Transcript of Module 3 Public Hearing on 17 September 2024.

(10.00 am)

Lady Hallett: Ms Carey.

Ms Carey: Thank you, my Lady. May I invite Dame Ruth May

to be sworn, please.

Dame May

DAME RUTH MAY (sworn).

Questions From Lead Counsel to the Inquiry for Module 3

Lady Hallett: Sorry, send a message, I’ve got the wrong

notebook. If someone could go and get the right one I’d be grateful.

Ms Carey: Thank you.

My Lady, may I make a start on some background matters and we’ll remedy the notebook.

Lady Hallett: Do please, I can catch up.

Dame Ruth, your full name, please?

Dame May: Ruth Rosemarie May.

Lead 3: You made a witness statement to the Inquiry dated 17 May this year, INQ000479043, and I hope you have a copy of that in front of you.

Dame May: I do.

Lead 3: A little bit of background about you, please. I think it’s right that you have been a nurse since student days in 1985.

Dame May: Yes.

Lead 3: You were made the Chief Nursing Officer in 2019 –

Dame May: Yes.

Lead 3: – until you retired in July of this year?

Dame May: Yes.

Lead 3: Can I ask you, please – and if it helps you to refer to your statement, please do – just give us an overview of the role of the Chief Nursing Officer?

Dame May: I was the former Chief Nursing Officer for England, from January 2019 to end of July. I was the most senior nurse in England. I led my profession and I was the adviser to the government, to DHSC and to the NHS on nursing.

Lead 3: I think you said there are currently around 386,000 nurses and midwives working for the NHS in England?

Dame May: Yes.

Lead 3: Is it right that you do not line manage the nurses?

Dame May: Absolutely.

Lead 3: I think you said in your statement that you have three categories really towards your work and, if it helps you, paragraph 17, Dame Ruth: you say you are accountable as an Executive lead. Can you give us an example of what you did in that role?

Dame May: Of course. So I, as a professional leader, I led on some of the national programmes. For example, international nurse recruitment, maternity, nosocomial transmission programmes.

Lead 3: You also say part of your role is to act as

a collaborator. Again, an example of that, please?

Dame May: I worked with my National Medical Director on the

DNACPR. We worked to promote the practice on that.

Lead 3: That’s Sir Stephen Powis?

Dame May: Yes.

Lead 3: Thank you. You also have a role as a stakeholder or

adviser. Again, an example of that, please?

Dame May: Of course. So the black, Asian, minority risk assessment, I was an adviser to the CPO – and my views I’m sure we’ll come to.

Lead 3: I think, whilst you were the Chief Nursing Officer and during our relevant period for Module 3, you were supported by four deputy CNOs, and there were chief nurses in each of the seven regions in the NHS in England?

Dame May: Yes, there were. There were regional chief nurses who had the responsibility and leadership to support the trust chief nurses, and they worked very much as part of my team CNO.

Lead 3: Thank you.

I’d like to look at your responsibilities during the pandemic itself, and it may be that, during the course of my questions to you, Dame Ruth, I’ll ask for documents to be called up on screen. Before I do, and without causing you, I hope, any embarrassment, is it right that you have dyslexia?

Dame May: Yes, I do.

Lead 3: If I go too fast or you want to take a moment to read through a document, please will you let us know.

Dame May: Thank you.

Lead 3: So to the pandemic, please. You say at your paragraph 27 that you were the senior responsible officer for NHS England’s IPC cell. Help us, please, what you did as the senior responsible officer in relation to that cell?

Dame May: So the IPC – UK IPC cell, was a consensus group. I was responsible for IPC in England. The group was made up of professionals, public health professionals, microbiologists, IPC nurses, from across each country of the UK.

Lead 3: We heard yesterday from Dr Ritchie, so we’re a little bit familiar with the cell, and indeed we’ll be hearing from Laura Imrie, who was also a member of the cell; were you actually on the cell, though?

Dame May: No, I wasn’t. So my oversight came through – I met with Dr Lisa Ritchie, Professor Mark Wilcox, the National Clinical Director for IPC, and my deputy CNO with responsibility for this, almost on a daily basis during Covid, during the relevant period. Together with being a member of the HOCI working group –

Lead 3: Pause there, that’s the Hospital Onset Commission (sic) Infection working group?

Dame May: Indeed.

Lead 3: Thank you.

Dame May: So together with being a member of that, I was being able to see and hear views from across the whole of UK, from public health specialists, microbiologists and from infection control nurses. We relied as well on data, what the data was telling me.

I think finally my oversight was partly by membership of the senior clinical group as well.

Lead 3: I was going to come on to that –

Dame May: Okay.

Lead 3: – if I may. I think that was a group that was made up of who, please?

Dame May: The senior clinical group was chaired in the early days always by the Chief Medical Officer of England, and then it rotated chair between the UK CMOs. It had Public Health England, senior doctors, Professor Harries, and then she went on to be the chief exec of UKHSA. We had the public health senior medical director, Professor Susan Hopkins. It had the National Medical Director, Sir Stephen Powis, and it had all four UK countries’ CNOs and CMOs.

Lead 3: Right. I think that group is sometimes known as the senior clinicians group or –

Dame May: It is.

Lead 3: – or senior clinical group and is it also known as the senior clinical leads, or is that a different group?

Dame May: I always knew it as a the senior clinical group – clinicians group.

Lead 3: So that group of senior clinicians had oversight of the IPC cell?

Dame May: The oversight – the IPC cell was a consensus group. It was not a decision-making group. IPC members used to go back to their country and their country then would make the decision. So, for example, in England it would come to me and I would take a paper, often with the National Clinical Director, Professor Mark Wilcox, to our NIRB, our decision-making group. But always, always, after each country had taken it back to their decision-making group, it would go to PHE or UKHSA for the final oversight of the content of any IPC guidance.

Lead 3: Pause there. So I want to be clear: the IPC cell make a recommendation, it is seen by you and/or Mr Wilcox in relation to England, equivalents, I assume, in Scotland, Wales and Northern Ireland, once it’s been seen by those four nations, are you saying that PHE, UKHSA, as it became, still had final say?

Dame May: Absolutely, yes.

Lead 3: Right, so there’s a number of levels of authority that it’s got to go through before it ends up being published?

Dame May: Absolutely.

Lead 3: If you and/or Mr Wilcox said you didn’t like a recommendation made by the UK IPC cell, what would happen, practically?

Dame May: So, we would look at it, we would debate it. My role, of course, was around the operational implementation. So I had a view around how cohorting would work, how we would support staff in that. Then, of course, it would go to PHE and to UKHSA for the scientific sign-off of the guidance.

Lead 3: Right. So if you disagreed with the IPC cell, presumably you would make your views known, would you go back to the IPC cell and say “I don’t think this is quite right, it’s not going to work on the ground”? How would it actually evolve?

Dame May: So my role was to question, to challenge, to ask “Have the IPC cell reviewed and considered the latest evidence”, and I’ve done that a number of times during the relevant period. As all UK CNOs did, we all collectively and individually would always challenge and do that but, of course, the scientific advice came from the scientists, so public health doctors. I looked to the public health doctors a lot to give me that scientific advice, as well as the UK IPC cell and, of course, they had public health doctors within –

Lead 3: Yes.

Dame May: – theirs as well as other professionals.

Lead 3: So if there’s some – don’t take this pejoratively – backwards and forwards between you and the UK cell, between the four nations, hopefully agreed position amongst all of you. But are you still saying that, even if you all agreed, Public Health England and UKHSA, as it became, could still say, “We don’t think this is the right recommendation to make, we don’t think this guidance is correct”?

Dame May: Absolutely.

Lead 3: Okay, all right, we may come back to that, Dame Ruth, in a moment.

I think one of your other roles in relation to the pandemic was, as an executive director of NHS England, you attended the Covid-19 national incident response board. Help us, please, with what that board did?

Dame May: It was often referred to as NIRB; it was the decision-making group within NHS England. I was an executive director around there. I took almost 60 papers to that group during the relevant period.

Lead 3: I think you said they met three times a week or more –

Dame May: Yes.

Lead 3: – during that. You obviously engaged with your fellow CNOs in Wales and Scotland and Northern Ireland, and you said that there were 26 meetings just between March and May 2020; you clearly worked with Chief Medical Officer, Sir Chris Whitty; you’ve told us about the senior clinicians group; you met with the Secretary of State, Mr Hancock and, in due course, presumably Mr Javid?

Dame May: No, I didn’t.

Lead 3: You didn’t meet him, all right, thank you. You worked with PHE on IPC guidance, and one other aspect I’d like to ask you about is your engagement with frontline nurses. If it helps you, Dame Ruth, I’m at paragraph 54 in your statement but I think there you said there was initially an informal advisory group which then, in due course, became more formalised. Tell us about that transition.

Dame May: Thank you. So we were facing some extraordinarily difficult decisions in the very early part of the inquiry, difficult because it was a fast-moving environment, a time when we were seeing the number of cases come in, deaths that we hadn’t seen – like we had seen before.

So I wanted to check out the views of potential actions I was taking with some of the most very senior and experienced nurses. So I had a telephone book of probably the most forthright nurses in England at the time, and I chose them because I wanted them to give me their value of their experience, their expertise, but also they weren’t going to say “Yes, of course, CNO”, they were going to say, “Well, that won’t work, that will work, have you thought about …” and that really helped me make some tough recommendations and decisions .

Lead 3: You spoke there about your contact with senior nurses. What about those less senior on the front line?

Dame May: Yes, so I had a shared decision-making council that we set up in May 2020, and they were made up of frontline staff from all over England, of all sorts of backgrounds and settings.

We – they reviewed what we were doing, I used to go to them with questions, I attended a lot of their meetings and, indeed, I’m seeing them tomorrow for my final meeting with them. I also, of course, visited, like I would do pre-pandemic and post-pandemic –

Lead 3: I want to come on to the visits as a slightly separate topic. So you were having, though, some input through the shared decision-making council from those on the front line and in addition to your contacts with the more vociferous senior nurses that you’ve told us about. All right.

Dame May: And with the Chief Nursing Officer, Black Asian Minority Strategic – their SAG, they were invaluable colleagues –

Lead 3: I wanted to actually just ask you, please, about your involvement with the – I think they’re called CNO SAG, it’s not a particularly attractive name. Just help us, what does that stand for, Dame Ruth?

Dame May: The Black, Minority Ethnic Chief Nursing Officer Strategic Advisory Group has been running now for 22 years. It’s made up of people from a black, Asian, minority background, nurses from all levels across the whole of England, and they are the most wonderful group to work with. They are – they champion, they support each other and they did some great work to support their colleagues and to support our national decision-making during the relevant period.

Lead 3: I think you say at paragraph 60 in your statement that, thanks to the links through that group, you were involved in raising the issue of disproportionate impact of Covid on the black, Asian and minority ethnic staff, and indeed patients, in April 2020. Can you just, perhaps by reference to paragraph 60, set out, please, some of the issues that came to your attention?

Dame May: Yes. So they had held a number of teleconferences across all of the seven regions with frontline staff, and it came through that that they said that there were some people, particularly from a Filipino background and particularly women, that some of the masks weren’t fitting properly because of the shape of faces were different. I took that and my deputy CNO developed a programme, an improvement programme, to increase the number of types of mask, and indeed there were eight additional FFP3s available then for staff as a result of that programme. That was where listening to frontline staff for me made a change in a national policy.

Lead 3: Although, with that, the need to fit test another eight different types of FFP3 mask.

Can I ask you about this, whilst dealing with this topic: can you help, when did you first become aware that there was an issue of disproportionate infection and indeed death rates amongst black, Asian and minority ethnic healthcare workers?

Dame May: Yvonne Coghill, the then WRES director, emailed me, I think it was 7 April, I think it’s in my statement here somewhere, but she emailed me raising that. I immediately, immediately, talked that through with colleagues in the strategic incident team, and then the next day, I believe, we had a senior clinician meeting and I raised it with my senior clinical colleagues, and that is when the Chief Medical Officer for England commissioned some further work.

Lead 3: Yes, we’re going to be hearing from Sir Chris Whitty next week. May I ask you this, though, there’s a lot of people that say they raised issues, they spoke about it with colleagues, they escalate it, to use a phrase that is often used. What practically do you think could be done to help minimise the disproportionate infection and indeed death rate on black and minority ethnic healthcare workers?

Dame May: So there was a risk assessment process that was established for making sure that workers from a black, Asian, minority background, from all backgrounds, not just nursing midwifery professions. It was led by the CPO directorate and you will know that I raised later, I think it was early June, that I wanted that risk assessment process sped up because I was hearing, from again my colleagues from the Black Asian Minority Strategic Advisory Group that there were still people without a risk assessment and I wanted that sped up.

Lead 3: We will turn to that a little later in your evidence.

Aside from the strategic SAG group that you spoke about, was there any other way that you came to learn about issues and concerns faced by ethnic minority nurses?

Dame May: The Jabali network, which was a group of male – men in nursing. It started off just literally before lockdown, 9 March 2020, there was nine of them and now there’s well over 100. They would give me feedback and, of course, I worked on the front line myself.

Lead 3: Taking all of those different sources of information, what would you say were the key issues and challenges being faced by black and minority ethnic nurses and midwives?

Dame May: It was – it was tough for them, tougher for them than people from my background. If I think back at the Nightingale, there were 30 patients and all but one were from a black, Asian, minority background, and that was replicated in critical care units, and then, if you were staff treating patients that were also looking like you, that was tough for them, very tough. And so that’s why we did a lot of work to support the associations – so this was the Filipino Nurses Association, the British Indian Nurses Association, there were three of them at the start of the pandemic, and I think now there’s 36 of them. So we funded a small grant process to support them to do that. But it was tough for black, Asian minority nurses, particularly seeing so many patients from the same background.

Lead 3: You set out in your statement the work you’ve done with the Royal College of Nursing, the NMC and like associations. I think you said in your statement that you didn’t always necessarily see eye to eye with the Royal College of Nursing. Are you able to give us some examples of where you didn’t agree with them and how that impacted either your response to the pandemic or indeed their response to the pandemic?

Dame May: Thank you. So I had a very good relationship with Dame Donna Kinnair and then Pat Cullen, the chief executives during the relevant period. It was always a robust relationship, as it would be with any college/union. But we always had nurses’ and patients’ interests at heart. So Dame Donna, particularly around PPE, and I were in conversation where they supported the guidance.

But I knew that there were, particularly later into the pandemic, members within the RCN challenging some of the IPC guidance, for example. But at my level, the chief exec level, we had a very robust and challenging but excellent relationship, and I’d say that the same with Pat Cullen.

Lead 3: In relation to IPC, would that be around the provision or otherwise of FFP3 masks?

Dame May: Yes, and indeed the beginning it was around gowns and aprons.

Lead 3: Fine, we’re going to come on to look at some of the specific issues with PPE supply.

Finally this, you’ve alluded a number of times already to your work on the front line, and I think in your statement you say you worked during our relevant period on wards on 29 occasions and indeed undertook a number of visits of different wards, including critical care units.

Help us, please, on any of those occasions, what was it like?

Dame May: An utter privilege. Excuse me.

Lead 3: It’s all right.

Dame May: I’ll have a quick drink of water.

Lead 3: Please do.

Lady Hallett: Take your time.

Dame May: Thank you, my Lady.

It was an utter privilege. It really was a privilege to be a nurse.

Ms Carey: What did you see? Tell us, Dame Ruth. Give us a little insight into what –

Dame May: Yes, of course.

So early on, I did two shifts at the Nightingale. The first time I’ve already referenced, the second time was literally on the way back from my stepmother’s funeral in Wales. I then did another – I did an evening shift, and I actually nursed a nurse, which was a privilege.

I worked – I visited inclusion nurses, nurses that worked in the homeless, I visited a care home. I had a great privilege in January – December and January to work in the vaccine programme. That gave me hope.

But I also worked in ITU on a Sunday morning, under the radar, under the radar, worked alongside colleagues. There was death. There was death. There was – there weren’t visitors. Nursing ratios were stretched. But it was very powerful, because I was able to go back then to Matt Hancock, to the Secretary of State, and go, “This is what my recommendation is. No, we’re not doing that. Yes, we are doing that.”

So it gave me a real live experience of what it was like to wear full PPE. Dame Donna was with me on the first time in Nightingale, but nurses – nurses were at the brunt of this.

Lead 3: What was it like wearing full PPE, from a practical perspective?

Dame May: I was a theatre nurse by background, so we were used to wearing masks, but not FFP3, of course. I was fit tested at the Nightingale, but I was fit checking every shift I did when I was at Colchester going into – working alongside colleagues at critical care. They gave lots of nurses, including myself, indents into our cheeks, but they were the protection that was needed for critical care units.

But it wasn’t just the mask, it was the eye protection, the gown, the gloves. It frankly took ages to get everything on and off.

Lead 3: We might come back to that in a moment.

Can I change topic?

Dame May: Of course.

Lead 3: I’d like to ask you, please, about pre-pandemic work issues. Dame Ruth, if it helps you, I’m in paragraph 88 in your statement.

Dame May: Yes.

Lead 3: I think you say this, as at December 2018 there were workforce vacancies in the NHS in England alone of 39,686 nursing and midwifery vacancies.

Call it 40,000 just for ease.

There was some increased funding given, is that right, to provide 5,000 additional places for student nurses?

Dame May: Can I ask your permission to provide a bit of context before we get to that?

Lead 3: Of course. Of course you can.

Dame May: So you’re right, there was very nearly 40,000 vacancies. In England, which is different to the other devolved nations, the bursary was removed.

Lead 3: Is that a student bursary or a …

Dame May: So in 2017 or 2015 the then – George Osborne – Chancellor announced that they would get rid of the student bursary, which is, in effect, the student fees were paid for and a maintenance grant, which meant that there was a significant drop, indeed a 23% drop, in nursing and midwifery applications as a result of that.

So instead of nurses being trained, like I was, like many other nurses were, when we received free education and a maintenance grant, nurses and midwives now are students – well, at that period, were not receiving that. So they ended up in a lot of debt.

That meant – and HEE colleagues have done some analysis of that work –

Lead 3: Is that Health Education –

Dame May: Health Education England. They have done some analysis of that work, and it meant that we were 5,000 fewer nurses in March 2020 because of that decision, and 700 fewer midwives in March 2020.

Lead 3: So you have a general deficit in 2018 but come the start of the pandemic a significant number of fewer nurses and midwives?

Dame May: 5,000.

Lead 3: 5,000, right.

Dame May: 5,000 fewer nurses at the beginning of the pandemic because of the bursary decision.

Lead 3: Can you help us, how does that play out on the ground? If you had 5,000 more, put it another way, how many extra nurses would there be in a hospital?

Dame May: I reckon it would be about 40, around 40 extra nurses in each hospital. Now, of course hospitals are different sizes. That, I think, would have made a difference. Maybe we needn’t have made some of the decisions around critical care ratios. But – and of course if we had more nurses there would be less burn-out, there would be less psychological impact. Removing the bursary, for me, was a catastrophic decision.

Lead 3: All right. Let’s look at a programme in 2019, I think, launched by the Department of Health and Social Care to deliver 50,000 nurses by 2024 and 2025. Now, basically. Is that new recruits or getting people who were off the register back or international recruits or increasing students? How were they going to make up the 50,000 nurses as part of this plan?

Dame May: So just before that, of course, we had the £5,000 maintenance grant that I championed and the government supported. Indeed, Matt Hancock supported that coming in place, which was a support to attract nurses, and that did work, but it wasn’t, still, free education.

But going on to your point, the DHSC launched the 50,000 programme, and it was 50,000 extra. So of course we had to recruit and to retain more than the 50,000 in order to allow for people leaving and retiring. Nurse – I was responsible for international nurse recruitment, and at the time we had an aim to deliver 18,000. Of course we completely exceeded that, and we’ll no doubt come to it. And HEE colleagues at the time had a role to increase domestic nursing supply with the aim to get to 19,000 and the CPO nursing retention, so 13,000. So that 50,000 was broken down into international nurse recruitment, domestic supply and retention.

Lead 3: All right.

Can I ask you this: I think there were projections for between 20 and 30% staff absence in England alone during the pandemic. Does that mean on any given day or week it would be predicted that there would be up to a third almost of nursing staff missing? Or is that too simplistic a way of looking at it?

Dame May: So the way I recall it was that the strategic EPRR director, Professor Sir Keith Willett, wrote out to myself and to Steve Powis and said “We’re going to be 20 to 30% short”, it was because that was the formula that was part of the pre-pandemic planning. I think that’s where it came from. So increasing workforce supply was a key action for me.

Lead 3: Right. I want to – it may be I’ve not made myself clear. You’re going into the pandemic with a deficit of nurses and midwives. Then there is the impact of the pandemic, so nurses getting sick themselves or isolating, which could cause a 20 to 30% –

Dame May: Yeah.

Lead 3: – absence rate. The 50,000, was that meant to cover the pre-pandemic deficit and/or the absences caused by the pandemic itself?

Dame May: The pre-pandemic.

Lead 3: Right.

Dame May: And the 50,000 programme was the step towards the vacancies, it – my recollection was, in modelling, it should have probably been an 85,000 programme, but it was a 50,000 ambition that the government set.

Lady Hallett: And what happened?

Dame May: We delivered 64,000 additional nurses.

Lady Hallett: So I’m not following. You spent some time – as you’ll understand there is a limit to how much I can go into austerity measures and party politics and the like.

Dame May: Of course.

Lady Hallett: And who decided to introduce fees for education and things. But you did say that you blamed the withdrawal of the bursary for the fact there were fewer nurses, but now you said that the programme recruited 64,000 additional nurses. So I’m not quite following.

Dame May: So the – we went into the pandemic with nearly 40,000 vacancies. We would have had an additional 5,000 vacancies at the start of the pandemic if the bursary hadn’t been removed. The 50,000 ambition came because nurses were going to be – carry on increasing in need and demand, so the government decided to have a 50,000 ambition. I supported that. We actually delivered, by November 2023, with – using September 2023’s data we delivered 64,000 additional nurses. So during – at the start of the pandemic, September 2019, the programme was launched. We worked hard to increase the number of nurses and even harder throughout the pandemic to make sure that we overdelivered against that.

Ms Carey: Thank you.

I just briefly asked you about staff absences. Can I just ask you about Long Covid absences in nursing. If it helps you, I’m further on in your statement, at paragraph 219(a), but I think you attended a meeting certainly in December of 2021 looking at the issue in relation to Long Covid absences and the impact it might have on nursing.

Can you just summarise what you learnt at that meeting and indeed what was your takeaway in relation to the impact of Long Covid on the nursing profession?

Dame May: I believe this was the roundtable chaired by Lord Bethell.

Lead 3: It was.

Dame May: My medical director colleagues, Nikki Kanani, Cathy Hassell, they presented a paper on Long Covid to the minister with what they were doing on that. I took away from that meeting and others that we needed to support nurses supporting patients with Long Covid, and that’s why we developed a framework to do that to support them.

Lead 3: In a nutshell, what did the framework achieve or set out to achieve?

Dame May: It set out to support nurses because this was – this was new, it involved multi-professional working and nurses from all sorts of clinical backgrounds. There were – I received some advice from Dr Elaine Maxwell, who was very helpful in this area, and we got experienced people that were – through life were experiencing Long Covid, to support that framework development, but by a different one of my deputy CNOs.

Lead 3: Can you give us a practical example of the support, perhaps not provided by you, but through the Chief Nursing Officer Directorate, how practically you supported people with Long Covid?

Dame May: Well, people with Long Covid, they’re often nurses that had Long Covid. Most of the support for that came from the – how we supported them with their pay, their terms and conditions, how we got them back to work in a part-time capacity, in a very different capacity. I met one of the Long Covid nurses on a Teams call that was describing how she’s now doing part-time research and part-time in her old job, so that it supported her back to her full health.

Lead 3: We looked there briefly at some of the issues going into the pandemic and some attempts to increase nursing capacity.

Can we call onto screen, please, INQ000421158 at page 2.

If it helps you, Dame Ruth, it’s in tab 2 of the bundle, but it might be easier just to use the screen.

This was a letter that you wrote on 6 April from you and indeed the chief nursing officers of all four nations I think outlining the four-ways that it was intended to increase nursing capacity.

The first one there is:

“Once the government has passed the legislation to enable the NMC [the regulator] to establish a Covid-19 temporary register our first focus, we will be inviting those … who have left the register within the last three years to opt in should they wish to do so.”

All right, so to get people who have come off the register in the last three years to come back onto the register. Why was the three years chosen?

Dame May: Because it was – it would give us a potential 50,000 people. The NMC looked at the data and said that they thought it was – three years would be the right years – the right number of years. UK CNOs debated that and agreed, and so it was three years. I think later on we did longer.

Lead 3: Thank you, I’m going to come on to that, but I think you said it was anticipated that if you went back three years the NMC thought that it might give you a cohort of around 60,000?

Dame May: In the UK –

Lead 3: In the UK –

Dame May: – and –

Lead 3: 51,000 –

Dame May: 51,000 –

Lead 3: All right, so that could potentially fill the gap?

Dame May: Yes.

Lead 3: All right. It was aimed, I think you say, at people under 65 who were perhaps now working in different areas of the healthcare market. You widened that, though, as I understand it, to cover people who’d left the register within the last four to five years. Why was it widened from three to the four to five?

Dame May: Because the picture we were facing with Covid and the number of patients coming into hospital was increasing at a further rate, so we needed to take further action.

Lead 3: Was it thought that those who had left within three years would effectively be more up-to-date with their skills, if I can put it like that, than those perhaps where four or five years has lapsed?

Dame May: Indeed.

Lead 3: But notwithstanding that, the need was such that you needed to go back four to five years, all right.

Now, whether it was three years off the register or four to five, can you help us with what plans were put in place to ensure that those who were returning were sufficiently skilled and up to date?

