18 November 2024

(10.30 am)

Lady Hallett: Mr Scott.

Mr Scott: My Lady, please may I call Robin Swann.

Mr Robin Swann

MR ROBIN SWANN (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: Hello again, Mr Swann.

Mr Robin Swann: My Lady.

Mr Scott: Good morning, Mr Swann.

Mr Robin Swann: Morning.

Counsel Inquiry: Would you please give your full name.

Mr Robin Swann: Robert Samuel Swann.

Counsel Inquiry: And it’s correct that from 11 January 2020 until 27 October 2022 and then again from 3 February 2024 to 28 May 2024, you were the Minister of Health in Northern Ireland.

Mr Robin Swann: That’s correct.

Counsel Inquiry: We set out with the Chief Medical Officer the structures of the healthcare system in Northern Ireland so I don’t propose to go back over all of that ground. I just want to ask you, when Sir Michael McBride gave evidence he was asked did the population of Northern Ireland have the healthcare service they needed at the start of the pandemic, and he said no. He was also asked whether HSC was actually equipped to meet the needs of the Northern Ireland population at the start of 2020, and he replied:

“No, I don’t believe it was …”

Do you agree with him?

Mr Robin Swann: I would fully agree with both of those statements, yes.

Counsel Inquiry: Why was that?

Mr Robin Swann: I think we have – I think the Inquiry has heard in regard to the status that the health service was in prior to the pandemic. We’d been three years of not having a sitting or functioning Executive. The health service itself had been through single-year budgets from the year 2016 and a lot of the reforms, the investments and the dedication to our health service and the health service staff and the people who relied on it had not been delivered.

Counsel Inquiry: So, is it effectively that capacity was limited by the funding restraints that had been put upon it over the previous years?

Mr Robin Swann: It would be a fact that it was constrained by not just the funding constraints that had been put on it but also the lack of political decision-making on political direction that the health service, again, needed to make, that – the transformation that it had needed to make best use of the funding that it had but also the investment of the additional funding whether it could receive.

Counsel Inquiry: Again, as I set out with Professor McBride, as the chair has set out in the Module 1 report, there is only so far the Inquiry can go to look at funding. So, in terms of answers that you have throughout the course of the day, if funding is a core issue, please do say, but I think the value of repeatedly referring to funding may be relatively limited in terms of what the Inquiry can achieve.

But in terms of the funding constraints that you found yourself in, whatever the situation that you found, as health minister, you’d agree that you had to provide the most effective healthcare service that you could with the resources available to you?

Mr Robin Swann: That was correct, but what we also find is, my Lady, when I took up post in January 2020, our health service workers – the nurses were already on strike, they’d taken industrial action, the first time that health service workers across the UK had actually been forced to take that step in regards to what they felt was necessary, not just in regards to the financial package but also the asks that they had around CF staffing. And when the New Decade, New Approach agreement was agreed between the two governments as to what was going to be part of the restoration package for the new Executive come in, actually additional nursing training places was one of those core agreements, because we had – there was the recognition that the lack of training places across health and social care in Northern Ireland had been cut due to previous budgets as well.

Counsel Inquiry: Let’s look at your assessment of the state of the healthcare in the end of January 20. How prepared did you think Health and Social Care would be to respond to a pandemic?

Mr Robin Swann: When I first took up the post in regards to that, our biggest challenge, again, was the industrial action but also where Northern Ireland was in the desperate situation in regards to the length of our waiting lists, the worst across the United Kingdom.

So the challenges that I faced or the health service faced was also that of additionally in regards to staff but also the challenges of our waiting lists. So as a priority, as a stress on its own, Northern Ireland I think was an outlier in regards to being in a worse position than some of the other health services across the United Kingdom.

Counsel Inquiry: Okay, well, let’s look at it a slightly different way. By the end of January 2020, did you believe that Health and Social Care would have a capacity to respond to a pandemic?

Mr Robin Swann: Not at that point because I don’t think we had the available capacity built within the system to take on the additional strains that a pandemic would actually present because – I think we’re referring to that earlier answer in regards we didn’t have the resource nor the capacity of the challenge the waiting list situation that was the immediate impact in Northern Ireland.

Counsel Inquiry: Mr Swann, I just want to make sure we’re focusing on capacity to respond to a pandemic. Those are potentially two different things when we’re talking about resourcing other areas compared to responding to a pandemic. I mean, you first attended COBR about Coronavirus on 24 January 2020; is that right?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Around that time did you ask what plans Health and Social Care had to respond in the event of a pandemic rather than necessarily just the Coronavirus pandemic?

Mr Robin Swann: I don’t recall that specific question but I am aware that there was the pre-pandemic preparedness plans that we covered in Module 1 in regards to what was necessary, what different management systems could actually be brought in regards to gold, silver bronze commands within the Health and Social Care system.

Counsel Inquiry: Those are more structures as opposed to physically how Health and Social Care would respond, how it would build capacity, how it would surge in the event of additional critical care capacity needs. Do you remember anything on those lines?

Mr Robin Swann: I don’t remember anything along those lines but I think that’s where, you know, those – preparedness of silver and gold – gold commands were there.

Lady Hallett: Could I ask you to speak more slowly. You’re like me, you speak very quickly, so we’ll try to encourage each other to speak more slowly.

Mr Robin Swann: Apologies, my Lady.

Mr Scott: What did you think would be the major factor or factors that would limit Health and Social Care’s ability to extend or expand its capacity to respond to the Coronavirus pandemic?

Mr Robin Swann: The main factors would be that of available staff but also space and capacity within the healthcare structures that we currently had. Again, I’ve already stated that we were challenged with the number of healthcare staff that was available but also our structures were – across the healthcare estate, were ageing and needing updating and investment.

Counsel Inquiry: In terms of the staff, you would have been able, in late January, early February 2020, to be able potentially to re-organise your staffing capacity to make sure that the staffing was focused in the areas where it would need to be to respond to the pandemic, is that right?

Mr Robin Swann: That would have been something that would have been an operational decision for the trusts, and I think that was part of that planning preparedness that the only ability that we had to do that was to actually step down other services because we didn’t have that inbuilt capacity, that spare capacity within Health and Social Care and, again, as I said in a previous answer, that was one of the reasons that our healthcare service had actually – went and took industrial action prior to the Executive being restored.

Counsel Inquiry: But in terms of – you say that’s an operational decision. Given your understanding of the capacity, given your knowledge of what you were hearing at COBR in January and February, did that make you personally focus on ensuring that there was a maximisation of capacity, particularly staffing, within Health and Social Care, to respond to the pending pandemic?

Mr Robin Swann: It was an issue that was already there in regards to we didn’t have enough staff actually to deliver the healthcare service that we wanted to, even pre-pandemic, so, as I keep reiterating, that additional leeway, that flexibility, wasn’t something that we had available to disperse and actually engage without having to displace other functions.

Counsel Inquiry: Yes, Mr Swann, but that’s the point, you’re walking in – that’s the baseline that you’re saying there isn’t sufficient staff. The question is: did you put a focus on making sure that you were maximising the ability to use the staff that you had available to you?

Mr Robin Swann: I think what I’m trying to say is yes, there were those plans in place in regards to what we needed to do but the challenge was that there wasn’t flexibility there actually to do what we would have wanted to do.

Counsel Inquiry: What direction were you applying to any planning for the pandemic in February 2020?

Mr Robin Swann: Sorry, in regards to?

Counsel Inquiry: In regards to whether there were plans, what the response was going to look like, whether there was sufficient capacity being built in, whether there were actually plans in place for how the capacity would be used that could be made available within Health and Social Care?

Mr Robin Swann: There was in regards to the activation of the pre-pandemic preparedness plans that, again, engaged and actually stepped up, and gold and silver commands were at operational delivery, was brought in at silver command. We were bringing the trust together, chaired at that stage by the Public Health Agency in regards to what steps would be taken or could be taken.

Counsel Inquiry: Yes, but the question is what you were doing. So silver command, gold command, they were a level below you, is that right?

Mr Robin Swann: Yes.

Counsel Inquiry: So were you doing?

Mr Robin Swann: I was meeting with the senior officials within the department, we were meeting at an Executive level, as well, to make sure that there was also a response ready for across the Executive as to how we could respond to a pandemic.

Counsel Inquiry: But the Executive weren’t directing how the Health and Social Care should respond; that’s a matter for you as the health minister, is that right?

Mr Robin Swann: That’s correct.

Counsel Inquiry: So I just want to look then at the detail of surge planning for the first wave. So it’s right, isn’t it, that on 17 February the CMO wrote requesting a detailed surge plan? Do you remember what modelling was being relied upon at that point in terms of, firstly, what capacity Health and Social Care would require to meet the first wave and also what the peak of wave 1 would look like in terms of when it would arrive?

Mr Robin Swann: I think that module – that modelling at that point was coming from SAGE in regards to the figures that were coming across.

Counsel Inquiry: Do you remember any of the detail about it?

Mr Robin Swann: I don’t remember off the top of my head, not in regards to the January figures.

Counsel Inquiry: If I look at the modelling of 9 March.

If we could please have on the screen INQ000425604.

So, I believe you’re familiar with this document?

Mr Robin Swann: Yeah.

Counsel Inquiry: And so this is modelling that was commissioned from SPI-M-O; is that correct?

Mr Robin Swann: Yes.

Counsel Inquiry: And this is the first Northern Ireland specific modelling of the potential impact of the pandemic; is that right?

Mr Robin Swann: It seems to be, yeah.

Counsel Inquiry: We will look at the specific figures in a second, but when you saw this modelling – I presume you saw this on 9 March or around 9 March; is that right?

Mr Robin Swann: I don’t recall the exact date I saw this specific document, but I am aware of these figures.

Counsel Inquiry: But it probably would have been given to you around the same time it had been received?

Mr Robin Swann: Yeah.

Counsel Inquiry: Did you feel that these were the numbers that actually Health and Social Care were working towards in terms of what the impact would be on them in terms of number of cases, deaths, symptomatic cases, or did this present a dramatic change in terms of the numbers that would have to be dealt with?

Mr Robin Swann: This – at that specific point in regards to the 32,000 peak daily new symptomatic cases was, I suppose, a stark focus in regards to what Northern Ireland was actually going to be facing in regards to those numbers without any intervention, actually being taken.

Counsel Inquiry: Yes, but the question was more when you received this modelling, did it present a step change to what you were working towards?

Mr Robin Swann: Yeah, I think it was also at that point, my Lady, in regards to the 32,000, the daily hospital admissions of 4,000 possibly per day, was really that point that really made this whole thing real, both to me and to my Executive colleagues. In regards to that there had been hypothetical assumptions as to what could happen, what would happen, what was happening elsewhere, but it was in regards to those specific figures, and if I recall correctly, around that time, I think in the receipt of those, we actually made a press statement, the First and Deputy First Minister and myself in regards to those figures, that what could actually come about in Northern Ireland if behaviour interventions didn’t take place in regards to that.

Counsel Inquiry: You just said that these figures were the point that really made this whole thing real. This is 9 March. You’d been watching what had been happening across the world. Did it not feel real well before that point in terms of what was likely to happen in Northern Ireland?

Mr Robin Swann: It did feel real as to what was going to happen in Northern Ireland, but I think, my Lady, in regards to when you see that level of a population, a population of 1.9 million people in Northern Ireland, where they could be facing, 32,000 cases per day, 4,000 hospital admissions in regards to what our system, what the population was able to compete with, and again, those figures were without, as the paper says, without behavioural intervention. So I think that was the crux, as I say, that made it real for us, made it real for me as an individual in Northern Ireland.

Counsel Inquiry: Did that making it real, then, provide a different impetus to the level of planning or the pace of planning that was going on at that point?

Mr Robin Swann: I think it made quite a different inference in regards to how the rest of my Executive colleagues reacted as to what was actually coming, as I said in Module 2C, up until that pointed and part of the challenge that we had was that up until then, the Covid pandemic was going to be treated very much as a health issue rather than a whole society issue, but when you look at those sort of numbers when we had the intervention that those sort of numbers were possibly – what was going to happen to Northern Ireland without the behavioural interventions, that’s what focused a lot of minds.

Counsel Inquiry: As you were just talking about Module 2C there, the other minister’s responses was dealt with in Module 2C. I’m focused on the response of the healthcare system and the response of you as the health minister, are you satisfied, then, that prior to this modelling, prior to this starting to feel real, that there was sufficient pace of planning, sufficient depth of planning to ensure that Health and Social Care could respond to the pandemic?

Mr Robin Swann: I don’t think that the surge plans in their totality were preparing for the numbers that we were going to see or we were potentially going to see without the behavioural interventions because, as it states there, average daily beds available in Northern Ireland were actually less than what was being expected as the Covid peak daily new hospital admissions (unclear) that model and so would have crippled our system completely, my Lady, in regards to that, if we hadn’t took those behavioural interventions that we did.

Counsel Inquiry: Well, even taking those behavioural interventions, when you look at this modelling, so daily – peak daily hospitalised caseload of 10,000 when the average daily beds available is 3.8 thousand, peak daily invasive ventilation of 1,000, an average – so total level 3 ICU beds, so that is those that can deal with ventilation was 100, so a tenth of the peak daily invasive ventilation, did you think that HSC had any possibility of coping with those modelled numbers even with the interventions?

Mr Robin Swann: No, and I think that’s where the surge plans that were put in place at that stage looked in the beginning of the first wave but dramatically related, and actually stepping down a lot of the core issues and the core services that Health and Social Care were delivering so that we could best prepare for what was in front of us.

