5 November 2024

(10.00 am)

Lady Hallett: Mr Scott.

Mr Scott: Good morning, my Lady. May we please call Professor Fu-Meng Khaw.

Professor Fu-Meng Khaw

PROFESSOR FU-MENG KHAW (affirmed).

Questions From Counsel to the Inquiry

Mr Scott: Good morning, Professor. Can we have your full name, please.

Professor Fu-Meng Khaw: Fu-Meng Khaw.

Counsel Inquiry: And you are here today to give evidence on behalf of Public Health Wales; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And can I just ask when you started working for Public Health Wales?

Professor Fu-Meng Khaw: On 1 June 2021.

Counsel Inquiry: And prior to that, what were you working as?

Professor Fu-Meng Khaw: I was working in Public Health England as the centre director for the East Midlands then subsequently as the national programme director.

Counsel Inquiry: And since June 2021 what has been your role within Public Health Wales?

Professor Fu-Meng Khaw: I am the national director for health protection and screening services and the executive medical director.

Counsel Inquiry: Thank you. Just a brief outline of the role of Public Health Wales. So part of the responsibilities are maximising the use of digital data research and evidence to improve public health and also part of Public Health Wales’ responsibilities is it’s a Category 1 responder, as defined by the Civil Contingencies Act, and therefore plays a key role in relation to the preparation for and response to any emergency and major incident; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: So there’s very much a future-looking data-driven element to the Public Health Wales, is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: At the start of the pandemic, did Public Health Wales actually have all of the data and surveillance that it required in order to able to track cases of Covid-19, hospital admissions, or did it not?

Professor Fu-Meng Khaw: So at the start of the pandemic we were building on the surveillance of communicable disease processes that we routinely have and that includes monitoring cases of infectious diseases and particularly spotting clusters and outbreaks of communicable diseases so that we can take early interventions to control further transmission.

With respect to hospital infections, clearly anyone who had a laboratory test with a result of an infectious disease we would collect as part of our surveillance.

Counsel Inquiry: Yes, but were you able to get – let me do this a different way.

Can we please have on screen INQ000409575, page 4, paragraph 13.

So this is the Public Health Wales statement, and:

“… up until 24 March 2020, NHS Wales had few reports flowing out of our laboratory system on staff and patients who had positive Covid results.”

Apologies, this actually isn’t the Public Health Wales statement. This is a – let me find the correct reference.

Lady Hallett: Take your time, Mr Scott.

Mr Scott: This is a statement of Andrew Nelson, chief information officer at a health board.

Mr Nelson there sets out there that:

“… up until 24 March … NHS Wales had few reports flowing out of the laboratory system on staff and patients who had positive Covid results.”

So in the early days, admission volumes was left to text mine free text fields from the emergency department and that was relied upon to provide a record of who had been tested and what the outcome of the test was.

“The absence of this information meant that during March we had limited access to prevalence and admission data from which we could monitor or estimate growth rates and to provide an effective operational response.”

Now, if that’s the chief information officer at a health board is that unique to the health board or did that also apply to Public Health Wales?

Professor Fu-Meng Khaw: So let me set out the position as I see it. From 1 February Public Health Wales undertook laboratory diagnosis of Covid-19 and made this test available across Wales through its network of laboratories.

And any test coming through that system is reported on the LIM system which is mentioned in this statement, which the Laboratory Information Management system and the results of that would have been available to all health boards.

Counsel Inquiry: So did Public Health Wales have the tracking of all of these cases? Because if it was not available to this health board, which seems to be the implication particularly of that final sentence of paragraph 13, then how was it available to Public Health Wales?

Professor Fu-Meng Khaw: So we have access to LIMs in the same way but obviously we have direct access to the outputs of our own laboratories so we had access to the information to collate information about Covid positive test results and that information would have been also available to health boards at a local level.

Now we collated the information in our surveillance reports and through a variety of mechanisms, whether it was publication of the daily dashboard or sharing information at weekly meetings of our surveillance outputs, we were able to share the outputs of the surveillance of Covid-19 throughout the pandemic.

Counsel Inquiry: So you were satisfied that you were able to track – when I say “you”, I mean Public Health Wales, were able to track all the cases that there were in Wales from February 2020, is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And were you also able to track the – if we just go on to paragraph 15 of this statement. Just over the page. Thank you.

So:

“A further implication arising from the design of the hospital element of the record was … that data is not available to WG [presumably Welsh Government], NHS Wales or others at a coded date … level until clinical coding 3 months post event, unless the patient went to theatre … Subsequently … there was limited ability to use the data to:

“… monitor and analyse who was receiving what level of care.

“… assess whether somebody was admitted due to Covid or whether [it] was an incidental finding, or

“… assess how outcomes varied dependent on care pathway and treatment decisions.”

Are you satisfied Public Health Wales did have all of that information?

Professor Fu-Meng Khaw: So Public Health Wales has access to information that allows it to link up several information sources so hospital episode statistics means we are then able to track when a person was admitted to hospital and by linking it with datasets about the test results we were then able to say when the hospital admission occurred in relation to the test result to make assumptions about the acquisition of infection, whether it was community onset or hospital onset and we published reports of those outputs.

Counsel Inquiry: That’s not quite what this paragraph is touching upon though. Is – those three bullet points there, is that type of information that Public Health Wales would have sought to gather?

Professor Fu-Meng Khaw: So we worked very closely with Welsh Government through the Health and Social Services Group, Planning and Response Group that had an overview of NHS planning and response throughout the pandemic and we provided epidemiological reports on the surveillance of Covid occurring whether it was in the community or in the hospital.

And the level of information in this statement talks about clinical coding and outlines some of the challenges in having official results of the level of care that an individual receives in hospital. That wasn’t in the direct remit of the surveillance function for Public Health Wales on monitoring communicable diseases.

Counsel Inquiry: So the answer, effectively, is this isn’t something that Public Health Wales needed to know?

Professor Fu-Meng Khaw: It wasn’t our direct responsibility to report on the level of care received by patients in hospitals.

Counsel Inquiry: Yes, but in terms of your levels of responsibility, when you’re in the middle of a pandemic, roles, remits, areas and importance can slightly shift compared to non-pandemic times; is that fair?

Professor Fu-Meng Khaw: That is fair but we clearly have to prioritise against what we had the expertise and capability and capacity to do, which was the surveillance of communicable diseases.

Counsel Inquiry: Right, so the surveillance of diseases, did that take up all of Public Health Wales’ capacity then?

Professor Fu-Meng Khaw: No, it didn’t. We were also there to help with the control of transmission through investigation of outbreaks, we also established genome sequencing and used that to understand the transmission of the disease.

Counsel Inquiry: So these elements here that we can still see on the screen, those are aspects that fall outside of Public Health Wales’ remit and is it your evidence that actually they shouldn’t have fallen within Public Health Wales’ remit during the pandemic at all?

Professor Fu-Meng Khaw: Not entirely. So assessment as to whether somebody was admitted due to Covid or whether Covid was an incidental finding was absolutely within our remit and we did publish nosocomial transmission reports to that effect.

Counsel Inquiry: I just want to come back to the reason why I was looking at this. You have an information officer from a health board who is talking about a lack of access to what seems fairly fundamental data. Would you agree with that?

Professor Fu-Meng Khaw: That is what I read in this statement, yes.

Counsel Inquiry: And if Public Health Wales is looking to make sure that it was having access to the relevant data in its role as maximising use of digital data to improve public health and as a responder for a major emergency, a major incident, is this – is making sure that boards have access to this type of information something that Public Health Wales did do or should have done?

Professor Fu-Meng Khaw: We contributed to the thinking and the planning and worked directly with the Welsh Government Health and Social Services Group.

Lady Hallett: I’m sorry to interrupt, Mr Scott.

Can I just go back a step, Professor, and it’s probably a different point from the one that Mr Scott is pursuing.

To carry out surveillance of the spread of Covid infections in Wales, you need to survey how many people are positive in the community, how many people are positive in hospital admissions?

Professor Fu-Meng Khaw: That’s correct.

Lady Hallett: How widespread was testing at the time that we’re talking about in Wales?

Professor Fu-Meng Khaw: In the early stages of the pandemic testing was very limited because of the lack of availability of testing kits and testing platforms at the time and there was a huge competition for these across the globe. So we had to prioritise our testing for those who needed it most and mostly it was testing to diagnose.

Lady Hallett: So in other words, your data is coming from positive tests in a hospital healthcare setting?

Professor Fu-Meng Khaw: Mainly because these were symptomatic people who were admitted to hospital and the case definition at the time was that they had to be fulfilled before a test was requested.

Lady Hallett: So the data you had at the time would have given you virtually no idea of what was going on in the community?

Professor Fu-Meng Khaw: Indeed.

Mr Scott: Should you not have found a way or should you not have planned to make sure that you did have access to that information prior to a pandemic?

Professor Fu-Meng Khaw: But we rely on testing activity and if there was limitation in the testing activity there was no way of ascertaining whether or not someone in the community indeed had Covid.

Counsel Inquiry: Talking also about the surveillance and you’re talking about causes of death in your statement at paragraph 109, and the form was created, and it’s described as saying:

“… throughout April 2020 Public Health Wales, DHCW, the Welsh Government and health boards worked together to construct an electronic reporting form …”

So that was the form that was then used in order to provide key information about deaths; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: If we can have that on screen, please. That’s INQ000276009.

So this is the form that was created?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: Why was it that it was only throughout April 2020 that work was being done on creating a form such as this rather than being done at an earlier stage?

Professor Fu-Meng Khaw: So there were systems of notification around deaths occurring in hospitals at the beginning but it transpired from early experience that this wasn’t reliable. So we wanted to put in place a consistent method of rapid surveillance and mortality occurring in hospitals and on 23 April this was implemented after discussion with the chief statistician at Welsh Government and also in liaison with the national Wales information service.

Counsel Inquiry: You say it transpired from early experience this wasn’t reliable. When did you realise it wasn’t reliable?

Professor Fu-Meng Khaw: I think there was a document summarising some of the challenges in existing systems. There were multiple routes of reporting. Some relied on official information through the ONS with a data lag of 10 to 15 days which at the time was not acceptable because we wanted a rapid surveillance system to indicate the trends in mortality occurring in hospitals.

Counsel Inquiry: Yes, but the question was when did you realise it wasn’t reliable?

Professor Fu-Meng Khaw: Very close to that time, in early April.

Counsel Inquiry: And so early April you realised it wasn’t reliable. And then it was on 23 April when this form became widely used; is that correct?

Professor Fu-Meng Khaw: Well, it was implemented on 23 April with the communication from Dr Andrew Goodall who was chief executive of NHS Wales and Director General of the Health and Social Services Group and in the email there were signposts to guidance documents on how to complete the form and a training video that we prepared.

Counsel Inquiry: So if it was implemented on 23 April, from what point in time were you satisfied that the information that you were gathering via this form was accurate and was a complete representation of what was happening in hospitals?

Professor Fu-Meng Khaw: That’s a difficult question to answer because throughout the pandemic it was clear that there were elements of the form that were not as well completed as they might be and there was missing information, for example in the 6,514 deaths that had been registered throughout the life of this form, there were over 1,000 elements of missing data in the question around key worker status, for example. So we couldn’t reliably report on some of the elements in this e-form.

Counsel Inquiry: What did you do, because you generated this form in April 2020, it clearly contained information that was required by Public Health Wales or other bodies, what did you do to make sure that it was accurately completed, because it was all necessary information?

Professor Fu-Meng Khaw: So there were weekly meetings at the outset with all the health boards, with clinicians from health boards, particularly through medical directors and my predecessor and the chief statistician for Welsh Government co-chaired these mortality meetings and that was an opportunity for improvement in reporting using the e-form. The e-forms were completed often not by a single person in each health board and were shared amongst the clinicians in the health board reporting the deaths.

Counsel Inquiry: I just want to look at one line at the bottom. It was highlighted earlier on, if we could please have that highlighted again. The highlighted line “Was the patient a key worker?” And there are five different buttons that can be pushed, one of which is a healthcare worker. So it was intended when this form was created, was it, that you’d be able to flag up whether somebody who died was a healthcare worker?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: In your statement at paragraph 126 it says:

“We do not hold data in respect of the number of staff within healthcare settings in Wales recorded as having died of COVID-19. This is because the occupation of cases was not recorded on most laboratory reports or rapid death reports.”

How is it that you weren’t getting the information that you required from this form?

Professor Fu-Meng Khaw: As I said earlier, there was a significant element of missing data in this particular question, about 17% missing data. Where we were able to collect information on healthcare worker status, I think there were 36 responses to the status as a healthcare worker, representing 0.6% of the mortality reported.

Counsel Inquiry: It was very important information that you had an understanding of who the staff were who were dying of Covid-19, is that fair?

Professor Fu-Meng Khaw: It is an important aspect of our surveillance, and clearly this had to be understood in the context of the denominator as well, and this is information that we don’t usually report on, so the denominator of healthcare workers in Wales.

Counsel Inquiry: Yes, but it was a question that was included in the form specifically for the purpose of capturing that data.

Did you think to make it – there are ways when you complete electronic forms that you can’t submit a form unless you’ve answered a question. Did you think that that should have been done for that question so that you made sure that every form included all the information rather than a 70% gap?

Professor Fu-Meng Khaw: That is a possible improvement that we would consider in the future.

Counsel Inquiry: Is there any other improvements that you can think of to capture the data about deaths or infections of healthcare workers in Wales?

Professor Fu-Meng Khaw: I think there’s more we can do in the future and – I think the mechanisms we put in place were intended to improve the quality of reporting and we could have done more to continuously improve it throughout the pandemic.

Lady Hallett: Can I just ask a question. Sorry, I’m interrupting all the time this morning.

Going back to you could consider a form that you could only submit the information if you completed all the boxes. But can I challenge that. I appreciate it was put to you by Mr Scott and you accepted it, but wouldn’t it be more important to find out how many people had died of Covid? I mean, obviously it’s important to find out their status if you can, but wouldn’t you rather get the information even with the incomplete boxes?

Professor Fu-Meng Khaw: There’s always a balance between having a robust method for collecting information, that might take a lot longer and at the time, as you can imagine, it was a pretty difficult time for everyone and filling a form like this might be one of many things people had to do. So the purpose of this surveillance wasn’t to provide a comprehensive capture of information, which there are official statistics that do that through death registration, that are more robust and more defined but this was a very raid surveillance method for capturing mortality which was the primary purpose of this.

Mr Scott: Can I move on to understanding of ethnic grouping.

That document can come down, thank you.

Did Public Health Wales have access to sufficient information about the various ethnic groups that people fell into when they were testing positive with Covid?

Professor Fu-Meng Khaw: So in order to have data on ethnicity we rely on information from either the requester of the test or information available on the so-called master patient index available in Wales which has all the demographic information collected at the point of entry into the NHS, and this routine data allows us to understand whether ethnicity plays a role in a whole range of outcomes, not just around Covid.

So we had access to that information. The reality is that for the laboratory reporting forms, this data was typically not available.

Counsel Inquiry: Why is that?

Professor Fu-Meng Khaw: That’s because it wasn’t completed if requested and often this would rely on a requester making assumptions about ethnicity and putting it on the request form.

Counsel Inquiry: So when you say making assumptions, can you just expand a little bit about how someone was making assumptions rather than recording information?

Professor Fu-Meng Khaw: So recording information about ethnicity will require someone to designate an ethnic group to an individual. If they don’t have direct access to that individual, for whatever reason, maybe they didn’t have capacity at the time of taking the sample, then that field is often not filled in.

Counsel Inquiry: Was there any guidance that was given by Public Health Wales for those who were taking a sample to say: we need to make sure that you’re recording these various categories of data?

Professor Fu-Meng Khaw: There wasn’t specific guidance, no.

Counsel Inquiry: Do you think that should have been issued?

Professor Fu-Meng Khaw: I think we relied very heavily on routine systems for data collection and if it’s not in the routine system then it – the extra steps we take might not have been adhered to, despite guidance.

Counsel Inquiry: Again I come back to the question I asked earlier on, when you are looking for that extra information beyond the routine systems, you’re asking for that information for a reason and therefore is it not incumbent upon Public Health Wales to do what they can to make sure that they are getting as much of that information as they can? It wouldn’t necessarily be perfect but you have taken all steps to satisfy yourself you get that information you need?

Professor Fu-Meng Khaw: So our preference would be to rely on the data available through routine registration of a patient and individual in the NHS and that allows us to have a consistent ethnic designation for any individual and allows us to define therefore the denominator.

Counsel Inquiry: Because if I can please take you to INQ000224048. So this is page 11. I wonder if we can go to page 1, please. So this was a rapid analysis of ethnic variation in Covid-19 outcomes in Wales using Onomap, a name-based ethnicity classification tool, and this is dated 24 May 2020.

Could you please explain the reason why Onomap, which is a software package to classify ethnicity based on names, was used rather than the access to the information that you actually had on the systems about ethnicity?

Professor Fu-Meng Khaw: The system that we had access to where information around ethnicity on individuals is stored didn’t have a very good completion rate.

Counsel Inquiry: What was the completion rate?

Professor Fu-Meng Khaw: But I understand it’s about 40%. So for 60% of individual across Wales, we didn’t have information around ethnicity.

Counsel Inquiry: Pausing there. From a public health perspective, can you draw any conclusions if you’re missing important information about 60% of the population?

Professor Fu-Meng Khaw: I think it depends on what you’re investigating, so statistically you would undertake a power analysis to understand whether a gap in the data of that proportion will have a bearing on the findings of whatever you are studying at the time.

Counsel Inquiry: When did it become apparent there was a 60% gap? Was it at the start of the pandemic or had it been known prior to that?

Professor Fu-Meng Khaw: I think it had been known generally, prior to that, that the capture of ethnicity data is not good.

Counsel Inquiry: Has any steps been taken to improve that capture?

Professor Fu-Meng Khaw: So one of the things that came out is the First Minister established BAME advisory group, recognising the disproportionate impact on black and Asian minority ethnic groups in Wales, and one of the elements of the recommendations and the report published in September 2021 was for work to be done to improve the capture of ethnicity data in the NHS.

Counsel Inquiry: How is that going?

Professor Fu-Meng Khaw: I can’t comment, I’m not in a position to clarify what the process is undertaken led by Welsh Government.

Counsel Inquiry: Okay. Is Public Health Wales involved in that programme then?

Professor Fu-Meng Khaw: It is.

Counsel Inquiry: So, then, just coming back to the Onomap assessment, this was – is it fair to say this was the best that Public Health Wales were able to do to provide an understanding of ethnic variation of Covid-19 in Wales by using Onomap?

Professor Fu-Meng Khaw: We had experience of applying Onomap to other infectious diseases and understanding of blood-borne viruses prior to the pandemic, so it was an opportunity to use this to develop understanding about SARS-CoV-2 at the time, and we were proactive in this regard and obviously shared our findings of the initial assessment with the relevant decision-making groups, including the First Minister’s BAME advisory group.

Counsel Inquiry: And there are difficulties with Onomap, is that fair to say?

Professor Fu-Meng Khaw: That is correct, and the strengths and limitations of the software are discussed in the final published article.

Counsel Inquiry: Yes. I think if we can actually go to that it’s INQ000276032, and that is at page 8. This is, I think, the published article that came out in the BMJ; is that correct?

Professor Fu-Meng Khaw: Can you give me a tab number reference, please?

Counsel Inquiry: This is 11. So this is the table of, effectively, the difference between the ethnicity that was reported and the ethnicity that was predicted. And I think to summarise it, it was recognised that Onomap has a habit of overestimating the white population and in particular underestimates the black population; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And so you can see there in particular that the ethnicity reported by the participant is of black or black British is 377, and Onomap actually predicted 143. So, less than half.

How useful was this tool to be able to allow you to have an understanding of the impact of Covid-19 on ethnicity if the tool that you’re using has not a hugely successful rate of identifying, in particular, black or black British ethnicity based solely on their names?

Professor Fu-Meng Khaw: There are limitations in using the software and you’ve you know talked about some of these and you know the rest are in the published article. So in terms of its utility, clearly at the time there wasn’t much else in terms of analysis. We were also working alongside other sources of information and the ONS had published – had started to publish mortality data demonstrating the differential impact of Covid on black and ethnic minority groups. So this helped build our understanding, but with the limitations, we had to interpret it alongside other sources of information.

Counsel Inquiry: Did it build an accurate understanding or did it build just a general understanding?

Professor Fu-Meng Khaw: I think it contributed to the understanding. It wasn’t the whole understanding because of the limitations of the use of this, but it was useful in forming the work of the BAME advisory group.

Counsel Inquiry: I want to ask you about hospital capacity and modelling now. It’s correct that Public Health Wales didn’t have any role in providing advice or guidance on the capability of different sectors of healthcare systems to scale up or scale down to areas of need, is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: But Public Health Wales did have a role in modelling reasonable worst-case scenarios which was then used to inform how that capacity should be scaled up and scaled down; is that correct?

Professor Fu-Meng Khaw: That is correct.

Counsel Inquiry: And if we could, please, have on the screen INQ000469765, page 17, paragraph 49. And this is the Public Health Wales statement. And we’re saying here the model from NHSE was refined because I think it’s correct that Public Health Wales didn’t have the capacity or the capabilities to come up with reasonable worst-case scenario, so the one that had been created by England was adopted for Wales, is that a broad summary of it?

Professor Fu-Meng Khaw: It was used to model potential impact in Wales at the very early stages.

Counsel Inquiry: And then there was a disagreement between Public Health Wales and the Welsh Government about whether it should use 25% or 40% of the reasonable worst case scenario and four lines up from the bottom:

“Public Health Wales is unsure as to why the Welsh Government provided estimates for 40% of the [reasonable worst case]. The effect of using different percentages is to reduce the numbers …”

I just want to unpack that a little bit. 25 or 40% of the reasonable worst-case scenario, what does that actually mean?

Professor Fu-Meng Khaw: So the reasonable worst-case scenario is a prediction about the worst scenario that health services could face in terms of a – Covid as it was emerging at the time through modelling trajectories of cases.

Counsel Inquiry: Her Ladyship has heard a lot about this in Module 2 in particular, so yes.

Professor Fu-Meng Khaw: So the reason for choosing something less than that was to allow health service planners to also plan for other context where perhaps it was 40% of the worst-case scenario or 25% of the worst-case scenario, so that there was an understanding if the worst-case scenario didn’t emerge as to be the case, then this is what 40% or 25% might look like.

And, as we said in my statement, the first wave actually produced 7% of the revised worst-case scenario.

Counsel Inquiry: Yes, but I’m struggling to understand what 40% is. Is it 40% of the numbers that were in the reasonable worst-case scenario? I mean, what actually was it because it sounds like a multiplier but it doesn’t seem that straightforward.

Professor Fu-Meng Khaw: It is a multiplier. So it’s 40% of the numbers you would expect from the reasonable worst-case scenario.

Counsel Inquiry: Was it based on a 40% compliance with control measures in Wales?

Professor Fu-Meng Khaw: No, it’s based on 40% of the numbers predicted through the reasonable worst-case scenario and therefore planning what hospital admissions might arise from that, and therefore the resources required to meet with that demand.

Counsel Inquiry: Okay, and why was the Welsh Government providing estimates rather than Public Health Wales?

Professor Fu-Meng Khaw: Well, Welsh Government were using an interpretation of reasonable worst-case scenarios to help with the planning, and Public Health Wales in the early stages recognised that it didn’t have a primary role in modelling, it didn’t have the capability to undertake sophisticated modelling, and therefore it looked to the modelling that was undertaken in England to extrapolate to Wales to give an early indication of the capacity demand of the system.

Counsel Inquiry: So whose primary responsibility was it to model that capacity, Public Health Wales or Welsh Government?

Professor Fu-Meng Khaw: It wasn’t Public Health Wales.

Counsel Inquiry: It was or wasn’t, sorry?

Professor Fu-Meng Khaw: It wasn’t Public Health Wales.

Counsel Inquiry: I want to move on now to infection prevention and control. So there’s a team within Public Health Wales called the Healthcare Associated Infection, Antimicrobial Resistance & Prescribing Programme, I think the acronym is HARP?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And it was HARP who engaged with the UK IPC cell, and the head of HARP and the assistant medical director and the consultant nurse within HARP became members of the Covid UK IPC cell, is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And was it right that effectively HARP didn’t create IPC guidance itself but it applied the UK IPC guidance?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: Were there any differences of opinion about what the form of the guidance should be between Public Health Wales and the UK IPC cell?

Professor Fu-Meng Khaw: There wasn’t. We were completely aligned.

Counsel Inquiry: Did Public Health Wales have any capacity or capabilities to be able to independently, so distinct from anybody within the IPC cell, assess the routes of transmission, benefits of masks, any of those elements?

Professor Fu-Meng Khaw: No, there was no need to because of the construct of the UK IPC cell and how it looked to emerging evidence and considered it in issuing updates on the guidance.

Counsel Inquiry: Did Public Health Wales engage with any groups in Wales, professional bodies, representative groups, patient groups about IPC guidance and what it should say in any of their views on its impact?

Professor Fu-Meng Khaw: So we established a network of healthcare epidemiologists just before the pandemic, and these epidemiologists are in each of the six health boards where there are hospital settings, and they work very directly with the infection prevention and control teams locally. And through that network we were able to stay in touch with the experts at a local level. We also liaised with the Welsh Government Nosocomial Transmission Group that was co-chaired by the deputy Chief Medical Officer and the Chief Nursing Officer.