Dame May: So each of the trusts where people went, nurses went, they did an induction programme, they did some key skills training, but it depends on where they were. So I worked alongside some children’s intensive care nurses. Of course they’ve got very real and very transferable skills. I also worked alongside some people that had been in education and not been on the register but wanted to support. They needed more of those skills. But of course we were in the middle of a global health emergency, we weren’t going to be able to provide an induction programme over 12 weeks that you would potentially provide in peacetime. This was unprecedented times.

Lead 3: Now, I think expressions of interest from those who were potentially returning do not always equate to staff actually being employed. Can we have a look at that, please.

And can I ask that it’s put up on screen, INQ000421170.

Dame May: Which tab?

Lead 3: It is in tab – I’ve got the wrong note, but we’ll put it on the screen and we’ll just work off the screen.

Now, this is a very long email setting out the returners. Can we go to page 68, which is the position at the beginning, and as you go through an email inevitably we end up where we need to be.

Dame May: Yep. I’ve got it.

Lead 3: Bottom of the page there, this is the position: very early on, just as we’re about to go into lockdown, as at 11.30 am on Saturday, 21 March, the NMC had received nearly 4,000 applications to join.

Dame May: Yes.

Lead 3: Can we just go to page 67, a day later it’s gone up to 5,633 applications. I’m going to jump forward a month – to page 4, if I may, please.

Dame May: Yes.

Lead 3: It’s just coming on screen now. Set out in a slightly different format, with more detail, but here we are, one month on from the nearly 4,000, and now we can see the NMC confirm there is nearly 12,000 nurses and midwives across the UK on its temporary register, and the data has now been broken down into midwife, nurses, into which country, and indeed which age bracket they’re in.

Dame May: So the NMC set this up very quickly, and we appreciated that by the UK CNOs, and of course we understood that it was UK data to begin with, but as soon as they could they broke it down, as you can see.

Lead 3: If we go to page 3, there is an email, I think, from you at the top:

“Great to have nearly 12,000 back on the register .. how many of these have done their first shift?”

That really brings me on to the point that just because you went back on the register –

Dame May: Indeed.

Lead 3: – did not necessarily result in people on the ground.

Dame May: Absolutely, and I was corrected by Scott, in my team, quite rightly, because that was the UK figure and the England figure, as he then further goes on, was less. But that was my first time going, “It’s all very well having them on the register, temporary register” –

Lead 3: But what next?

Dame May: But what –

Lead 3: So let’s look at page 2 of the document, please –

Dame May: Yep.

Lead 3: – and there’s an email from Scott Binyon –

Dame May: Yes.

Lead 3: – setting out, just for England, you’ve got 9,841 opting into the temporary register –

Dame May: Yes.

Lead 3: – of whom 8,950 are passed to the regions for deployment.

Deployed by regimes to the front line, we go from 8,950 to 2,785.

Can you help with the decreasing numbers that we see set out in that table? I will leave 111 for a moment but how come is it that there’s a lot of people looking to join the register but, when we get to deployed by regions to front line it’s 2,785?

Dame May: I think this is one of the areas of learning for us. This was an issue that all four countries experienced. There was a lack of capacity within our regional BBS, bring back staff, teams, because they were – they had a lot of people interested. Now, where it worked well was when critical care nurses had just left two, three years ago, in their local unit and they still had a relationship with them and they rang them up. That’s when it worked very well.

Interestingly, though, the NMC held – does hold data on their branch of nursing, whether it’s paediatric, mental health, adult, but doesn’t hold data on their specialism. So doesn’t have a data about – so these amount of anaesthetic nurses, theatre nurses, critical care nurses, A&E nurses and, if we’d had that, I think we would have been able to concentrate on those first –

Lead 3: Yes.

Dame May: – and then maybe we wouldn’t have seen the lack of BBS regional capacity like we did.

So the bottlenecks, there was pre-employment check bottlenecks, and there was also a difference between what returners, by then, are wanting to do. When we got to wave 2, of course, though, a lot of these people went into the vaccine programme. I’m grateful for everybody that came back to help us and I think what my email does show is there was a lack of data on deployment.

Lead 3: Well, you also make the point there – sorry, Scott makes the point, in the bottom bullet point, that 15 to 20% of those opted into the temporary register withdrew from the process prior to deployment, the regions are working through this but there are a number of reasons: changes in circumstances, for example people self-isolating –

Dame May: Yep.

Lead 3: – individuals not wanting to work on the frontline and then there was the pre-employment checks and individuals not returning their – a multitude of reasons as to why initial interest did not always translate to nursing in the wards?

Dame May: Yep.

Lead 3: All right.

Can I just ask you this: is there any merit in always having a temporary register, do you think?

Dame May: The NMC does not have the legislative – I can’t say that word, sorry –

Lead 3: Legislative.

Dame May: – ability to set up a temporary register, whereas the GMC do.

Lead 3: Ah.

Dame May: It is part of the legislative reforms that are being considered but, yes, that is something that they do need –

Lead 3: So –

Dame May: – certainly, to have.

Lead 3: – in short, if there needs to be a temporary register for whatever reason, there’s got to be legislation passed to deal with the NMC aspect of it, whereas the GMC already have a ready-made legislative power to do it?

Dame May: Yes.

Lead 3: All right, okay.

Can I go back, please, to INQ000421158 and look very briefly, if we may, Dame Ruth, at the two other ways of increasing capacity. We’ve just got to revert back to a different document, or it’s in your tab 2, if it helps you. Thank you very much.

The second way to increase capacity was:

“Encouraging those skilled who are currently on the register, but not working in clinical care, to come into clinical practice …”

Who was this aimed at?

Dame May: It was aimed at the many staff who were in organisations, so there were people in governance teams that were a nurse by background that could support, it was aimed at people in our ALBs, in my own directorate, in Health Education England directorate, it was aimed at those people who were still on the register that could provide support.

Lead 3: Thank you.

The third way was:

“Changing the nature of the programme from undergraduate nursing and midwifery students of the last six months of their programme so that they may be delivered in a clinical placement.”

I think it’s a three-year degree for nursing; is that right?

Dame May: Yes, it is.

Lead 3: So just help us, what was the plan in relation to the students in the last six months of their programme? If it helps you I’m at about paragraph 116 in your statement, Dame Ruth.

Dame May: That would be very helpful, thank you. 116.

Lead 3: I think you say there the NMC requires 2,300 hours of academic study –

Dame May: Yes.

Lead 3: – and 2,300 hours of supervised practice-based learning for those student nurses, is that right, and midwives?

Dame May: Yes, so for student – for students, they needed to be supernumerary, they supervise –

Lead 3: What is that?

Dame May: They don’t – they’re not in the numbers, they are there to learn, they are learners.

Of course, we then needed to change the standards, the educational standards, for these learners, for these students, to be able to be working in critical care, therefore without their supernumerary status but we wanted their work to be able to be counted towards their educational studies.

So the NMC needed to do that, and they were very, very supportive of us, and they needed to do that across the whole of the four countries. This wasn’t something that could just be done for just England, and that’s why working with my CNO colleagues was so important.

Lead 3: I think you said in your statement that it had been identified that there were 18,700 –

Dame May: Yes.

Lead 3: – nursing students in their final six months, so potentially nearly 19,000 nurses that could start helping out. Is that across England or the UK?

Dame May: That is across England, but I need to make a correction, because that is nursing and midwifery.

Lead 3: Ah, okay, thank you.

Dame May: So it was 16,547 for nurses and 2,175 for midwives, and together that made 18,700.

Lead 3: Can I ask you this about the student nurses and midwives, though: they’re finishing their academic studies, they’re doing their practical supervised learning, did you receive any feedback about how young nurses and midwives coped when they were deployed onto the front line? It just seems, if I may put it like this, a baptism of fire. What did you do or how did the CNO try and help cater for that specific cohort of nurses and midwives?

Dame May: So this was, again, one of those tough decisions that again I took to my strategic advisory group, this group of very senior, experienced nurses, and none of us wanted to do this, we wanted to continue their education, but we’re in such a position that we needed to increase workforce numbers. So we made the decision collectively, we debated it, we wouldn’t do first years because they were literally only just out on placement in the January, we wouldn’t do third years in the first – we’d only do them in the very last cohort. Now – the last part of their training.

It was not mandatory to do, though, it was a choice by which people were able to make, and people did make that choice not to go onto the front line, and we respected them to do that.

The second years, though, we wanted to continue as much as we could, so they still had one day in their university to keep them linked in. There were risk assessments but this was not an easy decision. But student nurses were amazing support, and their feedback – the seven-point plan review fed back, there’s lots of surveys that the Health Education England colleagues did at the time, fed back, what more support we needed to do, that’s one of the things the RCN wanted us to do, which we did do, was to make sure they got sick pay. So there’s – it was difficult but they were amazing.

Lead 3: I’m not going to ask you about the temporary register at point 4. Can I briefly touch on international recruitment. I think you said in your paragraph 141 that the process of recruiting internationally is not new, it’s been a long-established process within the NHS but, in reality, given the lockdowns, was it possible to boost the nursing numbers by international recruitment during the pandemic?

Dame May: Yes, it was.

Lead 3: How did that happen?

Dame May: Through a lot of hard work by a lot of directors of nursing and colleagues in the teams. We were recruiting between 5,000 and 6,000 international nurses anyway, and we’ve welcomed international nurses since the beginning of the NHS, with the Windrush generation, with Filipino and Indian nurses back in the early 2000s, and then this big campaign, recruitment campaign.

But, of course, restrictions, like global travel affected everybody, so there were times, particularly at the beginning, that early summer, when nobody was travelling, so even those people that were due to come weren’t able to come, they were delayed. Then, of course, there were the closing of the OSCE centres, which was a training – clinical training centres.

Lead 3: So that meant that international nurses couldn’t go through the requisite training to ensure they had the same standards as applied in the UK, is that right, or in England?

Dame May: In the UK.

Lead 3: Thank you.

Dame May: So they could go through the training but they couldn’t go through the assessment and that was – so in peacetime, what happens now, an international nurse would come over, they’re internationally educated, they’re trained in their own country. They then have to go through an OSCE assessment of their clinical skills in order for them to go onto the permanent register.

With the OSCE centres closed, and they didn’t open until July 2020, we would have to use these international nurses in a different way and that’s why we came up with the temporary register with them as well.

Lead 3: Would a number of the international nurses be from a black and ethnic minority background?

Dame May: Yes.

Lead 3: Given we know that they were disproportionately impacted, was there any thought given to whether it was the right thing to do to ask black and minority ethnic nurses to come to the UK and potentially face the consequences of a disproportionate impact on them; was any thought given to that?

Dame May: Yes, of course. So in wave 1 they were here. In wave 2, of course, as we were headed towards the winter of 2020, by that stage all black, Asian, minority nurses had had a risk assessment and some had been removed from clinical frontline care. So yes, of course.

Lead 3: Can I deal with one other topic, please, perhaps before we take a break, if I may, and it’s in relation to redeployment. Can I ask you, please, Dame Ruth, to turn to paragraph 166 in your statement. In particular, I’d like to examine redeployment to critical care and changes to patient and nurse ratios, and you’ve already referred to that.

Dame May: Which paragraph, sorry?

Lead 3: Probably easier actually just to go straight to paragraph 171.

Dame May: 171. Thank you.

Lead 3: If we could have on screen, please, INQ000421219_0005 is the page reference, thank you very much.

Can you just help us, in non-pandemic times, in critical care, what should be the nursing-to-patient ratio?

Dame May: Critical care has patients on a ventilator needing high level of intervention and with highly skilled staff. So always, 24 hours a day, there is a trained critical care nurse. Let me just spend half a minute on telling you what that is.

Lead 3: Yes. How is that different from – I don’t mean an ordinary nurse but you understand there is a distinction.

Dame May: So I’m a registered nurse, like many, many thousands of other nurses, I have had experience and a qualification post my registration in theatre nursing, which meant I was a trained theatre nurse. It’s the same with critical care. These are registered nurses, all with some experience, and many of them many years’ experience, but all trained in additional level of skill and expertise, all with an additional qualification. So these are true experts.

Lead 3: They tend to the sickest patients, if I can put it like that, in theory one to one, in non-pandemic times?

Dame May: Yes, and, obviously, with medical colleagues, part of a multi-professional team, with the pharmacist, the physio and other colleagues.

Lead 3: During the pandemic, however, was there a decision taken to change the patient-to-nursing ratios?

Dame May: Yes.

Lead 3: Who made that decision, please?

Dame May: All four countries made that decision and, for us, the decision formally was made by NIRB.

Lead 3: By NIRB, the national incident response board; is that right?

Dame May: Yes.

Lead 3: Were you part of the decision-making process?

Dame May: I led it. So –

Lead 3: Can I ask you, then, how is it that you came to take the decision that, in some cases, we may need to go from one critical care nurse to six patients?

Dame May: Yes, so Sunday, 23rd – 22 March was a day that I will never forget. It started off at 9.00 in the morning when we were – had our meetings and we were – I was being told that we’ve got 4,000 critical care beds in England but in 16 days’ time we’re going to need 7,000. But I had a meeting at 1.30, actually, on the Sunday with the British Association of Critical Care Nurses, Nicki Credland as chair, excellent critical care nurse leader and one of my deputy CNOs, and of course with some other critical care nursing experts, and they’d been doing some great work, this work. They’d been talking to colleagues from across the UK and other colleagues within their profession, that this could be a proposal to take that forward. A team approach, not ideal at all, and I know that – I know there’s been consequences because of it.

Lead 3: Let me pause you there. It’s not, 1:6 may be slightly misleading because, as you can see there, there are other staff there as well performing rolls. You’ve got staff A, staff B, but they are not those with critical care training skills, are they?

Dame May: No. Staff A are nurses with recent or past critical care experience and staff B are nurses with no critical care experience, and staff C are with healthcare support workers. So it was much more of a team.

So I worked as a staff B and I was on a 1:2 ratio at that time, working in my local hospital, and it didn’t feel like a 1:2 at all because, when somebody went for a break it wasn’t a quick cup of tea and back, it was taking all the PPE off and back on again, so it was a 45-minute experience. So it actually felt like 1:3.

That’s why in wave 2 we didn’t do this. We did this in –

Lead 3: Before we come to wave 2, what happened then when the one critical care nurse who is looking after two, three or four patients needs to take a quick comfort break, who was there to fill the gap?

Dame May: There was always a 1:4, there was people that would cover for each other, but there were occasions where there was one nurse to six patients, one critical care nurse to six patients. There were other professionals.

This is a decision that will stay with me forever.

Lead 3: Dame Ruth, do you think that the diluted staff ratios affected the care that those patients received?

Dame May: Yes.

Lead 3: What about the impact on the critical care nurse themself, an inevitable impact on them, I assume?

Dame May: Inevitable, and what we now know, with Kevin Fong’s work, for example – and that’s why we launched the Professional Nurse Advocate Programme for Critical Care, but, yeah, this wasn’t – this was not where we wanted to go.

Lead 3: Why did you do it, why did you make that decision then?

Dame May: In critical care the capacity was doubling, trebling, quadrupling, ten times the capacity in other places. We were seeing reports in Italy where patients weren’t able to get into hospital. Yeah.

Lead 3: You mentioned, and perhaps we’ll pause then after that, if we may, my Lady, you said, “We didn’t do it in wave 2”. Why not?

Dame May: Because 30 July 2020, Professor Kevin Fong’s briefing shared with me the impact that it was mainly having on nurses. So we developed the Professional Nurse Advocate Programme, we developed a whole range of practitioner health. But I made the decision then that I’m not doing – we’re not doing this again.

But it was a critical care shift that I did in January 2021, a Sunday morning, and I had my regular meeting with the Secretary of State – Matt Hancock, at the time – the next day, and of course there’s the pressure of getting on with the electives again, and he said to me, you know, “Why can’t we do 1:3 ratio all the time”, and I said “No, I was there yesterday morning”, and I explained to him what it was like.

He backed me and we did maximum of 1:2 during the next wave.

Ms Carey: All right.

My Lady, would that be a convenient moment?

Lady Hallett: Certainly.

I hope you were warned that we take regular breaks. You might welcome one as well. I shall return at 11.20.

Ms Carey: Thank you very much.

(11.08 am)

(A short break)

(11.20 am)

Lady Hallett: Ms Carey.

Ms Carey: Thank you, my Lady.

Dame Ruth, can we turn, please, to a different topic and that of the IPC guidance and it starts in your statement at paragraph 230 onwards. I think you were the national director of IPC for NHS England; is that right?

Dame May: Yes.

Lead 3: As you told us, you were the co-chair of the hospital onset Covid working group –

Dame May: Yes.

Lead 3: – and you say in your statement you have national responsibility for NHS England’s Covid-19 nosocomial infections programme?

Dame May: Yes.

Lead 3: Right. Turning to the guidance itself, at paragraph 232 you say that:

“NHS England’s role in [the guidance] was through membership of [the cell] …”

You brought together the leads and specialists from across the UK:

“Initially the … Cell provided comments on draft guidance, [but], from June 2020 onwards the UK IPC Cell drafted [the] guidance …”

I think, if I’ve understood your evidence from this morning correctly, you would then see that guidance and have the opportunity to comment on it, agree, disagree, amend, as you saw fit?

Dame May: Yes, and indeed the draft guidance would go back to each of the countries for their equivalents, their public health and their leaders to consider as well, before it then went to PHE for final approval.

Lead 3: I think you say in your statement that you don’t have specific scientific and technical expertise, and you say “It is not my role to make decisions on issues such as PPE specification and the use and types of disinfectant to use”. I just want to be clear what you mean by that. When you say you didn’t make decisions on PPE specification, what did you mean there?

Dame May: I mean that the scientists provided me and across the UK the advice on the scientific elements of the IPC guidance, of which that was it.

For my role, my role was much more about providing executive leadership, supporting the conversation, supporting the coming together of UK-wide discussions, as part of UK-wide CNO discussions, supporting, for example, the National Clinical Director, Professor Mark Wilcox, when I was going with him to the senior clinical group, and indeed supporting Dr Eleri Davies, the microbiologist – the public health doctor in Wales, when she presented the consensus statement in late 2021.

Lead 3: All right, she, in due course, I think, became the chair of the IPC cell after Dr Ritchie?

Dame May: She did, the second year.

Lead 3: I just want to be clear, was it part of your remit to say “I don’t agree that it should only be FRSM, I think it should be FFP3”?

Dame May: I would – my remit was to challenge, to ensure that the scientists have taken the latest evidence, and the scientists were the public health doctors and the UK IPC cell, which had a range of professionals within it from across the UK.

Lead 3: So if you thought that a wrong decision had been made about the level of masks, for example, that should be worn –

Dame May: I would question it –

Lead 3: Right, and then it would go back to the cell for their view?

Dame May: – and indeed questioned Dr Susan Hopkins – Professor Susan Hopkins, and Jenny. Jenny and I and Susan and I had many a conversation, as did the National Medical Director, Steve Powis, with Susan and Jenny, and Chris Whitty.

Lead 3: Sorry, I didn’t mean to interrupt you.

Dame May: Sorry, I apologise.

Lead 3: Were you familiar with the different modes of transmission of this respiratory virus: contact, airborne, droplet?

Dame May: Yes.

Lead 3: Are you a scientist by background, familiar with the physics and engineering and droplet sizes?

Dame May: No, I am absolutely not. I needed to rely on public health specialists and other specialists.

Lead 3: Can you help us: at; the beginning of the pandemic, what did you understand to be the mode or modes of transmission of Covid?

Dame May: I understood it, like the World Health Organisation was advising at the time, to be mainly droplet but, of course, with aerosol, particularly then. That’s why we had the guidance for AGPs, so that we supported – it was making sure that – making sure that we had guidance for aerosol-generating procedures but, at that time, all of the guidance, all the advice, scientific advice, was predominantly droplet.

Lead 3: Do you accept that, on the back of the scientific advice, consequential decisions were made about what IPC measures should be put in place?

Dame May: Yes.

Lead 3: Right. So droplet goes down one or a number of routes for IPC, aerosol and airborne transmission may require different IPC measures; in general, do you agree with that?

Dame May: In general. IPC measures are a combination of – a combination not just around masks. Masks are very, very, very important but so is distancing between beds, so is eye contact – eye wear, gowns, gloves, a whole range of measures.

Lead 3: Did you gain an understanding as the pandemic progressed that aerosol transmission played a larger part in the way that the virus spread?

Dame May: Yes.

Lead 3: Can I ask you, please, about December 2020. We heard from Dr Ritchie yesterday – it’s not in your statement –

Dame May: No.

Lead 3: – that Public Health England were telling the IPC cell that they thought that their understanding about aerosol transmission had changed and there was a bigger role that aerosol transmission was playing. Public Health England recommended a move to FFP3 masks on a precautionary basis. Now, that was not the position the IPC cell came to on a consensus basis but Dr Ritchie told us that there was a paper produced and that you and the senior leaders saw the paper.

So can I ask you about that, please: do you remember being made aware that Public Health England had come to a changed view about the role that aerosol transmission had played?

Dame May: I remember that the Public Health England member of the IPC cell had come to a potentially different view. I’m also aware of UK colleagues from public health backgrounds had a different view. There was a consensus. Now, I’m also aware that, because of the differing view, I wanted to make sure we belt and braces, and that first statement was agreed by the most senior medical scientific adviser in PHE/UKHSA, Dr –

Lead 3: When you say that first statement, what do you mean there, Dame Ruth?

Dame May: That statement you’re talking about then.

Lead 3: That their understanding had changed?

Dame May: Yes. The consensus statement, end of 2021, I’m sure we’ll come on to later, but …

Lead 3: So –

Lady Hallett: Could you just complete?

Ms Carey: Yes, let me deal with it.

You became aware then that PHE’s understanding had changed?

Dame May: I –

Lead 3: You were aware that the consensus cell had come to a slightly different view, it was raised with you, I think you said, you agreed with. Did you agree with the decision of the IPC cell?

Dame May: I took assurance that there was a debate. I was actually pleased there was a debate. I didn’t want groupthink. I wanted to know that people had the confidence to debate the merits of the evidence and the merits of potential action. So in terms of process, for me, that was good. I took assurance that there were other colleagues across the UK from all sorts of professional backgrounds that had a differing view but I also wanted to make sure that PHE’s more senior doctors – I wanted to know their views.

Lead 3: Right.

Dame May: And we did have their view.

Lead 3: Pause there. The question I asked you was: did you agree with the decision of the UK IPC cell?

Dame May: Yes.

Lady Hallett: So even though you said you were concerned about having – sorry to interrupt –

Ms Carey: Not at all.

Lady Hallett: – belt and braces?

Dame May: Yes, because I – my role has always been to challenge, to ensure that everybody’s looking at the evidence – that has got the scientific evidence, scientific background.

Lady Hallett: But surely belt and braces, or what I think some have been calling the precautionary principle, would involve going down the path recommended by the Public Health England member who said FFP3 masks, wouldn’t that be belt and braces?

Dame May: I think, at that time, there was nobody other than – as you said, my Lady, saying the evidence – there was evidence for FFP3s all of the time. What I also know was I wanted to seek PHE’s most senior doctors’ view of whether the guidance needed to be changed on FFP3, and we did that, and the view was we didn’t need to change it.

Lady Hallett: You say that you rightly wanted to avoid groupthink, as you may know it’s something I reported on in Module 1. Did you ever consider that there might have been an element of groupthink when it came to the mode of transmission, that the groupthink, including the World Health Organisation, was the mode of transmission was droplet?

Dame May: I don’t think we did because there was the World Health Organisation, there was the UK IPC cell, like – we know it’s got lots of people involved with very technical and scientific expertise – there was the senior clinical meeting with every UK CMO, CNO, UKHSA chief exec, the senior medical, plus some of the other deputies in there. There were so many people in so many different groups, there was the HOCI working group as well, with another range of people. So there was so many different groups saying that and, even today, as I understand it, World Health Organisation hasn’t come out and said it’s predominantly aerosol.

Ms Carey: My Lady, may I just finish this topic in this way:

When you came to learn that Public Health England had a changed understanding of the route of transmission, did you speak to anyone in Public Health England about that and what underpinned that change in understanding?

Dame May: Can I just check for clarity it was that December 20 –

Lead 3: Yes, 22 and 23 December 2020.

Dame May: There is email correspondence, I know – I think I recall it was Mark Wilcox talking to Susan but I also know my National Medical Director spoke to PHE colleagues. I can’t recall who, whether that was Susan or Jenny, so I apologise.

Lead 3: Did you speak to any PHE –

Dame May: I don’t think I did, but I can’t recall.

Lead 3: Fine.

What about Sir Chris Whitty, did you speak to him and say, “Well, PHE have got a slightly different view here, Sir Chris, let’s discuss the merits or otherwise of it”?

Dame May: I think we discussed it at senior clinical meeting which Chris was chairing. I’m absolutely sure we did.

Lead 3: All right.

Can we look at some of the specifics in relation to PPE itself. Now, you are not responsible for the supply of PPE, you make that clear in your statement. But I think you say in that statement at paragraph 252, Dame Ruth, that you became aware of supply issues.

Can you just help us, how did you become aware of problems with PPE supply?

Dame May: Oh, numerous ways: from regional chief nurses feeding back; from the UK IPC cell feeding back and, indeed, the first time I game aware was 16 March when the then head of IPC, Linda Dempster, told me and my deputy CNO that there were PPE supply challenges; from the incident, the strategic fusions, when their feedback from the EPRR colleagues; from me going to talk to care home colleagues; from me – there were PPE – from the RCN, Dame Donna, yeah.

Lead 3: A number of different sources there?

Dame May: Yeah.

Lead 3: I think you make it clear you were not involved in the decision to declassify Covid as a high-consequence infectious disease. Obviously, you’re aware that it was classified and then declassified, and you were not involved in the decision for IPC guidance to recommend FFP3 masks only in intensive care and/or when AGPs are carried out, all right, but you’re aware that that’s the background and where we end up, essentially, by about 6 or 13 March 2020?

Dame May: Yes.

Lead 3: Were you concerned that recommending only FRSM to the vast majority of healthcare workers in the guidance in March 2020 did not sufficiently protect those healthcare workers?