Counsel Inquiry: Because four days – so on 19 March, the department published what was called the summary plan for mid-March to mid-April. So that’s about 10 days after this modelling had been received and it’s four days after the first Covid-19 related admission to critical care in Northern Ireland; that’s right?

Mr Robin Swann: That’s correct, yeah.

Counsel Inquiry: So there had been ten days before that plan was published to respond to that modelling; that’s right?

Mr Robin Swann: That’s correct, yeah.

Counsel Inquiry: And the purpose of that summary plan was, as it says, to ensure that there’s sufficient capacity within the system to meet the expected increase in demand. That was the point of that plan at that time?

Mr Robin Swann: That’s correct.

Counsel Inquiry: So by the time that summary plan was published, why wasn’t there a defined surge plan for critical care?

Mr Robin Swann: For critical care specifically, that was something that Critical Care Network for Northern Ireland had been asked to organise. Our bed – critical care ICU capacity was 88 beds at that point in time from my recollection, so the surge plan in regards to intensive care specifically was something that was built up looking across those networks, how we actually maximised the trust but, again, the limiting factor in regards to be able to supply ICU beds, that critical care capacity, was actually the availability of trained workforce who could actually staff and manage critical care beds.

Counsel Inquiry: Yes, but that’s not an answer to the question about why there wasn’t a defined surge plan for critical care alongside the summary plan that was published on 19 March?

Mr Robin Swann: There wasn’t one developed at that stage that I am aware of. My Lady, I do know that the Chief Medical Officer had asked the Health and Social Care Board to prepare a surge plan and he had some concerns about that and it had actually been returned before that one was actually published was delivered to the department.

Counsel Inquiry: Yes, and this comes back to the fact that the CMO had requested that on 17 February. So it was over a month since the initial request to when the summary plan was then published and the summary plan didn’t include a surge plan. And the question is, why did it not have a surge plan if the point of the summary plan was to make sure you had sufficient capacity within the system?

Mr Robin Swann: I’m unsure, my Lady, has to why that surge plan at that point didn’t include a specific in regards to critical care. There was a later plan developed in regards to how we managed our critical care beds across Northern Ireland, looking at all trusts coming together but also how we actually, at a later date, instigated a Nightingale facility with the Belfast tower blocks specifically around critical care beds.

Counsel Inquiry: Did you see the summary plan before it was published?

Mr Robin Swann: I would assume I did, yes, from recollection.

Counsel Inquiry: Did you ask: where is the surge plan?

Mr Robin Swann: For critical care beds, no. If it’s not in the submission, my Lady, at that point I mustn’t have.

Counsel Inquiry: No, but as the health minister, you’re there to critically assess the submissions that you were getting?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: Did you look at this and say: actually, how are we going to scale up critical care here? Do we have a plan in place?

Mr Robin Swann: If that’s not in that submission, at that point I didn’t.

Counsel Inquiry: On reflection, do you think that’s a question that you should have asked?

Mr Robin Swann: In reflection, yes, my Lady, pointing out that I was newly into the position in regards to that, in regards to there had been no health minister previously, in regards to the specific questions of the surge plan that I could have been asking. On reflection, and what I know now is very different from what I knew then, but I can get back to the work that was taken under the Critical Care Network for Northern Ireland in regards to how they were able to flex up critical care beds where they looked at at later dates.

Counsel Inquiry: I am just going to push that one stage further. You say that you were new in the role. It’s not a matter of how long you were in the role to assess whether there was actually a plan in place for how you were going to scale up critical care. That doesn’t require experience as a health minister, does it?

Mr Robin Swann: No, it’s that ability to be able to ask the right questions, at the right time, my Lady, in regards – in hindsight, knowing what I know now compared to what I know then, I would have asked that question, would have insisted on it.

Counsel Inquiry: So do you think, then, that, whatever the reason, that you weren’t providing a sufficient level of direction as the health minister that you believe you probably should have provided?

Mr Robin Swann: Yes.

Counsel Inquiry: I see you’ve also mentioned the Nightingale plan, it was also a fact that the Nightingale wasn’t included in that summary plan of mid-March; that’s correct?

Mr Robin Swann: No, Nightingale was at a later date.

Counsel Inquiry: The surge plan eventually was published on 16 April, that’s right?

Mr Robin Swann: Correct, yeah.

Counsel Inquiry: You’d received modelling on 1 April that set out – sorry, let me start that again.

You had received modelling on 1 April from the Northern Ireland regional modelling group; correct?

Mr Robin Swann: Correct, that’s right.

Counsel Inquiry: And that modelling set out when it was anticipated that the peak would arrive in Northern Ireland; that’s correct?

Mr Robin Swann: That’s correct, yeah.

Counsel Inquiry: And I think it was anticipated it would be between 6 and 20 April; is that correct?

Mr Robin Swann: As far as I recollect, yes.

Counsel Inquiry: So do you know why the surge plan was only being published at the very end of the peak period?

Mr Robin Swann: It was in preparation of what was available and, as I said earlier on, my recollection was that the CMO had asked the Health and Social Care Board to develop a surge plan and he had queries and questions in regards to that, that it was returned for the second publication and iteration. But it wasn’t to say, my Lady, just because the plan wasn’t there it didn’t mean that action wasn’t already being taken.

Counsel Inquiry: No, but the action wasn’t complete. If you’re talking about a plan, you need to make sure that your plan is complete to know how you’re going to respond to the peak of the pandemic; isn’t that right?

Mr Robin Swann: That’s correct, yes, but there was actions being taken.

Counsel Inquiry: Do you know why – again, maybe this is repeating itself, but do you know why it had taken a month from the publication of the summary plan on 19 March to the publication of the surge plan on 16 April 2020? What was the reason for that length of –

Mr Robin Swann: I don’t know why that delay was from – from my recollection of those.

Counsel Inquiry: Can we move on and look at the actual surge plan from 16 April.

Can we please have INQ000377154. Thank you very much.

So we can see at the top there:

“Overall planning assumptions: Modelling on 7th April …”

So, 9 days before this was published.

“… indicates [reasonable worst-case scenario] of 140 COVID beds needed at peak, in addition to 35 NON-COVID … This … [requires] 175, this Plan will reach that target at high surge with a margin for delivery of higher volumes.”

So, at the time that this surge plan was published, it was anticipated, based on the modelling, that Health and Social Care would be able to deal with the first wave of the pandemic; that’s correct?

Mr Robin Swann: That would be the assumption – for critical care beds, yeah.

Counsel Inquiry: Yes. I want to look on the left-hand side, please, and it’s a section called “Key points”, and it says:

“Triggering points identified for each phase by CCaNNI.”

That is Critical Care Network for Northern Ireland?

Mr Robin Swann: That’s correct.

Counsel Inquiry: What was the role of the department in terms of when the various levels under this surge plan would be escalated through?

Mr Robin Swann: From a departmental point of view it was up to the CCaNNI to actually instigate and move between each module, each stage, each step.

Counsel Inquiry: Why wasn’t the department exercising effectively the final decision that could be informed by the advice of the CCaNNI? Why wasn’t that a departmental responsibility?

Mr Robin Swann: Because in regards to how the Critical Care Network had actually been setting up, it was agreed it was their established practice that they would trigger the additional points rather than the department stepping in to make decisions which were operational at that point.

Counsel Inquiry: Is there not a loss of this central element of control if it’s not being taken by the department, given the department’s oversight of all aspects of health and social care in Northern Ireland?

Mr Robin Swann: I think in this specific instance, I – it was that the Critical Care Network for Northern Ireland is made up of those senior officials within each trust working with the representation, as far as I can recall, from Health and Social Care Board, so it is for them to make the operational decision as to what they need.

The surge plan itself looks at different hospitals and different trusts escalating different numbers of beds at different times, so it’s how they deploy their staff and their resource. I personally think it was best left in the hands of those professionals to make those decisions at those points.

Counsel Inquiry: And there wasn’t a regional command structure for managing the surge plan prior to January 2021; is that right?

Mr Robin Swann: That’s correct, yes. In regards to critical care?

Counsel Inquiry: Yes.

Mr Robin Swann: Yes.

Counsel Inquiry: Sorry, when I say “the surge plan”, we’re talking about the critical care services’ surge plan.

There was an assessment done by a military assessment team in December 2020 that suggested that that regional command and control structure should have been brought in. Did you think that there was a loss in terms of the way that Northern Ireland responded by the department not having that central control in 2020?

Mr Robin Swann: I’m not sure that there was anything lost, my Lady, in regards to how we actually responded, and that’s – we wanted to make sure that that Critical Care Network and how it actually functioned was as robust as possible coming into the second wave, and that’s why we actually commissioned that military assessment through – through a MACA request in regards to making sure everything we were doing was right. They recommended that central control and command structure, which was more robust than what CCaNNI, I believe, had previously through that.

Counsel Inquiry: So I want to know, did you have any specific knowledge, as the pandemic progressed, about how far each ICU had surged over the baseline figure, so ie, compared to what’s on the screen, the number of beds above what’s set out in the steady state for each hospital?

Mr Robin Swann: There was regular updates on our Covid NI dashboard in regards to how many patients were actually in ICU at any one time, and those reports would have been coming in – every time we surged I would have received an update.

Counsel Inquiry: Is there a slightly different matter when you’re talking about how many beds there are in ICU across Northern Ireland as a whole as opposed to how many beds there are available in each individual hospital? Was it – that hospital-level information that you had or did you not have that?

Mr Robin Swann: I believe I had hospital information, but not on a daily basis, in regards to the number of ICU beds that were occupied both by Covid and non-Covid patients that were available on the – actually on a public-facing dashboard as well. When it come down to that level in each hospital, I don’t recall if I was receiving that level of data.

Counsel Inquiry: But you’re satisfied the department did have that knowledge?

Mr Robin Swann: I would be satisfied they did and that also that’s been managed through CCaNNI.

Counsel Inquiry: Okay. The Department of Health data statement sets out at paragraph 6 that between 20 March 2020 and 20 May 2022 there were 651 dates wherein at least one hospital in Northern Ireland all ICU level 1, 2 and 3 beds were occupied. Did you know how critical care admissions would be managed when all the critical care beds in any given hospital in Northern Ireland were full?

Mr Robin Swann: Well, that was the rationale for the Critical Care Network, that anybody requiring that critical care could then be supported through another hospital somewhere else, and, my Lady, at one stage, I think through the – the CNO had developed a memorandum of understanding with the Republic of Ireland, where if such a situation in Northern Ireland actually arose that we didn’t have available ICU bed capacity that we could use cross-border function as well. And I’m not aware we ever actually had to trigger that but it was something that we had prepared.

Counsel Inquiry: When would this have been escalated to you? I say this, when would a decision about escalation of surge states, whether local escalation, regional escalation, whether one hospital is full, is there any time when that would have been information passed to you?

Mr Robin Swann: It would have been after the fact. It wouldn’t have been – they wouldn’t have been coming to me to seek authorisation or clearance to move from one surge level to another.

Counsel Inquiry: I want to talk now about your understanding of staffing ratios once these surge plans had been produced, because if we can look at key point 10, please – again on the left-hand side, thank you very much.

“Staffing levels per patient will reduce as surge levels progress, staffing ratios across units to remain stand constant.”

And then, on the right-hand side, but I don’t think we need to go to this, there’s an explanation about how staffing would operate for each of those individual levels.

So, for example, if we go down to “Step three – High Surge”:

“Patients to staff ratios diluted further in line with CCaNNI plan.”

Were you told what were the anticipated staffing ratio for critical care for each of those surge levels?

Mr Robin Swann: I remember having the conversation with the Chief Nursing Officer, my Lady, because I know it was something that distressed her greatly, that the dilution of critical care beds would be less than one critical care trained nurse per patient across each of the sections. So it wasn’t something that was taken lightly.

Not every occasion when we escalated actually reduced or caused that dilution to occur, from my recollection. It was necessary in some instances. But that wasn’t to say that those patients weren’t being supported. It meant the ratio of critical care nurses weren’t to the desired level that either I or the CNO would actually have wished have happened, and has come back to an earlier answer in regards to our ICU beds, that our limiting factor at the beginning of the pandemic was those nurses who were actually trained to deliver that ICU critical care capacity.

Counsel Inquiry: Why was it that the Chief Nursing Officer felt the need to raise it with you?

Mr Robin Swann: Because it was – I suppose it was a step away from what was normal. And again the Chief Nursing and I had a working relationship where those sort of concerns that she had she could come to me and have those conversations in regards to being one of my professional officers in regards to that. It was a step that was necessary but it was a step that she wanted to make sure I was aware of was actually something that was going to be necessary to deliver the level of care that we didn’t envisage that we would ever have to but was necessary due to stepping through the different levels of surge for critical care.

Counsel Inquiry: Does that not reflect the fact that you should have had more involvement in understanding what the surge plan was going to look like and how triggers were for moving between the various surges and also what happened as the pandemic developed?

Mr Robin Swann: And I think in regards to an earlier answer, knowing what I do now, yes in regards to that. But as the pandemic developed and we stepped through these surge plans, that’s why when we developed the Nightingale for critical care and the Ulster tower block, that’s when it was specifically target toward that critical care capacity.

Counsel Inquiry: One question before we come to the creation of the first Nightingale. This surge plan, did you actually know where the staff would come from to be able to staff up the increased beds across all of the various surge levels?

