady opposite her. There was only
20 the two beds.
21 Q. And was there a wash hand basin in the bay?
22 A. Yes. Yes.
23 Q. We see the indication with the black spot on the plan?
24 A. Yes.
25 Q. At the time that she was moved then into this new ward,
113
1 did you have any conversation with the nurses as to what
2 was going to happen?
3 A. Yes. When we found she was in ward 5, I didn't think
4 she was very good that night. She said her back was
5 very sore; she did have -- quite often my mother had
6 a sore back. When she was quite young she had a bit of
7 an injury in her back and every so often it would give
8 her a bit of pain.
9 A nurse came through and I said I was a bit
10 concerned because I didn't think my mum looked very
11 good, and the nurse said, "She is complaining about her
12 back being sore." She said, "I've asked her on
13 a category of 1 to 10 how sore her back is." She did
14 have hearing problems and we were concerned she wasn't
15 picking up what they were saying, but at that point
16 I felt my mum wasn't very well and I wasn't happy with
17 how she was. But the nurse I spoke to said, "Did you
18 know they have done X-rays on your mum's back?" I was
19 not aware. That nurse, unfortunately I can't remember
20 her name, gave me more information than I'd had the
21 whole time my mum was in the Vale.
22 Q. What did you understand the main problem with your
23 mother to be at this time? What was your understanding
24 as to what the main problem with your mother was?
25 A. What I felt strongly with my mum at that point was it
114
1 was just the after-effects of the heart attack, because
2 she was very tired, but she seemed to be becoming more
3 lethargic and she felt quite nausea quite often, she
4 didn't have an appetite, and I could see her condition
5 starting to go down. And the nurse was saying, "We've
6 got her on strong painkillers, very often they can do
7 this." But I just had this niggle there was more to it
8 but I couldn't pinpoint it. She used to be mobile, and
9 she was terrified that she wasn't going to go back to
10 the way she'd been before, and, again, I thought, is she
11 getting depressed, does she think she's never going to
12 go home? I --
13 Q. Was she -- sorry, carry on. I interrupted you.
14 A. I didn't foresee health problems. Basically I thought
15 she was down because she wanted to be able to do more
16 than she could.
17 Q. Did she move to another bay, then, within ward 5?
18 A. Yes, yes.
19 Q. Where was that? What bay was that?
20 A. That was further down, which -- I thought this was ward
21 4. It seemed to be further down, ward 5. As far as I'm
22 aware, ward 4 and 5 are quite near each other.
23 Q. Again, if you look to your statement, what you said was:
24 "After a couple of days in room 9, mum was put into
25 room 14."
115
1 You can see room 14 on the plan?
2 A. Yes.
3 Q. Is that where you understood she was?
4 A. Yes.
5 Q. How many beds were in that room?
6 A. There were four and they were very close together.
7 I wasn't happy the day I saw her in that ward. She
8 didn't look good. She was --
9 Q. Well, were you told why she was moved from 9 to 14?
10 A. No.
11 Q. Did you ask any of the nurses?
12 A. I was told from the nurse that gave me the information
13 regarding the X-ray of my mum's back, and showed me
14 there had been a problem with her spine when she was
15 younger, she had said the reason she was in ward 5 was
16 for assessment, to see when she was ready to go home.
17 They'd taken her along to a make-shift kitchen to see
18 how she coped, and I thought, this is good, this means
19 she's on the way home.
20 That nurse did tell me, the nurse on ward 5. When
21 she was moved to ward 4, no, I wasn't told why she was
22 moved yet again -- down to, sorry, bay 14. I do
23 remember saying to my mum, "Don't worry about it, you're
24 getting nearer and nearer the door to get out, so don't
25 worry." I made a joke about it. I don't know why she
116
1 was moved though.
2 Q. We're now into some time towards the latter part of
3 the first week of January, are we, at this point?
4 A. Mmm-hmm.
5 Q. Again can I ask you, in relation to this ward, about the
6 staffing levels? Did you form any view as to the
7 staffing levels in ward 5?
8 A. I always felt that there should have been more staff.
9 I always felt the girls were very busy and understaffed.
10 I did.
11 Regarding doctors, there was never, never a doctor
12 about to ask. I always felt when I went up at night
13 they seemed so busy, and trying to get hold of somebody
14 was always -- I would think, I'll wait until the end of
15 visiting, and then as sure as fate two or three people
16 were in front. If I tried to get somebody as I went
17 onto the ward, my mum would be concerned where was I.
18 No, I just wasn't getting information regarding my
19 mum's health at all and I put it down to the lack of
20 staff.
21 Q. Perhaps I could ask you about visiting hours. When did
22 you normally tend to visit your mother?
23 A. At the weekend I went twice a day, in the afternoon and
24 then again at night. During the week, due to work
25 commitments, I only went at night, but ...
117
1 Q. Were you a daily visitor though?
2 A. Yes. Every day, yes. I saw her every day.
3 Q. If you turn to paragraph 30 of your statement, you're
4 there talking about a visit you had on Sunday,
5 6 January 2008 when you noticed the sign above your
6 mother's bed "Nil by mouth."
7 A. Yes.
8 Q. Did you make some enquiries about that?
9 A. Nobody had told me. I actually had brought a drink for
10 my mum. I'd got -- I'd put some ice cubes in a wee
11 bottle with some water with diluted juice, and I'd made
12 sandwiches as well, because I could see her starting to
13 go down and I couldn't understand why. She definitely
14 was looking poorly at that stage. She didn't look
15 fresh, she just didn't look -- my mum was very proud,
16 always liked to be fresh, I took a fresh nightdress
17 every day.
18 And I went to give her a drink, and a domestic was
19 passing at the time and she pointed out that up above
20 her bed it said "Nil by mouth," and I went to look for
21 a nurse and I said, "Why was I not told?" And she said,
22 "We're carrying out a few tests," and I said, "What sort
23 of tests?" She said, "We're just trying to see if
24 there's anything we need to look into, they are just
25 tests being done". There actually wasn't much of
118
1 a definition as to why, I just got told they were
2 carrying out tests.
3 Q. Were you given any explanation as to why they considered
4 it necessary to carry out tests?
5 A. No indication regarding the nil by mouth either. I was
6 quite angry about that. I was given more information
7 the next day.
8 Q. Just to be clear, then, on this day when you saw the
9 sign, and if we look to paragraph 31, you say there that
10 there was a reference to tests as they thought she
11 perhaps had a "wee bug"?
12 A. That's right.
13 Q. Was that something you were told on the 6th, then?
14 A. It was, it was the Sunday. Yes, it was the Sunday.
15 Q. Was that by a nurse?
16 A. It was, yes, by a nurse.
17 Q. Were you given any explanation as to what the "wee bug"
18 might have been?
19 A. No, I was told the doctor would be coming around, but at
20 that point my mum was getting very concerned because she
21 was so uncomfortable. The pain in her back was
22 unbearable and she had very severe stomach pains. Her
23 stomach was very distended and very, very tender to
24 touch and she was very uncomfortable and she was
25 anxious, and we didn't know what was going on at that
119
1 point.
2 Q. I think at that same visit, as you tell us in
3 paragraph 32, you say a doctor came and you thought she
4 was a German, a female doctor; is that correct?
5 A. Yes.
6 Q. Did you speak to the doctor?
7 A. I tried to. I did ask and she said that she examined --
8 I was told by a nurse the doctor was coming to see my
9 mum. I was asked if I would leave my mum's bedside, and
10 she examined my mum and she went away, and I went to
11 look for her, and the words were, "I'm not willing to
12 say anything at this point. We're carrying out some
13 tests."
14 Q. So you actually spoke to the doctor?
15 A. I did. I had to go looking for her, she didn't come to
16 tell me, I had to go and look for her.
17 Q. If you could go back to the medical records, please, at
18 GGC00080079, you can take it that these are the medical
19 records that relate to your mother, and if you go
20 towards the bottom, against the date 6/1/08, 6 pm,
21 there's a note, we can perhaps highlight:
22 "Patient complains of diarrhoea... "
23 I think that's:
24 "... for 24 hours," over the last 24 hours.
25 This is the same day I think as we have been talking
120
1 about. So far as you're aware, was your mother
2 suffering from diarrhoea at the time of your visit on
3 the Sunday?
4 A. Yes. Previous to that, I think it was a Friday night,
5 she asked me to come closer to her, she wanted to tell
6 me something, and she said she'd had a bit of an
7 accident and would I take some underwear out of her
8 cabinet. I always took her night dresses and underwear
9 home, but she was concerned because they were soiled.
10 Q. Yes.
11 A. But I had taken some fruit for her and she was sure it
12 was the fruit. I didn't think at that point if that was
13 something I had to go and say to the nurses, I just
14 thought the fruit had upset her stomach. So she had had
15 a bit of diarrhoea two days previous to Sunday. On the
16 Saturday I asked her again, and she said she'd some
17 underwear, would I take it, and I said, "Mum, you'll
18 have to tell the nurses," and she said, "It's only --
19 it's these tablets are upsetting me."