Dame May: I think I was more concerned at the time about supply because that’s what was being fed back to me all of the time. So if I think back to – I think it was 3 April 2020, when I had a webinar with my National Medical Director, Sir Stephen Powis, with medical directors, chief nurses, on the webinar. Susan Hopkins very helpfully came to present the tables guidance. It was all about supply, it wasn’t about the guidance. So the main concern that was coming in to me was supply.

Lead 3: Let’s look at that supply issue because I think you say that there were concerns about supply through March and April 2020; there were increasing concerns from frontline staff about PPE shortages; concerns were discussed at the senior clinicians group on 9 April; and a pinch point, effectively, coming here around 12/13 April. So I would like to focus on that, please, for a moment.

Is the position this: that there was a discussion regarding gown use amongst senior clinicians and indeed a number of the people that you’ve spoken about?

Can we have a look on screen, please, at INQ000477782, and it’s behind tab 13, Dame Ruth, but it might just be easier to look here. Here we are, 12 April, an email to you from Dame Donna Kinnair of the RCN. She’s had a discussion with you:

“… want to confirm my discussion with you that RCN (and you as our CNO) would not support sending nurses or healthcare assistants to look after patients without the appropriate PPE equipment as determined by the WHO guidance and the recent guidance that we supported that [PHE] issued on 10 April. Whilst we recognise that PPE gowns are in short supply with a possibility of us running out, our stance would be that sending nurses to look after patients without appropriate personal protection is a failure of our duty of care to them as individuals and in breach of health and safety legislation.”

The issue was with gowns, clearly. Do you know why there was an insufficient supply of gowns?

Dame May: Yes. The pre-pandemic planning stockpiles did not include gowns and that left us extremely short. It was a very stressful time, it was Easter weekend and Donna and I spoke more times than I spoke to my family and she spoke to her family. We were completely aligned that we needed to concentrate on getting more gowns, and not moving to aprons, because that wouldn’t protect nurses in the way we felt that they needed to be protected.

Lead 3: I think the IPC cell in due course, and certainly the guidance, recommended what’s called sessional use –

Dame May: Yes.

Lead 3: – and reuse. Can you just help us, what is sessional use, please?

Dame May: Well, you use it for a session, so you use it for the time you’re in caring for a patient. So I, for example, when I used it, and Donna, actually, when we did it in Nightingale and, indeed, in my other shifts, you’d go in, in your head, your mask, your eye contact – your eye wear, your gown, your gloves, and your gown would be for the session that you were in there. When you cam out –

Lead 3: How long might this session be?

Dame May: Three or four hours, or – yes. It would be different in different places.

Lead 3: Let me ask you this, then: in non-pandemic times, in three or four hours, how often would you expect a nurse to change their gown?

Dame May: Erm … I … I don’t know what an HCID unit would do day-in, day-out in a normal time. I would have to come back to you on that. But I genuinely believe it would be a single use for a single patient.

Lead 3: Right. So if you’ve got six patients in a bay, you might change your gown six times, or is that – I don’t want to be overly simplistic about it, Dame Ruth, but is the bottom line that, in non-pandemic times, you would have changed your gowns more than you did when they were recommending sessional use, all right?

Dame May: As indeed we would have more staff on a 1:1 ratio in a normal time.

Lead 3: Yes. So here is you and Dame Donna not supporting the proposal for sessional use or reuse?

Dame May: And I then also talked to my strategic advisory group, my forthright directors of nursing, and they were equally of the same view, as was the UK IPC cell, and my deputy CNO at the time then fed that back. Donna’s and my main concern was the safety of our staff and we just felt that this wouldn’t be a safe option.

Lead 3: Well, that was the question: how did the nurses feel about this guidance? Did you get any feedback from the front line about what they thought about sessional use and reuse?

Dame May: I can’t recall about sessional use versus reuse. I can recall how frontline nurses were in fear of not having gowns and going potentially with just aprons, which is why Donna and I were aligned and agreed so much.

Lady Hallett: By Easter 2020, this is obviously a major issue for you and your other colleagues; when did you first bring it to the attention of Mr Hancock as Health Secretary?

Dame May: Of the supply of gowns?

Lady Hallett: The supply problems of PPE.

Dame May: Supply problems. I can’t recall an exact date when I –

Lady Hallett: Roughly?

Dame May: I’m sure Mr Hancock was aware at this time that we were struggling with supply. Of course, my colleague Emily, Dr Emily Lawson, was supporting the DH and the DH was leading this, and I’m sure they would have been made aware.

I also was on the podium at Number 10 with Mr Hancock, I think it was 3 April, I think, and I think it was 10 April, something like that, so he knew then because we were talking about it. In fact, I talked about it in –

Ms Carey: My Lady, may I interrupt to help to this extent: we’re going to hear from Professor Hopkins and I think it’s clear, unless my memory is failing me, that this change to sessional use and reuse was, in fact, agreed by Mr Hancock. So he was aware that there was (a) the concern and (b) the change in the guidance in this regard. We’ll perhaps deal with that tomorrow.

Lady Hallett: I’m not sure if you’re the right witness to ask this question, so just say if you’re not. As a layperson, I’ve never quite understood the concept of use-by dates for PPE if it’s made of cloth. I can see how over decades cloth might weather but why does PPE have a use-by date?

Dame May: As I understand it, the Health and Safety Executive have that as a role – as a rule for the protection of staff. So I think it may need to be asked of them. I’m sorry, my Lady.

Ms Carey: No, not at all.

Can I just deal briefly, Dame Ruth, please, with a little later on in the pandemic at paragraph 266, if it helps you, the Alpha variant emerged in the end of 2020, and I think we then had Omicron later in due course and that did not necessarily result in a change in the IPC guidance. But I think you commissioned the IPC cell to review the IPC guidance in November 2021. What led you to asking the IPC cell to review the guidance at that stage?

Dame May: I remember that. It was the UK CNOs were meeting and, actually, we discussed it as a group, and Sue Tranka, the then – she was my deputy but then she was the CNO of Wales, she emailed on behalf of the UK IPC – on behalf of the UK chief nursing officers, but yes, we all agreed as a UK –

Lead 3: What was it, just that Omicron had emerged by then and that’s why you asked for the review to be undertaken?

Dame May: Yes. It was, we knew it was more transmissible, that was coming out, so, yes, we wanted to do that.

Lead 3: I think –

Dame May: It was also in June 2021, from 1 June 2021, it was following a steer from SAGE, you know, SAGE, the most senior scientific advice. They were saying that within the IPC guidance staff could wear respiratory protective equipment such as FFP3 masks following a risk assessment process. So that came on the back of the June as well.

Lead 3: I see.

Dame May: June 2021.

Lead 3: What was the outcome of the November review that you asked the IPC cell to undertake.

Dame May: The outcome was a consensus statement that was drafted by the UK IPC cell. Dr Eleri Davies was the chair by then from Wales, so it was a truly multi-UK-wide cell – consensus discussion, and then that went to the senior clinical meeting for a discussion.

Lead 3: I think you say in your statement that the consensus that was presented ended up in a document which supported the existing position –

Dame May: It did.

Lead 3: – on FFP3 use in the guidance, noting there was provision in the guidance for extended use of RPE, following a local risk assessment but agreed to make this position clearer to staff by stating this at the start of the guidance.

So, in short, if a risk assessment suggested that FFP3 should be worn, then that ought to be provided to the staff member; is that right?

Dame May: Yes, and that was in place from June 2021.

Lead 3: Yes, why is it –

Dame May: But this –

Lead 3: I’m sorry to interrupt you but can I just ask you this on that point: why is it necessary to move the reference to risk assessments making it clear at the start of the guidance?

Dame May: Because feedback was that it wasn’t as clear as it needed to be. So the consensus was we needed to make it even clearer to frontline staff that they had the ability to have a – where a risk assessment indicated it, they should be able to wear an FFP3.

Lead 3: Was there any concern being relayed back to you that the risk assessments, although recommended in June 2021, were not, in fact, being undertaken?

Dame May: I – I remember, I recall colleagues being fed back about whether they’d had a risk assessment recently or moved an area, which is why we, one of the reasons why it was moved up, but also one of the reasons why we did webinars with chief nurses and medical directors, to reinforce the messages to them, and I remember doing webinars with chief nurses and medical directors that said, “And we are reinforcing the fact that local risk assessments need to be done and, if, by then, you need – a member of staff needed to have FFP3s they should have them”.

Lead 3: I understand that is what should have happened, and if the risk assessment recommended FFP3 it should be provided. What about the staff member or the nurse or midwife who just wants it for their own peace of mind? In those circumstances, would you have expected them to have been provided with an FFP3 mask?

Dame May: I know there were units, there were staff that would do that.

Lead 3: So that was an option still even if the risk assessment and the guidance didn’t necessarily drive you to that conclusion?

Dame May: Absolutely.

Lead 3: May I turn to a different topic, please, Dame Ruth, and some challenges in particular in relation to maternity care.

If it helps you, it’s at paragraph 310 in your statement. I think you set out in that paragraph five challenges. I just want to ask you about three of them: there were challenges with staff absence due to illness and self-isolation, there was obviously the concern about the impact of Covid on pregnant women, the implementation of cohorting – what do you mean by that, what was the challenge there?

Dame May: So I remember very well that there were units – of course we had women that had Covid, women that we weren’t sure had Covid, women that we definitely knew hadn’t got Covid. So of course estates had directors of nursing, chief midwives – the labour ward co-ordinators were having to make sure they provided safe care and separated care for women, to protect the women and the staff.

Lead 3: I think you are aware that Amanda Pritchard, the now CEO of NHS England, has said in her statement that nursing and midwifery staff, due to their age profiles, were forecast to be the worst affected group for absences; is that right?

Dame May: (Nods).

Lead 3: Against that background, can we have a look, please, at a table in your statement at page 69.

So it’s INQ000 – thank you very much.

This table, I think, sets out some of the impacts of staffing pressures on maternity care.

Dame May: Yes.

Lead 3: If we just look at the top box to start with:

“Due to the current pressures experienced across urgent and emergency care services, LAS [London Ambulance Service] are no longer in a position to guarantee an ambulance response to women choosing to have a home birth, or birth in one of London’s three standalone birth centres.”

And the risk is set out there in no uncertain terms:

“Should there be an obstetric emergency requiring transfer to hospital, there will be no ambulance service to respond.”

You set out there that midwives are legally obliged to attend the birth and LAS (London Ambulance Service) have been asked to review – discuss this decision with a view to various options.

How did it come to pass that if a woman wanted to give birth at home, not go to potentially a ward where she might get infected with Covid, and/or infect babies, and/or infect the staff, we ended up in a position where she wasn’t allowed to have that choice? Do you know what led to decisions like this?

Dame May: Yes, I do. So, we had over 700 vacancies, 800 vacancies of midwife roles before the pandemic, and you’ve already heard me say that because of the bursary we could have had those 700 there. But moving on, that each day, regularly, pre-pandemic and post-pandemic, a midwife in charge of a midwifery service at any of our local hospitals would balance operational pressures with staff absences. But these were of a different scale.

Midwifery-led care in a home birth situation is often with one and sometimes two midwives, so it’s particularly resource-intensive. Now, whilst women quite rightly wanted to have their birth preference supported, in wave 1 in particular, and I know that my chief medical officer and my national clinical director for obstetrics and gynaecology wrote to me on 23 March with this table, and this time, of course, LAS capacity was stretched to the absolute limit because they were transporting patients to hospital with Covid in huge numbers. So it was a difficult situation. And we know that I think it was 57% of birthing units closed during that period, but London closed all of their units.

Lead 3: Well, can we just close that box, I just want to look at one other different type of concern, the third box down:

“Potential withdrawal of epidurals for non-emergency situations [are] being explored …

“The choice of epidural for pain relief during labour may not be available and therefore women’s choice of pain relief will be limited.”

Was there a supply problem with epidural pain relief – sorry, the use of epidural for pain relief?

Dame May: Yes. So anaesthetists were a key member of the team supporting patients that were ventilated on critical care, and I believe you heard last week that we didn’t, again with workforce planning, we didn’t have enough anaesthetists going into the pandemic. There were women that had their epidural delayed.

Lead 3: It may be not a question for you, but do you know how that was resolved? Did we manage to get more pain relief or was there an alternative option offered? Can you help with any way they tried to manage that?

Dame May: So the 9 April guidance did advise that anaesthetists need to be freed up for labour care. Equally, I know that anaesthetists worked extraordinarily hard to get to provide that care. And there was – there was only a small amount of people – women that didn’t get it, but that – I don’t want to trivialise that it was even a small amount of women that didn’t get it.

Lead 3: One of the other challenges that you are aware of in relation to maternity care was women not accessing maternity care at all, and I think you say in your statement that there was an NHS Open for Business campaign launched, pregnant women being one of the main target audiences.

Did you become aware of the reason or reasons why women did not want to access maternity services during the relevant period?

Dame May: Well, there was the stay-at-home message that was around, but of course some people still needed to access the NHS, and that included women of course. We know that there was messages to women, and indeed I gave a message at my second Number 10 conference on 10 April, that: please – particularly aimed at pregnant women – if you need to contact your midwife, please do. And it’s important they did. And then of course this campaign was launched on 25 April.

Lead 3: Can you think of any way in which the messaging could be done differently to try to encourage people to access necessary health services in the event of a future pandemic?

Dame May: Of course women were put on the – pregnant women were put on the vulnerable list, the vulnerable list that was developed, and that probably caused even more concern for them. There were lots of women though that had very, very good care from their midwifery teams and their obstetric teams. I know the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives really supported professional leaders – as well as my own team – in making sure they’re cascading the message, which was: pregnant women still need to access. Because of course it was an area of work that couldn’t be stepped down.

Lead 3: No.

Dame May: It wasn’t like elective care. So this needed to continue.

Lead 3: Do you think the stay-at-home message got the balance wrong?

Dame May: In hindsight, I wish it was “stay at home but not if you’re pregnant or you are” – in hindsight, yes.

Lead 3: I think in particular during wave 1 you became aware of evidence that there was a particular reluctance to access maternity services from black, Asian and minority ethnic communities – I’m at paragraph 339, Dame Ruth – and did that result in, I think, four specific actions being taken to try to encourage women from those communities to come forward?

Can we look on screen very briefly at INQ000280429_2, please.

Can you see this is taken from, I think, the Maternity Transformation Programme, but can you see in the middle there, England’s most senior midwife has recommended the following common sense steps:

“1. Increasing support of at-risk pregnant women – e.g. making sure clinicians have a lower threshold to review, admit and consider multidisciplinary escalation in women from a BAME background.

“2. Reaching out and reassuring [those] women with tailored communications.”

There is a recommendation about vitamin D.

And:

“Ensuring all providers record on maternity information systems the ethnicity of every woman, as well as … risk factors, such as living in a deprived area … co-morbidities, BMI [whether they’re] aged 35 … or over, to help identify those most at risk of poor outcomes.”

So that was the recommendations, but do you know whether there was any positive uptake as a result of those recommendations or whether any review was done to see how efficacious or otherwise they were?

Dame May: So the Chief Midwifery Officer, the then Chief Midwifery Officer, wrote those four areas out. It was about reinforcing the message. So, for example, vitamin D, a supplement, has been there as an advice for a long time, way before the pandemic. I know that there was a CQC survey done that was done – asked the questions in 2020 and published in 2021, that actually showed that white women felt that they had enough information about their pregnancy, 74% of white women, and 81% of women from a black, Asian, minority background felt that they had enough information. So clearly some of that messaging did get across.

And of course local organisations, local trusts, local midwifery teams would be able to tailor some of their communications to their populations. That was really important. It’s the tailored communications that was important to …

Lead 3: Can I ask you about visiting restrictions in the context of maternity care.

I think – is this the position, and correct me if I’m wrong, was the guidance that partners should be allowed to accompany a woman in labour?

Dame May: Yes.

Lead 3: Is that correct?

Dame May: Yes, it was. So the 16 March guidance said visitors should be limited to one patient – one per patient or less, unless it’s a partner in a birthing situation.

Lead 3: Yes.

Dame May: And the same with the 25 March. And that was just after lockdown, the first national lockdown, which is visitors suspended except for birth –

Lead 3: Yes, so generally speaking no one allowed into the hospital unless one of the exceptions applied, and one of those exceptions was that if you were in labour you should have your partner with you or a partner with you?

Dame May: Yes.

Lead 3: All right. Now, did you draw or aware whether there was drawn any distinction about active or non-active labour?

Dame May: Yes.

Lead 3: What was the guidance meant to be? Was it meant to draw a distinction or was that something that was created by those who were in charge of trying to manage visitors?

Dame May: It was the latter. You know, this must have been really difficult for chief midwives and labour ward co-ordinators and the like because they were trying to balance their staff safety and the women and babies’ safety. So whilst 97% of women had their partners in labour, half of them only, or half of them, had it due in active labour. Now, there is a definition for active labour, but in practical terms it’s when a woman goes from antenatal ward into the labour suite. So that would have been tough for some of those partners, not being – and for the women – not being there in the antenatal –

Lead 3: Yes.

Dame May: – as well as then in the labour –

Lead 3: So although the guidance didn’t make reference to whether a woman was in active or non-active labour, it was interpreted by those on the ground, as it were, to be a potential dividing line as to when partners were or weren’t allowed?

Dame May: Yes, I think it’s one of those learning points for me for a future pandemic about being more specific earlier.

Lead 3: Do you think partners should have been allowed in for the entirety of labour?

Dame May: Yes, I do.

Lead 3: Were you aware of reports that some women felt obliged to undergo a vaginal examination to prove they were in active labour and therefore get their partner in with them? Did you hear reports of that?

Dame May: I heard reports of that, and when I talked to Gill Walton, the chief executive of the Royal College of Midwives, some of that could have been true.

I find it hard to believe that a midwife would do that, so it could be in translation, I don’t know, but in practical terms it’s when a woman moves to labour ward.

Lead 3: Can I just ask you this: when you became aware that there was this distinction being drawn between active and non-active labour, did you or the Chief Midwifery Officer put out any communication to say that’s a distinction that shouldn’t be being made?

Dame May: So what I am aware of is that there was some work done by the Royal College of Midwives and the Royal College of Obstetricians over the summer of 2020 which led to the 8 September guidance, which was much more specific, and a regret I have is that wasn’t – that specific detail in the 8 September guidance wasn’t in the original guidance.

Lead 3: I think in your statement you say that by the first week of April 2020 you had had reports coming to you, and indeed to the Chief Midwifery Officer, of not only partners not being able to attend the full range of appointments, scans, partners not being able to stay with their mother and the baby immediately after birth, so a range of difficulties in relation to people accompanying pregnant women. I think you say in your statement that decisions about which scans were able to be attended with, how long the partner could stay after the birth, were decisions for trusts to make; is that right?

Dame May: Yes.

Lead 3: Do you think that led potentially to an inconsistency of approach with trust A doing one thing and allowing a partner in, and trust B doing something different and not?

Dame May: Well, of course their estate is different in different organisations, so what may be safe for staff and for women in one unit may not be the same in others. And some of our estate in maternity units is extraordinary and has great facilities that will allow for this much easier. Some of our NHS estate in maternity services, for example in sonographers, for ultrasound rooms, is very tight, very small, and that created a difficulty, in practical terms, for those leaders and staff.

Lead 3: If there had been more PPE available early on in the pandemic, which the visitor, the birthing partner, could have worn, do you think that might have affected the stance taken on visiting restrictions?

Dame May: I don’t know, I wasn’t involved in the visiting restrictions consideration, that was the clinical cell reporting to the EPRR structure, so I can’t tell you whether PPE supply was part of the decision-making. I can tell you, though, that midwives were nervous, as were nurses were nervous, and Royal College of Nursing and Royal College of Midwives, quite rightly, were equally advocating for the support of their staff to be considered.

Lead 3: If there had been more testing available earlier, to show that the partner was Covid negative, do you think that might have affected the way the visiting guidance was drafted and published?

Dame May: Oh, without doubt. Without doubt. So it wasn’t until the 14 December guidance that – you know, where those key actions was around – we had the LFD, we had the lateral flow tests. If we’d had lateral flow tests at the beginning, with us being able to say whether a partner was positive or not, gosh, that would have relieved a lot of anxiety and tension between staff and women and families, and provided better outcomes – or experience.

Lead 3: Can I ask you briefly about postnatal support. Do you consider that to be an essential part of maternity care that should be prioritised in the event of a pandemic?

Dame May: Absolutely. Antenatal care with the scans, postnatal care, I agree completely.

Lead 3: Did you become aware that health visitors were being redeployed and so were not able to visit new parents?

Dame May: I was made aware of that, and Alison Morton from the IHV very helpfully made me aware, as well as of course the chief nurse for public health, that – I didn’t have a responsibility for health visitors and school nurses until November 2023, but yes –

Lead 3: The IHV is the Institute of Health Visiting; is that right?

Dame May: Yes, it is.

Lead 3: Can I ask you about face-to-face support for new parents. Clearly some meetings had to be done virtually, but do you think that there should be more prioritisation of face-to-face support for those new mums and dads?

Dame May: I think it was – the IHV very helpfully set out concerns about how we should not redeploy staff, redeploy health visitors, away from their core duties.

Future pandemic health visitors should stay being health visitors, they should not be redeployed, and then they would have more ability to do the face-to-face contact.

Lead 3: Can I widen the topic of visiting to more general restrictions on visitors. Clearly you were working on the front line at times. What was the impact on patients, and indeed staff, of not having a visitor when you broke an arm, had an appendix out, whatever the position may be? What was it like for them?

Dame May: Awful. It was – particularly with end-of-life care. And whilst the visiting restrictions were done to reduce the footfall, to reduce transmission and to support the balances of staff safety, I can understand if I had a loved one in hospital at that time … like I did actually.

Lead 3: Different topic, please.

Lady Hallett: Just before you move on, what about those who needed extra support? So, for example, I think we heard about people who are disabled or I think on – we heard from a gentleman whose daughter was Down’s Syndrome. What about people who needed the extra support? It must have been dreadful for them, even worse.

Dame May: Yes. Although I do believe the guidance was there that people with a learning disability to have somebody to support them would have been there and, in practical terms, the vast majority of times that would have happened.

But these were scary times for staff, and for patients, and for carers. If we’d had testing at the time, we could have tested more easily and allowed more people in. Difficult decisions, my Lady.

Ms Carey: Another difficult area, if I may: DNACPRs, do not attempt cardiopulmonary resuscitation. Did you become aware of any instances of the inappropriate use of DNACPRs?

Dame May: Would you direct me to my –

Lead 3: Yes, I think you deal with it at –

Dame May: I’ve got it.

Lead 3: – paragraph 364, Dame Ruth.

Dame May: Sorry, I apologise. Yes, I did become aware, early in 2020. It was raised with me directly actually at Number 10. I think it was my first Number 10 experience, on 3 April.

DNACPR is a very sensitive area, a very important area, an area that is part of end-of-life care planning. It should be done sensitively, it should be done with the patient and with family, if possible. I’ve been part – as a nurse, in the past, been part of those conversations. But to blanket DNACPRs was wrong.

Lead 3: Yes. You I think in your statement say that in April 2020 you co-signed a letter, along with NHS England’s National Medical Director, to reiterate that blanket DNACPRs should not be used, and I think you say that the issue was raised again with you by the Queen’s Nursing Institute in September 2020.

I suppose really the question is: if you told everyone in April 2020 to not do it, can you help as to why in September 2020 you’re still hearing reports of blanket or inappropriate use of DNACPRs?

Dame May: So I’m really grateful the QNI raised this directly with me. As I understand it, the survey was done in May and June 2020, so still after the guidance – the letter had been written.

It was raised, I think she said, I think – Crystal – it was the 16 out of the 163, so it’s still there.

When I questioned, went back to the QNI, because of the way the survey was done, I wasn’t able to find out where – which of the care homes it was there. But there was a difficulty still in getting the information out.

Lead 3: So forgetting that, putting the location, I should say, to one side, there still seems to be an issue, notwithstanding the efforts you made in the April 2020 letter, and in March 2021, is this right, you were among senior clinicians who signed another letter reiterating the NHS England position that it was unacceptable for people to have a DNACPR on their record just because they had a learning disability, autism or both.

What prompted that letter in March 2021?

Dame May: Because there were still further reports coming through but, between all of these, the National Clinical Director for end-of-life care, working in the medical division, was working and taking all of this into the work on advanced care planning. This is something that should not happen.

Lady Hallett: Also I’ve heard on my travels, there are a number of aspects to their use, the blanket use you talked about, people with a disability, without consultation of the patient or their family, but also it wasn’t just been used, as I’ve been told – I’ve yet to hear much evidence on it – it wasn’t just used for do not resuscitate, it was used for do not treat. That’s totally wrong, isn’t it?

Dame May: It is completely wrong. It’s a fundamental principle of the NHS and one that I hold dear as a nurse – well, former nurse now – to care for and treat people on an equal basis. So I fundamentally disagree with blanket DNACPR and the same with treatment, my Lady.

Ms Carey: Can you help as to why you think people merged a DNACPR notice, which is very specific, with escalation of care and end-of-life care decisions? Do you know why they got the two confused or elided them?

Dame May: Good or best practice, excellence in advanced care planning for end of life does include a conversation about DNACPR. If I was in a situation that I was facing a terminal illness, I’d want to have the conversation, and I’d expect people to have the conversation with me but I wouldn’t want it as a blanket decision.

Lead 3: No.

Different topic, if I may, and I have to just deal with a number of discrete issues now, so forgive me if I’m jumping around.

Earlier this morning you made reference to risk assessments for black, Asian and minority ethnic workers, and it’s at paragraph 192 in your statement. I think you mentioned that you were responsible for increasing the pace of implementation. I just want to go over that so that we’re clear what the problem was and what you did to try and solve it.

Just help us, please, I think you were aware of the disproportionate impact of Covid on black, Asian and minority ethnic staff, and I think there was concerns, was there, about – or there was work being done, I should say, around risk assessments for that particular group of people.