Mr Robin Swann: In regards to these in a specific level that would have been an operational model for each of the trusts, but it was by taking staff from other parts of the hospital delivering other parts of care that we had to step down to make sure these beds were managed and supported.

Counsel Inquiry: Given your concern about staffing and capacity of staffing when you first took on the role of health minister, when you first saw this surge plan did you think to ask: do you have – I say “you” – do the trust have plans in place about how you’re actually going to make sure that you have the staff to meet the numbers that you’ve set out in this plan?

Mr Robin Swann: And that was – although the surge plan was not specifically in critical care, actually looked about what services unfortunately we’d have to step down so we could deliver the staff to meet the demand at that we had through Covid and critical care beds.

Counsel Inquiry: That’s the generality. Did you know the specifics about where they were going to come from?

Mr Robin Swann: No, I wouldn’t have had that level of knowledge coming from each hospital nor each trust.

Counsel Inquiry: Were you told that there would be sufficient staffing to meet those numbers?

Mr Robin Swann: By displacing other services, yes.

Counsel Inquiry: I want to look now at the creation of the first Nightingale.

The Department of Health statement says that it was:

“Informed by [the] reasonable worst-case scenario modelling …”

That would have been 1 April, from the regional group.

“… the Department initiated a rapid assessment of potential sites … on which to locate a Nightingale Hospital facility to provide additional critical care …”

The CMO statement says that the site visits were on 28 March. Are you able to remember precisely when planning for the first Nightingale actually commenced?

Mr Robin Swann: I don’t remember when the planning actually commenced. I remembered the options in regards to a number of non-hospital sites that were explored. I actually was part of the site visit to the Eikon centre in regards as to what a facility could actually be for the first Nightingale. At that stage, and following various assessments both internally but also in regards to engaging military support again, there was – none of those sites were actually deemed feasible in regard to the amount of physical work that would actually be needed. So that’s why the decision was taken to actually step up the first Nightingale within the tower block within the Ulster Hospital.

Counsel Inquiry: Can we look at a briefing paper, please.

It’s INQ000276382. And if you just go back a page.

This is actually the briefing paper that was sent on 18 April, so it’s not the first facility, but this provides an overview of some of the lessons that had been learnt as parted of the planning and process, so I think it’s a helpful document.

If we can please go to just to raise the point that you were just discussing, page 4. And then there’s, as you say, first wave site visits, there’s a couple of visits, and then paragraph 18:

“Of these three sites, the Eikon was considered the most suitable due to the location …”

However, due to the second visit:

“… a decision was taken not to progress the project … due to the amount of work that would have needed to be carried out in a short time scale in order to make the site suitable.”

That’s what you were just saying there about –

Mr Robin Swann: That’s correct.

Counsel Inquiry: And that’s the reason why the Nightingale ended up in the Belfast City Hospital Tower, and it’s fundamentally because the preferred option couldn’t be made ready in time?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: Is that a reflection, do you think, of the fact there had been a lack of planning for a Nightingale at an earlier stage?

Mr Robin Swann: I don’t think Nightingales across the United Kingdom – and specifically, my Lady, in regards to the Nightingale facility in Northern Ireland, it was a critical care facility that we were looking at in regards to where we were seeing the most need of beds. The work that would have been done to make oxygen available, to make all the proper medical necessities available for a critical care bed, the Eikon centre would have taken an inordinate amount of work to bring it up to status, because it is actually a large exhibition centre, it’s a large warehouse, rather than the facilities that would actually become available by the adaptations of the tower block and the city hospital.

Counsel Inquiry: Yes, those are the practical difficulties that were faced. The reason why it didn’t end up in that centre.

But I’m asking, should there have been planning at an earlier stage which would have allowed you to then use what would have been the preferred site, apart from logistical issues, as the Nightingale?

Mr Robin Swann: I think it was the physical work. It wasn’t the ability to assess or actually see what site would have been more suitable; it was the timescale that we had to put the actual physical mechanics, the oxygen lines, the oxygen generators, on to site. As I say, the Eikon is a large centre that’s used for conferences and – or an agriculture show more so than being a medical facilities, so the level of works to bring it up to spec would have been – would have taken more time than actually just the planning phase.

Counsel Inquiry: Yes, so if you’d started planning earlier you’d have had more time to put all those physical specs in; is that true?

Mr Robin Swann: In a roundabout way I could agree but I think what – there’s a difference between planning to make these changes and actually putting physical site works in place that would have allowed to us put ICU beds into that facility rather than what actually came about with the physical works that we were able to step up at the tower block and the Ulster Hospital.

Counsel Inquiry: But effectively the Belfast City Hospital Tower was not the preferred option, all things being equal. You would have preferred it to be elsewhere?

Mr Robin Swann: All things being equal, the recommendation was that the Eikon would have been a preferred site. But as it wasn’t – as we weren’t able to make it physically ready in the short timescale that we had, the Ulster – the tower block at the Ulster Hospital then was the preferred side for actually being able to deliver that large-scale critical care that we would have needed.

Counsel Inquiry: Because I think, as this briefing papers sets out at paragraph 5, back on page 2, that the layout of the Belfast hospital actually wasn’t ideal because the layout meant the maximum group of patients that can be safely managed is 24, but with the same staffing complement, the Nightingale in London is able to deliver care to 42?

Mr Robin Swann: That’s correct.

Counsel Inquiry: So the location of the hospital rather than being in a big site was actually then limiting the ability for you to take in more patients.

Now, as it turns out, the full capacity was never required?

Mr Robin Swann: But can I – maybe just to clarify and take a step back in regards to the Nightingale in London, if I recall, my Lady, it wasn’t critical care beds that was actually deployed in the Nightingale in London, whereas we were into critical care beds –

Lady Hallett: I think it may be that it was Wales and Scotland – I’m not sure it was London that wasn’t critical. I thought London was critical –

Mr Robin Swann: It was – I apologise.

Lady Hallett: But you are certainly right that one of the nations wasn’t critical care.

Mr Robin Swann: Wales wasn’t. Apologies, sorry.

Again, we were fitting something into the physical space that we had to be able to make the changes, the physical changes that we actually need, whereas the Eikon would have been the preferred site if we’d have had time to do that.

Mr Scott: Wasn’t there another disadvantage about putting the Nightingale in the BCH Tower, that you were putting the Nightingale in the middle of the regional cancer centre?

Mr Robin Swann: That’s correct.

Counsel Inquiry: What were the consequences for infection prevention for those people who were suffering from cancer who were visiting the BCH by having the Nightingale in the middle of the tower?

Mr Robin Swann: It was on specifically different floors so there was that segregation between the provision of further – or additional and continual services that were in the tower, as well as being able to adapt those floors that were used for the Nightingale.

Counsel Inquiry: Was there another difficulty caused by BCH being in the Nightingale that it had a consequential impact on the ability to actually provide cancer care because you didn’t have the same level of facilities, you didn’t have the same level of staff to be able to offer that cancer care because they were going to be required for the Nightingale?

Mr Robin Swann: It wasn’t – it wasn’t that those staff were being simply redeployed to the tower block. Again, we had to step down certain specialities, certain provisions, that we wished we hadn’t to have done so, my Lady, but in regards to be able to complement the additionality in regards to critical care, and I’m again referring back to the point with regards to availability and the service of staff was something we did not have in Northern Ireland at that point.

Counsel Inquiry: I’m asking about a choice that did fall to you, effectively, about the location of the first Nightingale. If you hadn’t put the Nightingale in the middle of the BCH tower, you could, had you chosen to do so, have continued to use those facilities to provide cancer care; is that not right?

Mr Robin Swann: It wasn’t that we had to stop cancer treatments in regards to the placement of – to supply the additional critical care beds. It was the fact that some of those treatments and supports were displaced elsewhere in regards to what we did, but again, going back to the operational decision of the trusts in regards to do that. My Lady, we had to step down services that we didn’t wish we had to in regards to what we had to do to support the Covid delivery of supporting patients and, again, I think it was something that, again, was more impacted in Northern Ireland due to the status and the state that the health service went into prior to Covid.

Counsel Inquiry: Let me ask one final question in relation to the first wave Nightingale. Do you remember how much it cost?

Mr Robin Swann: I don’t.

Counsel Inquiry: I’m going to turn now to testing of patients in healthcare workers.

At paragraph 301 of your statement you say:

“It was brought to my attention that there was not sufficient testing capacity, particularly at the start of the pandemic. To address this, in April 2020, I established and an Expert Advisory Group.”

Do you think on reflection that you sought to increase testing capacity early enough?

Mr Robin Swann: Testing in regards to where we finished up in the pandemic in regards to the availability, the easy use test that we had compared to where we actually were at the beginning, I think there was a rapid change in the science which was beneficial in regards to that. We had access to a number of not only in-house delivery mechanisms but also public sector and private sector in Northern Ireland that we sought to make use of. In regards to were tests developed at a rapid pace, the testing facility in Northern Ireland, if we could have had more tests earlier, I think everyone would have been welcome of those.

Counsel Inquiry: But did you put a focus on ensuring that you ramped up all available sources of testing in Northern Ireland early enough?

Mr Robin Swann: There was a request across – because, if I do recall, my Lady, we did make appeals and actually utilised some of the Department the Agriculture labs in regards to testing platforms and testing specifics were actually identified as to what was necessary, and we were using APHA facilities, we were using private care facilities, and even private providers in regards to that.

Counsel Inquiry: Yes, I think the question is not what you did but at the time that you started doing it. Do you think that you could have started securing that additional testing capacity at an earlier stage?

Mr Robin Swann: We could always have done something earlier if we’d have been able to facilitate and look at it, in regards to where we were, in regards to what was needed to actually produce the tests and actually deliver the tests and actually produce the results reliably from them. I think we moved at pace in Northern Ireland in regards to how we were bringing together those different providers and different delivery avenues that we were able to bring together.

Counsel Inquiry: I want to move now away from the first wave and start to look at learning from the first wave ahead of the second.

Staffing during the first wave. Were there any specific staffing shortages in terms of location, whether it be geographical, speciality, that were identified in the first wave?

Mr Robin Swann: In regards, and I think it falls back to your earlier line of questioning in regards to the specifics around specific ICU care capacity, in regards to what was necessary as we stepped up through those in regards to that. And I think that was the main one that I can recall, my Lady.

Counsel Inquiry: So what steps did you take to improve staffing levels particularly in critical care capacity?

Mr Robin Swann: Well, it was about that additional ability to bring in the different resources, also different ratios as well, but again, we were looking at a point where, as I said, New Decade, New Approach was actually about providing additional nursing training places. Nurses can’t be trained in a matter of months nor weeks and that’s why we were looking to increase the nursing numbers but also looking to see where those weaknesses were in regards to – I don’t remember any specific additional training courses that were identified or delivered in preparation for the second wave.

Counsel Inquiry: Yes, but at this point in time, after the first wave, you’ve experienced the first wave, you have seen how Health and Social Care has responded to it. You have an understanding of your capacity and your staffing. You had to work with the resources you had available to you. I think the department set out that it wasn’t possible to train new nurses in that time. So what focus did you put on making sure that there was an increase in staffing, as much as you possibly could, to be able to respond in the event of a second wave?

Mr Robin Swann: We did put out a number of workforce appeals but they were at the start more generic in regards to bringing in additional resource towards bringing in those staff who had either just retired or were working elsewhere to see if they could actually support Health and Social Care. But, my Lady, moving from the first wave into the second wave, we also had to be aware of the strain and the stress that was actually on an already overstretched workforce who had been on industrial action, come off industrial action, and then went head long into a pandemic facing something that healthcare workers, we would never have expected them to be facing at that pace and time. So there was a need, as well, to give them time to actually step back and recharge their batteries as well, as we prepared for that second wave as well.

Counsel Inquiry: Did you do that?

Mr Robin Swann: Yes, we did – as much as possible, I remember, in regards to regarding engaging with trusts and the Chief Nursing Officer in regards to make sure that if there was leave available that could be taken, was taken. But again, that put additional strains on our ability to quickly re-step up other services as well, always cognisant of the critical nature of what we wanted to do against the resources that we actually had.

Counsel Inquiry: And was that with an eye on a potential for a second wave or is that just to allow, effectively, staff to recover from the exertions of the first wave?

Mr Robin Swann: In fact it was a reflection of both, because I think moving into the second wave – sorry, in the first wave, we’d relied extensively on the goodwill and resilience of our healthcare staff and without giving them time to have time to, as I say, to recharge their batteries, actually to get their heads around what they had just been through prior to moving into a second wave, I think it was only fair and right to do that.

Counsel Inquiry: Because you mentioned about the workforce appeal. So was the workforce appeal the main route by which you were trying to bring in additional members into the workforce?

Mr Robin Swann: There was, at that point, in regards to that workforce appeal, as to how we re-engaged additional resource into Health and Social Care.

Counsel Inquiry: In your statement at paragraph 151 you say:

“From April 2020, and throughout the second wave …”

Do you remember when the first workforce appeal went out?

Mr Robin Swann: I don’t off the top of my head.

Counsel Inquiry: “… the Workforce Appeal handled almost 60,000 Expressions of Interest, and generated over 35,000 formal applications. This level of interest delivered a total 5,949 new temporary appointments … of which 2,800 were health and social care … The other appointments were non-medical, covered support services …”

How was the workforce appeal meant to function in terms of how quickly were you meant to be getting workers in?