20 A patient on the Sunday said to me, "You know, your
21 mum races out of this ward with her Zimmer. She's the
22 fastest Zimmer walker in this ward," and I wasn't aware
23 as to why, but it was because it was the terrible
24 diarrhoea she was having, she was rushing to the toilet.
25 Q. And having little accidents, I think, as you've
121
1 explained?
2 A. Yes. She wasn't fresh, as I said, at that point. I did
3 go to look for a nurse to say she wasn't fresh, and the
4 nurse's answer was, "Well, your mother was in the
5 bathroom long enough. I don't know what she was doing,"
6 and the fact that if they knew she had diarrhoea, they
7 should have known.
8 Q. I think when you went back on the Sunday evening --
9 A. Yes.
10 Q. -- were you then given some information about results
11 that had come back?
12 A. Yes.
13 Q. What had happened then?
14 A. I had asked if the results were back, and they said they
15 were still waiting on them, and while I was visiting the
16 doctor came to see my mum again and then went away, and
17 I went to look again for nursing staff, and I said, "Are
18 the results back?", and they said, "Yes, it's okay, we
19 know what it is. She's got a wee bug," and I said,
20 "What sort of bug?", and they said, "Oh, it's C. diff."
21 Q. I'm sorry?
22 A. "It's C. diff," which didn't mean anything to me. And
23 they said, "We'll possibly be moving your mum again,"
24 and I said "Right." And at the time I said, "You know,
25 I'm very, very concerned. There's something wrong with
122
1 my mum." We thought she possibly had a bowel tumour,
2 something major, and for some -- at the time when she
3 said C. diff, I actually was relieved, because
4 I thought, it's just a wee bug.
5 Q. Just pause there now. I will come back to that. If you
6 go back to the medical records then and just move on
7 a page to page 80, if you look towards the bottom
8 two-thirds of the page, the date 6/1/08, and at 8.30 pm,
9 there's a note:
10 "C. diff +ve."
11 I think you are telling us that at about this same
12 time you were actually told your mother suffered from
13 C. diff?
14 A. Mmm-hmm.
15 Q. Were you given any explanation then as to what C. diff
16 was?
17 A. No. I asked -- the ward sister for that night came on
18 duty and I asked if I could speak to her. I said,
19 "Could you please speak to my mum. We've discovered
20 she's got a wee bug, C. diff," I asked her as in
21 a question, and I said, "We thought she possibly had
22 a bowel tumour because she's been so uncomfortable,
23 she's been getting examined." I said, "Could you
24 reassure her?" She said, "I'll speak to your mum, don't
25 worry," and I was told nothing of what C. diff was
123
1 about.
2 Q. The doctor that you mentioned earlier, did you get
3 a name for that doctor?
4 A. No, sorry, no.
5 Q. At this time, was your mother still in room 14?
6 A. She was.
7 Q. I think you mentioned there was another patient in that
8 room; is that correct?
9 A. There were the beds, there were four beds.
10 Q. Four beds.
11 A. Yes, and there were patients in all these beds.
12 Q. Yes. Perhaps I should have asked you before: did you
13 form any view as to whether they were elderly --
14 A. They were elderly. The two opposite my mum were
15 elderly, and the lady on the left-hand side was possibly
16 late 70s, she was a good bit younger than my mum, but
17 they were all elderly patients in that bay.
18 Q. Can you remember if there was a wash hand basin in
19 that --
20 A. Yes, there was.
21 Q. Do you know if your mother was moved then from
22 a four-bed bay into another bay?
23 A. Yes, she was moved into a ward on her own.
24 Q. Did that happen on the --
25 A. It seemed to happen that night. Before we were leaving,
124
1 the ward sister said, "I think your mum will be getting
2 moved again." I wasn't told it was isolation, I wasn't
3 told anything else, just "It's possible we'll probably
4 be moving her."
5 Q. Were you given any explanation as to why she had been
6 moved again?
7 A. No, no.
8 Q. Could you look, please, at GGC00650001. You will see
9 that is a floor plan for ward 3. Is this the ward your
10 mother was moved to at this point?
11 A. As far as I can remember, it looked as though it was
12 room 19. As far as I can remember.
13 Q. Room 19. If you go to your statement, at paragraph 36,
14 I don't think you mention the ward number, but you say
15 you think your mum was moved to a single room, and you
16 have identified the room as 20 or 21 on a plan of ward
17 5?
18 A. Yes. I do have -- I can't 100 per cent clarify. My
19 father has been in hospital twice since my mother was
20 in, and I'm afraid I get to the stage where trying to
21 remember what room in what ward has been quite
22 difficult. But to the best of my knowledge, I know it
23 was a single room that my mother got put in and it
24 appeared to be opposite the bay that she had been in.
25 Q. I know that in your statement you said it was ward 5.
125
1 Can you remember now which ward -- leaving aside the bay
2 for the moment, which ward she was moved to?
3 A. At the time I thought she was moved from ward 5 to ward
4 4, but when I saw that was bay 14 -- she was moved
5 further down the corridor, ward 5, she was moved further
6 down the corridor, which to me was ward 4.
7 Q. If you could go back to the medical records,
8 GGC00080080, against the date for 7 January, there's
9 certainly a reference there to ward 3; do you see that?
10 A. Yes. Initially I had actually said in my first
11 statement I thought it was ward 3.
12 Q. Remind me, then, if you thought it was ward 3, what bay
13 in ward 3 do you think --
14 A. It was a single room in ward 3, I can't remember the
15 bay. As I said, my father's been in hospital twice
16 since my mother's been in, and I'm afraid the wards are
17 starting to get jumbled up with me.
18 Q. In any event, then, your mother was put into a single
19 room?
20 A. She was put into a single room, yes.
21 Q. At this time, were you told why she was put into a room
22 on her own?
23 A. No.
24 Q. Just look at the room, can you remember, was there
25 a wash hand basin in the room?
126
1 A. As far as I remember, there was a wash hand basin.
2 Q. If we go back a little bit, I think you deal with this
3 in the next section of your statement, there is this
4 reference to your mother being the fastest Zimmer walker
5 she had seen. I think this is because your mother was
6 trying to hide the fact she had diarrhoea?
7 A. Yes.
8 Q. It may be obvious, but from whom was she trying to hide
9 this fact?
10 A. I think she was worried that it would stop her getting
11 out of hospital. I honestly don't know. She was very
12 proud, she was trying to cover up -- but it angered me
13 that hospital staff weren't aware of how ill she was
14 feeling and the effects the diarrhoea was having on her.
15 Q. I think what you're saying is she was trying to not let
16 the nurses know that she had the diarrhoea so she could
17 get home earlier?
18 A. At that stage they must have known. At that stage to me
19 it had been quite obvious.
20 Q. Certainly by the 6th they knew because they carried out
21 the tests and found out she was positive for C. diff?
22 A. Mmm-hmm.
23 Q. I think you mentioned one of the ward sisters you spoke
24 to was Irish; is that correct?
25 A. Yes.
127
1 Q. Did you make that out from her accent?
2 A. Yes.
3 Q. If you turn to page 9 of your statement, when your
4 mother was in either ward 3 or 5, you're not sure
5 which --
6 A. Ward 3 is the one that I'm sure was the isolation ward.
7 I'm sure that was the isolation ward. As I said, at the
8 time, when she was taken from bay 14, my recollection
9 was I thought the room was exactly opposite, but
10 initially I had thought she was in ward 3. She was
11 definitely in ward 5 and then moved further down the
12 ward.
13 Q. Go back to the plan of ward 3. GGC00650001. Which bay
14 do you think, if you try to get the geography sorted
15 out, your mother was in when she was in ward 3?
16 A. Possibly room 19, I'm not 100 per cent sure. I know she
17 was next to the nurses' desk.
18 Q. This room 19 we can see is a single room with a wash
19 hand basin in the corner. I think you said there was
20 a wash hand basin in the room; is that right?
21 A. Yes, there was also a wash hand basin outside.
22 Q. I think we see that in the --
23 A. Yes.
24 Q. How long did your mother spend in the isolation room?
25 A. She went in on the Sunday.
128
1 Q. The 6th?
2 A. Yes, and she passed away the following Sunday.
3 Q. Did she spend the rest of the time then in that room?
4 A. Yes.
5 Q. You have indicated already that you spoke to the doctor
6 I think before your mother was transferred to that room;
7 is that correct?
8 A. I spoke to the -- yes.
9 Q. Did you speak to a doctor again after that?
10 A. No. When I spoke to the doctor, the doctor -- that was
11 when the doctor told me they were doing tests on her.
12 Q. Yes.
13 A. And she wasn't willing to discuss -- to say any more
14 until the results of the tests came back. And then at
15 night-time I spoke to the ward sister after I'd been
16 told that the test results were back and she had
17 C. diff. I never was spoken to by a doctor again and
18 given any indication of what the outcome was with
19 C. diff, how they were treating it. I was told nothing
20 else.