What work was being done, firstly: was it just risk assessments?

Dame May: So this was led – a piece of work led by the chief people officer team but as, of course, a professional and executive, fellow executive, I inputted into it and I had an opinion, because, of course, the BME’s strategic advisory group had raised it with me and I was in regular contact with them.

The risk assessment was key. The risk assessment is a conversation about a person’s risk to working in a frontline Covid environment and, without the risk assessment, action couldn’t get taken, which is why I was very keen, probably forthright, in wanting it to be brought forward, so it was achieved sooner because, without the assessment, the action would be delayed.

Lead 3: So was it, in short, that the plan for implementing the risk assessment was going to be within four weeks and, as a result of your efforts, that came down to two weeks to roll this out; is that where we get to?

Dame May: Yes. I proposed that it would be two weeks. I cannot recall whether the two weeks was achieved or not.

Lead 3: Right.

Dame May: I’m sorry.

Lead 3: Do you know why it was that a four-week period had originally been suggested?

Dame May: Because it’s a huge task, and I’m not criticising any – my colleagues at all because it’s a huge task, it’s one that we would be requiring a lot of energy and effort of trust leaders.

Lead 3: Do I take it, though, that you felt that the four-week period was too long?

Dame May: Yeah, I wanted it sooner because, without the assessment, the action couldn’t take.

Lead 3: Do you know whether the effects of those risk assessments were monitored and reviewed to make sure that it was happening and it was helping BAME nurses and midwives?

Dame May: This wasn’t just for nurses and midwives, of course. Yes, the CPO team would have been monitoring this, the implementation and the impact. I also know from my own feedback, though, that people were being assessed.

Lead 3: Different topic. It’s my fault, I touched on the issue of Long Covid earlier this morning but I didn’t, in fact, ask you when it was you, as CNO, became aware of the effect of Long Covid on healthcare workers. I don’t mean a precise date but can you pick a point in the pandemic where it came to your attention?

Dame May: I’d have to go back to my notes to give you a more accurate picture but I’m very grateful to Dr Elaine Maxwell who brought forward the concerns around Long Covid. I’m so sorry, I can’t recall when that was. I don’t want to give you a false date.

Lead 3: No. Just before we conclude, please, Dame Ruth, can I ask you some questions really about the health and wellbeing of the nurses and midwives that you led, and can I ask you, please, to turn to paragraph 182 in your witness statement. I think you speak there, in particular, of surveys conducted on critical care staff and that work was being led by Professor Kevin Fong, and the output of those surveys was shared with you.

Could we show on screen, please, INQ000421181, it’s behind your tab 10 if you want to look at it, but it might just be easier to use the screen. Was this the note that he provided to you?

Dame May: Yes, it was. It’s a note that was dated the 10th, as I recall, but I received it on 30 July 2020.

Lead 3: Right. We can see there just the summary for these purposes, it assesses the impact of wellbeing and psychological health on the frontline ICU and anaesthetist workforce, there was pilot survey across five hospitals, more than 700 respondents and this:

“There is evidence of significant psychological harm to frontline NHS staff following the first [Covid] surge with high rates of post-traumatic stress amongst frontline professionals.”

When you received Professor Fong’s summary here, what steps if any did you take to try and establish (a) whether it was right, and (b) try and ameliorate the harm that was caused?

Dame May: So I was raising back in May 2020, before I received Kevin’s report, the need for something of a wellbeing service specific for nurses. Obviously, the wellbeing work was very good and developed very quickly and was accessed widely but I was wanting something more for nurses. So I’d started the – started asking my head of nursing to develop the Professional Nurse Advocate programme. But when I had Kevin’s briefing, I met with Kevin virtually but I met with Kevin several times. As more data came out, I met with Kevin.

I believed his data, I took his data, and I then – I wanted to make sure that we did everything possible –

Lead 3: Pause there because I’m going to ask you about the programme in a moment, but is this the position: that at the end of July 2020, I think you attended a psychological harm roundtable and reported to people at that roundtable that four staff nurses had died by suicide, with one further nurse in ICU and a member of staff who had made an attempt to take their life?

Dame May: Yes.

Lead 3: Now, against Professor Fong’s work, the reports you made at that roundtable, tell us please about the Professional Nurse Advocate programme, what was it meant to do and what did it actually achieve?

Dame May: So the Professional Nurse Advocate programme was a programme of restorative clinical supervision. It came about by my experience, what I was hearing, and my head of mental health nursing, mental health nurse by background, saying, “We’re going to need to provide some more support for, particularly, critical care nurses”. So we developed a programme and it was a programme that supported nurses in their workplace.

Lead 3: Give us an example, what did it actually do?

Dame May: Have a conversation, check in with people, make sure they were okay, debrief. It was there as a support. It was very successful, the feedback from it was very successful and, of course, then we needed to roll it out, and I think that’s what my comments were on that roundtable.

It wasn’t just for critical care nurses we needed to do this, it was for those that needed to go into critical care and, of course, what we realised was there are lots of nurses elsewhere that wanted this, and so it’s been more rolled out, I put in more money into it from my budget, and we developed this – you know, Kevin was involved with the development of this and saw it in reality but it wasn’t the only thing we did, of course. We ended up having practitioner health as well opened up for nurses, which was really important.

Lead 3: Can I ask about you, please: is it right that, as part of your role as Chief Nursing Officer, you were the victim of abuse meted out to you online?

Dame May: Yes.

Lead 3: Can you just give us a couple of examples of kind of things that were said to you, or summarise it in whatever way you can, Dame Ruth.

Dame May: Yes. The one thing I have learnt throughout the whole of this is the importance of acting with integrity, and sometimes that comes at a cost, and sometimes you have to make decisions or be involved in decisions that mean that in social media, in particular, you are vilified or by some other senior people you are vilified. I wasn’t the only one but it was pretty horrible.

Lead 3: The future, if I may. If you were to try and summarise what worked well for the nursing and midwifery profession, what would you say?

Dame May: The workforce expansion worked well. The students that came, all 23,000 of them, in wave 1 to support us. The international nurse – educated nurses that throughout the pandemic joining the temporary register, joining the substantive register, worked well. Delivering the 50,000 extra nurses early and overachieving worked well, very well.

Lead 3: What did not go well, from a nursing and midwife perspective?

Dame May: A number of areas. So we went into the pandemic with vacancies, nearly 40,000 vacancies, we could have had 5,000 less.

Lead 3: Yes.

Dame May: The maternity visiting guidance I genuinely believe could have been more specific earlier, and that would

have been better for women, better for their partners

and better for the staff. And if we’d only had testing

in the early days. If I think about the nosocomial

transmissions, if only we had testing, because we didn’t

have testing even for day three testing until

20 November. So it wasn’t just we didn’t have testing

to begin with, we didn’t have testing for a main part,

you know, a big part of the early pandemic.

Lead 3: If you could make a recommendation or two to her Ladyship to consider, what would be your top picks, if I may put it colloquially?

Dame May: Ensure we have the workforce supply and everything we can do to either bring back the full educational package or write-off of debt, but the domestic supply of future nurses and midwives in this country is key to a future pandemic.

Second, my Lady, it would be that we are able to have testing because not only would visitors have been back earlier, staff would have been safer but patients would have been safer too.

Ms Carey: My Lady, they are all my questions. There may be a number that you wish to ask.

Questions From the Chair

Lady Hallett: No, there was just one other one I wanted to ask.

You’ve mentioned just then about things that didn’t go well, and you talked about visiting guidance with maternity care. Presumably, you would add to that visiting guidance when it came to people who required carers? You remember I asked you about people who had difficulties and relied on a family member for support. If that guidance that you say should have been followed wasn’t being followed, presumably you would say that that too is something that ought to be …

Dame May: Yes. I said the maternity because that was extremely difficult for lots of women but it included people with a disability of whatever disability too, I agree with you.

Lady Hallett: Thank you very much indeed, Dame Ruth. I can’t believe that people could be so stupid and wicked as to subject you to the kind of personal abuse that they did. Just ignore them. I’m afraid it looks like it is a fact of life, and it is a dreadful fact of life. So I’m sure we’re all genuinely sorry that that happened to you. I know it can’t have been easy giving evidence today, reliving not only your own experience but the experience of your colleagues, so thank you very much indeed for your help.

The Witness: Thank you.

(The witness withdrew)

Lady Hallett: Right, I’m asked to break now for lunch and

come back at 1.40.

Ms Carey: Thank you, my Lady.

(12.40 pm)

(The short adjournment)

(1.40 pm)

Lady Hallett: Ms Carey.

Ms Carey: May Professor Jean White be sworn, please.

Professor Jean White

PROFESSOR JEAN WHITE (sworn).

Questions From Lead Counsel to the Inquiry for Module 3

Lady Hallett: I hope we haven’t kept you waiting too long. I appreciate you were probably here this morning. I’m so sorry.

The Witness: It’s okay.

Ms Carey: Professor, your full name, please.

Professor Jean White: Jean Christine White.

Lead 3: You were the Chief Nursing Officer in Wales, I think, from October 2010 to retirement on 6 April 2021?

Professor Jean White: That’s correct.

Lead 3: Your statement is at INQ000480133. I hope you have it in front of you.

Professor Jean White: Yes.

Lead 3: Just to explain, the statement was, in fact, written by you and indeed your successor CNOs. Obviously I’ll be asking mainly about your role but it means we will have to cover a number of pages as obviously some of the statement deals with them.

Your professional background, please, could you just give us a summary?

Professor Jean White: So I’m a registered general nurse, a registered nurse teacher, I have postgraduate qualifications up to PhD level.

Lead 3: When did you become a nurse, if it’s not too rude?

Professor Jean White: I was born and brought up on the Gower Peninsula and I trained at Swansea University – well, Swansea Hospital, as it was then.

Lead 3: You know that we have just heard this morning from the Chief Nursing Officer in England during the relevant period. Can you just help us, in relation to the CNO Wales role, is there any substantial difference in functions you had that would differ from those in England?

Professor Jean White: So the CNO role in Wales is a substantive civil service role, whereas it’s an NHS role in England, I think that’s the largest difference. So my role was to give advice to Welsh Government ministers and support policy delivery.

Lead 3: I think you are the head of the nursing and midwifery professions in Wales with about 40,000 practitioners, or thereabouts, as at the relevant time.

Professor Jean White: That’s correct.

Lead 3: I think you are responsible for the performance of nurse directors in each of the health boards and trusts in Wales?

Professor Jean White: That’s correct.

Lead 3: I think you say in your statement, if I may take you to it at paragraph 62 onwards, you said you didn’t have a specific role in respect of public health emergencies?

Professor Jean White: That’s correct.

Lead 3: Do you think that the Chief Nursing Officer should be involved in planning for public health emergencies?

Professor Jean White: From my experience in this current pandemic, I would say yes, particularly – not for infection management processes but more around the workforce implications, some of the consequentials really about how nursing and midwifery practice is affected during a pandemic.

Lead 3: Have you raised with anyone more senior than you the fact that you think the CNO would have a vital role to play?

Professor Jean White: No, I didn’t before I retired but I can see in the statement that the current CNO is of a shared view – that’s Sue Tranka – and I would expect her to be part of the post-Covid preparation for the next pandemic.

Lead 3: Your particular role during the pandemic, are you able to give us an overview of how that role and your responsibilities changed during the relevant period?

Professor Jean White: So some things were built on the pre-pandemic period. So, for example, I had to performance manage and support the executive nurse directors, so I did more of that, and they were sort of key partners in the collective leadership we had to deliver services in Wales. But there were particular new responsibilities that came. For example, I jointly chaired the Nosocomial Transmission Group with the Deputy CMO, which I’m sure you’ll come on to in a little while, and there are things to do with changing the way that the nurse education, midwifery education standards were changed by the regulator. So all of the CNOs across the UK were involved in that. So that’s an unusual thing for us to do. We didn’t normally get that close to changes of the regulator’s work.

Lead 3: I think you were also a member of the NHS planning and response cell in Wales –

Professor Jean White: Yes.

Lead 3: – which was established towards the end of February of 2020. In a nutshell, what did the planning and response cell do?

Professor Jean White: So this was chaired by the director of planning, so I was a member of it, rather than the leader of it, and that cell brought together folk from the NHS services to work out how we could plan and deliver services during the pandemic, the sorts of things that would affect how the NHS functioned. So we were planning for closures or re-opening. Anything to do with the operational delivery of services in Wales was worked out there and then advised on, if you like.

Lead 3: Can I just ask about your role in the pandemic. We heard from Dame Ruth that she was able to take a number of visits and did ward rounds. Did you perform a similar function during the pandemic?

Professor Jean White: Unfortunately, I wasn’t able to go out and meet people face to face, I have rheumatoid arthritis and, therefore, I have immunosuppressant therapy, which makes me clinically vulnerable, not a shielded person, but it did require me to work remotely and that was enabled, fortunately we had good IT, so I was able to talk to the people I needed to talk to, and was always accessible. But I couldn’t physically go and see for myself, which I think is a great shame.

I would have liked to have actually talked to people about what it was like to be there and do the role under those extreme circumstances. Obviously, you’d have to be careful with that because you don’t want to be one of the agents carrying disease from place to place, so I’m not suggesting I would have done a round-Wales tour, if I’d been able to but I certainly would like to have had more of a chance to talk to people face-to-face, which was a shame, but there you are.

Lead 3: How was the frontline impact on nurses and midwives then conveyed to you, given that you couldn’t, for the reasons you’ve set out, go to wards and hospitals?

Professor Jean White: So clinical networks pre-dated the pandemic, as well as relationships with the trade union senior officials, so I used the existing frameworks, we have clinical groups on various things, and I had close working relationships, as I said previously, with the executive nurse directors, and I relied on them to tell me what it was like.

Occasionally, I would have correspondence between folk that would also tell me what was going on, if they had a particular issue, then I would be able to respond to it, and there were members of nurses – nursing and midwifery workforce, on the various cells that I sat on, so whether it was the planning cell or the Nosocomial Transmission Group, there were also representatives on it. So I had lots of contact with people, it just wasn’t seen for myself and feeling what it was like on the ground.

I knew from those conversations that it was very scary and, as a clinically vulnerable person, I have to say that really resonated with me about fear. At the beginning of the pandemic, without a vaccine, the testing was limited, not knowing really what was going to happen to folk, I really felt for everybody affected because I felt it myself and it restricted my life a lot because of it, like a lot of other people.

Lead 3: Can you give us an overview of what was the state of the nursing and midwifery profession in Wales pre-pandemic in terms of vacancies?

Professor Jean White: So, obviously, vacancies change almost every day because people leave and they join, and so on. We weren’t in the same position as England, we didn’t have the volume of vacancies but I’m not suggesting that it was 100%. So there were vacancies in various bits of the health service in Wales, and we had lots of activity to continue to both recruit and retain staff. It’s – the retention often is the issue, rather than the amount of people you’re training.

So, for example, ours was different from the rest of – from England for example. We required – if anybody had a student bursary package – I think you heard about bursaries earlier. If they received that support from Welsh Government, they were then required to work in NHS Wales for two years on qualifying and, if they chose not to, they had to pay back the money that we had given them. So it was a kind of golden handcuffs approach to keep the staff we had trained.

Lady Hallett: You speak, as I do, very quickly.

Professor Jean White: Oh, I’m sorry.

Lady Hallett: Don’t worry, it’s just to head off any complaints.

Professor Jean White: I’ll slow down.

Ms Carey: It’s my fault, let me slow down as well.

Can I call up on screen INQ000480133 at page 58, please. I want to check I’ve got the right reference for a start, but I want to ask you, Professor, about some of the efforts made to increase capacity within the nursing workforce.

We heard this morning there were four main ways that was aimed to achieve that, one of which was, of course, to invite people onto the temporary register, and I just want to look at it from the Welsh position, if I may, and, if that’s page 58, I hope it sets out the position as of 21 April 2020.

We looked at it this morning in relation to England but we should see, I hope, Wales. Yes, there. Registrants, there were 537. Just pause, please, it’s just at the top of our screen there, nurses, as at 21 April that joined the register.

Can you help with how many of those actually got to work on the front line?

Professor Jean White: So I don’t know accurate numbers but I certainly heard sufficient evidence that quite a number of folk didn’t end up practising in the way they wanted to, and that was multifactorial. Some people, when they’d done a risk assessment, realised that they were at higher risk and, therefore, we couldn’t deploy them to places that we would have wanted them to do. So a lot of folk would say “Well, I can’t travel to that place” or “I don’t feel confident to work in that place”, so there was a degree of choice amongst the folk that kindly and bravely put themselves forward to come back on the register. We tried our very best to place them. We developed a central system to help with that, that ran during 2020, which supplemented what the local recruitment arrangements were doing but it would be fair to say that not everybody that put themselves forward ended up working for us.

Lead 3: But the numbers of which you’re not clear?

Professor Jean White: I don’t know that number off the top of my head for that particular month in time, sorry.

Lead 3: Initially, the temporary register was opened up to those who had been practising in the last three years and then expanded to four to five. Were you ever made aware of any concerns about the length of time people had been off the register for, coming back and working and perhaps not having the skill set that they had as at the time they left the register?

Professor Jean White: Yeah, so anybody that had left the register and was brought back into employment were given an induction programme and were given sort of reminders, if you like, about how infusion technology worked, about moving and handling, those sort of basic things. For the staff that had been away a long time or had been working in roles that were not clinical – because some academics would come back to practice – they needed more support and were always supervised by colleagues, if they were not feeling competent; it was part of the safety arrangements.

I wasn’t told specifically about that age group, that length of time, if you like, being away from the register but all of them needed support, so I wouldn’t necessarily pick them out as needing or being a problem, shall we say.

Lead 3: Okay. Was that support provided though by fellow nurses and midwives?

Professor Jean White: It was supported by Health Education and Improvement Wales, which is a body we have in Wales, my Lady, who do things on behalf of the government to support the workforce. So that’s everything from commissioning education to doing things to develop the workforce and support the workforce.

So we asked them to work with the local health boards, who are the employers of the staff in Wales, to make sure that they had the stuff they needed. But most of this was delivered on the ground with respect of who was being brought forward to enable them to get into jobs as an onsite induction programme.

Lead 3: I suppose really what I was asking was, if you bring them back, they’re designed to help relieve the burden but is there not a burden in training them, making sure they’re up to speed, as it were, with the skill set? I was trying to work out who that burden fell on.

Professor Jean White: Well, it would be sort of the health boards, the employer body in the majority, supported by others. I suppose it’s a payoff, isn’t it? You’re going to end up with hundreds more staff but you’re going to have to invest a little bit to makes sure that they’re safe and competent to work. So it was unavoidable, I’m afraid.

Lead 3: Can I turn to nurse staffing levels, please?

Professor Jean White: Yes.

Lead 3: I think there is an Act in Wales, the Nurse Staffing Levels (Wales) Act 2016, which imposes a number of duties and obligations on the health boards and trusts. If I may, without a legal lecture, are you able to summarise what the Act says and its import?

Professor Jean White: So the Act brings in a range of duties. The first duty, that across the health system in Wales every organisation must have a duty to see they’ve got enough nursing staff to sensitively care for patients in all settings.

The second duty is to say that in specific service areas, that is adult and medical and adult surgical wards, they must use a defined methodology of working out how many staff they need to sensitively care for the patients in that ward.

During my time as CNO we extended the law so it now covers paediatric inpatients, but – it didn’t exist in my time there but it does exist now. The Act goes on then to say how often you need to report, and it has to be reported to Welsh Government every three years.

Lead 3: So if I understand it correctly, the Act doesn’t stipulate it must be one-to-one care in this but it tells the boards that they have to have a process, or a methodology to use your word, to be able to monitor their ratios?

Professor Jean White: That’s right.

Lead 3: Is that it in a nutshell?

Professor Jean White: In a nutshell. And this methodology is determined by government, so they can’t just make it up themselves.

Lead 3: Understood.

Can I ask you about the ratios in intensive care, please, and the changes that were brought about during the pandemic. If it helps you, Professor, I’m at paragraph 191 in your statement, and it may be we will look at some documents that were shown this morning. But do I take it that in non-pandemic times it should be one critical care nurse per one level 3, ie a patient that’s being – on a ventilator, for example? Is that the general rule?

Professor Jean White: Yes.

Lead 3: Ratios were stretched or diluted, were they not, in Wales as well during the pandemic?

Professor Jean White: Yes.

Lead 3: Who was responsible for making the decision to change the nurse to patient ratios?

Professor Jean White: So Wales required its service to double the capacity, so we needed to, if you like, double the capacity of critical care nurses that they were covering – the patients they were covering. So we have a critical care network that supports all of critical care services across Wales, and it was Welsh Government advice to them to consider the national guidance that had been shared with us about what might be sensible to do, and they then looked to see how that could be delivered within our NHS. So it was a process of a UK collaborative of expert groups coming together to say “This is what we think might work” and that then being given to us as Welsh policy leads to translate into what could happen within our NHS systems in Wales, given that we wanted to increase the number of critical care beds by 100%, so there’s, like, 200% of what we used to have.

Lead 3: So it wasn’t your responsibility as CNO. Who – was it the Health and Social Services Group that made the ultimate decision?

Professor Jean White: So I gave professional advice into the policy leads and then they worked with the network, so they followed the advice that came from the UK collaborative, if you like, but the critical care network were the ones that had on the ground experience about what would work in practice, and they then challenged back.

And the original guidance around dilution was quite extreme, to be honest, it was something like one up to six.

Lead 3: Yes.

Professor Jean White: And they were saying “Whoa, that is just – that’s much too far”, and the furthest we ever went was one to three and that was only in extraordinary circumstances, so we never went further than that. And that’s because the critical care network were giving a push-back, if you like, about what was being suggested by these professional advisory groups.

Lead 3: I think you said it was one to two or occasionally one to three?

Professor Jean White: That’s right.

Lead 3: Who was responsible for monitoring the ratios?

Professor Jean White: Well, the health boards all have responsibility of delivering the services to meet the needs of their patients. The critical care network across Wales, the trauma and critical care network, support them and helped have mutual arrangements. So I’m happy to say we never ran out of critical care bed in Wales. Anybody who needed level 3 care got level 3 care, there was never a moment when there wasn’t a bed available. But it may not necessarily be the local bed available, it may be in the next hospital, in the next health board area. And the network helped make the movements around because they knew what vacancies there were. So it was much a collaborative approach across the whole system rather than individual hospitals trying to cope.

Lead 3: So there may have been the bed available and staff available albeit at a diluted ratio. I wanted to ask you, though, do you think that that dilution impacted the level of care that patients got in Wales?

Professor Jean White: I would say it added to the stress on the staff, all of the staff, because it wasn’t just the nurses obviously, we had more patients, therefore the medical staff and so on were also impacted. Like other parts of the UK, we developed supplementary teams that would support them. So we’d have turning teams, for example, that had –

Lead 3: To literally turn the patient?

Professor Jean White: Turn patients for this – an approach called proning. It was found that those who were very ill, they were – they did well if they were also put face down, and that takes about six people to do that.

So we recognised that the critical care nurses would be under tremendous pressure so we tried to bring in things that would support that. But to be honest, I suppose if you’re looking after twice the number of patients it’s going to be difficult.

Lead 3: Yes. I follow bringing in someone who can physically help turn the patient or prone them. What about actual support for them, though, dealing with the stresses now dealing with two critical patients or three critical patients day in, day out? Did you, as CNO, do anything to try to help them in a sort of more pastoral context?

Professor Jean White: So I met with the executive nurse directors from about the middle of March onwards, I think it’s from about 18 March onwards, twice a week, and throughout the first wave certainly the welfare of staff and the concerns about critical care staff and the pressures they were under were part of our conversation.

Obviously the health boards have responsibility for the welfare of the staff as their employer. They have a duty of care. What we did was we supplemented that local support that was being offered by a national offer as well of resources, and that was facilitated by Health Education and Improvement Wales. Remember I said there was a body that helped with the workforce? And so we have had contracts to do with Samaritans – we extended a programme called Health for Health Professionals, which is an approach that was – pre-existed pandemic, which was for doctors only but we extended it for all staff, and students, during the pandemic, which is where if you rang up and said “I’m in need, I’m in distress”, you would be assessed by a doctor and then a programme would be worked out for you, some of it would be one-to-one guidance and so on. And then we had lots of programmes like SilverCloud, which is online mental health stuff. It wasn’t specifically for critical care, there was a doctor –

Lead 3: Can I pause you there, because I want to just look at one very specific issue in Wales, and I’m sorry to have interrupted you, Professor.

Professor Jean White: No, it’s fine –

Lead 3: But can I ask, please, that you look behind tab 9.

We call up on screen INQ000412539, and actually start at the back of that document, on page 0005.

Because clearly there was pressures at the beginning of the pandemic, but I want to ask you about an email chain that is from January 2021. And to put it in context Andrew Goodall, who I think was the chief executive at the time of the Health and Social Services Group?

Professor Jean White: Yes, that’s right.

Lead 3: He sent round to a number of people a newspaper article talking about the dilution in England, which then prompted a discussion about the position in Wales. Just for the context.

If we go to page 3, having skimmed through the article, I think he was asking you what was going on in Wales, and you say at the bottom:

“Is there anything I should be saying back to Andrew re: dilution of staff in our units. Can you give me a summary position.”

Then up to the email above, so here we are, 12 January 2021, and you are addressed:

“Sorry for the delay in replying on Monday for example, 11 of the 13 ICU units were on a ‘stretched nursing ratios 1:2 for level 3 patients’. Redeployed staff have been moved to critical care to help out these units. However, given the whole hospital strain and vast number of patients in critical care, redeployment hasn’t actually been 100% enough for all critical care patients/units in Wales. Uncertainty around the impact of this on the quality of care and ultimately to the outcomes …

“I raised staffing ratios in the critical care network meeting they were off the opinion particularly as in many units there are not redeployed staff to support stretched 1 [to] 2 … care … we should only further stretch this by exception …”

Professor Jean White: Yes.

