13 November 2024

(10.00 am)

Dr Andrew Goodall

DR ANDREW GOODALL (continued).

Questions From Counsel to the Inquiry (continued)

Lady Hallett: Ms Nield.

Ms Nield: Dr Goodall, yesterday we had just looked at the data from the sitrep of 30 March. We’re going to look now at the sitrep data from a week later, 7 April. But before we do that, could we have a look at the information that you were passing to the local health boards on that same day, 4 April 2020.

Can we go to table 7 that’s at page 171 in your witness statement, please.

You explain that you wrote to the local health boards on 4 April to discuss their capacity plans and included this table at page 171 in your letter to them.

This is in INQ000485721.

So this sets out the all-Wales requirement: 900 beds would be required in critical care, is that right, and 10,000 additional acute hospital beds?

Dr Andrew Goodall: Yes, that’s correct. This was based on the work that SAGE had undertaken that we had been reviewing since early March. There had been some refinement of it but we were using that methodology and just translating it into what that would mean for Wales based on the reasonable worst-case figures.

Counsel Inquiry: And numbers have been allocated for each of the local health boards. Had these numbers come from the local health boards as to what they were going to be able to provide, or had this been sent out to the local health boards as these were their targets?

Dr Andrew Goodall: Yes, health boards had been working on the ways in which they could expand their own capacity on a local basis, but this was very deliberately a national approach to say what we believe the numbers should be for planning purposes.

The reasons for that was to just give support to our hospitals across Wales, to the clinical teams to know what their planning assumptions were, to prevent people spending too much time trying to do a whole range of local assessments. Because we were using the standardised methodology of SAGE at that time, it was very reasonable for us to direct that at an all-Wales level and it was to give clarity. You’ll notice that there is one health board which wasn’t allocated any beds; that’s simply because of its particular function.

Counsel Inquiry: They don’t have an acute hospital in Powys.

Sorry if I haven’t quite understood, are you saying then that these were figures that were given to the local health boards rather than figures coming from the local health boards as to what they could achieve; is that right?

Dr Andrew Goodall: Yes, these were planning figures that we set at a national level which we wanted all health boards to give us plans and proposals for.

Counsel Inquiry: Thank you.

So at that stage 900 critical care beds were going to be needed in total, that’s including the existing beds; is that right?

Dr Andrew Goodall: Yes, that’s correct.

Counsel Inquiry: Thank you. So we’ve seen that that’s changed somewhat from the figure in the TAC advice of 15 March when 1,650 ICU beds were projected to be needed, and we can see here that this says reasonable worst-case scenario 40%. So is it that it was on a different modelling basis that – is that why the figures have changed from 15 March?

Dr Andrew Goodall: There had been some refinement of the SAGE model through March and we were just using the latest version. I think this was based on version 2.3 at the time. You’ll recall that the early March modelling was talking about a figure of around 1,500 critical care beds and this was reflecting a reduction in that. But the 40% reasonable worst-case figure that we were using was based on an assumption of 40% compliance of a population with control measures, and it was expecting a conversion to hospital beds of patients needing hospital beds of around 4.4%. And at that time there was an understanding, an expectation that about 30% of patients who were hospitalised would require critical care. Obviously those assumptions changed over time as we learnt more about the virus but they were the SAGE modelling assumptions at the time.

Counsel Inquiry: Okay. The Inquiry heard from Public Health Wales that 40% reasonable worst-case scenario did not mean 40% compliance or 40% of the population complying with non-pharmaceutical interventions, it meant 40% of the reasonable worst-case scenario. Do you know which is correct, which interpretation of 40% reasonable worst-case scenario?

Dr Andrew Goodall: Figures were introduced here and my statement is clear on this: these were based on the 40% compliance with the control measures. And that’s referred to in my statement.

Counsel Inquiry: Thank you.

Can we have a look then, please, at the data that you collected from the local health boards of 4 April. This is shown at page 167 of your witness statement. There are some changes in terms of the categories of data that are collected here compared to what we saw yesterday from 30 March 2020.

So we can see that the data collected here is invasive, ventilated beds is split into: in a critical care environment; in a hospital but outside of a critical care environment; and temporary beds providing invasive ventilation outside of a hospital building.

And the total invasive ventilated beds have gone up somewhat to 356 beds.

If we can look at the box below that, we now see: the total number of designated Covid-19 hospital beds; non-designated Covid-19 hospital beds; total hospital beds, which is 6,786; temporary beds providing hospital care outside of a hospital building; and total other, and it says “(non-invasive ventilated) beds”, so that seems to be beds that do not provide invasive ventilation rather than bed that are providing non-invasive ventilation; is that correct?

Dr Andrew Goodall: That’s correct.

Counsel Inquiry: So we don’t see here any beds that are providing non-invasive ventilation and we don’t see here beds that are providing CPAP, which we did have on the 30 March. Why have those categories been removed when they were there the week before?

Dr Andrew Goodall: I’m not sure why they were removed, whether this was just an aggregate that we were able to pull together. I would assume that the data was still being reported underneath but I think there was a particular focus on the intensive ventilated bed capacity that was required. We were still able to track and did introduce later ways in which we understood where patients receiving ventilation were outside of the critical care environment. But I would need to check. I can’t recall from my statement that that is complaining why that was the situation.

Counsel Inquiry: I don’t think it’s set out in your witness statement, Dr Goodall. We heard from the medical director of NHS England last week about why categories of data were collected and the type of data that was collected in relation to hospital beds, and the approach in England was less to do with the physical location of the bed and more to do with the clinical capabilities of the bed and the kind of support that could be given, so whether it was staffed, whether it had equipment and consumables, the staffing ratios that would designate that either as a level 2 or level 3 critical care bed, whether it had oxygen capability, whether that was high or low flow oxygen capability.

But that data doesn’t seem to be collected here. Did that change at any point or was this as granular as the data got?

Dr Andrew Goodall: No, the data was changing as we continued responding to the pandemic. So, for example, later on in April we saw further changes where we were able to bring in the field hospital data. Because during March we had been assessing the numbers of ventilators, non-invasive ventilators. We’d been tracking oxygen support, for example. Rather than have separate submissions, we were able to draw those into the sitrep reports as well as we had that more broad view of things that were happening on the ground and that were helpful to us to understand at a national level.

Counsel Inquiry: All right. But certainly at this point, on 4 April, that level of data isn’t being collected.

We can see that surge capacity is shown here, but already in the total invasive ventilated beds – which isn’t in the surge capacity section – 356 beds, that is the expanded number of beds, isn’t it? That’s not the baseline, how many you started with?

Dr Andrew Goodall: That is the number that we were planning that we could expand to, given the requirement for 900 and what had been 1,500. As I explained yesterday, it was always really important to set that in the context of what was the normal critical care capacity that was available in Wales, and that was at 152.

Counsel Inquiry: That doesn’t appear on this table, does it, it doesn’t show the original number of beds as 152. It doesn’t differentiate, does it, even between bed that are functional and ready for use and beds that are theoretical in that they exist but they’re not necessarily staffed or with an oxygen supply for example?

Dr Andrew Goodall: No, indeed we would know those number of beds within the health boards’ own reports, they would understand their baseline levels as well, but as the proforma moved we did introduce that, and also I was very clear in the personal updates that I chose to give from a very early stage of the pandemic, these weren’t the official sitrep reports but it was me giving a sense of how the NHS was responding. I was always very clear in those reports to refer to the baseline for critical care beds for example so that ministers would understand actually that stretch on the system and the pressures that were being experienced across the hospital.

Counsel Inquiry: Is it righted that it was the minister in fact who asked to have that information included, wanted to know the baseline and how much over baseline it was? Is that right?

Dr Andrew Goodall: Yeah, the minister was aware of those numbers from previous involvement when we were expanding critical care beds in Wales before the pandemic. He was also aware, because I was reporting on that to him in my own more personal reports that were being submitted as well and he felt that was a helpful addition just to make it very clear to wider colleagues as well beyond just himself and the First Minister of course.

Counsel Inquiry: Can we stick with this table then and what’s shown on this table. Who is this table for?

Dr Andrew Goodall: This table was being reported in to us to have a national summary. It was underpinned by local hospitals –

Counsel Inquiry: But who was it for? Who is supposed to be looking at this?

Dr Andrew Goodall: This was for us in NHS Wales but it also satisfied the reporting that was able to feed up to ministers to have an understanding of the performance of the NHS across Wales.

Counsel Inquiry: So it’s not clear at a glance from this which beds are ready to be used, which beds are in surge capacity, which beds are purely theoretical, how many patients are receiving CPAP, how many additional beds are available for patients who need mechanical ventilation. None of that information is immediately apparent in looking at this, is it?

Dr Andrew Goodall: It’s not immediately apparent from this but we would have expected that health boards would have that – their own understanding when they were submitting this information. And in terms of the immediately available beds, they would be represented by the totals that were on the left-hand side in terms of the total numbers that are available, and the additional capacity available within 24 hours, 24 to 7 days, and after 7 days, they were reflecting that they were beds that we could step up into based on need if they needed to be commissioned by the local health boards and that was the national picture on those.

Counsel Inquiry: All right. Can we have a look at the way the local health boards were dealing with the data that was being collected and their access to that data. You’ve been provided with the witness statement from the Chief Information Officer from Cwm Taf Morgannwg Health Board. I don’t think we need to go to that witness statement itself INQ000409575. And the Chief Information Officer is quite critical of the limitations on the data that was collected by the Welsh Government particularly in relation to CPAP. He says this:

“The recording of CPAP use was never resolved in Wales. As a result the sitrep reports were never relied upon by anybody undertaking analysis. Rather than addressing the shortcomings, the publishers presented the numbers with a warning on that they included suspected numbers … The absence of reliable CPAP data meant that we went through the first and second waves unable to evidence our preparations as to whether we had enough CPAP machines and oxygen to meet need … The lack of data diminished the ability of clinicians to use data to audit and compare the effectiveness of care for Covid patients. Better data would potentially have helped care optimisation or have helped the clinical teams to make changes to how they delivered care earlier.”

Dr Goodall, do you think those are valid criticisms of the data collection by the Welsh Government?

Dr Andrew Goodall: I think they are valid criticisms of the data in some of the summary and aggregate reports we had. There were other ways in which we could access that information. So, for example, the references that Mr Nelson has made to oxygen and CPAP, we were assessing those through the planning and response structures and able to draw on those. And actually after the oxygen assessments that had been undertaken, given that they had been escalated by the NHS Wales and we were involved in supporting the plans for those, we were able to maintain a group that was overseeing those oxygen arrangements that had a particular focus around our estate’s infrastructure as well, so – and whilst the summary and aggregate information may have frustrated some of the understanding there were other sources of data that were available that we were able to pull in from those operational experiences within the NHS in Wales as well.

Counsel Inquiry: What about the point that’s made that it was hampering the ability of clinicians to assess what was the most effective form of clinical support for Covid patients? Data wasn’t just for use by the Welsh Government in terms of counting how many beds were there. Data has a number of important uses, doesn’t it, during a pandemic?

Dr Andrew Goodall: Data has many important uses and certainly from a Welsh Government perspective reporting into the Health and Social Services Group we wanted to make sure that we had subset of data that was helpful to us at a national level which we were able to collect routinely and without inappropriate impact on the system. All of the operational data that is normally in use by the NHS in Wales were still available in terms of that local use.

What was helpful to us was the way in which our clinical networks in particular were able to step into some of the understanding of this data, so, for example, through our national respiratory lead or through our critical care network we were able to make sure that there was a more refined understanding of some of that data and, again, there was a way in which could be fed into us as well.

Counsel Inquiry: Can we have a look at the pressures on the system in terms of critical care occupancy during the pandemic, please, and can we have a look at a graph that’s been prepared, I think, by the Welsh Government. This is on page 182 of your witness statement, figure 7. And it shows, I think, weekly patients in invasive ventilated beds. And we can see there that the black lines show confirmed Covid patients, the brown lines suspected Covid patients. Is there any reason why confirmed and suspected Covid patients have been split up in this data? Would they not be cared for in the same facilities?

Dr Andrew Goodall: Yes, they were cared for in the same facilities but it was just allowing us to understand that for some patients there was a time lag, even if it was short, about having confirmation of their test but they were treating as if they were Covid patients. On occasion you may end up with a patient who was suspected to be Covid where the test result did not confirm that, yet they still needed to have access in critical care, of course, but it just allowed us to understand some differences around the data. So confirmed was really the core actual position. It allowed us to understand the surveillance of the virus, if I can put it that way.

Counsel Inquiry: Well, if I can stop you there. Can we have a look at what we’re seeing on the graph. This is split up non-Covid and Covid patients, so the number in invasive ventilated beds would be the combined number, I think. These are numbers rather than percentages. Did the Welsh Government ever have data on the percentage of available beds in intensive care that were occupied whether by Covid or non-Covid patients?

Dr Andrew Goodall: Yes, because we had the data, we were able to track the percentages as well.

Counsel Inquiry: And did you have that information by hospital and local health board to show whether there was pressure on capacity in particular places?

Dr Andrew Goodall: Yes. Yes, we did. The aggregated summaries you showed earlier were all supported by individual health board and hospital positions.

Counsel Inquiry: All right. Can we have a look, please, at your witness statement at page 183. This is paragraph 455. The final sentence there says:

“In terms of whether critical care capacity or general bed capacity was reached or exceeded in any local health board or individual hospital [Digital Healthcare and Wales] will be best placed to confirm this information.”

Why does the Welsh Government not have that information?

Dr Andrew Goodall: We had it at the time as we were going through the pandemic and receiving it on the spreadsheets and the databases. I think that’s just a practical data issue for DHCW to provide it based on holding all of the information throughout the whole period of the pandemic, they have it accessible on their database.

Counsel Inquiry: Does that mean you –

Dr Andrew Goodall: We had it at the time.

Counsel Inquiry: – had it at the time but you don’t have it anymore?

Dr Andrew Goodall: That’s correct.

Counsel Inquiry: Why is it that the Welsh Government hasn’t retained that data?

Dr Andrew Goodall: I don’t know why that is the case in terms of responding to the Inquiry. I would have to check outside, I’m afraid, with colleagues supporting me but we did have it at the time because – (unclear: multiple speakers)

Counsel Inquiry: You did have it at the time –

Dr Andrew Goodall: – had the individual information for hospitals, for example, from those spreadsheets and the way the information fed through.

Counsel Inquiry: Do you know how long it was kept for or at what point that data was disposed of?

Dr Andrew Goodall: I’m sorry I can’t comment on that. I would have to check with the team supporting the responses to the Inquiry, I’m afraid. I’m very happy, of course, to do that today.

Counsel Inquiry: All right. Perhaps we can move on to CRITCON levels because that was another way of tracking capacity and the pressures on capacity in critical care. Is it right that CRITCON levels were recorded on the unscheduled care dashboard for Welsh Government data only from December of 2020; is that correct?

Dr Andrew Goodall: Yes, that’s correct.

Counsel Inquiry: How was Welsh Government then collecting information on the pressure in critical care prior to December of 2020, why was it not recorded until then?

Dr Andrew Goodall: We were receiving the daily updates that allowed us to track in data terms the pressures on the system. At the same time we were able to link regularly, usually daily, on occasion through the day with the critical care network that was made up of our frontline clinicians. There is a national clinical lead for critical care, as well, and a team supporting them and they were also involved in supporting us with some of the operational requirements of the system in Wales. They’re not an operational unit themselves but during the pandemic they really helped to make sure that there was a more direct understanding of the pressures that were being experienced across critical care but we felt that the inclusion of CRITCON from December, particularly as we were moving through the second wave and with the pressures that the NHS were experiencing were a further helpful way of understanding those pressures across Wales.

Counsel Inquiry: Would you accept the recommendation that was made by Stephen Mathieu of the Intensive Care Society it would be beneficial for CRITCON to be used across Wales in future pandemics or at times of extreme for example winter surge pressures?

Dr Andrew Goodall: Yes, I would agree with that. One of the reasons it works very well in England is an issue of scale, because of the coverage of the very many critical care units. Because we have smaller units in Wales, and with the Critical Care Network they do liaise with each other very frequently, but I do agree that having the CRITCON status available again just provides another level of information beyond the data.

Counsel Inquiry: You touched on the fact that the Wales Critical Care and Trauma Network is not an operational network so it’s not a critical care transfer network in that sense.

Were the Welsh Government informed if local health boards had to transfer critical care patients out to another hospital or local health board during the pandemic?

Dr Andrew Goodall: Mostly if that was happening that would be an operational issue in respect of mutual agent support happening between individual health boards and indeed individual hospitals. There were escalation mechanisms available, daily bed calls. The Critical Care Network itself was meeting and often they would be brokered through that. They were not happening very regularly but they would tend to be held at that more operational level within the health boards themselves.

Counsel Inquiry: So is the answer to that, no, the Welsh Government were not informed if local health boards had to rely on mutual aid?

Dr Andrew Goodall: We were not informed as part of the process but we would often have team members from the Health and Social Services who would be sat on those calls, but the answer would be no in terms of the operational pressures.

Counsel Inquiry: So is it right that the Welsh Government didn’t ask the local health boards to keep them informed of whether they were having to rely on mutual aid from neighbouring health boards? Would that not have been a useful piece of information to have had?

Dr Andrew Goodall: It would have been a useful piece of data and information to have. Often those type of experiences were reflected in the chief executive calls or with the medical director calls and we would have a sense of the way in which, certainly in the first wave, the virus was spreading across South Wales. But that would be useful information to receive, I agree.

Counsel Inquiry: Finally, in terms of numerical data that was collected by the Welsh Government during the pandemic, do you think that the Welsh Government were collecting sufficient data at the right level of granularity during the pandemic? Do you think this is an area where the Welsh Government could have done better?

Dr Andrew Goodall: We were, in the very early stages, trying to ensure that we could draw on appropriate data that was in use by our local hospitals and by our local health boards across Wales, and indeed some of the other sectors.

I do agree that the pandemic has given us learning about the level of detail that is useful to use which didn’t provide a burden or pressure on the system but really brings to life the experiences across the system. I think the data doesn’t just tell you the experience, even though we can track and see how things are changing, even day-to-day. It’s really important that you build in wider experiences as well. And it was why it was so important to have other ways of talking to our hospitals, to our frontline clinicians, to our executive teams, to make sure that we had a genuine understanding of the pressures that they were experiencing, that their staff were experiencing as well. I think we enabled that through national calls, through our clinical networks in Wales, to try and, I hope, bring that more to the surface than just the data itself.

Counsel Inquiry: Could I ask you, please – I think you’ve been provided with the evidence of Professor Fong, who explained to the Inquiry that he was involved in a scheme of peer support visits to intensive care units to see really the reality on the frontline, going beyond the numerical data to the experiences of staff in very pressured intensive care units.

Professor Fong explained that he had received requests from other nations to carry out similar visits but he said he wasn’t aware of any similar scheme taking place in other nations. Were you aware of any request for peer support visits coming from any hospitals in Wales where they wanted a scheme like Professor Fong’s?

Dr Andrew Goodall: I’m not aware directly of a request for a similar scheme. We were receiving advice from our clinical networks in this respect, particularly the Critical Care Network, but often that was a way of hearing that voice very directly anyway, but I’m not aware of any requests for a similar scheme given that I’ve obviously had the opportunity to read and seek Professor Fong’s evidence.

Counsel Inquiry: In the event of a future pandemic would you see the benefit of a scheme like that in Wales?

Dr Andrew Goodall: I would, absolutely. I thought it was very powerful evidence and I do believe that would definitely help us to have even more of that frontline experience demonstrated to us and be able to use it in that very effective way.

Counsel Inquiry: Moving on from data now. Can we look briefly at the steps that were taken by the Welsh Government to maximise existing capacity in the NHS in Wales. I think it’s correct that on 13 March the Minister for Health and Social Services published a ministerial statement setting out a framework of actions for the healthcare system in Wales.

Can we have a look, please, at that ministerial statement. And if we can look at the first four of those bullet points, please. Can we look at the numbered points. Thank you.

So this was where the local health boards were being advised to:

“1. Suspend non-urgent outpatient appointments and ensure urgent appointments are prioritised.

“2. Suspend non-urgent surgical admissions and procedures (whilst ensuring access for emergency and urgent surgery)

“3. Prioritise use of Non-Emergency Patient Transport Services to focus on hospital discharge and emergency response.”

And:

“4. Expedite discharge of vulnerable patients from acute and community hospitals.”

I think it’s right that that wasn’t a ministerial direction so there was discretion for the local health boards as to how they were going to implement this framework; is that correct?

Dr Andrew Goodall: That’s correct, they had the opportunity to implement this at a local level and these issues emerged from a range of discussions with senior leaders in the NHS in Wales, medical directors, about the types of actions that would genuinely help them to prepare. So, rather than just decide these nationally, these really emerged over the course of the previous few days and in fact were set out in some correspondence that we received collectively from chief executives and also from medical directors in Wales.

Counsel Inquiry: After this framework of actions was issued on 13 March, which effectively were suspending elective treatment, can you help us, was there any guidance or instruction from the Welsh Government about restarting elective surgeries? And if so, when was that made?

Dr Andrew Goodall: So that happened later as we had come through the first wave and had seen the peak and were starting to see the opportunity to focus on other activities in the NHS.

We formally set these out in terms of requests within quarterly frameworks, quarterly operating frameworks that we used. And that’s where we asked, although it was done in a cautious manner, that there were opportunities to start to recover some of our activities.

In the first wave, in practical terms, our planning horizon was having to work two or three weeks ahead only, so the introduction of those quarterly frameworks were really important to give that wider guidance to the system and track it alongside the concerns and worries of the virus as well. I should explain that these operating frameworks were usually discharged over a 3-year period, so this was quite a change in our outlook for planning.

Counsel Inquiry: If we can focus, please, on elective care in Wales and when that was resumed.

The Inquiry has heard from two experts in orthopaedic surgery, Professor Metcalfe and Ms Chloe Scott, and I think a transcript of their evidence has been provided to you. But they have explained that multiple figures showed that the delivery of restoration of elective care in Wales was significantly delayed compared to that in England.

And Professor Metcalfe told the Inquiry that meetings were first held about recovery of elective orthopaedic care in Wales in 2021 and the first guidance document was released in 2022. He made some criticisms of the guidance document, saying that it’s more vague than the NHS England guidance and it’s not linked to any financial incentives for local health boards and, as a result, treatment delays in Wales, in the words of Professor Metcalfe, were absolutely huge.

Do you think that the Welsh Government should have planned to recover elective care sooner in the pandemic and taken steps to incentivise local health boards to restore those local services?

Dr Andrew Goodall: Looking back now, where we are, I think we should have done that earlier than we did. We did give permission for the instigation of routine activity, including in our first operating framework in May 2020, but that was absolutely in recognition of the environment we were in at the time. They were operational matters for health boards to take forward. Whilst the orthopaedic summit took place in 2021, other guidance had been given in those operating frameworks for actually taking the opportunity to restore guidance as well.