Counsel Inquiry: I want to ask about the relationship between PPE and IPC guidance. Did at any point in time the availability of PPE drive the way that the IPC guidance was constructed, as opposed to whether it was able to be applied in due course due to supply issues?

Professor Fu-Meng Khaw: I am led to believe that the UK IPC cell did not consider the shortage of PPE in that considerations as it was outside the scope.

Counsel Inquiry: So, I think you were careful when you said you were led to – you weren’t in role at the time this information had been given to you?

Professor Fu-Meng Khaw: I wasn’t.

Counsel Inquiry: Were you aware or was Public Health Wales aware that there were differences within Public Health Wales itself about whether there should be a greater use of FFP3 masks compared to FRSMs during 2020?

Professor Fu-Meng Khaw: I’m aware of the email from Brendan Keely, one of our consultant microbiologists, and you will have received that communication in exhibit, and we clearly responded to the inquiry around the wider use of FFP3 masks. And, clearly, in the hierarchy of controls, the use of personal protective equipment is the last thing one would consider. So we would look at eliminations, substitution, administrative and engineering solutions, before looking at personal protective equipment.

Counsel Inquiry: Yes, but I’m just interested in discussions within PHW, because if you had that individual who was sending emails – I believe he says “This isn’t the first time I’ve raised it” – were there internal discussions within Public Health Wales about what they should be saying at the IPC cell about whether there should be greater use of FFP3s and, if so, what was the outcome of those discussions?

Professor Fu-Meng Khaw: So the response to the email was guided by the UK IPC cell guidance that, actually, we need to consider this as a whole, that if there are outbreaks or concerns about local transmission, there needs to be a root cause analysis to identify whether additional precautions need to be taken over and above the use of PPE and that advice was given and in response to the email.

Counsel Inquiry: Yes.

Lady Hallett: Can I just go back to the hierarchy of controls, Professor. I have some problems with it and can I explain one of those problems which you just touched on. If your first port of call is elimination in the hierarchy of controls, why isn’t personal protective equipment part of your strategy for elimination? Surely if more people are protecting themselves from catching the virus, then that’s going to help with elimination. So why are they separated and put into a hierarchy; why are they not a package of measures as opposed to hierarchical structure?

Professor Fu-Meng Khaw: I think there is a rationale behind the hierarchy of controls that actually in the healthcare setting elimination might not be an option because you can’t eliminate the threat from a hospital setting because that is the very place that people will seek treatment if they have Covid. So I think the elimination agenda may not be applicable in some settings as easily as in other settings.

Lady Hallett: Not sure you’ve addressed the question. My question is, why is the hierarchy of controls a hierarchy, as opposed to “Right, we’ve got this virus, it’s possibly spreading, and here are a package of measures that we can put in place to try and make sure it doesn’t spread too far”?

Professor Fu-Meng Khaw: I think you are right in describing as a package of measures, and I think the hierarchy connotes some of the earlier steps you might take in order to control the transmission of infection and in some settings elimination is an absolute option. In others, it is more challenging.

Mr Scott: But when you’re talking about, for example, an emergency department, a waiting area, something along those lines where you can’t eliminate it –

Professor Fu-Meng Khaw: Exactly.

Counsel Inquiry: – then, when you’re talking about a package of measures, you need to look along those lines as you deal with it effectively as a collective piece?

Professor Fu-Meng Khaw: Indeed.

Counsel Inquiry: I just want to look at one particular document. It’s INQ000398224. This is the IPC cell meeting of 22 December 2020 which we’ve seen on a number of occasions in the Inquiry and four lines up from the bottom.

“ED”, and I think that there is Eleri Davies, head of HARP; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And she says there:

“There will be pressure from organisations and bodies for more precautionary measures. The confidence of staff in high intensity units is being lost. If there is a high-risk pathway we should take precautionary measures.”

At some point in time Public Health Wales is saying more should be done, is that right?

Professor Fu-Meng Khaw: So I think this is recognising that more should be done in the face of any high risk and in this context it could include aerosol-generating procedures.

Counsel Inquiry: Right. But nothing was done as a result of this. The guidance stayed the same, is that correct, after there had been discussions on the 23rd, as well?

Professor Fu-Meng Khaw: This was a discussion at the IPC cell at one of their meetings and will have informed the decisions of the group.

Counsel Inquiry: So Public Health Wales said, well, that’s been the consensus of the IPC cell and therefore we’re going to abide by that consensus?

Professor Fu-Meng Khaw: So the decisions of the UK IPC cell were clearly not individual decisions from individual members but it was a collective consensus based on the scientific evidence available at the time, and best practice where this was not available, and this discussion will have been taken into account in coming to the various iterations of the UK IPC cell guidance.

Counsel Inquiry: Right, so effectively Public Health Wales did abide by the consensus view that was taken at the cell, is that right?

Professor Fu-Meng Khaw: It did.

Counsel Inquiry: So even though at this point in time it had been recognised that the confidence of staff in high-intensity units is being lost, if the consensus was then followed what steps did Public Health Wales take to ensure the confidence of staff was maintained?

Professor Fu-Meng Khaw: So it reiterated the elements in the UK IPC cell that talked about local risk assessment and it talked about identifying root causes in order to put in interventions that would better control transmission.

Counsel Inquiry: That sounds a little bit like there’s been repetition of what the guidance already says. Surely this required a little bit more in order to retain the confidence of healthcare workers in Wales. Was that done?

Professor Fu-Meng Khaw: So in terms of, you know, doing more, there was a report published in September 2020, identifying lessons learned with lots of elements in that describe the measures that we should take in securing the – strengthening the ability to avoid nosocomial transmissions.

Counsel Inquiry: But did anybody from Public Health Wales talk to any representative groups of any healthcare workers and say: look, we recognise confidence is being lost, this is the reason why we’re taking these decisions, please have confidence, and actually explain it to them, rather than simply pointing people back to the guidance that they were already losing confidence in?

Professor Fu-Meng Khaw: I’m not aware of any direct conversations with healthcare workers. Our work on the Nosocomial Transmission Group was to co-ordinate this across Wales through that group.

Counsel Inquiry: Ventilation then. Public Health Wales didn’t have any role in advising about ventilation or portable air-cleaning devices; is that right?

Professor Fu-Meng Khaw: That’s right.

Counsel Inquiry: Despiting the fact that ventilation was an important part of IPC guidance?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: Why did it not have such a role?

Professor Fu-Meng Khaw: It’s not for me to speculate why that is but there are other parts of NHS Wales that have that role.

Counsel Inquiry: Well, do you think it’s a useful role for Public Health Wales to have in the event of a future pandemic?

Professor Fu-Meng Khaw: It might be a consideration but with any role we would need to ensure that we have the right capability and capacity to fulfil that role competently.

Counsel Inquiry: Before I look at nosocomial infections I just briefly want to touch upon visiting.

Did Public Health Wales provide any IPC assessment to show the relative benefit of imposing visiting restrictions for pregnant women and partners at hospital?

Professor Fu-Meng Khaw: So the Chief Nursing Officer in Welsh Government established a hospital visiting group that we were part of and contributed to the discussions of. We didn’t issue any guidance directly on this issue.

Counsel Inquiry: No, but did you provide any specific advice about visiting restrictions?

Professor Fu-Meng Khaw: I don’t have that information.

Counsel Inquiry: Did that visiting group seek the views of patients, families, about changing rules, the application of visiting guidance or not?

Professor Fu-Meng Khaw: I don’t know.

Counsel Inquiry: Do you think that the role of families was actually taken into account within that visiting group or do you know not that either?

Professor Fu-Meng Khaw: I don’t know but I assume it will have.

Counsel Inquiry: In terms of nosocomial infections then. I think it’s right that there were – there was a report on 13 April 2022 which identified there were more than 10,000 probable or definite hospital acquired cases in Wales over the pandemic period; is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And the probable layer is defined as 8 to 14 days after admission to hospitals when they test positive and definite is 15 days or more; is that right?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: If we can please have on screen INQ000276011, page 4. And ACM there we see referred to, that’s all cause mortality; is that correct?

Professor Fu-Meng Khaw: That’s correct.

Counsel Inquiry: And if we zoom in, please, on table 2 if possible. So we can see there a table which sets out the various different categories across the waves, and this is across the entirety of Wales.

So the one I want to focus on is probable hospital onset and definite hospital onset in wave 2. It looks like probable and definite hospital onset is over 50% of cases of Covid in the population during wave 2. Am I reading that correctly?

Professor Fu-Meng Khaw: That is correct.

Counsel Inquiry: And when we’re talking about wave 2, I think we’re talking, is that September 2020 through to July 2021?

Professor Fu-Meng Khaw: I think it’s September to May.

Counsel Inquiry: September to May, yes.

Professor Fu-Meng Khaw: July to May.

Counsel Inquiry: July to May.

So what lessons had been learnt from wave 1 about how to prevent nosocomial infections between wave 1 and wave 2?

Professor Fu-Meng Khaw: So the document we published was in September 2020 and that set out a range of lessons learnt and this was shared with the directors of nursing in Wales. It was also shared with the NHS leadership board through the Chief Nursing Officer and it was used on an ongoing basis through our network and in ongoing communications with the infection prevention and control teams at the health boards.

Counsel Inquiry: Okay, but what specifically was learnt?

Professor Fu-Meng Khaw: The lessons identified are wide-ranging and, you know, they include elements around testing and case definition, disease presentation, IPC and PPE use, patient placement, staff movement, social distancing.

Counsel Inquiry: Do you think that those lessons had been learned or even if they were learned whether they were necessarily entirely effective if more than 50% of cases in Wales were probable or definite hospital acquired in wave 2?

Professor Fu-Meng Khaw: I don’t have the information to confirm or otherwise whether the lessons were learned but the lessons were identified and in commenting on the mortality rate in different waves I think that also has a bearing on the severity of the variant concerned because during most of that period in the second wave we were dealing with the Alpha variant at the time and that may have a different characteristic in terms of clinical impact when compared with the other variants such as Omicron that was predominantly during wave 4.

Counsel Inquiry: Yes, but you are also then looking at preventing infections in hospital because even if your mortality isn’t – if death doesn’t occur, you still have serious illness issues such as Long Covid that arise. So standing back and looking at what happened in wave 2 and subsequently, could more have been done to prevent nosocomial infections in Wales?

Professor Fu-Meng Khaw: So we can see that the numbers of probable and definite hospital onsets as a proportion actually reduced throughout the pandemic and when you look at that table that you’ve highlighted the percentages have continued to reduce from a total of 70% in wave 1 to 24% in wave 4.

Counsel Inquiry: I’m not sure I understand the statistics but I think I’ll have to work that out myself in due course.

Can I please just ask you briefly about Long Covid. Did Public Health Wales have – that document can come down, thank you.

Did Public Health Wales have any role in identifying Long Covid within 2020, or putting in place any treatment measures that should arise for Long Covid?

Professor Fu-Meng Khaw: Public Health Wales doesn’t have any services that would address symptoms of Long Covid and it didn’t have a role in monitoring it.

Counsel Inquiry: Did it have a role in identifying Long Covid as a concept?

Professor Fu-Meng Khaw: No.

Counsel Inquiry: So Public Health Wales doesn’t have any role in identifying long-term impacts of a pathogen in a pandemic?

Professor Fu-Meng Khaw: It hasn’t so far, no.

Counsel Inquiry: Do you think that would be a beneficial addition to its role?

Professor Fu-Meng Khaw: It could be.

Counsel Inquiry: And then finally the last point I want to touch upon is shielding. So Public Health Wales didn’t have any involvement in the development of guidance in Wales around shielding. That was led by the Welsh Government and co-ordinated through clinical teams across the health boards. Did Public Health Wales provide any advice about any aspect of the support, the health that should be offered to those people who were shielding or their families?

Professor Fu-Meng Khaw: We didn’t and nor were we asked.

Counsel Inquiry: Just very finally. Are there any recommendations that you would wish the Chair to consider?

Professor Fu-Meng Khaw: So I have three suggestions. One is for the four nations of the UK to work closely together in the pandemic and we’ve seen some of the benefits of that in co-ordinating the UK IPC cell guidance which applied equally across the four nations and early involvement of the devolved administrations particularly in the development of guidance would be very beneficial.

The second is with respect to what we do in preparedness now for the next pandemic to clarify very clearly roles and responsibilities of different agencies. To learn the lessons of exercises that we undertake but also to undertake exercises at a national, regional and local level so that we get through the operational, tactical and strategic aspects.

And the final thing is around research and to focus on undertaking and co-ordinating priority research studies at the beginning and putting in processes to enable research to be undertaken efficiently, effectively and that are well resourced.

Mr Scott: Thank you, Professor Khaw.

My Lady, those are my questions.

Lady Hallett: Can I ask you to go back to your second possible recommendation, Professor. You said to clarify the roles and responsibilities of various organisations. What areas were there where you felt there wasn’t sufficient clarity of the roles and responsibilities?

Professor Fu-Meng Khaw: I think this was manifest during Module 2B in terms of the early experience we had around contact tracing and contact centres that for that to fall to one organisation without the ability to surge was quite challenging. So having clarity around our surge capacity, the workforce that we have in readiness to surge, and what digital solutions there might be to help us would be really helpful during this planning phase.

Lady Hallett: Thank you. Those are all the questions Mr Scott has for you. Mr Wagner has a question or some questions. He is over that way.

Questions From Mr Wagner

Mr Wagner: Good morning, I ask questions on behalf of 13 pregnancy, baby and maternity charities. I only have one area to ask you about and it relates to visiting guidance. You said in your answers earlier the Chief Nursing Officer in the Welsh Government established a hospital visiting group that you, Public Health Wales, were a part of and contributed to the discussions of.

Do you recall during those discussions whether any consideration was given to the health benefits of pregnant people having their partners available just, for example, having a support partner able to assist them post birth rather than requiring a nurse for assistance?

Professor Fu-Meng Khaw: I don’t have any specific recollection, partly because I wasn’t in those discussions, nor have I been given information to suggest that was a specific discussion by the group.

Mr Wagner: Thank you. That’s my question.

Lady Hallett: Thank you, Mr Wagner.

Miss Foubister. She’s behind the pillar.

Questions From Ms Foubister

Ms Foubister: Good morning, Professor Khaw.

I represent John’s Campaign, Care Rights UK and The Patients Association and I have some questions about the impact of public health messaging on access to healthcare.

At paragraph 104 of your witness statement you say that you understand that some – you understood that some patient groups had concerns about people with chronic health conditions not accessing or attending key appointments. What did you and/or Public Health Wales do about those concerns?

Professor Fu-Meng Khaw: Thank you. The co-ordination of public health communications was something we worked together as a system so that no single organisation would be seen as leading and we always worked very closely with Welsh Government who clearly oversaw the policy context, so Public Health Wales’ communication team would advise on statements and on the communications strategy.

Ms Foubister: Just specifically on my question though, in relation to your understanding that there were concerns about people with chronic health conditions not accessing or attending key appointments, did you do anything in response to learning about that?

Professor Fu-Meng Khaw: We didn’t do anything specifically but we did share that information with the relevant groups.

Ms Foubister: And why did you not do anything about that?

Professor Fu-Meng Khaw: Because we are part of a system and there are implications of communicating to the public about access to services that were beyond our direct control. So we would have to work in collaboration with other parts of NHS Wales, for example health boards who provide those direct services because if we are signposting people to access those services and those services are not prepared to take them then we wouldn’t be communicating the right messages.

Ms Foubister: And who did you tell about these concerns about people with chronic health conditions not attending appointments? Who were the specific people that you shared that with?

Professor Fu-Meng Khaw: So I do not recall and I do not have the information to know where that specific information was shared with but we can get that information for you.

Ms Foubister: Thank you.

At paragraph 103 of your witness statement you say there was no systematic assessment of what the impact of a Stay at Home messaging would be on planned and emergency care. Would such an assessment have been helpful?

Professor Fu-Meng Khaw: So we did undertake a health impact assessment to look at the impact of the social distancing and Stay at Home policy and that report was published and shared widely within Wales and that demonstrated some of the downsides of the policy and highlighted some of the concerns around health-seeking behaviours.

Ms Foubister: But you do refer to the health impact assessment at paragraph 103, but your first couple of senses in that paragraph explain that there wasn’t a systematic assessment, and so presumably you were drawing a distinction between the health impact assessment and a systematic assessment. And so what would the systematic assessment have provided that what was done wasn’t able to?

Professor Fu-Meng Khaw: So I would see a systematic assessment as something that was routine, that was undertaken on a continuous basis. The health impact assessment was a one-off assessment in the light of the change in policy.

Ms Foubister: And in this section of your witness statement you also talk about there being limited information about what the impact ultimately was of the Stay at Home messaging, there’s those two health impact assessments that you refer to. Why weren’t steps taken to collect or monitor that information, including from patient groups?

Professor Fu-Meng Khaw: I cannot answer why that wasn’t taken, but at the time, I think that the policy decision and its impact might have been another organisation’s responsibility because it didn’t directly relate to health protection.

Ms Foubister: And which organisation you would say would have been responsible if it wasn’t Public Health Wales?

Professor Fu-Meng Khaw: I cannot specifically answer that at this time but I think this is something we might need to consider going forward.

Ms Foubister: Thank you.

Thank you, my Lady.

Lady Hallett: Thank you very much.

Ms Polaschek. I think she is – that way.

Questions From Ms Polaschek

Ms Polaschek: Good morning. I ask on behalf of Clinically Vulnerable Families, and we just have one set of questions today in respect of the public health measures that were taken to protect those particularly clinically vulnerable to Covid-19.

The Chief Medical Officer, Frank Atherton, gave evidence to this inquiry that he recalled that close consideration was given to providing clinically extremely vulnerable patients with surgical masks. Do you recall or are you aware that there were discussions about providing either clinically vulnerable or clinically extremely vulnerable patients with masks and, if so, which type of mask was considered appropriate for their risks of catching Covid?

Professor Fu-Meng Khaw: I’m not aware of those discussions.

Ms Polaschek: Thank you.

In which case, madam, that is my question.

Lady Hallett: Thank you very much.

Mr Thomas.

He is behind you, Professor. If you could make sure, please, that even if you look at Mr Thomas while he’s asking the question, your answer goes into the microphone. Thank you.

Questions From Professor Thomas KC

Professor Thomas: Good morning, Professor. I am representing FEMHO, that’s the Federation of Ethnic Minority Healthcare Organisations and FEMHO is particularly interested in how data tools and methods can be refined to better understand and address the disparities within these communities.

At paragraph 151 of your witness statement, you reference an Onomap tool. Mr Scott referred to this earlier on today, which was a 2021 study to analyse ethnic disparities through named-based classifications.

Question: given the recognised limitations in using names alone for an ethnicity, how effective do you believe the Onomap tool was in accurately identifying ethnic health disparities during the pandemic?

Professor Fu-Meng Khaw: Thank you. Clearly the strengths and limitations of the use of Onomap are detailed in the published paper and I wouldn’t want to repeat those but we did recognise there were limitations in the findings as a result of that, and therefore we were keen to look at other evidence sources to develop understanding about the differential impact on BAME communities. We knew, at a very early stage, of the differential mortality incomes reported through the ONS which collects data through death registrations, and so this evidence that we generated proactively contributed to our understanding and contributed to understanding particularly in Wales. And some of the findings were interesting around younger people, greater admission to intensive care units, and also mortality rates, but it was part of our wider understanding about the differential impact.

Professor Thomas KC: Okay. I think you’ve touched upon my second question so I’ll move on to my next question.

Following the findings derived from the Onomap tool in identifying ethnic disparities did Public Health Wales explore other methods or other tools to complement these findings and further close gaps in understanding ethnic disparities?

Professor Fu-Meng Khaw: So our work on ethnic disparities relies on information about ethnicity, both in terms of the numerator, ie those people who were confirmed to be Covid-positive and the denominator, ie those people in Wales and their ethnic background. Without the denominator it is very difficult to make assertions around significant differences between different population groups, and the Onomap allowed to us understand the numerator but not necessarily the denominator.

I know it’s a very technical response, but in the absence of good denominator data then the evidence generated through these other studies may have limitations, and we have identified that with the use of Onomap.

Professor Thomas KC: Sorry, I don’t think you quite answered my question. Let me repeat it. My question was, you recognise that there were limitations with this tool. Simple question, bearing in mind you recognised that, did you use additional tools to assist in your understanding?

Professor Fu-Meng Khaw: So I repeat my response which is any investigation on disparities for ethnic minority groups relies on good quality data, and we didn’t have access to data around ethnicity, both in terms of people with Covid and in terms of people who didn’t have Covid, which therefore limited our ability to undertake any more robust investigations around differential impact, and in our assessment the use of the Onomap tool, which we had applied to other areas with some success, was a good tool for us to explore how it could contribute to the science.

Professor Thomas KC: So it’s a simple answer to my question, “No, we didn’t use additional tools”?

Professor Fu-Meng Khaw: That’s correct.

Professor Thomas KC: Thank you. If as you’ve just accepted no additional tools or methods were employed to supplement the Onomap findings, would you agree that this represents a critical gap in the data?

Professor Fu-Meng Khaw: That’s correct, and this is why the First Minister’s BAME group made several recommendations in its report from September 2021 and one of this was about strengthening the data around ethnicity in Wales.

Professor Thomas KC: Let me come on to my third and final area. And I want to be forward-facing to assist the Inquiry. In your view what should future public held strategies implement to address these data limitations to ensure a more accurate and inclusive representation of ethnic disparities in health outcomes?

Professor Fu-Meng Khaw: So our fundamental building block for this, going forward, is to improve our data collection around ethnicity status for all people in Wales, and I understand that work is ongoing.

Professor Thomas KC: And just following on from that, what role do you think cultural competency should play in any future public health data collection efforts?

Professor Fu-Meng Khaw: I believe very strongly in cultural competency for all in all that we do, that without an understanding about differences between ethnic groups, it will challenge our – the effectiveness of the work that we undertake. So I think it has an important bearing for all parts of the process around developing cultural competency.

Professor Thomas: Professor, those are all my questions, thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Mr Thomas.

Ms Woodward. I think you probably can see her directly.

Questions From Ms Woodward

Ms Woodward: Thank you. Good morning. I ask questions on behalf of Covid-19 Bereaved Families for Justice Cymru. And I’m going to ask you some questions about what was covered at the very start of your evidence, and that’s in regards to data collection in Wales.

And you’ve already been asked some questions about the Covid-19 mortality surveillance e-form, and as I understand it, your evidence was that some elements of that form were not as well complete as they might have been, and that led to lots of missing data. As well as forms being completed with missing data, and despite the assurances at paragraph 110 of your witness statement that the timeliness of reporting to that e-system was good, would you also accept that as set out in the review of the reporting Covid-19 deaths in Wales – Professor, that paper is at tab 19 of your bundle if you want to turn there and the reference is INQ000395663 – so would you accept that as set out in that report, that there were also difficulties with health boards failing to use the new centralised system, which led to delays by health boards in the reporting of deaths, and that there were also difficulties with ambiguity in the definition of what constituted a death to be reported, and that this led to the under-reporting of deaths in at least two health boards in Wales?

Professor Fu-Meng Khaw: That’s correct.

Ms Woodward: So given those delays and the under-reporting, would you agree that the system therefore wasn’t even working well to find out how many people had died of Covid, let alone where that infection had come from?

Professor Fu-Meng Khaw: So the issues identified in the report that you referenced talks about the identification on 23 April, for example, of 84 deaths in one of the health boards, and the e-form was implemented following an instruction from Welsh Government on 23 April to address this very issue, we had mechanisms to ensure a timely reporting from clinicians on an ongoing basis, and as I said earlier, initially weekly meetings chaired by the chief statistician and the director of Public Health Services at the time.

Ms Woodward: The report there also sets out difficulties with using the e-form at the start of its implementation as well, so there were continuing difficulties, weren’t there?

Professor Fu-Meng Khaw: Yes.

Ms Woodward: Sticking with data. In your evidence earlier, as I understand it, you agreed that nosocomial infection data was something that was well within the Public Health Wales remit, and you also recognised that testing was, of course, a limitation of data collection.

In written evidence given for Module 2B, Andrew Nelson, who is the Chief Information Officer at Cwm Taf Morgannwg University Health Board, and you’ve already been taken to his statement, Mr Nelson is critical of the use of data in wave 1 as no consideration was given to differentiating community and hospital-acquired infection. And he infers that a lack of reporting and awareness may have resulted in people not thinking about healthcare required for infections as being as much of an issue as it became.

My question is this: do you agree that there were specific difficulties in differentiating between hospital and community acquired infection in the data in Wales?

Professor Fu-Meng Khaw: We relied on definitions of this and I think ultimately we had a four nations agreement of what would be counted as a community onset case and what would be a probable or a definite hospital onset case. Once we agreed those definitions we were able to apply them to the data analysis that we had. So I can’t think technically there was an inability to do that because we had access to the datasets to allow us to link the data but it may be a question more about agreeing the technical definitions and what would constitute a hospital onset case.

Ms Woodward: And would you accept that that may therefore have posed a problem at the local health board level as identified by Mr Nelson in his statement?

Professor Fu-Meng Khaw: It is possible, it is possible that the lack of accepted definitions may have affected the early work on this.