Lead 3: So by January 2021, is it fair to say that “stretch” might be an understatement –

Professor Jean White: Yes.

Lead 3: – for the 11 of the 13 ICU units across the nation?

Professor Jean White: Yes, it was very tough. During the second wave, to a degree, I suppose it was worse than the first wave because a lot of staff were needed, because we were starting to re-open other bits of the hospitals, so there weren’t the availability of staff to redeploy. I think the network was very sensible in saying, look, we can’t have sort of 1:3, that would be too dangerous because there aren’t the supplementary staff to support them.

So that’s what this was all about because, at that time, we were having other guidance to say, “Yeah, yeah, you might still be able to do 1:3 but no further than that”. I think that’s what the UK guidance was kind of suggesting, and the network, as I said, with our sounding board about what was actually happening on the ground was saying that that wouldn’t be safe to do that, and so we listened to that.

Lead 3: A slightly different topic but still on ratios, I think in your statement at paragraph 257, there was a concern raised with you about ratios of registered nurses to patients in the field hospitals in Wales. Can you help, what were the ratios in the field hospitals and what was the concern?

Professor Jean White: So it wasn’t necessarily that I was worried about the number of nurses, it was more how the make-up of the teams were being constructed. So field hospitals in Wales were not intensive care provision, they were actually step-down provision. So we wanted to increase the flow of patients out of hospital. So these were people that were taking some time to recover before returning home or needed to have some more support before returning to a care home, for example.

So I discussed with the nurse directors, and this is what this document starts to talk about here, is how are we going to do this, what kinds of teams should we have, and the nurse directors were of an opinion, actually, we should have occupational health nurses, mental health nurses, physiotherapists, rather than it all be nurses, registered nurses and nursing staff, we needed to have a more multidisciplinary team. And so the nurse directors themselves shared their practice and, as the field hospitals started to come live, if you like, in sort of a phased approach across Wales, they learnt from earlier experience to work out what would be best.

Lead 3: Different topic, please –

Professor Jean White: Okay.

Lead 3: – looking at the Nosocomial Transmission Group.

Professor Jean White: Okay.

Lead 3: It starts in your statement at paragraph 316 but it was established, I think, on 19 May 2020, you jointly chaired it with the Deputy Chief Medical Officer in Wales. What was the purpose of the group, please?

Professor Jean White: So it had a number of functions. We were there as an advisory and oversight group to look at the evidence based guidance that the system needed about giving advice on everything from, you know, how far apart hospital beds should be to handling how the deceased person’s body should be managed. It was there to look at the education and skill set around IPC, and trying to support how the system was responding to hospital-acquired infection, which is what nosocomial transmission is about.

Later on, after a few months, we took on a particular role in oversight of outbreaks because we were finding that the health boards, some of them were struggling to get on top of outbreaks of the infection and so what we wanted to do is promote best practice and keep a closer eye on the system to help them deal with that, so we took on more of a role to do with outbreaks later on.

Lead 3: I think in your statement you give a number of examples of operational matters that the group became involved in but I would like to ask you about one, please.

Professor Jean White: Sure.

Lead 3: If you look in your statement at page 121, it’s in relation to the wearing of face masks in non-clinical settings, and can we just – we haven’t heard very much about non-clinical settings yet, but what are they in a nutshell?

Professor Jean White: So, if you like, it’s the backroom arrangements, so that would be your folk in offices, perhaps dealing with ordering kit, it could be, well, anything where you’re not actually looking after a patient, I suppose, would be the simplest way of doing it.

Lead 3: Okay. I think the position is that there was UK and IPC guidance issued in due course by England, I think it may have been Scotland as well –

Professor Jean White: That’s right.

Lead 3: – that said that face masks or face coverings should be worn in both clinical and non-clinical areas, and when that came out in England and Scotland, Wales decided not to make face masks mandatory in non-clinical settings; have I got that right?

Professor Jean White: That’s right.

Lead 3: Why did Wales take the decision not to make face masks mandatory?

Professor Jean White: So I was not the policy lead on this, I did take sort of the steer from the CMO, who had given advice to government on this issue. So we had found that the evidence around face coverings and face masks, in a sort of a community setting, rather than a clinical – I’m not talking about the kind of delivery of care settings – was less robust than it was for clinical settings and, particularly, concern had been expressed in the summer time about how people in the public were actually using face masks.

It increased things like touching your face and not – it caused people to perhaps not follow some of the other guidance, it took more risky behaviours, and so on and so forth, there is a long list that I have listed out in my statement.

So the CMO was of the view that the evidence wasn’t strong enough to require that, so we had taken the policy position in Wales that we will do it where the evidence took us, which is in clinical areas.

Now, I think in his evidence he’s gone on to say how that then –

Lead 3: Well, we’ll hear from Mr Atherton in due course but can I just ask you this: do you think though that, by not making face masks mandatory in those areas, there was a lack of protection for those workers who were in the non-clinical areas?

Professor Jean White: I think hindsight’s important here because, at the time, we felt that if you kept distance and had good ventilation, and had other sort of environmental factors in play, the risk was probably low. That’s what the evidence was telling us at the time.

Lead 3: Pausing you there, Professor, is a non-clinical area likely to be well ventilated in most of the Welsh hospital estate?

Professor Jean White: Some of it probably not so much, I couldn’t hand on heart say everybody was able to open a window, and so on and so forth. Some of our estate is very old in Wales.

Lead 3: Do you not think that the benefit of mask-wearing outweighed the asserted downsides of people touching their mouths or touching the mask?

Professor Jean White: At the time we didn’t feel that they did. I think, as time went on – and I’m looking in hindsight now, not from what I felt at that moment – understanding about how the disease was spread would probably give different advice now, if we were to go back in time. But, at that moment in time, the evidence wasn’t very strong about wearing face coverings, unless you were in a high-risk area, which is direct patient care in closed confined areas. In well ventilated areas with other good IPC practices, the risk was less.

Lead 3: In due course though did Wales make face mask wearing mandatory in non-clinical areas?

Professor Jean White: They did.

Lead 3: Was it about three months or so after –

Professor Jean White: Yeah, so it was the autumn, I can’t remember exactly the date.

Lead 3: Why did it change its stance, come the autumn?

Professor Jean White: I think partly it was leading to confusion with the public because there were different messaging across the four parts of the UK, and our intelligence was growing about what was needed to prevent infection. I think that was it. But, as I say, I wasn’t the policy lead for this, I was in more of a supportive role and the Chief Medical Officer was, if you like, the lead adviser on this. I don’t have personal expertise in infection prevention and control measures, I’m not a scientist by background. So I needed to follow the advice I was being given rather than saying “No, I think I’ll go UDI here and make my own device.”

Lead 3: I think in due course, certainly there have been some studies to suggest that infection rates went down when there was universal mask wearing. Although it won’t be a decision taken by you in due course, do you think that had there been universal mask wearing throughout the hospital estate, that would have helped prevent infections of patients and, indeed, healthcare workers?

Professor Jean White: I’m sure it would have helped but also the other practices were very important. Face mask wearing on its own would not stop the spread of disease, if people were not hand washing, were not keeping distance and doing all the other things that we were advising. So I would say it’s part of a package. It’s not a panacea of stopping all infections but it certainly has a part to play.

Lead 3: One of the other things that the Nosocomial Transmission Group did was set up what’s called a sort of lessons learnt group. Was it the early learning platform?

Professor Jean White: Yes, we called it Corsil(?), which sounds like some sort of chemical you would use, but it was the Covid – early learning is what it was, it was a platform.

Lead 3: What was the kind of things that were being reported via the early learning platform?

Professor Jean White: So this was set-up so that anybody in any of the health boards across Wales and the trusts as well could say, “Look, I’ve done this thing, whatever it was, large or small, and it either worked or didn’t work and perhaps you shouldn’t do it”. So it could be anything from cohorting patients who have the disease when you’ve got lots of open plan areas, to anything, it could have been anything at all and, throughout the pandemic, that was available to people to do that.

Lead 3: Do you think it was a useful reporting platform?

Professor Jean White: I think it was helpful. It had a one particular limitation in that it was on a separate IT system to – we have lots of different IT systems, my Lady, across the service.

Lady Hallett: I’ve got that T-shirt from this Inquiry!

Professor Jean White: So you know exactly what I mean.

So it meant that, rather than it automatically sucking things and easily transferring information, you had to go out of your system, into another system and then report it I think it put off a few people. So I think it was useful, I certainly would have it again but probably on a system that is a little bit more joined up.

Ms Carey: I just want to understand the genesis of a document that I’m going to ask to be called up on screen, which is INQ000473936 and we can go to 0001. I want to understand how this document was reported. It’s a Covid outbreak reporting, is this linked in any way to the early learning –

Professor Jean White: No.

Lead 3: That was my error, then, thank you. Can we nonetheless look at this document, though, please?

Professor Jean White: Yeah, yeah.

Lead 3: This is an example, is it not, of weekly reports that were submitted showing outbreaks and changes and the location of the outbreaks within Wales; is that right?

Professor Jean White: That’s right.

Lead 3: Here’s one for 11 December 2020. Who is collating this information?

Professor Jean White: So a little bit of context, if that would be all right.

Lead 3: Yes, please.

Professor Jean White: So outbreak management was previously managed by Public Health Wales, pre-pandemic, but we were finding that the data had a delay in it. So you would have a report of the outbreak that was last month. Well, when you’re managing outbreaks you needed it to know every day.

So where the Nosocomial Transmission Group developed a form that was required to be filled in by the operational manager in each hospital on a daily basis and sent in to the Public Health Wales and Welsh Government mailbox, and so this report is the data that was submitted by each of the health boards about what was happening, so that’s the number of patients involved in any outbreak, the number of staff affected, and any patients that had died within 28 days of the outbreak. So it’s showing us a direct impact on the patients of those outbreaks.

So we needed to know exactly where they were happening, how quickly they were coming under control, and what the health boards were – actions they were taking, so they were also telling us what they were doing.

Lead 3: Pause there, let’s look at one example. Can we turn to page 5 in this document, please, and I think a submission, by the Hywel Dda health board.

Professor Jean White: Yeah.

Lead 3: If we see what that health board submitted that day, I presume all of those there are different hospitals –

Professor Jean White: Yes.

Lead 3: – with the names of them, and you can see, across the four sites, there were two wards closed in Glangwili; the position there in Prince Phillip Hospital, they’ve had to transfer patients?

Professor Jean White: Yes.

Lead 3: We have a ward closed in Withybush and a slightly different position in the community hospital.

Was this being done on a daily basis?

Professor Jean White: So the data was being reported to us on a daily basis, and we had sort of a weekly position, if you like, to see what was going on. But it was useful for both us, as the government, and Public Health Wales to look at what’s happening across the whole system, but it was also useful to the managers in the hospital because they have – the data was shared back to them, if you like, they could see what was happening.

It also meant that if, say, Hywel Dda was struggling in Prince Phillip Hospital, yet another hospital was doing very well and very quickly getting under control we were able to say to them “You need to talk to that manager to see what they’re doing that you’re not doing to learn from this”.

So this was a really transparent way for us to see what was going on and a really good way to help the system learn because people were obviously catching the disease in hospital when they were already ill and there because of another reason.

Lead 3: I wanted to ask about that actually, because I think it’s right that there was guidance issued that said that there should be testing for all patients admitted into hospitals in Wales issued on 3 June 2020?

Professor Jean White: That’s right.

Lead 3: I’m in paragraph 324, if it helps you, Professor.

Professor Jean White: Yep.

Lead 3: So the guidance came in on 3 June for testing of all patients but was brought in in Wales on 15 July. Can I ask you, why was there a gap between the guidance being issued at the beginning of June and it not coming in until six weeks later?

Professor Jean White: I can – I think we gave them a run-in time to actually get the systems in place in order to do that consistently. Now, obviously, once the guidance is out there, there will be early adopters but some folk will take a little bit longer to get systems in place. So often we would give them a couple of weeks’ time lag to get to a position where everybody was doing it. It’s a big system.

Lead 3: We heard this morning from Dame Ruth that she thought that the roll-out of testing would have a big impact on the healthcare system’s response and, indeed, in particular on nurses and midwives and visiting restrictions, for example.

Professor Jean White: Yes.

Lead 3: Do you agree with her as to the importance of testing in the event of a pandemic?

Professor Jean White: Absolutely. If you want to try to enable the system to keep delivering other care, you need to separate out those folk who have got an infectious disease from those folk who don’t, so that you’re able to have, I hate to say, sort of a clean system, but those not affected. I don’t know what language I should use here which doesn’t sound inappropriate, but you understand what I’m trying to say.

Lead 3: Yes.

Professor Jean White: If you want to run an orthopaedic service, you want to know those folk that have got and who hasn’t got it because the last thing you want to do is bring somebody into the system that’s then going to contaminate the system that they’ve gone into. So testing was very important, which is why it’s a requirement.

Lead 3: Am I right in thinking that testing of healthcare workers in Wales was not fully rolled out until March 2021; is that right?

Professor Jean White: I believe so, I can’t remember exactly the dates.

Lead 3: Do you think it should have been rolled out sooner for healthcare workers?

Professor Jean White: I think that the issue was more around asymptomatic testing and symptomatic testing. So we did have testing availability and staff could test if they had any symptoms, so there was a lot of issue about when they should return, because obviously it’s – shorten the number of staff you had if they were off sick for a long period of time, so you needed to know when they were fit and safe to return to work. I think the issue is more around asymptomatic testing because at the early days we didn’t know that the disease could be spread by those who weren’t showing any symptoms and therefore you didn’t know that they had it in order to spread it. Testing was not my policy area so I may not be the best person to fully explain all of this –

Lady Hallett: But on that point, sorry to interrupt.

Professor Jean White: Not at all.

Lady Hallett: I think I heard that asymptomatic transmission was recognised by the summer of 2020, certainly by the autumn, so it still leaves quite a long gap until Wales introduced testing for all healthcare workers, symptomatic and asymptomatic?

Professor Jean White: Yes, I think that’s about right.

Lead 3: Is it a capacity issue?

Professor Jean White: As I say, I’m not really the best person to ask about this, because I wasn’t involved at all in anything to do with the testing, I’m sorry.

Lead 3: All right, don’t worry, we’ll seek to answer it through someone else.

Professor Jean White: Okay.

Lead 3: IPC guidance, please. Can we be clear at the outset, what is your role in relation to the approval or otherwise of IPC guidance?

Professor Jean White: So the IPC guidance, we had an agreement to work collaboratively across the UK and there was a UK IPC cell. Public Health Wales contained our experts and so we sent our representatives of experts to the UK cell. Once the cell had made advice, it then was brought back to Wales and was presented to the Nosocomial Transmission Group, because that seemed a sensible place for it to go, but it did feature in other conversation, but it was mostly at that. And then –

Lead 3: So you saw it as part of your role on the NTG?

Professor Jean White: That’s right.

Lead 3: I’m sorry to interrupt you, but did you then comment on the guidance?

Professor Jean White: So the NTG looked at the guidance and looked to see whether or not there were things in it that didn’t fit or might be challenging for us or – a sense check I suppose it would be.

The people who were sent from Public Health Wales also sat on the NTG, so we were able to sort of say to them: does this sound about right? Were you able to say the Welsh position in the development? So it wasn’t like there was great separation out, we were all one and the same, if you like.

So the UK guidance was given to us as a best practice guidance. The NTG then received it to work out what was best for the system. But I understand the UK cell were drawing scientific evidence from things like SAGE and NERVTAG, which we weren’t involved with at all.

Lead 3: Right. So in your statement, where you say the CNO played no role in providing advice or guidance as to the types of PPE or RPE that nursing or midwifery staff should use in the workplace, that is correct in terms of your CNO role but you had a role reviewing it as part of your role chairing the NTG; is that a fair way of summarising it?

Professor Jean White: Yes.

Lead 3: Can you recall now any examples of you in your NTG capacity saying to the cell “We don’t agree with that recommendation” or “That bit of guidance we’d like to re-word or amend”?

Professor Jean White: No, I do recall us talking about face coverings in non-clinical areas, which we referred to earlier, but on the whole, because we’d had experts from Wales help design it, it mostly fitted our system, so there was very little “Oh no, we don’t agree with that” kind of conversation.

Lead 3: I think you were made aware, though, in your CNO role, of issues in relation to FFP3 masks. If it helps you, Professor, it’s at paragraph 309 in your statement.

You say that there was:

“Issues regarding the fit and suitability of PPE … raised with [you] during … meetings of the Nurse Directors.”

You give an example there that on 3 April concerns were raised around FFP3 masks used in critical care that were not fully waterproof and staff were resorting to double masking. I assume that means wearing two FRSMs, does it?

Professor Jean White: Mm-hm.

Lead 3: How were those concerns – so they were coming to you from those directors, what, presumably from the front line to the nurse director and director to you?

Professor Jean White: That’s right. So we had a PPE cell which pulled together folk from procurement, who knew about the supply chains and what we had in stock, along with folk from service, which is about distribution and so on.

Lead 3: Right.

Professor Jean White: So my role here was really to make sure any issues I came aware of were reported to the cell for them to take action on. And that’s what I did. Whenever there was an issue raised about any PPE, whatever it was, or shortages or difficulties in accessing it, I made sure it was reported.

We had a lot of stock, often the issue was around distribution, so people on the frontline were not necessarily receiving what they wanted. We didn’t run out of stock, it’s just not necessarily – we had everything but not necessarily in the right place.

Lead 3: Of course. Let me ask you about that specific example there, though. There was a concern about the masks in critical care not being fully waterproof. What did you actually do when a concern like that – who did you tell? How was it resolved?

Professor Jean White: So I think in the text here I mention I talked to David Goulding, who was our health emergency planning officer, because he was part of the cell, but in other examples I would have gone to Dr Chris Jones, who was the deputy chief CMO, who was chairing that cell. If it was – depending on what it was that was the issue, I would report it to a lead policy officer in that cell.

If I felt it was a distribution thing that might be inside a hospital – because I think I gave an example further on in my statement about that – I would make sure I also told the nurse director, “I’ve heard from your staff there’s an issue, I think you should look to see if that ward or that team are actually getting access to the things that they actually need.”

So sometimes it would be back down the chain rather than into policy, so I was more of a conduit of information than a fixer of the problem.

Lead 3: I think you set out in your statement a number of other problems, for example straps perishing?

Professor Jean White: Yes.

Lead 3: You also dealt with an example on 19 May where you, in – one of the nurse directors noted that up to 50% of FFP3 masks were failing fit testing. I just wanted to be clear about that, do you mean that the fit, it didn’t work 50% of the time?

Professor Jean White: Yes. A lot of it was not suitable for the staff there so they couldn’t fit them tightly to the face, because you’ve got to have a good seal. So I would say, if we come on to recommendations, we need to think about having masks that fit different shapes of face. Different ethnic groups have different shapes of face. If you have a beard, it’s very difficult to have a good fit. So there’s lots of things around fit that probably need to be looked at in the type of stock we have.

Lead 3: Were you made aware of any specific issues regarding PPE fit for ethnic minority nursing staff in Wales?

Professor Jean White: That’s what I was referring to there, some of that was to do that with. If you have a different shaped face, it is a little difficult – more difficult –

Lead 3: Now, you mentioned to my Lady that in due course there might need to be a recommendation about broadening the types of mask that might fit different type faces, but if you’re made aware of a problem with PPE fit for ethnic minority staff in Wales, what steps did you take to try to address that, given you can’t just rustle up a new mask overnight?

Professor Jean White: No, again, I fed it into the PPE cell because they are the ones that were working with our NHS shared services. What we have in Wales is an arrangement where all the health boards fund one body to do things like procurement for them. It’s a way of saving money and being more efficient. So if it became – they became aware that they needed to have different kinds of equipment, that would be the place where the procurement would be dealt with. So that was the route back. And they sat on the PPE cell.

Lead 3: I’ll turn to visiting restrictions.

Professor Jean White: Okay.

Lead 3: We have heard that visiting was restricted unless there were a number of specific exceptions that applied, for example end of life or a woman in labour. Can I ask you this: did you have any role in developing the restriction on visiting guidance?

Professor Jean White: Yes. It was my – I was the lead adviser on that.

Lead 3: In developing that guidance or determining that you shouldn’t visit unless you’re in one of the exceptions, did you consult with any people like disabled groups or any of the groups that might be impacted by that decision before coming to your ultimate view?

Professor Jean White: So there were five versions of guidance. So if I take us at the very, very beginning, when the complete lockdown came. The nurse directors asked me to set out a policy position for Wales because they felt they needed to have one voice for Wales and the Welsh Government was able to do that for them, and I agreed with them what it is that they thought was suitable for the NHS. And so the very first iteration which was in the beginning of – middle of March – 20 March, I think it was – was very restrictive.

Over the iterations that followed that, it became far more nuanced and far more permissive as we heard more voices saying about the impact, and certainly issues around folk that may have dementia or other cognitive learning, about the importance of people who might need an interpreter. So there were lots of folk that might need to accompany a patient in any part of their hospital journey would need to be involved.

So yes, we listened, but in the very first I was responding from a request from the nurse directors in Wales to say “Please, Jean, will you just give us a statement about what we should do to lock down”. There was a tremendous amount of fear at that time caused by it and visiting, they were fearful for the staff, for bringing it in. I have to say visiting and the role I played in visiting is the thing that has stayed with me the most out of all my experiences during this, because I was acutely aware that stopping loved ones being together, stopping a father seeing the first blip of life in an antenatal scan, you don’t get that back again and, to this day, it’s the thing that I reflect on the most, I think, and with the heaviest of hearts, that I did it at the time and was able to hopefully listen and respond as more and more voices came to us about changing it.

But always it was a balance between what the staff felt they could manage with in the environments in which they were working, given the lack of vaccination, in the first three versions of the guidance, that’s – you know, we didn’t have vaccines until December, so all of 2020 this was done in a time where the staff were very fearful.

Did we get the balance right? I’m not sure we did –

Lead 3: Well, I was going to ask you that: is it a necessary evil or was the balance not struck; what do you think?

Professor Jean White: Well, as time went by, we got much better at giving guidance around taking a risk based approach and, as we started having lateral flow tests and point of care testing, so we knew a lot more about who was carrying disease, and having a vaccine that protected a lot more people, some of those risk-based approaches became easier to do. But in the first period of between March and December, when the vaccine came in, staff anxieties were through the roof about this.

Now, I always wrote into the guidance that we needed to be as enabling as possible, particularly at end of life. The last thing I ever wanted was somebody to pass away without their loved ones having contact, and that was even from the get go, when we’d locked everything down, I always said that that was something you should enable.

We got more and more permissive, if you like, in the guidance, but it was only ever guidance, it wasn’t a “you must under” – you know, it wasn’t legislation, it was guidance to service and they were allowed to depart from it.

Lead 3: Although there comes with that an inconsistency, depending on which board, which hospital, maybe even which ward?

Professor Jean White: Indeed, indeed.

Lead 3: All right. Can I ask you about, I think, a change that was made in Wales, where there was a relaxation in July 2020, whereas, providing the visitor did not have Covid and the visit was agreed in advance, then the visitor could come on to the ward but PPE may need to be worn, and there may still need to be social distancing. I appreciate that was an attempt to allow more people to visit, but –

Professor Jean White: Yeah.

Lead 3: – do you think that was an onerous ask to make of the staff who had to manage the visitors, make sure they were Covid negative, provide them with PPE, make sure they were socially distancing, agree this all across a ward; what do you think about those considerations?

Professor Jean White: It’s a fair point. However, I go back to saying there was still a tremendous amount of anxiety about this because we didn’t have a routine testing of visitors sort of – and I should say a word about the lateral flow test. It isn’t a 100% accurate, there are lots of false positives, false negatives, so it wasn’t like it was a sure-fast way. If you did a swab that says you’re clear, you might still be carrying the infection and, when we didn’t have the vaccines, which was the case in the summer, staff were keen that, if folk were coming in, they wanted to be as safe as possible for everybody, the last thing you would want to do is either give it to the staff or to another patient or another relative visiting, so they did have to manage their environments to keep it safe for everybody.

Lead 3: Thinking about maternity services in particular, was it right that in Wales women in labour should be permitted a birthing partner from their household from 25 March 2020; was that the general rule?

Professor Jean White: Well, it was for them to have a birthing partner, yes, when they’re in active labour, and it stayed like that in the next three – further two iterations – there were the three iterations – that was the case.

Lead 3: So we heard from Dame Ruth this morning that, certainly, the guidance in England didn’t make a distinction between active and non-active labour. In Wales, was it only allowed in once in active labour?

Professor Jean White: That’s right.

Lead 3: Right.

Professor Jean White: The reason being, it’s to do with the geography because if you’re starting off early in labour you might be in a ward with many other people. When you’re in active labour, you’re taken into a room on your own. So it’s much easier to manage. So it was a practical physical thing at that – that kind of helped with that.

Lead 3: Were you aware of examples of women being examined vaginally to prove they were in active labour and therefore have the support of their partner?

Professor Jean White: That wasn’t told to me, and it sounds extraordinarily distressing if that was the case. Normally, there would be examinations, as normal, part of it to –

Lady Hallett: To check where you are.

Professor Jean White: Exactly. So I’m not sure if anybody would do it just to have their partner in. If they’re in active labour, they ought to have support, and we increased the type of people who can come with them. So if somebody needed extra support because of whatever issue, they may have a mental; health problem or a language problem, we also said that they may have an essential worker, as well as a birth partner, that came later on, because we listened to what people were saying to us.

Ms Carey: Just standing back and thinking about the visiting restrictions, would you make the same decision next time?

Professor Jean White: Well, fortunately, I don’t have to do this again because I’m retired. Should I be –

Lead 3: Were you in that position, would you make the same decision again?

Professor Jean White: Were I in that position, I think I would like us to be more permissive earlier on and find ways to do it, and I would say, in particular areas, neonatal services, I’ve reflected on this quite a lot, I think both parents should have always been allowed to be with their child. I certainly was affected by the Bliss report that described what the impact on was having not the two parents seen as a unit, if you like rather, than one parent in there and the other parent not there.