Mr Robin Swann: It was meant to be – it was actually subcontracted to a specialist in recruitment in healthcare, as I recall, in regards to that we could turn around some of those appointments as quickly as possible. I was disappointed in regards to the high numbers of people who expressed an interest as to the numbers that actually were employed but I think there was a number of legitimate reasons that we were given in regards to those people who were coming forward, maybe not having the specific requirements, the specific training, or the ability to fix into slots where they were actually needed.

I think one of my recommendations, if there is the further need for a workforce appeal that they were actually targeted in regards to what we actually were needing and what we were requiring and where we wanted to put that workforce in. Because it worked when we went looking for social care workers, for GPs, and actually for vaccination teams. When there was a targeted workforce appeal we were able to get a more focused requirement, I think. In regards to the general workforce appeal, people had applied looking for full-time positions rather than the temporary positions that the workforce appeal was offering.

There was also people who, I think, were coming forward as an expression, what can I do, how can I help, rather than following through as to what the job may actually entail.

Counsel Inquiry: It’s that targeted point that I want to pick up, because you also said earlier on, that “put in a number of workforce but they were at the start more generic”, and you said there was a benefit when they were more targeted. Why wasn’t the workforce appeal more targeted at the beginning?

Mr Robin Swann: I think the more targeted appeal was a learning from the first workforce appeal in regards to that, but it was just a generic, you know, how can you come and help, that’s what the workforce appeal was. And as I say, there were later examples I actually just gave, when it was more targeted, it was more beneficial.

Counsel Inquiry: Was the reason why it was generic because it wasn’t actually known exactly how these staff would be used?

Mr Robin Swann: Well, I think it was an ask for staff to come and help without, again, that targeted focus and I think, you know, your statement, it’s not just as how they would be used but it’s also where they would be used and what they would be used for so at that point, so it was more a generic ask than that focused ask which the later appeals actually were.

Counsel Inquiry: And is that a consequence of the lack of planing to understand how many staff you would have available, where they needed to be, what specialities there need to be, so you then couldn’t provide a targeted workforce appeal in order to plug those gaps?

Mr Robin Swann: I think that’s a fair assumption, yes, in regards to what that workforce appeal could have been rather than what it actually was.

Counsel Inquiry: And the logic of what you’re saying in terms of if you think it would be more targeted, it would be even more successful –

Mr Robin Swann: Yes.

Counsel Inquiry: Do you think it would have been more successful?

Mr Robin Swann: I think it could have been more successful if we had knew at that point in time, again, my Lady, as to how the generic workforce – it was something, again, you know, something our health and social care in Northern Ireland had never went out in that state or form before, so it was something new, it was a novel approach for us and we learned from it in regards to how a future one, if necessary, should be targeted and focused.

Counsel Inquiry: As far as you’re aware, in the event of a future pandemic, is there a plan within the department for how you would conduct a future workforce appeal?

Mr Robin Swann: From my point, when I left the first time, I wasn’t aware of any further work being done. That’s not to say it hasn’t been, but it’s not something that I can answer from my position at this time nor when I came back in the second time was it brought to my attention that one was being developed.

Counsel Inquiry: Did you ask when you went back in the second time about what learning there had been from between when you were first health minister and after the hiatus when you started again?

Mr Robin Swann: Unfortunately, when I went back in the second time I was faced with the same difficulties as I did the first time with staff once again being on industrial action and in regards to how it had been another two years without a health minister in post and there were a number of specific decisions and requests that needed to be handled and, again, we were faced with an even worse situation in regards to waiting lists across all specialities and all disciplines in regards to that, so it wasn’t specifically that I asked in regards to had we updated our workforce appeal and how it could actually be utilised.

Counsel Inquiry: Could you not have asked for a briefing paper from the department to say: this is what we’ve learned?

Mr Robin Swann: I could have asked and I think maybe if I’d been there longer, my Lady, it would have been something we could have got around to in regards to what was the normal working and day-to-day running of the Department of Health rather than being back the first day after another two-year hiatus without a minister in place.

Counsel Inquiry: You say if you’d been there longer. Was it a matter of time to review this or a matter of interest to review the learning?

Mr Robin Swann: It definitely wasn’t due to a lack of interest. I can assure you I went into that post the second time with my eyes wide open in regards to the difficulties that were in Health and Social Care and again in regards to one of the few parties who actually stepped up and took the health portfolio. I went back in to see what I could do because I knew what pressures and strains the health service had been under the first time, and knew the difficulties coming back in after not having a minister in place. But I willingly went into that post the second time.

Counsel Inquiry: Can we come back to planning for the second wave with the learnings from the first wave.

In July 2020, the Critical Care Network asked trusts to provide an updated local surge plan. The second wave surge plan was produced in October 2020. Again, do you know why it took three months for that plan to be developed?

Mr Robin Swann: Well, I think in regards to taking the learnings from the first surge plan, making sure it was robustly communicated. I don’t know why it took three months but I think the three-month space from actually assessing the first one and the development of the second one would be timely.

Counsel Inquiry: By October 2020 you were aware that there was a possibility of a second wave, if Northern Ireland wasn’t already in the middle of a second wave. So did you ask, based on your experiences from the first wave, where is our plan, where is our surge plan, how are we going to respond to escalating critical care?

Mr Robin Swann: In regard there were continual surge plans and, actually, we rebuilt plans in regards to how we were trying to get the health service back on its feet as well. We already had the surge plans from the first wave as well to build on and the specifics of the ask, I don’t recall, my Lady.

Counsel Inquiry: Is it you don’t recall or you don’t recall whether you did ask?

Mr Robin Swann: I don’t recall whether or not I did ask.

Counsel Inquiry: And can we just, please, display the two surge plans next to each other with – the 16 April surge plan, which is INQ000377154, and then the October surge plan, which is INQ000377221, I believe the one on the right is the one that you’d expected to your statement.

Not a huge amount of difference between the two. If anything, the surge plan in October, the one on the right-hand side of our screen is a scaled-down version of the initial surge plan. For example, we can see the extreme surge is equivalent to the high surge in the first plan, high surge is equivalent to medium surge but the bed numbers are slightly less. Do you know why the surge plan for the second wave was a scaled-down version of the first wave?

Mr Robin Swann: I would assume at this point it’s in regards to actually the learnings from the first wave, in regards to the number of beds that were actually needed at each surge level or actually at maximum capacity when we were using those critical care beds at the height of each wave.

Counsel Inquiry: And so is this a reflection of the capacity of health and social care to scale up or you’re saying that this is actually all that was required of Health and Social Care?

Mr Robin Swann: This is what was required. This is from the learnings of what was actually there and it moved from local to regional escalation.

Counsel Inquiry: So were you satisfied, then, by October 2020 that there was this surge plan in place to be able to respond to the second wave?

Mr Robin Swann: Yes.

Counsel Inquiry: I want to ask then about the briefing that you gave to the Executive on 8 October. You said:

“All of our hospitals are currently under significant pressure. Most hospitals are running at more than 85% capacity, with some over 90%. There are already trolley waits in EDs and ambulances queueing outside. This level of pressure does not usually manifest until later in the year. There is therefore a concern about how the system will deal with rising pressures over the winter period alongside increasing numbers of Covid-positive patients.”

That was 8 October. What did you actually do about those rising pressures in light of what you’ve considered to be an impending second wave?

Mr Robin Swann: And that was where we actually moved to the surge planning in regards to what was there, in regards to how we actually began to step down other services, and again, as had been actually, unfortunately, normal, my Lady, during winter pressures in Northern Ireland when it came to those challenges as well.

Counsel Inquiry: Right, and in terms of the normal winter pressures, so your statement says in the period since 21 October – sorry, this is a statement that you made, I believe, to the Assembly in December 2020 in which you said:

“In the period since 21 October, regional bed capacity has not dropped below 92%. There are only 5 days on which it has been lower than 95%. Some hospital sites have consistently been operating above 100% capacity for this period.”

If I can just show you that graphically at your statement, INQ000492281, page 50, thank you very much.

This is the reflection, in pictorial form, of what you were telling the Executive and the Assembly in October and then in December 2020. What steps had you taken, between October 2020 and December 2020, in order to try and prevent these levels of occupation arising?

Mr Robin Swann: That was – between those levels was actually the introduction of the non-pharmaceutical interventions that had been taken by the Executive that we talked through in M2C in regards to the steps we took as a society, as an Executive, actually to break those chains of infection so we could cut down the number of beds that were actually Covid occupied, as can be seen from that graph, and the number of Covid beds actually increase is when those additional beds in over capacity actually put pressure on our system as well, so that’s why we as a Department of Health were asking for those additional interventions, especially in October and November and coming into the Christmas period, that we’ve covered in M2C to – or even just to reduce the number of Covid-occupied bed in regards to how we actually implemented non-pharmaceutical interventions but also increased the uptake of vaccination and other methods at that point in time so we could break the reliance on the number of beds that were actually being utilised by Covid patients.

Counsel Inquiry: Yes, that’s stopping people coming into hospital, but if in October hospitals are running at more than 85% capacity and then that didn’t drop below 92% from 21 October, what steps had you taken to try and make sure there was going to be capacity for the second wave? I don’t just mean critical care capacity, just generally, given the pressures that you were telling the Executive?

Mr Robin Swann: Well, the decisions that we were taking and it’s actually in that statement in regards to how we reduce the pressures on our health and social care and on our hospitals and our bed capacity was actually to reduce the number of Covid patients who were coming into hospital and we did that through the non-pharmaceutical interventions, because Health was already at its peak, at the major stress of what it could actually deliver.

Counsel Inquiry: So we’ll look at how you were looking to prioritise services and rebuild services a little later on, so I’ll come back to this point then.

I just want to ask one questions about your statement. If we can go to paragraph 144 of your statement, just on this same page, thank you.

“I cannot recall the date on which regional critical care capacity fell below 90% for a period of 7 days in a row …”

When you were preparing this statement, did you check with the department whether they actually held that information or not?

Mr Robin Swann: Not that I can recall. If it’s in my statement that’s what I would have considered to be factually correct.

Counsel Inquiry: Okay. If we can move then to the military assessment that was conducted of the surge plan.

If we can please go to page INQ000276389_0002.

So this is a briefing that was provided to you, if we just go back a page so we can see the cover sheet.

This is a briefing that was provided to you on 18 December 2020, talking about the regional ICU surge plan. We’ve looked at the levels of the surge plan and if we can just go down to paragraph 3, please. It says:

“As you are aware, critical care surge plans were assessed by medical colleagues from … 9 to 11 December 2020 …”

Do you know why it had taken two months for there to be this assessment of the surge plan that had been published in October?

Mr Robin Swann: I’m not aware as to why it would have taken two months but it may be because of the availability of the military assessment team and the response to a MACA request coming in as well, and actually being supplied to have been able to link up that assessment.

Counsel Inquiry: Well, there had been a delay in planning for the first wave in terms of how long it had taken the surge plan to be produced. Did you take any steps to make sure there was no delay in planning for the second wave?

Mr Robin Swann: In regards to the preparations that was already being made throughout the department, I think we were preparing for the second wave in regards to the specific, as I say, bringing in the military assessment team. It wouldn’t be dependent on their availability and the approval of the MACA request as well.

Counsel Inquiry: So following completion of their assessment, they made a number of recommendations. What was your reaction when you read the recommendations that had been provided by the military assessment team?

Mr Robin Swann: I was fully supportive that all the recommendations should be implemented as quickly as possible. I don’t recall anything that was overtly challenging in regards to that. The stuff you’ve presented there as well, I also – well, I also say there was nothing for me to decide, it was all to note, so in regards it was to the officials within the department informing me of what was happening.

Counsel Inquiry: Did you think those recommendations reflected structural issues within Health and Social Care?

Mr Robin Swann: I think they highlighted, my Lady, something that we probably knew and were aware of and that’s why we asked for that, I suppose, set of outside eyes to actually come in and reinforce and bring to focus what we needed to do.

Counsel Inquiry: Could you specify what it was that you probably knew and were aware of?

Mr Robin Swann: In regards to the recommendations I think it was – I come back the earlier point about that need for that central control.

Counsel Inquiry: So did the department know that there was a lack of central control prior to this assessment and had done nothing about it or did they not think that there was much that needed to be done from central control?

Mr Robin Swann: I think there was a reliance that the CCaNNI was providing that level of central control but that the military assessment highlighted they needed to go a step further.

Counsel Inquiry: Because if we can go down to page 9. We’ll look at some of these individual recommendations.

So the way this briefing is structured is that you have got the briefing paper to you. There’s then a summary of what the recommendations are and the department’s response, and then behind that there are, effectively, the report or the summary of the military assessment team. And I just want to look, first, at recommendations 5 and 6. So, recommendation 5:

“Very limited use,” made of a number of categories of staffing.

That was something that could have been resolved at an earlier stage, would you agree?

Mr Robin Swann: Yes. And that’s what I was saying, it was agreed by Health and Social Care Board and CCaNNI.

Counsel Inquiry: But it shouldn’t have taken the military assessment team to tell you that you were under-using categories of people who could help provide extra capacity; would you agree with that?

Mr Robin Swann: I would agree with that but I think some of that additional capacity had been utilised elsewhere.

Counsel Inquiry: And then at recommendation 6:

“Trusts appeared to hold little flexibility or willingness to share redeployed staff to other trusts.”

Again, is that not a matter that if there had been that level of departmental control rather than leaving it to the trusts, that would have been identified and potentially ironed out at a much earlier stage?