Ms Woodward: Apart from the weekly meetings that you described earlier in your evidence, were there any other measures taken by Public Health Wales to address any of these difficulties in relation to data collection, and reporting and the completion of the e-form monitoring?

Professor Fu-Meng Khaw: Nothing in addition and in those meetings we would provide the latest analysis so that people were sited on the gaps and clearly with health board representation we would look to them to implement any improvements locally.

Ms Woodward: Professor, would you therefore agree that there was in fact no comprehensive form of monitoring put in place to ensure that health boards at the local level had rectified any reporting areas other than simply attending a weekly meeting?

Professor Fu-Meng Khaw: Well, attending a weekly meeting clearly had responsibilities for the person attending to take back any improvements that were discussed and we relied on that mechanism. It wasn’t for Public Health Wales to hold people to account, it is not our role to hold health boards accountable for the information they provide but we can help by providing information that would hopefully lead to improvement. But recognising that, you know, the e-form was one of many things that people had to complete.

Ms Woodward: You say that it’s not Public Health Wales’ role to hold health boards to account but would you agree that it is part of Public Health Wales to ensure that data collection and reporting is happening as accurately as possible so that you know what’s happening on the ground in pandemics such as this?

Professor Fu-Meng Khaw: That’s correct, which is why we engaged very actively with those routine meetings.

Ms Woodward: Thank you, Professor.

Thank you, my Lady, those are my questions.

Lady Hallett: Thank you. Those are all the questions we have for you, Professor. Thank you very much for your help in providing your statement and for coming to the Inquiry to give evidence today.

The Witness: Thank you, my Lady.

Lady Hallett: We shall break now. I shall return at 11.30.

(The witness withdrew)

(11.15 am)

(A short break)

(11.31 am)

Lady Hallett: Mr Scott.

Mr Scott: My Lady, may we please call Aidan Dawson.

Mr Aidan Dawson

MR AIDAN JAMES DAWSON (sworn).

Questions From Counsel to the Inquiry

Mr Scott: Mr Dawson, can we have your full name, please.

Mr Aidan Dawson: Aidan James Dawson.

Counsel Inquiry: And you are currently chief executive of the Public Health Agency; is that correct?

Mr Aidan Dawson: That is correct.

Counsel Inquiry: And you’ve had that role since July 2021, is that right?

Mr Aidan Dawson: I have.

Counsel Inquiry: And prior to that you worked within the Belfast Trust; is that correct?

Mr Aidan Dawson: Yes, that is correct.

Counsel Inquiry: And is it right that you personally don’t have a clinical background?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Healthcare management is your primary background, is that right?

Mr Aidan Dawson: Yes, that is correct.

Counsel Inquiry: So you haven’t held a role prior to July 2021 in PHA so it wasn’t that you’d gone to PHA and then to the trust then back to the PHA?

Mr Aidan Dawson: No, I had never worked in public health prior to taking up the role of chief executive in ‘21.

Counsel Inquiry: So in terms of the statement that’s been provided on behalf of PHA, that’s been done in conjunction with people who were within PHA at the time, is that right?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Where is the self-reflection on what went wrong in terms of the role that PHA played during the pandemic?

Mr Aidan Dawson: I think some of that comes from the Hussey review which we have built upon and since the – since I’ve taken up the post and we’ve moved out of the pandemic we have gone into a significant review of the agency, its structure, its operational capability and how it prepares and works as an organisation to support the people of Northern Ireland.

Counsel Inquiry: It doesn’t appear to be set out in terms of the role that the PHA played during the pandemic, it doesn’t appear to be set out in the statement, any of that critical analysis. Is that a fair assessment or not?

Mr Aidan Dawson: I think that’s perhaps a reasonable assessment, yes, but I do think it also builds on what we’ve learnt through the pandemic.

Counsel Inquiry: Why isn’t there that critical assessment in a statement from the PHA to the UK Covid-19 Inquiry?

Mr Aidan Dawson: I suppose we built our review around what Public Health Agency should be. I do believe we’ve taken in the consideration as we moved through it, learning from our reflection of what we went through in the Covid Inquiry as an organisation but we’re also hoping that we will, and it’s an iterative process as well, and obviously we will learn as we go through the Inquiry as to what lessons we should take out of that.

Counsel Inquiry: So has there been any internal proactive assessment of the PHA’s performance during the pandemic or is it waiting for reviews or external bodies to assess the performance of PHA?

Mr Aidan Dawson: I think the review is an assessment of what we’ve – what we went through to some extent, probably not as critical as you have suggested so I would concede that.

Counsel Inquiry: And I want to move to staffing and capacity of the PHA. So at the start of the pandemic, was there sufficient staffing and capacity within the PHA to perform the roles and functions it would envisage that it would have during the pandemic?

Mr Aidan Dawson: No, there wasn’t. I think critically we did not have enough in terms of professional public health qualified individuals and that issue has – is being addressed through our review. We have also put in place two additional training numbers for public health consultants above what NIMDTA actually provide us with.

Counsel Inquiry: So NIMDTA, if you could just define that, please?

Mr Aidan Dawson: Northern Ireland Medical & Dental Training Agency, so they are the primary trainers of doctors and dentists across Northern Ireland.

Counsel Inquiry: So if you didn’t have enough professional public health qualified individuals, how did that impact upon the PHA’s response to the pandemic?

Mr Aidan Dawson: It hampered it, although we would identify that we had a number of people who had retired and returned, as well, who had significant experience, going back many years.

Counsel Inquiry: Right, and is it also correct that during the pandemic staff were seconded to work directly to the Department of Health or redeployed or redirected to work in new areas; is that right?

Mr Aidan Dawson: That is correct.

Counsel Inquiry: And is it also right that a number of the staff who were seconded to the Department of Health were actually your senior staffers?

Mr Aidan Dawson: There were some senior staff, as well, yes.

Counsel Inquiry: So, again, after those individual had been seconded to the Department of Health was there sufficient capacity and capability within PHA to perform the roles that it had at that point in time in relation to the pandemic?

Mr Aidan Dawson: I think at that point in time we worked so closely with the Department of Health, there was a balance between where those individuals sat and where they could best provide service during the pandemic and I think that we probably didn’t have enough but we did the best with what we could at the time.

Counsel Inquiry: So can you provide any specific examples of where that insufficiency of capacity and capability hampered the service that PHA could provide?

Mr Aidan Dawson: I think we had, and it’s borne out in the Hussey Review, as well, that we didn’t have modelling capability as a public health agency going forward, or at that time, and I think that was one of the areas that we were hampered. We did work very closely with the department and – with the Department of Health, I should say, and we established a modelling group that sort of worked between the department and ourselves, but I think one of the things that we have learnt coming out of the pandemic is the necessity to have our own modelling capability going forward.

Counsel Inquiry: So you didn’t quite have the modelling capability that you required?

Mr Aidan Dawson: Mm-hmm.

Counsel Inquiry: Did you have the ability to conduct surveillance of data and cases that you needed as the PHA?

Mr Aidan Dawson: I think we lacked in terms – we had the capability for day-to-day work that we would have had but for something on the scale of the pandemic I don’t think we had that capability when we started the pandemic, no.

Counsel Inquiry: Did it improve throughout the course of the pandemic or did it get worse?

Mr Aidan Dawson: It did. I believe it did.

Counsel Inquiry: In what way did it improve?

Mr Aidan Dawson: I think our information became better and we worked very closely with the trusts, the Department of Health and Queen’s University, as well, I think, in developing our information flows where we would draft information in to give us a better understanding of how the disease progressed.

Counsel Inquiry: Two very closely related questions. One, what was the reason why you didn’t have that capability? And two, how do you prevent that happening in the event of a future pandemic?

Mr Aidan Dawson: I was not there pre-pandemic so it’s hard to say that. I don’t think that we –

Counsel Inquiry: Presumably it’s a question that you’ve asked in preparation?

Mr Aidan Dawson: Yes, I think it’s one of the – we as – in Northern Ireland we did not embrace the mixture of multidisciplinary approach in terms of developing public health consultants which the rest of the UK has adopted. We have since addressed that and we will do that going forward, but I think that’s one of the key reasons why we didn’t have the people coming through.

Counsel Inquiry: And is that a PHA failure to identify or is that the department or anybody else?

Mr Aidan Dawson: I think probably both. We’re a very small system in Northern Ireland. We work very closely with the likes of NIMDTA and the Department of Health and I think there has been, it’s probably fair to say not – we haven’t invested in public health consultants and capability but you could also say that of many other medical specialties across Northern Ireland at this point in time, as well.

Counsel Inquiry: I want to look now at data and surveillance in terms of what PHA did with that information so Joanne McClean gave evidence in Module 2C, and could you please tell us in terms of what Ms McClean’s role was within the PHA?

Mr Aidan Dawson: Well, currently she is the DPH for Northern –

Counsel Inquiry: Director of Public Health?

Mr Aidan Dawson: – Ireland, Director of Public Health, yes, and that’s why she was giving evidence at that time.

Counsel Inquiry: And she says in her evidence – this is at page 28 of her transcript:

“… a really important part of responding to infectious diseases is knowing how many infections there are in the community and any changes in that infection, and … the technical term for that is surveillance, [and that’s] a core bit of our function.”

Presumably you agree with that completely?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Did you actually have the level of surveillance in terms of the primary care data that you needed during the pandemic?

Mr Aidan Dawson: I don’t think we had that sort of level of primary care data that we would require.

Counsel Inquiry: And did you have the requisite level of critical care data that you required?

Mr Aidan Dawson: Not at the beginning of the pandemic, no.

Counsel Inquiry: Was there any type of data that you did have at the level you required?

Mr Aidan Dawson: I think we, as I said, we would have had normal sort of surveillance data around flu and around RSV and conditions like that, and things which would have come up on a seasonal – sort of normal seasonal process throughout the year.

Counsel Inquiry: But when you went into the pandemic, so let’s say this is January – because Public Health Agency had been aware of the Wuhan virus in January 2020, that’s fair?

Mr Aidan Dawson: Yes.

Counsel Inquiry: So did you look, then, at the data in the information that you had available to you and think, is that sufficient or do we need to get access to more?

Mr Aidan Dawson: I don’t know exactly what they would have considered at that point in time, but I do know, as we sort of moved into March and April, that there was concern that we didn’t have the access to information that we may have needed.

Counsel Inquiry: Okay, so you said March and April there.

Mr Aidan Dawson: Yes.

Counsel Inquiry: Lockdown was 23 March 2020. So it was still in April 2020 that you were concerned that you didn’t have the information you needed?

Mr Aidan Dawson: Well, I think at that point people were discussing what sort of information we would need and how you would develop those information flows out of such areas as critical care.

Counsel Inquiry: Okay, and so what did you identify you required, and how did you develop those flows?

Mr Aidan Dawson: We had a small team to identify – through – led by Declan Bradley, who is one of our public health consultants working with others to identify the number of people coming into critical care that might have Covid, and the pressures that that was exerting.

Counsel Inquiry: Okay, and so when were you satisfied that you had accurate information about the people coming into critical care that might have Covid and the pressures that was exerting?

Mr Aidan Dawson: I think around about sort of April/May, but I think the sort of confidence in the data grew over a period of time.

Counsel Inquiry: Is that not the end of wave 1, that the confidence in the data actually arrived?

Mr Aidan Dawson: I think – yeah.

Counsel Inquiry: Any other areas in terms of critical care?

Mr Aidan Dawson: Not that I’m aware of.

Counsel Inquiry: And so are you satisfied that by the end of, let’s call it end of May, that there was sufficient information that PHA had about critical care? Or was there more that you required?

Mr Aidan Dawson: I think at that stage they were pretty sure that they had sort of the information they required, but I’m not wholly sure of the answer to that, my Lady.

Counsel Inquiry: Okay, because – can I show you, please, PHA statement INQ000485720, at page 41, paragraph 116. It’s at tab 1 of your bundle or it’s going to be up on the screen. So this is the genesis of these questions, the data that was most challenging was primary care and critical care.

And it talks about that there was access to the influenza – is that what you’re suggesting, that the surveillance of flu, RSV, was available?

Mr Aidan Dawson: Yeah.

Counsel Inquiry: And:

“… information was initially considered to be potential and relevant and useful but upon discussion with HSCB …”

Just in terms of the acronyms, HSCB is effectively the commissioning body. It no longer exists, but it was between the trusts and the Department of Health at the time; is that right?

Mr Aidan Dawson: That’s correct.

Counsel Inquiry: And so “it was established that there were no permissions [for] the primary care data owners to use this source for Covid-19 monitoring, and it was not subsequently used.”

That sounds like data access was preventing PHA getting access to information it needed during a pandemic, is that right?

Mr Aidan Dawson: That is correct.

Counsel Inquiry: What steps were done to break that data access block?

Mr Aidan Dawson: Discussions between sort of the primary care – so Health and Social Care Board would have primary responsibility for the management of the primary care contracts. So there was the significant piece of work done with the Department of Health and Health and Social Care Board around data access agreements, over that period of time, but I think that probably took too long.

Counsel Inquiry: Was that because it was August 2023 that it came in?

Mr Aidan Dawson: Yeah.

Counsel Inquiry: So it’s two-and-a-half years?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Could things not have been moved a little bit quicker to get access to the information PHA needed in primary care about tracking cases of Covid-19 in Northern Ireland across the lifetime of the pandemic?

Mr Aidan Dawson: In hindsight, yes.

Counsel Inquiry: Surely it’s not just hindsight –

Mr Aidan Dawson: Yeah.

Counsel Inquiry: So was there any consideration taken to passing legislation, for example, to get access to the information that you needed?

Mr Aidan Dawson: Not that I’m aware of.

Lady Hallett: Who were the primary care data owners?

Mr Aidan Dawson: My understanding is the primary care data owners are the GPs themselves.

Lady Hallett: That’s what I assumed, but I just wanted to check.

Mr Scott: Because is it right that there’s not a centralised system like you might find in other countries, in the United Kingdom each one has their own system? Is that broadly correct –

Mr Aidan Dawson: Yes, I think there’s actually three different systems in use. I think they are now moving towards one type of system, and each GP is obviously their own independent contractor for their practice.

Counsel Inquiry: And then just moving slightly further down that paragraph, individual level critical care data. What does individual level critical care data mean, as opposed to systemic data, which I presume –

Mr Aidan Dawson: Individual critical care data is specific to the individual patient.

Counsel Inquiry: Right. So that was initially reported manually to the PHA, and then was discontinued. Why was that?

Mr Aidan Dawson: My understanding is that then they had flows established that came in straight in from the information systems.

Counsel Inquiry: Right. And so:

“As of August 2023 [so at the same time] governance arrangements and data transfers have now been established from critical care units in Northern Ireland to the PHA for the purpose of monitoring the epidemiology of severe COVID-19 and respiratory infections.”

Again, so why did that take two-and-a-half years to get those governance arrangements and data transfers in?

Mr Aidan Dawson: I think that’s what’s been established in August ‘23, but my understanding is that we would have had flows directly from the ICU and HDU facilities during the pandemic as well.

Counsel Inquiry: So what did the PHA lose out on by not having access to all that information from primary care and critical care?

Mr Aidan Dawson: I think that we had a considerable lack of information in what was happening in the community, in terms of tracking the disease, whilst I think from sort of early on in the pandemic we had good information about what was going through ICU, HDU, and the hospitals, we continued to have a lack of information through primary care.

Counsel Inquiry: And that goes all the way through to August 2023?

Mr Aidan Dawson: Not as good as you would have wanted it, yes.

Counsel Inquiry: What impact did that have upon the response of healthcare systems in Northern Ireland to the pandemic?

Mr Aidan Dawson: I think in terms of hospital level, it probably had very little. I think in community care it continued to be a blind spot.

Counsel Inquiry: Why doesn’t the same apply then to the information you were getting out of the critical care units, or was information being sourced in a different way that meant that you had the information you needed?

Mr Aidan Dawson: I think because we were able to source information directly from critical care units, that allowed us a good picture of what was happening within the hospitals.

Counsel Inquiry: You said it was a good picture; was it a sufficient picture that you needed in order to perform your role?

Mr Aidan Dawson: I think so.

Counsel Inquiry: How could it be improved in the future if it needs to be improved at all?

Mr Aidan Dawson: We are obviously now in Northern Ireland implementing a new system, encompass, which relies on the Epic hospital information system. That will connect up the laboratories, it will connect up the ICUs, ICUs, etc, and give us a more complete digital picture and feeds of information into the Public Health Agency. I think it was a better facilitated view of what exactly is happening in the hospitals.

Counsel Inquiry: Is that system then going to include all the various categories of data that you would wish it to in the event of a future pandemic, such as age, gender, ethnic group, disability?

Mr Aidan Dawson: I understand it will contain all those. However, it will not in-reach into GP systems. So, obviously, where we’ve had a lack of information that was in community care in our – in the community through our GP systems, Epic is a hospital-wide system across the trusts and laboratories, etc. It is not in community care. They will continue to have their own systems, but I believe the data access agreements are now better and in place to better access through NIHAP – and please don’t ask me what that stands for, I can’t remember – but NIHAP is a system whereby we can access anonymised data through the GP systems going forward, I think –

Counsel Inquiry: So have the blind spots gone?

Mr Aidan Dawson: I wouldn’t say it’s completely gone, but I think the picture is improving.

Counsel Inquiry: What remains then?

Mr Aidan Dawson: I think we’re probably still limited in what we can get out of the – it’s not sort of complete access as you would want into it, because it’s obviously coming out as anonymised data and feeds in and our groups continue to work with our GP colleagues and SPPG, which is the replacement from Health and Social Care Board, to identify what feeds we should get. So I think it’s an improving picture.

Counsel Inquiry: In terms of deaths and recordings of death, so your statement sets out, effectively during the pandemic, there were two ways of recording deaths. There was – or two systems, maybe, I’ll put it that way, there was one through PHA and one through NISRA, Northern Ireland Statistics and Research Authority, have I got that right? I’m making the “A” up –

Mr Aidan Dawson: “Agency”, I think.

Counsel Inquiry: “Agency”, thank you. But they were doing two different things?

Mr Aidan Dawson: Yes.

Counsel Inquiry: And actually the PHA’s role wasn’t a role you had prior to the pandemic?

Mr Aidan Dawson: No, NISRA and the GRO, which is the General Registrar Office, I think have the legislative responsibility for the recording of deaths in Northern Ireland. PHA, prior to the pandemic, had no role in the recording or reporting of deaths.

Counsel Inquiry: So why did the PHA get that role at the start of the pandemic?

Mr Aidan Dawson: I think expediency. The minister in Northern Ireland was frequently being asked about the level and impact and number of deaths that was happening. NISRA is quite a prolonged – there’s a data lag, and therefore the –

Counsel Inquiry: There’s a data lag – could you say how long is that, is it five days or longer?

Mr Aidan Dawson: I think it’s longer than five days. So that data lag, when we were looking for sort of realtime data, was obviously causing concern. Whilst the PHA put in place a way of tracking deaths, it wasn’t obviously as wholly accurate as NISRA because it obviously goes through the death certificates, I mean, that is a part 1 and part 2, but we had data on deaths which allowed us to put forward sort of trends and make decisions.

Counsel Inquiry: Why wasn’t it foreseen prior to the pandemic – and maybe you can’t answer this question – by the PHA that in the event of a pandemic they might need to have an accurate and up-to-date system for reporting deaths from whatever pathogen was causing the pandemic?

Mr Aidan Dawson: I think prior to – there was an assumption because that legislative responsibility sits with NISRA, that that would be provided through them, and we had never been asked, and I don’t think it had ever been considered.

Counsel Inquiry: On reflection, do you think it should have been considered?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Didn’t it cause difficulties for the PHA, given its staffing and capability requirements we discussed earlier on, at the start of a pandemic, to get a new function to track deaths when there wasn’t a system in place for identifying those deaths? How was that likely to ever be an accurate and easy system to put into place?

Mr Aidan Dawson: I don’t think it was easy to put in place. It was never going to be – it was something that we were asked to do at that time, and which our team worked to quickly – to put in place because we were asked to do so.

Counsel Inquiry: Did you push back and say, “We just don’t have the capability to do this”?

Mr Aidan Dawson: No, I think people wanted to be helpful. I think people at the time thought that it was information that would be useful as well in tracking the progression of the disease, and as I understand it there was no push back at all.

Counsel Inquiry: Was it more beneficial to the response of healthcare systems for PHA to be helpful or to make sure that there’s an accurate system put in place which is sufficiently staffed and manned by those with the capability and capacity to do it?

Mr Aidan Dawson: I think at the time it was a very fast-moving environment, and I don’t think whether or not people thought this was our responsibility, I think people did what they felt was the right thing to do at the time, and that’s why they proceeded to do it.

I don’t think it was ever suggested that it was wholly accurate, I think what was suggested, it was a tool that allowed us to track progression and trends in deaths.

Counsel Inquiry: One of the features which we’ll discuss is ethnic group data wasn’t kept. Was disability data kept?

Mr Aidan Dawson: I think we had very poor data on both disability and ethnicity in Northern Ireland.

Counsel Inquiry: Why is that?

Mr Aidan Dawson: It’s hard to say. I think certainly in terms of ethnicity in our 2001 census people from a black and ethnic minority background were less than 1%, and I think even in 2021 it’s gone up to somewhere between like 3 to 4%, and therefore I don’t think it ever got the focus that it probably required or deserved.

Counsel Inquiry: Well, just to put the numbers to that. So the 2021 census, and this is tab 19 of your bundle, INQ000474456, that is – it’s 96.5% is from the white ethnic group across Northern Ireland. So across the other 12 groups identified in the census, that’s 65,604 people?

Mr Aidan Dawson: Yes, over a population of 1.9 million, I think.

Counsel Inquiry: Yes, but that’s still 65,000 people whose impact wasn’t tracked; is that right?

Mr Aidan Dawson: That’s correct. And I would say, and I have said I don’t think we had the focus that was appropriate on ethnicity or disability that is required.

Counsel Inquiry: But wasn’t ethnicity important for the Public Health Agency to perform its just non-pandemic public health functions?

Mr Aidan Dawson: I think the agency had a history of more focusing on people with – from sort of – from a disability point of view or an ethnicity or migrant point of view, on the ground in terms of working with community groups as opposed to in the disease side of things. So I think in terms of health improvement we had a greater focus on working with local communities, etc, as opposed to tracking disease and its impact.

Counsel Inquiry: Is it fair to say that PHA never chose to make it a focus to ensure that they kept that data?

Mr Aidan Dawson: Yes.

Counsel Inquiry: And has that changed since?

Mr Aidan Dawson: Yes, we’re in the process of drafting a new corporate plan at this point in time and we will refocus the organisation into how we address things in terms of ethnicity, in terms of disability and a greater focus on people from a disadvantaged background across Northern Ireland.

Counsel Inquiry: So how did PHA assess the impact of the pandemic upon minority ethnic groups?

Mr Aidan Dawson: I don’t think it did it at all – or well.

Counsel Inquiry: At no point during the pandemic?

Mr Aidan Dawson: I think as time went on we worked – we had a low uptake group in terms of vaccination, etc, but in terms of surveillance of hospitals and the impact upon people from a black and ethnic minority background, no.

Counsel Inquiry: I want to ask about staff infections and deaths. I believe it’s right, is it, there was effectively a spreadsheet, and this is the document behind tab 3 of your bundle. It was a big spreadsheet that had been provided, I believe from PHE originally.

Mr Aidan Dawson: Yes.

Counsel Inquiry: And it kept a series of categories of data and one of that was staff illnesses and staff deaths and my reading of that is that that was never included in terms of the data was never inputted alongside those rows, yet other bits of data were put in alongside other rows. Is that a fair reading of that document?

Mr Aidan Dawson: I think that is a fair reading of that document, yes.

Counsel Inquiry: Why wasn’t there any record kept of staff illness, staff deaths – maybe staff deaths is easier to focus on than staff illnesses?

Mr Aidan Dawson: I think staff deaths was, when I discussed it with the team, was that it would have been very difficult to differentiate as to whether those deaths – through staff – were due to them acquiring the disease in line with their work, or whether or not they had acquired it in the community.

Counsel Inquiry: But how can you tell that unless you actually keep the data and know where they were working at the time?

Mr Aidan Dawson: We just didn’t have access to that data at that time. It is one of the things which we have now addressed going forward and that we will have, but it wasn’t at that time.

Counsel Inquiry: Can I just understand the sequence. Was it that there was an assumption made that it wouldn’t assist you because you didn’t have access to the information about where people were working, whether it be home acquired or hospital acquired, and therefore you didn’t seek the data or was it that you sought – I see you nodding. Was it that way around?

Mr Aidan Dawson: I think it was that way around. We didn’t see that the data would actually help us manage at that point in time.

Counsel Inquiry: On reflection was that the right decision?

Mr Aidan Dawson: I don’t know the answer to that. It’s not something which I have reflected on, sort of, greatly and I probably need to give it some more thought but I’m quite content to do that.

Counsel Inquiry: Has the PHA institution given it any thought, or no?

Mr Aidan Dawson: No. But if I may, if it is now one of the things which we are – I’ve said that and I’m now reflecting that it is one of the things which we would collect and be able do in a future pandemic so obviously our information team have thought that that’s one of the things, because my understanding is they are able to anonymise sort of healthcare workers, their vaccination status, and going forward, their cause of death.