21 Q. Were you told that your mother was being given
22 antibiotics?
23 A. No, I was told nothing. I went to work the following
24 day and I mentioned to a colleague that my mum wasn't
25 doing that good and she had C. diff, and my comment was
129
1 overheard by a doctor and they said, "Did you say
2 C. diff?", and I said, "Yes, but it's all right, she's
3 not been sick". I said, "It's just she does have very
4 bad diarrhoea". I said, "It's just seemingly a type of
5 bug." And I knew, looking at the doctor's face,
6 I thought, "Hmm," and the doctor, being professional,
7 obviously didn't say any more to me.
8 But that night I went home and went on the internet
9 to find out about C. diff and I was horrified.
10 I had to find out about C. diff on the internet.
11 I was given no indication from the hospital the
12 consequence of what my mother had.
13 Q. Can you tell me what day it might have been, then, when
14 you did your internet search?
15 A. On the Monday, it would have been about the 7th. The
16 day after my mother went into the isolation room, on
17 that day.
18 Q. Just leaving the internet search aside for the moment,
19 in relation to the hospital itself, were you given any
20 instructions in relation to hygiene, for example in
21 relation to washing your hands?
22 A. Yes.
23 Q. What was the position?
24 A. We went up the Monday night when my mum was in the
25 isolation room. A nurse did come forward and said,
130
1 "Have you used the gel on your hands?", and I said, "We
2 always do. In the corridor, we always do." She said,
3 "Could you wash your hands again and use the gel."
4 Yes, they did point out before we went in to see my
5 mother that we were to make sure our hands were
6 thoroughly clean.
7 I also realised that obviously by this time this was
8 something to be worried about, and I was concerned about
9 my elderly father, and I asked if it was all right for
10 him to go in to see my mother, and I was told, yes, as
11 long as he did wash his hands.
12 Q. And the advice you obtained in relation to washing your
13 hands was with gel and not soap and water?
14 A. No, we were to wash and then use the gel.
15 Q. So use soap and water first?
16 A. Yes, there was two -- yep. There was two containers,
17 there was one with an antiseptic wash and one with
18 a gel, and we were instructed to use both of them.
19 Q. And what about gloves and aprons, were you told anything
20 about that?
21 A. No, no.
22 Q. I think your sister visited your mother on 10 January.
23 You talk about that in paragraph 44. She was concerned
24 about your mother's condition by then; correct?
25 A. Previous to that I asked if I could speak to a doctor,
131
1 because I was shocked how much my mother was
2 deteriorating. I saw a dramatic change in her and
3 I asked if I could speak to a doctor, and the ward
4 sister said, "Certainly," and she phoned somebody and
5 told me I could come up the following morning. And
6 I went up the following morning to hopefully see the
7 consultant and I was told he was busy, there were no
8 doctors available, but the house doctor would speak to
9 me.
10 I spoke to the house doctor, I can't remember her
11 name. She said did I realise that my mother was dying
12 through the effects of the infection from C. diff, and
13 I -- at that point I wasn't aware my mother was dying,
14 I thought they were trying to make her better, and
15 that's why she was in the isolation room.
16 I asked why this had happened, and she started to
17 say about when you're on different antibiotics, your
18 immune system, my mother's age, and she went into
19 medical technology. She told me they would not be
20 resuscitating my mother, and as long as I was aware that
21 what she was saying was she was dying.
22 Q. Can I try to get some timescale for this, Mrs Logan, if
23 you bear with me. If you go back to the medical
24 records, GGC00080083. Just looking to that page of
25 the records you will see the entry at the top for
132
1 9 January, 09:33:
2 "Still very poorly, diarrhoea ..."
3 And so on. Do you see that reference?
4 A. Yes.
5 Q. Then it looks like the same handwriting at the very
6 bottom of that same reference:
7 "Speak to family re poor condition."
8 If we can just move down, I think you will see that
9 entry there.
10 A. Mmm-hmm.
11 Q. If you turn over the page, there's an entry timed at
12 11:55 on the same day, 9 January, and it begins:
13 "Long discussion with patient's daughter."
14 Is this a reference to the discussion you have just
15 been telling us about?
16 Can we take it in bits? First of all, was it
17 shortly before midday on the 9th that you spoke to
18 a doctor in the hospital?
19 A. Yes.
20 Q. We see the time is 11.55?
21 A. Yes.
22 Q. So that would tie in with that.
23 It says:
24 "Long discussion with patient's daughter. Explained
25 to her that her mother is dying, has multiple organ
133
1 failure."
2 Does that ring a bell with you?
3 A. Yes.
4 Q. Would this appear to be the discussion that you had with
5 the junior doctor?
6 A. Yes.
7 Q. It goes on to say, as I understand it:
8 "Currently being treated with strong intravenous
9 antibiotics to treat C. diff."
10 Now, were you given that information by the doctor?
11 A. No. We were aware that my mother was on intravenous
12 pain relief. We asked if my mother could be given pain
13 relief because we were distressed at the pain she was
14 in. I thought that intravenous was pain relief she had.
15 Q. What about the antibiotics, was that mentioned to you at
16 this stage?
17 A. The doctor did say to me -- she did mention antibiotics.
18 She did say about very often when a patient has been on
19 antibiotics -- I can't remember the exact medical
20 terminology she used, but, you know, she said that the
21 immune system could be lowered for somebody that's
22 vulnerable, therefore they're prone to -- they're at
23 risk of infection. And it was more or less put in
24 a way, too, that my mum was weak and vulnerable and
25 that's why she took this infection.
134
1 Q. In any event, this was obviously pretty awful news from
2 your perspective.
3 A. It was. I was shocked. And when she said, "We will not
4 be resuscitating", I think I did ask why and, again, she
5 repeated, "Well, your mother has multiple organ
6 failure." And having worked in the environment that
7 I did previously, I knew once I got told she had
8 multiple organ failure, I knew the significance of it
9 before she said, "You do know your mother is dying?"
10 I was aware that that was what the next line was going
11 to be. I was shocked because I thought they were
12 treating her.
13 Q. Can I go back to paragraph 44 in your statement, and can
14 we just leave the notes up for a moment. You are
15 talking about the visit by your sister, and there is
16 some reference there to your sister being told that
17 a doctor from the Royal Alexandra Hospital had told her
18 that they could do an operation on your mother. Can you
19 explain that to me?
20 A. I would have liked it explained, because that caused the
21 family a lot of distress. I didn't go to the hospital
22 that afternoon. My sister was coming up from Newcastle.
23 As soon as I came out of work I phoned her, and she was
24 very distressed, and I couldn't understand where this
25 was coming from; having been told that they would not
135
1 resuscitate my mum one day, for my sister to be told the
2 next day, and I thought there must have been crossed
3 wires. That was something I could not understand.
4 Q. Are you saying that the reference to your mother not
5 being resuscitated was the day before your sister spoke
6 to somebody --
7 A. Yes, it was.
8 Q. -- and there was some reference to a surgeon; is that
9 correct?
10 A. Yes.
11 Q. Do you know what sort of operation was being discussed?
12 A. No. They had said to do with the organ failure,
13 sometimes they can -- organs can start to heal, and --
14 I honestly don't know. At the time, my sister was so
15 distressed about it I thought, I'll leave it for another
16 day, she must have gotten it mixed up. But we've
17 actually spoken about that quite a few times. We
18 thought of actually going to the hospital together to
19 ask for a detail of what they meant, and by this time we
20 knew my mum was dying and we thought, what's the point?
21 One doctor is telling us one thing and one is saying
22 another. So it was left at that, but that did cause us
23 quite a bit of distress.
24 Q. The "do not attempt to resuscitate" point that you
25 raised there, was that discussed with you then on the
136
1 9th, when the junior doctor really gave you the bad news
2 that your mother was in a pretty bad way?
3 A. I was told. It wasn't -- to say "discussed", I was told
4 that my mother would not be resuscitated.
5 Q. Can you be clear about that? Can you give us a flavour
6 of exactly what was said by the doctor?
7 A. She explained about the multiple organ failure, she was
8 dying and they would not resuscitate. And I gathered --
9 I thought, does that mean if she takes another heart
10 attack they won't try and save her?
11 I just -- the fact that she had multiple organ
12 failure and they weren't resuscitating, I gathered it
13 was because her organs were failing, they didn't see any
14 point trying to resuscitate her. It wasn't
15 a discussion, I was just told. As far as I was
16 concerned afterwards I thought it was quite brutal
17 because of the way it came over, to be told. I wasn't
18 asked, "If there's any way, would you like us to?"
19 I was told they weren't resuscitating.
20 Q. If you go back to page 84 of the notes, that was the
21 entry for 11:55, there is some reference there to kidney
22 impairment, and you will see that about halfway down
23 that note. Then it goes on to say:
24 "We will endeavour to seek advice from surgeons
25 although unlikely she will be for any surgical
137
1 intervention. Also explained DNAR given, it will be
2 a futile and unkind attempt given current multiple
3 co-morbidities."