Counsel Inquiry: In terms of practical steps that could be taken, can I ask you this. The Inquiry has heard a recommendation from those two orthopaedic care experts, and also in relation to cancer care, colorectal cancer care, about the use of elective hubs which would provide elective surgeries on a separate site, away from urgent and emergency care. Is that a recommendation that could practically be implemented in Wales or are there barriers to doing that?

Dr Andrew Goodall: Yes, that’s a recommendation that can be implemented and we did have set up within individual hospital sites as well. There is a need for an understanding of the way in which that would mean that services would be changing across different areas of Wales. And when we are normally working through these sorts of choices, there are consultation processes, for example, not least with communities, about understanding those change of services. So it’s just about recognising that there are consultation and engagement mechanisms that we need to do. But obviously within a pandemic there are different ways in which you can respond to that in – more in an emergency mode.

Counsel Inquiry: All right, thank you.

Perhaps we can move on now to following on from the framework of actions which was published on 13 March. As well as expediting discharge, I think the Welsh Government also produced some guidance on admission to secondary care and published, on 23 March 2020, the Covid-19 primary and community care guideline, and can we look very briefly at this, please.

It’s INQ000226967. Thank you.

On page 7, please, there is a flow chart. This is for primary care practitioners to go through this flow chart as to whether to admit a patient, and there are a series of questions there:

“Does your patient meet criteria for respiratory distress?

“Does [the] patient have an advance future care plan that applies in this case?

“Is the patient likely to benefit from ICU escalation?”

“Yes”, they’re admitted to acute hospital; “No”, discuss admission with the front door clinician. And there’s an asterisk at “ICU escalation”, and it says:

“Evidence shows that the following groups do not respond well to ICU escalation:

“Clinical Frailty Score of 5 or above …”

And if we can have a look quickly, please, at, I think, page 16, it shows the Clinical Frailty Scale there. 5 is “Mildly Frail”.

Is it right that the purpose of the Welsh Government in publishing this guidance and this flow chart was to try to minimise the number of Covid patients being admitted to hospital by general practitioners?

Dr Andrew Goodall: It was to try to support the overall preparation but also to try to push patients to the right level of service that needed to be available. And this guidance had been developed by our primary and community response group, which included a wide variety of representatives from all of our health organisations in Wales and was led by clinical leaders as well.

Counsel Inquiry: Thank you.

So this guidance was published on 23 March 2020, and a little over two weeks later, on 8 April, it was updated, according to your witness statement, to include guidance that the Clinical Frailty Scale should not be used in younger people, people with stable long-term disabilities such as cerebral palsy, learning difficulties or autism.

Now, the inquiry has heard from Dr Paul Chrisp of NICE that the guidelines for critical care for Covid patients that had been published on 20 March 2020 were amended on 25 March to make that amendment about the Clinical Frailty Scale not being appropriate for younger patients with long-term conditions, as I’ve just set out. Can you explain why it is that, after those amendments were made to the NICE guidelines to clarify that it was not appropriate to apply the Clinical Frailty Scale to younger people – why it took until 8 April for the Welsh Government to make similar amendments to this admission criteria?

Dr Andrew Goodall: I can’t respond to why that delay would have been there. I would just be speculating but I would have thought that the planning and response group could have been taking a look at it again. But I won’t be able to respond to the specific question, I’m sorry.

Counsel Inquiry: All right. Perhaps we can move on to increasing capacity in terms of the medical equipment and supplies that were going to be needed by the NHS in Wales.

And I think there were some concerns initially in relation to items that were going to have to be sourced on a four-nations basis.

And can we have a look, please, at INQ000479929.

This is an email from you, on 27 March, to Vaughan Gething, who was then the Minister for Health and Social Services, and this is raising issues about supply arrangements for the UK, and we can see some of the concerns that you had at this point of time.

So, you set out that there are some concerns because of the way that testing and testing kits were being supplied to Wales that you were concerned that there may be some similar supply arrangement problems with Wales not getting equitable access to either tests or PPE or ventilators.

And can we see there point 3:

“Speaking to other devolved governments the supply process is feeling that we are excluded from the UK/NHSE arrangements, we are not sighted on the workstreams at any level of detail and [this is] … affecting our ability to plan.”

The, going on, it says:

“There is an emerging discussion about how supplies – whether ventilators, PPE or others – will start to be distributed to an assessment of need rather than equity. The concern for this is that in planning terms this will create concerns for Wales about resilience and business continuity …”

Your concerns seemed to be at that point that effectively if the wave hit England first, their need would be greater and all those finite resources would have been used up by the time Wales needed to draw upon them. Would that summarise what your concerns were at that point?

Dr Andrew Goodall: Yes, they were genuine concerns and it was a very fast-moving picture, but, yes, there were early signs of planning for England having an impact on some of our supply lines in Wales and we were just looking to make sure that didn’t happen in practice.

Counsel Inquiry: Can I ask, did that happen in practice? Did those concerns materialise?

Dr Andrew Goodall: It didn’t happen in practice. I was really pleased with the way in which colleagues responded. I think there was possibly some clumsiness on some of the instructions provided, so, for example, when liaising on areas such as PPE, NHS England was being used as the criteria rather than the NHS more generally and this is why affected colleagues in Scotland and Northern Ireland as well. But when able to escalate and talk to our colleagues through our structures, at the times I did that personally myself there was always a very appropriate response and we were able to ensure that that settled down.

But at this time we were seeing very significant pressures in London for example. They were a few weeks ahead of the first wave than the Welsh position and you could just see how there was the potential for resources to be drawn to those starting points for the virus in the United Kingdom.

Counsel Inquiry: All right. So looking then at ventilators, I think you’ve set out in your witness statement that at the start of the pandemic NHS Wales had 415 invasive ventilation machines, 207 non-invasive ventilation machines, and in 2020, 1,238 further ventilators were procured by NHS Wales and also through UK arrangements with the Department of Health and Social Care. At that point when additional ventilators were in the process of being procured or supplied, were any steps taken by the Welsh Government to ascertain whether there would be sufficient numbers of staff trained to operate those additional ventilators?

Dr Andrew Goodall: In the first wave we were working through where it was really important to make sure that we had the physical capacity and then we had the equipment capacity. The workforce plans were always being progressed and working through. Just because we were planning at that point for 1500 ventilators did not mean, of course, that there would be 1500 – sorry, staff available to support those 1500 ventilators. That will be something that we would have to continue to progress, introduce the training and introduce the skills. But we were always starting with making sure that the physical requirements were in place first.

Counsel Inquiry: And did the Welsh Government take any steps to ensure that there were enough trained staff to operate that additional number of ventilators?

Dr Andrew Goodall: Not to that number at the outset but we were introducing additional training, health boards had produced plans, they were re-deploying staff, there was both local training available, we were also escalating training through the Critical Care Network, as well, I was making sure that we were able to grow the number of staff who were available but we were, at that point, well short of any ability to manage 1500 ventilators if that situation had happened in practice.

Counsel Inquiry: All right, thank you. Now, plainly an increased use of ventilators in hospital is going to require an oxygen supply, sufficient oxygen supply, and I think it’s right that Welsh Government worked with NHS Wales and the British Oxygen Company and the Royal Engineers to try and expand existing oxygen capacity in the NHS estate. And by June 2020 I think the Royal Engineers produced a report which indicated that a 75% increase in oxygen provision had been achieved. Was that sufficient to meet the likely or the projected increase in demand for oxygen?

Dr Andrew Goodall: If we were still moving to some of the modelling levels which could still be at extreme, that level still would not have allowed to us achieve it, but at the time in June it was felt to be an appropriate recovery of the oxygen facilities and we’d had some physical developments in our estates as well, so we’d been able to access oxygen for field hospital facilities where that was needed and necessary. But if we had continued to see the modelled position right through 2020 and into 2021, that would have continued to stretch our oxygen capacity. Having said that, we were in liaison with British Oxygen, we had clear recommendations, and we had a group that was working that through with the local health boards in Wales, and very regularly as well, so we were always looking to progress that position.

Counsel Inquiry: Now, can we move on, please. You touched there on field hospitals. Can we look at field hospital provision in Wales and the role of the Welsh Government in relation to field hospitals.

I think it’s right that the Welsh Government provided funding for field hospitals and you’ve set out in your witness statement that initially £166 million was allocated to local health boards for field hospitals. In 2020 to 2021 capital funding of 50 million was provided for field hospitals, in addition to £10 million for the early opening of the Grange hospital in Aneurin Bevan University Health Board. £83 million was also spent on works across the estate, some of which would have been spent on field hospitals.

So having allocated £166 million initially, can you assist us with the total, the final Welsh Government spend on field hospitals during the pandemic?

I can take you to paragraph 521 of your witness statement if you like, which contains those figures, but there aren’t any other figures that have been provided. Was that the final spend?

Dr Andrew Goodall: The formal cost – yes, that was the final spend. I mean, you’re right that in respect of some of the enabling estates work we were unable to set out the specifics that were for field hospitals themselves so the revenue costs as set out in that table were for 136 million but there were those additional capital costs that we used as well.

Counsel Inquiry: In terms of the number of patients admitted to field hospitals during the pandemic, if we can go to page – page 206, please, of your witness statement, paragraph 514. You say that:

“In terms of numerical data of how many patients were admitted to field hospitals for the relevant period, the Welsh Government did not request this data from the health boards as distinct from the admission data.”

That’s the information we saw before about how many bed were occupied, and so on.

Why did the Welsh Government not request data from the local health boards about how many of the beds that had been created in field hospitals had been utilised?

Dr Andrew Goodall: Within the sitrep reports, the category you were showing earlier was allowing to us report on patients who were outside of the normal hospital facilities, so we were able to track the data very generally in there but it was very minimal data because of the change and the mitigating factors, the lockdown that occurred, we ended up not needing to use the field hospitals as intended of course. So there was a real change on it. But it was set up within the sitrep report.

In respect of an understanding of how the local health boards were using it, we did undertake reviews at various points drawing in that experience and there was a group available in Wales that was also tracking it as well. But I think it would have been the sitrep data field that would have allowed to us understanding it, but there were very minimal numbers in there, as I was saying, because we simply didn’t use the field hospitals as intended. They were a contingency preparation and fortunately they did not need to be used in the way that was intended.

Counsel Inquiry: Can we look at some concerns that were brought to your attention by some of the local health boards about the resources that were going into field hospitals.

Can we see, please, INQ000474458.

This is an email from a local health board, Cardiff and Vale local health board to the deputy Chief Medical Officer. He says, if we can go to page 2, please:

“I feel I need to send this email just to relate what I see on the ground in Cardiff at least. I don’t have access to the [NHS Wales Information Service] data on capacity elsewhere.”

So the local health boards didn’t have information, is that right, about what was going on in other local health boards or nationally across Wales, they didn’t have access to that data?

Dr Andrew Goodall: I would assume that they would have had access to the data. We were always sharing it and discussing it in the meetings that were happening at that time, but from a sitrep perspective their focus would have been on the submission of the local data.

Counsel Inquiry: But it seems that the writer of this email is saying that he doesn’t have access to information about what’s going on in terms of other local health boards and their capacity. But he goes on to talk about what’s happening within his health board. And he says:

“I write this because I am concerned about the huge amount of resources going into dragons heart. My prediction is that this will be an enormous white elephant. I fully understand that [Welsh Government] need to prepare for worst case scenarios, but I question whether this is necessary given what is happening on the ground.”

And he says that there is huge capacity in the system, at least in relation to that health board.

Were you aware of those kind of concerns? Did the deputy Chief Medical Officer speak to you about any of this in terms of the amount of resources that were being diverted from local hospitals into field hospitals?

Dr Andrew Goodall: I can’t remember if the deputy Chief Medical Officer spoke to me directly on that day. I would typically expect it because we were all with each other on a daily basis and we were having these very open conversations. The context at this time, of course, was that we had built up these plans on the modelling and had been working on those through March. We were still very much in the first wave at this stage. Even, I think it was six days after this that the peak of critical care capacity that we reached in the pandemic was hit.

But I do agree with Simon in his note here that we were actually seeing a very big impact on our available capacity from the steps that had been taken on 13 March so I –

Counsel Inquiry: Right.

Dr Andrew Goodall: – at that point was doing press conferences, and I was reporting on the available capacity for the NHS in Wales.

Counsel Inquiry: All right. If we can focus then on what was happening in field hospitals, and I think it’s right that the model of care for field hospitals was to provide step-down care rather than intensive care facilities; is that correct?

Dr Andrew Goodall: That’s – yes, that’s the way the model worked in Wales, that’s correct.

Counsel Inquiry: All right. So this was for patients who no longer needed acute care but weren’t well enough to go home; is that right?

Dr Andrew Goodall: Yes, that’s correct.

Counsel Inquiry: And also to provide palliative care for patients with a ceiling of treatment; is that correct?

Dr Andrew Goodall: That’s correct.

Counsel Inquiry: So can I ask you this. Given that the projections from 4 April were for 900 intensive care beds or critical care beds and by that date we know that 356 beds had been created with surge capacity within hospitals, although they may not have been staffed at that point, it was looking at that point as though Wales was not going to be able to create 900 additional critical care beds. In that case, why is it that no critical care beds were to be created in field hospitals?

Dr Andrew Goodall: It was the clinical model that was determined for Wales. It reflected the way in which the health boards wanted to use their local capacity. What they were looking to do was to make sure that they were able to expand their critical care capacity on their individual acute hospital sites and that they would be able to decant or displace other patients into those other peripheral beds which may at a moment have become the use of the field hospitals as well, so it was an attempt.

Secondly, from a geographical perspective, and just a reflection of our rurality, to some extent, we needed to have a distribution of those beds that was available across Wales and that’s why that model was used as a very local model as well, but it was to expand the capacity on the acute hospital sites for critical care and then to manoeuvre other beds into other areas.

Counsel Inquiry: All right. Were the palliative beds for patients with a ceiling of treatment, were those beds for patients who could not be admitted to intensive care in the event that full capacity had been reached? Was that the thinking at that time? We’re not going to be able to create as many intensive care beds as the projected – as the modelling is telling us we’re going to need, we’re not going to be able to create 900 beds, we’re going to have to have some sort of palliative care facility for people who, if intensive care is full, they’re going to have to go to a field hospital for palliative care?

Dr Andrew Goodall: I don’t directly recall that being the intention because it was intended to bring patients who had gone through their experience in the hospital and were to move to another facility. It was possible that it could provide some of that support if necessary. It would really just be a question of the pressures that we were experiencing and having the flexibility to use our capacity for those different purposes.

Counsel Inquiry: All right. So if we can move on past the first wave then and the way that field hospitals were used there. It appears from a briefing provided to the minister on 26 November that only two field hospitals were used during the first wave and 46 and 34 patients were admitted respectively. Where was that information coming from if Welsh Government weren’t collecting data on the use of field hospitals?

Dr Andrew Goodall: We had information in that sitrep line which talked about other hospitals but also the teams were just always in contact with the individual health boards and with clinical teams in Wales. That’s just the way we work on a normal basis and we would have been using those relationships to describe that as well. There was also a group in place that was overseeing and supporting field hospital provision across Wales, partly a peer support mechanism and Health and Social Services Group officials were part of that group as well.

Counsel Inquiry: So do you know whether any of the field hospitals were utilised in the second wave, whether any patients were admitted in the second wave?

Dr Andrew Goodall: There were. We were very fortunate that field hospitals didn’t need to be used. They were ultimately there as a contingency based on the model. Having established them we wanted to use as much as possible those that were remaining for alternative purposes. So there were field hospitals that were used for some patients when we received the peak in the second wave, that was in January 2021, and through that period of time, but there were also alternative ways in which the field hospitals started to be used including as vaccination clinics.

Counsel Inquiry: If we can focus on their uses as field hospitals for now, because I think the minister on 26 November was being informed that three of ten remaining field hospitals were operational at that point in November?

Dr Andrew Goodall: Yes.

Counsel Inquiry: You don’t think they were used at all in the second wave; is that right?

Dr Andrew Goodall: There were three field hospitals that were operational but during the second wave which took us into 2021, there were some of those small numbers of field hospitals that were used and they were available. Again, as we went into the second wave they were a contingency preparation for us to have capacity that we could expand into, so they were still discharging their original role and intention, but we had reduced the number of field hospitals from 19 to 10 by the time we got to November 2020.

Counsel Inquiry: All right. I think the three field hospitals that were operational at that point were Deeside in Betsi Cadwaladr University Health Board, Seren in Cwm Taf, and the Grange University Hospital which wasn’t technically a field hospital. And I think you’ve been provided with a Healthcare Inspectorate Wales report dated 19 March 2021 into concerns about quality of care provided at the Deeside field hospital, so that appears that that was being used in the second wave; would that be correct?

Dr Andrew Goodall: Yes, that was one of the field hospitals that was in operational use at that time, yes.

Counsel Inquiry: And that report identified a number of failings including problems with IPC measures at that field hospital, a lack of individualised end-of-life care planning and failure to use the end-of-life care pathway.

Can I ask you this, had you been made aware of those concerns about the quality of care being provided in that field hospital prior to the Healthcare Inspectorate Wales report?

Dr Andrew Goodall: I hadn’t been advised of it before it, but I was obviously aware when Health Inspectorate Wales did their visit.

Counsel Inquiry: So those concerns hadn’t come through, through any of the groups that you’ve just mentioned that were set up within the Health and Social Services Group, that information wasn’t filtering through?

Dr Andrew Goodall: It hadn’t, nor had they come through the health board itself, no.

Counsel Inquiry: Did the Welsh Government have any way of monitoring the quality of care provided at field hospitals?

Dr Andrew Goodall: We were in contact with all of the health boards on their plans and proposals. We had our professional networks in place. So nurse directors would be able to speak with the Chief Nursing Officer and oversee those arrangements. We weren’t doing our own assurance visits, we were very much leaving those legal and operational visits to the health boards at the time and the regulator’s role, Health Inspectorate Wales, is one of those ways in which we were able to get that more independent voice and to allows us to understand that from a national level as well as, of course, the direct actions needed to be taken by the health board.

Counsel Inquiry: Did the Welsh Government undertake any review of the field hospital programme in order to evaluate what worked and what didn’t?

Dr Andrew Goodall: There were two points in particular where reviews were undertaken. There was one in June 2020 which was an early review of the way in which the facilities had been established and the issues that had been faced. As I said, there was a group available.

Counsel Inquiry: What was the nature of that review, please? Was that an Audit Wales review or what was the body?

Dr Andrew Goodall: It wasn’t an Audit Wales review. That was actually done by the Health and Social Services Group working with a field hospital group in Wales to review it, and there was a similar review done on a similar basis, I think it was in March 2021, as well.

Counsel Inquiry: So June 2020 and March 2021, but nothing at the end of the programme?

Dr Andrew Goodall: You would have to speak to Judith about how she picked up issues after the end of the programme, after the pandemic was finished, after October 2021, but I don’t recall anything. There were learning reports that were produced, I know, because of the interest in field hospitals and how they had been established and how staff worked together but they weren’t directly commissioned by the Welsh Government.

Counsel Inquiry: Perhaps we can move on and look at the use of private hospitals for NHS care during the pandemic. I think, again, this was funded by the Welsh Government and £30 million of funding was agreed on 25 March 2020 for the commissioning of additional capacity from the independent sector. Is it correct that that total capacity was 152 beds, some of which were day case beds in six inpatient hospitals across Wales? I think it’s right that there weren’t any intensive care beds provided in private hospitals; is that right?

Dr Andrew Goodall: Yes, that’s correct, and your point on critical care capacity is correct as well.

Counsel Inquiry: Did the Welsh Government collect data on how much activity was performed under those contracts that it had funded?

Dr Andrew Goodall: The contracts were overseen by the Welsh Health Specialised Services Committee that was acting on behalf of the local health boards.

Counsel Inquiry: Did you collect data on how much activity was performed?

Dr Andrew Goodall: The tracking and monitoring was done through that mechanism. It wasn’t necessarily done through Welsh Government at that time. It was an operational matter for the health organisations.

Counsel Inquiry: Did you have data – do you know how many operations or other activities, outpatient appointments were delivered through independent providers for NHS patients?

Dr Andrew Goodall: We had reports from the Welsh Health Specialised Services Committee but they were not part of our daily sitrep data.

Counsel Inquiry: No, I didn’t ask whether they were part of your daily – perhaps we can go to page 218 of your witness statement paragraph 545.

If we can get up page 218, please, thank you.

You say:

“Weekly sitreps on activity were developed … on behalf of NHS organisations for monitoring purposes and to ensure maximum usage of the capacity available. This information was not produced by or held by the Welsh Government as it was not a party to the contract arrangements.”

Does that mean that you didn’t have that information?

Dr Andrew Goodall: It means that we were – we would receive the information when officials were liaising with the Welsh health services committee, but we were not formally part of the contract review and monitoring information so we could have it available, we could be provided with it, but we weren’t formally monitoring the contracts.

Counsel Inquiry: Do you know how much activity was performed under those contracts when the contracts ended? Would you be able to give us –

Dr Andrew Goodall: I can’t recall where in my statement I set out those numbers but we had information available that was provided to us by the Welsh Health Specialised Services Committee that would tell us what those numbers were, and we were reporting it internally in order to have an understanding from – various occasions within our Health and Social Services Group arrangements and also with the NHS leadership board as well.

Counsel Inquiry: I don’t think there is anywhere in your witness statement where you set out those figures, but they are available to the Welsh Government, are they?

Dr Andrew Goodall: They will – I’m happy to report back on those figures that we have available.

Counsel Inquiry: All right.

Can we turn, please, to some PPE issues in healthcare settings and in hospitals. You have explained in your witness statement that there was a PPE pandemic influenza stockpile that was held in Wales, and at the beginning of the pandemic that was utilised until the pandemic arrangements were completed with the Department of Health and Social Care and so on.

In your view, were the existing pandemic influenza stockpiles of FFP3 masks at the start of the pandemic – were they adequate for the Welsh Government needs?

Dr Andrew Goodall: I think, based on our experience, the supply set aside was inadequate for what we were seeing in respect of the Coronavirus experience. So whilst they had been established for a pandemic flu, we were receiving something different. Nevertheless, the availability of the stocks alongside the central stores and of course local health boards’ own supplies meant that we were at least able to flexibly use PPE stocks available across Wales until we had been able to restore some more effective supplies.

Counsel Inquiry: And you set out that in Wales there was a dual pronged approach to PPE procurement: there was the four nations basis, where the UK acted as the lead purchaser and led on behalf of the four nations, and then there was a Wales-only basis, where I think it was the NHS shared services partnership in Wales were operating a separate procurement system; is that correct?