Counsel Inquiry: So there is planning ongoing?

Mr Aidan Dawson: Yes.

Counsel Inquiry: How about keeping information or data about people who are suffering from Long Covid, is that information being kept?

Mr Aidan Dawson: Not that I’m aware of.

Counsel Inquiry: Does the Public Health Agency have any role in identifying those with Long Covid, trying to provide information to the department or HSCB – I may have got the acronym wrong now.

Mr Aidan Dawson: SPPG.

Counsel Inquiry: Thank you – about – to inform them about commissioning that may need to be put in place?

Mr Aidan Dawson: I haven’t been involved in any discussions for that. I can’t for certainty say yes or no whether or not we have been involved in the provision of information around the commissioning of services for people with Long Covid.

But I am quite content to answer that question and come back to the Inquiry if that’s helpful.

Counsel Inquiry: Thank you.

I want to look now at infection prevention and control. Again, it’s right that there was a UK IPC cell, which the Inquiry has heard a lot about, and then there was a smaller cell put in place in Northern Ireland; is that right?

Mr Aidan Dawson: Yes.

Counsel Inquiry: And effectively the Northern Ireland IPC cell didn’t produce its own guidance, it followed and applied the UK cell, is that right?

Mr Aidan Dawson: That’s correct.

Counsel Inquiry: Did the PHA have any or sufficient scientific knowledge capabilities to determine routes of transmission and create IPC guidance in response?

Mr Aidan Dawson: I think we had input into the national cell. I think the four nations worked very closely together on that and therefore I don’t think there was a necessity seen to replicate that or whether or not we would have had that capability. Northern Ireland has always relied on health – NHS England and now UKHSA to provide to us sort of guidance in many areas.

Counsel Inquiry: Throughout the pandemic there are obviously different periods of time where different areas would have different levels of Covid-19. Hospitalisations were different, impact upon healthcare workers would often be different depending on the pressures that they were feeling at the time. Is that a fair summary?

Mr Aidan Dawson: That is correct.

Counsel Inquiry: So to what extent did PHA see it was part of its role in terms of informing the IPC cell discussions to engage with healthcare workers, patient groups, anyone in Northern Ireland about what was being felt in Northern Ireland at the impact of those IPC guidance?

Mr Aidan Dawson: I’m not aware that we conducted an awful lot of work with sort of various groups. I think we took much of our lead from England at that point in time.

Counsel Inquiry: Was Northern Ireland not looking to feed into the impact, that was being felt in Northern Ireland to those discussions?

Mr Aidan Dawson: Yes, and I think they did that through our involvement of the people that went to there but I’m not sure that there would have been a wider discussion. We obviously were part of the gold and silver command structure, we would have had discussions with trusts, etc, but in terms of specific groups I’m not aware.

Counsel Inquiry: I want to look briefly at some of the comments that were being made by the UK – the Northern Ireland representative in the UK IPC cell. And it’s on 23 December – it’s at tab 9 of your bundle, INQ000398242, the individual is stated to say:

“In the absence of robust evidence to support the move [and then the initials are given] felt that colleagues might think that they have not been appropriately protected with what has been previously recommended.”

Are you aware of what discussions were taking place within PHA in and around December 2022 – December 2020 about what the impact might be on the confidence of healthcare workers in Northern Ireland if there wasn’t a change of guidance?

Mr Aidan Dawson: I’m not aware of those discussions. I would be aware, because I worked in the trust during that period of time, that there was always a degree of concern that people wanted to use PPE, etc, at a, sort of, maybe beyond what was recommended, I think you discussed earlier the use of FFP3 masks, etc, people may have felt that they give them added protection in – but the guidance was, you should use them only when you’re in – or used in AGP, aerosol-generated procedures, etc, people might have thought, well, actually I should be using that if I’m working in an ED department or not involved in non-aerosol-generated. So I think there was always that concern. I think people were genuinely frightened and sort of always sought to have a higher level of protection than was sometimes what was being recommended within the guidance.

Counsel Inquiry: And what did PHA as the body with representatives on the UK IPC cell do to assuage those fears of healthcare workers in Northern Ireland? Did they explain the guidance? Did they provide further information? Did they talk to representatives?

Mr Aidan Dawson: I think through – so the gold – that we would have had discussions each day with trust representatives or, as the pandemic progressed, every sort of number of days through that sort of command structure in terms of providing the evidence and saying, look, this is the best evidence we can have confidence in at this point in time and we had nothing to dissuade to us move away from it.

Counsel Inquiry: Did that message pass down to your healthcare workers who were actually on the wards, because it seems that that fear never went away. Is that a fair description of what happened?

Mr Aidan Dawson: I think that fear never went away. Whether or not that was because people just had a high degree of anxiety at that point in time and whether or not you could have ever dissuaded it in terms of that, I don’t know.

Counsel Inquiry: Did PHA do enough to try to dissuade it or should they have done more?

Mr Aidan Dawson: We probably should have done more but again in – it was a very fast-moving environment as well at that time and we had a very limited resource in terms of what we could actually put on the ground and where we could have those conversations and we went back to that – we took that up at the start that we probably didn’t have the number of staff, we had a very small team.

Counsel Inquiry: So that would be another lesson learned, effectively, about something that should be done, something that should be thought about within PHA in the event of a future pandemic?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Paragraph 91 of the PHA statement says that there were no issues in relation to PPE reported to PHA. Is that true?

Mr Aidan Dawson: My understanding is that we never had concerns about the lack of supply of PPE across Northern Ireland if that’s the issue that people are referring to.

Counsel Inquiry: Right. So that’s at a very high level, that’s Northern Ireland as a whole rather than individual healthcare workers were saying that they didn’t have access to PPE that they needed within their own hospital, GP surgery, pharmacy?

Mr Aidan Dawson: I’m not aware of any reports of people ever saying that they didn’t have access to appropriate PPE as advised in the guidance.

Counsel Inquiry: Are you saying that throughout the whole pandemic there wasn’t one report to PHA that people didn’t have access to the necessary levels of PPE?

Mr Aidan Dawson: When I’ve spoken to my team that’s what I’ve been advised. I don’t think there was ever a major concern over the supply of PPE across Northern Ireland.

Counsel Inquiry: Okay.

Mr Aidan Dawson: Can I add, I think there may have been general concerns where people at times felt that they should have been using higher levels of PPE than was recommended but again that goes back to that sort of fear issue, I think.

Counsel Inquiry: I also wanted to, if we could, I hadn’t flagged this up ahead of time, so I apologise for this.

If we could have on screen INQ000398219.

So this is an IPC cell meeting minutes and this is at tab 10 of your bundle, and I just want to scroll down to that bottom paragraph, please. Again, that’s the individual from Northern Ireland who had been, I wouldn’t say seconded, was a member of the cell:

“… AGP discussions have been had around individual organisations to decide what an AGP is which is causing confusion in trusts in NI as some are going with resus council guidance over PHE guidance … these additional guidelines are causing ongoing issues.”

To what extent did the Northern Ireland IPC cell seek to try and bring some clarity about what guidance should be applied?

Mr Aidan Dawson: I think the Northern Ireland IPC cell through the trust would have advised that we should follow the PHE guidance. I think prior to the pandemic organisations followed the Resuscitation Council guidance and as the pandemic progressed there was much discussion around well, what is an AGP? And guidance on AGPs and what could, should be considered an AGP progressed at the time of the pandemic.

Counsel Inquiry: Because if we could please go over the page. It’s the top line, I am very hesitant to stray into Module 6 territory around care homes but, again, there’s a comment that care homes were refusing to undertake CPR due to this issue. Isn’t that exactly the type of thing that the Northern Ireland IPC cell should have been making sure did not happen, that there was absolute clarity that care homes knew that they could undertake CPR?

Mr Aidan Dawson: Sorry, could you say that to me again.

Counsel Inquiry: Sure. Isn’t that exactly the type of thing that the Northern Ireland IPC cell should make sure was not happening so that care homes knew that they could undertake CPR?

Mr Aidan Dawson: I think – I know that comment was made when I checked it with the team. They have said whilst the comment was made about care homes refusing to undertake CPR due to this issue, there were – whilst there may have been a refusal, we don’t know that there were any incidences where it was actually not given at all.

Counsel Inquiry: But did the Northern Ireland IPC cell make sure that there were no situations in Northern Ireland of people not providing CPR as a result of any potential misunderstanding or lack of clarity in the IPC guidance that applied?

Mr Aidan Dawson: I’m not sure it would’ve been as specific as that. I think what would have happened was that notification would have been that the PPE in use was sufficient to meet the needs, and I think CPR later was not considered an aerosol-generating procedure.

Counsel Inquiry: That document can come down now, thank you.

How did the Northern Ireland IPC cell or Public Health Agency track and assess whether the IPC measures that were being implemented were actually working? Putting it a different way, did they track nosocomial infections to just have an understanding about how those were arising?

Mr Aidan Dawson: I think nosocomial infections were tracked through Northern Ireland, but again we would have had lack of information in sort of the community, etc, and GP surgeries.

Counsel Inquiry: But did the IPC cell in Northern Ireland have any understanding of how the various trusts, maybe different hospitals at different times, were applying that guidance, whether they thought that their local risk assessment meant a higher level of IPC protection was needed, or actually whether the level was low so it wasn’t as necessary? Was there any record kept, tracking kept of that?

Mr Aidan Dawson: No.

Counsel Inquiry: Why not? Would that not have been useful to understand how the IPC guidance was operating in Northern Ireland?

Mr Aidan Dawson: I think there was an assumption the IPC guidance was out there, it was being adhered to and the general sort of tracking of the disease was not sort of significantly different from other parts. But I can see the point you’re making, was it specifically tracked on whether or not the IPC guidance was effective, I don’t think it was, don’t believe it was.

Counsel Inquiry: Is that not a failing to – as the body sets the guidance to check to see whether it’s actually working or not, and how it’s being applied?

Mr Aidan Dawson: Yes.

Counsel Inquiry: And, again, maybe this isn’t something you have given any thought to, but how do you prevent that happening in future? How do you address that situation?

Mr Aidan Dawson: I think we – in the future, we – the way the surveillance systems are now being set up, we would have a better understanding of the disease progression at this point in time so I think they would rely on that but I don’t think any consideration has been given specifically to how you understand so the safeguards put in place are actually effective.

Counsel Inquiry: Did the PHA ever provide any advice about visiting restrictions that were applied in healthcare settings?

Mr Aidan Dawson: Visiting was sat, I think as in other nations, with the Chief Nursing Officer for Northern Ireland, but we would have provided the advice into her and sat as part of that group, but the decisions around visiting sat very clearly with the CNO.

Counsel Inquiry: Has there been any analysis done within the PHA about the impact of the visiting restrictions put in place, and whether actually they were too high, just right, whether they had the effect that they sought?

Mr Aidan Dawson: No, but I think that would have been difficult to do because I think the visiting was very much impacted upon the type of a state you would have had, so it would have been hard to get around a very general basis as to – what – how the visiting restrictions had an impact. And I think much of it was based on local risk assessment as well. So two maternity units with two different types of estate may have had different restrictions based on their own local risk assessment.

Counsel Inquiry: And to what extent were those local risk assessments being fed back in to show what worked well, what didn’t work well, in different situations?

Mr Aidan Dawson: I don’t know. I’m assuming that would have went in to the CNO. I don’t think we did any of that.

Counsel Inquiry: Okay. Moving now to the role of testing and the role that testing can play.

Did PHA do enough to increase the availability of testing to allow for a greater understanding of those who present to either primary care, particularly hospitals, about their Covid status?

Mr Aidan Dawson: Obviously we were – all of us staffed and led the expert group on testing, and I think they did quite a bit of work over that period of time, if you look at the guidance, there’s like nine iterations of that, and as understanding grew and the availability of tests grew, and their accuracy grew, and confidence grew, I think the guidance was adjusted to reflect that.

Counsel Inquiry: I want to then ask about Long Covid. Does PHA have any role in relation to identification of Long Covid?

Mr Aidan Dawson: Not that I’m aware of.

Counsel Inquiry: And then another corollary of visiting is the use of technology in the provision of services, and this is something that is set out at paragraphs 68 to 70 of your statement.

Again, there doesn’t appear to be any analysis of what went well, what went badly, about the use of technology in the provision of services in Northern Ireland. Is that something that the PHA was looking into, has had consideration of?

Mr Aidan Dawson: I think we provided some guidance around the use of sort of virtual visiting, and I think that’s in the pack as well, and how that could be used and to – very practical approaches. Its impact, I don’t think, was followed up in terms of analysis of whether or not that could have been improved or not.

Counsel Inquiry: Well, why wasn’t it followed up?

Mr Aidan Dawson: Again, I would go back to perhaps we have a small team. There are things that we prioritised during that, and I don’t think that was one of the ones we did and visiting again, I think, sat with the CNO’s group as opposed to us.

Counsel Inquiry: Okay. So was there any assessment of the impact of those living in rural areas to access services?

Mr Aidan Dawson: No, that wouldn’t have happened.

Counsel Inquiry: Has there been any review done by the PHA of the ongoing use of technology and the provision of services and the impact that has upon health in Northern Ireland?

Mr Aidan Dawson: In terms of visiting or in terms of use of virtual technology overall?

Counsel Inquiry: Either way. As far as it falls within the PHA remit.

Mr Aidan Dawson: No, and I don’t think it does fall within our remit either.

Counsel Inquiry: PHA Deputy Director of Allied Health Professions and Public Involvement was the chair of the HSC Covid Staff and Well-being Group, is that right? That was established in early March 2020, and the role of that group was to provide – well, part of the role of that group was to provide staff with support, guidance and advice. And I think there was a website that had been established.

Was enough done to provide support for HSC staff during the pandemic?

Mr Aidan Dawson: I don’t think it was. I think we can reflect back and say that we didn’t do enough, and I think it’s something which is lacking in our preparedness about how you support, because as you can see, those things were developed after the event, an arrival of the pandemic. And that surely should have been something which was in our planning prior to that as to how we support staff through that.

I think one of the other things was, at the outset, people were hopeful it was going to be a short-lived thing, no one expected it to go on so long and therefore the impact upon staff health and well-being wasn’t considered, and I think more could have been done.

Counsel Inquiry: Just to push back on that slightly. It was anticipated there would be a second wave, I think, in early 2020 –

Mr Aidan Dawson: Yeah.

Counsel Inquiry: – so – knew this wasn’t going to be just a one wave issue.

Mr Aidan Dawson: No, but I think it did – at the very outset, I don’t think people thought that it was gonna be – last as long as quite it did, and have the far-reaching impact that it did.

Counsel Inquiry: And so when that became apparent that it was having those long-lasting, far-reaching impacts, was more done to provide the extra support for staff?

Mr Aidan Dawson: I think that could continue to meet and think about it, and the psychological blows, seen through the PPE etc, was around physical protection of staff, I think the significant issue around whether or not the mental health of staff was protected was not addressed in the way that it should have been.

Counsel Inquiry: One of the points of this, the advice that was given was psychological helplines that were open to staff and within the trust, local GP practices and independent care providers. And I think every trust had its own line that was – allowed staff to seek psychological help, is that right?

Mr Aidan Dawson: That is correct.

Counsel Inquiry: Again, reading the one that we have in your tab 5 at INQ000416738, all of those are 9 am to 5 pm Monday to Friday; what would the staff member do if they needed help on the weekend?

Mr Aidan Dawson: I suppose their own – trust would have had their own access to occupational health during those periods of time as well, and there are others who have psychological helplines which are right there, available to the general public, I’d say, those hours.

Counsel Inquiry: During a pandemic, could more have been done to make sure that there were psychological services available to health and social care staff?

Mr Aidan Dawson: Yes.

Counsel Inquiry: Are there any – apart from the topics that we’ve covered today, are there any other lessons learned or recommendations that you would wish the Chair to consider?

Mr Aidan Dawson: I think for me, and I think it’s come out in the evidence that there was a – we did not have enough information flows or give enough due diligence to the impact of pandemics or healthcare disease and people from a black and ethnic minority background, and I think certainly in Northern Ireland that needs to be a focus for us, going forward.

I think the other thing which we are acutely aware of in Northern Ireland is we are the only part of the UK with a direct land border with another country, and we I think there needs to be a recommendation about how we work as an epidemiological unit, as an island, going forward, and certainly we are working with the Republic counterparts on maybe an all-Ireland surveillance system.

Counsel Inquiry: To test you quickly on those two, the second one certainly has quite a large political element to it, is that fair? Whole-of-Ireland epidemiological unit?

Mr Aidan Dawson: I’m not thinking it in terms of politics, I was only thinking about it in terms of health, because one of the things that we are acutely aware of is that it’s a very open land border, and that people and disease flows across that without recognition. And yes, I am aware of the politics of that, but purely from a health perspective, in talking to our health colleagues, that that would be welcomed and I think it’s – certainly in terms of H5N1 and things like that which may be caused by migrating birds coming across from the Atlantic from America, they could land either side of that border, could cause disease, and individuals will travel back and forth.

Counsel Inquiry: So is it that within the healthcare system, do as much as you possibly can do, let the politicians, and then to quote Ms Campbell in a different setting, just get on with it?

Mr Aidan Dawson: I mean, there are other examples where we do work very, very well with our counterparts in the Republic of Ireland in terms of health, but I do recognise that there are political decisions which are outside my remit, but in terms of the health service, it sort of makes sense.

Mr Scott: Thank you, Mr Dawson.

My Lady, those are questions we have.

Lady Hallett: I think we have some questions.

Ms Foubister, I think you are going first. Behind the pillar.

Questions From Ms Foubister

Ms Foubister: My Lady.

Mr Dawson, I represent John’s Campaign Care Rights UK and the Patients Association. At paragraph 181 of your witness statement you refer to work undertaken to identify learnings from the pandemic, and to identify areas for improvement. And you report that virtual visiting services were found to be successful and valuable in maintaining connections between patients and loved ones.

Were you aware and did PHA consider that many patients and staff found using or facilitating virtual communications traumatising, particularly around the end of life?

Mr Aidan Dawson: I think they were difficult around end of life at that point in time, and I appreciate that for families and loved ones who lost people in those circumstances, doing that over electronic means is very difficult and hard. But I think that there were other complexities at that time, around IPC, etc, and the protection of other people that might have been in the unit as well.

Ms Foubister: And was anything done to address those concerns particularly around end of life as you say?

Mr Aidan Dawson: I don’t think a lot was done, I think there was empathy around it happening, and none of us felt that that was a satisfactory way, but I don’t think anyone could think of a better way of doing it, at that point in time when the disease was expanding.

Ms Foubister: And had there been any reflection on how it could be done better?

Mr Aidan Dawson: I think it is something that we need to reflect further on when we go through it, but at this point in time I’m not aware of anything.

Ms Foubister: Thank you.

That’s my question, my Lady.

Lady Hallett: Thank you very much.

Mr Wagner. Over there, Mr Dawson.

Questions From Mr Wagner

Mr Wagner: Thank you.

Good afternoon, Mr Dawson, I ask questions on behalf of the clinically vulnerable families. I first want to ask you about the IPC guidance. Professor Susan Hopkins, who I’m sure you know, is the chief medical adviser of the UK Health Security Agency, gave evidence to the Inquiry earlier in this module. One of the things she said was that in her opinion, the use of air filtration was not given sufficient priority in IPC guidance, and she said that going forward, greater consideration should be given to, for example, to portable HEPA filters. Do you agree with that?

Mr Aidan Dawson: Yes, I do agree with it. I think even in our office now we have a portable HEPA filter. I don’t think they were in use as much before the pandemic or people gave any great thought to it, but again there is an issue around, sort of, the building stock of the NHS, and some have better air handling facilities than others. It goes back to the age of estate and the local estate knowledge of where sort of turnover of air and oxygen within a facility might be, so it would be hard to do, I think, very sort of high-level guidance, but again it might come down to local risk assessment based on buildings and estate knowledge.

Mr Wagner: Thank you. Did the Public Health Agency, through the Northern Ireland IPC cell, at any time give or consider giving guidance on IPC measures to be implemented to protect clinically vulnerable or clinically extremely vulnerable patients in healthcare settings, for example, staff wearing FFP3 masks or indeed patients wearing masks?

Mr Aidan Dawson: I’m not aware of that specifically. If helpful, I can find out and report back to the Inquiry.

Mr Wagner: Thank you. And if that guidance wasn’t given, would you agree it does make sense that where there is a relatively high risk to particular patients, that specific guidance is put in place to protect them?

Mr Aidan Dawson: Yes, I do think, in terms of IPC, in terms of some of the most vulnerable areas around cancer, that there may have been some discussions in how you protect in that sort of very clinically vulnerable group who might be more immunosuppressed than the normal sort of population in hospital, that’s where there was some discussion.

Mr Wagner: Thank you.

Lady Hallett: Thank you, Mr Wagner.

Mr Thomas.

Behind you, but could you make sure your answers are going into the microphone, Mr Dawson, please.

Mr Aidan Dawson: Yes, my Lady.

Questions From Professor Thomas KC

Professor Thomas: Give me one moment.

Good afternoon, Mr Dawson. I’m asking questions on behalf of FEMHO, Federation of Ethnic Minority Healthcare Organisations.

I want to first turn to limitations on the ethnicity data collection. In paragraph 124 of Sir Michael McBride’s statement, he addresses limitations in data collection due to poor coding of ethnicity in healthcare records in Northern Ireland. Despite awareness of proportionate health inequalities. Given Northern Ireland’s smaller proportion of ethnic minorities, do you believe that this demographic factor contributed to the oversight in prioritising ethnicity data?

Mr Aidan Dawson: Yes. Yes. As I said previously, I don’t think we served that population well in terms of our data and our data collection. And I agree with you, I think that the size of the population, I know we discussed that earlier, did probably lead to an oversight in that area, or wasn’t given the focus I think I had as it should have been.

Professor Thomas KC: Well, given that, what strategies you would suggest to prevent similar data limitations in the future, if we have another public health crisis, to ensure that all communities are represented accurately?

Mr Aidan Dawson: Well, firstly I think the strategy in terms of the information data is led by the department, and I’m not gonna step away from that, but my understanding is through – and we have had these discussions – our new digital encompass project, that sort of trust data, and the ethnicity will be much better and there are single ways which data can be entered in, and I think going back, it – sort of like the failsafe that you have to record ethnicity.

So I do think there’s a strategy now, going forward, to have better data across all the range of information relating to our population that we haven’t had previously. But that strategy sits, I think, with the Department of Health. Although we’re a significant user we would wish to see that as well.

Professor Thomas KC: Both you – so I’m now moving on, I’m looking at intersection between social deprivation and ethnicity and in health inequalities – both you and Sir McBride discuss the significant role of social deprivation in health inequalities exacerbated by the pandemic. In Northern Ireland where ethnicity data remains poorly coded, there exists a critical intersection between social deprivation and ethnicity that may not be fully understood or addressed. So, moving forward, how do you propose that this intersection could be better incorporated into data practices?

Mr Aidan Dawson: Again, we are developing our new corporate plan, and I think it’s one of the things that we would focus on is people from sort of a wider or diverse range of ethnicity. In terms of the – where we would want to see better data is obviously we will get that from the hospitals, but as identified earlier, the data owner for GP practices remains with the GPs. And I would like more access into that information because that will give you a better basis of the whole population, not just those which end up in our healthcare trusts. We already have good data in terms of our child health system, but that obviously only runs to a certain age.

Professor Thomas: Thank you.

My Lady, those are my questions.

Lady Hallett: Thank you, Mr Thomas.

Ms Samantha Jones for the – there we are, behind you to your right.

Questions From Ms Jones

Ms Jones: My Lady, your counsel covered one of our questions pretty adequately, pretty well, and I wondered if I could ask permission to ask one follow-up question on the corporate plan that Mr Dawson has mentioned a number of times. I will keep to my three minutes.

Lady Hallett: All right.

Ms Jones: Thank you very much.

Mr Dawson, thank you. So just to clarify an answer earlier that you gave to Counsel to the Inquiry you said and accepted there was very poor data on disability kept by the PHA during the pandemic. Can I just clarify, was any mortality data on disabled people kept by the PHA during the pandemic?

Mr Aidan Dawson: Not that I’m aware of but I can’t sort of say that for certain so I’d be happy to come back on that.

Ms Jones: Thank you. And then my additional question. On the corporate plan that you’ve mentioned a number of times in your evidence today, could you just help us with when that corporate plan will be finalised in its drafting and when it will be implemented by the PHA?

Mr Aidan Dawson: Our aim at this point in time is to go to consultation in December and then that’s a public consultation. Final drafts should go to the agency board in March with its implementation from April going forward.

Ms Jones: Thank you. My final question then is in relation to paragraph 161 of your statement and there you outline several different sources of deaths data and that was in respect of the ways that the deaths data was collected. I don’t want to take you to it. In respect of that, can you explain whether any of those sources of that deaths data, collected data on whether someone had a disability?

Mr Aidan Dawson: Again, I don’t know if disability is recorded on that. Again, I could come back if any of those are – I’m very clear to say we don’t a statutory responsibility that sits with NISRA and the GRO in terms of the information which is collected around deaths.

Ms Jones: Thank you very much, those are my questions.

Lady Hallett: Thank you very much, Ms Jones.

And Ms Campbell.

Ms Campbell is there.