Mr Robin Swann: It also comes back to, and I say it was agreed by the Health and Social Care Board and CCaNNI to consider the issue of small deployable teams, and the department was asked to consider the issue of incentives. I think that goes back, my Lady, unfortunately, to the employment structures that we have in Northern Ireland within Health and Social Care where staff are actually employed by the individual trust rather than an overall employment contract where they can be easily and readily deployed across a Health and Social Care estate which I think would be of benefit in future, future incidences again.

Mr Scott: My Lady, I wonder if that might be a convenient point?

Lady Hallett: Yes, certainly. I shall return at 11.55.

You remember our breaks, Mr Swann.

(11.38 am)

(A short break)

(11.55 am)

Lady Hallett: Mr Scott.

Mr Scott: Thank you, my Lady.

Mr Swann, if I could turn now to inequalities data, please.

So, Aidan Dawson, who gave evidence on behalf of the Public Health Agency, said, when he was asked about surveillance of Covid-19 in the community by way of primary care data, that:

“I don’t think we had that sort of level primary care data that we would require.”

This was in relation to his statement that said:

“For primary care … PHA had existing access to … surveillance as a result of reporting of influenza-like illness for in- and out-of-hours primary care. This system was established during the 2009 influenza pandemic. This information was initially considered to be potentially relevant and useful, but upon discussion with HSCB, it was established that there were no permissions from the primary care data owners [GPs] to use this source for COVID-19 monitoring, and it was not subsequently used.”

So, it therefore appears there was a lack of surveillance of Covid-19 at primary care, and therefore surveillance of the community, due to data protection issues. Were you aware of that?

Mr Robin Swann: I wasn’t aware of that, and actually when I heard Mr Dawson’s evidence, I – trying to recall what – was I actually there and what was I – because I do know that, my Lady, we had what was called sentinel GP practices that actually reported back a number of influenza cases in regards to that, and I know they were stepped up early on in the pandemic to actually report back in Covid cases. I’m not sure what Mr Dawson was actually talking about in regards to that data transfer, whether things were automatic or whether actually they had to be asked for in a manual input, that – especially as data had been delivered through spreadsheets or written documentation rather than having access to online systems or automatic data dumps, for want of a better explanation. I’m not sure where Mr Dawson was going with that.

But the surveillance of Covid-19 within primary care was something that we were alive to because we actually took a step in Northern Ireland where we opened Covid centres, working with our primary care colleagues in Northern Ireland, community GPs and BMA in regards to where our primary care, our GPs actually set up specific Covid centres, working among our GP federations, so that if anybody was identifying with Covid symptoms they were actually sent to those specific facilities rather than going into a GP practice as well.

So I’m not sure in regards to exactly where Mr Dawson was going to in that statement. It wasn’t something that was raised with me as minister in regards to those difficulties with that transfer of data between primary care and the PHA.

Counsel Inquiry: I think he was talking about something a bit more fundamental than just transfer of data. I think what he’s saying is the PHA didn’t have access to the surveillance data that that it was needing, and he said it took until August 2023 for that to be resolved.

But is your evidence that actually you were never aware that there was any issues with any access to –

Mr Robin Swann: I wasn’t aware of any issue in regards to that because, my Lady, we had other concerns that were actually raised in regards to that transfer of data, and we covered it in M2C, between ourselves and the Republic of Ireland that we worked on and worked on actually intensively. If something like that was actually in fact there and had been brought to my attention, we’d have worked on it as well.

Counsel Inquiry: Okay. But you wouldn’t dispute the fact that Mr Dawson had raised it as an issue, said it was issue and said it took a long time to be fixed?

Mr Robin Swann: Well, look, if he has raised it to the Inquiry, I’m not disputing what Mr Dawson has told the Inquiry and his evidence. I’m conscious that he wasn’t in the position he is now in regards to when we were during that as well, but if it’s something he has raised, my Lady, I’m sure there will be further questions from the Inquiry to the department.

Counsel Inquiry: Well, if it’s not something you’re aware of then I’ll move on to – in terms how deaths were actually counted.

You set out in your statement that the Health and Social Care response was mainly driven by community transmission, case numbers and HSC pressures, that the manner in which Covid-19 deaths were recorded did not have significant impact on the way HSC responded to the pandemic. That’s at paragraph 86.

At paragraph 87 you say that you agreed to the CMO commissioning the PHA to provide the relevant clinical data. You talk about the established system for monitoring and reporting deaths in Northern Ireland was through the General Register Office, and that system continued to operate throughout the pandemic and remained the definitive source of reporting on deaths in Northern Ireland.

It appears from your statement that you’re saying that actually there was sufficient surveillance of deaths through the General Register Office. So why was it necessary for PHA to be asked to provide data about deaths?

Mr Robin Swann: And I think that, my Lady, was in regards to the frequency of reporting as well. And NISRA were at that stage, as the official collection statistics agency, reporting once a week. Elsewhere across the United Kingdom there was an acknowledgement of the number of people who were losing their lives to Covid on a daily basis. I’d asked that Northern Ireland move to be in keeping with that, so PHA through – well, the CMO had asked PHA to start to gather that data so that we could make sure that we were contributing the same data at the same level as other parts of the United Kingdom as well.

Counsel Inquiry: So did you consider that there was a data gap, where it was actually just trying to make sure there was comparison across?

Mr Robin Swann: I think it was making sure there was a comparable measure of number of cases, number of hospitalisations and number of deaths due to Covid, and that was the same measure and the same criteria across the United Kingdom, whereas NISRA were the official keepers of the GRO data.

Counsel Inquiry: So you’re satisfied that if Northern Ireland had simply relied on the NISRA data that you would have had all the information that you needed?

Mr Robin Swann: We would have, but it wouldn’t have been common at the frequency that was being asked for, that was actually being sought from other parts of health and social care, but also what was actually being reported elsewhere actually on a daily basis.

Counsel Inquiry: Why did you not ask NISRA to increase frequency rather than asking the PHA to create a system?

Mr Robin Swann: I did. I wrote to NISRA. I asked them to increase that frequency. I think they moved to twice-weekly reporting as well, because NISRA take – and again, my Lady, this is from my understanding – NISRA take their official statistics from returned death certificates, so there always was the delay in regards to those coming back and to them as a central reporting agency. That was my understanding at the time.

Counsel Inquiry: I move on to monitoring deaths of healthcare workers.

So a letter sent from the CMO to trusts on 12 May 2020 conveyed your request for all trusts to advise the department on a daily basis as the number of health and social care workers died from Covid.

For reference, that’s INQ000490088.

Why did you want that data?

Mr Robin Swann: I – it was also something that was being asked for at a UK-wide basis level as well. I wanted to ensure that we were getting the appropriate data in regards to our healthcare workers – my healthcare workers, my Lady, also, not just in regards to the number of healthcare workers who were losing their lives due to Covid but also I asked for the further – as to how many were being hospitalised, how many were in ICU, in regards to the effect that Covid was actually having on our workforce.

Counsel Inquiry: Was that driver for that you or seeking to have an equivalence to the UK-wide basis?

Mr Robin Swann: It started off there was a request at a UK-wide basis. I actually at that point felt our system hadn’t responded and that’s why I asked for it to be done.

Counsel Inquiry: What did you do with that information?

Mr Robin Swann: I was aware of it and I think something that has been brought to my attention through earlier evidence/statements was that the department wasn’t collating that centrally. It was being reported through silver and gold command reports, but I don’t think there was actually a central correlation as to that data.

Counsel Inquiry: So when you asked for that information, did you think that there had been a gap in the mechanism by which that information had been gathered?

Mr Robin Swann: It wasn’t something that had previously been gathered before, through any of the other pandemics, so I think it was a different request that had actually came.

Counsel Inquiry: Okay. And in terms of the request, didn’t you also want to know the role that the healthcare worker was working at the time?

Mr Robin Swann: Yes, I wanted to know where.

Counsel Inquiry: Did you get that information?

Mr Robin Swann: Not that – I think that was being reported through – again, through silver to gold in regards to where they were and who they were, actually in that regard, and I think looking through previous evidence, one was I think Chris Hagan from the Belfast Trust had actually provided that in his evidence report.

Counsel Inquiry: It looks like a slightly disjointed picture. Weren’t you looking for the information that you wanted to get as a whole in one easy-to-access piece of information?

Mr Robin Swann: Yes, that’s what I’d requested. But, as I say, I don’t recall that ever being formally tabulated through the department.

Counsel Inquiry: If that’s what you’d requested, why isn’t that what you got?

Mr Robin Swann: I was – I suppose I was getting that data through silver and gold reports as well, rather than just a regular update coming from the department to myself.

Counsel Inquiry: Did you not also want to know what the ethnicity was of healthcare workers?

Mr Robin Swann: Not at that point in time. It wasn’t a question that we were asking unfortunately. It’s not something that was generally recorded actually in Northern Ireland systems, my Lady. I know it’s something that you have taken an interest in and has been raised in previously evidence sessions as well.

Counsel Inquiry: You say “not at that point in time”. So the letter conveying your request is dated 12 May. Chief Medical Officer, when he gave evidence – it’s page 22 of his transcript – says it was in April 2020 that he became aware that those from an ethnic minority background may suffer disproportionate impact.

So by the time that you made the request it was known that there was a disproportionate impact upon ethnic minorities. So why did you say “not at that point in time”?

Mr Robin Swann: Well, sorry, in response to the answer, I don’t think there was the linkage of the request of data between the ethnic identification of our healthcare workers and those who were losing their lives and those who were hospitalised.

Counsel Inquiry: Was it not a link that you were making in your head, about if there seems to be a disproportionate impact upon healthcare workers that you wanted to know what the impact was on healthcare workers? Your healthcare workers, you used the phrase earlier on.

Mr Robin Swann: It wasn’t a linkage that I made at that point in time, because I was – I think I was caring about my healthcare workers irrespective of ethnicity.

Counsel Inquiry: But you’re talking about those who may be potentially the most at risk?

Mr Robin Swann: As were all our healthcare workers, and I think that’s the lack – the lack of our data and I think it was the data systems that we have in Northern Ireland that doesn’t actually record – at that point record that level of detail of individuals.

Counsel Inquiry: Let’s look at this in a different way. So every March there’s a Health and Social Care Workforce Census; is that correct?

Mr Robin Swann: That’s correct.

Counsel Inquiry: And that census doesn’t record the ethnicity of the healthcare workers, does it?

Mr Robin Swann: Not that I’m aware of.

Counsel Inquiry: Why is that?

Mr Robin Swann: I don’t know, but I think one of the learnings coming out of this Inquiry, my Lady, is that it should in regards to that, because I know there has been a general weakness in Northern Ireland in regards to the recording of ethnicity of workforce across Northern Ireland, not just in Health and Social Care but also in Northern Ireland Civil Service as well.

Counsel Inquiry: Was that important information? Because if you don’t know how many of your healthcare workers are minority ethnic, how can you work out questions such as how to risk assess them, how many staff you might lose to illness, any additional measures that may be required?

Mr Robin Swann: I would agree, my Lady, it’s an apparent weakness in regards to that data collection in Northern Ireland that needs to be addressed.

Counsel Inquiry: Who is responsible for collecting that data?

Mr Robin Swann: I’m not sure who actually carries that.

Counsel Inquiry: Okay. Who do you think should be?

Mr Robin Swann: Well, the department should within its workforce directorate.

Counsel Inquiry: Okay. Well, if the department should be, then why isn’t it?

Mr Robin Swann: I think, as – as the previous health minister, as I said here, I think it should, and I think going forward it would be a recommendation that could be made in regards to that. Why it’s not been done, I can’t answer that.

Counsel Inquiry: But as the health minister, aren’t you responsible essentially in making sure that there is sufficient understanding of your workforce?

Mr Robin Swann: Yes. And that goes back to the understanding of knowing what to ask and when to ask it, and I think one of the weaknesses that has been brought to fore in regards to the outworkings of this Inquiry is that fact, my Lady.

Counsel Inquiry: Well even in non-pandemic times, wouldn’t you want to know the ethnicity of your workforce?

Mr Robin Swann: It hasn’t been something that was previously asked for in regards to those annual workforce returns, but in regards to what – and as I’ve said, what has been brought to fore in regards to this evidence session and previous evidence sessions, I think it is something that should be done.

Counsel Inquiry: One final question on that. Health and Social Care is under a duty, under the Northern Ireland Act, to promote equality; correct?

Mr Robin Swann: Correct.

Counsel Inquiry: How could it do that if it doesn’t know the ethnicity of its workforce?

Mr Robin Swann: In regard to, I suppose, section 75 requirements in Northern Ireland, there’s a number of different strands across the workforce and across the department that are undertaken, and it gets – goes back to the witness and data collection and it’s not something that that I can – I can say that I’m proud of, that we weren’t doing it, but it’s something, my Lady, that I acknowledge is something that we should be doing.

Counsel Inquiry: Professor Bamrah, on behalf of FEMHO, gave evidence to Module 3. He says:

“It’s about retention and recruitment as well, isn’t it? If everybody feels valued then they will give the best in their job that they can and if they are just a statistic or even a non-statistic then how are they going to do their best for the NHS.”

So isn’t it also, in a sense, self-sabotaging for the department not to know about the ethnicity of its workforce?

Mr Robin Swann: It is, yes, but it’s – also, I think, my Lady, goes further in regards to that, in regards to the Professor’s statement, in regards to how you treat your workforce. And again, I don’t think Northern Ireland has been good at treating its health service workforce at all, or we wouldn’t be now looking, even with the restoration of an Executive, of the potential, again, of industrial action in Northern Ireland. So that’s a collective responsibility that the Executive and the Assembly need to address and should be addressing in regards to that.