Dr Andrew Goodall: That is correct, although we shifted more towards the use of the Wales approach through our experience in those early weeks in particular.

Counsel Inquiry: Can I ask how effective it was to have those two systems operating in parallel and whether there were any difficulties with that? You said that you ended up moving more towards the Welsh system.

Dr Andrew Goodall: We were finding difficulties with the supply system being put in place at UK government level. Of course, for NHS England, because the procurement that was taking place was often buying up in bulk supply lines that meant that the NHS in Wales was sometimes not able to access its normal supply routes as well.

I think one useful example I set out in my statement is of a company based in Wales that, whilst it always provided some residual stock to England, they suddenly had an approach which would have taken away all of the usual stock that we would have been drawing into our central stores in Wales. So there were very practical experiences.

There were, however, some good examples where we were able to access some of the international supply lines through UK colleagues and working with the NHS in England as well. But ultimately we decided that the best way of securing the national supply for Wales was reverting more to working through our Welsh national shared services arrangements in place, and we were very fortunate to have established a national organisation with this very specific role.

Counsel Inquiry: Can we look briefly at some of the concerns that were coming from the front line with healthcare workers who were using PPE and their concerns about the stocks and availability of PPE in Wales.

I think you’ve been provided with the witness statement of Adam Morgan, from the Wales Trades Union Congress, and he sets out in his witness statement that, due to concerns about very low stocks of PPE in Wales, measures were taken in healthcare settings including staff being told to be sparing with PPE, to reuse PPE, to purchase their own items that they could use as PPE, like using bin bags as aprons, and staff being encouraged to share single-use PPE.

Is it correct that those concerns were brought to the attention of the Welsh Government in April of 2020?

Dr Andrew Goodall: Yes, that was correct. We had also had other views reflected on concerns on PPE. I remember the BMA, for example, who spoke to me as well as wrote to me at the time, in March, so those frontline experiences and concerns were really important and to respond to it, but also to be able to communicate about the availability of PPE as well.

Counsel Inquiry: Can I ask you then what steps the Welsh Government took in relation – in terms of addressing those concerns that were brought to their attention?

Dr Andrew Goodall: Well, when we were looking back at this in early March, which is when I recall having the concerns raised, it was one of the reasons to start using the countermeasure store, the pandemic flu stock. And that required ministerial authorisation. And we were able to get those out across the NHS and Wales, not just to hospital sites and distribution centres but actually out to primary care and to GP surgeries. So it was really important that we showed that there were other stocks available beyond the local stores.

We had a PPE cell established and were working through choices that we needed to make. We were trying to work on the supply chains that were available. But I think one of the most significant things was trying to give confidence about the availability of the supplies and the stocks that were available both nationally but of course more on a local basis as well. I thought there was some very good practice that was introduced by health boards that we adopted for all, which was communicating to their staff actually about the supplies, which would not be done on a normal basis but were describing the number of days’ supply that were available. And we also translated that at a national level, to be describing that through both ministerial statements but actually being asked those questions in press conferences, for example, where we were very open about the supplies that were available.

So our role was to secure those national stocks, and we did so, but we had to share in a very salutary way, at a national level and very publicly, but we were down on some supply areas, even to a couple of days of supplies. I think, gowns, at one point we were down to only two days of supply left in our central stores across Wales, and then they were replenished within the following 24 hours.

Counsel Inquiry: Can we leave PPE there for now, please, and move on to steps to test patients and healthcare workers in hospital settings. And if we can look at first of all at patient testing. I think on 7 April the Welsh Government issued Covid-19 hospital discharge requirements and, although that was later updated, I think the initial guidance did not require the patient to be tested before discharging from hospital into a residential placement. I think it was on 24 April that that requirement came into force; is that correct?

Dr Andrew Goodall: Yes, the guidance on 9 April reflected the evidence at that time, and yes it was updated on 24 April to make those changes to require a test before a discharge to a care home.

Counsel Inquiry: Do you know why it took until 24 April to make those changes?

Dr Andrew Goodall: I would – I can’t recall that it explains that in my statement. As I recall, we were always taking the very rapidly changing evidence at the time. Groups were working on that. We were trying to issue it into the NHS out to our staff and to our hospital sites to make sure that they were aware of it, but I can’t recall why there was a particular delay for it at that time, because our practice tended to be that we were trying to update the guidance as soon as we were aware of the changes as well. But I can’t recall the area in my statement that explains that.

Counsel Inquiry: Obviously the concerns with or the necessity to test patients before they were discharged into a residential setting was clearly the concern that that patient might be infectious and then would go on to infect the people in that residential setting.

Can I ask you this, community hospitals are not mentioned in the discharge guidance or the letter setting out those changes of 24 April. Was there ever a discharge policy or guidance which required testing of hospital patients before they were discharged from an acute hospital into a community hospital?

Dr Andrew Goodall: I can’t recall that, because they would be within the local health board facilities so patients typically would move across areas because that’s the way in which we function: somebody comes into an A&E department, they move to a ward, they move to the best location, safely of course, for their care.

I can check that for you but I don’t recall that there was different guidance. It was just part of the normal way of the NHS discharge and its arrangements.

Counsel Inquiry: So that would mean, wouldn’t it, that patients wouldn’t be tested before they were moved from an acute hospital into a community hospital? Wasn’t there the same risk of them causing an outbreak within the community hospital?

Dr Andrew Goodall: There’s possibly the same risk. I would just have to go and check what those arrangements are but I just can’t answer the specific question, I’m afraid, without checking that with other colleagues. And I don’t recall it being in my statement either.

Counsel Inquiry: Wales was, we have heard, behind England in relation to both the expansion of testing for asymptomatic healthcare workers and NHS patients, and, again, on the announcement in December of 2020 of routine testing of asymptomatic healthcare workers. What was the reason for the delays in Wales in relation to those testing policies?

Dr Andrew Goodall: The testing policies that were set out were always set in context of the available testing capacity that we had. So as we went through 2020, we obviously saw some very significant changes in the numbers of tests that were available that could be used for all of the different purposes, from diagnosis to surveillance through to those protective measures with our staff as well.

If you look at the outset of the pandemic, back in March and April we only had between 2,000 and 8,000 tests available on a weekly basis. By the time we got to December, those numbers of PCR tests that were available were as high as 130,000, for example, in a week. So you’re suddenly at a very different position in terms of how you can use things.

Counsel Inquiry: Yes, if I can stop you there, Dr Goodall, I wasn’t asking why it took that long to be able to have a policy of routine testing of asymptomatic healthcare workers, I’m asking why there was a delay in Wales in comparison to when those policies were rolled out in England. Was there a specific reason why it took six weeks?

Dr Andrew Goodall: There was a reason at that time. So when England rolled out their asymptomatic testing, they were using LAMP technology where they had laboratory systems in place to support them. From our perspective in Wales, and having had the advice that we wanted to revert to the asymptomatic side, if we had gone down the use of the same LAMP technology and accessed that through the national laboratories, we would have had to have set up and trained laboratory staff with those particular skills, and that would have had to have been dedicated, so that would have taken time.

The game changer for us at that time though was the alternative opportunity to use lateral flow devices. They were still subject to some scientific assessment but we were able, with that clarity, to confirm the start of the testing regime on 4 December 2020, and then we were able to start the roll-out on 14 December.

Ms Nield: All right. Thank you very much.

My Lady, I don’t know if that’s an opportune moment.

Lady Hallett: Of course, yes.

11.32.

(11.17 am)

(A short break)

(11.32 am)

Lady Hallett: Ms Nield.

Ms Nield: Dr Goodall, if we can move on to a new topic, please: the shielding programme in Wales.

The Inquiry understand that the shielding programme was led by the Chief Medical Officer, and my questions to you are based on your oversight role or your role in relation to those logistical issues which arose rather than anything on the clinical side of that programme.

You’ve set out within your witness statement that there were some problems with 13,000 of the initial 91,000 shielding letters going to the wrong address, being sent out to an old address, a previous address. I’d like to ask about some more issues with letters going to the wrong people, if I may, and particularly about shielding letters that were sent to people with Down’s syndrome.

I think the shielding patient list was updated to include adults with Down’s syndrome, and I think those – that decision was made by the four nations’ chief medical officers on 30 September 2020. It appears that the Easy Read letter for people in Wales with Down’s syndrome was drafted in November of 2020. I don’t know that we need to go to that letter but it’s in draft form.

Can you help us with why it took at least a month to send that letter out to those adults in Wales?

Dr Andrew Goodall: I don’t recall why there was a specific delay. We wanted to update the letters in the light of the clinical evidence and the agreements amongst the chief medical officers. I can’t recall me explaining that in my statement and I don’t know if there were any specific reasons why that wasn’t issued. My own view would be that it should have been issued when the chief medical officer changes were made but I don’t know why there was a delay.

Counsel Inquiry: Can we have a look at a letter that was sent to children or under 18s with Down’s syndrome.

That’s INQ000469066.

This, again, is an Easy Read letter. It’s dated 5 January 2021. And it explains that it’s a correction to a letter of advice that had previously been issued.

It doesn’t explain when that letter was previously issued. Do you know whether, when adults with Down’s syndrome were written to, to advise them to shield, whether children or those under 18 with Down’s syndrome were written to on the same occasion?

Dr Andrew Goodall: I don’t know that.

Counsel Inquiry: All right. You maybe can’t assist with that. But it appears that, erroneously, children with Down’s syndrome should not have been added to the shielded patient list but were written to and told that they were needing to shield. It may be that you don’t know how that mistake occurred. Can you assist us with that?

Dr Andrew Goodall: The whole process of the shielding letters was a very technical and complex process. We had never done anything like this in Wales before, about the way in which we were linking a wide variety of databases that were available. There were so many technical processes to go through. We were having guidance that was changing. We were having to update it. Obviously there were patients who were being diagnosed with conditions that fitted within the shielding criteria that changed from even the first issuing of those letters.

So I just would want to describe that kind of context, is there would never have been any intention to send an inappropriate letter or the wrong guidance but it was often happening at pace and it was very technically complex to keep on top of the changing arrangements of patients during that period of time, and I apologise if there is any impact of that, of course. But I hope by correcting that in January we were at least able to make sure that the guidance was clear in terms of how shielding should be applied or not.

Counsel Inquiry: But you can’t assist us with how long it was after the letters were sent out incorrectly to under 18s with Down’s syndrome that this correction was made?

Dr Andrew Goodall: I don’t know. It would feel that there was a delay up until this point reading the letter. What I can say is when the original 13,000 letters had gone to previous addresses, that was addressed very immediately and they were sent out within a few days of that particular error at that time. But I can’t respond on this very specific area, I’m afraid.

Counsel Inquiry: Perhaps we can move on then and look at the use of – the increased use of remote technology, briefly, in healthcare settings. You set out in your statement that the Welsh Government took a number of steps to encourage greater use of remote technology in healthcare settings, both in secondary care and in primary care, using the Attend Anywhere platforms and through other means.

The Inquiry has heard that the increased use of remote technology has the potential to risk exacerbating inequalities for patients who may have struggled to access healthcare through those remote means, and we’ve heard about the “digitally excluded”, that’s the terminology that’s been used.

Can I ask you this, did the Welsh Government take any steps to address that potential risk of digital exclusion of some patients when they were encouraging the greater use of remote technology in healthcare?

Dr Andrew Goodall: Yes, there were steps taken. We already had excellent policies for the use of technology in Wales that reflected on digital exclusion, and of course that would mean that we were using that excellent guidance and guidance throughout this process as well.

There is always a danger that when you are changing the way in which you organise our services – and this was done in an exceptional way, at the – at speed as well – but you still need to retain, of course, those other routes for patients as well. And we wouldn’t have assumed that there would have been comprehensive coverage for these areas. But these were at least a way in which we could, at volume, have alternative ways in which patients could still be seen within the system as well.

By the time, through the pandemic experience, we were in 2021 we were able to make sure, for example, that the digital strategy that was re-issued was able to reflect on those areas and make sure that we were able to understand that not everyone would be able to access the digital technology that we were using as well.

But it was there for professionals to use and was there, in line with a general offer that people would have the right access to those services as well.

Counsel Inquiry: A new topic, please. Can we look at staffing issues within the NHS and, first of all, in terms of staff availability, and the impact of staff absence for illness and other reasons.

Your witness statement sets out that the Welsh Government requested information on staff absence from all NHS bodies from 20 April 2020. Was – that was the first time that that information had been requested I think on a daily basis; is that right?

Dr Andrew Goodall: Yes, requested on a daily basis but we had certainly been using operational information from health boards before that time, and I personally recall using it in some of my press conferences, for example, when I was talking about the NHS experiences. But it was the first time that we’d introduced it as a daily requirement, yes.

Counsel Inquiry: And is the importance of collecting staff absence rates on a daily basis that that gives an idea about the operational impact of that staff absence, so that particular unit is down by this many staff, or this percentage of staff, and that affects how many patients can be seen, and so on and so forth? Would that be correct?

Dr Andrew Goodall: Yes, that’s absolutely the position and, you know, there would be examples across Wales through that data where we would be seeing potentially even individual departments affected so that they were unable to carry out their functions and, you know, it would be a very salutary way in which you had this understanding of the impact on our staff across Wales.

Counsel Inquiry: So if that data was being presented as monthly absences, for example, we’re not able to see the, sort of, day-to-day impact of those absences; is that right?

Dr Andrew Goodall: Yes, typically NHS Wales wouldn’t have been looking at it on a daily basis. It was an exceptional introduction to track the experience of the pandemic.

Counsel Inquiry: And you explain that from 9 August 2020, that workforce absence data was collected once a week or fortnightly depending on the Covid situation. Can I ask why that changed at that point from daily collection, given the information you’ve explained to us about the importance of knowing the daily picture?

Dr Andrew Goodall: I think at that time, in the summer, we had seen a reduction in the Covid prevalence levels. We had hospitals across Wales reporting available capacity and lower numbers of Covid patients. It was an adjustment in respect of removing that requirement from the health organisations, they had it themselves, and obviously an opportunity to re-introduce it, which we did later, of course, when we were going into subsequent waves and seeing those pressures rise again. But it was a moment where there was not the same level of pressure at that precise point during August 2020.

Counsel Inquiry: Can you help us with when daily data collection was re-introduced?

Dr Andrew Goodall: I can’t recall and I don’t think it’s set out in my statement when that was re-introduced again, but I recall using the sickness absence data very regularly myself. I can check that, of course, further to today’s attendance.

Counsel Inquiry: We’ve also heard about returning NHS staff who have either retired or moved to work in different occupations who were added to the temporary or emergency register to assist with the workforce during the pandemic. Did the Welsh Government obtain any data to identify how many of these registrants were in fact deployed or offered roles in the NHS in Wales?

Dr Andrew Goodall: We only had the overall position of those who had returned. We didn’t have any of the local information in the manner in which they were deployed and there were other staff, as well, that we were using in these figures. We were also using students, for example, within their educational placements who were also supporting us, so it was a wide variety of staff coming in through there. But we would be able to report the aggregate position but not specifically where they were being used. That would be more a matter for the local health boards.

Counsel Inquiry: What I’m seeking to ascertain is whether the Welsh Government had any data on how many of the people who had, effectively, volunteered to come back and work in the NHS and had been added to the register, ready to be deployed, how many of them were actually used? Because we’ve heard there were some difficulties with people ready and willing to return to work in the NHS and never receiving a call that they had a place to go and work.

So did the Welsh Government keep any data on that or, indeed, on the students that you’ve mentioned?

Dr Andrew Goodall: I don’t recall on the use. We set up those arrangements, we enabled it at a national level, we made it available, but I would have to go and seek those figures as well. I know Jean would have reflected on some of those in her own evidence on the nursing side. But unless you could take me to a section of my statement, I don’t recall that it’s set out there in the detail that you’re asking me for today.

Counsel Inquiry: No, I don’t think that figure is – does appear there.

So, Welsh Government did, I think, have absence rate information from a TAC science evidence report in February 2023, which you cite in your witness statement at paragraphs 603 and 604, but if I can summarise it in this way, that report from February 2023 indicated that the average number of sick days per employee had remained consistent over the preceding five years and that the leading reason for sickness absence amongst NHS staff was anxiety and stress, and that absence due to anxiety and stress had increased year on year, so the total number of staff absent had not increased but there was a greater weighting towards stress and anxiety as the principal cause.

Can I ask this, was there any national monitoring of staff mental health and well-being undertaken by the Welsh Government during the pandemic?

Dr Andrew Goodall: There was monitoring and there were also actions that we put in place and enhanced. So there was a national scheme, for example, about support for health professionals that was run by Cardiff University. We ensured that that was available, it traditionally being available for doctors but we expanded it to include a wider range of NHS staff.

We were always working with the health boards to understand things that could help. I have to say that a lot of the mechanisms that were most supportive to staff to allow them to reflect on their experiences were overseen locally, whether they were through formal occupational health arrangements or whether they were just peer support mechanisms that were put in place.

But there were some things that absolutely we could do at a national level and we have continued to, obviously, monitor and support those areas. One of my outstanding concerns, given the extended period of time here, is that whilst we are through the pandemic experiences we will still have staff who have experiences that are affecting them right now and it’s really important to be able to keep up those support mechanisms both nationally and on a local basis.

Counsel Inquiry: You mention there that some of the effective forms of support were provided by the local health boards. Can I ask you this: did the Welsh Government undertake any review or evaluation of staff well-being programmes or staff support offers to identify what were the most effective means of support?

Dr Andrew Goodall: I would need to check directly but I recall our workforce group under our planning and response structures were working on those areas. They were helping us with some of the enhancements that we needed to agree – both ourselves and also with ministers as well, but I’d have to check the specific detail.

Counsel Inquiry: Thank you. Could we look, please, at the steps the Welsh Government took in relation to creating a risk assessment tool for NHS staff or, at least, initially NHS staff.

Can we go, please, to INQ000282020.

This is a report of the workforce risk assessment subgroup which is a subgroup of the First Minister’s black, Asian and minority ethnic Covid-19 advisory group.

Can we go to page 23 because this sets out a timeline of the development of the tool.

And so we can see that expert advisory group meetings began on 29 April. On 1 May you, Dr Goodall, endorsed the use of an existing risk assessment tool that had been developed by Aneurin Bevan University Health Board, so that was already in existence, is that right, and it was going to be used across Wales or was that going to be used as the basis for the all-Wales risk assessment?

Dr Andrew Goodall: This was an important area because the correspondence came in on 19 April, but even though we had commissioned the group to do the work and wanted to do it apace we just didn’t want to have a delay and we were aware of the work Aneurin Bevan Health Board had done. So just in a very practical way, just wanted to make that available, roll it out and give all of the health boards and health organisations access to it, pending the production of a template.

So I know that the group, of course, reflected on that template that did exist but they also did their own work to produce a much better and more refined version as well.

Counsel Inquiry: Right.

Dr Andrew Goodall: But it was more to ensure that there was no delay in terms of the support that could be provided.

Counsel Inquiry: So we can see on 5 May the risk assessment subgroup first met and commenced its weekly meetings, and then on 27 May the workforce risk assessment tool was made available as a pdf on the Welsh Government website for immediate use across the NHS and social care.

Can you assist with why it was that the Welsh Government tasked this particular group, the black and minority ethnic subgroup with the development of the workforce risk assessment tool?

Dr Andrew Goodall: There was an opportunity because of the correspondence that had come in from Professor Singhal on 19 April. We have close relationships with our clinical teams, with our groups and with our organisations in Wales and Professor Singhal had written to the First Minister. The First Minister was very clear on this, that he wanted the external support to be very visible. We were able to put in the relevant NHS support, as you would expect, and was very happy to be able to take up Professor Singhal’s offer to lead the work and we were able to balance the NHS representation alongside, some of the expertise we had in Welsh Government and beyond it as well.

But it did form part of the wider arrangements that were put in place for our black, Asian and minority ethnic staff and people and other work that the First Minister had commissioned as well, so I thought it was useful to have that as a package.

Counsel Inquiry: All right. Can we look briefly at the way that that tool developed or to, perhaps, contrast the initial tool, as first published on 27 May, with at the time of this report, which was I think July or June of 2021.

So if we can have a look, please, at page 33. Thank you.

And if we can see the steps are set out there, that the first thing to do is to complete the risk assessment, understand the risk and identify the right actions for you.

And we can see, at the bottom, that pregnant women may be particularly vulnerable and must not work in direct patient-facing roles beyond 28 weeks. And it says:

“Important note – If you are of a Black, Asian, Minority or Ethnic … background and under 28 weeks pregnant.

“New information … indicates that they are at considerably increased risk throughout that their pregnancy and so should avoid face-to-face contact with COVID-19 cases. This means no frontline work where there is sustained community transmission.”

And if we can see page 34, please, this gives the scores for the risk assessment tool. And can we see step 1, please. The box that says “confidential once completed”.

So here we see the risk factors are set out and there if you’re aged between 50-59, 1 point, 60-69, 2 points and over 69 doesn’t appear on this initial iteration. But “Ethnicity”:

“Do you identify as one of the BAME or Mixed race groups as set out in [a] link?”

There is 1 point there. And then we also see there are 1 point for various comorbidities, obesity and family history.

And can we come on, then, to look at what was then the current version on page 37, please. We can see that’s 29 June 2021.

If we can go over the page to page 38, please. Can we see at the bottom pregnancy, the advice has changed now. It says:

“All pregnant women should undertake an individual risk assessment. This is because pregnant women may be particularly vulnerable …”

So the advice for pregnant women has changed.

And if we can go on to page 39, please, and see the scores that are attributed for different risk factors. And if we can see the box in the lower half of that page. The risk factors, there’s now included workers aged between 70-79 and they’re ascribed 4 points if they’re in that age bracket.

So would you agree that failing to include that age range in the initial risk assessment was quite a significant omission?

Dr Andrew Goodall: Yes. I think clearly we knew that age was a factor on Covid. Of course this was the work of the group and we were very happy to take advice on the amendments that needed to be made but, as I look at your comparison, that would feel that was an omission, I agree.

Counsel Inquiry: And we can see that on that page there’s a point for ethnicity still at that stage and still the same comorbidities are set out, obesity and family history. Do you know at what point it was that those changes were made to include older members of the workforce?

Dr Andrew Goodall: I don’t know. Those numbers would have been small across Wales, over those age groups, but I don’t recall the precise date. But this work was done by an expert clinical group with our clinicians across Wales, with workforce support and they were left to develop it in line with the guidance and the evidence, and I thought they really did an excellent job pulling that together and very quickly, given the circumstances as well, but I don’t recall precisely the date, I’m afraid.

Counsel Inquiry: Can you tell us this, was it mandatory for the local health boards to ensure all their staff or workers, whether employed or outsourced, was it mandatory for them to ensure that they undertook a risk assessment for all staff?