Questions From Ms Campbell

Ms Campbell: Mr Dawson, thank you, my name is Brenda Campbell and I represent the Northern Ireland Covid-19 Bereaved Families for Justice.

Can I take you back, please, to the topic of testing and in fact all of my questions will focus on testing. And just to give it some context, we know that as at 23 January 2020, so we’re looking at a very early stage in the pandemic, the Public Health Agency had established the emergency operations centre. We know that shortly thereafter the agency was asked to lead departmental initiatives around testing and particularly the expert advisory group on testing. And we know from paragraph 95 of your statement that there then began some nine iterations of guidance issued by the PHA but in conjunction with the department on testing, the first of which was on 19 March 2020.

And that focused – it’s behind tab 11 in your bundle, it focused on testing of healthcare workers and patients in hospital settings.

Mr Aidan Dawson: Yes.

Ms Campbell: And just for the Inquiry’s reference, the INQ number is INQ000120705. It’s that 19 March guidance that I’d like to ask you some questions about. It was three pages long and to give it some context the later guidance was, towards the end of the guidance, were as many as 25 pages long. And it focused on the testing of some symptomatic patients in hospital and some healthcare workers in certain frontline duties starting at surgeons and physicians. It didn’t address anything about testing on hospital discharge into other care facilities, it didn’t address anything about testing in, for example, non-hospital care settings or care homes.

In relation to those issues, wider groups of testing, do you know whether they were on the PHA’s radar at the time?

Mr Aidan Dawson: I’m not sure that they were on PHA’s radar at that time. I think the greater focus at that time was around capacity within those secondary care settings to deal with people with illness. So I’m not sure that they were. But, again, I wasn’t there and that’s not something which I think is covered within the documents that you’re referring to therefore, but I’m happy to go back and check as to what consideration was given to that, if helpful.

Ms Campbell: You see, by 19 March, and again this Inquiry has heard much in terms of context, we had been long witnessing what had been happening in other parts of Europe, we were the best part of a month after Northern Ireland’s first positive case. We were a week after Northern Ireland had in fact suspended community Test and Trace and it was very shortly before relatives of at least two of our client group had passed away both having contracted the virus in the same Belfast hospital. Do you as an agency understand the concerns on the part of the Northern Ireland Covid Bereaved that there appears to have been, even at that very early stage, a failure on the part of the Public Health Agency to identify the importance of widespread testing of healthcare workers and patients in various settings?

Mr Aidan Dawson: I accept that, yes.

Ms Campbell: And do you agree that what appears to be some last-minute scrambling to produce a three-page guidance of the nature that you’ll have looked at in preparation for your evidence, from the perspective of the Northern Ireland Covid Bereaved is inadequate?

Mr Aidan Dawson: I think it is inadequate. Again, as we said at this point in time I wasn’t there and whether or not those who felt at the time it was adequate or it met the needs, I don’t know what pressures they were under or what information they had in front of them or for what purposes it was intended to be produced at that point in time and what their driving factors were. Like you, I have read the guidance but some of the information behind that I’m not aware of.

Ms Campbell: Picking up on that answer and in fact some of the questions that you were posed by Mr Scott at an early stage, given that you weren’t there and you are not aware of what impacted that guidance at the time, has there been any reflection in the Public Health Agency, about gaps and missed opportunities at that very early stage?

Mr Aidan Dawson: I think it’s fair to say no, that we haven’t, I think that was probably picked up as we went on. And the further guidance that would have been more reflected in further guidances that came out during the progress of the pandemic. More as it happened as opposed to in a retrospective way.

Ms Campbell: Looking then at what happened at later stages in the pandemic and actually coming to a point in time in which I think you took up your post, although I’ll be corrected if I’m wrong, can we move in time then to summer into autumn 2021, July in particular.

At paragraph 102 of your statement you tell us about the Expert Advisory Group drafting a paper in relation to testing support in relation to hospital visiting?

Mr Aidan Dawson: Yes.

Ms Campbell: And that paper concluded that testing of visitors should be used in addition to other mitigations such as PPE, and it observed that there was no consistent approach across the UK, having done some analysis.

The paper – and again for the Inquiry’s reference it’s at your tab 15, INQ000343958 – again, it’s a 3-page document. And within it, it observes that individuals from within the Northern Ireland testing team had met with officials from NHS England in January, so six months previously. And at that time in January, NHS England had offered testing to visitors to maternity settings and to end-of-life care as a means to facilitate visits at those very important times. This document that’s discussing those visits is dated July 2021, so six months on from those discussions. And you go on in your statement to indicate that it wasn’t until September 2021 that the CMO issued a letter outlining then the availability of lateral flow tests to support visiting in hospital settings.

Again, can you understand the concern of the Northern Ireland Covid bereaved, many of whom were denied access to their loved ones, that there was a failure to appreciate the detrimental impact of those restrictions on visiting at an early or a rapid enough stage?

Mr Aidan Dawson: Yes, I can understand that.

Ms Campbell: And can you understand why that chronology of January to July to September gives the impression that there was a lack of urgency or understanding in the PHA which was leading on this in relation to both the plight of patients and their loved ones?

Mr Aidan Dawson: Yes, I can understand that. Again, it’s not a discussion I have had with that team so it’s hard for me to understand what their considerations or things that were going through their head as to why they were – why that took that period of time. But I do understand that that is seen as a lack of timeliness on our part.

Ms Campbell: Well, can you also understand why the Northern Ireland Covid bereaved might be so concerned that you haven’t had those discussions with those teams, and that again there appears to be a lack of reflection and therefore identification of areas of improvement going forward?

Mr Aidan Dawson: Yes, I can.

Ms Campbell: And what’s going to change?

Mr Aidan Dawson: I think as I leave today, I will discuss that with our team, as to how we are better prepared to reflect on the things that have happened during the period of Covid.

Ms Campbell: Thank you.

Lady Hallett: Thank you, Ms Campbell.

Ms Iengar. I hope you’re not going to get me into trouble today.

Questions From Ms Iengar

Ms Iengar: My Lady, no.

Mr Dawson, I appear on behalf of the Long Covid groups, I have some questions on the response to Long Covid in Northern Ireland.

You’ve said to Mr Scott that data on staff deaths and staff illness wasn’t recorded in – with reference to the spreadsheet in tab 3. To confirm, does it follow then that the Public Health Agency wasn’t collecting data on the number of healthcare staff with Long Covid?

Mr Aidan Dawson: No, it hasn’t that I’m aware of.

Ms Iengar: So there wasn’t and still isn’t a clear picture of the harm Long Covid causes to healthcare staff?

Mr Aidan Dawson: That is correct.

Ms Iengar: Do you agree that it’s necessary to bridge that data gap so that healthcare workers can be better protected from long-term harm?

Mr Aidan Dawson: Yes.

Ms Iengar: And, finally, Mr Dawson, you’ve been asked some questions about the steps the Public Health Agency took to support staff health and well-being and quite some detail in your statement is provided on that, paragraphs 72 to 84. Did the Public Health Agency take any steps to support the health and well-being of healthcare staff with Long Covid?

Mr Aidan Dawson: As I sit here, not that I’m specifically aware of but again I’m quite content to discuss that with the team and address that going forward and come back to the Inquiry, Ma’am.

Ms Iengar: Do you know why the impact of Long Covid on healthcare staff was overlooked?

Mr Aidan Dawson: No, I don’t.

Ms Iengar: Thank you.

My Lady, I’m grateful.

Lady Hallett: Thank you very much for your help.

Thank you very much, Mr Dawson. I appreciate it. It can’t have been easy answering questions before you were in post but obviously you’ve done your best. Thank you for your help.

The Witness: Thank you.

(The witness withdrew)

Lady Hallett: I shall return at 1.50.

(12.47 pm)

(The short adjournment)

(1.50 pm)

Lady Hallett: Mr Scott.

Mr Scott: Good afternoon, my Lady. May I please call Laura Imrie.

Ms Laura Imrie

MS LAURA JANE IMRIE (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: I hope you haven’t been kept waiting too long.

Ms Laura Imrie: No, thank you.

Mr Scott: Good afternoon. May we have your full name, please.

Ms Laura Imrie: Laura Jane Imrie.

Counsel Inquiry: And you are the clinical lead for NHS Scotland Assure and Antimicrobial Resistance & Healthcare Associated Infection Scotland, commonly known by the acronym ARHAI?

Ms Laura Imrie: That’s correct.

Counsel Inquiry: And that’s a position you’ve held since 2018?

Ms Laura Imrie: Yes.

Counsel Inquiry: Could you please give us a little bit about your professional background and qualifications?

Ms Laura Imrie: Yes. I qualified as a nurse in 1993 and then went into healthcare-associated infection surveillance quite quickly in 1997. And then undertook a BAC in nursing with a specialist practitioner called Vocation Infection Prevention and Control and then took up an infection control national job in the year 2000 and that’s where my career in infection control really started.

I completed a master’s in infection control at the University of the Highlands and Islands. I have held jobs in large health boards in Scotland, NHS Glasgow, NHS Lanarkshire, as lead infection control nurses, and I came to Health Protection Scotland as the clinical lead for their healthcare associated surveillance programme and being there a few years I then became the interim lead consultant and then I got my current post in 2018.

Counsel Inquiry: And so just a little bit about ARHAI. So ARHAI is a clinical service providing national expertise – in that circumstance is “national” within Scotland?

Ms Laura Imrie: Yes.

Counsel Inquiry: – for infection prevention and control, antimicrobial resistance and healthcare associated infection. It’s part of NHS Scotland Assure which is a directorate within NHS National Services Scotland.

Could you give us a little bit of relationship between ARHAI and NHS Scotland Assure, please?

Ms Laura Imrie: So in 2020, NHS Scotland Assure was formed as a directorate within National Services Scotland and it took – which was the HAI Group and Health Protection Scotland and Health Facilities Scotland and brought them together as one directorate within NSS.

That came around after the cabinet secretary had been involved in two children hospitals and there’s currently an inquiry ongoing into – Scottish hospitals inquiry, around the buildings of hospitals, and it was concluded that facilities and infection control had to work more closely together and to allow this to happen it was felt that a national group, team, should be responsible for looking at the guidance and the process that was put in when we were building new hospitals or kind of any kind of infrastructure builds to ensure that infection prevention and control and engineering science worked together.

Counsel Inquiry: And is it working?

Ms Laura Imrie: Yes, there’s a number of projects we’ve supported. So ARHAI Scotland has six priority programmes. One of them is clinical assurance, where we have infection control consultant nurses and some time of a consultant microbiologist who support what we call key stage assessment reviews, so KSARs. So when we work with the board who is commissioning the build and NHS Assure looks for the assurance that at the design stage, the procurement stage, that they are meeting the guidance, and that we are not progressing, spending money in developing a build that would not meet the guidance for facilities or IPC.

So, I think the feedback we have received from the boards supported so far is that it takes a lot of resource, it’s a new process, but it’s supporting the board to build hospitals and support the local infection control teams, the local facilities teams, to do a lot of the translation of the guidance, and put that into place when they’re signing contracts as well.

Counsel Inquiry: And part of ARHAI – we’ll come a little bit later on to how it makes guidance, but part of ARHAI’s role is to produce the national IPC manual?

Ms Laura Imrie: That’s right.

Counsel Inquiry: And when was the national IPC manual brought in in Scotland?

Ms Laura Imrie: It was first published in 2012.

Counsel Inquiry: And obviously we’ve heard a lot of IPC guidance over the course of this Inquiry. Did the Scottish IPC guidance in relation to Covid-19 and particularly about routes of transmission, use of masks, healthcare workers, did it follow the UK IPC cell guidance throughout the course of the pandemic or did it differ at any point?

Ms Laura Imrie: So the IPC guidance, that was a decision that was taken by NERVTAG, for what infection control guidance were going to be in place.

Counsel Inquiry: Just in terms of whether there’s been any diversion between Scottish guidance – is it right that the Scottish specific guidance first came in in October 2020?

Ms Laura Imrie: Yes, we developed our own guidance in 2020, but I think it’s quite important for the Inquiry to understand what – when we developed guidance in 2020, how we got to the guidance that was already in the UK.

Counsel Inquiry: I’m going to approach this chronologically, so maybe when we get to October 2020 we’ll touch on it then, rather than it take out of sequence, if that works.

Ms Laura Imrie: Okay.

Counsel Inquiry: I just want to ask you a couple of very broad questions.

On reflection, do you think that the IPC guidance – and when I talk about IPC guidance, I’m going to be focusing on routes of transmission, use of masks of healthcare workers primarily, and also the use of ventilation – was it always correct as that guidance developed over the course of the pandemic?

Ms Laura Imrie: Was it always correct?

Counsel Inquiry: Yes.

Ms Laura Imrie: The mode of transmission?

Counsel Inquiry: The IPC guidance about how it assessed what the mode of guidance was, about what masks should be used by healthcare workers. When you look back on the guidance, would you change anything?

Ms Laura Imrie: I think it was an evolving situation. There was evidence that had to be reviewed continuously. We had a very small team of scientists, but they were working 7 days a week to try and keep on top of the evidence that was coming out. I think we did respond to evidence either from groups like NERVTAG, SAGE, the Advisory Committee on Dangerous Pathogens, international evidence, I think there was a constant review of the guidance, and there was changes made as we understood the pathogen and the transmission routes throughout the course of the pandemic.

Counsel Inquiry: So the answer yes, as the guidance changed over the course of the pandemic at all times, you made the right changes at the right times?

Ms Laura Imrie: Yes.

Counsel Inquiry: And so I assume, based on your answers, you’re satisfied that it accurately reflected scientific understanding throughout the pandemic?

Ms Laura Imrie: Yes.

Counsel Inquiry: Do you think it took a sufficiently cautious approach to the risk of airborne transmission or aerosol transmission when AGPs or aerosol-generating procedures are not being used?

Ms Laura Imrie: I think the position we were in, it was very constrained by the dichotomy of describing something as “droplet” or “airborne”. My position today would probably align with that of the technical group, the World Health Organisation, where although they can’t come to a consensus whether there’s traditional airborne or droplet, they did come to the consensus that it would be more helpful to start to describe things as transmitting through the air. And in fact, ARHAI have completed the systematic literature review now on transmission, it’s that would also support in – a transmission through the air rather than describing things as “droplet” or “airborne”.

Counsel Inquiry: So it appears from that that the fundamental starting point was that airborne-droplet dichotomy; is this where you’re talking about there’s that boundary of size and everything underneath it is considered to be aerosol, and everything over, I believe it was 5 micrometres, is a droplet? Is that the genesis of this?

Ms Laura Imrie: Yeah, I think, on reflection, to describe by size isn’t, for the people using the guidance, always an easy way to understand what you’re asking them to do. I think going to there was transmission through the air of a pathogen and a risk-assessed approach of what environment you’re in, what procedures are you doing, what is the pathogen – if you know – that there needs to be a more risk-based approach.

Counsel Inquiry: Okay, I’m going to come and look and see how some of those appeared in practice.

If we can please have on screen INQ000474276. That’s page 50, paragraph 129. And this is the expert report provided by Professor Beggs to the Inquiry. And it says that:

“Prior [to] the Covid-19 pandemic and up [until] 23 December 2021 when the WHO softened its stance scientific consensus amongst the medical community (but not … physicists and engineers) was that SARS-CoV-2 and influenza were not airborne …”

And then the classification of the WHO, and this was reflected in the WHO guidance on the ventilation of healthcare facilities.

To what extent did the IPC guidance seek to follow the approach of the WHO?

Ms Laura Imrie: We reviewed the WHO, any communication, any reports that they put out. We did review it. We reviewed the other international evidence, CDC, and as we touched on earlier, Scotland moved to its own guidance in October 2020, and through the Covid Nosocomial Review Group we brought in international experts to join our meetings and to listen to the discussions and the challenges that we were having, and to offer us advice based on their experiences as well. So I think we did look widely to see what other people’s experiences were, if we could learn anything from that, and that included the WHO, but much wider as well too.

As an emerging situation, you were looking to the literature that was published, but quite often, by speaking to counterparts in other countries, you could get really good information that hadn’t been published, so we were really, as an infection control community, looking to share learning as quickly as possible.

Counsel Inquiry: Was there a desire to closely follow the WHO’s guidance over the course of the pandemic?

Ms Laura Imrie: No, I don’t think there was a desire that we were sticking with the WHO regardless of what they said, no.

Counsel Inquiry: So just on this point here. When the WHO softened its stance on airborne transmission of SARS-CoV-2, in your own mind, was there a connection between the WHO’s change of stance towards airborne transmission in December 2021 and the change of the UK IPC guidance in early January 2022 which appears to have followed the WHO’s change?

Ms Laura Imrie: So, again, I’m thinking back to what the guidance in Scotland said. In October 2020, in Scottish guidance we had made FFP3 available for all pathways, for when we were doing AGPs. And we made some changes, I think in 2022, there was actually a directorate level policy from the government to say in Scotland you could wear the FFP3 if you’d done a personal assessment, and that was on our guidance.

I’m not sure the IPC guidance change was made then.

Counsel Inquiry: But as far as you can remember, you were still on the IPC, UK IPC cell in January 2022?

Ms Laura Imrie: Yes.

Counsel Inquiry: So, given we’re talking about the relationship between the WHO and the UK IPC cell, was there a change in the IPC guidance within the United Kingdom that had been produced following the views of the UK IPC cell that arose because the WHO had changed its stance in December 2021?

Ms Laura Imrie: I think there was a more robust approach taken to the hierarchy of controls around that time, and that might have been – the WHO might – though the evidence that came out from the WHO might have, you know, been something that was considered, and that – I can’t remember exactly why those changes were made at that time.

Counsel Inquiry: Okay, because the CMO technical report was published 1 December 2022. I believe that you were a reviewer of the IPC section of chapter 10 about improvements in care of Covid, is that right?

Ms Laura Imrie: Yes.

Counsel Inquiry: And contained in the CMO technical report is a line that it is important that UK Covid-19 IPC guidance remained consistent with WHO recommendations. Why was it – conceptually, why was it important that the UK’s guidance remained consistent with the WHO recommendations?

Ms Laura Imrie: I think it was important that as a minimum, the IPC guidance within the UK was aligned with what the World Health Organisation were saying. The World Health Organisation are the experts across the globe, so they are the people that have studied infectious pathogens and how we control them, their whole careers. So I think it is important that we trust that the minimum of what is required by the World Health Organisation we are consistently meeting.

Counsel Inquiry: So does that mean that you were never likely to go below a level of protection that the WHO were suggesting?

Ms Laura Imrie: Yeah, I don’t think we’d ever went below what the World Health Organisation were suggesting.

Counsel Inquiry: But it was entirely open to the IPC cell to take the decision to offer additional protection to that protection proposed by the WHO, is that fair?

Ms Laura Imrie: Not the IPC cell. So the IPC cell had no role, remit or authority to change the mode of transmission and the mode of transmission that the controls were put in place for healthcare were the same mode of transmission that Public Health were putting public health measures in place for, for the general public, other key workers such as teachers, police, shopkeepers, so I don’t think the IPC cell had the role, remit or authority to change what the mode of transmission was for a pathogen when it’s been decided internationally by international experts and we have NERVTAG, ACDP, the senior clinicians, UKHSA, so I don’t think the IPC cell were ever going to be the ones who changed how we controlled a pathogen.

Counsel Inquiry: That document can come down now, thank you.

But the UK IPC cell were the ones who were providing effectively their views on what the guidance should look like in terms of IPC guidance in the United Kingdom, isn’t that right?

Ms Laura Imrie: Yeah, so that – I think that’s an important point. So NERVTAG who are the governance advisory group to the government and they have the structures around it, they had done the assessment and it was decided long before the IPC cell was set up that the guidance that we would do would be the pandemic influenza guidance.

Now, this is a group that assesses new and emerging respiratory pathogens so we would take counsel from them as to what the IPC – and then we would look at the evidence and write the IPC for healthcare guidance around that. The IPC cell was, if you like, an informal cell, it hadn’t been set up as part of the pandemic structure for response. It was, if you like, the UK leads in each of the four countries saying: let’s come together and try and put some guidance together rather than us all doing something separately.

We reported informally to the chief nursing officers, but it wasn’t an advisory group the same as ACDP, NERVTAG, SAGE or the senior clinical group, so we didn’t have the authority to start changing the mode of transmission. We can give consensus that the mode of transmission and the evidence that we are reviewing both in our local epidemiology, from the hospital local teams, and the evidence that’s published in international journals, we could then give a consensus to say, well, actually, we’re seeing signs now that the controls we are putting in place around droplet are not working.

But we would never be the ones who would have changed the modes of transmission.

Counsel Inquiry: The reasons I’m asking the questions is to have an understanding of how you and how you thought that the IPC cell functioned and effectively what its role was within providing IPC guidance.

So, the fact that the IPC cell was set up at all was as a result of a perceived gap in the response to the pandemic?

Ms Laura Imrie: Yes.

Counsel Inquiry: So it was clearly doing something above and beyond what NERVTAG was doing?

Ms Laura Imrie: Yes.

Counsel Inquiry: And it had the four public health bodies, so it had the IPC specialty and specialisms across the United Kingdom who were all members of it?

Ms Laura Imrie: Yes.

Counsel Inquiry: And guidance was produced as a result of the consensus view of the IPC cell, is that right?

Ms Laura Imrie: So NERVTAG had made the decision that we –

Counsel Inquiry: I’m not talking about the specifics, I’m talking just generally that IPC guidance, after the initial guidance had come through from the pre-pandemic that was based on the influenza, everything subsequent to that, any changes that may arise would have been following a consensus view expressed by the UK IPC cell, is that right?

Ms Laura Imrie: Yes, we make the guidance thereafter.

Counsel Inquiry: And so you would have been aware and other members of the cell would have been aware, as far as you know, that you were the ones who were providing that core advice as to what the IPC guidance was going to look like?

Ms Laura Imrie: Yes, in consultation with other organisations, groups and feeding up. We didn’t come to a consensus and then publish the guidance. So if there was changes to be made to the guidance, for instance in Scotland I would have taken that back. If there was changes that I felt were going to affect the kind of principles of the guidance that would affect Scottish guidance that would have come back to the Covid Nosocomial Review Group which was a multi-agency, multi-disciplinary group. We had consultants in public health, virologists, microbiologists, occupational physicians, workforce, Scottish Government. A wide, wide variety of specialists and organisations and those changes would have been discussed in depth at that group. That was our governance about if we accepted.

So there was no decisions, discussions being made at an IPC cell on guidance.

And likewise, other members of the IPC cell, whether they were Public Health England or NHS England, they would have went back to their, whatever their governance was around guidance for their country and then brought that back to the IPC cell for discussion.

Counsel Inquiry: Yes, but given that you were a pan-UK body that was set up specifically to respond to the pandemic that has effectively the lead knowledge of infection prevention and control in the United Kingdom, the consensus view of that body was always going to carry the most weight about what that guidance should look like; isn’t that right?

Ms Laura Imrie: Well, not necessarily. We have the specialty of infection prevention and control but if I took something back to the infection control doctors network in Scotland and infection control nurses network and they said to me, “That’s never going to work, that’s not practical, you can put that in your guidance but we can’t follow it”, then that needs to be fed back and then we need to address what’s going into the guidance.

So it’s always in consultation and all through the pandemic there was a lot of consultation done with a lot of groups to understand what it meant.

And it was a two-way conversation. So ARHAI facilitated weekly meetings with our networks and the boards and the special health boards and the issues that they brought back were then considered at both CNRG and we’d feed back into the IPC cell, and that was things like – the networks were feeding back that although staff were wearing masks, and this was quite early on in the pandemic, that they’d discovered there was a lot of car-sharing going on and when they investigated staff clusters it turned out that they were car-sharing and that was fed back and then very quickly it went into the guidance and into policy about car-sharing and masking.

Lady Hallett: I missed the word and so did the stenographer.

Did you say “cashiering”?

Ms Laura Imrie: Car-sharing.

Lady Hallett: I am so sorry.

Mr Scott: But that information would then have been fed back into the IPC cell, it wasn’t that there was somebody – it wasn’t there was another level who would have said, “Well, thank you very much for your advice but we’re going to do something different.” Isn’t the practical reality that the advice that came out of the IPC cell which said “This is what our advice is”, was going to be followed across the United Kingdom?

Ms Laura Imrie: Yes, but it didn’t just come from the IPC cell members. What came out of the IPC cell was as a result of wide consultation with CMOs, CNOs, you know, NERVTAG, and each country had its own nosocomial group that was considering what the guidance changes would be alongside the local Epi and other evidence.

Counsel Inquiry: Did anybody in any part of the United Kingdom ever change or not adopt a view that had been expressed as a result of consensus of the UK IPC cell or were those always implemented?

Ms Laura Imrie: No, I think there was some colleges that developed their own IPC guidance that might have been different.

Counsel Inquiry: Yes, but that’s separate. I’m talking about when consensus advice had been provided by the UK IPC cell to the four different nations to the United Kingdom or any other Senior Clinicians Group, did anybody ever change it or did they just say, “We’ve taken that advice, thank you very much”, and it got adopted?

Ms Laura Imrie: Well, I think that was one of the things that led to Scotland developing their own guidance in October 2020. Some of the feedback we got from our service providers and stakeholders was around they wanted, you know, more flexibility in using FFP3 across all pathways. There was some kind of local guidance that they felt their UK guidance couldn’t provide and therefore it left gaps for the Scottish workforce.