Neonatal care is very fraught and often the child may not survive. So it is a very difficult area, and I think, on reflection, I would have said they always should be as a pair.

And other areas, I think we should have been much more careful around giving support, so if somebody’s got dementia, it’s a very difficult situation and having someone they have some recognition of, so there’s lots of folk that I think we should have made more exceptions of earlier on. So yeah, I would have – wouldn’t have done exactly the same thing all over again. But, you know, hopefully next time there will be a vaccination sooner so that we could be more confident in doing that anyway.

Lead 3: Can I ask you, please, about DNACPRs. Were you made aware of any concerns that they were being issued inappropriately or there was blanket use of them in Wales?

Professor Jean White: So I had heard from various groups about concerns about having a blanket do not resuscitate – cardiopulmonary resuscitation. They came from the disability advisory group that advised into government. But I also was aware from Healthcare Inspectorate Wales, which is our inspectorate body, that they had come across one GP practice that had sent out a letter suggesting to their patients that perhaps you should all consider – not all patients but, you know, certain groups of patients – should consider signing this, which is completely inappropriate.

Every bit of guidance we’ve ever issued before the pandemic, during the pandemic, makes it very clear that these conversations should be individual, should be based on agreement with the patient and their loved ones and about what’s best for them in their care pathway.

Under no circumstances, and I think Ruth may have said this this morning – under no circumstances is a blanket approach ever, ever appropriate.

Lead 3: Can I ask you about an example, if that be the right word, behind your tab 15 and at INQ000300091_0009, please, which is a note of the executive director’s daily calls on 3 April. It’s probably going to come up on screen in a moment. There we are. I just want to ask you about the PPE box.

Professor Jean White: Right.

Lead 3: I know you’re not in this meeting, but there was:

“[a discussion] held on PPE and specifically on ventilators. The Deputy Minister has held discussions with Ty Hafan …”

Is that a hospice service?

Professor Jean White: It’s sheltered accommodation.

Lead 3: Sheltered accommodation, right. I’m so sorry if I pronounced it incorrectly.

Professor Jean White: That’s okay.

Lead 3: “… as their service users had received a letter from their GPs which said that if they caught the virus and were seriously ill they wouldn’t be resuscitated.”

Oh, you are in this, forgive me. You and your colleagues were working on the ethical framework?

Professor Jean White: Yes, there was a moral and ethical framework that Dr Heather Payne and I and others worked on and issued which sort of – it was to help people make the right kinds of clinical decisions in extraordinary circumstances, and it was certainly highlighted in that, but there were also subsequent letters that the CMO and I wrote out reminding people about not doing blanket do not resuscitate order –

Lead 3: Did you ever see the letter from this example?

Professor Jean White: I didn’t – not that example but, as I say, I heard from different sources, that wasn’t the only example I was told about. It came from a number of routes.

Lead 3: May I ask you about Long Covid –

Professor Jean White: Yes.

Lead 3: – please.

Was any data collected on the number of nurses and midwives that reported symptoms of Long Covid?

Professor Jean White: No, it wasn’t. As far as I can see, the health boards would have kept their own records about staff sickness, but there was no central reporting back to Welsh Government, then or – I don’t think even now that we know exactly how many staff have got Long Covid symptoms, and certainly not in the time I was the CNO.

Lead 3: Well, I was going to ask you, did it come to your attention during your tenure?

Professor Jean White: No. I was aware that some people were taking a longer time to recover from it, so Long Covid became a thing during my tenure, because Welsh Government started work on setting up a framework of how to support patients and members of the population, and that would include staff members who developed the symptoms of Long Covid.

Lead 3: Final two topics from me, please. I’d just like your assistance, please, Professor, on the impact on the nursing and midwifery profession in Wales, and it starts at your paragraph 287 if it helps you.

You’ve told us about some of the support that was provided and practical help for nurses and midwives. Can you, though, give us, if it’s possible, an overview of the impact on the profession in Wales?

Professor Jean White: I think it was an extraordinarily difficult time for anybody in frontline services – and for the people who were managing the services, because obviously I was seeing the senior leaders, they were having to make extraordinarily difficult decisions as well. I think it’s had a long-term effect on the health and wellbeing of many people. We’ve seen people leave the service as a consequence of their experience. And because of that we’ve had to continue offering a wide range of national support that has been described in my statement and my two successors, and I’ve touched on them before.

Health Education Improvement Wales has this very large reservoir of resources that are there for people. The sort of Health for Health Professionals programme is still there. There’s now a programme called Adferiad, which is a Welsh Government-funded service for staff with Long Covid. It has taken a much more of a holistic approach rather than a disease approach. This is about helping people’s mental health, mental wellbeing, getting physically active again. So it’s a much more rehabilitative model than a medical model.

But to be honest, the legacy of Covid is going to be quite long and I have – obviously I’m retired now, but I see the stories about people leaving the workforce, and certainly reports like the Royal College of Nursing reports –

Lead 3: I was just going to ask you about that, if I may, and if it helps you let me just summarise it. But I think you received a query from Vaughan Gething about a report of an RCN nursing survey in November 2020 which highlighted that 34% of staff, nurses in particular, felt undervalued by the Welsh Government. This was the highest figure of any government in the UK. And 74% of staff believed they’d seen an increase in the stress levels.

I don’t doubt that the Welsh Government didn’t want to undervalue their nursing –

Professor Jean White: No.

Lead 3: – and midwifery profession, but the stress levels, how were they addressed?

Professor Jean White: So obviously receiving a report like that is very concerning. I was worried about the staff then and I understand the longevity of the condition, how it’s affected people’s health and wellbeing after the surge of pandemic, is now still an issue for a lot of people. And I had a conversation with a lot of my colleagues within Welsh Government about what more could we do, what more can we respond to, and, as I said to you before, we already had a series of programmes of work under way to do with the mental health and wellbeing issue, and there was a Welsh health circular, which is an instruction to the health service issued by Andrew Goodall, reminding all the health boards and trusts about their employer responsibilities, about providing wellbeing services. So there was a push-back from us, it wasn’t just Welsh Government that needed to do this, all the employers needed to do something about it.

I think I was also aware that the report was part of a call to address pay and conditions, so that – an element of this, I had to talk to my workforce colleagues who were involved in pay negotiations. So this isn’t something that Wales does in isolation, it is part of a UK pay thing, and both the UK RCN report and the Welsh RCN report also make a claim about “we need to be recognising, and staff will feel more recognised if they have more pay”. So I’m not trying to diminish what they were saying, because the stress was really real and the effect on their health and wellbeing is pronounced, I couldn’t do anything about the pay though, I’m afraid.

Lead 3: I think you are aware, though, of the disproportionate impact of Covid on the black, Asian and minority ethnic healthcare workforce. Is this right, there was a – I think you asked that nurses took into account where they were deployed, to try to, presumably –

Professor Jean White: Yes.

Lead 3: – mitigate that disproportionate impact?

Professor Jean White: Yes.

Lead 3: Can you help us, please, with the all Wales Covid-19 risk assessment tool and how that helped that disproportionate impact if at all?

Professor Jean White: Okay, so early on in the pandemic, the First Minister asked for a series of work to be done to look at the impact on the black, Asian and minority ethnic population in Wales, and one of the groups that was established was to look at developing a risk assessment tool – for all staff, not just people who are black, Asian and minority ethnic, and it took the learning that we had to that point about who was more at risk, so people who are older, people who have diabetes or and so on and so forth. So it wasn’t just what ethnic group you were from.

The tool was developed and issued in May of 2020, I think, 20 May sticks in my head, and it was sent out both in paper form and then electronically, and all staff within the system were invited to complete it and then go to their manager to say “I’ve assessed myself either as low risk or medium risk or high risk”. It’s like a traffic light system, so you could work out where you are. And if you are in a high-risk group, it’s a reasonable suggestion you should be deployed somewhere not in frontline.

I should point out that the people who were excluded from that were people like myself, who were clinically vulnerable or shielding, because we expected them not to be in frontline – in fact not to be in work a lot of the time, the shielded people were at home. So it was designed for everybody else, if you like.

That changed when the shielded people came back, so there is a second iteration of it. So I did ask to find out so how many people from black, Asian and minority ethnic background staff-wise had completed it, and you will see in the pack there, I think, that the – all of the directors of workforce in each of the health boards and trusts came back to say: yes, everybody has completed this. Even when the IT systems didn’t quite capture it automatically – it’s another element of the IT systems – they were still able to do it paper-wise, to track down – so everybody was able to do it. And most were in a low-risk group not in a high-risk group.

Lead 3: All right.

Finally this, please, you’ve obviously endorsed recommendations in relation to testing and the roll-out, but if you were to provide my Lady with another alternative, perhaps Wales-based, recommendation, what would you say would be the most important thing from your perspective that could help the nursing and midwifery profession in Wales?

Professor Jean White: I think my reflections from the time would be around infection prevention and control expertise, both in terms of every staff knowing more about it but also having expert leadership. We really struggled during Covid to actually have people who had the right knowledge and had the senior leadership in this area.

So I would say we need to invest in that pre-registration existing workforce and I would say there should be a senior leader in each health organisation with expertise, rather than somebody who is a leader who covers infection, if you see the difference there.

So that would be my first – am I allowed a second?

Ms Carey: My Lady, they’re all the questions that I have. Is there anything that your Ladyship would like to ask?

Lady Hallett: No.

Professor White, there are some questions for you that I think might take something like 20 minutes. Are you okay to come back after the break?

The Witness: Of course.

Lady Hallett: Thank you very much. In which case, we will break now and I shall return at 3.10.

Ms Carey: Thank you, my Lady.

(2.56 pm)

(A short break)

(3.10 pm)

Lady Hallett: Mr Weatherby, are you asking the questions, or is Ms Munroe? I thought you were the one sitting there and when I saw Mr Weatherby arrive, and it says Mr Weatherby on my list, I got confused. Ms Munroe.

Questions From Ms Munroe KC

Ms Munroe: Good afternoon, Professor, my name is Allison Munroe. I ask questions on behalf of Covid Bereaved Families for Justice UK. I’m instructed by Nicola Brook of Broudie Jackson Canter, solicitor, who assists me today, along with counsel Oliver Lewis.

Just a few matters, please, three discrete topics and a couple of questions on each, my Lady, some of which have been sufficiently addressed by Ms Carey King’s Counsel, so I won’t trouble you with those.

First topic, relationships with Wales and the CNOs in Wales and the other CNOs in the three other nations of the UK. Now, I’m mindful, Professor White, of the evidence you gave this afternoon that the role of the CNO in Wales is a substantive civil service one, as opposed to somebody like Dame Ruth May, who has an NHS role.

With that in mind, could you assist us, as succinctly as possible here, please, with what communications did the Welsh CNO have with the other CNOs across the other nations of the UK. I know it’s a rather broad and what I have in mind is sort of the nature and effectiveness or otherwise of those communications, please?

Professor Jean White: So each part of the UK has a Chief Nursing Officer who gives advice to government. They have slightly different roles but, essentially, that’s what we do. Before the pandemic, we would meet on a quarterly basis, either in person or virtually, to help drive the professional agenda forward, because nurses and midwives are regulated to work anywhere in the UK, we needed to have a shared understanding of what that would mean. We can’t have health policies completely different because it would make it difficult for nurses to work across the whole system.

During the pandemic, we just increased the amount of contact we had, partly to give peer support but mostly so that we could learn from one another the approaches being taken in our health systems, so that good practice could be shared or systems to find solutions.

So I’ll give an example, the hospital visiting guidance, we talked about that, so we all were taking a similar approach, so there was less difference geographically.

Ms Munroe KC: Thank you.

On 30 March 2020, nursing directors raised concerns regarding delays in the publication of Public Health England’s guidance on dealing with deaths. Why was that delay in England relevant to what was going on in Wales, and decision-making in Wales?

Professor Jean White: So quite a bit of guidance around infection prevention and control was being developed at a UK level, so rather than each country going their own way, we tended to share good practice, particularly in infection prevention and control, and we had decided to take the Public Health England guidance and apply it to Wales, in this particular instance.

Ms Munroe KC: So was the reality, as you saw it, that Public Health England was making the major decisions and Wales were following suit or was it more collaborative than that?

Professor Jean White: I think it was more collaborative than that. There can be a lot of wasted energy if everybody had to go from first principles and develop guidance. It’s much better to share information and then apply it to systems if we all agreed that that original piece of work was sound. So, yes, it was more of a collaborative and building into application to our own systems, rather than develop from scratch.

Ms Munroe KC: Lastly, on this first topic, about temporary registration of third year student nurses, we heard a little bit about that this morning from Dame Ruth May. On 17 April 2020, in a nursing directors’ meeting, concerns were expressed that temporary registration of third year students may hinder their progress and delay full registration.

Professor Jean White: Yes.

Ms Munroe KC: Now, a decision was taken in Wales not to adopt the NMC’s emergency standards which was placing third year students in rostered aid employment.

Professor Jean White: That’s not correct, we did place third year students in their last six-month of their role into paid employment. They weren’t on a temporary register, that was the bit.

Ms Munroe KC: Right.

Professor Jean White: They were still students and the hours they did in practice counted towards their degree. Sorry, if the note was not clear enough. So they were paid as a band 4 healthcare support worker for that six months and they had a six-month contract dated from 27 April 2020.

Ms Munroe KC: So, in that respect, Wales was not adopting a different position from the NMC’s –

Professor Jean White: That’s correct.

Ms Munroe KC: – and IPC standard. I’m grateful for that clarification, thank you.

Second topic, then, communications within Wales. My first question has actually been addressed, it was about the absence of a CNO role in pre-pandemic planning. That’s been sufficiently addressed by you already.

But my second question is this, Professor White: do you think there was a gap in the communication between health boards in Wales and the CNO, bearing in mind the absence of the CNO role in the pre-pandemic and emergency health planning?

Professor Jean White: I had a very close relationship with the executive nurse directors. Wales is not a very large place, so we met regularly before the pandemic and I met with them twice weekly during, particularly, the first wave and then it reverted to a less frequent contact, and then increased again as the second wave came along. So I wouldn’t say that I had a poor relationship, it was a very good relationship, actually. Did you have a specific area that you felt that it was difficult?

Ms Munroe KC: No, it wasn’t so much about the quality of the relationship, whether it’s poor, but whether there were any gaps in terms of the communications?

Professor Jean White: I didn’t feel so at the time, no.

Ms Munroe KC: I’m grateful, thank you.

The last topic, then, the CNO’s ability to act on concerns. Now, the word “concerns” is something that is repeated throughout your very lengthy and very helpful witness statement. You’ve already told us in detail about the visiting guidance and you were the lead in relation to that, so that takes care of my first question there.

So my second question in terms of concerns is this, Professor White: at a meeting on 10 April 2020, concerns were raised about the deployment of returning staff over the age of 60 years of age into Covid-19 areas, and this was particularly so, this concern was raised, because of the very well publicised, at the time, numbers of older staff in Italy that were being affected.

Professor Jean White: Yes.

Ms Munroe KC: What actions did you personally, or collectively with others, take in terms of addressing those concerns?

Professor Jean White: So that was back in April, so –

Ms Munroe KC: Yes.

Professor Jean White: – it was raised at a meeting with the other nurse directors. This was from – the Cardiff and Wales University Health Board Nurse Director raised it. So that practice was shared with others at that moment, but it was fed into the development of the Wales risk assessment tool that we developed for all healthcare workers. So age on its own is not necessarily exclusive, it’s the things that go with age, you often have a chronic condition, like I have, when you’re older. So age was one of the factors that was described in the risk assessment tool that all workers were encouraged to do to work out how susceptible they might be, and that included other chronic conditions or from a black, Asian and minority ethnic background, and, in fact, men were more susceptible than women, for example. But that on its own wouldn’t be necessarily a thing to move you to somewhere else. Does that answer your question?

Ms Munroe: It does, thank you very much, Professor White.

Thank you, my Lady, those are my questions.

Lady Hallett: Thank you, Ms Munroe, very grateful.

Now you have questions from Ms Weereratne KC. Have you got a direct line of sight?

The Witness: Yes, I have, thank you very much.

Ms Weereratne: Thank you, my Lady, an excellent line of sight, there’s just a pillar between you and I, which I’m sure I can navigate.

Lady Hallett: I’m afraid we always knew that would be a problem, sorry.

Questions From Ms Weereratne KC

Ms Weereratne: Thank you very much.

I’m asking questions on behalf of the Covid Bereaved Families for Justice Cymru, many of whose members were bereaved through the loss of loved ones to nosocomial infection.

You may already know that this group is critical of the Welsh Government’s response to the pandemic and, amongst other things, has said that it was slow and disjoined.

I do have some questions for you remaining and they will involve a little bit of context setting, so if you would just bear with me on that.

First, I wanted to ask you about timings of responses by three of the Welsh Government bodies that responded, and the context of the questions is that of urgency.

So on 30 January 2020 the WHO declared a global public health emergency. On 4 February 2020, SAGE confirmed the first case of human-to-human transmission had occurred outside of China. On 28 February 2020, Covid-19 struck for the first time in Wales.

So first question on that is from paragraph 68 of your witness statement, and you don’t need to look at this, you say it was only on 16 March 2020 that the executive team meetings of the Health and Social Services Group to discuss issues affecting planning and delivery of health and social care in Wales stepped up frequency of its meetings from monthly to weekly. So bear with me. Then, secondly, at paragraph 69, you also say that on the same date, 16 March, monthly Welsh nursing directors’ meetings increased to twice weekly meetings to share information on service issues that may require Welsh Government response.

So the first question is: do you accept that increasing frequency of these meetings in key groups on 16 March was too slow a response to an already urgent situation?

Professor Jean White: Some groups were meeting sooner than that, so I think it would be fair to say that the planning and response cell actually started meeting in February to start working out how the system could change. So it was – certainly certain meetings were starting to step up its frequency during March. Possibly it was later than that could have been done, but I’m not sure what more we could have done earlier until we had some of the plans in place, which other groups were already working on.

Ms Weereratne KC: So I was going to ask you that. Of course I was talking about key groups in relation to the executive team, HSSG group, and the nursing group, which you would accept are key groups, wouldn’t you?

Professor Jean White: Yes, yes. And the executive director team meeting was weekly, so I would meet with other colleagues and the director general on a weekly basis, usually a Thursday morning, and that was supplemented by daily contact as soon as the pandemic really started to get its claws into us.

Ms Weereratne KC: All right. So if I was to offer an explanation for the delay on 16 March would you have anything additional to add?

Professor Jean White: I don’t think so. As the work escalated, so our need to meet more frequently escalated alongside it. I’m not quite sure whether meeting more frequently before that of some of these groups would have been necessarily helpful. Hindsight’s a wonderful thing, you know. Possibly, I don’t know.

Ms Weereratne KC: I’ll ask you another question on that point. The Welsh Government’s Nosocomial Transmission Group was established on 19 May –

Professor Jean White: That’s right.

Ms Weereratne KC: – 2020. Its role, you’ve already been asked about, was to provide advice, guidance and leadership on actions needed to minimise nosocomial infections. So you were the joint chair of that group –

Professor Jean White: That’s right.

Ms Weereratne KC: – along with Chris Jones. Again referring to the state of knowledge in January and February regarding the virus as it emerged, and that nosocomial infection had been identified by SAGE in March 2020 as being a pressing issue, do you accept that 19 May 2020 was too slow a response to establish a Welsh nosocomial group?

Professor Jean White: Yes, well, Public Health Wales were working on the infection prevention and control issue. The IPC cell I think had met in January of that year. So we were relying a lot on the expertise and support of Public Health Wales. It was decided that additional support would be needed at a government level. Possibly we could have started it a few weeks earlier, I accept that, but certainly it became a focus of our attention and we met very, very regularly throughout my time as CNO –

Ms Weereratne KC: Yes.

Professor Jean White: – and produced a lot of guidance as a result.

Ms Weereratne KC: But do you accept there was about a six-week delay between the SAGE announcement and your group being set up?

Professor Jean White: As I say, that was because we had other mechanisms that were already in play, so this was an additional thing we added later on. I wouldn’t call it a delay particularly. It was as the issues started to emerge we realised we needed more support and a place where we could work on broader guidance rather than the immediate infection prevention and control measures that Public Health Wales already was dealing with.

Ms Weereratne KC: But as we know it became a pressing issue, nosocomial infection, and you were asked about outbreak surveillance monitoring, which you said in evidence came later on. Now, it’s correct, isn’t it, that “later on” means, November 2020, so that’s yet another six months after the setting up of the Nosocomial Transmission Group; that’s correct, isn’t it?

Professor Jean White: So what I said in my statement was that we had a pre-pandemic arrangement that Public Health Wales dealt with all outbreaks, but the way that their data was presented to us as a Welsh Government was there’s some time lag, so we didn’t know every day what was happening across the system, so we had to develop a way of gathering real-time data. So I would say yes, there was a delay in having real-time data, not that we weren’t actually managing outbreaks in a particular way. It just wasn’t timely enough. So that would be fair to say that, yes.

Ms Weereratne KC: Yes, because the daily reporting didn’t start till November 2020, and that’s the evidence you referred to –

Professor Jean White: That’s right.

Ms Weereratne KC: – earlier.

So in relation to what I’m going to call slow responses at this critical time in Wales, it would be correct to say, wouldn’t it, that valuable planning and response time and data was inevitably lost?

Professor Jean White: Well, certain systems had to be established, and I would say that that was slow to happen. Some of our systems, IT systems, I think, my Lady, I’ve already mentioned that some of them didn’t talk very well to each other, so it’s quite hard at a government level when you don’t have access to real-time data. So that certainly took a while.

We did have a planning cell that was working with the service about how to change what we were providing, so that was done in a reasonable time. I wouldn’t say it was early, but it was reasonable. So it’s a mixed answer, I would say to you. Some of it was possibly slower than we would have ideally liked because we had to establish systems.

Ms Weereratne KC: Thank you.

I’m just going to move on to another topic now, because I only have ten minutes to ask you questions.

Professor Jean White: I’m so sorry.

Ms Weereratne KC: So within your statement you do explain that on 3 April 2020 a conflict was brought to your attention by directors of nursing between the Public Health England PPE guidance and the UK Resuscitation Council guidance in respect of whether CPR and chest compressions constituted AGP and whether, in hospital settings at least, full protective equipment should be worn, including FFP3 respirators. Do you know what I’m referring to?

Professor Jean White: Yes, I do.

Ms Weereratne KC: So on 10 April, you were told that practitioners in Wales did not want to use the Public Health England guidance. Can you confirm that on 21 April you received an email from one nursing director of a local health board alerting you to the fact that some health boards were insisting on accepting the Resuscitation Council position over that of Public Health England?

Professor Jean White: Yes, this remained quite a contentious issue within the service for a number of months, it wasn’t just that one instance. We talked about it multiple times as executive nurse directors and, in the end, the CMO and I actually put out what we hoped was helpful guidance to find a way through, while the scientific experts looked at the issue. I’m not in an expert in this area, so this became a problem for some months and, eventually, an aerosol-generating procedures specialist group was established at the request of the –

Ms Weereratne KC: Yes, I’m going to interrupt you, if you don’t mind, there was a specific line of questioning that I wanted to follow.

Professor Jean White: Okay, go ahead.

Ms Weereratne KC: But I want to be fair, on 14 April you did issue a letter, which is in your statement at paragraph 208. I believe you’ve set that out there. But I just wanted to ask you this: so you did receive that there was an insistence on the part of some local health boards to use the RCUK guidance and you forwarded that, didn’t you, to Frank Atherton, then the CMO of Wales and also to Chris Jones –

Professor Jean White: Yes.

Ms Weereratne KC: – the Deputy CMO, and you stated:

“As I said before, I wonder if we should have made a decision to just accept the Resus Council position as best practice for Wales, given the level of distrust now apparent within the PHE PPE guidance.”

Bear with me. The response you received from

Chris Jones was that it was not for the Welsh Government

to mediate the stand-off between the RCUK and PHE, that

the Welsh Government supports the PHE guidance and that

it was for organisations to consider what advice they

wished to adopt, and Frank Atherton said that there

should be no further action.

So my question is this: do you agree that further

action should have been taken to provide clear leadership in respect of the PPE guidance to be used in Welsh hospitals during CPR?

Professor Jean White: So Frank and I did actually send a letter, I think it was about a week after that, which tried to mediate a way forward while the issue was being sorted out. So this needed to have further scientific view on it. The whole issue about whether chest compressions causes aerosol particles to a degree that would actually cause a risk to staff, so we tried to be helpful, but it wasn’t really Frank or I’s place to try to sort out the scientific argument that was going on.

Ms Weereratne KC: Yes, so do you accept though that the argument, if you like, was causing confusion on the ground –

Professor Jean White: It did.

Ms Weereratne KC: – and that patients and staff were at risk as a result?

Professor Jean White: Probably.

Ms Weereratne KC: Yes.

Professor Jean White: I mean, all I can say is we tried to find a way with advice to mitigate the risk but, certainly, having the confusion added to a distrust of guidance that was coming out, and that was not helpful to anybody.

Ms Weereratne KC: So that was my final point on this, in relation to the distrust of guidance, and my question is this: did this attitude of distrust by the local health boards spill over into other aspects of PPE guidance and damage the confidence in Public Health England’s guidance and compliance by hospital staff in Wales?

Professor Jean White: Possibly, but it was not reported to me as an issue as clearly as this. This was, I would say, the standout conflict between advice that was given to staff. It may very well have made people question what other guidance was out there, but it – and it needed to be clarified to help. So I can’t give you another example, I’m sorry.

Ms Weereratne: All right.

Lady Hallett: Thank you.

Ms Weereratne: Thank you very much, those are my questions.

Lady Hallett: Thank you very much.

Thank you very much indeed, Professor White, I’m really grateful for your help. I don’t know if it’s pleasant meeting your former colleagues in this

situation when you’ve all got to relive such a dreadful

time but, anyway, thank you for coming along today.