Counsel Inquiry: Yes, but those are completely two unrelated points about those issues in terms of the restoration of the Executive and the industrial action and whether the Health and Social Care knows the ethnicity of its workforce?

Mr Robin Swann: I think it goes back to the point being made and the question been asked in regard to how do you respect, value and maintain staff within health and social care. And not just Northern Ireland, but actually across the patient regards the – give everybody that equal respect and give them the value that they deserve.

If the point is we haven’t been collecting that data, I’ve admitted that I think we should in regards to that and I think it’s a weakness that the Inquiry has brought to the fore that I think needs to be addressed.

Counsel Inquiry: And presumably all the points you’re making about ethnicity are not just about healthcare workers, it also applies to understanding the ethnicity of your patients; is that correct?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: Is there also sufficient collection of disability data about the population of Northern Ireland and how it interacts with health and social care?

Mr Robin Swann: I don’t think there is in regards to the generic definition of disability, and I hope that is actually corrected and addressed with the introduction of encompass in regards to what data is actually held and held central, really, in one system.

My Lady, when we were looking at the introduction of – or the issue of letters to those who were clinically extremely vulnerable, I know at the start of the pandemic it took significant trawling of various databases actually to identify who was to get a letter and who should have got a letter, whereas I hope that the introduction and from what I’ve been told the introduction of encompass should make that a more efficient and easier system to use because of that data and it actually being held centrally.

Counsel Inquiry: Okay. I’m going to move on and look at visiting restrictions. Do you consider the visiting restrictions throughout the course of the pandemic struck the right balance between the benefits of visits to patients and their families and reducing the risk of visits bringing in infection?

Mr Robin Swann: I do, but I also acknowledge and respect that they were difficult. They were difficult for people who had people in hospitals and that included at one point, my Lady, my own family as well in regards to members of my family who were in hospital during the pandemic as well. But those balances that were brought and those guidelines that were actually introduced were done so I think in the balance of protections in regards to what was known about the pandemic and the virus at that – at any individual time, and I think that’s why the CMO was always keen to provide those refreshments and those updates as and when they were able to do that.

Counsel Inquiry: You say in your statement that you were advised of any changes to the level of applicable restrictions and my endorsements sought at every stage; that’s the advice you were being provided by the CNO?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Was that an area where you felt competent to challenge the advice, if you sought to challenge it, of the CNO?

Mr Robin Swann: It was on occasion. I do believe there was a couple of occasions that I did challenge the specifics. I don’t recall at this moment in time but there were a number of occasions – maybe not challenged but questioned in regards to the advice that was being given.

Counsel Inquiry: But you don’t remember those specifics?

Mr Robin Swann: I don’t remember the specifics not at this moment.

Counsel Inquiry: There is one in your statement at paragraph 241:

“On 16 April 2020, I asked Critical Care Network … to undertake a rapid review of the situation with respect to visiting within Northern Ireland Intensive Care Units at the end of life as I was keen to facilitate visiting in such circumstances.”

Could you provide a little bit more detail, if you remember it, about the reason why you asked that on 16 April?

Mr Robin Swann: I do, my Lady, in regards to that because the initial visiting guidance was that there should be – end-of-life visiting should be permitted but I think the initial guidance actually said with the exception of ICU, so it wasn’t advised, that the guidelines were against end-of-life visiting within ICU and I felt that there should be opportunity for people to visit with a loved one at the end of life even if they were in ICU, so I did ask the CNO to have a look at that again to see if it was possible and my recollection was there were provisions then made to enable that.

Counsel Inquiry: There was a discussion on 17 April at the executive committee meeting about the balance of visiting and whether it was struck correctly. Why did you take that topic to the Executive?

Mr Robin Swann: Because those updates at the Executive were generic – well, not generic, they were all-encompassing conversations that were being had around the Executive table, all Executive ministers at that point were interested in what was happening, I felt it was important that all my Executive colleagues were updated in regards to what was happening, especially in regards to visiting. I’m not sure it’s something that an individual minister had raised with me in regards to that specific point.

Counsel Inquiry: Because it could be seen that because a minister takes a matter to the Executive that it’s seen as a political issue. Did you consider visiting as a political issue or more of a clinical issue?

Mr Robin Swann: No, it was more of a clinical and humane issue in regards to what we needed to do and I think – I hope, my Lady, during my tenure as health minister, especially during the pandemic, politics didn’t enter into any of the decisions that I made.

Counsel Inquiry: The Inquiry received a report about Every Story Matters in terms of a lot of extensive work that’s been done to gather accounts from all across the United Kingdom. Some of those are included in your evidence proposal. Do you recognise the stories about the pain that was caused by lack of people to visit their loved ones in hospital?

Mr Robin Swann: I do, my Lady. Having watched the video in regards to – and again, in regards to opening of this model just last night in preparation of today, those stories are heartfelt. They too – they are reflective of the experiences of many people across Northern Ireland. Our Health and Social Care workers, departmental workers and even in regards, as I said, my Lady, in regards to even my own family in times.

Counsel Inquiry: When John’s Campaign gave evidence their view is there should be a “Find a way to say yes” approach to visiting. Do you think that was an approach that was adopted in Northern Ireland?

Mr Robin Swann: I do and I think not just in regards to the doctors but I think in regards to the nurses on the wards as well, in regards to that ability to look for those individual matters as well. But I also think it was reflective, my Lady, and again, I’ll go back to that engagement, I think it was reflective of the work that the Chief Nursing Officer led because of her understanding and compassionate role she brought as a profession, actually, to the guidance that she was developing. So it wasn’t just a specific policy guideline being created by a civil service. She actually brought that empathy and understanding, I think, as a professional nurse as well. And I believe that was reflected in our guidance.

Counsel Inquiry: Module 2C heard a lot of evidence about the importance and focus that Northern Ireland puts on death and the circumstances of death. Is that something that played into the consideration of balance to be drawn, particularly for end-of-life visiting?

Mr Robin Swann: It was and, again, I think there is – that value of end of life and of death in Northern Ireland, my Lady, I know it’s something that was particularly challenging in regards to guidance and guidelines specifically around funerals in Northern Ireland and Wales –

Counsel Inquiry: I don’t want to take it outside, just in terms of the visiting restrictions.

Mr Robin Swann: But in regards to that overall, not just end of life because I think that – how Northern Ireland looks to death and the celebration of life is more ingrained in Northern Ireland society, so it’s not just that end-of-life visiting within the hospital. There was a wider package around that. But I think I can come back to that change that was asked about the end of life and ICU, that was something that we asked for.

Unfortunately, my Lady, it wasn’t always something that was possible. And on every occasion and I think the Every Story Matters video and evidence that has been presented by different individuals across the United Kingdom, and Northern Ireland specifically, reflects that level of challenge and empathy. It’s not a situation I would like to put any family in or any individual in, but in regards to where we were at certain points in time, what we knew, what guidance was there, unfortunately it was necessary at times.

Counsel Inquiry: I want to ask you about care partners and specifically about care partners in hospital, so nothing to do with the care sector. So it’s right that care partners are introduced on 23 September 2020 in relation to visiting care homes, correct?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Were they introduced at the same time for visiting into hospital or not?

Mr Robin Swann: They were introduced at a later stage.

Counsel Inquiry: Why were they not introduced in hospital visiting at the same time?

Mr Robin Swann: I’m unaware as to the specifics but in regards they were brought in to meet the specific needs within care homes and social care settings, as well, in regards to how they could be supported for those people who were in care homes and social care settings were actually there for a longer term and a longer duration. I’m unsure as to why it took that additional period of time before they were actually introduced into hospital settings but I’m aware that the care partner relationship was actually something that was provided again by the CNO in regards to how we supported visiting within care homes.

Lady Hallett: You’re speeding up.

The Witness: Apologies, my Lady. Sorry.

Mr Scott: So the Department of Health statement defines care partners as:

“… specific individuals allowed the introduction of individualised and tailored arrangements to assist in meeting the needs of the patient.”

Based on what you were saying that that wasn’t the same specific need arising in hospitals as it was in care homes; is that correct?

Mr Robin Swann: There was, I don’t want to misrepresent what I was saying in regards to that, but there was those specific needs within the hospitals but the care partner arrangement wasn’t introduced into hospitals until a later date.

Counsel Inquiry: On reflection, do you think that the care partner scheme should have been introduced into hospitals earlier?

Mr Robin Swann: On reflection, and again, my Lady, it goes back to what I know now compared to what I know then, what I knew then. In regards to the introduction of care partners, on reflection, I wish we’d have brought it in earlier in the care home and other care settings, in regards to what we’re doing, and in reflection, take that to the next step is yes, I do think we could have brought it in earlier within hospital settings as well, but again, that’s knowing what we know now to where we were then.

Counsel Inquiry: Because one of the main problems that was caused by visiting restrictions was that people didn’t have the same level or ability to communicate with their family members who were in hospital. You remember people expressing their views that they weren’t able to actually understand what was happening to their loved ones?

Mr Robin Swann: Yeah.

Counsel Inquiry: Do you think there was enough done within Health and Social Care to help families have a current up-to-date understanding of how their loved one was getting on in hospital?

Mr Robin Swann: I do, but I’m also aware of the weaknesses where the communication systems that we hoped and envisaged to being in place across different hospitals, different trusts, let patients down, let families down at specific points. But I know also the dedication and delivery of our healthcare workers who were with individuals at that very challenging point within their time as well was also a challenge to them, something that they weren’t expected to do when they first took up their posts as well in regards to that, just the additional asks and strains that we were putting on our staff as well, but – could we have done more? Could we do more? Yes, knowing what we know now in regards to additional PPEs, testing, all the rest of it, as to how we could actually facilitate that, and I think as visiting guidance and guidelines progressed, I think that was something that was taken into account.

Counsel Inquiry: You say that the communications systems that we hoped and envisaged being in place let patients down, let families down. How did those failures occur?

Mr Robin Swann: Well, I think it was always at that point in time on the workload in regards to the staff that were actually working on wards and being able to provide that up-to-date information and data in regards to how a loved one was being actually updated of their care on a ward wasn’t always possible in the time they needed, and I do know in the occasions where that does cause stress, I apologise, you know, that we weren’t able to get it right every time, but there were many wards, many healthcare workers, who were providing that care, that information, where we were able to meet those needs and the needs where we failed.

I want to apologise, my Lady, because it’s not something that we would – sorry, it’s not something the healthcare service or even those working on those wards would have wanted to happen.

Counsel Inquiry: Could more use have been made of non-clinical staff to be able to do that uploading onto the systems or to provide an extra resource to do those tasks to help provide that communication?

Mr Robin Swann: There could have been opportunities to do that as well but always taking into consideration of the infection control and the ability of healthcare staff to do that. I know it’s something some trusts and some wards did actually do but I’m not aware that it was something that was actually promoted across all hospital sites.

Counsel Inquiry: Has there been a review done of the department about how that system could be improved in future?

Mr Robin Swann: I’m not sure, at this point, having left office in regards to that and, again, it’s not something that I’d ask for an update on.

Counsel Inquiry: I’m going to move on to PPE and RPE. It’s correct that you didn’t have any involvement in creating or overseeing the guidance about what PPE should be used in different circumstances in the healthcare settings?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Did you have any understanding, and maybe the answer is “no” based on what you’ve previously said – did you have any understanding whether FFP3 masks were more protective than FRSM, so the fluid-resistant masks?

Mr Robin Swann: No.

Counsel Inquiry: You didn’t have any understanding or you didn’t think there was any difference?

Mr Robin Swann: I didn’t have any understanding.

Counsel Inquiry: I just want to ask you about a meeting that you had on 24 March 2020 with the First Minister and the deputy First Minister and a number of officials.

If we can have on screen INQ000289853, thank you very much.

So you can see there it says, on the health side of things there’s yourself, CMO, CNO, Chief Pharmaceutical Officer, and then the senior official from the Department of Health; correct?

Mr Robin Swann: That’s correct, yeah.

Counsel Inquiry: And then just under PPE we have:

“DoH noted that there is a misperception that PPE is a major problem.”

Was PPE access from healthcare workers within hospitals a problem within Northern Ireland over the pandemic?

Mr Robin Swann: It was a problem at the start but as the note goes on to describe and as we worked out, our PPE supply mechanisms across Health and Social Care wasn’t as robust as it could have been and it wasn’t in a position where – well, sorry, it was reliant on PPE being something that was always there, always available and just-in-time development and deployment and I think that’s something that was reflective across health and social care and not just in Northern Ireland but the UK and even worldwide in regards to that.

Counsel Inquiry: Because I’m acutely conscious there’s another module coming up dealing with procurement. So are you saying these issues in terms of access were more procurement issues and for BSO –

Mr Robin Swann: There was a mixture of both from procurement and delivery and management of PPE across all our sites where it was always that, and my understanding at the start was individual wards were able to order what PPE they needed and always had that supply whereas through the pandemic in the early stages it was something that was more of a controlled management system, at trust level and BSO level.

Counsel Inquiry: So that kind of trust level, how quickly was that situation resolved in terms of delivery and storage?

Mr Robin Swann: It was quickly resourced in regards to BSO and PALS working in conjunction.

Counsel Inquiry: So by the date of this meeting, 24 March 2020, the local level, the trust level issues of access to PPE had been resolved?