So there was feedback like that. And I think there was maybe a couple of occasions where the CNOs came back to ask for more information or to understand the evidence better.

Counsel Inquiry: Okay. Why was it ARHAI was providing rapid reviews to the UK IPC cell?

Ms Laura Imrie: We weren’t providing them to the IPC cell.

Counsel Inquiry: Then why were they being looked at by the IPC cell?

Ms Laura Imrie: Because there was nothing else available.

Counsel Inquiry: So does that mean it was only ARHAI providing scientific advice that was considered by the IPC cell?

Ms Laura Imrie: No. That means that very early on in the pandemic, both infection control professionals and clinicians were coming to ARHAI to say, “I’ve seen this article online today, and it tells me that if you smoke, you’re less likely to get Covid”, and there it was, it was published, they didn’t – it didn’t feel right, there was a lot of information coming through quickly. That was one example.

So ARHAI decided to do rapid reviews so that we could provide our Scottish stakeholders with a single place to go and see what’s been published online, and again, we were doing a lot of pre-print publications. So, normally, if you have a publication in a peer reviewed journal that has went through quality assurance, you’re quite reassured that the methodologies used and the outcomes have been checked with peers. During the pandemic, in order to get intelligence out quickly, a lot of journals were doing what they call pre-print publications. So we –

Counsel Inquiry: We’ll come to look at the methodology, I’m just trying to have an understanding about who was providing rapid reviews –

Ms Laura Imrie: Yes.

Counsel Inquiry: – (Unclear: multiple speakers) – of the IPC cell, because ARHAI were providing rapid reviews?

Ms Laura Imrie: ARHAI were providing rapid reviews to allow infection prevention and control specialists in Scotland to go to one place so they could see what had been published and what the scientists had reviewed. We chose to publish them rather than just share them through email so they were easily accessible.

We never intended that we would be the organisation that done rapid reviews for the next two years on IPC. We thought that an international body or UKHSA, or – you know, somebody would then take over looking at the international evidence that was out there, but nobody did, so we continued to do a rolling programme of rapid reviews.

My reflection on that is that we filled a gap and we continue to do that, and maybe it would have been more beneficial if the IPC cell had had a separate subgroup, an evidence subgroup that maybe brought people from some of the other groups, say it’s NERVTAG, and it was a UK group.

Counsel Inquiry: Different – would that include different – groping for the word here – experts, thank you – of different then – so physicists or engineers or anyone of that category, or so just simply the IPC?

Ms Laura Imrie: No, it would include – it would be a separate evidence group that could look at the evidence and then provide recommendations or conclusions for guidance development, the same way that we use the methods in the manuals. Now, albeit you would have to reduce some of the stages, but I think on reflection that might have helped other UK nations feel that there was a sense of belonging, that it had been more of a collaboration, that they were more – it was more clear to them how the rapid reviews had been done, if that was the only thing that was available for the IPC cell to use.

Counsel Inquiry: Did you get a sense that other bodies did feel like that?

Ms Laura Imrie: I think sometimes, when you’re working across the UK, it can be challenging if there’s a piece of work just done by one country and the other countries are asked to adopt it. So – maybe because they don’t buy into it the same because there’s not been the same involvement, maybe because they don’t understand or they don’t know the people who have done the rapid review and they don’t know the people that have done that bit of work, so there’s maybe the confidence on how it’s been done.

Counsel Inquiry: So how did it work? If you’re a UK IPC cell member, were you emailed the latest ARHAI rapid review after it had become apparent that nobody else was doing these rapid reviews?

Ms Laura Imrie: No, no. Our rapid reviews were never commissioned by the IPC cell. They were published every month, so they were readily available to anybody, members of the public, anybody. They were there.

Counsel Inquiry: So it could be that a UK IPC cell member would arrive at the meeting and wouldn’t have read the rapid review?

Ms Laura Imrie: It may be.

Counsel Inquiry: In the absence of any member of the UK IPC cell not having read something like the ARHAI rapid review, how would they necessarily have had a sufficiently broad understanding of what the current scientific basis was for what the IPC guidance should be based on?

Ms Laura Imrie: I don’t feel I can comment on how others prepared themselves to come to IPC meetings.

Counsel Inquiry: I want to then look at the methodology that was used by ARHAI on the basis of these rapid reviews.

It’s right to say that prior to the pandemic, ARHAI, or when you were creating the National Infection Prevention and Control Manual, then, when you’re producing guidance, that would take a period of a minimum of six months?

Ms Laura Imrie: Yes.

Counsel Inquiry: And that would form a well-established process and a systemic – systematic literature review?

Ms Laura Imrie: Yes.

Counsel Inquiry: And that’s not something that was possible to do in the context of the pandemic?

Ms Laura Imrie: No.

Counsel Inquiry: And so there was a different methodology that was applied?

Ms Laura Imrie: That’s right.

Counsel Inquiry: How did you choose the methodology that was used to make those rapid reviews? Is there an international or national standard, or?

Ms Laura Imrie: No, there’s no international or national standard for doing rapid reviews. Rapid reviews are normally done to – and we do rapid reviews routinely. If you’re supporting an instant management team that is looking to control an outbreak, you might make a rapid review for them, so you’re just quickly looking at the evidence. But they wouldn’t then go and – to be published as guidance.

During the pandemic, the evidence was emerging so quickly that you would not have been able to do a systematic review. By the time you finished, the evidence would have changed, you would have moved on to a different variant. So the methods that were chosen – we chose to use for rapid review were really a cut-down on the methods that we would do a systematic review, and removing some of the kind of more resource-intense steps, like normally in a systematic review we would have two independent reviewers; we didn’t have that, we had two reviewers and they both reviewed different publications. We cut down the number –

Counsel Inquiry: Just when you’re talking about two reviewers but they reviewed independent – different publications, so it wasn’t that –

Ms Laura Imrie: There was no one – there wasn’t two independent reviewers going through the same as we would for a systematic, but the scientists were reviewing thousands, thousands of articles every week.

Counsel Inquiry: How much time did they spend doing that?

Ms Laura Imrie: They’re full-time, 7 days a week. They worked hours. We only had access to four scientists at the time.

Counsel Inquiry: Could you – without naming them, are you able to give broadly their qualifications for the role they were in to be able to perform that task?

Ms Laura Imrie: Yes. One of the scientists is actually a dentist who left dentistry and had developed research interest around healthcare-associated infection and came to ARHAI. And the other scientist is the principal scientist for ARHAI who has been working in the area of healthcare infections for many years, and has been kind of fundamental in the development of our methodologies and indeed our kind of updated methodologies that we published in 2024.

Counsel Inquiry: Do you have any – and this may be on reflection – did you have any concerns or thoughts about whether they were necessarily the best qualified people to perform those rapid reviews?

Ms Laura Imrie: No, I don’t have any concerns. They were following science methodologies although it was cut back. They are very experienced in both literature reviews, guidance and working in healthcare. And developing infection prevention and control.

We have very robust structures when we’re doing guidance. We publish. We are – although we have reflected on some of the criticism around how open we were in the rapid reviews and which evidence we didn’t consider, and – as I said, the lead scientist has now developed a new methodology that we’ve piloted for the last two systematic reviews, which is more open, as in we would provide our kind of considered judgment forms on – we’ll publish them as well so that people get a better understanding of what evidence we reviews, what messages we took from the evidence and how it became a recommendation, and – so they can really follow through from the evidence we’ve reviewed, through to what comes out in the guidance. So –

Counsel Inquiry: Is that a lesson learned from the experiences during the pandemic?

Ms Laura Imrie: Yes. We fed back within our teams that a lot of the criticism we got, and some of it was on social media, some of it might have been coming in through questions, that people couldn’t really follow where the guidance got the evidence from. So the rapid reviews, again – and another thing we reflected on was – in some of the rapid reviews, there is the word “recommendation”, and it wasn’t a – which might have confused some people into thinking that the rapid reviews in theirself were guidance. So we’ve now made changes that in rapid reviews, we will never say there’s a recommendation from a rapid review. And there will be more conclusions that we’ve drawn that would then go on to be considered for guidance.

So there, I think are kind of two things we’ve changed.

Counsel Inquiry: Would you change the – because when you read the rapid reviews, it doesn’t appear in the way that you would for a systematic review, that there is a kind of grading that is assigned to any of the studies or any of the conclusions. Doing a rapid review now, would you include that grading?

Ms Laura Imrie: So that’s part of what I think, you know, if you have an IPC cell then you need to resource that cell. So we had an IPC cell that brought together the kind of national leads and some of the staff within those teams –

Counsel Inquiry: So just at the moment – maybe I’m talking about two different things. At the moment I’m trying to talk about those who were writing the ARHAI rapid reviews and how that document looked when it’s finished.

Ms Laura Imrie: Yes, so we didn’t have the resource to do that, to do what – you’re talking about the grading and – you know, that’s part of why a systematic review can take up to six months. We were turning these over and, as I said, the scientists were reviewing thousands of papers a week. So we were turning these over very quickly, and the limitations are all there.

I think the lesson I would take for the future is if you need to do rapid reviews because you have another emerging pathogen and you don’t have the evidence historically, then you should resource an evidence subgroup for IPC guidance that could then maybe take on some of that, and have the grading, and make it more clear and open for people to understand what the evidence has said.

Counsel Inquiry: Because that grading would also then help the readers to have an understanding of the strength of the assessment?

Ms Laura Imrie: Yes, yes.

Counsel Inquiry: And it would help prevent any risk of bias?

Ms Laura Imrie: Yes.

Counsel Inquiry: And you said you were resourcing this evidential subgroup. What resource do you think it needs? How many bodies does it need?

Ms Laura Imrie: I think, first, we need to look at what are the groups that are set up for an emergency response when there is an infection prevention and control or a healthcare nosocomial element to it. And I think that came through in some of the lessons learned both from CNRG and the IPC cell about – that the structures should be in place, so, similar to SAGE, NERVTAG, ACDP and other advisory groups. And the terms of reference should be agreed outwith the group rather than the group coming together and agreeing their terms of reference, and asking CNOs and others, “Is that what you want to us do?”

Counsel Inquiry: Is that because it would provide better transparency and openness by doing it that way? Is that the reason why you think it would be a good idea, or?

Ms Laura Imrie: I think it would be a good idea because when WHO or UKHSA announced that we have an epidemic, a pandemic response required that the structures are well understood and the roles and responsibilities are well understood of what groups are going to be asked to deliver.

Counsel Inquiry: I want to then talk about the start of the pandemic, so moving away from how the rapid reviews were conducted and have a look about what the guidance actually said.

You were talking about the NERVTAG guidance from, I believe it was around 13 March, and that was the pandemic influenza guidance that had been adapted; is that correct?

Ms Laura Imrie: Yes.

Counsel Inquiry: Why do you think, at that point in time, that in terms of the understanding the route of transmission, so whether aerosols could be generated outside of AGPs, why do you think that that evidence, that that guidance was right at that time?

Ms Laura Imrie: Sorry, I don’t understand the question.

Counsel Inquiry: I’ll rephrase. I phrased that very badly.

The NERVTAG guidance said that you should be using FFP3s because there could be a route of transmission via aerosols when there are AGPs. It didn’t suggest using FFP3s when there wasn’t the use of AGPs; that’s right, isn’t it?

Ms Laura Imrie: Yes.

Counsel Inquiry: And so, effectively, that’s suggesting that there’s no risk of aerosol transmission when there’s no AGP?

Ms Laura Imrie: Yes.

Counsel Inquiry: And did you agree that that was a correct analysis based on the science at the time?

Ms Laura Imrie: Yes.

Counsel Inquiry: And why do you say that was?

Ms Laura Imrie: That – the droplet transmission?

Counsel Inquiry: Yes.

Ms Laura Imrie: Historically it involved the use of fluid-resistant surgical masks. It has been used for influenza outbreaks in healthcare for many years. I think the science behind it was that not that you’re not expelling aerosols, it’s just that only when you were doing aerosol-generating procedures was there enough expelled that would then be a risk.

Counsel Inquiry: Is that based on a presumption or is that based on clear unequivocal scientific evidence?

Ms Laura Imrie: So I think there’s lots of gaps even today and the evidence between droplet and airborne, and I’m sure you’re aware even the technical group at WHO that published in April brought together experts from engineering, aerosol science, IPC, and I think the first thing that the chief scientist said is they were unable to agree on many of the key points and I think today there’s still not agreement from everybody around whether aerosols actually cause the transmission outwith AGPs.

Counsel Inquiry: Can I take you to the CMO technical report. If we can go to INQ000203933, page 51. And it’s the second substantive paragraph up from the bottom, it’s just following on from footnote 214. It says:

“Even transmission at close range was subject to prior assumptions, with the belief that the risk was posed by large droplets rather than the more concentrated small aerosols, resulting in reduced focus on masks for protection against inhalation for people at close proximity.”

Do you agree with that analysis contained in the CMO technical report?

Ms Laura Imrie: Yes.

Counsel Inquiry: Do you believe now that what’s classified there as prior assumptions, are they a correct representation of the scientific position or actually has the science today shown that those assumptions are wrong, or potentially wrong?

Ms Laura Imrie: I think there needs to be more research to truly understand and I think that’s why I would agree with the approach that WHO are taking to stop using the dichotomy of droplets and aerosols and move to a more risk-based assessment of the patient, the pathogen, the procedure and the environment, and the staff member as well. I don’t find it helpful, and I did, I have seen another bit that says, it suggests we move the droplet size or the aerosol size but I don’t think that will make it less confusing.

Counsel Inquiry: Does it come down to, do you not need to protect against a route of transmission where there might be a risk that that pathogen will transmit via that route? It doesn’t really matter about the science behind it, if a risk exists, you protect against it, particularly at the early stages of a pandemic?

Ms Laura Imrie: So they start off – Covid-19 started off, as you know, as a disease of high consequence and then it was reviewed by NERVTAG and others to be downgraded, I think; yes, if you have an emerging pathogen then we should take the highest precautions.

Counsel Inquiry: Do you think you did in the way that the IPC guidance was first looked at and first reviewed by the UK IPC cell, whether or not NERVTAG had originally provided it, did you not look at it and then think maybe we need to change this, quite early on?

Ms Laura Imrie: There is still no evidence in healthcare settings that you, to recover viable viruses from aerosols – I mean, we’ve recovered RNA, there is always a risk that yes, that can be a route of transmission, but you have to weigh that up against all the unintended consequences when you apply that precautionary principle.

Counsel Inquiry: I just want to look at the way Health Protection Scotland dealt with aerosol-generating procedures.

If we can go, please, to INQ000189647, and it’s page 2.

Did you have any involvement in creating this in your role within ARHAI?

Ms Laura Imrie: No.

Counsel Inquiry: If we can please go to page 7. And it’s that second page, sorry that second paragraph. So:

“In the systematic review completed by transaction …”

We heard from Professor Beggs that this is effectively the genesis of AGPs, that there was believed to be an increased risk of transmission of SARS.

“That said, some of these procedures are considered to have a theoretical risk of aerosolisation, and therefore are listed as AGPs based on the consensus of expert opinion, specifically, induction of sputum.”

Is it not there that Health Protection Scotland in the context of AGPs are saying that you need to take a cautious approach to whether these AGPs do produce aerosols, yet even at the time that they recognise that aerosols could be produced by the human body outside AGPs, they weren’t taking such a cautious approach?

Ms Laura Imrie: Yes, I think attributing risk to any single procedure is – with any level of certainty is very challenging and we’ve seen that throughout the pandemic where several independent AGP panels internationally looked to describe what an AGP was and the risk was to a single procedure and they found it very challenging that the evidence was sometimes missing. And again that’s why I would say we should be moving towards allowing staff to make that assessment on the risk based on the procedure, the patient, the pathogen.

Counsel Inquiry: Yes, but I am more talking about an approach. Because if we just go slightly further down in this document, it’s the bottom paragraph, it says:

“Although there is an absence of strong evidence to support some of the procedures listed as AGPs in this document this does not mean that there was an absence of risk. A precautionary approach should be taken for all AGPs specified as potentially capable of generating infectious aerosols from patients suspected or known to have respiratory infections.”

So that was the view taken in March 2020, so in the paragraph above which was talking about only theoretical risk of aerosolisation, would you agree that’s taking a cautious approach to AGPs in March 2020, that’s what that document is doing?

Ms Laura Imrie: Yes.

Counsel Inquiry: If you were to read that bottom paragraph again, and you were to replace “AGPs” with “aerosol transmission by the human body outside AGPs”, why wouldn’t exactly the same paragraph apply? So if you were to read it:

“Although there is an absence of strong evidence to support [aerosol transmission outside of AGPs] this does not mean that there is an absence of risk. A precautionary approach should be taken for [aerosol transmission outside] … AGPs … as potentially capable of generating infectious aerosols from patients suspected or known to have respiratory infections.”

Isn’t the same true?

Ms Laura Imrie: No, because you’re talking about transmission. So there’s no evidence that – in healthcare there’s no studies that have actually found viable virus in aerosols. And if you’re working on the theory if you’re doing AGPs you’re producing such a large amount of aerosols. So if you imagine an aerosol that’s tiny and a droplet is ten times its size then the theory being they are inoculating those depending on what that is, the droplet will carry more of the virus, but if you’re doing an AGP and you’re doing it in lots of these small particles at the same time then the risk is that you’re generating but you’re saying it’s transmission.

Counsel Inquiry: Apologise. I’m not following the logic of that. So you’re saying that there’s no evidence that there’s viable viruses in aerosols?

Ms Laura Imrie: In healthcare. There’s not been any studies that – so we’ve found RNA, we’ve found that there is – now, that doesn’t mean that it’s not happening, it’s just that the number of studies that are done we have still not got that evidence.

Counsel Inquiry: So – but, again, I want to go back to the logic of what you were saying that there’s no evidence in healthcare, there’s no studies that have actually found viable virus in aerosols yet you’re saying that AGPs because they produce such a large amount of aerosols it was presumed there was a risk of transmission?

Ms Laura Imrie: So that would be the highest risk.

Counsel Inquiry: But isn’t the logic of that that you can have viable viruses in aerosols?

Ms Laura Imrie: Yes, at that time when you’re doing your AGP but how long they last and how long they’re viable for – most of the studies that have shown staff transmission through aerosol-generating procedures have been done in very – and by the very nature that you’re doing an aerosol-generating procedure, you are very close, in very close proximity and normally for an extended length of time.

So, again, we’re going back to the procedure you’re doing, the time you’re spending. It’s not the same as some of the other risks that may have been described.

Counsel Inquiry: But –

Lady Hallett: Can I just – what you actually said was there’s no evidence in healthcare that viruses are found in aerosols. Do I understand what you’re really saying is there’s no evidence in healthcare that viruses we need to worry about in sufficient quantity are found in aerosols; is that what you’re saying?

Ms Laura Imrie: So the studies that have been done to look at aerosols and I’m specifically talking about Covid-19, although they have recovered RNA they have not recovered the kind of viable virus that could go on to transmit. So – and I’m not saying it doesn’t happen, I’m saying there’s a gap in the evidence.

Mr Scott: But I’m trying to understand – let’s leave aside Covid-19 because this was a view taken prior to the pandemic, isn’t that right, about AGPs had a risk of transmission via aerosols but non-AGPs didn’t. That was the basic dichotomy, is that right?

Ms Laura Imrie: And droplet.

Counsel Inquiry: Yes, yes. So there wasn’t the strong evidence prior to the pandemic to support that there was transmission in aerosols?

Ms Laura Imrie: No.

Counsel Inquiry: So why was there not an equivalent approach taken to the risk of transmission between AGPs and non-AGPs when aerosols might be produced by the human body? I’m struggling to understand the reason why you’re drawing a distinction between the two if they’re not based on strong evidence either way.

Ms Laura Imrie: I’m not sure I’m following you.

Lady Hallett: I think you may be going around in circles. I’m not sure I’m following questions or answers at the moment.

Mr Scott: It was known about how to protect against the risk of aerosol transmission. That was use of FFP3s, that’s right?

Ms Laura Imrie: Yes.

Counsel Inquiry: Along with all the other IPC measures, I’m talking about the difference between droplet transmission and aerosol transmission is that you use FFP3 for aerosol transmission, is that right?

Ms Laura Imrie: Yes.

Counsel Inquiry: What would have been the harm at the start of the pandemic of using FFP3s if there wasn’t any issues in relation to supply? Would there have been any concern about using FFP3s in those circumstances?

Ms Laura Imrie: I don’t think we were in a position to use FFP3s widely in the NHS. As you’re aware, due to the UK legislation to advise the use of FFP3 means that someone needs to have a face fit test. I know roughly in Scotland at the start of the pandemic there was around 7,000 staff members who had an up-to-date face fit test which is a drop in the ocean. And I believe that the other UK countries would have been in a similar position. That was one of the considerations.

And there was also – I am assuming what you’re talking about is applying a kind of precautionary principle. There was also supplies. If we wrote guidance as a precautionary principle to put everybody into FFP3 then not only would they have had a large amount of the workforce that couldn’t comply with the guidance, and therefore couldn’t come to work, we would also have had high risk areas where we had identified for intensive care units, high-risk pathways that might have been left without the FFP3s.

They were probably two of the main constraints if you were looking at putting in a precautionary principle of an FFP3 without the evidence, but – the evidence that, you know, we didn’t have staff face fit tested and there was at the beginning of the pandemic a very quick and a rapid stocktake of what stock we held and what was required, and from my understanding that would have made it really difficult to supply the FFP3s to the ITU units and the other areas we deemed high risk.

Counsel Inquiry: So was supply and practical considerations driving the advice that’s being given?

Ms Laura Imrie: No. It was a consideration. If you were looking at the precautionary principle which was discussed numerous times across the course of the pandemic but at the beginning of the pandemic I think that would have been two of the main considerations, that would have been taken into account was the face fit testing and what stocks were available from the pandemic stock.

Lady Hallett: Ms Imrie, you said some time ago that you should take the highest precautions subject, obviously, to the considerations that you’ve just been outlining with masks. Face masks are just one aspect –

Ms Laura Imrie: Yes.

Lady Hallett: Of taking the highest precautions and I’m afraid at the moment what I don’t follow, and I wonder if you could help me, is, if, when the pandemic starts, you don’t know if it’s aerosol or droplet – I appreciate you say that you wouldn’t go there any more – but at the time that’s where people were going, and it sounds as if people still aren’t agreed as to whether it was droplet, why don’t the people issuing guidance and advice say “Well, we don’t know, too early in the pandemic for us to tell you if it’s airborne or if it’s droplet”, as seemed to matter at the time, “and therefore we suggest that you take the following precautions if you’re able”? It may be that you can’t do the masks for the reasons you’ve given, although I think others might argue to the contrary, but surely there were other things that people could do, or did they all have unintended consequences and downsides?

Ms Laura Imrie: I think what we need to, or what I certainly reflect, going back at that time, was we were asking people to go to work and look after infectious patients and, you know, with all the media attention and all the death that surrounded them, if you had said “We think you should bring in an FFP3”, and they would take that as the guidance, “but actually we don’t have the masks to give you”, I think that would have been an unbearable anxiety for somebody going into work and looking after Covid.

Lady Hallett: I understand that. I’m just trying to move beyond masks for a moment.

Ms Laura Imrie: Yes.

Lady Hallett: If you tell people it could be airborne, it could be droplet, then essentially you’re telling people who know about these things, “Keep Your distance when you can. Try to avoid contact. When do you have contact try to make sure you’re wearing at least some kind of mask. Be careful in staff areas”.

Surely that kind of advice might help stop the spread?

Ms Laura Imrie: No, I think that’s really important. I think, unfortunately, at the beginning of the pandemic we neither recognised presymptomatic carriage or asymptomatic carriage, and we didn’t have the testing either. So if there was another pandemic tomorrow, would I wait to see if there was evidence of presymptomatic or asymptomatic, no, I think we would go into enhanced mask wearing straight away.

Would we – and we did during the pandemic, because in Scotland, from March we collected local Epi data on all our amber and green, so – not the Covid areas but the non-Covid areas, any areas where we had clusters, so unexpected clusters, we asked the local teams to go in and look at what are the lessons learned, did something go wrong? And there was things that came through around, as you said, staff areas. I mean, some hospitals had airlines set up first class lounges where they invited staff to have breaks and take their mask off, and they weren’t doing anything, you know, contrary to the guidance because at the time we didn’t understand all the presymptomatic and asymptomatic.

But even as we moved through the pandemic, we still seen a lot of the lessons that were learned from the cluster was staff were removing their masks in changing areas and duty rooms. And Scottish Government, through CNRG, commissioned the University of Edinburgh to do some behavioural insights work with some of the medical and nursing staff, frontline staff. And they did – their findings were that the clinical teams viewed patients at a far higher risk than they did their colleagues, so their behaviours were adjusted when they were in a staff-only area. I think in hindsight we knew all that and certainly if there was another similar pandemic I think we would go in quite strong and say it’s masking for everybody all the time.

Mr Scott: Is there any harm in including in guidance the fact that there might be some uncertainty about circumstances in which issues may arise?

Ms Laura Imrie: I think you’d be raising anxiety within frontline – without any evidence to do that.

Counsel Inquiry: Isn’t that an assumption, because there was anxiety raised by the way the guidance was used, was applied anyway?