The Witness: Thank you very much, my Lady.

Ms Carey: Thank you very much.

(The witness withdrew)

Lady Hallett: Ms Carey.

Ms Carey: May we now hear, my Lady, from Ms Fiona McQueen,

who is just coming in.

Ms Fiona McQueen

MS FIONA McQUEEN (sworn).

Questions From Lead Counsel to the Inquiry for Module 3

Lady Hallett: You have been waiting a long time, I’m very sorry.

The Witness: Not a problem, my Lady.

Ms Carey: Ms McQueen, your full name, please.

Ms Fiona McQueen: Fiona Catherine McQueen.

Lead 3: I think you were initially the interim Chief Nursing Officer in November 2014, became the Chief Nursing Officer then until February 2021?

Ms Fiona McQueen: That’s correct.

Lead 3: Can you just help us, please, with your own professional background, just summarise that if you –

Ms Fiona McQueen: So I essentially am a generalist nurse leader, I became an executive nurse director in 1993. So the bulk of my clinical practice has been in nurse management or executive nurse director roles. So generalist leadership across a number of areas.

Lead 3: I think the Chief Nursing Officer has its own directorate which sits within the DG HSC, or Director-General Health and Social Care, in Scotland?

Ms Fiona McQueen: That’s correct.

Lead 3: Your roles and responsibilities are set out in your statement but they include providing policy and professional advice to ministers and leading on professional and policy aspects of healthcare associated IPC and antimicrobial resistance measures?

Ms Fiona McQueen: Yes.

Lead 3: A mouthful, but is that it in a nutshell?

Ms Fiona McQueen: That’s it.

Lead 3: All right.

You provided advice to a number of groups, I think, during your tenure as CNO Scotland, including the Health and Social Care Management Board. I know that was briefly reconstituted to be called, I think, the Health and Social Care Planning and Assurance Group before going back to the board; is that right?

Ms Fiona McQueen: That’s right.

Lead 3: Just tell us, what was the board’s remit?

Ms Fiona McQueen: Essentially, within Scotland, the NHS is run by NHS boards from a legislative perspective, and the Director General is also known as the Chief Executive of the NHS in Scotland and the accountable officer financially, and the Director General has a team of directors, including the Chief Nursing Officer, and we would oversee policy on health and provide advice to ministers, but also look at enabling that policy to develop into strategy for delivery of the NHS.

Lead 3: I think one of the other advisory groups that you either attended or was associated with the CNO and the directorate was the Covid-19 Nosocomial Review Group, or CNRG, as it was known. Was that something that you set up alongside the CMO in Scotland?

Ms Fiona McQueen: Yes, in Scotland, I think we have a very effective national group. Now, over March to April 2020, at Health Protection Scotland – we had the creation of Public Health Scotland and Health Protection Scotland, which was NHS ARHAI, the derivative of that. So sometimes HPS and NHS ARHAI are used interchangeably.

So we had a good system in Scotland for oversight of nosocomial infection, antimicrobial resistance and that was there. Obviously, during the pandemic there were other bodies nationally across the UK that were set up but I wanted, you know, after a few weeks, I realised there was a gap and I had wanted to have a more expert group who could look at what was happening in SAGE, look at what was happening internationally, and provide advice to myself and Gregor Smith, the CMO, and we could then onward to ministers or into the service. Just wanted something that was more locally applied to Scotland, more responsive to our questions and our direction, and able to formalise what was happening within Scotland.

Lead 3: I think you said in your statement that that group first met on 7 May 2020 and, as I understand it, are you actually a member of the group or do they report to you?

Ms Fiona McQueen: They reported to me.

Lead 3: Right, and the CMO as well?

Ms Fiona McQueen: Yes.

Lead 3: All right.

Were you involved in any advice giving to ministers between January and March 2020, so the pre-pandemic phase –

Ms Fiona McQueen: With regards to IPC or in general?

Lead 3: In general.

Ms Fiona McQueen: No, a lot of that was done by the CMO, the Cabinet Secretary for Health, and the resilience unit did a lot of that work. But we were beginning to ramp up in terms of looking at the student nurse – our senior student nurses moving into employment. Similarly with the ITU guidance. So I wasn’t involved in the national – advice that would be happening nationally across Scotland. It was more bespoke with regards to the nursing midwifery workforce.

Lead 3: All right, thank you very much.

Can we look at the CNRG in a bit more detail, please.

If I understand it correctly, it was there – set up to try to understand nosocomial infections and identify any other IPC measures that might be needed to try to combat those infections; is that right?

Ms Fiona McQueen: Yes. I think it’s important to clarify. Nosocomial infection exists, unfortunately. It exists right across the world and it’s a well known phenomenon internationally. Also when there is circulating infection in the community, then the people who are in the community bring that into institutions. It’s easy to see in the winter vomiting bug, when we see the norovirus coming into hospitals or care homes over the winter, which is why visiting can be suspended for particular wards or departments. So I think the understanding of nosocomial infection is quite clear, but what we wanted to have was additional advice from a group on – in particular, because we would not normally – in normal times you don’t have the infection being brought into the organisation, so needing to have advice about how it was travelling through the organisations, what was happening with staff, and giving advice particular to Covid-19. And we very quickly published cluster information and minutes of the CNRG as soon as we could.

Lead 3: Yes, I think you said you published the minutes, but did you publish the recommendations that the CNRG made?

Ms Fiona McQueen: So they would be summarised in the minute.

Lead 3: Right, okay, thank you.

You say in your statement that the CNRG’s advice was provided to you and the Chief Medical Officer and thereafter you and ARHAI considered the advice and used it to inform policy development. Can you give us an example of what, practically, you did as a result of CNRG’s advice?

Ms Fiona McQueen: So a bit of context as well.

Lead 3: Of course.

Ms Fiona McQueen: Within my directorate, I had policy civil servants as well as clinicians who worked in what we would call the HAI team. The chair of CNRG was also the nurse director of NSS, so was associated with ARHAI, and there were members of NHS ARHAI on CNRG, so to say it then went to ARHAI is correct, but there was a lot of commonality amongst that.

Things like whether or not to test staff in high-risk areas, whether or not to look at testing – so one of the early pieces of advice it gave us was where you have an unusual or even one member of staff testing positive for Covid or a patient testing positive for Covid in a ward, an elective ward, which was not a Covid ward, they recommended testing patients and staff.

Lead 3: You mentioned testing, and I was going to ask you, please, about paragraph 28 in your statement, where I think you say that there was advice from the group to the directorate in May, late May 2020, for “additional targeted [healthcare worker] testing to protect highly vulnerable patients in hospital at risk of poor outcomes from acquiring Covid-19”.

Who were the highly vulnerable group that were being spoken of there?

Ms Fiona McQueen: So this is against the backcloth of testing capacity not being what we would want it to have been. So oncology patients, so inpatient oncology patients, including those who were having chemotherapy – if chemotherapy had started back by then, I know we suspended it for a short time – care of the elderly, so our frail elderly wards, and also our long-term – our wards where we had long-term mental health patients for longer than three months. So we thought – or the advice from CNRG was this was a group who were particularly vulnerable and therefore we would look at testing staff on a weekly basis.

Lead 3: What about those with dementia, were they as part of this group or not –

Ms Fiona McQueen: So that would be – I do beg your pardon, Ms Carey, that would be part of the older people’s wards.

Lead 3: Right, understood. Thank you very much.

Can I ask us, please, to have a look at INQ000250382.

Ms McQueen, it’s behind your tab 3 but it might just be easier to look at it on the screen. This is a note from you to the Cabinet Secretary in June of 2020, on the 3rd, in relation to healthcare worker testing in hospitals, and you can see it’s:

“To propose an approach for healthcare worker testing for COVID-19, further to the advice of the [CNRG] …”

And I think we can see the background to this is “Asymptomatic transmission and testing”, and at that stage in Scotland only healthcare workers who were symptomatic were tested and the proposal was to test more to try to identify those who may be asymptomatic; is that it in summary?

Ms Fiona McQueen: That’s correct, yes.

Lead 3: I think you say there, I might just need your help with this, at paragraph 4:

“Latest analysis finds that approximately half of the cases in all of the reported NHS Scotland cluster outbreaks in non-COVID wards are healthcare workers …”

Can you help us with a “cluster outbreak”; how is that term used in Scotland?

Ms Fiona McQueen: So the term “cluster” and the term “outbreak” are both used epidemiologically within public health and within infection prevention and control. An outbreak would be two or more cases where there’s a common source, and a cluster would be two or more cases, not necessarily needing that common source. So it’s at a higher – an outbreak as a subset of a cluster.

Lead 3: Thank you very much.

So, here:

“… at present, almost 70% of cases in the active clusters are healthcare workers.”

Then the six active incidents involved 26 patients, 59 members of staff, the 118 closed incidents. What is the “closed incidents” a reference to?

Ms Fiona McQueen: It’s where the cluster or outbreak has been deemed to have stopped, so no more new infections, and not being actively managed.

Lead 3: So it had historically been the position in Scotland that there were 118 closed incidents involving the 888 patients, 213 deaths?

Ms Fiona McQueen: Yes, at that time.

Lead 3: At that time. And 862 staff cases.

I think if we just go to page 2 in that document, at paragraph 7 – at the top of the page, thank you – there was some work done on mathematical modelling which:

“… estimates that the weekly screening of [healthcare workers] could reduce onward transmission from [healthcare workers] by a further 16-23% on top of self-isolation …”

Although that was an assumption, essentially, here, were you asking the minister to bring in testing for the asymptomatic healthcare worker?

Ms Fiona McQueen: No, I think – so I think we weren’t asking that as a blanket way, I think the recommendations are in under paragraph 11.

Lead 3: Yes.

Ms Fiona McQueen: I think what we were saying is where there’s an unexpected cluster or outbreak we would want to look at that, and where the infection prevention and control teams believed they needed to do that, that they would do that as well.

Lead 3: So you were wanting to do target testing where there were these unexpected clusters or outbreaks. Is there any reason why it wasn’t wider and just an implementation of asymptomatic testing across the board?

Ms Fiona McQueen: So I’m not sure if it’s – if it was close. So we would brief the minister post-CNRG or post something new happening, and I think the Imperial College presented a paper that talked about the value of asymptomatic testing. Now, CNRG looked at that and their view was it was a theoretical or abstract piece but, in the real world, good infection prevention and control measures would actually be more effective because it would reduce nosocomial infection by 80%, and their advice at that time was not to test – blanket test asymptomatic workers.

My sense is, if we had had the testing capacity we would have been there –

Lead 3: That’s what I was going to ask you: so if I understand your evidence correctly, there was an evidence-based decision taken not to roll it out more widely, was that the driver of the decision or was it the lack of testing capacity?

Ms Fiona McQueen: I think if it had been only a lack of testing capacity, then the briefing that I would have had from CNRG and my team, that I would have given to the minister and I would have talked to Gregor Smith about was we don’t have enough testing to do this. Is it a priority and how can we possibly do that. So I think it was an on-balance, actually, it may not be productive and good IPC measures are important with the testing where there are even just one unexpected case.

Now, that didn’t last, because we then moved – I don’t think that lasted because this was before the end of June, when we were starting to do the vulnerable patients, I think, but – so I don’t think it was predominantly because there was a lack of testing capacity but there’s no doubt at the early days of the pandemic lack of testing capacity was a problem.

Lead 3: I don’t know if you heard any of Dame Ruth May or your Welsh counterpart’s evidence, but they have both spoken to her Ladyship already about the role of testing. Did you hear any of that evidence whilst you were waiting?

Ms Fiona McQueen: I did hear on and off both Ruth and Jean, but I don’t remember testing because I was travelling across London at times.

Lead 3: They both, in short, for an increased amount of testing to help with visiting restrictions and the need for it, or otherwise, prevention of nosocomial infections; do you have any dissent or assent to their –

Ms Fiona McQueen: Complete assent. You know, increased testing would have been enormously beneficial, I think right across society, but since we’re here to talk about health, within our health system.

Lead 3: A different aspect of CNRG’s work, please, in relation to face mask guidance and, Ms McQueen, it’s at your paragraph 35 and I may need to put up on screen the table that you’ve set out in your statement, could we have, please, INQ000474225_0013. I think really you’ve set out a timeline there of the changes to the face mask guidance that was brought in in various stages in 2020.

June 2020, there is introduction of interim guidance on the wider use of face masks, decision to introduce the face masks in adult hospitals and care homes for the elderly, and the reason for the change is set out there: to help reduce nosocomial transmission in hospitals and care homes.

I presume we’re talking about FRSM masks?

Ms Fiona McQueen: Yes.

Lead 3: That guidance in June 2020, did that include people working in non-clinical roles?

Ms Fiona McQueen: No, I think that was – the non-clinical roles was in September 2020.

Lead 3: Yes.

Ms Fiona McQueen: It does seem curious now that it didn’t, but no, it didn’t.

Lead 3: Do you think now you would make a distinction between those in clinical roles and those in non-clinical roles for something as simple as an FRSM?

Ms Fiona McQueen: Absolute – for something as simple as an FRSM, and knowing now – and it is always difficult to move us from where we are today to where we were then, and knowing now what we know about ventilation, about, you know, air throughput and about transmission, I think it would have been better if we had had that as early as possible.

Lead 3: September 2020, as you rightly pointed out, updated face mask guidance to cover now primary and wider social care, primary care including GP practices, dentists, opticians, pharmacies and the wider community care are set out there.

Can you help as to why GPs and pharmacists weren’t included in the roll-out in June 2020?

Ms Fiona McQueen: So they would have been wearing it in patient facing, when they were seeing patients, but not when they were perhaps in the staff room or, you know, if the pharmacists were in dispensing areas. So it would be the non-patient facing roles then as well.

Lead 3: At the bottom of the screen, we can just see there June 2021, a year on from the initial introduction of the interim guidance, now we’ve got wider FRSMs by clinical and non-clinical staff. So is it right that a year elapsed before the recommendation was for non-clinical staff to wear FRSMs?

Ms Fiona McQueen: So by that time, I had (unclear) office, at the end of February 2021 –

Lead 3: Yes.

Ms Fiona McQueen: – so I apologise, Ms Carey, I would have thought from memory that we introduced FRSMs for non-clinical staff earlier than that but I could –

Lead 3: You think it happened in your tenure?

Ms Fiona McQueen: I thought it did but I may be wrong. So when we talk about clinical staff, if you were part of the trades workforce and that would have included them, going into wards and departments, in the June 2020.

Lead 3: It’s my fault, I’m not familiar with the trades workforce. What do you mean by that?

Ms Fiona McQueen: Well, plumbers, electricians, engineers.

Lead 3: Right, sorry, okay.

If I understand you correctly, though, for the porters, the cleaners, people in that non-clinical role within the hospitals, though, when do you think they were advised to wear FRSMs?

Ms Fiona McQueen: So I think – I think in the September – so I think in June 2020 we would have been looking at the introduction for all staff. So we weren’t just seeing clinicians, so anyone who was in a ward or department, which would be the trades workforce or cleaning staff or catering staff, as well as doctors and nurses, would have worn that, but in the workshop, the trades workforce may not have, in June 2020, but they ought to have in September 2020.

Lead 3: Okay. Dealing with guidance but in a different sphere, can I ask you about the IPC guidance, please. We can take that down, thank you.

I think, is this right, that Scotland followed the UK-wide IPC guidance but, in October 2020, Scotland published its own Covid-19 specific guidance; is that correct?

Ms Fiona McQueen: In terms of IPC or –

Lead 3: Yes.

Ms Fiona McQueen: So it would have been a Scottish version of it.

Lead 3: That’s what I was going to ask you: did it replace the UK-wide or did it supplement the UK-wide IPC guidance?

Ms Fiona McQueen: So I struggled with the UK IPC guidance because – and the feedback we got from staff was it was confusing going onto the – to have a look online because the National Infection Prevention and Control Manual that we had had in Scotland for some time was an online manual, and staff were used to going online to check what the most up-to-date guidance was, and then they were sent through to Public Health England, and at times that may or may not have had everything that was relevant to Scotland. So I was always keen that we had very clear and explicit communication for people working within the Scottish health service and social care.

Lead 3: So although the UK IPC guidance was designed to try and standardise the position across the UK, in fact did it serve to confuse in Scotland; is that really where you get to?

Ms Fiona McQueen: Yes.

Lead 3: Okay. You do say in your witness statement that there were 15 times that guidance was issued on a Friday. Was that IPC guidance or guidance across other areas?

Ms Fiona McQueen: I think the IPC guidance was particularly problematic and particularly – because, realistically, NHS and the civil service were working seven days a week, so in a way, whether or not it was issued on a Friday, was kind of immaterial, but smaller – in social care, we had much smaller organisations who had less resource, who struggled with information coming out on a Friday. So I think there were other issues, other than IPC guidance, that would be issued on a Friday as well, other workforce issues.

Lead 3: Did you become aware of concerns though about it being received, in theory, late in the week albeit –

Ms Fiona McQueen: Definitely and it wasn’t ideal but the question was do we hold it until – because we weren’t going to issue it on Saturday or Sunday, do we hold it until Monday or do we issue it and give people time to get it in place. We didn’t criticise people for not having immediate implementation because some of these things would take a number of days to take over and implement.

Lead 3: Can you think of any way to try and, if there is a concern about it coming out on a Friday and saying it’s got to be in place by Monday, is there anything practically that you think could or should be done to try and soften the blow, if I can put it like that?

Ms Fiona McQueen: I think resourcing is an issue so, in reality, coming out on a Friday I would be, I may be wrong but I’d be surprised if we said this is for implementation by Monday or, you know, there will be firm words taken. I think we would have said “As soon as you can, could you implement this, please”, and we would often give a bit of time for things to be implemented, depending on what it was, if it went to an NHS board, our biggest NHS board has over 20,000 staff, so that’s never going to reach the front line in anything other than a matter of days.

Lead 3: Generally in relation to the IPC guidance, we’ve heard that there was the UK IPC cell, with representatives from Public Health Scotland on it, and all the other public health agencies, and a number of other bodies. What role, if any, did you have in approving, amending, disagreeing with any guidance that the IPC cell wished to have published?

Ms Fiona McQueen: I’m a generalist in terms of my leadership skills, I’m not an infection prevention and control expert. I had policy but, in particular, clinicians working in my team and I relied completely on NHS ARHAI, so if they came and said “This is the guidance that we believe we should be implementing”, I may have asked questions, and I may have queried parts of it so that I could have a better understanding of how that guidance was formulated before I then advised ministers, because I was not going to have NHS ARHAI saying “Fiona, I think we should do this”, and then me say to the minister, “I don’t think we should”. So I was relying on the clinical experts in NHS ARHAI and also my policy team to advise me.

Lead 3: Can you ever recall an occasion where you disagreed with the guidance that was coming from the UK IPC cell and pushed back, I think to use the popular phrase?

Ms Fiona McQueen: So in the early days, when I was unaware of the IPC cell, I think it was late March because it was the 2 April guidance that was being worked towards. My team alerted me to the IPC cell developing guidance and, in Scotland, we have a heavy – not just tradition, our working practice is to work in partnership with the trade unions and the professional organisations. So almost anything that we develop, we develop in partnership and it’s in partnership rather than develop it and then consult. And the Royal College of Nursing were concerned because they had not been involved in the development of this guidance and they had concerns about access to fluid-resistant surgical masks for some staff.

Now, at that time, and again it seems very strange to think back to when we would ask clinicians to go into – and it was particularly into homes, into patients’ homes and not wear an FRSM, but that was the guidance at the time: if your client or patient wasn’t displaying symptoms of Covid and didn’t have Covid, you didn’t need a face mask.

That – so my team had signalled to me there was real concern here because there was a UK body or a UK group trying to develop guidance and it wasn’t listening. So I became involved then and, after that, we – there were four tables in that guidance and table 4 – so there was table 1, 2 and 3, which outlined what happened when you either suspected someone had Covid or someone had Covid.

Table 4 was where there was high levels of circulating virus in the community and the member of staff believed they would be better and safer to wear a mask, and that’s where we insisted on moving to have a wider level of guidance.

I think there was also another time when there was a safety alert, a CAS alert that NHS England had issued, that appeared on the UK website, and I advised my staff that that could not happen. We needed to have either completely UK or we’d just go back to the four countries.

So there were times – and, similarly, with a letter I wrote in May about AGP or not of CPR and whether or not staff could wear FFP3 masks on that. I had a discussion with Gregor Smith, the CMO, and we issued a letter to say if staff want to wear that then they may.

Lead 3: Yes, I think you set some of that out at paragraph 55 in your statement. I won’t take you to it but, in short, was the position in Scotland that, if staff wanted to wear FFP3 during CPR, then they could, even though that wasn’t necessarily the recommendation that was coming from NERVTAG and perhaps the UK-wide guidance?

Ms Fiona McQueen: And before doing that I talked – because I was hearing concerns, I talked to the IPC team because I didn’t want to be seen to be trumping them and I wasn’t saying this was IPC advice, but cardiopulmonary resuscitation is such an emotional response, as well as a physical response, to try and save your patient’s life and I just didn’t think it was worth arguing about whether it was FRSM or FFP3, I thought it was better to give people as much support as we possibly could.

Lead 3: May I change topic slightly, please, and just ask you about the temporary register. We know that certainly by April 2020 the figures of those returning to the temporary register were broken down nation by nation. Could we just put up on screen INQ000421170_0004, please, and we’ve looked at this now with your counterparts and I just wanted to look at the Scottish position. So by 21 April, there were 1,272 nurses and/or midwives going back on to the register in relation to Scotland and the question really for you is how many of those were actually deployed to the frontline, do you know?

Ms Fiona McQueen: So I don’t know but I think anecdotally not that many, because remembering we – a live registration we revalidate every three years, so somebody could have, they could almost be five or six years out of practice when they came on to the temporary register, and I’ve already heard evidence from my two CNO colleagues about choice, so people may not have wanted to go to the front line and we certainly used people on the temporary register or on the other – we also had returners – within the vaccination centres.

But I think there was something about need and demand, so whether or not NHS boards actually needed the additional staff and in many cases they didn’t, and then whether the additional staff wanted to do frontline work or whether there was work that they could do. So – and also I think there’s learning that on-boarding process, although Scottish Government paid for their PVG checks and tried to facilitate it, the on-boarding took longer than was helpful.

Lead 3: So, happily, you say the board didn’t need the staff returning to the register but the bottom line is that you don’t know how many were in fact deployed to front line. Do you think that kind of data would be helpful or not in the case of Scotland?

Ms Fiona McQueen: I think it would be helpful, I think we have to have a balance between, depending on how good your electronic systems are, if you had good electronic systems at the press of a button you could find out, you know, 300 went to the front line, but it would have been adding more bureaucracy and more paperwork to already hard-pressed clinicians and managers. So I think in the future it would be helpful to know but I didn’t feel bereft because I didn’t know.

Lead 3: I think you said in your statement at paragraph 108, I’ll just read it to you, you say:

“I was not aware of issues and concerns regarding the lack of relevant training, the suitability of roles to which staff were redeployed and/or support for redeployed nursing staff and midwives.”

So no concerns were raised to you about those either coming back on to the register or being moved from one department to another?

Ms Fiona McQueen: No, I’m not saying they weren’t there and concerns would be raised to me in a variety of ways, particularly through the nurse directors, who I met with on a regular basis, who would signal things but also anecdotally things could come up, but I wasn’t aware, no.

Lead 3: Did you ever have discussions with someone like the TUC – or the Scottish TUC, I should say – about concerns about those who were being redeployed?

Ms Fiona McQueen: So I wouldn’t have but every, probably, twice a week, so the health workforce, so there’s a director of health workforce who would take the lead on workforce issues and she would convene meetings probably twice a week and one of my deputy chief nursing officers, Diane Murray, would be at that, and that would be where, whether it was the Royal College of Nursing, UNISON, Unite, that would be brought up there.

Lead 3: Can I ask you about a different concern that may have been raised with you in relation to the fit of PPE and around face fitting, and particularly in relation to ethnic minorities and the like. Were concerns raised in that regard with you?

Ms Fiona McQueen: So concerns were raised, so even pre-dating the pandemic, there was always a niggle about face fitting, and everyone should be face – you know, should have face fitting, it was something that was sometimes tricky because people didn’t see the immediate need to have an FFP3, so, actually, going to be face fitted was not necessarily high on their priorities. So, even before the pandemic, I was aware of the fact that face fitting was not universally carried out and there were times when the size of the mask, the type of the mask didn’t fit.

That clearly was highlighted during the pandemic, and so both for – I say the shortage, the lack of supply meant we were having to source internationally, so there were a number of different masks which would need to be face fitted for different people. So it was a huge exercise, but yes, I think facial hair, black, Asian and minority ethnic colleagues and a lot of women as well would have trouble with that.

Lead 3: In relation to black, Asian and minority ethnic nurses and midwives, were there any other major concerns, or what were the major challenges facing them, I should say, as far as you were made aware?

Ms Fiona McQueen: I think the real worry of – what was the impact the pandemic was having on the black, Asian and minority ethnic community in terms of – and there was a lot of uncertainty at first, this was a new virus, we weren’t quite sure what was happening, and was there a greater death rate or not, and in the early days of the pandemic it was difficult to be definitive about it. So I think there were aspects of morbidity and mortality, who was going to be affected more by the virus, as well as then physically in work not having the right protective equipment. So there was a suite of measures which I think is why there was a response in May – Scottish Government – but my sense is we probably all did this roughly the same time –

Lead 3: May 2020?

Ms Fiona McQueen: Yes, risk assessment. So where we issued an instruction to the NHS in Scotland that every member of staff from black and minority ethnic communities should have a conversation with their manager which should be a supportive conversation and, within that, have a risk assessment where they could talk to them about, you know, did they have any other predisposing conditions, how did they feel about being – you know, whether they were on the front line or not, and where did they want to be redeployed, did they have the right level of PPE or not.