Mr Robin Swann: I wouldn’t say it had been resolved but it had been noticed there’s some issues of management with PPE with trusts and healthcare professionals. “Need to avoid the use where it’s not needed”, in regards to that, so there was though challenges as well. And again, going down through the document, more videos in development, but who used them and where it was, and again, about how we went about actually introducing measures to calm fears in regards to the clear need and message around PPE that it should be used. At that point in time we were also looking, as the final bullet points to, the release of the pandemic stock which was being held at a UK level.

Counsel Inquiry: So the calming fears, it’s the point above I wanted to ask you about. It says:

“DOH have introduced additional measures to calm fears.”

Did you hear concerns from healthcare workers that they didn’t feel safe with the PPE that they had been given?

Mr Robin Swann: Yes. And, again, that was I think work that again – and, my Lady, I’m conscious about continually referring to the CNO but it’s going back to, I think, her evidence as well in regards to the very detailed work that she did along with her colleagues in regards to the explanation videos, in regards to what PPE was used and specific issues and specific situations as well and I know she put a lot of work and dedication into actually developing videos that were distributed throughout the system as well, as to what to wear, when to wear, and how to wear it.

Counsel Inquiry: So did those concerns about healthcare workers not feeling safe, did they disappear throughout the course of the pandemic?

Mr Robin Swann: No, there was always that general concern and I think one of the steps that we actually took was the creation of a specific email address.

Counsel Inquiry: PPE inbox?

Mr Robin Swann: PPE inbox, yes, where it was advertised and widely spread across that if anybody had those specific concerns they could email that inbox directly and their query, their concern would be dealt with anonymously.

Counsel Inquiry: And you set out the details, or the department set out the details of that inbox in the statement, so I’m not going to ask you about that.

But from your perspective, hearing those concerns of healthcare workers, did you feel that the CNO was doing enough to address those concerns?

Mr Robin Swann: Yes. And as I say, my Lady, I’m conscious that I’m speaking here in her absence on her behalf but I think that the level of dedication that the CNO put in to addressing those specific issues I think were to be commended.

Counsel Inquiry: I want to ask you about in your statement which, paragraph 289, it appears to relate to fit testing but I wonder if you can expand upon this. You say:

“I regret, however, I cannot recall being made aware of issues specifically in relation to age, race, disability or pregnancy and so I did not take any steps to address them.”

Could you expand upon what you mean by that paragraph?

Mr Robin Swann: And I think in regards to the flow of the statement, I think it was, as I think you’ve indicated, it was around fit testing, and I don’t think there was any of those specific issues were brought to my attention as to why we were seeing at that point, was actually the number of failures in regards to staff coming forward for their fit testing.

Counsel Inquiry: You so recognise that there were failures?

Mr Robin Swann: There were, yes, there was quite an extensive piece of work in regards around that because we did see, I think it was one of the contractors who were actually brought in by the trusts to conduct the fit testing, that there were a high degree – or a high number of staff who failed those or passed those when they shouldn’t, and the contractor was then challenged in regards to that.

Counsel Inquiry: Do you think that those failures, particularly in relation to age, race, disability, or pregnancy, should have been brought to your attention?

Mr Robin Swann: If that was one of the reasons why those tests were being failed, yes.

Counsel Inquiry: Just moving to the PPE review. So on 15 April 2020 you commissioned a Rapid Review that was led by the department’s internal audit team of PPE to assess the appropriate receipt, storage, distribution. Was that in response to concerns raised by healthcare workers in the first wave or was that planning for the second wave?

Mr Robin Swann: I think it was a mixture of both. It was an issue that had been raised and that PPE was an issue, I think, that was live across all parts of Health and Social Care and not just in regards to the supply, the distribution, the utilisation. My Lady, again, I think in Northern Ireland we kept that within BSO, within PALS, and we were able to make sure that supply and purchasing systems were, I believe, quite robust.

Counsel Inquiry: The terms of reference review didn’t include any equalities issues; do you know why not?

Mr Robin Swann: In regards to that point I think it was specifically to look at the supply and distribution in purchasing of PPE.

Counsel Inquiry: As far as you’re aware, had there been issues raised about inequalities with PPE in terms of difficulties fit testing?

Mr Robin Swann: At that point I was aware we had – there were some issues again, brought to me in regards to masks not maybe being specifically accessible or utilisation with women’s smaller faces in regards to that, so there was work done in regards to that.

Counsel Inquiry: Should that not have been included in the review? If you’re reviewing PPE as a whole, should you not want to include equalities issues?

Mr Robin Swann: On reflection, it could have been and it wasn’t at that stage. My Lady, I’m unsure why it wasn’t included at that point.

Counsel Inquiry: It seems there’s a number of instances where there’s a failure of the department to consider what seemed to be fairly fundamental questions of equalities. Does the department actually hold equalities at the centre of all the decisions that it takes?

Mr Robin Swann: Again, my Lady, for – from responding now in my position and not being able to speak on behalf of the department, I would hope that it did but coming out from even this morning’s evidence sessions and from previous evidence sessions, there may be a query that it needs to do more.

Counsel Inquiry: So a query it needs to do more, or would you go further than that?

Mr Robin Swann: I would go – well, speaking in a personal capacity, my Lady, I think it should go further. I said that in an earlier session in regards to previous answers as well.

Counsel Inquiry: I’m going to move now to the support that was provided to healthcare workers. You talked earlier on about after the first wave there was a need for rest and recuperation for healthcare workers. Do you think throughout the course of the pandemic, whether first wave, second wave or subsequently, that there was sufficient support given to healthcare workers?

Mr Robin Swann: I think at the beginning there wasn’t but I think as we moved through the pandemic, the additional supports, again, identified through the Chief Nursing Officer and chief professionals, Chief Medical Officer, there was additional number of pieces of work actually brought in to how we engaged and how we supported our workers as well. I’m aware that the Chief Nursing Officer actually worked with our Regional Trauma Network, my Lady, in regards to the pressures that were on Health and Social Care staff, Regional Trauma Network being a specific body in Northern Ireland that looks to help and support victims and survivors of the troubles in regards to the psychological pressures that they’re under. So I do know that she reached into them as to what supports could be given to our healthcare workers.

There was a development of, I think, the Thrive project as well. I’m aware that the Chief Scientific Adviser actually commissioned work through the Ulster University in regards to the pressures that had came on on our healthcare workers in response to that, and I think Thrive actually engendered or engaged psychological supports.

Counsel Inquiry: Psychological support is one of the areas I am particularly interested in, because your statement has talked about a number of areas of psychological support that’s been provided. Was there actually 24-hour psychological support available to healthcare workers?

Mr Robin Swann: I’m not aware and I don’t have the detail of that specific contract and support that was actually delivered.

Counsel Inquiry: I think we’ve seen documentation which shows it was 9-5, Monday to Friday. Do you think there should have been 24-hour –

Mr Robin Swann: In reflection, yes, in regards to what should have been available, what could have been available, it would have made a better use.

Counsel Inquiry: You say “on reflection”. Is that not a reflection that should have been made ahead of at least the second wave?

Mr Robin Swann: Yes.

Counsel Inquiry: I want to ask two other points about additional support. So the Department of Health emergency response strategy from March 2020 talks about providing free travel for Health and Social Care workers on public transport and making car parking free for staff, and car parking and free public transport was provided from April to June 2020 and then it wasn’t provided after that; is that correct?

Mr Robin Swann: I think it was provided at later dates, as well, in regards to the ability to do that. I know it was actually as a result of a private members bill in regards to the Assembly as to making car parking free at all hospital sites both for staff and visitors alike. We also provided not just free car parking, but all free travel, we were working with the Department of Infrastructure, supports to child care, we provided a £500 payment to all Health and Social Care staff without tax or National Insurance being taken from it, as well, in regards to that.

Counsel Inquiry: The reason I’m asking this question is that the military assessment team from December 2020 that we looked at earlier on say that:

“Simple incentives (beverages, food, free parking, laundry, et cetera) should not be underestimated and should be equitable and transparent across all trusts.”

That was the assessment in December 2020. Does that not indicate that those basic necessities hadn’t been provided for all healthcare workers prior to that date?

Mr Robin Swann: They had been provided but not just on – I think what the military assessment is actually saying is that we shouldn’t underestimate the value of those things rather than the fact that we haven’t been providing them, if I’m correct, because we had been providing childcare support, as I say, and the free car parking as well. And, again, one of the steps that I took, my Lady, was I actually put £15 million across our five geographical trusts, putting £3 million into each charitable – each trust’s charitable status so they could actually utilise that into how they would support their staff over and above what was, I suppose, general costs that were available to them.

Counsel Inquiry: I’m going to move on to DNACPRs and advance care planning. At any stage of the pandemic were you made aware of concerns that blanket or inappropriate DNACPRs were being imposed upon patients?

Mr Robin Swann: Not that they were being imposed upon patients but I am aware that there were a number of written questions from Assembly members and correspondence and my replies to those is one that I believe that they were unethical and not necessary to actually be deployed be it on age or disability.

Counsel Inquiry: I just want to tease that out. You set out in your statement at paragraph 307, where you say:

“I received a number of written questions from my fellow MLAs asking about the application of DNACPRs. In my response I made it clear that orders based on age or disability were discriminatory and unethical. In terms of the policy in Northern Ireland media reports were ill-founded.”

It’s that last sentence that I just want to focus on. In response to those MLAs, were you saying that complaints of any inappropriate use were ill-founded or that it was ill-founded to suggest that there was a blanket DNACPR as to policy in Northern Ireland?

Mr Robin Swann: It was ill-founded that there was a blanket response.

Counsel Inquiry: On what basis were you saying that it was ill-founded that there was a blanket response? How did you know that?

Mr Robin Swann: On from feedback from officials in regards to that, my Lady, in regards to if that was a response that I’d have had to either an MLA question or a member’s correspondence, not just in response but there would have been back-up documentation supplied with that statement well.

Counsel Inquiry: So you’re satisfied that there was a response provided to the department from, presumably, the trusts?

Mr Robin Swann: Yeah.

Counsel Inquiry: That were provided documentation setting out an assessment of whether the DNACPRs had been applied inappropriately?

Mr Robin Swann: That they were being applied appropriately and there wasn’t a blanket response.

Counsel Inquiry: You were aware of the concerns of families that there was an increased number of DNACPRs being applied to patients being admitted to hospital; is that right?

Mr Robin Swann: I was aware there was concerns being raised, yes.

Counsel Inquiry: And what did you do in response to the concerns about an increase in numbers rather than inappropriate usage?

Mr Robin Swann: Well, again those DNACPRs were medical assessments in regards and they should have been, on all occasions, from my understanding, and negotiated, are discussed in regards to the individual and the family as well.

Counsel Inquiry: Because this was an area, would you agree, that requires maximum transparency in order to dispel family concerns about the use of DNACPRs?

Mr Robin Swann: Yes.

Counsel Inquiry: So there was a review done by CQC in England. Why wasn’t there an equivalent in Northern Ireland?

Mr Robin Swann: I believe the CQC investigation actually covered Northern Ireland as well in regards to some of their responses.

Counsel Inquiry: But there wasn’t an in-depth assessment done of DNACPRs that had been imposed in Northern Ireland.

Mr Robin Swann: No.

Counsel Inquiry: Do you think that there should have been in order to provide that level of transparency that might have assisted families?

Mr Robin Swann: Well, I think, taken from what I’m aware of, there was a reliance on the work that had been done by CQC.

Counsel Inquiry: It’s true that the DNACPR forms weren’t available on the Northern Ireland Electronic Care Record; is that right?

Mr Robin Swann: I’m not aware of that, my Lady.

Counsel Inquiry: Okay. That is from the statement of the witness on behalf of the Western Trust who gave evidence as to the spotlight hospital. As far as you were aware, did inability to collate DNACPR forms play any role in not ordering a review that could then be published?

Mr Robin Swann: Not that I’m aware of.

Counsel Inquiry: You were involved in what’s called in your statement a single integrated process for advance care planning to support DNACPRs that was approved for publication in October 2020. Is that the ReSPECT forms that you’re talking about?

Mr Robin Swann: Yes, it takes into – the advance care planning looks at – is proposed planning for all aspects, should it be financial, inheritance, and engaging with families in an early occasion.

Counsel Inquiry: Yes, because it’s right, isn’t it, that actually there is no power in Northern Ireland to provide a lasting power of attorney that covers Health and Social Care decisions?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Because those powers do exist under the Mental Capacity Act Northern Ireland 2016 but they’ve never actually been brought into force?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Do you think that during a pandemic it’s beneficial for there to be an option for people to put in place a lasting power of attorney?

Mr Robin Swann: There should be the option in regards to that and I think coming out of this Inquiry, and in today’s session, I think it will be a recommendation that I would bring forward or even ask my Executive colleagues to look at in the regards to the legislative basis for that because I do believe, my Lady, that across (unclear) and the Department of Health there is a Department of Justice requirement for input too.

Counsel Inquiry: Why wasn’t that something that was looked at in the middle of 2020, for example, about bringing those provisions into –

Mr Robin Swann: I’m not aware why it wasn’t raised at that point. It’s definitely something that wasn’t brought to my attention, nor was it something that I contemplated.

Counsel Inquiry: It’s difficult to ask why you didn’t contemplate something but I’ll try anyway. Is that not something that you should have thought about, about using the powers that were available to the department for health to actually plug a gap that would have been beneficial for the pandemic?

Mr Robin Swann: It actually wasn’t until preparing for this evidence session that I was made aware that that lasting power of attorney wasn’t available in Northern Ireland under those occasions.