Ms Laura Imrie: But there is no evidence to support you asking staff to wear, or advising staff to wear PPE that they can neither access nor they feel comfortable wearing.

Counsel Inquiry: Can I please show you it’s the WHO guidance of 1 December 2020, just as an example of what guidance can look like. It’s INQ000349135. Page 1, and this is mask use but I think it comes back to her Ladyship’s point about using things as a package of measures. If we can just have a look at the first paragraph at tab 25 of your bundle if you’re following paper. The first tab of key points. It’s the paragraph underneath that.

So it’s that first tab where it’s talking about use of masks as part of a comprehensive package, even when it’s used correctly, it’s providing adequate protection or source control. So, setting out there it need to be part of a comprehensive piece.

And then if we can just go down, please, to page 4, and WHO sets out in quite a lot of detail what the reviews have shown, and if we just look under the guidance, it talks about the WHO guidance on the type of respiratory protection is based on – sets out the basis for these, for the guidance. It sets out – if you can just go down a fraction. So it’s talking there about all available evidence, it’s discussing considerations that have been taken into account, and then it says that there’s a majority of members. So the WHO has not shied away there of showing that the members who are creating this guidance have disagreed.

And then it goes down to the bottom page. So the bottom paragraph on this page and it says:

“In general, healthcare workers have strong preferences about having the highest perceived protection possible … and … may place high value on the potential benefits about of respirators in settings without AGPs. WHO recommends respirators primarily for settings where AGPs are performed; however if health workers prefer them and they are sufficiently available and cost is not an issue, they could also be used during care for COVID-10 patients in other settings.”

What would have been the harm of using a paragraph like that in the IPC guidance within the United Kingdom?

Ms Laura Imrie: We did include that in our Scottish addendum that a preference and individual risk assessment could be done, and in FFP3 and – just last month, we published our winter campaign which also follows this – so we roll out to stakeholders to let them know that we’ve done a systematic review, but the stakeholder groups that we meet with to develop the guidance had asked that we did not change the guidance coming into wintertime. But we’ve put out a position statement which is very similar to what WHO have said here, that you can do a personal risk assessment. So it’s still directing you to the hierarchy of control, so, you know, choose the environment, think about the procedure, the pathogen, this isn’t just for Covid, it’s winter preparedness for all respiratory viruses. But – and if you do all that and you still prepare to use an FFP3, then that is certainly included in the Scottish National Infection Prevention and Control Manual as it is now.

Counsel Inquiry: Yes, but I asked you earlier on, is there any harm in including the fact there might be uncertainty in which issues may arise, and your response was “I think you would be raising anxiety within frontline without any evidence to do that”.

Ms Laura Imrie: So I don’t think there was uncertainty, I think NERVTAG had reviewed the evidence and we’re quite confident that the influenza pandemic guidance should be used. I think there was and still is many studies that were done outwith healthcare that have concluded that there may have been aerosol transmission. Now, whether or not these are transferable into healthcare, you’re comparing community settings where you have absolutely no control, so no masking, no IPC education, no distancing, no contact tracing etc to a very controlled healthcare environment that did have universal masking, that did have distancing and all of the other environmental controls. So the uncertainty was, there wasn’t enough good evidence to say that we were uncertain.

Counsel Inquiry: So you’re saying that there was sufficient certainty within the IPC guidance –

Ms Laura Imrie: I don’t think just within the IPC, I think – and that’s why I’m referring back to NERVTAG and others, I don’t think they said go with droplet and influenza pandemic guidance, but we’re not certain about it. I think there was an understanding, and there is an understanding, that you need to be constantly reviewing the evidence and that’s why our National Infection Control Manual is a living document, we do constant updates to check if there’s any evidence contained in it that is out of date, or if there’s any new evidence that contradicts what’s in it.

I think there was always an intention that these groups would be reviewing the evidence in a recurring basis, alongside looking at the local epidemiology so locally what’s happening in the hospitals. And we followed quite closely both the clusters, so the unexpected cases that we had, plus the hospital onset which all the UK countries come together to put their definitions together, and what we seen across the whole pandemic, through all variants, was, as your community prevalence went up, 10 days later hospital onset went up, because people were coming in, and then we seen the nosocomial infections going up as well, so –

Counsel Inquiry: Can I bring you back to the start of the pandemic again.

There is just one final question before I move on to a different topic, my Lady.

Lady Hallett: I have a question about the hierarchy control.

Mr Scott: I’m entirely in your hands, naturally, my Lady.

Lady Hallett: I’ll ask it now.

I appreciate I’m a layperson, it’s not my field of expertise, but I have serious difficulties with the hierarchy of controls. And I’ve been looking at the guidance on the ARHAI website and it says, it’s a well-established protocol, which is why I am commenting with diffidence as a layperson in this area, but it sets out, as I’ve heard earlier, the levels of protection, the elimination, substitution, engineering controls, administrative controls, PPE. And on your website it says:

“PPE is seen as the least effective control measure and should be implemented only if the other four levels have been found or expected to be infective at removing risk.”

I find that really strange, that the use of PPE is not considered to be part of the measures, the package of measures that you would use to eliminate the virus. In other words, step 1.

Ms Laura Imrie: Yes. For a non-clinical person that’s maybe had background in IPC training and things, I can see that that’s not as clear. I think what you’re looking for is the highest level is not to have the pathogen in the clinical environment, so, you know, you do telephone consultations, you don’t bring people into hospital that don’t need hospital care because we have had previously the UK responds to things like swine flu was admit them into an infectious diseases unit and we can contain them in there, whereas I think most IPC specialists would say, “No, please don’t bring them into hospital because you’ve introduced something.”

It’s not that you would look at the hierarchy controls and just pick one. I think the hierarchy controls are really designed, as well, for organisations so what we were trying to get across to our organisations was if you’re going to have a high-risk pathway, if you are going to have a ward where you are going to put all your Covid patients then that ward should have everything, it shouldn’t be overcrowded, it shouldn’t have poor ventilation or no ventilation, because if you’re doing all this then the risk does accumulate. And certainly within the Covid addendum, we advised local infection control teams if they worked through the hierarchy controls and they couldn’t provide the environment then they would – they should be considering FFP3 in high-risk areas.

So I’ll go back and look at that wording and speak to the team.

Lady Hallett: I was going to say – well, I’m challenging the orthodoxy. I’m afraid whenever I dislike something I say someone has been on a course, and “hierarchy of controls” looks to me like someone has been on a course and thought it’s seemed to be a good idea.

I understand all that you said about keep your distance, better ventilation, all makes perfect sense, but that is not taking into account that if you want to stop the spread of the infection and eliminate it then if people are wearing appropriate PPE surely that would be part of your elimination programme?

Ms Laura Imrie: Yeah, and I will go back and look at it. You would still wear a mask, yes. But if, for instance, you were going shopping, you couldn’t eliminate it, you can’t control the environment and everything so we ask you to wear a mask, but I’ll go back in the context that you’ve raised it.

Lady Hallett: Do you want to ask your question before we break?

Mr Scott: No.

Lady Hallett: Are you sure?

Well, ask it and then I will break at 10 past.

Mr Scott: Is the position that when the IPC guidance had been produced by NERVTAG in terms of the pandemic flu guidance that was then translated to become the Covid-19 guidance, is it the position that effectively you were satisfied that there was no evidence that there was transmission via aerosol outside of AGPs and so you would only change your position about whether FFP3 should be advised when there is a risk – in terms of aerosols outside of AGPs, if there was strong evidence to suggest that that was a route of transmission?

Ms Laura Imrie: So I think we were constantly reviewing all the intelligence –

Counsel Inquiry: But in terms of was that the starting point?

Ms Laura Imrie: I don’t think anyone said this is the conditions that need to be met for us to say the FFP3s is required. It was much more a constant assessment rather than trying to achieve a certain position before you would change your stance. If NERVTAG or ACDP or the senior clinical team in the UK had came and said “We want the IPC guidance to reflect something different”, then we would have written the guidance based on the evidence that they were showing. It wasn’t the IPC that had a sole remit, role and authority to say what was going to be included in IPC guidance.

Lady Hallett: I hope you were warned we take breaks, Ms Imrie, and I shall return at 3.25.

(3.08 pm)

(A short break)

(3.25 pm)

Lady Hallett: Mr Scott.

Mr Scott: Ms Imrie, I think you said in your evidence earlier on that if the pandemic started now, that you would recommend widespread use of masks. Did I hear that correctly?

Ms Laura Imrie: Yes.

Counsel Inquiry: Why would you do that now?

Ms Laura Imrie: Probably for the same reasons we done it once we recognised presymptomatic and asymptomatic transmission.

Counsel Inquiry: Could you expand upon what that was?

Ms Laura Imrie: That there was transmission events that when they were followed up, some of the subjects didn’t develop any symptoms but their households went on to develop symptoms, but they had tested positive first, indicating that they were the index case. Or others who tested positive and then went on to develop symptoms a number of days later.

And I think that’s part of continuously reviewing the evidence to make sure that you are gathering as much intelligence to inform the guidance, that you don’t just stick with “These are the signs and symptoms and this is when you need to wear a mask”, that we use the epidemiology as well to advise the guidance.

Counsel Inquiry: Okay, so I think the opening of your answer was “there were transmission events”, is that what it boils down to? That there is now evidence of transmission events?

Ms Laura Imrie: For establishing an asymptomatic or the – somebody, up until that point, globally, it was understood that in order for transmission to occur, you would be having to display symptoms.

Counsel Inquiry: So when you say “universal masks”, do you mean outside healthcare or within healthcare?

Ms Laura Imrie: I think if we have a similar situation everywhere, as explained earlier, the community prevalence had a direct effect on the infections that both came into hospital and were transmitted in hospital. So if we want to control the nosocomial infections, then we are really highly reliant on the community controls that are put in place.

Counsel Inquiry: I just want to ask briefly about December 2020, and there was an IPC cell minutes – meeting on 22 December that you attended, and there was a discussion there about whether the understanding of aerosol transmission had changed, and there was no change to the guidance, but following that, there was an email sent round by Lisa Ritchie that was asking for people’s views about whether that consensus should change, that’s right?

Ms Laura Imrie: Yes.

Counsel Inquiry: And could we please go to INQ000348370.

And this is your email in response to that request which was, “Please can any of the members let us know if you wish to recommend the use of FFP3s in a high risk pathway”.

That’s right?

Ms Laura Imrie: Yes.

Counsel Inquiry: And it was – the consensus had been based on the rapid review that there was currently insufficient evidence to change precautions. You set out the rationale there and, then it’s the bottom – we currently see on the page:

“There is no clear evidence of airborne transmission.”

Ms Laura Imrie: Yes.

Counsel Inquiry: And then if we just go over the page, please. It says:

“There is a larger evidence base for the assessment that also includes prospective sampling …”

I think that’s what you were talking about earlier on, about that there hadn’t been any air samples that had found viable viruses – even though they had found viruses, they weren’t necessarily viable, is that correct?

Ms Laura Imrie: I’m not sure all of what I’m referring to there, but yes, I believe that’s …

Counsel Inquiry: Because – it’s the middle line of that bottom paragraph that says:

“This evidence base is in line with the SAGE position, which states that ‘the evidence that aerosol transmission is significant compared to other routes is not sufficiently strong to recommend that respirators are used in locations other than high risk clinical areas where aerosol generating procedures take place.”

And at that point in time, you say that the Scottish had produced their own guidance and that was in October 2020?

Ms Laura Imrie: Yes.

Counsel Inquiry: And what was the difference between the Scottish guidance and the UK guidance at that time?

Ms Laura Imrie: In that time you could choose to wear FFP3 if you were doing an AGP in any pathway.

Counsel Inquiry: And why was it that Scotland had made that decision?

Ms Laura Imrie: I think there was feedback from stakeholders that staff felt that testing, universal testing and things, hadn’t yet been implemented, certainly we didn’t have the kind of near-point testing that allowed staff to test somebody. We were doing a lot of testing before people came into hospital and then giving them advice to stay at home, and protection, and not to have contact before they come in so that they could enter a green pathway. And the stakeholders fed back to us that staff felt if they were doing an AGP, even in a green pathway, they would like to be able to choose to wear an FFP3. And that was then put into the Scottish addendum.

Counsel Inquiry: Okay, and that was taken up following those views of the healthcare workers?

Ms Laura Imrie: Yes, as part of our connect comms between the NHS boards.

Counsel Inquiry: And is that very much in line with what the WHO’s guidance had been on 1 December, which is given that healthcare workers want that high level of protection and if there’s no issues with supply, then there’s no reason they shouldn’t be able to use them?

Ms Laura Imrie: I think it goes some way towards that. It’s probably later on before the individual personal risk review assessment was put into the guidance that allowed staff even in non-AGP areas to choose to wear the FFP3, which I don’t think that ever made it to the UK guidance, as far as I can remember.

Counsel Inquiry: Because it doesn’t appear in your email of 23 December that you are suggesting here – and tell me if I’m unfairly categorising – that actually at that point in time, that there could have been, should it have been wished, a change made to the IPC guidance which would have allowed healthcare workers to wear an FFP3 mask should they wish to do so?

Ms Laura Imrie: Sorry, which part of the email are you referring to?

Counsel Inquiry: Well, I’m saying it doesn’t appear in the email. I mean, you wrote the email. It doesn’t appear that you say, “Well, actually, this is what the WHO have suggested, Scotland has taken a slightly different view because we have been listening to our healthcare workers and so maybe that’s something that we could do if we don’t think there is any downsides to it.”

That doesn’t seem to appear in the email. That’s why I’m asking. Is that an unfair characterisation of this email?

Ms Laura Imrie: I’m not sure what you are saying doesn’t appear in the email. The use of FFP3s throughout or …

Lady Hallett: The use of FFP3s in – when someone is doing an AGP in any pathway. The way you changed the –

Ms Laura Imrie: So we had that in Scotland.

Lady Hallett: Yes.

Ms Laura Imrie: So the IPC cell were fully briefed and understood what the differences were within Scotland guidance and why we made those decisions.

Mr Scott: If we can just scroll down on this document, please. So that second paragraph under paragraph 2 is:

“In essence we would be changing the high risk event from a AGP to a Covid patient …”

And the line above that:

“In the absence of supporting evidence a clear understanding of the justification is required in order to communicate the risks that exist to staff in these areas that are not present in the other acute pathways …”

Again, it doesn’t appear you’re letting everybody else, the other members of the IPC cell, following a discussion in which PHE and others had said maybe we should look to change the guidance, you don’t seem to be saying there, “Well, actually, do you know what, the WHO on 1 December has said it has no issues, then let healthcare workers use FFP3s if it makes them feel safer.” Is there a reason why not?

Ms Laura Imrie: This was an email back to the IPC cell. The discussions have been around that. So I wouldn’t be recapping why we’re having the discussions in my email. I think there’s a general understanding that the people that the email, the audience are aware of the WHO’s – if I’m understanding.

Counsel Inquiry: Right. I’m going to move on to a different topic and talk about ventilation. Do you think more priority should have been given to ventilation than air filtration in the IPC guidance?

Ms Laura Imrie: There was separate technical groups that were looking at ventilation who were probably more qualified to look at ventilation, including our engineering colleagues.

Counsel Inquiry: Right, so how were you working with them to have an understanding about the role that ventilation played in terms of what the IPC guidance should be within healthcare settings?

Ms Laura Imrie: Within Scotland, Scottish Government commissioned Health Facilities Scotland to look at the impact of ventilation and the microbiologist from ARHAI was involved in that group as was the nurse consultant that leads infection control in the built environment, so they were feeding in the kind of clinical interpretations and aspects and heavily reliant on our engineering and Facilities colleagues to pool together but within Scotland, Scottish Government led on the kind of ventilation review for healthcare settings.

Counsel Inquiry: But Professor Susan Hopkins was asked, and she said she felt that air filtration hadn’t been given sufficient priority in the IPC guidance. Do you agree with that or not?

Ms Laura Imrie: Yeah, I don’t think it was an area that we really put any kind of guidance around. I think traditionally ventilation guidance is through the health technical groups which – there is UK and then Scotland kind of put their slant on it and call it the Scottish technical group.

So the ventilation guidance has not been written by infection control but on our Covid Nosocomial Review Group we did have architects and engineers and Facilities so there was those discussions happening and it had probably been led through a different group rather than an infection prevention and control guidance.

Counsel Inquiry: Were the same discussions taking place in Scotland as there were within the UK IPC cells or were these discussions about ventilation only taking place in Scotland?

Ms Laura Imrie: I was taking place – I was having discussions about ventilation within the CNRG which was ultimately our kind of nosocomial governance route for discussing the IPC guidance. I don’t think the IPC cell had a membership that would have allowed in-depth discussion around ventilation.

Counsel Inquiry: But if ventilation was a part of the IPC guidance then you had to make sure that there was sufficient ventilation because I think it was well recognised that there was a risk of aerosol transmission in poorly ventilated places, isn’t that right, at that time?

Ms Laura Imrie: Overcrowded and poorly ventilated.

Counsel Inquiry: Yes. So clearly the IPC guidance about the risk of aerosol transmission had to take into account the ventilation that was in place in these facilities, is that right?

Ms Laura Imrie: So we raised that ventilation was a risk to IPC but during the pandemic there was probably very little that could be done about the ventilation that we have in healthcare and I think that is a reflection that we have and certainly through the work of NHS Scotland Assure are considering the ventilation in the guidance that we currently have and the evidence around whether that’s sufficient or whether it needs to be improved and people talk about ventilation opening a window. That’s not really ventilation. You’ve got to consider how your air comes in and how it goes out, your air changes, your air filtration, your pressure. So that is certainly not an area that the IPC cell would have tackled.

Counsel Inquiry: But if the IPC cell was having to consider the possibility of the transmission of aerosols and it can happen in poorly ventilated and overcrowded places, but the view had been taken that it wasn’t going to happen in a healthcare setting, how did the IPC cell know when they’re considering whether to change the guidance about what was good ventilation, what was the measure about where the boundary was between what was overcrowding and poorly ventilated and where actually there wasn’t a risk?

Ms Laura Imrie: So the technical guidance that describes what’s good ventilation and in healthcare settings.

Counsel Inquiry: But that was created prior to the pandemic?

Ms Laura Imrie: But it is still a standard that will tell you air changes and where you should be using the HEPA filtration and things. I think it’s widely understood that if it’s not in technical guidance that you should have HEPA filtration there wouldn’t be HEPA filtration in a design plan for a hospital.

And indeed a lot of the assessments we do at our hospitals don’t even achieve the air changes that are in the technical guidance either because they were about prior to the technical guidance or they are failing to achieve.

But I do not think that was the role of infection prevention and control guidance to look at ventilation and I don’t think any member of the group felt that we were qualified to comment on the ventilation.

What we did do is highlight to organisations that if they were looking at the Covid-19 patients they needed to take all this into consideration, and I’ve taken on board my Lady’s comments about the hierarchy of control, that was why it was in the hierarchy of control so that organisations took that responsibility to appreciate that they needed to look at their facilities and consult with engineers in their Facilities team.

Lady Hallett: Can I just say before I get a flood of emails from health and safety specialists, my challenge as a layperson, and I emphasise that again, was to the utility of the hierarchy controls in the healthcare setting.

Ms Laura Imrie: Absolutely.

Lady Hallett: As long as everybody understands.

Mr Scott: But again, if they were being provided – if hospitals’ healthcare settings had been provided IPC guidance, how are they meant to know, particularly if parts of their hospital, parts of their facility are falling below the technical standards, how are they meant to know whether there is sufficient ventilation in order to prevent there being a risk of aerosol in a non-AGP setting? Because that doesn’t seem to have been given to them about where the boundary lies.

Ms Laura Imrie: So each board trust will have a director of facilities who has a legal responsibility for the health and safety aspects of a building and for compliance with standards, with building standards for healthcare, which there are many of them and they’ll set out within an ITU you should have 10 air changes, whether you should have negative or positive pressure depending on the patient population that you’re looking after, your haemato-oncology units, what their specialist ventilation will be, theatres, they’ll understand, in general wards what their mechanical ventilation is, they should for ID units and things understand the air flows, as well. So this is not a local infection control team or a national infection control team to set the guidance or the standards for ventilation.

The infection control team recognised where the risks are within a healthcare setting. Now, that might be the air, it might be water, but you don’t expect an infection control nurse to be able to go and examine the pipes and to say, you know, that that’s been set up in the wrong way. They can say if this and this and this occurs, then there’s a risk from the environment and this is how we address it. But it wouldn’t be the IPC cell that would be looking at ventilation guidance.

Counsel Inquiry: Did the IPC cell, given you were just talking there about infection prevention nurses saying “If this, this and this occurs and there is a risk from the environment”, was there any guidance given to facilities managers to say, “In this, this and this situation, actually there is now a risk of transmission and so you need to make sure you’re taking steps to prevent that occurring”? Was anything like that provided alongside the guidance either in Scotland or UK-wide?

Ms Laura Imrie: Yes. As part of CNRG, as I said, we had Health Facilities Scotland, we had director of facilities, the hierarchy of controls, set out that if you had a high risk area, that you need to do an assessment of overcrowding, of ventilation, and if you couldn’t meet them, then I had to go through a risk register and it should sit as a corporate risk so that your executive team are fully aware that they didn’t have a facility that was deemed safe.

So all of these things were put into the guidance, and they were discussed widely certainly within the Scottish CNRG group as well.

The – as I said previous, ARHAI had weekly meetings with the infection control managers, nurses and doctors networks, all the boards were represented and they would go back and speak about the guidance, about the challenges they learnt from each other, from the boards, if they had put anything in place or where their challenges had been, so there was full discussions around the environment.

Counsel Inquiry: What lessons have been learned from your perspective or from ARHAI’s perspective about the creation, the dissemination, the changes made to IPC guidance in the context of the pandemic?

Ms Laura Imrie: I touched on the actual structure and the remit, role and a kind of authority into how that fits into an emergency plan, a preparedness plan. CNRG did do quite a lengthy “Lessons Learned” around the experiences of CNRG. The IPC cell has also done a debrief of some of the lessons learned.

I’d say some of the main challenges was around publication, and there was a lot of red tape, so there was sometimes decisions made to respond to either international evidence or feedback we’d received, and the guidance was agreed, updated, and we in Scotland were updating our weekly meetings, sometimes we had them twice-weekly meetings – but then there was a delay of a week or ten days before it actually got published because of all the red tape it had to go through to be published on the Public Health England website.

Counsel Inquiry: Any recommendations you think the Inquiry should consider?

Ms Laura Imrie: Around the IPC cell?

Counsel Inquiry: Ideally, yes?

Ms Laura Imrie: I think as I said before, it would be beneficial for there to be an established remit role as there is with other advisory groups, and maybe not just for pandemics and emergency situations, but for UK response to anything. We’ve got two recent examples of measles and Mpox where guidances went out and the IPC specialists have – went back to the people that wrote the guidance to ask for some things to be changed or included. So we’re still not integrated into that response, so I would like to see that we’re at the table having the discussions rather than, as we were, with the Covid, told that “This is the guidance you should use” and then we go away and write it.

Mr Scott: My Lady, those are the questions.

Lady Hallett: Thank you, Mr Scott.

Ms Polaschek, who is that way.

Questions From Ms Polaschek

Ms Polaschek: Good afternoon. I will now ask the questions on behalf of Clinically Vulnerable Families. And you’ve discussed in quite a lot of detail the IPC measures in relation to healthcare staff, and I have just two specific questions about the IPC measures for patients who were particularly vulnerable to the effect of Covid-19.

And the first is, did ARHAI at any time give or consider giving guidance on the IPC measures for clinically vulnerable or clinically extremely vulnerable patients in healthcare, such as those patients wearing FFP3 or FFP2 masks, or the use of portable air filtration around those patients?

Ms Laura Imrie: Thank you. ARHAI Scotland were never involved in the development of the guidance around shielding our clinical vulnerable. What we did do is work with the clinical cell to identify some of the vulnerable groups and the measures that we should take in the green pathways to try and ensure that they could access healthcare in an environment where people had been tested prior to coming in that were reducing the exposure – and that was for both clinically vulnerable people and people that required a general anaesthetic, because it was understood at the time that if someone was Covid-positive and had the general anaesthetic, then that was very high risk. So there was a protective pathway that we worked with the clinical cell to advise. There was not the recommendations, as far as I’m aware, from any group for FFP2 or 3 to be worn.

Ms Polaschek: Thank you. Given the particular risks to the clinically vulnerable and clinically extremely vulnerable who were accessing healthcare including through green pathways because of nosocomial spread, do you agree it was common sense that there should have been some additional measures for their protection?

Ms Laura Imrie: Yes, I think possibly there could have been more done in these areas. I think it was a real challenge, it is a real challenge for patients to wear masks, and I could see how that would be quite worrying if you’re a clinically vulnerable person in a room and someone else is not even wearing a fluid-resistant mask, so, yes, there were real challenges around that. An FFP3 would be very difficult for somebody who maybe has other clinical conditions to wear. An FFP2 may be slightly more comfortable; however, we are governed by the health and safety legislation, and therefore we were not allowed to recommend FFP2 for either patients or staff.

Ms Polaschek: Thank you.

Madam, those are my questions.

Lady Hallett: Thank you very much.

Mr Simblet. He’s just behind you, but if you could make sure your answers go into the microphone.