Dr Andrew Goodall: It was not mandatory but this was issued to emphasise the importance of it to make sure that people used it. Our overall numbers showed us that not all staff were subject to the review. We know that 71,000 staff of around 100,000 NHS staff around Wales had the review done. We know there were 74,000 across public services that used it because this version, despite its health context, was then used in other sectors as well as a helpful way of understanding risk assessment in other areas too.

Counsel Inquiry: Did the Welsh Government do anything to monitor the local health boards’ compliance, did they do anything to check how many staff were being assessed?

Dr Andrew Goodall: It was left very much as a local operational matter for the health boards in line with their legal and statutory responsibilities.

Counsel Inquiry: All right. I think you’ve been provided with this statement of the medical director of University Hospital Wales. He sets out some concerns about the risk assessment tools and particularly the lack of guidance accompanying the risk assessment tool. He says it was originally only available as a paper document and then subsequently only on the ESR, which I think is the electronic staff record, is that right, where it was not easily found. Had you been made aware of any of those issues with the accessibility of the risk assessment tool for staff?

Dr Andrew Goodall: I was aware of some of the early problems because it was being provided in a static way. We tried to, over time, use the electronic staff record but we also wanted to make sure if people just wanted to download a paper copy and use it, that that was also appropriate as well, and there were 49,000 copies that were actually downloaded which we would assume were used as part of that more practical approach as well.

Counsel Inquiry: Thank you. So finally, lessons learned and recommendations.

You’ve explained to us that you moved from your role as Director General of the Health and Social Services Group in November 2021 and I think your successor in that role will be dealing with formal lessons learned and exercises undertaken by the Welsh Government, but I’d like to ask, if I may, for your personal reflections on the challenges that arose for the Welsh healthcare system in responding to the pandemic and whether you can identify for the Inquiry any areas of the pandemic response where you would seek to do things differently in a future pandemic?

Dr Andrew Goodall: It’s very difficult, even when giving evidence or the range of statements that I’ve already done, to convey how it was and how it felt at the time, with the way in which this virus was developing at pace, the need to turn the way in which we organised the NHS upside down and even approaching areas like being asked to double our capacity which was something that had never been considered in any previous arrangements as well.

And if I could just say on the record, I just thought our staff were extraordinary about the way in which they stepped up and responded to those. They were professional and they were committed and I think that gave an awful lot of assurance to the public about their experiences as they went through this as well.

I think there are learning aspects about that, having mentioned staff. I do think that we need to ensure that when staff are in normal day-to-day business they have the emotional support and counselling that is available to them. Often that can be delivered on a local basis but I do think we do have national responsibilities to ensure that is in place but it does need to be enhanced and targeted when you are going through such a sustained period of time.

We are very used to dealing with major incidents that last for a very limited period of time but not used to this experience of running through a sustained response, that lasted ultimately over two and a half years or so.

I just wanted to recognise and thank, though, our staff for the way they did that and the sustained way in which they did it.

On practical areas there would be three areas I would highlight which I think would be useful to reflect on.

The first one is, I think there is a real need to accept and validate contingencies. The NHS is often having to respond to being productive, efficient, value for money, and all of those are very appropriate. But sometimes there is simply a need to make available and invest in the contingency itself. You can argue that the level of supply that’s been made available for PPE is an example of that. Certainly as we go into a future pandemic the requirement to retain testing infrastructure and flexibility is really important and to have available from day one, that is something that would have affected a number of the choices that we could make and the tests that were available were a constraint on the system.

But you need to invest and have that available and the NHS is very used to always running hot, always using the available capacity, as you’ve seen in some of the figures you were sharing earlier on, bed capacity for example.

And I do think that specifically in this there is a need for us to ensure that we improve the critical care capacity that is available. We had started that before the pandemic but the levels across the UK need to be raised if they are to be able to respond to a future pandemic that emerges where we are still needing to expand critical care in an extraordinary way. So a very practical recommendation, for me, is to make sure we are able to explain critical care capacity and to make sure that that is available.

My second point is that, for understandable reasons, and this is right and proper, there is a lot of focus at the moment on recovering the backlog of the NHS experience. That’s particularly reflected through waiting lists and waiting times, and I know that every area of the UK will make progress on reducing the waiting times that were created as a result of the pandemic and will have their own plans in place.

What I am concerned about is that we have learnt through the pandemic about the impact of underlying health conditions and characteristics of our population and I would say that in a very practical way there needs to be a recovery plan for health that also forms part of those plans, otherwise we won’t be ready for the next pandemic as well.

And then my third point that I would reflect on, which would be on the back of my experience, and enhanced through the pandemic is the best support, guidance and direction we gave was when that was done collaboratively across Wales with organisations, with hospitals, with frontline staff. They were always the best because they were reflecting their experiences and they were informed by their experience and their expertise as well. And in the middle of all of the structures that we put in place, just recognising that that was a really significant thing that made a difference to us was our ability to do things together and in collaboration which you would expect, of course, from the NHS on the one hand, but sometimes organisational boundaries can get in the way and it’s really important to recognise that we did something that was very exceptional in that capacity during pandemic response.

Thank you.

Ms Nield: Thank you very much. I have no more questions for you, Dr Goodall.

Lady Hallett: Thank you, Ms Nield.

Mr Wagner.

Questions From Mr Wagner

Mr Wagner: Good afternoon, Dr Goodall. I represent the Clinically Vulnerable Families, a group which advocates for the interests of the clinically vulnerable, the clinically extremely vulnerable and their families.

The first topic I want to ask you about, please, is IPC, infection prevention and control, measures in healthcare settings. Do you agree, Dr Goodall that it was often necessary for clinically vulnerable patients to visit hospital in person more frequently than other, sort of, non-clinically vulnerable patients?

Dr Andrew Goodall: Just because of their nature, yes, I would accept that they would have to have a contact with health services more frequently than the general population, for example.

Mr Wagner: And do you agree that by definition they were more at risk from Covid-19?

Dr Andrew Goodall: They were more at risk from Covid-19. It, of course, is one of the reasons why we introduced criteria in the shielding approach, for example, in Wales and the wider UK.

Mr Wagner: At paragraph 293 of your statement you say that in November 2020 the Nosocomial, that is hospital-acquired, Transmission Group, in Wales found that hospital-acquired transmission was increasing in line with community transmission rates, that proper use of PPE in hospitals was limiting the spread between staff and patients but that transmission was happening from patient to patient. Do you recall that finding and that reference in your statement?

Dr Andrew Goodall: I recall the finding and I recall that part of my statement as well.

Mr Wagner: Given that those findings are November 2020, what steps were taken to provide additional protections for clinically vulnerable people?

Dr Andrew Goodall: The arrangements were put in place through the Nosocomial Transmission Group. In the report you were describing actually a number of measures were set out that would make a difference to the general infection prevention and control arrangements within our individual hospitals and sites across Wales.

We obviously, at this point, were still retaining shielding approaches and they were there to guide a general approach but of course that would still mean that people could be exposed to the hospital environment. The general infection procedures that we had in place would have been expected to be there for all of our patients, including those who were the most vulnerable as well. But on a local basis, health boards were able to ensure that they were adhering to those policies and also ensuring that they were able to track patients who were needing to come into our facilities as well.

Mr Wagner: So you’ve spoken about general measures but was anything specific done to put a ring of protection around the most vulnerable who would be most at risk of Covid-19 if they caught it in hospital?

Dr Andrew Goodall: We had put in the shielding mechanisms that allowed us to highlight those areas. Of course we were trying to ensure that any patient coming into our facilities would feel that they were doing so and were safe as well as ensuring that our staff were able to respond in that way. I don’t recall anything specific, nor in my statement, that says so but the range of measures that were introduced, not least in that November 2020 report, would have been intended to show that there were further actions that could take place.

Mr Wagner: So the answer is no, there was nothing specific to that group done?

Dr Andrew Goodall: I don’t recall anything specific. I could check, but I don’t recall it at the time.

Mr Wagner: Thank you.

In late October 2021 you were informed that nosocomial transmission rates remained particularly high between patients, as opposed to between staff and patients, so the same issue, and that in Wales they were higher than Scotland and arguably higher than England.

At that stage, in October 2021, almost a year later, was any particular action taken to put that ring of protection around clinically vulnerable patients because of their particular risk?

Dr Andrew Goodall: As I said earlier, the Nosocomial Transmission Group were still reviewing experiences. There were further measures that the group had introduced: from what had been a guidance role and monitoring, they had actually introduced support, through their group mechanisms, for outbreak management, alongside Public Health Wales and others, but I don’t recall anything specifically on the clinically vulnerable in the manner in which you’ve asked the question. So it would be no to – the specific answer, but, to the range of actions that were still in place, they were, of course, still being overseen by the Nosocomial Transmission Group.

Mr Wagner: So no again. In hindsight, do you accept that, given the particular risk to clinically vulnerable patients, it wasn’t enough just to put in general measures, more attention should have been put on putting that ring of protection around the clinically vulnerable in particular in healthcare settings?

Dr Andrew Goodall: Yes, in hindsight, and given your questions, I would agree that they are a group who would have taken additional confidence and assurance about measures that were wrapped around them. I can’t describe to you whether health boards, because they had access to the shielding list, did put in local measures because they were operationally responsible, but I do accept if we had made that clearer at national level then that would have helped with the confidence of people coming into our hospitals to have care.

Mr Wagner: Not just confidence but also the safety?

Dr Andrew Goodall: Safety and confidence, I agree, yes.

Mr Wagner: In September 2020 you advised that visitors to health and care facilities should wear face coverings and that staff who provide direct clinical care of patients should wear FRSM masks, that is surgical masks. Do you recall that, in September 2020?

Dr Andrew Goodall: I don’t directly recall it but I was sending out a lot of guidance as well, and that would be the kind of guidance that I would have issued, so I accept that that happened in September.

Mr Wagner: Okay.

For the Inquiry’s reference, it’s INQ000392008. I don’t think it needs to go up.

Is it right that the reason staff providing clinical care were required to wear those FRSM masks rather than just face coverings was as an IPC measure, that is to prevent the spread of Covid between staff and patients?

Dr Andrew Goodall: That would be one of the reasons for it. Obviously clinicians would give advice, and we would be in line with the UK guidance, but, yes, that would be one of the reasons for wearing it.

Mr Wagner: Was any consideration given to asking patients to wear masks rather than face coverings, given the relative benefits of masking and the known risk to patients of – the known risk of patient-to-patient spread of Covid-19 in hospitals?

Dr Andrew Goodall: I don’t recall consideration. You would have to ask colleagues who were in the UK infection prevention and control group. And I don’t know whether that would have been reflected in our Nosocomial Transmission Group arrangements but we were always adhering to the guidance that was available, and I don’t recall any guidance under consideration that was about providing that level of FFP3 masks to patients, for example.

Mr Wagner: I’m sorry, I was asking about FRSM masks, not FFP3. Does that change your answer or not?

Dr Andrew Goodall: Potentially, but I would still say we were issuing the guidance in line with the advice from the UK infection prevention and control, and they were aligning it with the international evidence at the time as well.

Mr Wagner: Thank you.

I want to move on to the shielding programme and how it was designed. You’ve highlighted an undated integrated impact assessment on the impact of shielding on vulnerable patients as an important review which was undertaken of the shielding programme. Do you recall that?

Dr Andrew Goodall: Yes, there was an integrated impact assessment that was done of the programme, and there was also one that was done of the food delivery process as well.

Mr Wagner: Do you agree that this involved an assessment of providing the support which was implemented, for example, food boxes, medicine deliveries, to those on the shielded list rather than or instead of a full analysis of the impacts of shielding on the clinically extremely vulnerable or any analysis of the appropriateness of the shielding measures selected?

Dr Andrew Goodall: I agree that what it wasn’t doing was determining the level of impact, for example, on transmission of the virus and whether it had prevented that. It was about the practicalities and making sure that people who were asked to shield did not feel isolated in respect of the contact and certainly the delivery of the food boxes as you describe.

Mr Wagner: Was any wider review undertaken of the shielding programme as a whole, including points like impact on the shielded and the general appropriateness of the design of the programme?

Dr Andrew Goodall: There was some work that was done by Swansea University, where they were looking at a wider range of issues and particularly trying to look if there was any evidence on the impact on the virus but also allowed them to reflect on some of the experiences, such as isolation, as well.

Mr Wagner: But that review wasn’t undertaken by your department or your government?

Dr Andrew Goodall: That wasn’t, no.

Mr Wagner: Should such a review have been undertaken, given the very significant impacts of the shielding programme on a large number of people?

Dr Andrew Goodall: Whilst we did those early reviews – and, you are right, ultimately we were providing shielding advice to about 138,000 people – that would be useful, to have some understanding of the shielding impact beyond those and be able to track it, certainly for future pandemics as well, and I hope the Inquiry will be able to give some reflections on that too of course.

Mr Wagner: Will your government be doing any kind of review of that kind?

Dr Andrew Goodall: I’ve been out of the NHS role for three years on the shielding side. I’m not aware that there is a review being undertaken, just through my permanent secretary experience, but I can certainly check on that.

Mr Wagner: Okay, thank you.

Finally, I want to ask you about the clinically vulnerable. And when I refer to the clinically vulnerable, I’m not including within – I’m talking about the wider group, that would also include the clinically extremely vulnerable but the larger group of clinically vulnerable people.

In a briefing note prepared for the First Minister on 20 March 2020 it said that, after securing the needs of the shielding population, a team would work on phase 2, identifying wider vulnerable groups and that potential support could be then be provided to them.

This is referred to in paragraph 7-8 of your statement. I think it gives the wrong date for the briefing.

That wider group of clinically vulnerable people, although not formally shielded, were still provided with stringent advice to keep themselves safe. Are you aware of any steps that were taken or put in place to give additional support to that group, rather than just generalised advice? For example, access to medication, avoiding public spaces, being able to explain their vulnerabilities to employers?

Dr Andrew Goodall: I know that when the chief medical officers were working through their criteria, there was a worry more generally about other people who, if exposed to the virus, would likely be more susceptible.

I know that from our approach that we were doing back in March 2020, and we were speaking very rapidly to local authorities and also to the third sector across Wales, we did put a focus there that, despite these particular individuals that we were putting arrangements in, that we did want there to be a wider understanding of others who would still be potentially exposed and would have to follow the guidance as well.

But I can’t directly respond to your question on the practicalities, but I do recall the third sector conversations and I know that both officials and the sectors themselves wanted to make sure that as much support could be given as was possible.

But the food boxes were only accessible for those who were in the higher level of vulnerability.

Mr Wagner: CVF, the organisation I represent, are aware from its members that, in practice, many clinically vulnerable people informally shielded to protect themselves due to the level of risk that they felt they were at. But without that statutory support.

Did NHS Wales, as far as you’re aware, make any effort to monitor that wider group of the clinically vulnerable and their response to the pandemic?

Dr Andrew Goodall: Not as far as I’m aware at the national level. Local health boards would have been more plugged in to the local operational arrangements and the distribution that was happening, and they may well be able to give some evidence that would explain that better.

Mr Wagner: My final question. We know that a significant proportion of those who died or suffered adverse effects from Covid-19 were clinically vulnerable but not clinically extremely vulnerable. Do you agree that a better understanding of the way they behaved and how they managed their risks could have informed the delivery and the design of more effective guidance and support for that wider group?

Dr Andrew Goodall: I agree. That would be additional information that would help us, and not just in respect of the experience we’ve been through but in planning for a future pandemic as well.

Mr Wagner: Thank you.

Lady Hallett: Thank you, Mr Wagner.

Ms McDermott.

Questions From Ms McDermott

Ms McDermott: Good afternoon, Dr Goodall.

Today I’m asking questions on Covid Bereaved Families for Justice and the Northern Ireland Covid Bereaved Families for Justice.

My Lady, if I may, I’m going to take the questions in reverse order as they appear.

Lady Hallett: Certainly.

Ms McDermott: Dr Goodall, in your statement of evidence, an initial section entitled “Broad overview and reflections on the Health and Social Services Group and NHS Wales activities during the pandemic period”, at paragraph 14 you talk about personal reflections, and under that rubric, at (h), you state:

“… it was an ongoing challenge to ensure that governance arrangements recognised the equal status of each of the four nations, and with the establishment of the UK Health … Security Agency there was a concern that the forum in which the UK Government engaged with [the] devolved nations was … adjunct to the main decision-making mechanisms.”

Now, today you’ve already mentioned in your evidence, this morning, that there was a concern in the early stages that the – early signs of planning for England having an impact on the supply lines for Wales, but you stated that that didn’t really happen in practice and so that’s probably something different.

My question, and I wish you to focus on this, is that in your statement and in your personal reflections you specify the ongoing challenge to ensure that the governance arrangements recognise the equal status of the four nations, and so my question is this.

Can you give some specific examples of the challenges that you refer to?

Dr Andrew Goodall: Yes, so I think they were usefully laid out in the email that I was exchanging in March. So, firstly, in respect of PPE distribution, with all of the positive and good intentions to make sure that there was a UK-wide supply line, and internationally, the danger that, in implementation, that became more about responding to NHS England than it did about the respective NHS arrangements in Northern Ireland, Scotland and Wales. Of course I was concerned for Wales but I was in discussion with others. We were particularly concerned at the outset at the way in which ventilators may be distributed, and going to be in line with the geographical transmission. And with it having started in the south east, and we were a few weeks behind, there was a genuine worry at the outset that the ventilators would go where initially needed rather than where needed over time, and, by the time that you are ending up in the top left-hand corner of Wales, the reality that actually there is nothing left to support those populations. It was really important that we were able to articulate that and, as I said earlier, I did feel that in escalating these concerns, although they were happening practically, that we were able to work that through with colleagues more generally as well.

And of course, as we generally make arrangements for the NHS, there is something about the way in which we understand the normal business of the NHS in operation as well, that there is, generally speaking, good contact across the NHS, and I deployed some of that to my advantage during the pandemic itself of course.

Ms McDermott: That point takes me to my next question in terms of the contact and communications, and I wonder did you discuss the perception that you had with your counterparts in the devolved nations and whether or not there was any credibility or evidence giving rise to the concerns that the devolved nations and your counterparts may have had?

Dr Andrew Goodall: Yes, I was having discussions, we met regularly and in particular during the first wave arrangements and the second wave arrangements as well. But, yes, there were clearly procurement arrangements that had been put in place that were labelled as “NHS England” and protecting supplies for the NHS in England. And that wasn’t just a worry or concern, it was the way in which suppliers were being engaged with as well.

So that was the thing that, you know, we needed to keep an eye on for procurement reasons, but it did affect some of our later reflections as well.

Ms McDermott: And I suppose then taking you to – moving forward and thinking about lessons learned, what was the impact of this issue and what lessons can be learned from it to draw forward and taking away, perhaps, a little bit from the direction towards NHS England?

Dr Andrew Goodall: Well, I think that when we are going into this again at a UK level, to be clear where we are making arrangements on behalf of the whole of the NHS rather than just the structures that we have in place that separate NHS Scotland from NHS England and from Wales. I think that’s really important for us to work through.

What it created at the time was anxiety, in a very rapidly moving position, with modelling that was telling us about the level of beds that were going to need to be available, and a real worry and fear that we were not going to be able to accommodate the patients with the right equipment or consumables that we needed as well. So there were genuine concerns at that time and there was fear at that stage. But I hoped that in the relationships we had and with the contact we had, we were able to de-escalate those concerns pretty rapidly, but it was absolutely a worry in the middle of March to the end of March.

Ms McDermott: Thank you, Dr Goodall.

I want to take you to a different topic now, and it’s in relation to the support for the bereaved families in Wales. In your statement you refer and note the nosocomial Covid-19 programme interim learning report, which was dated March 2023, and you rehearsed the key learning areas identified therein, which included briefed support services, which should be proactively made available in Wales to all families.

Now, in a final report – and I’m not going to take you to it, but for the reference for the Inquiry it’s INQ000501402 – that report, the final report was published in August 2024, and it’s obviously after you submitted your statement to the Inquiry.

Now, the final report identifies that bereavement services should be proactively signposted and offered to all families who are experiencing grief following the loss of a loved one. My question is this, how is the NHS in Wales ensuring that such support services are being proactively signposted and offered?

Dr Andrew Goodall: I think that question probably is better responded to right now by my successor, who obviously is giving evidence this afternoon. I’ve not been in the NHS role for three years. We did put in a bereavement strategy that was much clearer, even during the pandemic, in October 2021. I agree with the points that have come out of the learning report as well. It’s really important that that very personal experience is provided.

The NHS is a service of volume but it always has to make sure it is an individual experience going through it as well, and I think that we can absolutely improve the experiences for patients who are accessing our services and I think that report will be very important in terms of the way forward for the NHS in Wales as well.

Ms McDermott: Very grateful, my Lady, those are my questions.

Lady Hallett: Thank you, Ms McDermott.

Ms Gowman.

Questions From Ms Gowman

Ms Gowman: Doctor, I ask questions on behalf of Covid Bereaved Families for Justice Cymru.

You told the Senedd in November 2020 that the NHS in Wales was “stuck by the fabric of our hospital buildings and healthcare settings across Wales”. You acknowledged at that time that the underlying issue of ventilation was a factor that still needed to be explored and you were hopeful that more could be done.

Why had there been a failure to improve the NHS estate in terms of upgrading hospitals to have better ventilation? And what was done immediately to improve ventilations in hospitals following your statement in November 2020, as Wales headed into the second wave?

Dr Andrew Goodall: The estate in Wales is very mixed and we review the backlog of maintenance requirements. We also have health boards in Wales who come forward with their own local plans for how they wish to replace and improve local capacity. Sometimes that can improve new hospital builds. So one of the ways over the years in which we’ve been able to do that has been able to improve the hospital accommodation by new hospital builds.

But our capital that is available to us every year, it’s about 300 million a year, is quite limited in its ability to do that at pace and scale across Wales. So ultimately some of the choices that have been made both by health boards and by Welsh Government in support of their decisions would have been constrained by the available funding and finances as well. And I think that will continue to be a problem into the future.

On the evidence itself, in respect of ventilation we did have expectations that health boards had to do the best they could within their available facilities, and I know the evidence that Professor Kloer gave yesterday was very powerful in terms of giving an operational insight to what that meant, that there would have been some real constraints for ventilation, particularly during the winter months, for some of our oldest and, you know, ageing estates in Wales, that were, you know, decades old. So that would have been problematic.

On the ventilation side, whilst health boards would have had that individual and operational responsibility, we did have an estate infrastructure group. We also had other planning and response mechanisms that were available to work through this guidance, and by this point we also had the Nosocomial Transmission Group that was in place, because we had introduced that in May 2020. But I can’t, unless it’s clear and available in my statement, put my hand on something that says precisely what happened after November 2020, I’m sorry.