Lead 3: In your witness statement you set out the chronology of changes to various bits of guidance and, essentially, by April 2022, there was, I think, a letter issued setting out responsibility for ensuring staff were given access to FFP3 masks based on their personal preference, and not in response to a risk assessment or IPC guidance, but if they wanted it to make them feel safer at work, by April 2022 that was a stance that was being supported by the government.

What do you think about that having been brought in earlier and should it have been?

Ms Fiona McQueen: So that, of course, was after my time as CNO.

Lead 3: I know.

Ms Fiona McQueen: I think the whole precautionary principle piece is one that is important to explore, and the IPC world, we’re very keen to be particular, and I think it’s important to say and describe what PPE is appropriate for keeping people safe. So I think you do need a standard and you do need to have that rigorously implemented.

If people start wearing different types of PPE, whether it’s higher or lower protection, there are a number of factors, it can wane public confidence, it can cause difficulties, but I see now – it’s in the National Infection Prevention and Control Manual – when I was refreshing to come here, I see that, last month, under transmission-based precautions there is work going on which is looking at the definition of aerosol droplet and contact. And the problem I think we had was it was very linear and it was either FRSM or FFP3; people were, in a way, defending their corners, rather than trying to find the best possible solution, and because of that, I think we’ve been blinkered.

Now, there may or may not be unintended consequences of wearing FFP3. For instance, there’s an increased level of carbon dioxide within the wearer’s blood. We don’t know – now, if you’re working in – you know, a high-consequence infectious disease – so such as intensive care, where there were aerosol-generating procedures, then these staff were wearing FFP3 for 12 hours.

Lead 3: Yes.

Ms Fiona McQueen: So I think it’s something we would want to be exploring anyway, and I think, you know, given where Gregor and I were in May of 2020, saying “If you’re carrying out CPR and you want to wear an FFP3 then wear it”, I think I would have wanted to have at least the dialogue.

So one of the difficulties of being outwith the healthcare system now is I miss having colleagues to talk these things through with. And the unintended consequences of having that – more on the health and wellbeing of the workforce who’s wearing it, because if the employer is saying “You may wear FFP3”, then we need to be aware of the risks that that would entail for the member of staff.

So that’s a long answer to say, on balance, I think an earlier discussion would have been helpful.

Lead 3: Well, it will resonate with evidence we’ve heard, that her Ladyship has been hearing now for the last few days.

Can I deal with some topics very briefly, I’m afraid. I mean no disrespect to you for the lack of time that we’ve been able to afford you today.

Ms Fiona McQueen: None taken.

Lead 3: Inspections.

Ms Fiona McQueen: Yes.

Lead 3: They I think were stopped initially in Scotland and you asked them to be reinstated, I think it was, on 30 May 2020. You reinstated what’s called a combined safety and cleanliness inspection and an older people acute hospital inspection. Why were you asking for them to be reinstated and what were you expecting them to try to ensure didn’t happen?

Ms Fiona McQueen: So part of the CNRG work influenced me to think through: how can we keep our vulnerable people as safe as possible? And therefore we stopped the inspections, so that we weren’t intruding into difficult times delivering care, we wanted to redeploy clinicians who were involved in inspections, and we stopped them in March. So I was concerned about nosocomial infection, our inspections I think signal and flag up some very helpful areas for improvement, and therefore the programme of work that I agreed to was looking at settings where our more vulnerable patients would be, so community hospital, older people’s hospitals, and the inspections that we had there certainly highlighted areas where practice could improve and reduce nosocomial infection.

Lead 3: Different topic, DNACPRs. In your time as Chief Nursing Officer, did you become aware of any instances of inappropriate use of DNACPRs or blanket use of DNACPRs?

Ms Fiona McQueen: So there was anecdotal evidence of GPs writing to – you know, going into care homes and saying, “Well, we’ll have a DNACPR”. Now, anticipatory care planning is important, probably for all of us in this room never mind older people as they get near the end of their life, so it is something that should be done, but done sensitively and done in partnership with that person and in partnership with the families.

So a letter I think went out from the CMO in March, and that I think caused distress, but all it said was: make sure your ACPs were in place. It didn’t say anything else. And out of that we developed what is in my statement, care home professional advisory group, where we set up a group that was co-chaired by my DCNO and one of the senior medical staff in the CMO’s directorate. In that we had patients representatives, we had social work, social care, we had the chief executive of a social care organisation there, so that we could develop comprehensive guidance for social care.

So I’m aware anecdotally. Under no circumstances should it ever have happened and I think we put mechanisms in place in Scotland to prevent that from happening.

Lead 3: I think during your time in post you said you were not aware of any work specifically undertaken to support nursing and midwifery staff with Long Covid. That’s clearly an impact on nurses and midwives. Can you summarise from your perspective the impact of the pandemic on the nursing and midwifery profession in Scotland?

Ms Fiona McQueen: So going into the pandemic we had been strengthening the nursing workforce we had been increasing the nursing workforce, we had been increasing undergraduate nurse places, we had been investing in GP nursing workforce, over 200 additional school nurses. So going into the pandemic. And we also had developed legislation which would – was set in a statutory footing the number of nurses in a ward or department. Along with a wellbeing requirement for employers to make sure that they were measuring and supporting wellbeing of the workforce.

The pandemic was relentless and it’s affected probably every single person in society but I think that the nursing workforce – and I’m incredibly grateful to them all who stepped forwards – has had a real impact. Some have been exhausted. Others have been rejuvenated and found new areas that they want to work in, but I think having the right number of nurses – we did have a wellbeing hub, so we put – invested in the May of 2020 having wide support mechanisms for nurses, in fact we also – for all staff – National Education for Scotland also have – now are recovering from the pandemic, so they have a wellbeing section on their website which is to support health and wellbeing of nurses.

My daughter was one of the student nurses who was deployed to the front line, so I was well aware of the impact that that had on the whole workforce, so I had briefings every day of what was happening and the devastation it had caused, the death that they saw that they should never have seen, and the work that people have done, and I think as a society we need to be incredibly grateful.

But I’m confident and hopeful that the nursing workforce will move on and be stronger as a consequence of this.

Lead 3: Well, with that sense of hope, can I ask you finally this, please:

Aside from joining the call for better testing and greater testing capacity in the event of a future pandemic, do you have any other recommendation you would make to her Ladyship that would really, practically, you think help the response and help nursing and midwives in Scotland?

Ms Fiona McQueen: I think capacity, with surge capacity, is going to be really important, because I think we were caught on the hop in terms of we needed to cancel – and you would cancel – with a new virus circulating you’re going to cancel elective work until you see how the virus behaves, but I think making sure you have enough capacity in the workforce. The nursing workforce is iller and have more chronic conditions than the population in general, so I think looking at the health of the whole workforce but also having physical space and physical capacity so that you have surge capacity and you can move patient – you don’t need to move patients for space, that actually you have, you know, a sufficiency of space to care for patients.

And just one other I think small thing. We had return – retire and return gave us more capacity for nurses when we had that within the pandemic, but at that age the normal pension age was 60 and nurses could retire at 55 without actuarial reduction. The next pandemic the normal pension age is going to be at least 65, so we will not be able to, I don’t think, rely on nurses returning the way we did this time, and I think that’s where a lot of our additional workforce came from, rather than the temporary register.

Ms Carey: Understood.

My Lady, those are all the questions I have. I know there are some questions from core participants. Is there anything your Ladyship wishes to ask?

Lady Hallett: No, thank you very much.

Ms Mitchell. That way, and I do give permission for you to swop the question, Ms Mitchell, in case there’s any confusion.

Questions From Ms Mitchell KC

Ms Mitchell: I’m obliged, my Lady, that’s helpful.

I appear as instructed by Aamer Anwar & Company on behalf of the Scottish Covid Bereaved and there are just a short number of questions that I would like to ask you about.

My learned friend, Counsel to the Inquiry, has already taken you to paragraph 35 about the face mask timeline, and we saw from that that in June 2020 there was a wider use of face masks. You have also commented in your evidence about noticing after a few weeks that there was gaps in the expertise that you might need, including what was happening internationally, and I want to ask you quite a simple question really about face masks in healthcare.

When we were watching the experience of healthcare workers abroad and the unrolling of Covid, we saw in those healthcare settings in China and in South Korea, where they had dealt with SARS and MERS, we saw in those healthcare settings the use of face masks from the start, and I suppose my question is: given that we didn’t know what was the method of transmission that was most likely, ought a protective or preventative approach have been used and a decision been taken we should use masks immediately until we know the method of transmission? Could we have learnt from watching your colleagues abroad and implementing that as a precautionary principle?

Ms Fiona McQueen: Ms Mitchell, I’ve already, I think, said to Ms Carey I think one of the difficulties of being out of the health workforce is I don’t have colleagues with whom I can have a meaningful discussion who could perhaps caution me or – about some of my thoughts. But the whole precautionary principle of going in at a higher level of protection would make sense to me, having looked back on what we had.

I think the view was it was droplet transmission, so I think we very quickly came to a view. I think throughout the pandemic we’ve looked – so I think –

Ms Mitchell KC: Sorry, if I may stop you, we understand the progression that was made, it was really whether or not it would have been a good idea at a very early stage to have some ability to look internationally, to speak to colleagues across the various different countries where they had already experienced respiratory problems, and to have that expertise right from the very start and implement it?

Ms Fiona McQueen: So, Ms Mitchell, I do think so. I think our NHS ARHAI and the IPC cell would say they have looked internationally, but I do think that some of the countries who have experienced pandemics in a different way from us have the wisdom that we should perhaps be learning from.

Ms Mitchell KC: I’m obliged.

Moving on, can I ask you, you explained what your area of expertise is and then when you took guidance from others. Did you understand, having received guidance or advice, that transmission routes, droplets or aerosols, rarely function in isolation, ie where you have one you will have to a degree another, and if so, if you understood that to be the case, did you report or advise the need for a multi-intervention approach, and if so to whom?

Ms Fiona McQueen: So the advice I was given was it was droplet, and I don’t think for me the – the aerosol piece would be coming from where aerosol-generating procedures were carried out rather than routine day-to-day areas where they were not carried out. So it was not in my conscious level that the mixed mode, which – I think I talked about then the NIPCM and the work that’s going on just now, which I would welcome, to make it clearer what’s happening.

So at no time was I of the view that there was aerosol contamination whereby staff needed to have FFP3 protection and not – I took no action.

Ms Mitchell KC: So could I just be clear about that, are you saying that essentially what you were thinking was this is a droplet route and therefore you weren’t really considering the issue of aerosols unless it related to the carrying out of something that would produce aerosols per se?

Ms Fiona McQueen: That was the advice I received.

Ms Mitchell KC: Moving on to another question which my Lady has granted authority for, earlier on in your evidence you were talking about PPE and you said that – when talking about PPE, you indicated that you were having a shortage and then you corrected yourself and said the “lack of supply”, and I want to ask you a little bit about that, in particular your comment at paragraph 135 of your statement – I don’t need that brought up – but it said:

“Neither I nor my directorate were aware of any shortages in PPE or RPE for nursing and midwifery staff but were aware anecdotally of issues in supplies not being easily available to staff in some instances.”

Now, I just sort of want to break that down, because from the evidence that we have heard from various bodies, and indeed I think a comment my Lady made to Jeane Freeman when she gave her evidence earlier on about shortage in supply, it might come as a surprise that people hear you say that neither you nor your directorate were aware of any shortages.

Are we really talking about the difference in emphasis and language? If there were issues of supplies not being easily available, presumably the people on the ground floor would see that as a shortage?

Ms Fiona McQueen: So I probably haven’t been clear enough and the language choice of my statement I think could have been better. My understanding is if I put – if I maybe talk – I don’t know if I’m allowed, my Lady, to talk about social care separately, because –

Lady Hallett: I would rather you didn’t, if you don’t mind.

Ms Fiona McQueen: Okay, that’s fine, if we talk about the health system.

My understanding that every single person who needed an apron, a mask, a pair of gloves, a gown, got one. And there was a heroic effort from managers moving supply from ward to ward, sometimes from hospital to hospital, so that my understanding is that everyone had the PPE that they needed, but it was complex and challenging. And when I remember speaking to one of the nurse directors about: is there enough? He said: there is, but there’s a palpable sense of relief when a new supply comes into the hospital.

Ms Mitchell: I think you’ve mentioned that in your statement. Did you speak to people who were using PPE on the nursing floor and ask them if they had enough PPE?

Ms Fiona McQueen: So I didn’t, we relied on our twice-weekly meetings with the Health Workforce Directorate and the trade unions and the royal colleges to brief us on what was happening with PPE, and I think there’s no doubt in the early days that the supply was not as good as it should have been, and it did cause anxiety, and – because in my mind not just clinicians, anyone who needs it should be able to put their hand out, get a face mask or a gown and put it on and not have to worry about next time they go back to that will there be one there.

So there is early on in the pandemic we could – we would have been much better to have a better supply of PPE. There was one – so when you’re asking me if I knew – we had a system in Scotland, there was a single point of contact and there was a Scottish Government email and one of my colleagues emailed me to say: Fiona, I have this email, I wouldn’t normally bother you with it, we’ll deal with it, but because of what it said I wanted you to know. And someone had said emailed to say: I live near Fiona McQueen, I’m not getting enough PPE and if you don’t sort it I’m going to go and knock her door.

So they wanted me to know that, and I then – they said but they will sort it. I then spoke to the nurse director and she said that they had more than enough PPE. So I don’t want to say nobody ever alerted me to it or nobody – everyone said there was plenty, because that wasn’t always the case, but I was aware of anecdotal evidence, but it’s my understanding that everyone who needed it got it, and once we were a few months in there was a plentiful supply.

Ms Mitchell: My Lady, I would of course like to ask more questions, but that noise was my colleague setting the timer for me to tell me that my time was up!

Lady Hallett: I did wonder if somebody was giving you a warning.

Ms Mitchell: Albeit that I think there are many more questions that I would like to ask.

Lady Hallett: I think Mr Weatherby also may have some questions on this.

Ms Mitchell: I’m obliged.

Lady Hallett: Thank you, Ms Mitchell.

Mr Weatherby.

Questions From Mr Weatherby KC

Mr Weatherby: Thank you.

Can I just pick up, then, where Ms Mitchell left off. I ask questions on behalf of the Covid Bereaved Families for Justice UK group. Again, picking up on PPE, we heard evidence yesterday from the Scottish TUC of really acute shortages of PPE in the early stages. Now, you were represented on what was called the workforce senior leadership group, weren’t you?

Ms Fiona McQueen: Yes.

Mr Weatherby KC: That’s a group which brought together senior leadership from the NHS Scotland, the trade unions, professional bodies and health and social care partners. Were you aware through that group, who, presumably, one of its roles was this kind of liaison, were you aware in the early stages through that group of concerns about really acute shortages of PPE?

Ms Fiona McQueen: Yes, I was.

Mr Weatherby KC: Yes.

Ms Fiona McQueen: But as I’ve outlined to Ms Mitchell, it’s my – so yes, I understand –

Mr Weatherby KC: Right.

Ms Fiona McQueen: – there was a shortage but everyone – my understanding is that everyone who needed it got PPE.

Mr Weatherby KC: Were you aware of shortages in hospitals, for example, the Glasgow Royal Infirmary, where the Inquiry has evidence that it was running low of FFP3 masks in March 2020; were you aware of hospitals running short of masks and PPE at that stage?

Ms Fiona McQueen: Yes. So my understanding is, so before the pandemic came, that anyone who needed PPE and a supply of PPE did not have to think twice about going to the supply cupboard and taking it and using it, but once we increased the amount of PPE people had to wear –

Mr Weatherby KC: Yes.

Ms Fiona McQueen: – then stocks diminished and, at one time, for gowns, I think there was less than a full day’s supply within Scotland.

Mr Weatherby: That’s where I was going to head next.

My Lady, there’s a crossed wire I think about my next question?

Lady Hallett: Oh just put it up on screen, Mr Weatherby. It’s the end of the day.

Mr Weatherby: Thank you, I will be as quick as I can.

INQ000108737, and it’s page 12, please.

I think, just while it’s being put up, this illustrates the point that I think you were just about to make. Can we highlight the graph, please, at the top. Now, this is a report from Audit Scotland, a government report, and it sets out various pieces of PPE, and it’s between April 2020 and May 2021 and the levels, and just from a brief glance at that, it appears that, to start at April, the levels of PPE were almost out, putting it briefly; would you agree with that?

Ms Fiona McQueen: Yes.

Mr Weatherby KC: Yes, and were you aware of that at the time?

Ms Fiona McQueen: Yes.

Mr Weatherby KC: Okay. Just very briefly indeed, what actions did you personally take to resolve those issues, if any?

Ms Fiona McQueen: So PPE was not – in terms of the supply of it, was the responsibility of national shared services and –

Mr Weatherby KC: Right.

Ms Fiona McQueen: – but, however, that did not mean to say I did not have anything to do with it. So my DCNO was on these workforce meetings and she would feed back to me, we would be assured by our colleagues, policy colleagues who were overseeing it, that they were doing as much as they possibly could to do that –

Mr Weatherby KC: Right, so, effectively, you escalated it and you were reassured?

Ms Fiona McQueen: I think I would go further than reassure, I think I was assured, though evidence was given in terms of – and, of course by this time, there was an international demand, so –

Mr Weatherby KC: Yes.

Ms Fiona McQueen: – our suppliers were struggling to supply us, we needed to get PPE from different areas across the world, and that in itself was tricky. So, although we thought we maybe have a two-day supply and we know we’re going to get four weeks’ supply coming into Prestwick Airport from China, until it was actually into us and through Customs we didn’t know.

Mr Weatherby KC: Right. Just again, in one sentence, if you can, is there a lesson here, moving forward, for the next emergency of this nature which will occur?

Ms Fiona McQueen: For sure, I think that whole – the management of PPE, so the rotation of stock, how much do you have, looking at best and worst-case scenarios, then I think there’s absolutely no doubt that that is one of the key areas that needs to be addressed.

Mr Weatherby KC: Yes, thank you.

Ms Fiona McQueen: Subject to funding.

Mr Weatherby KC: Okay. I’ve got a second topic but I think you’ve probably dealt with most of it, so I’ll be very brief indeed.

You say in your statement that the Scottish Government’s specific role was limited to the general promotion of NHS Scotland as a potential employment opportunity for temporary registrants. My question was going to be why you said that. Is it right that you say that it was limited because of your earlier evidence that, in fact, you didn’t think the temporary registrants were in fact necessary?

Ms Fiona McQueen: So if I may take slightly more than one sentence to answer you.

Mr Weatherby KC: Sure.

Ms Fiona McQueen: I think at the beginning of the pandemic we didn’t know, in fact, I thought we would have been much more overwhelmed than we were. We were looking at pictures of Italy and patients lying on ED floors, nurses, you know, becoming incredibly ill at work. So we didn’t know what we were going to get, and we didn’t know whether or not, so we needed to open all avenues –

Mr Weatherby KC: Yes.

Ms Fiona McQueen: – so that we would have that supply.

I think there are ways we could better utilise temporary registrants, I think if we had a better system. Now, one of the things we did put in place from about May was we had a calculator of workload right across health and social care, so that we knew what the demand was and we knew whether or not there was a demand for workforce.

Mr Weatherby KC: Yes, okay.

Ms Fiona McQueen: I think we probably could have done more to help the temporary registrants into perhaps social care or some other place that was struggling.

Mr Weatherby KC: My last point, you refer later to further preparatory work that might have been done, does that relate to the point you were just making, in terms of how you could arrange it so that temporary registrants could be brought on, on-boarded and used appropriately?

Ms Fiona McQueen: I think most definitely, as well as looking at surge capacity and how we can keep practitioners who are not working contemporaneous in their practice.

Mr Weatherby KC: That’s perhaps something that should be looked at going forward?

Ms Fiona McQueen: Definitely.

Mr Weatherby: Thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Mr Weatherby, very grateful.

Mr Wagner.

Questions From Mr Wagner

Mr Wagner: Yes, I’m all the way over here, hello.

My name is Adam Wagner and I ask questions on behalf of 13 pregnancy, baby and parenting organisations.

I’ve got two topics to ask you about. The first is about guidance in neonatal care. In November 2020 the Scottish Government added a line to the neonatal care guidance, which said this:

“Parents should be offered opportunities to remove face masks where it’s safe to do so to encourage bonding and support skin-to-skin and kangaroo care.”

Just to pick up on those final two words, is it right to say kangaroo care is a method of holding your baby to your bare chest allowing for skin-to-skin contact?

Ms Fiona McQueen: Skin to skin, so the baby would be bare and you would be bare.

Mr Wagner: Were you involved in the changing of that guidance?

Ms Fiona McQueen: So I had another Deputy Chief Nursing Officer, who was the Chief Midwifery Officer and she would have developed that guidance, along with the Director of Children and Families Directorate.

Mr Wagner: Do you have any knowledge of why the Scottish Government decided to modify the guidance in that way and add in that extra reference to skin-to-skin care?

Ms Fiona McQueen: No, I don’t, but my view is skin-to-skin care is an evidence-based intervention that supports physical wellbeing of a neonate as well as the emotional health of the parent.

Mr Wagner: So that would be why that exception was made to the mask wearing, that they could take their mask off, because skin-to-skin care is so important.

Ms Fiona McQueen: It’s so important and, by that time, we would have seen how the virus was operating, we would have been able to take on balance proportionate risks that we were not prepared to take earlier on in the pandemic.

Mr Wagner: So on-balance proportionate risks relating to the mask wearing versus the benefits of skin-to-skin care.

The second area I wanted to ask you about is the wider restrictions that were placed on maternity services, and I appreciate you said that there was – that you had a deputy who was responsible for that care, but may I ask you just a couple of questions about that overall point because you do refer to it in your statement.

So just by way of context, there has been a number of reports since the very early stages of the pandemic relating to the impact of IPC, infection prevention and control, restrictions on maternity services.

Are you aware that, according to a 2022 report, perinatal depression – that’s depression around maternity and birth – and anxiety almost doubled during Covid-19?

Ms Fiona McQueen: Yes.

Mr Wagner: You are. Are you aware of the statistic that’s in the same report that the rates of depression and anxiety amongst women who gave birth during Covid-19 were as high as 61%?

Ms Fiona McQueen: So I wouldn’t have been able to give you the statistic, but I knew it was high.

Mr Wagner: Yes. Then, secondly, are you aware of the – there was an MBRRACE rapid report published in August 2020, relating to maternity services.

Ms Fiona McQueen: No, but I may know the topic, if you remind me.

Mr Wagner: One of the findings that the report made, so it looked at March to May 2020, and it was published in August 2020, and it found that four women who were pregnant or had recently given birth had died by suicide during that three-month period, and the authors found that changes to the service provision as a direct consequence of the pandemic meant that women were not able to access appropriate mental health care, and it found that the receipt of the specialist care they needed may have prevented their deaths.

Have you heard about that, those kind of issues arising?

Ms Fiona McQueen: I’ve heard about those kind of issues not necessarily associated with maternity but with wider societal issues, yes, tragically.

Mr Wagner: Then, thirdly, there was a study in October 2021 that concluded the re-establishment of face-to-face parenting support groups appeared to be imperative to postnatal emotional wellbeing and recommended the prioritisation of essential face-to-face healthcare visitation in the immediate postnatal period?

Now, you may not be aware of the report but would you agree with the sort of sentiment of that?

Ms Fiona McQueen: Yes.

Mr Wagner: So in that context, I just want to ask you about your statement at paragraph 208, and I don’t need to have it up on the screen, but you say there:

“Whilst we recognise the impact the virus had on the more vulnerable in society, I wonder if we could have done more during the pandemic to support such groups …”

You say:

“With hindsight a number of measures may have been beneficial, changing restrictions to support new mothers to receive additional in-person support from family and friends …”

So with hindsight, can you give a bit of detail about what kinds of changes you would have made for new mothers?

Ms Fiona McQueen: So without – I’m going to repeat that I have been out of healthcare for over three years and, therefore, I don’t have the benefit of the wisdom of having colleagues, but it’s my understanding that a new mother could not have visitors. So I think being able to have your mum or your sister or a close friend, or someone else coming in to help and support you, would have been beneficial.

So I think looking – and that, if we look at visiting in maternity hospitals, the real challenge there is, if somebody is looking for additional support, then the balance is people who come in may have been bringing Covid and then there would have been nosocomial infection right across the unit. So the balance there is someone’s benefit could be harming someone else.

Once pregnant women are home with their babies or, you know, in the lead-up to birth, when they’re in their own house then they can make their own decisions and take their own risks about the balance of having emotional support for their wellbeing versus the risk of Covid, and of course they could then talk to whoever was providing them with that support and know that their behaviour was keeping them safe without Covid.

So I think there are ways that we could have learned for how we could bubble bigger groups together to provide emotional support or provided, with social distancing, classes or supports. Because I know that – you know, in the postnatal period, if it had been – although you don’t have to have a toddler to go to toddlers groups, you can have a brand new baby, you know, there are many informal ways that people in society have support and new mothers have there as well.

So I think, you know, working with women to find out what was most distressing for them, and I think we know, but working to see what we could do I think would be important, so that we know for the next pandemic, and it needs to be rehearsed and looked over, at ways we can mitigate and prevent some of the tragedies that have happened as a consequence of this pandemic.

Lady Hallett: I’m afraid you’re going to have to leave it there, Mr Wagner, I’m sorry.

Mr Wagner: Yes.

Lady Hallett: I think I’ve stretched the stenographer’s patience to the limit today.

Thank you very much indeed, Ms McQueen. I’m really grateful to you. I hope your daughter didn’t get put off nursing, did she?

The Witness: No, she is thriving, thank you.

Lady Hallett: Wonderful. Well, I’m sure it’s a proud family tradition now. So thank you very much for your help, I’m really grateful, thank you.

The Witness: Thank you, my Lady.

(The witness withdrew)

Lady Hallett: 10 o’clock tomorrow.

(4.46 pm)

(The hearing adjourned until 10 am on Wednesday, 18 September 2024)