4 So there is a reference there to, as it is put, that
5 the DNAR was explained to you?
6 A. I actually -- that was more what was said to my sister,
7 not me. That was more the discussion that the doctor
8 had with my sister. I wasn't told about an attempt of
9 any type of surgery.
10 Q. I see. But you were told about the DNAR?
11 A. Sorry, could you?
12 Q. You were told there wouldn't be an attempt to
13 resuscitate?
14 A. Yes, yes, I was, yes.
15 Q. On 10 January, the day after you'd been given this
16 rather bad news, again I think you visited your mother
17 at the Vale of Leven?
18 A. Yes.
19 Q. Was she worse?
20 A. Oh, yes.
21 Q. You tell us in your statement -- it is very sad -- at
22 paragraph 50, that she just wanted to be let go, I think
23 is the way ...
24 A. Yes. Her last words were, "Nancy, let me go." She had
25 had enough.
138
1 Q. If you just look at paragraph 52, you do say that your
2 mother had a long and good life, but what point are you
3 making about -- that she went to hospital to get better
4 and not to die the way she did?
5 A. That's right. My mother was glad to be going to
6 Vale of Leven because she felt safe going from the RAH,
7 she felt that was her step towards getting home, and she
8 was glad to be going to a hospital that she felt she
9 would be well looked after in. And she came through
10 what we discovered was two heart attacks. She actually
11 walked out of the RAH into patient transport to be
12 transferred to the Vale of Leven Hospital where there
13 was an outbreak of C. diff with no infection control and
14 therefore contributed to her death. That wasn't right.
15 It would have been kinder if my mother had died of
16 a heart attack than have to watch her suffer the way she
17 did with the C. diff virus.
18 Q. I think in the next sections of your statement you
19 actually make a comparison between your perceptions of
20 the Royal Alexandra Hospital and the
21 Vale of Leven Hospital.
22 A. Yes.
23 Q. Can you summarise that for me, that comparison?
24 A. Sorry, which paragraph?
25 Q. We are now looking at paragraphs 53 onwards. You begin
139
1 by explaining that in the Royal Alexandra Hospital there
2 were very strict procedures.
3 A. Yes.
4 Q. Can you elaborate on that?
5 A. There was an outbreak of the norovirus while my mother
6 was in RAH, when she was transferred to I think it was
7 ward 20. We went up to visit my mother one night and
8 everybody was sitting outside for a good 20 minutes over
9 the visiting time. A nurse came out and told us there
10 was an outbreak of winter vomiting. There were notices
11 up with information, we were given handouts telling us
12 what the winter vomiting virus was about, and we were to
13 make sure we used the gel. It was brought to our
14 attention that doctors, anybody going in and out the
15 ward was using the gel.
16 When we went in to see my mum that night she was
17 sitting up in bed quite bright, and she said the ward
18 had been cleaned from top to bottom. She said, "This
19 ward seems alright, but the ward opposite", she said,
20 "there seems to be beds getting stripped." She said,
21 "Something is going on," and she was a wee bit
22 concerned.
23 I spoke to a nurse and I told her my concern, and
24 she said, "We're not concerned about the bigger outbreak
25 because we're taking the proper procedures, but my
140
1 advice is any soft toys your mum has" -- and we'd bought
2 a couple of wee soft teddies for her -- she said, "take
3 them home and boil wash them, but there's not any main
4 concern other than if you follow the rules and you have
5 your handout."
6 I asked again about my elderly father, was it all
7 right to take him in, and she said, yes, as long as
8 there was no contact, we made sure we used the gel,
9 et cetera. And I felt she was in a safe environment
10 because they were aware that there was an infection
11 going on but they were in control of it.
12 That's why I was so horrified when I went into the
13 Vale. At the time I didn't know there'd been an
14 outbreak of C. diff, but when I think back and compare
15 it to the RAH, I'm horrified.
16 Q. One of the things you say at paragraph 56 is that in the
17 Royal Alexandra Hospital staff were wearing gloves and
18 aprons. During the time that your mother was suffering
19 from C. diff in the Vale of Leven, and you saw staff
20 attending to her, did they wear aprons and gloves?
21 A. When she was in the isolation ward, yes. Not previous.
22 Q. Okay. You've mentioned leaflets being given to you in
23 the Royal Alexandra Hospital. Were you given any
24 leaflets in connection with C. diff in the
25 Vale of Leven Hospital?
141
1 A. No.
2 Q. I think what you are saying in relation to the
3 Vale of Leven and the use of hand gel is that, so far as
4 you could see, everybody was using the hand gel?
5 A. In the Vale of Leven?
6 Q. No, in the Royal Alexandra Hospital.
7 A. I beg your pardon, yes.
8 Q. What about the Vale of Leven?
9 A. No.
10 Q. What was the position there?
11 A. We were horrified, again, comparing it to the RAH, that
12 people were walking onto the ward and not using the hand
13 gel. It wasn't pointed out to them. There was a small
14 notice at the top of the stairs on the way into the
15 wards which had said about the winter vomiting, nothing
16 about C. diff, and just pointing out to patients to take
17 the necessary precautions.
18 Q. Are you talking about visitors taking precautions?
19 A. Yes. Sorry, I beg your pardon, yes. But when we were
20 going onto the ward on more than one occasion we noticed
21 people going onto the ward and walking past the hand gel
22 and not using it.
23 Q. What about the nurses and the doctors?
24 A. I wouldn't have -- it wasn't as disciplined as RAH,
25 I didn't always see nurses using it.
142
1 Q. I think what you say in paragraph 58 is that at the RAH
2 the staff were very proactive in giving advice?
3 A. Yes.
4 Q. Are you there making a comparison between the RAH and
5 the Vale of Leven?
6 A. Yes, very much so.
7 Q. In paragraph 63, you make some reference to room 21 or
8 22. I'm not clear whether this is ward 5 or ward 3 you
9 are talking about. Do you see that?
10 A. This is when she was in the isolation ward.
11 Q. In isolation. What's the point you are making about the
12 room and the condition of the room?
13 A. The room, to me, was -- it wasn't prepared for somebody
14 as ill as my mother. The room had boxes stacked up
15 either side of it. Again, there was a vase with
16 stagnant water. The overhead light, the casing was
17 broken.
18 But unknown to me -- my friend told me later, she
19 had visited my mum that afternoon, she did say she would
20 go to visit my mum, and she had actually tidied the room
21 up. The bed was adequate enough, but the surroundings
22 around about, for somebody -- for a patient as ill as my
23 mother, it wasn't practical, it wasn't the way an
24 isolation room should have been. In comparison, again,
25 to the RAH, albeit my mum was in CCU, and it's an
143
1 isolation room, it was spotless.
2 Q. You make a comparison in paragraph 65 between visits to
3 the Vale of Leven in previous years to see your father
4 the previous year.
5 A. Mmm-hmm.
6 Q. What's the comparison you are seeking to make there?
7 Was there a difference in the Vale of Leven between the
8 previous year when your father was in hospital and this
9 time when your mother was in hospital?
10 A. Yes. My father had been in hospital the year previous
11 to my mum taking ill, and it had been a long time since
12 I'd actually been in the Vale of Leven Hospital, and
13 I was shocked at the state of it. When my mum was in,
14 I thought it was actually worse. To me, they were just
15 letting the hospital run down. I was shocked.
16 Q. In paragraph 66, you are giving an example there of
17 a visit when you found your mother's nightdress in the
18 bathroom?
19 A. Mmm-hmm.
20 Q. Can you just explain that? First of all, can you give
21 us a date for that? You said it was the day before she
22 left ward 6. Now, I think we know from the records that
23 she left ward 6 on 3 January, so this would be shortly
24 before that, would it?
25 A. Yes, it's either the 1st or the 2nd.
144
1 Q. Your mother had had a bath?
2 A. She'd had a bath. It was actually -- it was -- as it
3 says, it was someone known to the family, and she had
4 asked my mum how she was doing, and my mum had said,
5 "I'd love a bath," and she said, "I'll run you a bath."
6 When I went to see my mum later on that day she just
7 looked so fresh and bright and was feeling so much
8 better for having the bath. I asked where her
9 nightdress was, and she said, "Oh, it must be still in
10 the bathroom." I said, "I'll get it on the way out."
11 When I got home I realised I'd forgot to bring her
12 washing home, and when I went back up that night I said,
13 "Mum, have you got your nightdress?" She said, "No,
14 I still haven't got it," and I went to find a nurse and
15 said, "I don't know where it is," and she went into the
16 bathroom and it had been lying there since that morning,
17 which to me was that the bathroom hadn't been cleaned.
18 If her nightwear was still lying there, the floor hadn't
19 been washed, far less the bath been done if
20 night-clothing from the previous morning was still lying
21 on the floor.