Ms Gowman: And to follow on from that point, the national nosocomial end of programme learning report that we’ve heard about, this was a programme designed to support the NHS Wales organisations to conduct investigations into patient safety and incidence of nosocomial Covid, and that was published in August 2024, and we can see in that end of programme learning report that issues pertaining to the NHS estate in fact persisted throughout the pandemic.

Does that not suggest that insufficient steps were taken to mitigate the concerns relating to the NHS estate, despite the fact that you had raised those concerns in November 2020?

Dr Andrew Goodall: It may suggest that, I agree, but it may also, in a very practical way, show the difficulties of individual hospital sites complying with those ventilation requirements, just because of the physical nature of their estate as well. And some of the things that would have changed those would not have been possible during the pandemic response.

And equally, some of the answer to some of those older buildings may well just be addressed by, for example, building a new hospital.

Ms Gowman: Yes.

Dr Andrew Goodall: And that would not have been something that was possible during the pandemic response anyway.

Ms Gowman: But it was important, I’d imagine you accept, to recognise the limitation to appropriately risk assess and to put in place whatever measures could be put in place in light of the limitations around the infrastructure; do you agree?

Dr Andrew Goodall: I agree that would have been an expectation, and operationally we would have expected health boards to put in a whole range of infection control measures to mitigate, but to do it on the basis of the wards and the buildings and the facilities that they had; that’s why we couldn’t control that at a national level, it had to reflect the local insight and experience.

Ms Gowman: But you’re not aware of any national oversight in respect of holding health boards accountable for what they were doing on the ground?

Dr Andrew Goodall: Through the group mechanisms that I gave you, through the planning and response cell arrangements, which had health board representation, and as I said there was an estates infrastructure group that usefully had been dealing with a number of the areas, including the original issues around oxygen supply, for example, and that was retained through the pandemic response as well.

Ms Gowman: Staying with the end of programme learning report, do you accept the report fails to deal with key issues, for example it fails to investigate causes for cluster outbreaks on wards and the closure of primary and emergency care services due to cluster outbreaks?

Dr Andrew Goodall: It may not have been the purpose of that report but I agree that they are described as not being handled and dealt with. But that of itself would be useful information still to find even if it’s through a different mechanism.

Ms Gowman: Finally on nosocomial transmission, many of our members witnessed healthcare workers failing to adhere to IPC guidance with regards to PPE. This is also recognised by Steve Ham, the chief executive of Velindre University NHS Trust, who discusses in his statement what he’s called compliance/complacency fatigue amongst staff. What measures were taken at national level to ensure the NHS health boards and trusts were properly enforcing the use of PPE by healthcare workers?

Dr Andrew Goodall: Firstly, to make sure that the national guidance was provided, the PPE guidance was always issued at a UK level and of course then transmitted and communicated within our Welsh structures, so just important that we were able to do that very regularly.

Secondly, to learn from outbreaks that occurred, initially in the first months of our experience, Public Health Wales had a very prominent role on that. Later, even though Public Health Wales continued to give that support, we used the Nosocomial Transmission Group for doing that. And the reports that the nosocomial group produced, including those attached to my statement, we spoke earlier about the November 2020 guidance. That was itself clear that we still had concerns about some of the adherence of staff, particularly in areas that were in non-clinical areas, rather than the clinical areas themselves.

So we focused on that. We met with unions. We met with our partnership forum and we tried to make sure that as much support nationally was available on that guidance but, ultimately, that became a matter for health boards operationally to deliver, and for them to work with their staff, of course, to wear the appropriate PPE, as I would expect myself.

Ms Gowman: Thank you, Doctor. My next topic is capacity and you’ve touched upon this at length in questions from the CTI. But just picking up on a couple of points. Your evidence has touched upon the fact that there were patients who may, under normal circumstances, have gone to critical care but instead were cared for elsewhere in hospital on various hospital wards. The intensive care expert Professor Summers gave evidence as to the importance of care being delivered on a critical care unit due to factors such as staffing ratios and the experience and qualifications of the care providers.

Do you agree that patients in Wales who were critically ill but managed outside of critical care were put at risk?

Dr Andrew Goodall: Anybody who was not in the normal critical care environment may have been exposed to risk. I’m not aware of any experiences that were described where that was the case through the health boards or that were brought to my attention. But, clearly, with the really exceptional arrangements we put in place to go beyond our historical capacity of 152, it’s a very different experience to be caring for somebody with a normal nursing ratio in a critical care ward than it is in a theatre that has been set aside that can be used that is providing good quality care but outside of that environment as well.

I think it’s important to recognise, and this is not for invasive ventilation, there were patients who were able to be cared for in a different way with some of our respiratory wards and supported the use of CPAP machines as we learnt about that treatment. But I do agree with the basic point which is we would wish to retain as many patients as possible in a traditional critical care unit environment even if that unit is expanding.

Ms Gowman: And similarly, the Inquiry has heard evidence on the importance of staffing ratios in critical care and that critical care capacity is not simply a question of available beds. The evidence of Jean White was that staffing ratios were diluted in Wales and this was particularly acute during the second wave.

Do you agree that that in itself demonstrates that the critical care capacity in Wales was stretched?

Dr Andrew Goodall: Well, bluntly, I would say the critical care capacity in Wales was stretched, I agree, and not just because of the ratios but because of the exceptional efforts of the staff and the way in which they were being asked to manage these patients, but the staffing arrangements were really important. We were looking to expand based on the pressures that we were experiencing. I know Jean, in her evidence, also commented on the moments when we were concerned about some of those nursing ratios and actually introduced national guidance to step back from some of the more extreme ratios that may have been used but were never used in Wales.

Ms Gowman: And finally on this point, and drawing together the consequences of that stretching, IFF Research that the Inquiry has received demonstrates that healthcare workers felt pressure to make decisions about critical care. This is supported by expert evidence which has been given to the Inquiry that clinicians were likely making conscious and unconscious decisions on the ground not to escalate to critical care in times of stretched capacity and resources.

Did your analysis as to the saturation of critical care in Wales consider or take into account that clinicians might have been making different decisions about escalation of treatment than they would have been in peace time?

Dr Andrew Goodall: It would be easier to receive that as direct evidence from the clinicians concerned. I know that was one of the worries about our moral and ethical group which was reviewing the criteria that we wanted to apply. Certainly wherever a critical care bed was asked for and when it was beyond the capacity of the critical care department itself, the advice I received was that we were always able to accommodate those patients. But you are right that clinicians can make individual decisions based on the pressures that a hospital site, for example, is under, and we were under very significant pressures during the first wave, particularly in April, and we were under highly significant pressure in the second wave, particularly in December and as I remember it, in a very difficult place in January 2021.

Ms Gowman: If the potential for conscious or unconscious decision-making and the impact of that on escalation of treatment was something that was a concern of the ethical group, what did the ethical group do about it to mitigate those risks?

Dr Andrew Goodall: I don’t know. I would have to check on that. On an ongoing basis they were issuing support and guidance into it at that stage and looking to give support. I know that the technical advice group also produced some supporting information for our workforce in Wales, basically on the judgments and the risks that they were being exposed to, and I haven’t got it to hand but I’m very happy to give that reference to the Inquiry because it was a way in recognising that personal impact on clinicians making decisions as well.

Ms Gowman: Thank you, Doctor. Moving on to the use of field hospitals. You say in your statement that the use of field hospitals was limited and that this was one indicator of what you deemed to be the success of measures taken by the Welsh Government.

You gave evidence during Module 2B that the decision to discharge patients into care homes without a Covid-19 test was a ministerial decision intended to “help the NHS create capacity”. Why didn’t you free up capacity by discharging vulnerable people into step down facilities as opposed to care homes? Couldn’t the use of field hospitals have served that purpose?

Dr Andrew Goodall: So, firstly, the advice was about expediting discharge more generally rather than only to a care home environment. Many of the patients who were discharged were actually discharged to a home environment and with support. In March, when that guidance was being issued, and even in April, we were still developing plans that we could rely on for field hospital use, some of the beds that were being extended and made available during April weren’t directly in field hospital facilities, so at that stage we weren’t able to use the field hospital facilities because they were still under construction in most of the health board areas as I recall.

Ms Gowman: Is this something that happened subsequently then, field hospitals as step-down facilities?

Dr Andrew Goodall: Well, field hospitals were used as step-down facilities for individuals who had been through a Covid pathway. I think one or two of the health boards may have used them for general step down when they were under more pressure but they were never used for the acute receipt of the patients and the model that we developed in Wales was always about trying to deal with patients once they were ready to move to that alternative environment as well.

Ms Gowman: And in a similar vein, and you’ve been asked about the report in November 2020, it was recognised at that point that nosocomial transmission in Wales had increased, a number of concerns regarding implementation of IPC measures in hospitals and a lack of available space to create low risk or green sites in the Welsh hospitals. Again, why weren’t the field hospitals used to mitigate against those challenges?

Dr Andrew Goodall: The field hospitals were temporary facilities. They were set up as a contingency to be available. We had other capacity available within our hospitals to use at that time and even during November into December 2020 there was still available capacity within our hospital systems and we did allow health boards, of course, to make some of their own decisions about those areas, but due to their temporary nature, for general patients there would have been some limitations on their use.

They were always there as an ultimate contingency because we had wanted, if we’d seen the modelled levels coming through, to make sure every patient, whatever the workforce practicalities we needed to put in place, would at least be accommodated in a bed.

So I just think it was for a different purpose and in that autumn period we still needed to retain the field hospital flexibility because we were seeing the numbers rise again.

Ms Gowman: Isn’t another interpretation of field hospitals being under-utilised that the resources were not being exploited to their full extent rather than they were not needed?

Dr Andrew Goodall: I would say that the reason that we didn’t use field hospitals as originally intended was because we were able to have confidence in the lockdown measures that occurred when that was announced in the last week of March and that we started to see the change in the transmission across Wales. If lockdown hadn’t happened the field hospitals could well have been in use and we may well have ended up seeing scenes that were similar to those that we were seeing from Italy, for example, and other European countries and we had wanted to mitigate that.

Because we had never locked down the whole of our society, we wouldn’t have had the confidence that we were going to see that kind of impact and that’s why we needed to have that preparation available.

For future, we would have learnt an awful lot more in a different pandemic about using available capacity in a different way, the field hospital model and how it could be used. And I know our clinicians would have their own views on whether they could be used for other alternative mechanisms as well.

Ms Gowman: Moving on to my final topic, access to GP services. At paragraph 738 of your witness statement you state that you were not aware of any specific difficulties with patients using the video consultation service that was rolled out to all GP practices in Wales.

Many of our members reported GPs being hard to get hold of and not offering virtual appointments when they should have been, and these concerns were widely reported in the press up to as late as September 2021. In addition, the Public Services Ombudsman for Wales raised several issues with GP services in Wales including a failure to provide virtual appointments for vulnerable individuals, and service failures in lack of face-to-face appointments.

With those comments in mind, do you agree that – given there were clear difficulties with the services that these were issues that you should have been aware of?

Dr Andrew Goodall: They were issues that we were made aware of in the way in which you said. The operational use of the systems were for every individual GP practices, they were supported by their health boards to implement that. We wanted to make sure that the platform was available at a national level to give that flexibility. Primary care was an essential service and it was really important that it was kept open throughout the pandemic.

I do know of moments when GPs themselves had problems either with their branch surgeries or in fact with an individual surgery being unable to open because of staff off sick with Covid, for example, but I believe that the technology should be used but I think there should also be a route for patients to access face to face when it’s required also.

Ms Gowman: Finally, we know no formal impact assessment was undertaken for digital inclusion and considerations of recommendations on the elderly, disabled and those with language or digital access issues were not always explicit in the submission of advice or recommendations to the Minister for Health and Social Services. Given that these were considerations that had been part of Wales’ strategy for digital health since as long ago as 2015, shouldn’t they have been easily identified? Shouldn’t they have been at the front and centre of advice to ministers?

Dr Andrew Goodall: Yes, they should have, you’re right, the previous strategies were there, we also incorporated that in the revised digital strategy in 2021 also in those early weeks and months. We were moving so rapidly on a range of different areas that some of those impact assessments were not done as we would wish but we were able to ensure, as we went through the pandemic, that those were discharged as we went forward and, as I said earlier, the concerns on the exclusion areas, digital exclusion in particular, I hope that we were able to ensure at least another platform was available, that there were other operational routes for patients to have access as well.

Ms Gowman: Thank you, Doctor, those are my questions.

Thank you, my Lady.

Lady Hallett: Thank you very much, Ms Gowman, very grateful.

That completes the questions we have for you, Dr Goodall. I apologise, again, for having to bring you from yesterday to today and also, obviously, for the imposition that the Inquiry makes upon you and your department and all your colleagues. So thank you very much for your help. And I promise to make sure we get through Ms Paget’s evidence today so she doesn’t get adjourned overnight.

The Witness: Okay, thank you, my Lady.

Lady Hallett: Thank you.

(The witness withdrew)

Lady Hallett: Very well, I shall return at 1.45.

(12.45 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: Mr Mills.

Mr Mills: My Lady, may I call Judith Paget, who can be sworn.

Ms Judith Paget

MS JUDITH PAGET (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: I’m sorry if we’ve kept you waiting, Ms Paget.

Ms Judith Paget: No, it’s fine.

Lady Hallett: I suspect you’ve been here since this morning, haven’t you?

Ms Judith Paget: I have, my Lady, but it’s absolutely fine.

Lady Hallett: Weren’t you here when I arrived?

Ms Judith Paget: I was.

Lady Hallett: I’m really sorry that you waited so long.

Ms Judith Paget: No problem.

Mr Mills: Your full name, please.

Ms Judith Paget: Judith Ann Paget.

Counsel Inquiry: Mrs Paget, you have provided two statements to this module of the Inquiry.

For reference, they are INQ000486014 and INQ000485240.

Ms Judith Paget: That’s correct, Mr Mills.

Counsel Inquiry: You are the CEO of NHS Wales and the Director General of the Health, Social Care and Early Years Group?

Ms Judith Paget: That’s correct.

Counsel Inquiry: The latter was, during the pandemic, known as the Health and Social Services Group?

Ms Judith Paget: It was.

Counsel Inquiry: A little bit about your background. From June 2014 to October 2021 you were the CEO of Aneurin Bevan University Health Board?

Ms Judith Paget: Correct.

Counsel Inquiry: After which, in November ‘21, you were appointed as the interim CEO of NHS Wales?

Ms Judith Paget: Correct.

Counsel Inquiry: A role to which you were permanently appointed in June 2023?

Ms Judith Paget: That’s correct.

Counsel Inquiry: Can we start, please, with the data NHS Wales received about Covid-19 infections and deaths during the pandemic.

Let us deal with NHS staff first. At paragraph 448 of your statement you say that the Welsh Government regularly received data on the number of NHS staff who were absent for reasons due to Covid-19, but that data did not, however, record whether the member of staff had contracted Covid-19 whilst at work; is that right?

Ms Judith Paget: That’s correct.

Counsel Inquiry: In the same paragraph, you say the Welsh Government does not hold or publish official or verified data on the number of NHS staff who died from Covid-19.

Ms Judith Paget: That’s correct.

Counsel Inquiry: Please can we have a look at INQ000475209.

This is the statement made by Professor Kloer on behalf of Glangwili General Hospital who the Inquiry heard from yesterday. At paragraph 50 we read that the hospital experienced one staff death attributable to Covid which was acquired within the community and not whilst at work.

Before I ask you about that, let us also look at INQ000480136.

This is a statement from the University Hospital of Wales, and at 62 we read that the health board was able to say that they sadly lost six members of staff who died following contracting Covid-19. Three of those worked at the hospital, one a surgeon, one a theatre assistant, and one a nurse.

It’s a small sample, of course it is, but it would appear, would it not, that staff deaths were being recorded by the local health boards?

Ms Judith Paget: Well, I think my view would be at a local health board level they would know whether they’d lost members of staff and that would be correct. What I understand to be the case was that there was no official mechanism for the number of deaths to be recorded and reported officially to Welsh Government and recorded on a Welsh Government system.

My understanding is that Welsh Government relied on the ONS data in order to advise them on the number of healthcare workers who lost their lives during the Covid-19 pandemic.

Counsel Inquiry: We’ll look at the ONS data in respect of patient deaths in a moment, but can I ask you this, please. Do you see the absence of an official mechanism for the number of deaths to be recorded and reported officially to the Welsh Government as being a serious issue?

Ms Judith Paget: So I think my view would be that the ONS data capture is well established and a reliable mechanism for recording information, and so I can understand completely why Welsh Government at that time relied on that as the evidence source. I think that in future arrangements it clearly would be helpful to know and understand the impact and recording of staff impacted by Covid-19 or any other pandemic, but I think that what would be really important to understand is the reliability of that data because clearly organisations will be reporting their understanding. You might have a member of staff in your organisation who sadly lost their life in a community or in a neighbouring health board, so it’s really about making sure that any data capture system can be relied upon.

Counsel Inquiry: Can I ask you about patient deaths. At your paragraph 450 you say that the Welsh Government did not produce its own Covid-19 mortality data during the pandemic, instead relying on two sources. What were those two sources, please?

Ms Judith Paget: The one source was a data capture that Public Health Wales had introduced and I recall this because obviously previously I was the chief executive of Aneurin Bevan University Health Board. I recall that Public Health Wales asked us to ensure that on a daily basis we completed a pre-prescribed form to provide them with details of any person who’d died in our care in the previous 24 hours, which we did, and sent that to them on a regular basis.

And then the second data capture was, again, the ONS survey data.

Counsel Inquiry: Can I just ask you about the first, then we’ll come to the second. It’s right, is it not, that the rapid surveillance data, what the first was called, suffered from systematic underreporting during the early stages of the pandemic?

Ms Judith Paget: I can’t comment on that. My experience in the health board that I worked in at the time was that we made absolutely rigorous efforts to ensure that the data was captured and verified and submitted. I can’t comment on what happened with other NHS organisations.

Counsel Inquiry: I’m just at your 454, and of course appreciating that you’ve had assistance in drafting this statement, but we do read, first sentence of your paragraph:

“Systematic under-reporting in the Public Health Wales rapid surveillance data was identified during the early stages of the pandemic.”

Are you able to share with us any of the reasons identified for that underreporting?

Ms Judith Paget: I’m afraid I’m not. It would be speculation on my part if I did.

Counsel Inquiry: The ONS data then, can you help us, how did that come to the Welsh Government?

Ms Judith Paget: I didn’t work in Welsh Government at that time but our statistics team get regular feeds of information from accredited sources, one of which would be ONS.

Counsel Inquiry: At your 456 you explain the ONS mortality data is based on death registrations and coroners’ reports.

Ms Judith Paget: Yes.

Counsel Inquiry: At 455, above it, you explain that it was published on a weekly basis. Was there a disadvantage in having that data only as regular as every week?

Ms Judith Paget: So my understanding based on the explanations that I was given at the time, clearly not in Welsh Government, was that Public Health Wales wanted a more timely reporting of deaths in NHS facilities, and that was why we were asked to do the rapid surveillance and submit that on a daily basis.

Counsel Inquiry: Can we think then about your time as CEO. Soon after your appointment in November 2021 you were tasked with leading the response to the Omicron variant.

Ms Judith Paget: Yeah.

Counsel Inquiry: Reflecting on that time now, did you have the data you needed at your fingertips in respect of NHS staff who contracted Covid-19 at work, staff who died from Covid-19, and patient deaths from Covid-19?

Ms Judith Paget: Going through the three, we would – I would have relied on the ONS data in relation to patient deaths. We had a regular feed of information from the NHS in relation to staff absence, including staff absence from Covid-19. We would not have had data about whether or not Covid-19 had been contracted in a work situation or in a community situation because it was impossible to know that for sure.

Counsel Inquiry: Yes, understood. Can I ask you this, please, before looking forward to improvements or changes that have been made. When you arrived in post in November 2021, were you surprised to discover that this data was not being actively collected by NHS Wales itself?

Ms Judith Paget: I was – I did ask questions about data availability. Clearly I was given the information that I’ve just relayed to you, and I accepted those explanations from colleagues around making sure that the data we had was from a reliable and validated source, so I accepted those explanations.

Counsel Inquiry: Can I ask you then what has been done to improve the collection of data in Wales in readiness for a future pandemic?

Ms Judith Paget: So, in relation to patient deaths, then we would continue to use the ONS data, and there has been no changes to that. In relation to staff health and sickness, we are implementing a new electronic staff record that would allow us to have a more reliable capture of information in relation to staff well-being and sickness absence levels.

Counsel Inquiry: Next, please, palliative care. At paragraph 382 of your statement – it’s page 134, Mrs Paget. I’ll let you get to it.

Ms Judith Paget: Bear with me, sorry.

Counsel Inquiry: Take your time.

Ms Judith Paget: Did you say 382?

Counsel Inquiry: It’s paragraph 382, yes.

Ms Judith Paget: Okay, found it, thank you.

Counsel Inquiry: You say:

“The Welsh Government required that palliative and end of life care in all hospital settings must continue [during the pandemic].”

And you go on, at 383, to say:

“[You are] not aware of any specific reports which were brought to the attention of the Minister for Health … regarding any failures to meet this requirement or of any particular instances of Covid-19 patients failing to receive palliative care …”

Ms Judith Paget: That’s correct.

Counsel Inquiry: I’d just like us to look at two documents and consider how reassured you are by the absence of specific reports to the minister that palliative care was not maintained.

The first, please, is INQ000182461.

Document titled “Maintaining Essential Health Services during the COVID-19 Pandemic - summary of services deemed essential”.

If we move to page 22 we find a section on “Palliative and End of Life Care”. From the fifth line down on this paragraph we read:

“Access to admission for palliative care purposes where necessary, to inpatient specialist palliative care expertise, and to palliative interventions should be preserved where it is possible and safe. This must be judged according to the local context.”

Do we understand from this that the instruction gives the local health board or even a hospital within the board discretion to decide not to admit a patient for palliative care if it is deemed not possible, not safe to do so?

Ms Judith Paget: That would be the interpretation of that. In practice, based on my own personal experience of course, our teams would have done whatever possible to meet the wishes of a patient and their family in terms of palliative care. So, absolutely, clearly if there were situations where it was judged to be unsafe for that individual to be admitted, then clearly they would’ve made arrangements to have appropriate and effective care in another setting. But the wording of the paragraph suggests that.

Counsel Inquiry: Yes.

Can we look, please, at INQ000469089.

This is an email chain from February 2021. It didn’t involve you, it involves your predecessor –

Ms Judith Paget: Yes.

Counsel Inquiry: – and Dr Goodall. But it considered a number of lessons learned in respect of palliative care. If we look at the paragraph beginning “Key lessons learnt”, in the second sentence we read this:

“Most palliative care units are not well set up to control transmission.”

Can you just help us understand this observation, please. Is this a comment on perhaps the size of most palliative care units? The level of ventilation?