Ms Laura Imrie: Okay.

Lady Hallett: Thank you.

Questions From Mr Simblet KC

Mr Simblet: Thank you, my Lady.

Ms Imrie, I’m asking questions on behalf of the Covid Airborne Transmission Alliance or CATA, and CATA was specifically name-checked by Mr Bowie KC in his opening address when he said that you and ARHAI Scotland would not shrink from the important issues that they raise, so I hope you will be able to help us with the two topics I’m going to ask about.

The first topic is the IPC guidance and PPE supply. Now, that’s been extensively covered with Mr Scott this afternoon, and we’ve – the Inquiry has heard various evidence about PPE supply and IPC guidance.

In your statement, you say that ARHAI had no concerns on the 1 March 2020 over PPE supply. Is the reason that you had no concerns because you expected the infection and prevention control guidance to reflect the state of supply?

Ms Laura Imrie: Thank you for your question. No, that is not the reason. In the statement the question that I was answering was, prior to the pandemic, did we have any concerns about the PPE. Prior to the pandemic, our understanding was, what I said was a pandemic stock that was held UK-wide, and rightly or wrongly we assumed that that stock would be sufficient for whatever controls were put in place.

Mr Simblet KC: Were you aware of minutes from the IPC cell around that time, not – in fairness, not at meetings at which you attended but you would have got the minutes, where it was observed that guidance on changes to PPE could affect PPE supplies, and that was to be noted as an issue going forward? Was that a consideration for either you or other members of the cell?

Ms Laura Imrie: If you say I wasn’t at the meeting, I wouldn’t be aware of the discussions, but what I am aware of is very late at night telephoning ITU units to find out how many FFP3s they were going to need for the following day depending on how many Covid patients they had admitted, how many times they had to phone them, counting it up, going back to national procurement. So there was a real issue that maybe prior to March we weren’t aware of what the stock was held, and what we had. We certainly weren’t aware of how many members of staff hadn’t had a recent face fit test. And one of the reflections that we’ve had in NSS, as myself and ARHAI working with national procurement, put a proposal up to Scottish Government that we should have mandatory face fit testing, and it should be an agreed period for all boards, and that national procurement should have access to all of these tests so that they hold the stock that is required for service rather than what is thought to be required.

Mr Simblet KC: Thank you. I’m going to move to a different topic now and you’re very politely looking at me when you answer, but I think it is important that you speak into the microphone, so I shan’t mind if you do that.

In the – this is about the IPC minutes of a meeting on 12 May 2021 which you were at, and I’m going to ask for the first page of that to be put on the screen. It’s INQ000398232 and the first page of that.

Lady Hallett: I have a document headed “12 May 2021”.

Mr Simblet: Thank you, now it’s on mine. Thank you. As long as my Lady and the witness have it then I suppose that should do.

The first thing to observe is this is a meeting at which you are in attendance. There’s a number of people whose names are redacted – I’m not going to ask you to say who they are, that’s why they’ve been redacted and generally it’s understood that people have their names redacted if they are at – depending on levels of seniority and so on, so those are relatively junior people in this meeting.

There was some discussions about revisions to the IPC guidance and the fact that Public Health England was feeling – well, unable to sign off on the cell’s proposal.

If we can turn to the next page, please, where that discussion begins at the bottom of the page. Can you see it on your screen, Ms Imrie?

Ms Laura Imrie: It’s just come up now.

Mr Simblet KC: Thank you. So then we see feedback from – we see in the middle of page there:

“… PHE wish to move this issue forward … it would be inappropriate to provide a decision statement prior to a decision from … evidence review …”

And the next – page 3, please. I think it’s the feedback – no, it is still on this page, it says – there you are, it’s your comment, so I have highlighted it on mine, but not – what you said was:

“LI suggested all nations involved as well as PHE should be involved in the work raising concerns in relation to the cell losing independence and work driven by the PHE agenda only. One organisation should not have the final say on UK IPC guidance.”

So the first question about that is: what did you mean about the cell losing its independence?

Ms Laura Imrie: I’m just looking at the notes above.

I think this is around the respiratory evidence panel review that Public Health England came to present. We had presented a number of studies done outwith healthcare that showed there may have been transmission but not in healthcare where we had the controls.

I’m not really sure –

Mr Simblet KC: Can I summarise it this way. Was it that Public Health England was taking a view that the cell’s consensus view, or perhaps more accurately what ARHAI was saying, that Covid-19 was spread by the droplet route of transmission but that was the cell’s position, that that was being undermined by these studies and you didn’t want that idea, as it were, to catch on?

Ms Laura Imrie: No, that’s not accurate. Public Health England had done a review that excluded healthcare settings and then they came in with recommendations that we should consider putting more controls into healthcare settings. I think the discussions that took place were around Public Health England providing a separate statement, which we agreed with, and the point was up until then we had done everything by consensus, and had been quite open in our consensus when we fed up to the CNOs or the senior clinical team, that we might not have had full agreement but this was consensus we agreed.

And I think what I’m saying here we can’t have one organisation leading the IPC cell. There wasn’t that remit for one organisation.

Mr Simblet KC: So was – did you regard consensus as being more important than accurate science?

Ms Laura Imrie: They weren’t presenting accurate science to show healthcare transmission. They actually excluded healthcare studies when they’d done their review. So it might have been more appropriate for them to increase controls in the community where the studies were conducted rather than in healthcare.

Mr Simblet KC: All right. And now something that I hope you will be able to agree with. Since, as your last sentence there records, you believed one organisation should not have the final say on UK IPC guidance, do you consider that discussions about guidance and PPE measures should have involved stakeholder organisations such as CATA?

Ms Laura Imrie: So within Scotland we had CNRG which was multi-organisation or multidisciplinary. Through CNRG we also took any recommendations and changes to guidance to the Scottish Government senior workforce which was represented with the unions and staff site representatives, so we did have full consultation. We also met other networks on a similar basis.

Mr Simblet KC: So do you agree with my question then, do you think it should involve stakeholder organisations?

Ms Laura Imrie: I’m not agreeing that it should be CATA. I’m agreeing that we should have a good consultation process that allows many people to give in their challenges and how they would implement the guidance. Unfortunately, when we do consultation we can’t do consultation with every party that has an interest. We try and now certainly our reflections are that we will try and demonstrate how the evidence is reviewed and put into guidance in a much more open and transparent way that allows people with invested interest to understand how the guidance came about.

Mr Simblet: Thank you.

Well, those are my questions, thank you.

Ms Laura Imrie: Thank you.

Lady Hallett: Thank you, Mr Simblet.

Ms Stone, who is there.

Questions From Ms Stone

Ms Stone: Thank you, my Lady.

Good afternoon, Ms Imrie. I ask questions on behalf of Covid-19 Bereaved Families for Justice UK. Can I take you back, please, I have a couple of areas which relate to the overarching topic of aerosol transmission and its impact on IPC guidance.

The first of those is liaison with the Chief Medical Officer in Scotland, Professor Smith.

For context, would you agree that during the course of 2020 the evidence in respect of aerosol transmission developed, and you were aware of that?

Ms Laura Imrie: Developed as in we were learning more about the pathogen?

Ms Stone: Yes, so there was emerging evidence which tended to suggest that aerosol transmission was taking place?

Ms Laura Imrie: In healthcare, that was not the evidence that we were seeing. It was close range.

Ms Stone: Well, I think in your evidence today this afternoon you referred, for example, to a report from the CDC at the beginning of October 2020, which identified circumstances in which airborne transmission appeared to have occurred. Do you remember that report?

Ms Laura Imrie: Not that I’m aware. Do you know what report – was it WHO or CDC –

Ms Stone: It was a report by the CDC in the USA, which I think you made reference to earlier in your evidence, in relation to airborne transmission.

Ms Laura Imrie: I’m sorry, I’m not …

Ms Stone: There was also in July 2020, for example, WHO acknowledged that airborne transmission could not be ruled out, do you recall that?

Ms Laura Imrie: I think there was the WHO around the AGPs, and when you’re in the very beginning of a pandemic you can’t rule anything out, and I think that’s why it’s so important that you do continue to review the evidence, both for controls for staff but also for patients.

Ms Stone: In his evidence, I’ll move to the question, Professor Smith told the Inquiry – and my Lady, for your note should you need it it’s the Day 11, 25 September, and it’s pages 35 to 46 – but Professor Smith said that he had had concerns about the possibility of aerosol transmission and in relation to the WHO’s messaging in the earlier stages of the pandemic, or at least by summer 2020. Did you know about that evidence?

Ms Laura Imrie: I wasn’t aware of Professor Smith’s concerns.

Ms Stone: No. Well, that was my – you’ve anticipated my question which was whether you or ARHAI were ever made aware, whether directly or indirectly, of those concerns on Professor Smith’s behalf.

Ms Laura Imrie: No, I wasn’t made aware are of his concerns, no.

Ms Stone: What lines of communication existed, please, between ARHAI and the Scottish Chief Medical Officer?

Ms Laura Imrie: There were a few meetings where ARHAI would present around the IPC guidance, Public Health Scotland held a weekly IMT which was attended by Professor Smith and other members of CMOD, alongside the Chief Nursing Officers Directorate as well, and other directorates from the Scottish Government, where there was the situation assessment governed, and the IPC ARHAI had an agenda at the weekly meeting to discuss any changes or what the guidance was.

Ms Stone: So would you have expected to have been made aware of those concerns on Professor Smith’s part?

Ms Laura Imrie: Yes. Also there was a number of occasions where the IPC guidance went up through the senior clinical team, which was all of the CMO, CNOs, and discussed there, around the healthcare controls, so …

Ms Stone: In your view, do you consider the lines of communication between ARHAI on the one hand, the Chief Medical Officer on the other, to be adequate, or could your work have been assisted by greater engagement with the Chief Medical Officer or indeed direct engagement with him?

Ms Laura Imrie: I think communication can always be improved, and it certainly could have been improved during this emergency situation. People were working 7 days a week, people were working, you know, crazy hours, and sometimes you would find that a decision had been made late at night and you were catching up. It wasn’t your normal kind of lines of communication, so I would, yes, say that we do need to improve both internally within our devolved country, but also wider than that, our communication lines.

Ms Stone: Can I move to ask you a little more, please, about the position as at the end of – or is it December 2020, you were asked a few questions about this by Mr Scott earlier.

Ms Laura Imrie: Mm-hmm.

Ms Stone: We know from your statement, Ms Imrie, that in 2020 there were 3,389 nosocomial infections with Covid identified. Would you agree that the level of nosocomial infection of Covid-19 was of itself evidence tending to suggest that IPC measures were inadequate in not preventing transmission in healthcare settings?

Ms Laura Imrie: Yes, so I think during that time, that was – 2.6% of all the positive Covids were nosocomial, so I think that gives you – it demonstrates how community transmission directly influenced what was happening in hospital and the controls within the community. Because as community prevalence went up, and that happened for many reasons that, you know, some of the measures, the public health measures were eased off, schools went back, do you know, we’ve soon different peaks and ten days later you have seen people coming in – not coming into hospital because they needed treatment for Covid, that they were an incidental finding.

Ms Stone: I understand the point, I think you’ve made it, that hospital infection tended to go hand in hand with levels in the community. But the question is slightly different, which is that – which is to say, do you accept that the levels of nosocomial infection of Covid in 2020 indicated that IPC measures weren’t working? Do you agree with that?

Ms Laura Imrie: It indicates that there was onward transmission, so if you have onward transmission, then the field –

Ms Stone: Yes.

Ms Laura Imrie: – and that’s why we done the kind of “Lessons Learned” with the local teams to try and understand, and some of that comes down to some hospitals were unable to put in the distancing. We didn’t have – in December 2020 we were only starting to roll out the testing, so, as I spoke earlier about presymptomatic, people might have been put in a room and they developed symptoms thereafter.

Ms Stone: Was it known by December 2020 that nosocomial infection was at concerning levels in Scotland and throughout the UK?

Ms Laura Imrie: Was it known what the nosocomial levels were?

Ms Stone: Did you consider that nosocomial infection, as at December 2020, was a matter of concern?

Ms Laura Imrie: I think healthcare-associated infection is always a concern. The difficulty here was the epicentre for this outbreak was outwith the healthcare, and it was very difficult to put the – for the infection control teams working locally, very difficult for them to put controls in.

Ms Stone: You’ve got to work with what you can control in the hospital; is that correct?

Ms Laura Imrie: Yes.

Ms Stone: And one of those things would be the masks that healthcare workers are wearing, for example, would you agree?

Ms Laura Imrie: Yes.

Ms Stone: And you’ve agreed, I think, earlier in your evidence that FFP3 masks are a primary means of protecting against aerosol transmission; would you agree with that?

Ms Laura Imrie: Yes.

Ms Stone: And so, as at December 2020, notwithstanding the levels of nosocomial infection that you were aware of, and the evidence that there was at least a risk of aerosol transmission, the UK IPC cell maintained its existing position on FFP3s and didn’t recommend wider use, is that right?

Ms Laura Imrie: Yes.

Ms Stone: Can you explain why there was a reluctance on the part of the UK IPC cell to depart from earlier guidance, and recommend that wider use of FFP3 masks, despite those factors ie nosocomial infection, plus emerging evidence about aerosol transmission?

Ms Laura Imrie: So the use of FFP3 masks would have had no impact whatsoever in nosocomial infections. So most of the nosocomial, where it was patient-to-patient transmission, was about the environment so that we’d have beds that are too close together, that we have waiting rooms that are jampacked full, that we didn’t have testing at that time, so you were putting people in. And, recorded frequently in the CNRG notes are discussions around patients being unwilling to wear masks, so an FFP3 may have reduced occupational exposure and transmission but I don’t – there might have been some improvement, but I don’t think that would be the main factor in reducing nosocomial, I think it was about testing and accommodation.

Ms Stone: But it would be a factor, wouldn’t it? Because it would have the potential effect of – well, it would have the effect of protecting – providing greater protection for healthcare workers, firstly, you’ve already explained that it’s the primary mitigation measure against aerial transmission, but it would have also had a potential impact on nosocomial infection, wouldn’t it?

Ms Laura Imrie: It wouldn’t be where I would focus for reducing nosocomial transmission.

Ms Stone: Do you consider that too high a threshold was imposed by the UK IPC cell for evidence of aerosol transmission and changing IPC guidance as a result?

Ms Laura Imrie: I don’t know that we imposed a threshold. As I said earlier, there wasn’t a criteria that we were waiting to reach. We reviewed the local epi data, the intelligence that we were getting elsewhere, and we had those discussions with other groups, and you know, international experts as well.

Ms Stone: I think earlier in your evidence when you were talking about early in the pandemic, you said “There wasn’t enough good evidence to say we were uncertain”. That wasn’t the position by December 2020, was it; it was clear that there was evidence suggesting aerosol transmission?

Ms Laura Imrie: I don’t know if it was clear that there was evidence suggesting aerosol transmission. I think, again, the position that I would say now is, it is constraining to talk about aerosol or droplet.

I think there was certainly a lot of evidence where we didn’t have distancing or consistent and correct use of PPE, that there was transmission. Or where we had patients who were too close together or who were housed in the same room as somebody that there was certainly evidence of transmission.

Lady Hallett: I’m sorry, we are going to have to leave it there, Ms Stone, I’m really sorry, it’s not your fault.

Ms Stone: I only have one question, my Lady, but I’m in your hands.

Lady Hallett: All right.

Ms Stone: I am grateful.

Final, final, final, Ms Imrie, do you now agree that the precautionary approach ought to have led to the wider recommendation of FFP3 masks, at least, by late 2020 as that evidence grew?

Ms Laura Imrie: No, I don’t think so we should go to a blanket approach. I think we should look at a risk-assessed approach, taking into account all the different factors and that is what we’re having discussions with our stakeholders since we’ve done the systematic literature review but we’re acknowledging that we need to probably do a lot of education and develop resources to allow people to do those risk assessments.

Ms Stone: Going back to the time, shouldn’t the precautionary approach have led to a recommendation, I accept it’s not a blanket approach, but a recommendation for wider use of FFP3 masks?

Ms Laura Imrie: I think, given all the reasons that I gave earlier, that was why we didn’t go to a recommendation that the evidence was weak to say that you would reduce the risk and it’s not a control you’d put in place for the kind of nosocomial. I think there’s other things we could have focused on.

Lady Hallett: Define “final, final”, Ms Stone.

Ms Stone: My apologies.

Lady Hallett: I will let you off. Thank you.

Ms Mitchell.

Questions From Ms Mitchell KC

Ms Mitchell: I’m obliged, my Lady.

I appear as instructed by Aamer Anwar & Company on behalf of the Scottish Covid Bereaved. I was looking at ARHAI’s remit and it says it was to provide evidence-based guidance and expert advice on infection and prevention and control to reduce healthcare-associated infection, so obviously very important for the Scottish Covid Bereaved.

The first thing I want to ask you about is that collection of evidence and consultation process that ARHAI takes part in. It’s the evidence of the Scottish Covid Bereaved that there was a significant disconnect between guidance on what was to happen and in fact what was actually happening within hospitals in relation to infection control, for example the use of PPE.

Would it have been a sensible idea to include patients and families to be part of the consultation group to capture this type of information?

Ms Laura Imrie: I think there could have been strategies explored to try and gather patient and family experience and I do think that is a lesson that many have taken on, not just IPC, but – no access the hospitals and things, so yes, it could have been considered and it may have helped give some of the intelligence that would be required to truly understand, as you say, what’s in the guidance and what was happening in reality.

Ms Mitchell KC: And also as a result of that another experience was that nurses were being – it’s the experience of the Scottish Covid Bereaved that nurses were being asked to work in wards where they had not been briefed on, for example, cleaning or nursing protocols. Again, is this the sort of information ARHAI should have been or would have been able to capture had they looked for it in that way?

Ms Laura Imrie: Each of the NHS boards in Scotland have an infection control team and an ARHAI executive lead that look at, if you like, compliance. Cleaning and protocols for infectious patients have been in the National Infection Control Manual since 2012 so that’s quite disappointing that that was your experience and I’ll certainly take that on board and take it back to the guidance development teams as well.

Ms Mitchell KC: But would that have been helpful experience for ARHAI to have captured at the time to have assisted?

Ms Laura Imrie: I do agree, if we had had some sort of process in place to gather people’s experience and not just, you know, the patients but the carers, I think that’s not just from an IPC point of view, but there’s obviously been a lot of discussion around the psychological effects and things like that. So I do think that there could have been more done to try and capture some of that experience.

Ms Mitchell KC: Moving on. A lot has been asked of you already about droplet and transmission, etc, and the Scottish Covid Bereaved were allowed an opportunity to ask you about the criticism in that regard.

I wonder if my Lady might allow me to ask a question that is pertinent to it, but I don’t think the answer has been given yet which my question would be this, I posit it to my Lady first so she can see if she’s interested.

The question was about criticism about acting too slowly in relation to droplet and transmission, etc, and we’ve heard from my learned friend, Counsel to the Inquiry, he posited the view that it was the World Health Organisation that caused the change, and I think the witness resisted that as a reason, and what I don’t think we’ve come to is, actually, what was the tipping point? If it wasn’t the World Health Organisation and it wasn’t the wealth of information that was coming before ARHAI to see aerosol as a real problem, what was it that made ARHAI change its mind?

Lady Hallett: Everyone is pushing their luck today, aren’t they, Ms Mitchell? All right, you may ask it.

Ms Laura Imrie: Sorry –

Lady Hallett: What was the tipping point?

Ms Mitchell: What was the tipping point for ARHAI to say, “Okay, we are now going to consider that aerosols are an issue in hospital settings”?

Ms Laura Imrie: At what period are you referring to?

Ms Mitchell KC: When the guidance was changed.

Ms Laura Imrie: The guidance –

Ms Mitchell KC: When ARHAI took the view, when it changed from just talking about hospital settings, droplets, to “We now accept that aerosols are now an issue too”?

Ms Laura Imrie: So we’ve done a systematic literature review on transmission, not just aerosol and droplet, but it’s a transmissions-based precautions literature review that’s been published online. I think we are looking not just at Covid, we’re looking at all respiratory viruses, and we are now agreeing, if you like, with what the technical group and WHO are saying, is around – that it’s not helpful to describe it as airborne –

Ms Mitchell KC: No, I appreciate that and I don’t want to go into that again –

Ms Laura Imrie: I don’t know what part in the guidance or when you’re referring to the change.

Ms Mitchell KC: I think I shall just leave it there because I don’t think it’s going to assist my Lady in any event.

Moving on, many of the Scottish Covid bereaved families suffered loss of their loved ones through nosocomial infection, as you will know, and the IPC guidance again, as you will also know, has come under significant criticisms. You’ve told us about a few lessons learnt by ARHAI to improve its ability to respond. One of them is showing your working in explaining where decisions have come from, and how you come to your guidance, and also the fact that you’re not using the word “recommendations” any more.

Criticism was also made of the speed of ARHAI and the speed at which they were able to respond to the changing circumstances, as you’ve described it, an evolving situation and evidence had to be reviewed continually.

Is there anything that has been changed or anything that has been considered to allow ARHAI to respond to things more speedily?

Ms Laura Imrie: I’m not aware of the criticism around inability to respond speedily. As I said, we were the only organisation in the UK that was putting these rapid reviews out on a monthly basis, so I think our response to trying to get the evidence out to our stakeholders was done quickly and efficiently. There may have been some criticisms of how we had done that, but we certainly were the only organisation to do it, and to continue to do it for 25 months.

I think the healthcare science team and the National Programme for Guidance and Evidence have learned a lot through the pandemic about – and some of it were discussed today about how you pool resources, we should be pooling from the UK and have a remit so it was a UK response to that emerging threat.

ARHAI Scotland are quite fortunate in the resource we have in HAI, and that is really as a result – in 2002 we had the work report into Salmonella outbreak in Glasgow Hospital, which had recommendations about putting more resources into infection control, that they shouldn’t be a subgroup of public health, that they were a specialty and they should be – and then we have, of course you will be aware of the Vale of Leven Inquiry that followed on, and the recommendations that came from that.

So ARHAI Scotland probably thought of the four UK countries it was the best resourced and most able to respond in that way. We were the only UK country that was, on a daily basis reporting in all the Covid clusters and monitoring that very closely as well.

So we did respond rapidly, maybe there were some areas that people would like to have seen us respond differently or quicker, but I think around the evidence it would have been beneficial if we had pooled resources within IPC across the four countries to make that more efficient.

Ms Mitchell KC: So more efficient, it would be more speedy if there was more collaboration, effectively.

Ms Laura Imrie: Yes.

Ms Mitchell KC: Finally, in trying to work out how ARHAI works and how it fitted into the whole system, I must confess I personally found it quite a challenge, I don’t know if other people did, to see where it properly fitted in. And what I was wondering was, would it help ARHAI if there were clearer governance and reporting structures or supervision so that it was clear to people looking at it exactly where you fitted, what your status was, who you were reporting to? It’s like you said about, earlier on, when you had the word “recommendations” and you changed it to “guidance” because you weren’t recommending things, it seems a bit diffuse and woolly. Would governance structures assist you?

Ms Laura Imrie: Earlier on I was referring to rapid reviews where there is no national or international standard for the methodologies. So we were, if you like, learning as others did during the pandemic what worked and what didn’t feel so comfortable for people when they were reading rapid reviews.

I wouldn’t like to consider supervision. You know, all our staff are employed because of the experience, skills and qualifications they have and we kind of monitor that we’re doing it, I would rather portray it as like a collaboration, I think we could do wider collaboration so that we’re bringing in different skill sets to help develop some of the guidance.

Ms Mitchell KC: And can I ask what those, if you had ideally someone to bring in to help you to do that, who would it be? What body?

Ms Laura Imrie: I think that depends on what guidance you’re writing. So recently when we have done the transmission-based precautions we’ve sought some international experts in aerosol science and infectious disease to go through the research questions that we’re setting and the other literature review we’ve recently completed was water in the healthcare environment, the risks of water in the healthcare environment, where we sought water and engineering expertise to help write the research questions.

So I think it depends on what guidance you’re writing.

Ms Mitchell KC: So it would simply be the ability to be able to access these resources as and when, would be the best way to put it?

Ms Laura Imrie: I think it’s important, as well, that – ARHAI has a working group that develop guidance which although we publish the final guidance there are multi-organisational and disciplinary people on the working group and they also help set the work plan for the year for the evidence. So they’re helping prioritise what’s important.

Ms Mitchell: My Lady, those are my questions.

Lady Hallett: Thank you very much, Ms Mitchell, very grateful.

That completes the questions for you, Ms Imrie. Actually, no, it doesn’t, I have one more, sorry, and it’s all to do with at the very beginning you told me about your expertise. You said you’d qualified but you didn’t tell me you qualified as what.

Ms Laura Imrie: Oh. I was a registered general nurse that qualified with –

Lady Hallett: I had guessed that might be the case but I just wanted to check. Thank you very much for your help.

The Witness: Thank you.

(The witness withdrew)

Lady Hallett: Very well. 10 o’clock tomorrow.

Just to alert people who haven’t been aware, because I wasn’t aware until earlier, there is the possibility that one of the unions is going to be striking on the London Underground on Thursday, so we just need to make our necessary arrangements. Thank you very much.

(4.29 pm)

(The hearing adjourned until 10.00 am on Wednesday, 6 November 2024)