22 Q. At paragraph 68 you make some reference to seeing on the
23 bed trolley items which had been there the previous
24 evening, such as sandwiches, packets of biscuits and
25 a newspaper; is that right?
145
1 A. Yes.
2 Q. The inference you drew from that is the table hadn't
3 been wiped?
4 A. Yes. I used to take wipes up, hygienic wipes, and wipe
5 down the table.
6 Q. Was this your mother's bed trolley or another?
7 A. It was my mother's.
8 Q. When you look at the nurses in the Vale of Leven,
9 I think you've said before that they were busy; is that
10 correct?
11 A. Yes.
12 Q. Were they approachable?
13 A. Yes. Oh, yes. There was just the once that I was upset
14 with one of the nurses, but apart from that, yes,
15 I would have said they were very approachable,
16 considering they did appear to be short staffed.
17 Q. I'm being asked whether or not you would like to have
18 a break, Mrs Logan. Are you quite happy to --
19 A. I'm quite happy to continue.
20 Q. You're quite happy to plod on.
21 A. Yes.
22 Q. In relation to the numbers of visitors allowed to visit
23 in the Vale of Leven, I think you do say something about
24 that in your statement. What did you observe in the
25 Vale of Leven?
146
1 A. To me, patients were -- they weren't adhering to the
2 rules. There was the odd notice up saying "Two to
3 a bed", but personally speaking people ignored that, and
4 that made me very angry, especially as the time was
5 going on and my mother was becoming more and more ill.
6 There could be times where there was about four or five
7 around a bed, which, again, I'm sorry, but I kept
8 comparing it to the RAH, because RAH were very, very
9 strict about when people came on to the ward how many
10 were around a bed.
11 Q. And how many were allowed around the bed in the RAH?
12 A. Two.
13 Q. In paragraph 74 of your statement, if you could turn to
14 that, you make mention of another patient who may have
15 been suffering from dementia, and this I think was when
16 your mother was in ward 6; is that correct?
17 A. Yes.
18 Q. There was a problem with that, was there?
19 A. She was a poor wee soul, as I have said, and she did
20 appear to -- the nurses were run off their feet with
21 her, the lady couldn't help her condition. She did go
22 on wards taking items from other beds, but she kept
23 trying to take my mum's Zimmer, and previous to that
24 a nurse had asked my mum for her Zimmer to try and aid
25 a patient who couldn't walk very well, and my mum had
147
1 said it was a few hours before she got her Zimmer back.
2 So when this elderly lady came and tried to take her
3 Zimmer, my mum used to say, "I've got to hang on to it
4 for grim death just because I won't get it back again."
5 It was like a game. But the Zimmer would get removed
6 quite often.
7 Q. Was this before your mother was diagnosed with C. diff?
8 A. Yes.
9 Q. I think in paragraph 75 -- again, this is when your
10 mother was on ward 5 -- you say that on one occasion in
11 relation to the hand gel dispensers the one at the
12 entrance to the ward was empty and the access to the
13 dispenser was blocked?
14 A. Mmm-hmm.
15 Q. I suppose you can't say how long it had been empty, but
16 you tried to use it and nothing came out?
17 A. Nothing came out, and my husband and my father walked to
18 another part of the ward further down the corridor to
19 use the other dispenser, and my husband pointed out to
20 the staff that there wasn't any gel in the dispenser.
21 Q. And did the staff respond to that?
22 A. Yes, they did say they would look into it, oh, yes.
23 Q. You talk in paragraph 77 about the use of aprons by the
24 staff, and I think you say there were a few occasions
25 when the staff came in but did not put aprons on.
148
1 A. Mmm-hmm.
2 Q. Were they dealing with your mother on those occasions
3 when they weren't wearing aprons?
4 A. When my mother was in the isolation room, aprons were
5 put on all the time.
6 Q. Okay. So this is before the isolation?
7 A. Yes.
8 Q. But you, yourself, were never asked to wear aprons or
9 gloves?
10 A. No.
11 Q. In relation to signs about the washing of hands and so
12 on, you have mentioned already the sign at the top of
13 the stairs. Were there signs within the wards --
14 A. I wasn't --
15 Q. -- advising visitors to wash their hands?
16 A. There were signs outside the wards, beside the
17 dispensers, yes, there were signs, yes.
18 Q. Were these perfectly prominent?
19 A. Yes, they were beside the dispensers.
20 Q. After your mother had been diagnosed with C. diff, were
21 you advised to use soap and water in washing your hands?
22 A. Yes. Before we went into the isolation room we were
23 told not only just to wash our hands, but to also use
24 the bacterial gel.
25 Q. I think you told us that you, yourself, carried out some
149
1 research on the internet in relation to C. diff?
2 A. Mmm-hmm.
3 Q. Did anybody at the hospital tell you about the nature of
4 the infection?
5 A. No.
6 Q. About how damaging it might be?
7 A. No.
8 Q. Can I talk a little bit now about the laundry. Did you
9 deal with your mother's laundry?
10 A. Sorry?
11 Q. I want to ask you some questions about your mother's
12 laundry, Mrs Logan.
13 A. Yes.
14 Q. Did you deal with your mother's laundry?
15 A. Yes.
16 Q. Generally speaking, what did you do? How did you handle
17 her laundry?
18 A. I just put it in a normal boil wash.
19 Q. After your mother had been diagnosed with C. diff, did
20 you still carry on collecting her laundry?
21 A. No, I was never ever given it.
22 Q. I'm sorry?
23 A. I was never ever given any of her washing. When they
24 put my mum in the isolation room they used hospital
25 gowns.
150
1 Q. Now, if you could turn to page 18 of your statement, at
2 paragraph 90, I think you tell us there that you gave
3 birth to both your children in the
4 Vale of Leven Hospital; is that right?
5 A. Yes.
6 Q. I think you thought it was, as you put it, a "great wee
7 hospital"?
8 A. Yes, we never had any doubts going into the hospital.
9 It was a hospital we felt comfortable in.
10 Q. But after your experience with your mother, has your
11 view changed?
12 A. Yes.
13 Q. What is your view?
14 A. I don't have confidence. To say I don't have
15 confidence; I have noticed, unfortunately, as I said, my
16 father has been back in hospital, and I have seen marked
17 improvements, but I still think there's a lot of
18 cost-cutting and a lot of things to be learnt, and it
19 worries me that the type of decisions that have been
20 made before will happen again in the way of infection
21 control not being carried out.
22 Q. Just going back to the transfer from the Royal Alexandra
23 to the Vale of Leven Hospital, do you know who made the
24 decision that your mother should be transferred back to
25 the Vale of Leven?
151
1 A. No. No, I didn't know a thing about that. We were
2 very, very taken aback that she was actually
3 transferred. Nobody told us that my mum was being
4 transferred that day, it came out of the blue. We
5 didn't know why.
6 Q. If you just bear with me, I will put some follow-up
7 points to you that I have been asked to raise.
8 I think I have covered this with you already, but
9 when you were made aware that the tests for C. diff were
10 positive, I asked you what information you got from the
11 nurses about C. diff. Can you perhaps just remind me,
12 to deal with this point, can you tell us exactly what
13 you were told?
14 A. I had to ask. I asked if the results were back yet,
15 because we were very aware that on the Sunday afternoon
16 tests were done on my mother and we were told the
17 results should be back later.
18 With reference to the doctor, she said she wasn't
19 willing to comment until the test results were through,
20 so when I went back up on the Sunday evening I did
21 approach a nurse, and by the time visiting had finished
22 the results had come back from the labs and she said,
23 "Yes, the results are back," and I said, "What was it?"
24 She said, "It's a type of" -- the words "wee bug" stick
25 in my mind, and I said, "What type of bug?", and she
152
1 said, "C. diff." But that was it, we weren't told of
2 the significance of C. diff.
3 Q. Were you able to form any view, from your perspective as
4 the daughter of a patient, to what extent the nurses
5 were getting back-up from the doctors in the hospital?
6 A. I felt the nurses were getting the raw end of the stick.
7 They were trying to deal with something that was out of
8 their hands. I didn't feel they were getting back-up.
9 There was never a doctor about to give advice, to help.
10 I just felt the nurses were left to get on with it,
11 understaffed as they were.
12 Q. You mentioned the one doctor, I think, that said they
13 couldn't give you any information until the results came
14 back?
15 A. Yes, I didn't see her again that night, but the doctor
16 that examined my mother on Sunday afternoon and was
17 doing tests on her, her only words were, "I'm not
18 willing to comment until we have the test results back."
19 Q. I don't know if I covered this in your statement, but
20 I think you do say at some point you thought the
21 curtains weren't particularly clean.
22 A. Mmm-hmm.
23 Q. Was that your impression?
24 A. Yes. The hospital was drab and run-down.
25 Q. Could it be said they were simply old curtains and not
153
1 brand new?
2 A. Well, they definitely were old. They'd definitely been
3 up for a long, long time.