Ms Judith Paget: Yes – I mean, the palliative care units will be located in local hospitals, so any implications around the condition of that estate, the availability of ventilation, et cetera, would impact on palliative care units in the same way as it would impact on other parts of the hospital.

Counsel Inquiry: Six lines up from the bottom of this paragraph we have this:

“We know a bit more about what really matters (good medical care, good symptom control, but also individualisation, human presence and flexibility in approach) and what doesn’t …”

And I’d like to focus on this:

“… (being too risk averse to protect ourselves).”

And if we recall that access to palliative care depended on a local assessment of whether it was safe, does what we read in this paragraph give rise to concern that people were not always provided with palliative care because the units were not well set up to control transmission, and there appears to be a recognition here that those managing the units have, on occasion, been too risk averse in order to protect themselves?

Ms Judith Paget: I’m not sure I can comment on that because I don’t really know what was in the thinking of the person when they committed that to writing.

Counsel Inquiry: This is an email chain from February 2021. Can you help the Inquiry, have there been any other reviews into lessons learnt in respect of administering and maintaining palliative care during the pandemic?

Ms Judith Paget: Yes, certainly. We have established a national programme, a forum that brings experts, clinical experts and patients and their representatives together to understand what worked well and what didn’t work so well during the pandemic, and as a result of that a quality statement has been published by Welsh Government which clearly sets out what good looks like for palliative care in Wales. The person who drafted this email is actually the national clinical lead for palliative and end-of-life care in Wales and is a key contributor to that work.

Also, if I could say that as a result of learning during the pandemic, the Welsh Government included two commitments in their programme for government which related to palliative care and one was to ensure that we reviewed hospice funding in Wales. And as a result we provided – or Welsh Government provided additional resource. But also that that strengthened focus on palliative and end-of-life care should continue and, as a result of that, investments have been made in additional specialist clinical nursing staff to work on weekends, additional district nurses to support people at weekends as well. So there has been additional – there has been learning but also changes made as a result of that.

Counsel Inquiry: Can we move to DNACPR, please. It’s right, is it not, that Wales has its own policy in this area, that’s the All Wales DNACPR policy?

Ms Judith Paget: That’s correct.

Counsel Inquiry: DNACPR decisions, being a clinical one, can you help the Inquiry understand what the purpose of the All Wales policy is?

Ms Judith Paget: So the purpose of the policy is to set out a very clear framework to guide clinicians in the application of DNACPR in Wales.

I’ll come back to any subsequent questions that you might ask me.

Counsel Inquiry: The version of the policy in place at the start of the pandemic was the 2017 policy?

Ms Judith Paget: That’s correct.

Counsel Inquiry: That was updated in 2020?

Ms Judith Paget: That’s correct.

Counsel Inquiry: Can you help us with when in 2020?

Ms Judith Paget: I think it was towards the latter half of the year but I would have to check the accuracy of that.

Counsel Inquiry: And it was updated again in 2022, by which time you were the CEO of NHS Wales?

Ms Judith Paget: That’s correct.

Counsel Inquiry: How is this policy disseminated to local health boards in order to ensure consistency of approach in this area?

Ms Judith Paget: So we have a national group that oversees the development of the policy and all subsequent materials to support the implementation of the policy. That group will disseminate the revisions to the policy, or any changes to forms, documentation, or advice to every NHS organisation.

The group have also provided educational materials, seminars, training to care homes, staff training modules on our electronic training records. There is e-learning elements as well, and all of the materials, both the policy and the supportive materials and video explanations and advice is all on a single website available to everybody.

Counsel Inquiry: Are you aware of the concerns that had been raised by both patients and those who lost loved ones about DNACPR practices during the pandemic?

Ms Judith Paget: I am aware, yes.

Counsel Inquiry: And that those concerns, as the Inquiry has heard, extend to DNACPR notices being issued in a blanket fashion to, for example, fit and healthy disabled people of working age; notices being issued without consultation, with either the patient or a family member; and that there were instances of DNACPR notices being confused with Do Not Treat notices?

Ms Judith Paget: I am aware of those concerns.

Counsel Inquiry: I’d like us to consider, then, what has been done in Wales to try to get to the bottom of this issue.

Can we go, please, to INQ000485929.

This is the review performed by Healthcare Inspectorate Wales. It was performed during 2023 into DNACPR decisions and it was published earlier this year.

Ms Judith Paget: I believe so. I thought it was published in October ‘23 but, again, I would need to check that.

Counsel Inquiry: Can I ask you this, please. Did NHS Wales commission this review and, if not, how did it come about?

Ms Judith Paget: I think it was requested so I think we requested that Health Inspectorate Wales undertake the review to inform the ongoing learning and understanding around DNACPR policy and application in Wales.

Counsel Inquiry: If we turn to page 11, please, we have an explanation of what the Healthcare Inspectorate did. Under “Scope and Methodology” we read at the first bullet point that the review considered DNACPR forms submitted by the health boards themselves. Then second bullet point, further DNACPR forms were read and compared to clinical records on site. That was at two health boards.

We know from elsewhere in the report that a total of 280 forms were reviewed, 66 of which were the ones reviewed alongside clinical records.

Looking at this list in respect of the forms, it doesn’t appear to say here that the forms reviewed were ones that were in fact completed during the pandemic. Are you able to help us?

Ms Judith Paget: I’m sorry I can’t, no.

Counsel Inquiry: Do you agree that it doesn’t make that clear?

Ms Judith Paget: I do agree.

Counsel Inquiry: From the bottom of this page we learn that the Healthcare Inspectorate launched two surveys, one for staff and one for patients. We have under the staff survey a total of 65 responses and in response to the public survey a total of 32 responses. Taking all of this together, a total of 97 responses to the surveys, 280 forms chosen by the health boards, 66 of which were reviewed alongside clinical records. No indication on the face of it that the forms reviewed were in fact completed during the pandemic.

Given the scope of this review has it allowed NHS Wales to gain a comprehensive understanding of DNACPR practices in Wales during the pandemic?

Ms Judith Paget: So my view would be that it is one element of a contribution to that understanding. It doesn’t stand alone and it doesn’t stand as being the total work to review this. My understanding is that every NHS organisation is required to do its own local audits of the application of the DNACPR policy and that’s undertaken by local resuscitation teams.

It’s further my understanding that quite recently an event was undertaken to review DNACPR to undertake a thematic review where all the learning from those audits was brought together –

Counsel Inquiry: I’ll ask you about those other reviews in a moment if I may.

Ms Judith Paget: Okay.

Counsel Inquiry: Can I first ask you about two recommendations that did come out of this review. Please can we go to page 7.

In the first paragraph starting on the fifth line down, we read this:

“We found some forms and clinical records either contradicted each other, were incomplete, or there was no evidence that a mental capacity assessment had been undertaken and without rationale. We are therefore not assured, based on the records we reviewed, that the DNACPR decision-making process is always completed in line with the all-Wales Policy, for patients who were deemed to lack capacity. This issue must be addressed by the health boards and trusts.”

Notwithstanding that last sentence, can I ask you this. What, if anything, has NHS Wales done in response to this particular finding?

Ms Judith Paget: So, further audits have been undertaken and shared across Wales. The learning from this report, alongside learning from other reviews undertaken, has obviously been taken into account with a subsequent change to the policy which is about to be issued.

But I do know that further letters were sent to NHS Wales organisations drawing to their attention the concerns around those particular things, particularly the signing of forms, the – making sure that forms were legible, and to make sure that in the local audits that were undertaken that attention was paid to these particular issues.

Counsel Inquiry: The last thing from this report then, please. Can we go to page 37. At the bottom of the page, where we have the bullet points, the Healthcare Inspectorate recommended the creation of an electronic repository of DNACPR decisions. We have three benefits here: improved documentation of key clinical details about the DNACPR decision, in one accessible system; immediate notification to ED staff when a patient arrives in an emergency; immediate notification if a DNACPR decision is cancelled.

Over the page, to add to these three points we have risks they say would be mitigated by an electronic repository, the need to document additional information in clinical records, physical loss of DNACPR forms, other healthcare providers not being alerted to a DNACPR decision.

Can I ask you this, please, has NHS Wales created or indeed begun to create an electronic repository of DNACPR decisions?

Ms Judith Paget: Welsh Government accepted that recommendation as having strong merit. Work has begun to understand how that might be developed. I don’t have any further information on the progress to that.

Counsel Inquiry: You have referred to other reviews having taken place in this area. Could you share with the Inquiry, please, what those reviews considered and any findings that you consider the Inquiry ought to hear.

Ms Judith Paget: So the NHS Wales Executive brought together colleagues from across NHS Wales to develop and consider the themes coming from those local audits. They brought together cases from January 2022 to January 2023 and shared the results of their local audits with each other.

Their work also included feedback from the medical examiner service in terms of their review of nearly 7,000 deaths, picking out, again, those themes that related to DNACPR that featured in about 3% of those reviews.

Again, the themes were consistent with some of the things that you’ve mentioned earlier, so forms not being signed in the correct place, sometimes not completed, and sometimes the information about the nature of the conversations with families that had taken place not fully documented. So that was one, and a number of relations have been made from that which will then feature in the updated DNACPR policy that’s currently being reviewed.

And then the other one was the end of programme learning report on nosocomial transmission in hospitals that was published earlier this year also considered DNACPR and took some of those thematic reviews as well. So those are the three: the HRW report; the mortality review, thematic review; and the end of programme report.

Lady Hallett: I’m sorry to intervene, but – so you obviously got plenty of evidence that things aren’t going right and you need to do something and you’ve had the recommendation Mr Mills has put to you that that you say has been accepted by the Welsh Government about an electronic repository which might avoid these things happening and make life a great deal better for the families of people upon whom these notices have been put and indeed for the patients themselves. But when Mr Mills asked you what’s been done to create it, you said the Welsh Government’s accepted it but then you used this expression “Work has begun to understand how that might be developed”. That doesn’t sound very specific to me. And what I’d like to know is, what do you mean by “Work has begun to understand how that might be developed”? What has happened, as opposed to having reviews, meetings, plans? I want to know what’s actually happened to make a repository happen.

Ms Judith Paget: So, as far as I know, my Lady, it’s our policy team, who are supporting all the work on DNACPR and related matters – is working alongside our digital team to work out how they can make that system happen, how it can link across NHS Wales, how it will link into existing data systems, so patient administration systems, et cetera, and how we can develop something that we can put in in a reliable basis.

What I don’t know, my Lady, is where we are in terms of that progress to be able to report to the Inquiry today.

Lady Hallett: And we have no suggested timeline?

Ms Judith Paget: I don’t. But if it would be helpful, I can determine that after the session today and drop a note to the committee in writing.

Lady Hallett: Thank you.

Sorry to interrupt, Mr Mills.

Mr Mills: Not at all, my Lady.

Mrs Paget can I finish with two questions about DNACPR.

Can I ask you this. Does NHS Wales have any plans to commission a wholesale review of DNACPR notices issued during the pandemic which currently remain in place in order to determine whether those notices are appropriate?

Ms Judith Paget: So I’m not aware of any indication that a wholescale review is required or requested. The DNACPR policy, as I understand it, not being clinical, gives clear advice and guidance to clinicians as to the regular updating and checking with patients during normal clinical contact around their status, whether anything has changed, and gives advice on the updating of those as needed.

Counsel Inquiry: Thinking then about advance care planning perhaps more widely can I ask you this. Has NHS Wales given consideration to adopting the ReSPECT form in order to ensure consistency with many parts of England and Scotland?

Ms Judith Paget: My understanding is that the advance and future care planning group that I mentioned earlier considers regularly what has come out of the ReSPECT process, and takes that into consideration when determining whether further reviews are needed to our current policy.

My further understanding is that the Resuscitation Council UK have indicated that they do not think the form is a DNACPR form, but actually a form for recording decisions.

The view of the group in Wales, which is made up of lots of clinical professionals, is that the DNACPR policy that we have in Wales, the advance care planning form and all the other things that we have in place, meet the needs of Wales, but clearly recognise that they need to draw on the widest possible advice to make sure that we keep up to date in terms of learning everywhere.

Counsel Inquiry: Next, please, can we consider what NHS Wales has learnt about the healthcare inequalities that were exacerbated during the pandemic. First this, please. What work has been performed in order to understand the unequal impact of the pandemic in Wales?

Ms Judith Paget: So, you will know from my statement and evidence from other colleagues that the focus of Welsh Government was very much on the impact of the pandemic on black, Asian and minority ethnic groups and a specific group was established by the First Minister that then resulted in two specific pieces of work, one looking at the socioeconomic impact, particularly looking at structural racism and the part that that continues to play in the lives of ethnic minority people in Wales, and the other one was the workforce risk assessment.

Both of those pieces of work, particularly the socioeconomic subgroup, made a number of recommendations for us in the Health and Social Services Group, I think there are seven listed in my statement. Six of those were enacted and completed at the time. There is a seventh piece of work that is ongoing which relates to racism and general issues related to the inequalities in health that exist across Wales.

So pieces of work that have been done in relation to that relate to trying to improve our data collection systems which have been not helpful in understanding those particular issues in relation to inequalities.

Counsel Inquiry: Before you tell us how data collection has been improved, can you help the Inquiry understand how NHS Wales’ understanding of these issues has been limited by an absence of data?

Ms Judith Paget: So I think many of our data collection – our information systems, I’ll use that word, many of our information systems have not traditionally collected ethnicity as a part of routine data collection, so we have done some audit to look at where there are gaps and we are trying to work, at the moment, to close those gaps in a number of service areas. But, clearly, the work around the all-Wales race equality plan in which the NHS has clearly an important part to play is fundamental to that.

And there are a number of service areas that we focused on, particularly maternity programmes, and we’ve just done some work on the inequalities and outcomes of our cancer services, we’ve looked at childhood vaccination, and clearly we’ve looked at Covid-19 vaccination from an equality point of view as well.

Counsel Inquiry: You say work has been done to close the gaps.

Ms Judith Paget: Yes.

Counsel Inquiry: Do I take it from that that the gaps have not yet been closed?

Ms Judith Paget: No, they have not been closed. So of the – we’ve looked at, I think it was 43 different service areas in terms of a whole range of indicators, and – as you might imagine, so age and sex is well represented in the data systems but ethnicity probably represented in about two-thirds of the data systems and we need to find a way of reliably capturing ethnicity data and we are exploring at the moment whether the work that we have done to introduce an NHS Wales app in Wales might be a reliable way of asking patients to submit ethnicity data into our NHS system.

Counsel Inquiry: Can you help us, when did problems with data in this particular area come to the attention of those in senior positions at NHS Wales?

Ms Judith Paget: So I think clearly the Covid-19 pandemic shone a light on that, but prior to that there had been work undertaken by Welsh Government, clearly before my time, but I am aware of it, in relation to race equality action, and that has continued.

I think what the pandemic has done has tried in some way to speed up the work on that, create a different imperative, one that everybody recognises, and focus the attention on the things we can do to try and tackle some of those issues.

Counsel Inquiry: Speed up but, from what you say, if there were another pandemic tomorrow, data collection on inequalities would remain insufficient?

Ms Judith Paget: So it can – it has improved because people are now much more aware of the need to collect that level of data. So new data systems are including it but clearly we have to go back and redress the gaps in the data systems that already exist. So there has been progress but absolutely more progress is needed.

Counsel Inquiry: New topic, please. The challenges the hospital estate in Wales presented to the implementation of IPC measures. Can we start in this way. Insofar as generalisation is possible, it may well not be, are you able to characterise the age of the hospital estate in Wales?

Ms Judith Paget: I would describe it as very mixed. So in my own health board – or the last health board I worked in, we had a brand new hospital that opened in 2020 that had 75% single rooms and two hospitals that had opened in 2010 and 2012 with 100% single rooms and, you know, all the things that go along aside that, in terms of ventilation, et cetera.

And then we had one other hospital that was built and became a hospital in the late 1890s, and everything in between. So with variation, I would say, and very mixed.

Counsel Inquiry: Please can we return to the Glangwili General Hospital statement.

That’s INQ000475209, thank you.

I’d just like to run through some of these issues that the statement sets out in respect of the hospital estate acting as a barrier to the implementation of IPC guidance.

And as we go through them, I might just ask you, Mrs Paget, to help us with the extent to which these are issues you recognise.

Ms Judith Paget: Okay.

Counsel Inquiry: Wards and corridors being narrow and not having air-conditioning or filtration systems?

Ms Judith Paget: Yes.

Counsel Inquiry: A limited number of side rooms?

Ms Judith Paget: Definitely.

Counsel Inquiry: Staffrooms too small for social distancing?

Ms Judith Paget: Yes.

Counsel Inquiry: Next, please, back to the University Hospital of Wales.

That’s INQ000480136.

Reading from paragraph 152:

“… no on-ward staff changing facilities.

“… limited control over entrances and exits for staff, patients/visitors.”

Ms Judith Paget: Yes.

Counsel Inquiry: “… no formal ventilation apart from a very small number of isolation rooms …”

Such that:

“… only natural ventilation (open windows and doors) was available, [making] it difficult to comply with IPC guidance in [extreme weather].”

Ms Judith Paget: Yes.

Counsel Inquiry: Recalling your time as CEO of Aneurin Bevan, are there any other challenges that you might add to this list?

Ms Judith Paget: I think that’s a comprehensive list, as far as I can remember, yes.

Counsel Inquiry: Can we next look at INQ000396261.

This is a ministerial briefing dated 15 November 2020, clearly before your time as CEO of NHS Wales. If we can move to page 8, please. Under “Bed spacing” we read this:

“The required 3.6m between beds has not been fully implemented across Wales, due to the consequence required of removing significant bed numbers …”

Two examples are given: 98 bets would have had to have been removed at the Royal Glamorgan Hospital, and 110 at the Prince of Wales. Do we see here the hospital estate presenting health boards with a difficult choice, between treating more patients or putting more space between them?

Ms Judith Paget: I think it was a very difficult choice for people to make. Clearly there were other choices to be made in terms of securing other capacity outside the hospital, so we did commission additional beds from the private sector, and we were, in some parts of Wales, able to secure step-down beds provided through field hospital-type arrangements and secure beds elsewhere. But, yes, it was a difficult choice, and I know – I see the paragraph refers to the use of perspex screens between beds, why I know was provided in parts of Wales as well. But, yes, but it was difficult.

Counsel Inquiry: Looking to the future then, and appreciating that a hospital estate cannot be transformed overnight, what changes have been made or indeed will be made to the hospital estate in Wales so that it can better implement IPC measures in a future pandemic?

Ms Judith Paget: So this year and for the previous two years we have made funding available to address some of the issues related to ventilation in hospitals. So my understanding is that an allocation of £34 million was made available in 2021, 22, and in the subsequent years, to address some of those issues, advised by our engineering experts in the shared services organisation that supports all NHS Wales organisations.

Other things, including oxygen supply and water systems, have also been included in that. So that’s one.

Clearly consideration needs to be given to any new-build facilities, particularly hospitals, to consider maximising the number of single rooms available. It was an issue prior to the pandemic, in terms of the isolation of patients with infections, and clearly it was a considerable issue during the pandemic. But I do know that the most recent hospitals built clearly have got an increased number of single rooms, which is a very positive feature, and I know has had an important impact on hospital-acquired infections as well.

Counsel Inquiry: Next, please, can we consider concerns around the communication of IPC guidance. Returning, I think for the last time, to Glangwili.

That’s INQ000475209.

At paragraph 92 we have the observation that national guidance contradicted professional guidance, and the example given here is about whether FFP3 masks should be worn during CPR. And we read in the final sentence:

“This was not an isolated incident.”

Do you recall from your experience as CEO of a health board that there were times when there was a difference between national and professional guidance?

Ms Judith Paget: I do recall. I can’t recall the specifics but I do recall that there were occasions where there was a contradiction in guidance received by the health board.

Counsel Inquiry: Do you have any reflections to share with the Inquiry on how such contradictions might be avoided in the future?

Ms Judith Paget: I think it will be really important for UK, so the three devolved administrations in UK government, to work together, as they have been, in relation to the PPE policies but also have very early engagement with the professional bodies so that we are seen to be working together and so that we don’t get to the situation where we have contradictory and different advice going out to the NHS, one through professional organisations and one through, you know, the government systems.

Counsel Inquiry: If we look at the following paragraph, that’s at 93, we have this:

“A problem in Wales was that Public Health England … guidance was usually announced on a Thursday, but guidance from Public Health Wales … the following afternoon (Friday). This caused an unnecessary level of anxiety for staff aware, through the media, of the PHE ‘Thursday guidance’ but unsure whether or not these changes would be effective in Wales until following day.”

Can I ask you, was this issue of publication on two separate days ever resolved during the pandemic?

Ms Judith Paget: I don’t recall it being resolved but I do believe it became less of an issue. So my recollection is – from my days in Aneurin Bevan, is at the very beginning of the pandemic it was problematic, but actually, as soon as we developed ways of working and understood that the guidance for Wales would come out on a Friday, and as there was more conversation between the NHS and Public Health Wales and Welsh Government about what might be in the new guidance when it came out on Friday, it became less of an issue. But it was an issue at the very beginning.

Counsel Inquiry: Do you think that, in a future pandemic, English and Welsh guidance ought to be issued on the same day?

Ms Judith Paget: That would be very helpful if that were possible.

Counsel Inquiry: Next, please, the statement of University Hospital of Wales, INQ000480136. We have this at paragraph 148:

“The fact that the national guidance changed so often led to a lack of confidence in some of the guidance.”

Was this a sentiment you were aware of during your time at Aneurin Bevan?

Ms Judith Paget: I was aware of the frequent changes in the guidance. I don’t recall any concerns being raised with me about lack of confidence in the guidance but the frequent changes were raised and I was aware of that.

Counsel Inquiry: You were then the recipient of guidance?

Ms Judith Paget: Yes.

Counsel Inquiry: You are now on the send side. In your view could the communication of changes in national guidance during a pandemic be improved, or are frequent changes a necessary consequence of the rapid development in understanding of a novel virus?

Ms Judith Paget: So I think at the very beginning it was, as you suggest, that understanding of the virus in all its forms was changing rapidly and therefore the guidance had to change.

I think that did become easier as time went on, and as I said, the most important thing is that there is a regular dialogue between Public Health Wales, Welsh Government and the service so that when the guidance does arrive there are no surprises in it because the communication of guidance and ensuring that everybody is sighted on it is a phenomenal task for organisations to do.

So the earlier we have notice, or organisations have notice of what’s likely to be in there, the earlier they can start getting ready for the changes.

Counsel Inquiry: Next, please, visiting restrictions.

Please can we look at INQ000469846.

This guidance was issued in November 2020. At page 2, please, under “Background”, reading from the third paragraph we have this:

“… the Welsh Government reiterates that the Guidance sets out the current baseline for visiting in Wales during the pandemic.”

It goes on in the next paragraph to allow healthcare providers to depart from the guidance in response to either rising or falling levels of transmission in their local areas.

I realise this is a single piece of guidance picked out, but can I ask you this. Is this broadly reflective of the Welsh approach to visiting, that is to allow local health boards flexibility in applying visiting restrictions?

Ms Judith Paget: So my understanding was by this point in time, November 2020, there was some clarity from Welsh Government around guidance on more relaxation of the restrictions that were put in in March 2020, so clearly there had been learning from that and Welsh Government were clearer about expectations in terms of maternity, neonatal care, and obviously end-of-life care, vulnerable adults, children et cetera.

But I think they recognise that the people who were best placed to understand the balance of risk between visiting and potential acquisition of Covid-19 through visiting and transmission were the individual organisations, so health boards and trusts, and so certainly by that point, I think, whilst encouragement from Welsh Government was to ensure that we were receptive to visiting and did whatever we could, the decision-making around that assessment of risk was left with organisations.

Counsel Inquiry: At your paragraph 395, that’s page 138, you refer to the exceptionality clause which allowed local health boards to agree to visiting requests outside of the guidance where the benefit to the well-being of the patient or visitor outweighed infection control risk.

Did this approach create inconsistency between local health boards in allowing visits in certain circumstances?

Ms Judith Paget: I think it may well have created a difference but I think there would have been difference anyway because even in my own health board we had different situations in different hospitals at different times which we were trying to reconcile, and so even in my own health board there would have been differences. So absolutely across Wales, yes.

Counsel Inquiry: So that’s different situations between different hospitals.

Ms Judith Paget: Yes.

Counsel Inquiry: Can we go to page 120 in your statement, paragraph 327. You refer – Mrs Paget, it’s on the screen in front of you if that’s better.

Ms Judith Paget: Thank you, yes.

Counsel Inquiry: You refer to – and I’m in the first line – other exceptions, and these are in respect of visiting restrictions in March 2020 in fact:

“Other exceptions were at the discretion of the Ward Sister/Charge Nurse or manager with advice from the [IPC] team.”

Did this discretion risk the creation of inconsistency within the same hospital because charge nurse A might approve a visit on Monday, but charge nurse B could reach a different view on the Friday and refuse a visit?

Ms Judith Paget: On the same ward I would expect the same and similar assessments but, clearly, a situation could change from a Monday to a Friday. There could have been an outbreak, there could have been something else that impacted on the ward. But I think the issue was about the justification of the decision and clearly the infection prevention control team were giving consistent advice across the organisation so they were in some ways able to try and do that consistency check on behalf of the health board.

Counsel Inquiry: Can I ask you this then, please, about the approach to visiting generally. In your view, should visiting restrictions aim to be, as far as possible, consistent nationally or do you endorse allowing for a more local approach?

Ms Judith Paget: So I think there should be consistency around what we deem to be essential visiting. As I mentioned, there are some key groups that during – based on our learning during the early part of the pandemic, we would want to have moved away from the very restrictive approach we had in March to the more supportive approach we had in November. I think it would be very difficult to have an approach that was absolutely consistent at all times, at all days, in all wards, in all hospitals, because there will be variation in terms of the situation on that ward at that time.

Counsel Inquiry: You mention consistency for key groups.

Ms Judith Paget: Yes.

Counsel Inquiry: Can I ask you to share some examples of who those key groups might be.

Ms Judith Paget: So for maternity and neonatal services I would, based on our learning and understanding, include partners from antenatal care all the way through. Clearly end-of-life care was seen as essential from the beginning. Vulnerable adults, people who act as carers for others, and clearly children, in terms of parental support, as well.

Counsel Inquiry: Final topic before perhaps we take a break, Mrs Paget. Long Covid.

Ms Judith Paget: Okay.

Counsel Inquiry: The Inquiry’s Long Covid experts, Professors Brightling and Evans summarise the Welsh approach to providing Long Covid treatment as delivering these services not through specialised clinics, as in England, but through primary care. Is that a fair summary?

Ms Judith Paget: We – our Long Covid service is an integrated, multi-professional, community-focused rehab model, with the ability to refer people to specialist clinics if they need to – or specialists, I should say, sorry, if they need to.

Counsel Inquiry: But it’s right to say, is it not, that Wales has not adopted the specialised Long Covid clinics that we see in England; is that right?

Ms Judith Paget: That’s correct.

Counsel Inquiry: Professors Brightling and Evans told the Inquiry that there is now evidence that specialised Long Covid clinics are both clinically and cost effective. I’m not asking you to comment on that. Can I instead ask this. Since you became the CEO of NHS Wales, has consideration been given to establishing specialised Long Covid clinics?

Ms Judith Paget: There has been a constant evaluation of the model that we have in Wales. It is compliant with NICE guidance. It fits the geography and the spread of the services and population of Wales. We are regularly reviewing the evidence from research and trials as it becomes available, and at the moment we haven’t been required to change our position but clearly, if new evidence comes to light that is a material, then clearly we will consider that in full.

Counsel Inquiry: What particular support is offered by NHS Wales to healthcare professionals with Long Covid in order to assist them in returning to work?

Ms Judith Paget: So the Long Covid support for staff is organised and available through our occupational health services. As far as I am aware, there is no specific range of services available consistently across Wales, but, clearly, occupational health support is available to everybody.

Counsel Inquiry: Looking to the future then, what can you tell the Inquiry about NHS Wales’ plans to continue to treat those suffering with Long Covid and research?

Ms Judith Paget: So Welsh Government has made ring-fenced money available to ensure that people who need access to Long Covid care and support are able to do so. That investment has increased in the last financial year. We have been, as I said, evaluating the current Long Covid service, including a significant focus on what patients are reporting as their positive outcomes. We will continue to review that and continue our commitment to providing support to Long Covid patients in Wales.

Counsel Inquiry: Finally this then, please. Based on what has been learnt about treating Long Covid, does NHS Wales have a plan in place to make sure that in the event of a future pandemic it is able to rapidly respond to the long-term consequences of whatever that future pandemic illness may be?

Ms Judith Paget: I do not think we have a plan at the moment but I do think, as part of our ongoing pandemic preparedness, we do need to think beforehand of what service models might need to be put in place, either to respond to the long-term impacts of a viral illness, if that’s what it were, or also to rapidly work with UK Government on rapid research into what might help respond to any underlying health conditions caused by whatever the nature of any virus might be.

Mr Mills: My Lady, would that be a convenient moment?

Lady Hallett: Of course.

I shall return at 3.10.

(2.54 pm)

(A short break)

(3.10 pm)

Lady Hallett: Mr Mills.

Mr Mills: My Lady.

Mrs Paget, turning to lessons learned and recommendations. At annex A of your statement, referenced INQ000485240, you set out the reviews that have been performed in Wales into matters within this module’s scope. To summarise, there have been a number of reviews conducted by different organisations into distinct areas of the pandemic response; is that a fair summary?

Ms Judith Paget: That’s correct.

Counsel Inquiry: So, to give some examples, we have the Equality, Local Government and Communities Committee, reporting on inequalities?

Ms Judith Paget: Mm-hmm.

Counsel Inquiry: We have Audit Wales performing the review into procurement and supply of PPE, and we have the Healthcare Inspectorate Wales producing a review into how healthcare services maintained patient safety during the pandemic.

Ms Judith Paget: Yes.

Counsel Inquiry: NHS Wales has not, however, produced a single overarching report into the pandemic response in Wales like the one produced by NHS England in 2023; is that right?

Ms Judith Paget: That’s correct.

Counsel Inquiry: Do you consider that NHS Wales has a duty to produce a single comprehensive report to enable it to identify and reflect on the lessons to be learnt from its pandemic response?

Ms Judith Paget: My view is that there have been, as you say – you’ve listed some, but there have been more, reports into how both Welsh Government and NHS Wales manage d the response to the pandemic. There was a formal review undertaken by the Health and Social Services Group that included input from NHS organisations and social care into the response that was done in August/September 2020, and then again in 2021, that made a number of recommendations around our lessons learnt.

We have followed those up and closed off now all the recommendations. So everything has been complete.

The last outstanding recommendation was the establishment of the NHS Wales Executive, which has now been established.

Counsel Inquiry: I’ll ask you about that in a moment, if I may, Mrs Paget but can I ask you this. Are you confident that the various patchwork of reviews performed has identified, together, all of the lessons to be learnt from the pandemic response in Wales?

Ms Judith Paget: So I am confident that it has. I am confident that organisations have learnt individually what we are now going to be doing. And I know you want me to ask me about the NHS Wales Executive, but, just in response to this question, we are now going to be reviewing all of the plans that NHS organisations have updated, following their own learning lessons and reflections. We will review those both individually with organisations and collectively through the NHS Executive, and if there are any further learning or lessons that we need to address then we will do so.

Also to say that in the last four weeks I did bring the chief executives of NHS Wales together, along with some of their senior team, plus the team that I support in Welsh Government, to review the Module 1 report, but also that did give us an opportunity to gather some further reflections from organisations as well on some key things. So that does exist. If you would like me to submit that to the Inquiry, I could do that.

Counsel Inquiry: You have, as we’ve moved through this afternoon’s topics, shared lessons and recommendations. Can I ask you about lessons in respect of some discrete matters, please.

First, two matters that Dr Goodall, your predecessor, was asked about this morning who said you may well be better placed to answer. First, what, if any, lessons have been learnt about the use of field hospitals, please?

Ms Judith Paget: The last review of field hospitals and lessons learnt was done in March 21. I am not aware of any subsequent reviews or lessons learnt since Dr Goodall left the role and I took over.

Counsel Inquiry: Are you able to share with the Inquiry any of those lessons?

Ms Judith Paget: I can make them available. I don’t have them with me but I can do that.

Counsel Inquiry: He was also asked about bereavement services –

Ms Judith Paget: Yes.

Counsel Inquiry: – by reference to the report produced by the nosocomial Covid-19 programme in March 2023, which identified that bereavement services – I apologise – final report produced in August 2024, in fact – identifying that bereavement services should be proactively signposted and offered to all families experiencing grief following the loss of a loved one.

Help us, please, how is the NHS currently ensuring that such services are being proactively signposted and offered?

Ms Judith Paget: So during and since the pandemic a national bereavement pathway has been developed by the NHS in Wales. It’s a consistent policy and pathway that all organisations are required to implement. Every organisation now has bereavement services in place and the executive teams of those organisations are charged with ensuring that they monitor, evaluate, and get feedback on the effectiveness of those services.

Also, you will know that, as you mentioned, the nosocomial transition programme, end of programme report also makes specific comments on this and we will be – I will be receiving a quarterly update on the implementation of the recommendations in that report to ensure that that is being followed up.

Counsel Inquiry: Aside from a quarterly update, what is the NHS Wales doing to ensure that these services are being changed in accordance with the report?

Ms Judith Paget: So the report – the pathway is there. There is a requirement to implement it. Additional resources have been provided to organisations to make sure it happens and, as I’ve said, organisations themselves should be ensuring that that pathway is followed and they regularly review that it is, and they will then report in to us through that mechanism, as I’ve just mentioned, with quarterly reports coming to me.

Counsel Inquiry: There have been several reviews into the supply of adequate PPE during the pandemic. I won’t ask you about each of those reviews individually but perhaps this, please. Can you share with the Inquiry the key lessons that have been learnt in respect of ensuring an adequate supply of PPE?

Ms Judith Paget: So my general reflections on PPE supply based on my experience in Aneurin Bevan was that Wales managed to ensure a good supply through procurement arrangements put in place by NHS Wales shared services. I don’t recall any difficulty around the availability of PPE during the pandemic but clearly the important thing is that we are really clear at the beginning of the roles and responsibilities of UK versus devolved administrations. In Wales it was agreed, or across the UK it was agreed the devolved administrations would procure and supply their own PPE during the pandemic and once that decision was made I think the system was quite effective. So the most important thing is we’re really clear who is doing what.

Counsel Inquiry: Staff well-being, please. What has NHS Wales learnt about the effectiveness of measures taken to support the mental health of staff working during a pandemic?

Ms Judith Paget: So I think the pandemic shone a light on something that was already receiving attention but actually the impact on staff well-being from working during the pandemic has been immense and so the investment that’s been made in additional services, both at a local organisational level and obviously on an across-Wales level has been well received, well evaluated, well supported, and our staff unions are very positive about both the impact it’s had and obviously the need to continue that.

I think alongside that, as well as the psychological well-being of staff, it’s really important that we continue to develop our occupational health services to make sure that we’re able to support staff with the physical impacts but also clearly Long Covid as we’ve discussed as well. So there is a balance to be struck not only around the psychological well-being support but the need to make sure our occupational health services are well resourced as well.

Counsel Inquiry: Can you tell the Inquiry, please, about the structural changes, then, that have been made to ensure that NHS Wales can be more agile in its response to a future pandemic?

Ms Judith Paget: So there have been changes made within the Welsh Government group that I’m the DG of. We have created a public health directorate with additional resource and focus to ensure that we’re continuing not only to focus on our pandemic preparations but also responding to individual issues as they arise, as they have even since the pandemic.

We have also embedded learning from the Technical Advisory Cell, so making sure that we’re able to develop our own modelling and reviews of evidence and linked through to research as well. So we have a small core of people now who support us with modelling data, most recently modelling what this winter might look like in terms of infectious disease. We’ve also created an ongoing commitment with Swansea University to help with that modelling data as well.

We’ve provided additional support for the CMO, with a second deputy CMO for public health, and we have outside of government created an NHS Executive by bringing together functions that already existed in NHS Wales to create a critical mass of individuals who can support us to deliver on ministers’ priorities and policies and ensure that the policy objectives of Welsh Government are consistently implemented across NHS Wales.

As part of that I would say we have created a new team within the executive which will have responsibility for emergency planning, preparedness and response and will co-ordinate and bring together and provide assurance on the plans of individual NHS organisations to make sure that we share good practice, quality assure the plans, but also support the testing of those plans on a frequent basis.

Counsel Inquiry: Have any of those plans yet been tested?

Ms Judith Paget: There was a table top exercise done a couple of months ago in relation to some of the plans and also in the preparedness of Mpox there have been further testing reviews of isolation rooms and other things which are related to preparedness for that.

Counsel Inquiry: Finally, then, are there any lessons which I have not yet invited you to comment on that you would like to share with the Inquiry?

Ms Judith Paget: I think we’ve covered most of them during my evidence, thank you. The only other one that I would probably add in relation to infection prevention control, as well as ongoing investment which I’ve mentioned, and single rooms which I have mentioned, is to make sure that we can agree a core specification for an optimal infection prevention control service and team because I was very struck during the pandemic that although we’d invested considerably in our infection prevention and control team they were stretched considerably, incredibly busy, worked incredibly hard but there is something to make sure that we’re all working to a consistent standard.

And other than that, we’ve picked up visiting, we’ve picked up palliative care, and all the other things I was going to mention. So thank you, Mr Mills.

Counsel Inquiry: Just finally please on the core specification. Can you help us, perhaps by way of example, of what that might include?

Ms Judith Paget: So I think it might include the competencies and capabilities that you might need in your infection prevention and control team and service, what the role of a consultant in infection prevention – consultant nurse in infection prevention control might look like, their job content, and what the make-up of the team might be, and what resources do they need access to in terms of training, development and ongoing support.

Mr Mills: Mrs Paget, thank you.

My Lady, that’s all I ask.

Lady Hallett: Thank you.

Ms Waddoup.

Over that way, Mrs Paget.

Questions From Ms Waddoup

Ms Waddoup: Thank you, my Lady.

Good afternoon, Mrs Paget. I represent Clinically Vulnerable Families and I have some questions for you, please, regarding safe access to healthcare for members of this group.

Firstly, was any specific consideration given to clinically vulnerable people who needed to access healthcare during the pandemic and, importantly, how they could do so safely?

Ms Judith Paget: So it’s difficult to know on what basis you’re asking me. So, as the Welsh Government – I can’t answer that question for Welsh Government. Clearly I wasn’t in Welsh Government then. But from a health board point of view, my reflection is that we worked really hard to make sure that people could have safe access to care, that we had a variety of options available to people, from virtual, face-to-face to telephone access, but also if people needed to come into our hospitals, that we would arrange for them to have safe routes into hospital and be cared for appropriately when they arrived with us.

Ms Waddoup: So, perhaps just with your health board hat on, what do you mean, sorry, when they arrived in hospital –

Ms Judith Paget: So if they were coming –

Ms Waddoup: – what were the specific measures?

Ms Judith Paget: – to an outpatient’s appointment, for example, making sure that they had a safe place to wait, that they didn’t wait too long, that they hopefully went straight into the clinic room, they were seen quickly and supported. If they needed a diagnostic test, that that was done as quickly as possible. And they were supported to get what they needed in terms of medical attention quickly and then could leave.

Ms Waddoup: Thank you.

Moving then to the here and now. The Inquiry has heard evidence from IPC expert, Dr Warne, that there is an ongoing need to consider how clinically vulnerable people can safely access healthcare settings, including hospitals.

Do you agree with Dr Warne with that, and if so what if any steps are being taken now to ensure this can happen?

Ms Judith Paget: So I would agree that we should always ensure that patients and family ability to access safe care is a priority. I’m not aware of any specific things that are happening at the moment to support that but clearly if our staff are aware that somebody is clinically vulnerable or extremely clinically vulnerable they will do their best to support them in whichever way possible.

Ms Waddoup: Thank you.

Next, I’d like to ask you, if I may, about the potential role of carbon dioxide monitors. And at paragraph 310, which is page 114, of your statement if that assists.

You describe there a letter sent by the Minister for Health to the Royal College of Nursing after the College has asked the Welsh Government to, amongst other things, consider providing CO2 monitors in healthcare settings. This is in March 2022.

The minister’s letter indicated that there were no plans at that time to do so because, and I quote from the letter, “different air change conditions are required in individual settings”.

Are you able to explain that further and to help us understand why a policy of providing CO2 monitors wasn’t adopted within the NHS Wales estate, given that we know that they’re a reliable measure of how well ventilated a confined space is and, therefore, give us an indication of the likely Covid-19 transmission risk?

Ms Judith Paget: Apologies, I can’t add any more clarity to what’s in my statement.

Ms Waddoup: Thank you.

Final question then, if I may, concerning inequalities. At paragraph 755 of your statement, that’s page 279, you indicate that the Welsh Government considered, amongst other groups, the clinically vulnerable when addressing changes to the delivery of healthcare services and also when giving input and advice and policies in the healthcare context.

Are you able to help us with any specific examples of how the clinically vulnerable were considered in these contexts and are you aware of current policy continues to be assessed for potential impacts on the clinically vulnerable cohort?

Ms Judith Paget: So I am aware that our impact assessments take a wide range of considerations into account. Particularly I recall the document that was published around the pandemic, “Next steps”, and the risk assessment in there makes specific reference to clinically vulnerable individuals as being a key consideration. So my view of the impact assessments that I’ve seen since I’ve been in Welsh Government is they take quite a wide view of impacts, disability, race, et cetera, but where there are significant impact on particular groups, they will draw that out.

Ms Waddoup: Thank you.

Thank you, my Lady, those are my questions.

Lady Hallett: Thank you very much, Ms Waddoup.

Mr Wagner.

Sitting next to her.

Questions From Mr Wagner

Mr Wagner: Good afternoon. I ask questions on behalf 13 Pregnancy, Baby and Parenting Organisations.

I want to ask you, first, about visiting guidance. In the visiting guidance that was brought into force in May 2022, a nominated partner was recognised as a partner in care. Do you agree this was a recognition of the essential care that pregnant people receive from their partners during and around pregnancy?

Ms Judith Paget: I do indeed.

Mr Wagner: And do you agree that this recognition came too late?

Ms Judith Paget: I can understand why the initial restrictions on visiting were as they were because people were very worried about safety of everybody, but I think the right decision was made to adjust the guidelines later to ensure that partners or close family members were able to support somebody through all stages of their pregnancy.

Mr Wagner: I’m sorry, that wasn’t exactly the question I was asking, I was asking if the recognition that these weren’t just visitors, they were partners in care, which only was added to the guidance in May 2022, two years – more than two years after the pandemic began. Do you agree that that recognition came too late?

Ms Judith Paget: I agree that it could and should have been recognised earlier.

Mr Wagner: You said earlier in response to a question you were asked about visiting guidance that:

“… for maternity and neonatal services I would, based on our learning and understanding, include partners from antenatal care …”

I think probably “in antenatal care” –

Ms Judith Paget: Yes.

Mr Wagner: “… all the way through.”

So just to clarify, your view is that partners should have been permitted to access antenatal care, so ultrasound appointments, that sort of thing, throughout the pandemic?

Ms Judith Paget: I mean, this is – it’s a personal view. I think partners play a really important part in supporting the delivery of care so I would absolutely support that.

Mr Wagner: And they’re a partner is care is what you agreed?

Ms Judith Paget: Absolutely.

Mr Wagner: Neonatal visiting, it wasn’t until May 2022 that directive guidance that both parents would be able to visit their baby on a neonatal ward together was introduced. Were you aware that Wales was the last of the four nations to direct hospitals to allow both parents to have unrestricted access to their babies on neonatal wards?

Ms Judith Paget: I was not aware.

Mr Wagner: Can you explain the reasons why it took until May 2022, over two years, to direct hospitals to allow that?

Ms Judith Paget: I don’t think I can, to be honest. I know that the – colleagues were reviewing visiting principles, and took a very broad view with colleagues from the NHS around an updating of the visiting guidance and developed principles. Whether that then – that changed to the neonatal visiting came as a result of that, I’m not sure but I wasn’t aware and I don’t know why it took so long.

Mr Wagner: Do you consider that it may have been there was a lack of priority being given to women’s and maternity-related care generally, that led to that delay?

Ms Judith Paget: I don’t accept that.

Mr Wagner: Do you accept, on reflection, that neonatal visiting restrictions ought to have been addressed earlier than May 2022?

Ms Judith Paget: I think that given that we were reviewing visiting restrictions from a wide range of perspectives, I am surprised that it took that long to develop those changes in guidance for neonatal care.

Mr Wagner: And do you think that if that partner in care change had been made earlier, so recognising partners as something more than a visitor, do you think that potentially would have flowed through to earlier changes in the guidance for visitors to those kind of services?

Ms Judith Paget: What I can’t comment on is, although the guidance changed in, I think you said May 2022, I’m not sure what the practice was at that time, so it could have been that practice had already changed and the guidance was changing to keep up with practice because clearly in units across Wales we had given the ability for health boards, ward managers, et cetera, charge nurses, to make decisions around visiting so it could be that actually practice had already changed and the guidelines were just changed to keep up with that.

Mr Wagner: Do you have any record or did you take any – did you do any research to see what individual decisions were being taken up till then?