4 Q. But something can be old and yet clean?
5 A. No. No, they weren't. No.
6 Q. You're saying they were old and not clean?
7 A. They were faded. They were faded.
8 Q. The nightdress episode that we spoke about, I think you
9 did confirm with me that that was before your mother was
10 diagnosed with the C. diff?
11 A. Yes.
12 Q. I've been asked to suggest to you that once C. diff was
13 detected, and we have looked at the medical records for
14 that, that fairly promptly after that your mother was
15 isolated?
16 A. Oh, yes, yes.
17 Q. And there was a regime put in place, for example,
18 washing your hands with soap and water --
19 A. Yes.
20 Q. -- that would deal with that?
21 A. Yes.
22 Q. I'm being asked to clarify something with you. Can you
23 just go back to the medical records, GGC0008/0187. We
24 had some discussion about the time and date when your
25 mother was transferred from ward 5, but you will see
154
1 here on 6 January -- 21:30 is the time -- there is
2 a note:
3 "Transferred from ward 5 due to recently discovered
4 [C. diff] for universal isolation procedures, requires
5 side room ..."
6 And so on. So that would indicate that the transfer
7 took place on the 6th at that time?
8 A. Yes.
9 Q. Really, the day it was diagnosed?
10 A. Mmm-hmm.
11 Q. Is there anything further, Mrs Logan, you would like to
12 add to your evidence?
13 A. Not really. It's just the fact that decisions were
14 made, that my mother was transferred from RAH, she left
15 a safe environment to be put into hospital where there
16 was a C. diff virus with no infection control, and
17 I just hope it never ever happens again.
18 MR MACAULAY: Thank you for that.
19 THE CHAIRMAN: Thank you very much, Mrs Logan. Thank you
20 very much for coming, and you are free to go.
21 A. Thank you.
22 (The witness withdrew)
23 THE CHAIRMAN: Mr MacAulay?
24 MR MACAULAY: My Lord, the next witness I would like to call
25 is number 3 on the list, Helen McGinty.
155
1 MRS HELEN MCGINTY (sworn)
2 Examination by MR MACAULAY
3 MR MACAULAY: Good afternoon, Mrs McGinty. Are you Helen
4 McGinty?
5 A. Yes.
6 Q. I think you are the daughter of Sarah McGinty?
7 A. Yes.
8 Q. I think your mother died on 1 February 2008; is that
9 correct?
10 A. Yes.
11 Q. Perhaps I could ask you just to come a little bit closer
12 to the microphone so that we can hear what you have to
13 say.
14 I think at that time your mother was 67 years of
15 age; is that right?
16 A. Yes.
17 Q. I think you stay with your partner and your family?
18 A. Yes.
19 Q. And you have a brother, Charles McGinty?
20 A. Yes.
21 Q. Do you have your statement in front of you, Mrs McGinty?
22 A. Yes, I do.
23 Q. You tell us there that you are a very close family and
24 that your mother lived close by. Is that correct?
25 A. Yes, that's correct.
156
1 Q. You were a regular visitor to her and she was a regular
2 visitor to you?
3 A. Yes, that's correct.
4 Q. Do you remember on 3 December 2007 going to your
5 mother's house and not getting a reply at the door?
6 A. Yes, I do.
7 Q. Could you tell us what happened then, on that occasion?
8 A. I went to visit my mum and I knocked on the door and
9 there was no reply, so I knocked on the door again and
10 I waited, and there was still no reply. So I looked in
11 the living room window, and that's when I saw her lying
12 on the floor.
13 Q. How had your mother's health been at this time?
14 A. She was fine. She kept in good health.
15 Q. So what did you do then, when you discovered this
16 problem?
17 A. I got -- someone was passing by and told me to get an
18 ambulance and the police, because there was no entry --
19 I couldn't get into the house.
20 Q. Were you able to communicate with your mother?
21 A. Yes.
22 Q. Did you eventually manage to get the ambulance to come
23 and did they manage to get access to the house?
24 A. No, it was two people I knew that worked in a house
25 association, they actually got into my mum's house
157
1 through the window.
2 Q. Was your mother taken to the Vale of Leven Hospital that
3 same day?
4 A. Yes, she was.
5 Q. Did you then go and visit her that day at the hospital?
6 A. I went in the ambulance with my mum.
7 Q. You went with her. Perhaps I could ask you to look at
8 the medical records, just to put this in context. If
9 you could look, please, at GGC00420003. Now, you will
10 see this is a record of the medical assessment unit. It
11 is for the Vale of Leven. If you look to the right, the
12 admission date is 3 December, you have been telling us
13 about that, and the admission time is 13:40. Does that
14 accord with your own recollection as to when your mother
15 was admitted to the hospital?
16 A. Yes, I think it was roughly around that time.
17 Q. Early afternoon, in any event?
18 A. Yes.
19 Q. There is a discussion under the heading "Initial
20 Assessment" that tells us she was:
21 "... admitted today via the emergency ambulance,"
22 and some other discussion, and:
23 "Patient's daughter found her lying on the floor
24 this am," and she was found to have a left-sided
25 weakness.
158
1 Can you tell us what you were told as to what might
2 have happened to your mother?
3 A. The ambulance people told us that day that they thought
4 she might have suffered a stroke, and when we got up to
5 the hospital it was confirmed later on by the nurses
6 that she had suffered a stroke.
7 Q. What ward was she admitted to then when she got to the
8 hospital?
9 A. Ward 6.
10 Q. If you could look at the plan for ward 6, it is
11 GGC00700001.
12 You will see on the screen, Mrs McGinty, a floor
13 plan for ward 6. Can you tell me, if you can, which bay
14 your mother was admitted to?
15 A. She was at the one nearer the window on your right-hand
16 side. That was where her bed was.
17 Q. Now, if you go to your statement, if you have that, that
18 might help. You thought then that your mother was
19 admitted to the room that's marked number 14 on the
20 plan. Do you see that?
21 A. Yes.
22 Q. If you imagine you come in the door where 2 is and walk
23 along the passage and turn left, does that ring a bell
24 with you at all?
25 A. No.
159
1 Q. Can you tell me, was it bay 14 that she was admitted to
2 or not?
3 A. It was ward 6.
4 Q. Ward 6. We have the plan for ward 6 on the board here,
5 but can you be a bit more precise as to which part of
6 ward 6 she went into?
7 A. I don't know. You just -- I just remember walking
8 through the doors and it was the -- there was two beds
9 on -- on your right-hand side and she was the one nearer
10 to the window.
11 Q. Do I take it there were just two beds in the room?
12 A. No, there were four beds.
13 Q. It was a four-bed room?
14 A. Yes.
15 Q. Were there other people in the other beds?
16 A. Yes, there were three other patients in the other beds.
17 Q. Three other patients?
18 A. Yes.
19 Q. If you go, then, to your statement, at paragraph 14 you
20 give us some information about what you were told by the
21 ward sister and that your mother had suffered a stroke.
22 Was that the ward sister at ward 6?
23 A. Yes, that was the sister at ward 6. She told us that my
24 mum had suffered a stroke.
25 Q. Can you remember her name, the ward sister?
160
1 A. No, I don't.
2 Q. The following day, did you go back to visit your mother
3 at the Vale of Leven?
4 A. I went up that night to visit my mum and I went up the
5 following day to visit my mum.
6 Q. I'm being asked to ask you to either move closer to the
7 microphone or take the microphone closer to you, because
8 I think people are having difficulty in hearing your
9 evidence.
10 Did you say you went back that same night?
11 A. Yes.
12 Q. You went in the afternoon and you went back the same
13 night?
14 A. Yes, the same night.
15 Q. Was your mother still in the same location in the ward?
16 A. Yes.
17 Q. How was she when you went back?
18 A. She was in and out of sleeps. She was in and out of
19 conscious.
20 Q. Was she?
21 A. Even when we were there.
22 Q. The following day, then, did you go back to see your
23 mother?
24 A. Yes, I went up to see her the next day in the afternoon.
25 Q. How was she at that time?
161
1 A. She was still the same.
2 Q. Did you have some discussion with the nurses as to how
3 she had been overnight?
4 A. They just said she slept most of the night, she had
5 a peaceful night's sleep, and they were just waiting to
6 transfer her into another ward when a bed became vacant.
7 Q. If you look at paragraph 17 in your statement, you
8 mention a problem your mother had with a ring. Early on
9 I think you say your mother was wearing an engagement
10 ring and you were concerned it was cutting into her
11 skin. Was that from the very beginning of her admission
12 or was that later on?
13 A. It was -- I think it was closer to the end of the week.
14 She'd been in hospital a couple of days.
15 Q. So she'd been there for a couple of days and you were
16 concerned about the ring biting into her finger?
17 A. Yes, because her hand was swollen up and the ring was
18 a bit tight on her hand.
19 Q. So you spoke to the nurses about that, did you?
20 A. Well, it was the nurses that actually asked me if they
21 could have permission to cut the ring off, and I said,
22 "Yes, you can cut it off." It was sometime later on
23 that they eventually cut it off.