Ms Judith Paget: I haven’t personally but I would be confident that the group that oversaw the changes to the visiting guidance and the principles would have been working very closely with NHS colleagues and would be well aware of what was happening in practice at that time.

Mr Wagner: Thank you.

Lady Hallett: Thank you, Mr Wagner.

Ms Hannett.

Now, Ms Hannett is over there, so please make sure your answers go into the microphone.

Questions From Ms Hannett KC

Ms Hannett: Mrs Paget, I ask questions on behalf of the Long Covid groups.

I’m going to ask you first about Long Covid services. In the July 2022 Adferiad Long Covid service report, feedback called for more medical diagnosis and testing to be available to facilitate treatment and not just rehabilitation. Service users were also still calling for dedicated consultant-led clinics reflecting similar requests in earlier national evaluations and meetings between Long Covid Wales and the Welsh Government and a petition to the Welsh Parliament.

You said in your evidence just now that Wales is not required to change its position on the provision of Long Covid services from the current model to a specialist Long Covid clinic model. But given the consistently large number of Long Covid patients reporting that the current system is not working for them, why have you not done so?

Ms Judith Paget: So I think, as I said, the model that we have in Wales has been designed by senior leaders, clinicians and service providers in Wales. It’s consistent with NICE guidance. It’s a rehabilitative community-based model that enables people to be referred into specialist services if their condition requires it. There have been four CEDAR evaluations of the service, the last one being on 14 February ‘23, and although there are still concerns around the service, they do relate to things such as a medical diagnosis which was picked up in the early part of the evaluation, that the rehabilitation was not always tailored around their own personal needs, appointments not being at convenient times and a slow referral process.

So I think that as far as the evaluations are concerned there’s still a very positive feedback from people. Clearly there are improvements to be made. As a result of the feedback from the most recent studies, additional resources were made available to health boards from Welsh Government to make the improvements in relation to that feedback and we have just received the health board’s most recent evaluation of their local services which are currently being reviewed.

But as I said earlier, if NICE guidance changed or if the evidence becomes very strong that the model should change in Wales then clearly that will be considered.

Ms Hannett KC: Ms Paget, what I’m suggesting is that the Inquiry’s Long Covid experts, Professors Brightling and Evans, gave evidence that the Welsh model has a number of distinct disadvantages, including disconnect with secondary care and also implications for training as there’s not a group of specialists. It’s also the case that three other nations adopt the Long Covid specific clinic model. So why is, in the light of Brightling Evans’ evidence and the approach of the other three nations, why is Wales the outlier?

Ms Judith Paget: As I have said before, and I will continue to say, as the evidence changes we will continue to review the model. Clearly, the geography of Wales is quite different. Our population of 3 million people is spread across, you know, I don’t know, 8,000 square miles trying to deliver centralised hospital based services, specialist clinics that are accessible for people so that they don’t – aren’t required to travel long distances to get to those services is a consideration but clearly we’ll keep the situation under review.

Ms Hannett KC: Can I turn to children and young people with Long Covid.

Again, there’s no dedicated Long Covid clinics or services for children and young people with Long Covid in Wales. In your letter to Andrew Goodall dated 6 May 2022 you acknowledge that there are a number of children presenting with Long Covid in Wales, and that some have very significant needs. You added that, as in the situation with adults with Long Covid, children with the condition are being treated close to home wherever possible rather than being seen in specialist clinics, as they might be in England.

Again, the Long Covid experts have said at paragraph 84 of their report that regions with lower rates of Covid-19 and fewer patients with Long Covid are likely to have inexperienced healthcare professionals, which supports the need for a virtual, multidisciplinary team, delivered by the post Long Covid children and people hubs. Would you agree with the Long Covid experts that creating a virtual, multidisciplinary team to deliver specialised care from Long Covid hubs for children and young people with Long Covid is advantageous, given that few paediatricians will have the knowledge and expertise to deliver specialist care?

And just to answer the geography point, it is a virtual hub as opposed to one that they would have to travel to.

Ms Judith Paget: So we’ve got a Long Covid pathway for children that was developed by Aneurin Bevan University Health Board that has been shared with all health boards. We have done awareness raising and sessions with them to draw out how that model can be implemented.

As I’ve said, we’ve just had the reports in from all the health boards around both adult and children services related to Long Covid so I’d be interested in seeing our own evaluation of that and views on the services before considering that further.

Ms Hannett KC: And as part of that evaluation, would you recommend that they consider the evidence that’s been provided to this Inquiry by Professors Brightling and Evans?

Ms Judith Paget: Absolutely. And only recently our strategic evidence and analysis team did a review of Long Covid services and evidence. I think it was August this year. They will do that on a regular basis. That evidence supports the group that are developing and designing the services in Wales, and that will continue. So any new evidence that comes to light will absolutely be taken into account in terms of reviewing the service on an ongoing basis.

Ms Hannett KC: Finally, final topic if I may, Mrs Paget, that’s data and Long Covid. In the January 2022 Adferiad programme report, that stated that there were difficulties robustly collecting the data that would have been needed due to changes in service provided, lack of Long Covid-specific clinical coding, and the importance of community services that would not be captured in databases such as the SAIL Databank.

Question: in Wales, was there a difficulty in relying on data drawn from the coding of Long Covid in GP practices?

Ms Judith Paget: So I think at the beginning my understanding is – clearly I wasn’t in Welsh Government then, so I’m speaking from what I’ve been told as opposed to what my personal experience has been – I understand that there was some concern that the GP systems weren’t recording all the cases of Long Covid but clearly we’ve been doing a lot awareness raising. There is now a dedicated health pathway in Wales that is consistently applied across Wales. So the quality of the data should be improving.

But again, as part of this review of the reports that have just come in from the NHS, we will also be looking at the number that are recorded on the GP systems as well.

Ms Hannett KC: Given that documented issue with the coding of Long Covid, how can the Welsh Government be confident that it’s able to assess if all of the people with Long Covid who need services are able to access them?

Ms Judith Paget: So I think that’s a difficult question to answer. Clearly we are promoting that the services are available. The GPs are aware that the pathway is there as people engage with them. And clearly not everybody who has Long Covid symptoms has wanted to seek help, but it is incumbent on us to make sure that we continue to raise awareness about the availability of services so that they are – so we are encouraging people to come forward.

So I think it’s about keep the awareness raising, ensure that GPs are familiar with the pathway and the services are available, and that access to the services is timely for individuals and that people are getting the services that they need.

And one of the things that we have done is made sure that we include in our ongoing evaluation patient-reported outcome measures, so we are absolutely capturing the benefit that patients have received from the services that they’ve had.

Ms Hannett KC: Final question, if I may, Mrs Paget.

ONS is no longer recording data on the prevalence and severity of Long Covid in Wales. Can you just explain – you may well have covered this in your last answer but can you just explain whether Wales maintains any current surveillance or data gathering of prevalence and severity of Long Covid outside of the clinical coding and access to Long Covid services?

Ms Judith Paget: My understanding is that we don’t, but I would have to double-check on that.

Ms Hannett: Thank you, I’m grateful.

Thank you, my Lady.

Thank you, Mrs Paget.

Lady Hallett: Thank you, Ms Hannett.

Mr Thomas.

Mr Thomas is behind you.

Questions From Professor Thomas KC

Professor Thomas: Good afternoon, Mrs Paget.

I’m representing FEMHO. That’s the Federation of Ethnic Minority Healthcare Organisations.

In paragraph 429 of your statement, the advisory group outline recommendations for mitigating risks to black, Asian and minority ethnic healthcare workers, such as ensuring access to appropriate PPE and conducting regular risk assessments.

I’m sure you remember that.

Ms Judith Paget: I do.

Professor Thomas KC: Can you provide specific examples of how NHS Wales ensured that these recommendations were practically implemented across different NHS Wales trusts.

Ms Judith Paget: So I wasn’t working in Welsh Government then so I can comment from a perspective from Aneurin Bevan Health Board, if that’s acceptable.

So there were, as I said earlier, seven recommendations that were directed towards the NHS, one of them, relating to unfair or illegal discrimination and anti-oppressive practices, is subject to ongoing work through the Anti-racist Wales Action Plan, which I can expand on further if you need me to.

The first few recommendations related to the dissemination of the risk assessment tool and encouraging of its use. And I recall very clearly that in Aneurin Bevan we clearly developed our own version of that risk assessment tool quite early and made it available to Welsh Government.

So by the time the Welsh Government one arrived with us, we’d already done a significant amount of work, not only through our staff group, so direct line management, but working with our staff and trade unions to actually make everybody familiar with the tool, highlight how important it was for it to be used, and made copies available electronically and on paper and promoted the use of it through our regular communications, which were going out into the organisation probably every day after our gold meeting.

And from a Welsh Government point of view, I understand from colleagues that they did review it regularly as evidence changed around the pandemic and its impact. I can’t tell you how many times it was changed but I know it was updated.

Professor Thomas KC: Well, in fact I think you’ve touched upon my second question. If you want to expand upon it – I’ll ask the question in any event, but I think you might have touched upon it, which is, what were the monitoring mechanisms that were established to track the implementations of these recommendations and how were these results reported and evaluated across NHS Wales, and the various trusts?

Ms Judith Paget: So I can’t recall – because I wasn’t in Welsh Government then, I can’t recall how it was collated across Wales. I can recall locally, in the health board we followed, at both the dissemination and uptake of the tool, clearly working with line managers to make sure that people who had high scores triggered by the tool were offered appropriate support. That we had stockpiles of PPE available. We used the support of the military to ensure that the PPE was available as close to our staff as possible, so we ended up putting PPE stores on all hospital sites and making them available close to primary and community services.

Clearly, we established a BAME network working with our trade unions, and we continue to support people to raise concerns about – concerns about racism or any issues related to oppressive practices within the NHS.

Professor Thomas KC: Thank you.

Let me move on. In your statement you refer to the work of the socioeconomic subgroup, which published its recommendations on 25 June 2020, and just to remind you the subgroup report made 37 recommendations to address inequalities for ethnic minority communities during the pandemic.

Can you provide us with an update on the specific actions taken by NHS Wales to improve the quality of ethnicity data collection as recommended by the subgroup and how this has impacted health outcomes.

Ms Judith Paget: So one of the key things that have happened in the last 12 months is that we have developed the Workforce Race Equality Standard and we have collected data from a variety of sources to provide out to NHS organisations information around the 12 standards that are in the race equality standard. We’ve collected the data from a variety of sources, put it together and created standard reporting mechanisms and reports out to organisations. We did also publish a national report that is available on the Welsh Government website.

In terms of following up, so as well as giving the report and the data out to organisations, colleagues in my team have met with every NHS organisation to go through the outcome of that report, the recommendations that are in there, but also, as part of my role in Welsh Government, we have also been looking at things that we can do on a national basis to support the NHS in Wales. So things like how can we ensure that we have more diverse membership of NHS boards, running a shadowing programme et cetera, et cetera. So there’s been a huge amount of activity in the last 12 months.

Professor Thomas KC: Again, I think you may have just overlapped a little bit into my next question, which is fine. If you want to develop it, please do. I was going to ask, how has that implementation of these recommendations been evaluated?

Ms Judith Paget: The Workforce Race Equality Standard?

Professor Thomas KC: Yes.

Ms Judith Paget: So, the reports went out in September – sorry, the reports went out in August. The meetings with all – organisations will be have been held during September, and I chair an equality diversity inclusion board and at the next meeting we’ll get feedback from the receipt of those, the feedback and next steps in terms of actions individual organisations are taking.

If I could also add that for the chairs of all NHS organisations, they have a specific objective from the Cabinet Secretary to ensure that they are paying due regard to that information and all the actions in the Anti-racist Wales Action Plan, and they will be required to update the Cabinet Secretary at their own personal appraisals as to the progress their organisation has made.

Professor Thomas KC: Thank you.

Can you provide examples of specific health outcomes that have improved for ethnic minority communities as a result of these actions?

Ms Judith Paget: So these are – the ones that I’ve been talking about are particularly related to workforce race equality. One of the areas that we’ve focused on actually relates to maternity care and we’ve been working with the universities to try to increase the diversity of people who are coming forward for maternity training, so that our maternity/midwifery services are better representative of the communities that we serve. That is still work in progress but it’s been a really important first area of work that we have ventured into in terms of trying to ensure that services in Wales better represent the people that they are serving.

Professor Thomas KC: This leads me on to my next area which is the advisory group made – recommended immediate action to improve ethnicity data collection quality, yes?

Ms Judith Paget: Yes.

Professor Thomas KC: Can you just share with the Inquiry what specific challenges NHS Wales faced in achieving this and how did this impact your ability to address health inequalities for ethnic minority communities during the pandemic?

Ms Judith Paget: So in relation to workforce, what we have identified is quite a significant number of staff, particularly at a senior level have not declared their ethnicity on our electronic staff recording system, so about 10% of staff. So we are working with organisations as well as responding to the findings of that report to actually ensure and encourage staff to make sure that their data is recorded on our system because that will help.

In relation to the broader data issues, I think as I said in response to a question from Mr Mills, clearly data capture on some of our NHS patient systems is definitely not where we need it to be. We have taken some steps to improve it and new data systems, new informations such as the Covid vaccination system clearly captures ethnicity data but I think I would have to say it’s work in progress but it is most definitely receiving attention as part of this work.

Professor Thomas KC: I think you’ve covered my next question so let me move on to the question after that.

One of the subgroup’s key recommendations was to enhance healthcare access for ethnic minorities. Can you explain the strategies that NHS Wales employed to ensure equitable access to healthcare, including culturally competent mental health services?

Ms Judith Paget: So I think – we’ve got a strategic programme for mental health and as part of their work they have a number of areas that they’re looking at but ensuring that – again, it goes back to the diversity of the workforce but also the training that is available to people in order to ensure that they’re able to appropriately support and develop the care of individuals that they come into contact with.

So as I said, there are a number of areas, mental health, maternity. We’ve been looking at – specifically at areas around cancer services and inequalities in relation to cancer and cancer screening and there are a number of other areas as well.

Professor Thomas KC: The report mentions black, Asian, and minority ethnic staff network group as platforms for ethnic minority staff to voice their concerns. Can I ask you this. How effective have these groups been in providing insights into inequalities within the healthcare system and what measurable improvements have resulted from their input?

Ms Judith Paget: I can’t comment on measurable improvements but clearly what we will want to see through the publication of the Workforce Race Equality Standard is a shift in those over time. So, clearly, they’ve only just been published. We would continue to expect those networks to play a full part in not only supporting the analysis and response to that – those recommendations at an individual organisation level but also be working with management teams in order to determine what the best actions to take and in what order.

Professor Thomas KC: Let me come on to my final –

Lady Hallett: I am afraid we are going to have to leave it there, I’m really sorry, Mr Thomas, I know it’s tough on all of you who come at the end of the day, but we’ve got a fair few questions to go through.

Professor Thomas: So be it, my Lady.

Lady Hallett: I’m really sorry.

Miss Samantha Jones.

Questions From Ms Jones

Ms Jones: Thank you, my Lady.

Ms Paget, I ask questions on behalf the Disability Charities Consortium.

Now, earlier you were asked questions by Counsel to the Inquiry on the all-Wales thematic review on DNACPR that was undertaken by the mortality review working group. And I would just like to ask you a few more questions about that review if I may.

The first question I have is: has that review been published?

Ms Judith Paget: I don’t know. I asked the same question myself and I didn’t have an answer in readiness for my appearance at the Inquiry today, but I will definitely continue to follow it up and I can ensure that that is shared.

Ms Jones: Thank you very much. Secondly then, seeing as we don’t have a copy of that review I have a few questions about what it specifically looked at.

Ms Judith Paget: Okay.

Ms Jones: Did the thematic review specifically look at whether DNACPRs were used inappropriately during the pandemic for disabled individuals solely as a result of their disability?

Ms Judith Paget: I don’t think it specifically looked at that but I know that I have seen a conclusion in the nosocomial programme report that said that there had been no evidence of DNACPRs being inappropriately applied. So clearly that’s already documented and in the public domain, so that is documented in that report.

Ms Jones: I appreciate you gave evidence earlier about the fact that the thematic review found that conversations had not been documented, conversations with family members, and individuals. But a slightly different point that I would like to ask you about is, did the review look specifically at whether individuals and/or their families were actually consulted about DNACPRs during the pandemic?

Ms Judith Paget: So I think it would have been, because it was a review of documentation, so I think it would have reviewed whether or not it was documented that they had been and the quality and legibility of the recording of those conversations. I also know that there was a recommendation that came to say that any correspondence or written communication that they had from patients or families was also to be kept with the DNACPR form as well. So I don’t believe that there were conversations with individuals as part of that particular piece of work because it was a review of documentation.

Ms Jones: Do you think it would be a helpful recommendation for a review of DNACPRs and the concerns that were specifically raised, specifically in relation to disabled people, should now be conducted by the Welsh Government?

Ms Judith Paget: I don’t have a view. I think that we have done a number of reviews of DNACPRs. They have been extensive. That has included HIW, this thematic review and, again, the Nosocomial Transmission Group. I’m not sure what benefit there would be to a further review but clearly if there are concerns that have come through the system to our national lead then clearly they would be quite within their remit to do that for themselves.

Ms Jones: Thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Ms Jones.

Miss Gowman.

Behind the pillar.

Questions From Ms Gowman

Ms Gowman: Thank you, my Lady.

Mrs Paget, I ask questions on behalf of Covid-19 Bereaved Families for Justice Cymru.

Photographs were taken in hospitals within Aneurin Bevan University Health Board. Some of those photographs included photographs of patients being treated, and body bags. Were those photographs taken with patient consent or the consent of their family members? If not, should those photographs have been taken and published online without such permission?

Ms Judith Paget: So, one of the conditions on any agreement for the taking of photographs was that consent was to be obtained from the patient, from members of staff or family members. If a patient was ventilated and then recovered then the consent was to be retaken when the patient was well enough to do so.

So an absolute requirement was that consent was to be sought and documented.

Ms Gowman: My Lady, may I ask a follow-up questions in respect of the process by which consent was obtained from severely unwell patients, patient dignity, and the impact on the bereaved?

Lady Hallett: I think we have probably got enough, I am afraid. I take the point, Ms Gowman.

Ms Gowman: I will move on.

Lady Hallett: I know – I’ve heard a lot of about this, as you can imagine, directly from the Welsh bereaved.

Ms Gowman: Thank you, my Lady.

Lady Hallett: And I will hear more from them.

Ms Gowman: Yes.

On that basis, Mrs Paget, I will move on to discuss the national nosocomial Covid-19 end of programme learning report which was finalised in August 2024. Now, those I represent are highly critical of what they consider to be the superficial nature of the learning points in the final report with some significant issues they say being underplayed or omitted and I’d like to touch on the process by which the report was compiled and some of the deficiencies that they have identified.

Firstly, what steps have you taken to satisfy yourself that all nosocomial deaths in Wales have in fact been recorded as patient safety incidents?

Ms Judith Paget: So, as part of this programme, as you will know, there were changes made and focus given to the making – to ensuring that all nosocomial transmissions or healthcare-acquired infections in hospital were reported through a national reporting system. So that’s been consistently applied across NHS Wales.

Ms Gowman: And are you satisfied that it has been consistently applied and that all nosocomial deaths have been recorded in the way that you suggest?

Ms Judith Paget: I have to rely that the system has done what it’s been asked to do. I understand over 18,000 cases have been reviewed as part of this process, which is a substantial number. I have to rely that the process of having a clear specification and a clear process and a consistent process across NHS Wales has meant that we have captured all cases.

Ms Gowman: But presumably this was a relatively new process. Are there no checks and balances or audits that can be carried out to verify that they’ve all been recorded?

Ms Judith Paget: So I think that I would probably need to go away and check myself with those who might have been closer to the audit than I would have been and it would probably be wrong of me to speculate, but I know that in organisations whenever there was an outbreak or whenever anybody was deemed to have got Covid-19 whilst in hospital, there was a really clear criteria about making sure that we were clear had that been community acquired or hospital acquired, and that was consistently applied, to the best of my knowledge, throughout the pandemic.

Ms Gowman: Moving on then in terms of a particular deficiency that the group has identified. Do you accept that the report doesn’t fully address cluster outbreaks that occurred in Wales?

Ms Judith Paget: So, I – the report, as I’ve read it, clearly it’s not a Welsh Government report, it was done by the NHS, but I have, clearly, read it. Does it make specific references to clusters? But I do know that they clearly would have been investigated through the normal incident management team that investigated every outbreak. And that was based on my – obviously my experience of working in Aneurin Bevan.

Ms Gowman: But the report itself doesn’t identify underlying causes for outbreaks, doesn’t identify, for example, the effectiveness and implementation of IPC guidance and any contributory factors in that regard toward outbreaks, does it?

Ms Judith Paget: So it doesn’t make any recommendations around broader clusters, but clearly the recommendations around infection prevention and control, PPE, the state of the NHS estate and all those things would be factors in any cluster outbreaks as well as individual cases.

Ms Gowman: But without looking specifically at the detail and root causes of clusters, do you agree that the learning points in the report are somewhat limited?

Ms Judith Paget: I think that the reviewers would have determined that the lessons learnt from clusters and investigations of outbreaks at ward or departmental level or hospital level are already captured and with Public Health – and with Public Health Wales.

Ms Gowman: And can I ask, Mrs Paget, is this report intended to be a key part of NHS and Wales’ learning on nosocomial infection?

Ms Judith Paget: It absolutely is. It’s not the only thing, of course, but it is a really important piece of work. And as I said earlier in response to a question from Mr Mills, we will be ensuring that there is follow-up within the NHS Executive on this report and that we get, in Welsh Government, a quarterly update on the progress against the areas identified for action.

Ms Gowman: And my final question.

Given that it is to play a role in NHS in Wales’ learning, in light of the deficiency that I’ve highlighted, do you think there’s any merit in further exploration of what contributed to nosocomial infection in Wales?

Ms Judith Paget: So, I think – so, my view would be it is recorded and documented. What we will need to ensure is as this piece of work now moves forward that there are the opportunity for Public Health Wales to continue contributing learning as they’ve got it recorded in terms of that. But just to say that’s been there for a little while now, it’s not a new thing, so Public Health Wales will have, and NHS organisations will have a lot of information around the issues that contributed to outbreaks. And clearly, as part of infection prevention and control policies and practices, those things will have already influenced what is happening.

Ms Gowman: Thank you, Mrs Paget, no further questions.

Thank you, my Lady.

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

Thank you very much for your help, Mrs Paget. We’ve now completed the questions for you and we don’t have to do what we asked Dr Goodall to do. We have completed you today.

The Witness: Thank you, my Lady.

Lady Hallett: 10 o’clock tomorrow.

(The witness withdrew)

(4.11 pm)

(The hearing adjourned until 10.00 am on Thursday, 14 November 2024)