24 Q. How much later, can you remember?
25 A. Six weeks or something.
162
1 Q. Did you mention it again to them?
2 A. Yes.
3 Q. How often?
4 A. I asked them a few times when they were going to cut it
5 off.
6 Q. And were you given any explanation as to why they
7 weren't doing it?
8 A. I think it was waiting for a ring cutter to come up from
9 down the stairs for it to be cut off.
10 Q. I think you tell us that eventually the ring was cut off
11 the finger?
12 A. Yes, it was cut off.
13 Q. Can you remember how long your mother stayed in ward 6?
14 A. She stayed there for one and a half days.
15 Q. Where did she go then?
16 A. She went up to ward F.
17 Q. If we could look at the plan GGC00760001, it may be
18 difficult to follow, Mrs McGinty, but according to the
19 logo, that's ward F. Can you help as to where she went
20 in ward F?
21 A. She went into a single room on your right-hand side as
22 you enter the doors.
23 Q. Do you remember the number of the room?
24 A. No, I don't.
25 Q. Well, were you told why she was being moved to ward F?
163
1 A. No. We just got told that that's where they were
2 putting her, up there.
3 Q. Were you given any information as to what sort of ward
4 this was?
5 A. No.
6 Q. If you go to your statement, you thought at paragraph 19
7 that the room that she was being put into was room 26.
8 We can make out 25. Was it in that general area that
9 she was put, can you remember?
10 A. I don't remember the details of the picture there that
11 you've got, but all I know is you walked through the
12 doors, and on your right-hand side she was put in that
13 single room.
14 Q. At that time, when you first visited her in ward F, did
15 you speak to the nurses and ask them what was the plan?
16 A. No, I didn't.
17 Q. Did you make any effort to speak to the nurses at that
18 time?
19 A. At the time my mum was getting taken up, before she got
20 taken up to ward F, one of the nurses from ward 6 had
21 told us that they were waiting on her head scan results
22 coming back.
23 Q. Yes.
24 A. Not head scan results, sorry, they thought she'd done
25 something to her arm, they thought she'd broken her arm,
164
1 so they were waiting on the results coming back from
2 that. So I asked about that when I was up on ward F and
3 they said they hadn't had anything back just yet.
4 Q. And did you ask what was going to happen to her at that
5 stage?
6 A. No, I didn't ask.
7 Q. Were you given any information about what the plan was?
8 A. No.
9 Q. In relation to hand hygiene at this point in time, were
10 you given any instructions about hand hygiene?
11 A. No.
12 Q. Was there a gel dispenser before you entered the ward?
13 A. Before you entered the ward there was one, on your
14 left-hand side.
15 Q. Did you use it?
16 A. Yes, I used it.
17 Q. On this occasion when you went to ward F, were you with
18 your husband when you visited or who were you with?
19 A. I was with my partner and I was with the rest of my
20 family.
21 Q. So how many of you were there?
22 A. There was myself, my partner, my sister-in-law Michelle,
23 my brother Charles and my sister Anne, and I think her
24 partner was with us as well.
25 Q. And in relation to seeing your mother, what was the
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1 position if many of you went to see her at the one time?
2 A. There was -- what, do you mean how many people went to
3 visit her on --
4 Q. Into the room? Did you take turns or --
5 A. No, we all went into the room with her.
6 Q. So there was quite a number of you in the room then?
7 A. Yes.
8 Q. Were you told that there were too many or --
9 A. No, we weren't told anything at all.
10 Q. Was there any information available as to how many
11 people should be visiting at any one time?
12 A. No, not to us. We weren't told anything.
13 Q. Were the nurses aware that there were as many as you
14 said in the single ward?
15 A. Yes, because they came into the ward and they were
16 checking on my mum and things like that, so they knew we
17 were all there.
18 Q. Did your mother appear to be improving then?
19 A. Slowly she seemed to be improving.
20 Q. I think there was a problem about her drip; is that
21 correct? Do you remember that?
22 A. Sorry?
23 Q. Was there a problem about her drip?
24 A. A rib, no.
25 Q. Her drip.
166
1 A. Oh, her drip.
2 Q. She was on a drip.
3 A. Oh, yes.
4 Q. I think you talk about this in paragraph 21 of your
5 statement, where you say that her arm was swollen and it
6 was discovered that the needle on her drip had gone into
7 the muscle rather than the vein?
8 A. Yes, that's correct.
9 Q. So that had to be sorted out?
10 A. Yes.
11 Q. You say in your statement that on 9 December you were
12 told by one of the nurses that your mother was going to
13 be moved?
14 A. Yes.
15 Q. Can you explain what the background to that was? Why
16 was she being moved?
17 A. We were told that the reason she was being moved was
18 because there was another patient further up that was
19 causing a disturbance amongst the other patients, so
20 they thought it would be best for my mum to be moved
21 into another room.
22 Q. Yes.
23 A. So that they could put that person into the room that my
24 mum was in.
25 Q. Did that happen?
167
1 A. Yes, that happened.
2 Q. Can you tell me then what room your mother was moved to?
3 A. I don't know the number of the room, it was just further
4 along the ward.
5 Q. But in the same ward?
6 A. Yes, in the same ward.
7 Q. How many beds were in this room?
8 A. Four.
9 Q. Were they all occupied at this time?
10 A. Yes, they were all occupied.
11 Q. I think when you gave your statement you thought that
12 this was room 11. Again, we can see where room 11 is on
13 the plan. Is that at all helpful to you?
14 A. Yes.
15 Q. Do you think that's where it was? Was there a wash hand
16 basin in that room?
17 A. Yes, there was.
18 Q. Did you make use of it?
19 A. When we could.
20 Q. Now, why do you say that?
21 A. During the day my mum was put in a wheelchair, sat right
22 next to the sink, so -- you have a limited space to use
23 it.
24 Q. I think what you are saying in your statement is that
25 someone who wanted to use the wash hand basin would have
168
1 to squeeze past her bed?
2 A. Yes.
3 Q. Is that because she was in a wheelchair and she was
4 blocking it; is that right?
5 A. Yes.
6 Q. So you had to go around the bed?
7 A. My mum's -- there was my mum's bed and then there was
8 a bedside cabinet and then there was a sink, and my
9 mum's wheelchair was right next to that sink.
10 Q. I see.
11 A. We could use it, the basin, if we squashed by her, but
12 nobody else would have been able to use that.
13 Q. If we look at the plan for room 11, we will see, at
14 least so far as the plan is concerned, the wash hand
15 basin has been placed towards the bottom right-hand
16 corner. Does that accord with your recollection as to
17 where it was?
18 A. Yes, that's where the sink was.
19 Q. In relation to the other patients in that ward, can you
20 tell me if they were elderly patients or not?
21 A. They all seemed to be approximately the same age as my
22 mum.
23 Q. In the following weeks, then, did you visit your mother
24 on a regular basis?
25 A. Yes.
169
1 Q. On a daily basis?
2 A. I was there mainly during the day and mainly at
3 night-time.
4 Q. From what you have said, you have a close family and
5 quite a large family, so were they all paying visits to
6 your mother regularly during that period?
7 A. Yes.
8 Q. At one point, you seemed to be concerned about the fact
9 that the catheter bag that your mother had would be
10 overflowing. Do you see that in paragraph 27 of your
11 statement? You say that your mother had a catheter from
12 the time she was admitted, and you were starting to get
13 concerned because it would always be full or
14 overflowing, and you had to tell the nurses about that.
15 Can you explain that?
16 A. Yes, when we used to go up we used to check to see if
17 mum was okay, and we noticed that the catheter bag was
18 full. So when we noticed it was full we'd go and tell
19 the nurses that it was full and they would come and
20 empty it.
21 Q. How regularly did this happen?
22 A. Quite a lot.
23 Q. Did you ask the nurses why it came to be that the bag
24 was overflowing and they hadn't emptied it?
25 A. No, we just used to go and tell them that it was full
170
1 and they would come back and change it -- empty it,
2 sorry.
3 Q. I think you were also concerned about the fact that your
4 mother was sitting in the wheelchair close to the
5 window, is that right?
6 A. Yes. She was sitting in a wheelchair under the window
7 where the window opens.
8 Q. And your concern was what?
9 A. She was always getting draughts on her neck, because
10 when we used to go up to the hospital, my sister would
11 put her cardigan around her neck to stop the draught
12 getting on it, and we'd end up closing the window as
13 well.
14 Q. Did you raise this with the nurses?
15 A. Yes, we said, "My mum's sitting at the window all the
16 time and she's freezing," and they never said nothing or
17 they never done nothing.
18 Q. Was your mother moved again, then, to another location
19 in ward F?
20 A. Yes, she was moved to the bed opposite the one she was
21 in.
22 Q. The bed, so she's in the same bay, is she?
23 A. Mmm.
24 Q. So if we go back to the plan, and perhaps I should ask
25 you this, you said she was in bay 11 and close to the
171
1 window. Where was she moved to, then? Which bed?
2 A. Straight across.
3 Q. So that was away from the window, was it?
4 A. Opposite -- well, the bed was straight across from her,
5 so she was --
6 Q. I see.
7 A. She was near another window as well. It was the bed
8 straight across from the one she was in.
9 Q. Do you know why she was moved from one bed to another?
10 A. Yes, I asked. I said, "Why is my mum being moved over
11 there?" And one of the carers said they thought it
12 would be best for my mum to be in that bed because she
13 could see the television a bit better from that side.
14 Q. I see. We are talking towards the latter part
15 of December. By this time, had you spoken to a doctor
16 about your mother's condition?
17 A. Yes.
18 Q. Can you remember when that was?
19 A. I think it was about two and a half weeks, just after my
20 mum had been admitted.
21 Q. So we are talking towards the latter part of December,
22 are we?
23 A. Yes.
24 Q. She was admitted on the 3rd, so perhaps the latter half
25 of December. Can you remember the name of the doctor
172
1 you spoke to?
2 A. No, I don't.
3 Q. Had you asked to see the doctor or did the doctor come
4 to see you?
5 A. I'd asked to see the doctor a couple of days beforehand,
6 and then when I went up to visit my mum, my sister had
7 said that the doctor had been up to have a word with me.
8 So I went away and I told the nurses I was here, to let
9 the doctor know that I was here to have a word with him.
10 Q. And then you had a meeting with the doctor; is that
11 correct?
12 A. Yes.
13 Q. And what then were you told about your mother's
14 condition?
15 A. They told me that my mum's condition wasn't getting any
16 better, that she was going to be paralysed all down her
17 left-hand side.
18 Q. Was that --
19 A. They thought she would have improved by then, but it
20 didn't seem to be getting any better; that's the way she
21 was going to be.
22 Q. This is all down to the stroke?
23 A. Yes.
24 Q. Was there some discussion then as to what would happen
25 to your mother if she was to be discharged from the
173
1 hospital?
2 A. They said that they were thinking of putting my mum in
3 a nursing home.
4 Q. What was your response to that?
5 A. I said, "No." I said, "I'll take her home and I'll look
6 after her."
7 Q. Did you enquire then to make some arrangements if that
8 were to happen?
9 A. The doctor said that for me to do that my mum would need
10 24/7 care, and I said, "That's fine," and they said they
11 would have to wait until after Christmas and the new
12 year to put a care plan in progress for her to come
13 home.
14 Q. Did you go to visit your mother on Christmas Day?
15 A. Yes, I did.
16 Q. Was there some difficulty with a nurse on that occasion?
17 A. It wasn't a nurse, it was a carer that was shouting.
18 She was raising her voice.
19 Q. Did you understand what the problem was?
20 A. I asked her what was wrong, and she said apparently it
21 was because my mum was kicking her slippers off her
22 feet.
23 Q. And what was being said?
24 A. She told my mum, "That's enough, my lady."
25 Q. Were you upset by that?
174
1 A. Yes, I was. I was upset to see my mum upset.
2 Q. Was the plan at that point in time, then, that your
3 mother would eventually be discharged and come to stay
4 with you --
5 A. Yes.
6 Q. -- and your family, and did you have some dealings with
7 social services in connection with the arrangements that
8 would be necessary for that?
9 A. Yes. The social services and that came out and had a
10 look at my house, and they said my house was fine for my
11 mum to come.
12 Q. The problem that you have already mentioned with the
13 catheter bags being too full, did that happen from time
14 to time again?
15 A. Yes, it did.
16 Q. In paragraph 34 of your statement, you talk about an
17 occasion when you were visiting and your mother said she
18 needed a poo, and you were told that the fact that the
19 catheter bags were not emptied and could flow back could
20 make her think she needed to go to the toilet. That's
21 the advice you were given, was it?
22 A. That's what I was told.
23 Q. Now, how was your mother then during this period?
24 I think you say she was getting distressed and was
25 wanting to come home, in your statement. Was that her
175
1 attitude?
2 A. Yes, she was wanting to come home near enough every day.
3 We were going up and she was asking us to take her home.
4 Q. In paragraph 36, and we are now into January, I think
5 you spoke to a nurse again because of the catheter bag
6 being full of urine. Do you remember that? You mention
7 it in paragraph 36 of your statement.
8 A. I remember telling them a few times that the catheter
9 bag was full.
10 Q. Was there a time when you were told that your mother had
11 a urine infection?
12 A. Yes, I was told that my mum had a urine infection.
13 I think that was just before Christmas, I think that
14 was, that they said she had a urine infection.
15 Q. Were you told she was being treated with antibiotics for
16 that?
17 A. Yes, they told me they were giving her antibiotics for
18 it.
19 Q. You were told that by a nurse, were you?
20 A. Yes, I was told that by a nurse.
21 Q. But into January, then, were plans being made to
22 discharge your mother home -- back to your house, should
23 I say?
24 A. Sorry?
25 Q. Into January, and I'm looking at your statement, were
176
1 plans being made to have your mother discharged --
2 A. Yes.
3 Q. -- from the Vale of Leven? Was there a date fixed for
4 that?
5 A. It was the Alexandria Medical Centre that phoned me up
6 and asked me if I would be available for 27 or
7 28 January, because that's when they were expecting my
8 mum to be discharged from hospital, and would I be in or
9 would someone else be in for when my mum's hospital
10 equipment arrives, to be in for that.
11 Q. Towards the end of January, did your mother start to
12 complain about having a sore stomach?
13 A. Yes.
14 Q. Did you look at your mother to see if there was anything
15 wrong with her stomach?
16 A. I never asked her what was -- I said, "What's wrong?"
17 She said, "I've got a sore stomach". I don't know
18 what's wrong, she was just complaining quite a lot about
19 having a sore stomach, so I'd offer to put my hand on
20 her stomach and give it a rub, and that's what I did, I
21 rubbed her stomach and it seemed to ease off a little
22 bit.
23 Q. Was her stomach distended, was it swollen?
24 A. I don't know.
25 Q. Can we just go back to the position with the catheter
177
1 bags and your discussion with the carers. Did they
2 empty the catheter bags --
3 A. Yes.
4 Q. -- at that time? Towards the end of January, was your
5 mother moved again?
6 A. Yes, she was moved at the end of January.
7 Q. To where was she moved on this occasion?
8 A. The same ward, but a room further along again.
9 Q. Can you remember the number of the room?
10 A. No, I don't remember the number.
11 Q. I think in your statement -- this is paragraph 42 -- you
12 thought that she was moved to room number 16 on the
13 plan. If we're looking at room 11, are you able to, in
14 relation to that, say where she was taken to?
15 A. I can't work it out from there.
16 Q. I certainly can't see a number 16, unless it is hidden
17 by one of the black dots. Can you tell me what sort of
18 room it was? How many beds were in the room?
19 A. There were three beds in that room.
20 Q. Three beds?
21 A. Yes.
22 Q. If you look towards the left of the floor plan, you can
23 see there is reference there to a three-bedded room on
24 that plan. Does that mean anything to you, that
25 location?
178
1 A. Yeah.
2 Q. Do you think that's where it is?
3 A. Yes, that's where it was.
4 Q. It doesn't seem far from room 11 where your mother had
5 been before?
6 A. No.
7 Q. It seems just across --
8 A. It's just across and along a little bit.
9 Q. Were the three beds occupied then?
10 A. Sorry?
11 Q. Were the beds occupied?
12 A. Yes, they were.
13 THE CHAIRMAN: I just wonder, Mr MacAulay, correct me if I'm
14 wrong, but we have yet to have Mrs McGinty suffering
15 from C. diff.
16 MR MACAULAY: That is a chapter which --
17 THE CHAIRMAN: Exactly. I wonder if it might be a chapter
18 we could embark on tomorrow.
19 MR MACAULAY: Yes, this is probably a good time to break
20 off.
21 THE CHAIRMAN: It is up to you.
22 MR MACAULAY: No, I think it is a good time.
23 THE CHAIRMAN: Could you be back here tomorrow morning,
24 Ms McGinty, for a 10 o'clock start?
25 A. Yes.
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1 THE CHAIRMAN: We will resume, then, at 10 o'clock tomorrow
2 morning.
3 (3.58 pm)
4 (The hearing was adjourned to
5 Tuesday, 8 June 2010 at 10.00 am)
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1 I N D E X
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3 MRS BRENDA BOWES (sworn) .............................5
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5 Examination by MR MACAULAY ....................5
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7 Examination by MR PEOPLES ....................86
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9 Examination by MS GRAHAME ....................92
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11 MRS NANCY LOGAN (sworn) .............................95
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13 Examination by MR MACAULAY ...................95
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15 MRS HELEN MCGINTY (sworn) ..........................156
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17 Examination by MR MACAULAY ..................156
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