Counsel Inquiry: So you didn’t know that until 2024?

Mr Robin Swann: That’s correct.

Mr Scott: My Lady, I’ll be moving on to another topic. Is that be a convenient moment to break for lunch?

Lady Hallett: If you’re moving to another topic, certainly. Very well. We shall return at 1.45. And I promise we will finish your evidence today, Mr Swann.

The Witness: Thank you, my Lady.

(12.45 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: Mr Scott.

Mr Scott: Mr Swann, I’m going to move on to look at services during the pandemic and I’m going to start with NHS 111, please.

Prior the pandemic Northern Ireland didn’t have access to 111; is that correct?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Why was the decision taken to join NHS 111 as part of the response to the pandemic?

Mr Robin Swann: I think so we were able to provide that telephone response in regards to telecommunications as to people who were concerned they had symptoms of Covid, or other queries.

Counsel Inquiry: So I think access was from 28 February; is that correct?

Mr Robin Swann: That’s correct.

Counsel Inquiry: And how did the department actually go about joining as part of the NHS 111?

Mr Robin Swann: I think that was an engagement that was actually had by PHA in regards to how that engagement was actually taken about, but then with the creation of our own Covid centres as a direct point of contact, we think was a more beneficial route for Northern Ireland patients.

Counsel Inquiry: Yes, I’m going to come next to the Covid centres.

But do you know how NHS 111 from Northern Ireland perspective was staffed?

Mr Robin Swann: There was supposed to be a specific section if you rung 111 and asked or indicated you were from Northern Ireland it took you down a specific path as well because of the peculiarities and the differences within our healthcare service and structure in Northern Ireland.

Counsel Inquiry: You said “supposed to be”. Was there not?

Mr Robin Swann: I think there were difficulties that were indicated at the beginning of the pandemic and I think that’s – the utilisation of that service in regards to that, that it wasn’t as seamless or efficient as we hoped it would be.

Counsel Inquiry: And were those difficulties ironed out?

Mr Robin Swann: Not to the extent that we thought that the Covid centres and our own “telephone first” services were actually a better solution to the problem.

Counsel Inquiry: So from 28 February Northern Ireland joined NHS 111 but then, due to difficulties in the service, was it almost put into abeyance because the preference was to go to Covid centres?

Mr Robin Swann: Yes.

Counsel Inquiry: On reflection, would there have been a better way to handle joining NHS 111 or would you just not join it at all in the event of a future pandemic?

Mr Robin Swann: I think on reflection we wouldn’t probably join it at all but actually go down our “telephone first” service, which is part our “no more silos” strategy that’s been directed as to – actually had a 111 alternative specifically for Northern Ireland, my Lady.

Counsel Inquiry: I’m going to look now at general practice. There was a perception that the population of Northern Ireland couldn’t get an appointment to see their GP. Do you think that perception was true?

Mr Robin Swann: I don’t think it was accurate on all occasions, as well. We did put out a number of messages not just from the department but also from the GP committee and the BMA in regards to making sure that people who did need to access healthcare could. There was also an introduction in regards to telemedicine and into, again, additional financial supports that the department provided to GP practices as well.

Counsel Inquiry: Yes, I think it is right, as the strategic framework from June 2020 sets out at paragraph 2.3, “GP appointments have reduced by 19.4% compared to last year.” Is that a statistic that you recognise?

Mr Robin Swann: It’s not a specific, but I do know there was concerns but, again, that was also offset in regards to those telephone and visual appointments as well.

Counsel Inquiry: Right. So any reduction in appointments was met by an increase in remote telephone appointments; is that right?

Mr Robin Swann: That was the intention, yes.

Counsel Inquiry: It may have been the intention but was it the result?

Mr Robin Swann: I believe it was.

Counsel Inquiry: Does the department keep detailed statistics about how many GP appointments there are?

Mr Robin Swann: It didn’t prior to the introduction of Covid but they do now.

Counsel Inquiry: At what point in time did it come in?

Mr Robin Swann: I can’t remember the exact date but I’m sure, my Lady, it was in the evidence bundles in regards to when that was actually introduced because it was, again, one of those measures that we found, I think, necessary and useful as well.

Counsel Inquiry: While we’re dealing with telemedicine then, that was the “telephone first” consultation process you were talking about?

Mr Robin Swann: Yes, and also at GP level.

Counsel Inquiry: Yes. That wasn’t a new concept, was it? That was a concept that had been considered in 2017; is that correct?

Mr Robin Swann: I think it was initially looked at then, yes, as well, but I think, due to the challenges of the pandemic, that I think it was something that was actually – additional monies were put in to show that GPs – GPs could actually put further resource into it as well.

Counsel Inquiry: Okay, because I want to compare the before and after, so the Royal College of GP’s statement at paragraph 14 says:

“The Department of Health in 2017 had encouraged practices in Northern Ireland to consider adopting a telephone first based triage system … as a way to manage increasing demand, but only a small number of practices had taken this up. There were few practices using digital telephony and no digitally enabled triage systems in place. There was also no e-prescribing capacity in Northern Ireland and this remains the status quo.”

So when “telephone first” was brought in, were you actually starting – well, not “you” – was Northern Ireland actually starting from a position where there was sufficient capacity to carry out telemedicine?

Mr Robin Swann: No, and that’s the way the department actually put the additional resource in to that point. I think the initial was in the region of £1.7 million in regards to that additional support specifically for that issue.

Counsel Inquiry: And at what point in time did you consider that there was sufficient capacity across primary care generally?

Mr Robin Swann: I would still be at an opinion, my Lady, in regards that we don’t have sufficient capacity still within general practice. And again, even when I returned as minister in February 2024, I did work to put additional supports into general practice to make sure that we had the ability to make sure that what we wanted general practice to do was actually – they were able to deliver it as well, because we still have challenges within our primary care in general practice.

Counsel Inquiry: Do you consider that telemedicine or the “telephone first” consultation process is one of the success stories of the pandemic?

Mr Robin Swann: It is something that was actually – well, as you’ve indicated, it was initially identified as 2017. It was disappointing it took until the additional investments that were made in 2021, due to the pandemic, that that was actually the enabler to bring about that transformation.

Counsel Inquiry: And can I please have your statement on screen.

It’s INQ000492281. It’s at page 38, paragraph 103.

Because it may have been a success story in terms of the roll-out of telemedicine to enable people to have telemedicine, do you think that there was sufficient consideration of equalities about the impact that moving to remote appointments in primary care would have?

Mr Robin Swann: I don’t think there was the ability during the pandemic to take all that into consideration. I do think there is more work needs to be done in regards to that. The messaging at the time was if you still needed to see your GP, you should be able to get an in-person appointment as well.

In regards to the additional supports to telemedicine, I do know that we provided additional resource to make sure that there was accessibility through British Sign Language and Irish Sign Language to anybody utilising the service.

Counsel Inquiry: Your statement says it wasn’t possible to carry out equality impact assessments. I think we’ve seen in statements they tend to take about 12 weeks, is that right, and tend to involve consultations?

Mr Robin Swann: Yes.

Counsel Inquiry: But it’s right that there is a slightly lower level in terms of equality screening that can be carried about in terms of policy that might be put in place; is that right?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: And the equality screening doesn’t have to take anywhere near 12 weeks, it’s done on a form, generally by an official within the department, and then reviewed and countersigned?

Mr Robin Swann: Yes.

Counsel Inquiry: If we can please go to paragraph 105, where you say:

“I cannot recall any specific mitigations for older patients, disabled patients particularly those with sensory impairments, patients whose first language was not English, those with literacy issues, patients in areas with poor internet connectivity, patients who were homeless, patients from lower socioeconomic groups.”

Are you saying that the Department of Health didn’t consider the impact of a change in the mode of access to primary care for all those groups?

Mr Robin Swann: I am, yes, in regards to the specific introduction to the telemedicines in regards to that. As I say, I referred earlier to the enabling of the sign language, which was already something that was available through Health and Social Care –

Counsel Inquiry: Yes.

Mr Robin Swann: – and the department, so it is regrettable, but unfortunately, my Lady, that was the reality that we were facing.

Counsel Inquiry: You say it’s a reality that you were facing. It’s not a reality that you can’t carry out equality screening on bringing in a policy such as “telephone first”?

Mr Robin Swann: In regards to the work that had been done in 2017 and the introduction to telemedicine, as I said, I think in a previous statement, there is more could have been done and more still could be done to make sure that we gain the full advantage of what is there.

Counsel Inquiry: In terms of more that could be done, has an assessment of the impact upon those groups been carried out since?

Mr Robin Swann: Not to my knowledge at this point and from the position I’m coming from.

Counsel Inquiry: Why not?

Mr Robin Swann: I don’t know, my Lady, and I’m not in a position to. To answer that, whether the department can, would be maybe appropriate.

Counsel Inquiry: Is this another example of the department not looking at decisions with an equalities lens?

Mr Robin Swann: And from the evidence that’s been put today and from the number of incidents that has been mentioned, my Lady, I think, yes, that can be another issue that can be asked and, as I’ve said in previous answers, I think it’s something the department could pick up on.

Counsel Inquiry: I’m going to move now to the primary care Covid-19 centres. So those were intended to provide services for those suspected of Covid-19, and the intention was people with Covid-19 would go to those centres and that would keep GPs free for non-Covid patients; is that correct?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: Where did the idea come from?

Mr Robin Swann: It came from, I think, discussions with the department with GPs, through the BMA and Royal College of GPs in Northern Ireland, and it was something we were able to deliver actually at pace. I think we were able to open the first centre towards the end of March 2020.

Counsel Inquiry: Did it work?

Mr Robin Swann: It did, yes – well, sorry, in my interpretation and my take from – my Lady, yes, I think it did. I think we’d seen up to 65,000 patients or people went directly to Covid centres rather than approaching GPs.

Counsel Inquiry: So that was the aim, wasn’t it, to keep people out of GP surgeries and also to provide a pathway to hospitals, emergency departments; is that correct?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: And so the department considers that that system achieved its aims?

Mr Robin Swann: Well, I’m not sure if the department does, but I do, my Lady. I think it was one of those successes where I actually saw primary care department and trust coming together to deliver those at pace.

Counsel Inquiry: Going to move now to ambulances. So we’ve seen in some of the department’s reviews of access to emergency care that it’s actually not possible to compare – or it is possible but it’s not appropriate to compare ambulance response data before 12 November 2019 with any data after that because there was a change in the clinical response model; is that correct?

Mr Robin Swann: That’s correct, from my understanding, yes.

Counsel Inquiry: And then there was another change actually in 18 October 2021 due to a slightly different way that the statistics had been recorded; is that right?

Mr Robin Swann: As far as I’m aware, yes.

Counsel Inquiry: So the statistic that effectively people are left with is the percentage compliance of how Northern Ireland Ambulance Service (NIAS) met the targets that had been set for response times; that’s a fair comparison?

Mr Robin Swann: Yes.

Counsel Inquiry: And the department statement sets out at paragraphs 429-430 that:

“Between April 2020 and March 2022, the mean and 95th percentile targets for Category 1 (Immediately life threatening for a response to arrive at the scene) and Category 2 (Emergency calls which are potentially serious) …”

So the mean and 95th percentile targets for both of those.

“… were not met during any month.”

Mr Robin Swann: That would be my recollection as well, but I think the T1 responses were actually – where a vehicle is required to be in attendance, were met.

My Lady, the pressures on our ambulance service in Northern Ireland are not specific due to the Covid Inquiry. In fact, there’s still a challenge in regards to what we’re able to deliver and, again, against what we want to deliver.

Counsel Inquiry: You say that you approved significant additional funding over the period of the pandemic for NIAS, and then, paragraph 94, you say:

“[You’ve] asked officials in the Department of Health as to whether there is information pertaining to … whether these funds resulted in the expansion of 999 capacity but I understand these figures are not held by the Department.”

Is there a difficulty here that if the department is providing additional funding to an organisation such as NIAS in order to improve its services if it then doesn’t actually track whether that funding has achieved the aim?

Mr Robin Swann: Well, as the sponsoring authority, on their value for money I believe it should in regards to those. I think at the time of the writing of the statement I wasn’t provided with that detail as to whether that had been applied.

Counsel Inquiry: So it may be that the department does have other information but you weren’t aware when you were writing your statement?

Mr Robin Swann: As far as I’m aware.

Counsel Inquiry: So when you were asked, for example, to provide funding for NIAS to improve its services, would you ever find out whether that funding had been considered to be effective?

Mr Robin Swann: Well, in regards to, I think all – I think actually the majority of the bids that come into NIAS were met during the Covid pandemic. Again, it was for additional hours, it was for PPE, it was for turnaround times, additional cleaning of ambulances to – sure – I’m not sure what metric was then applied to make sure that money was actually utilised to the extent that it was meant to, and that’s, I think, from that previous answer.

Counsel Inquiry: Okay. One sub-topic for ambulances. At the Executive meeting on 8 April 2020 there’s a question about “Air ambulance suspended”, and you replied “helicopter suspended air ambulance plane available OK”. I appreciate those notes are not notes you took, they’re not formal minutes. Was the air ambulance helicopter, as opposed to the plane, suspended at any point during the pandemic?

Mr Robin Swann: Not that I am aware of in regards to that specific – but, again, you’re referring to handwritten notes that only became evident and presented during the Inquiry.

Counsel Inquiry: Because given the geography of Northern Ireland, it is a critically important service to maintain; is that right?

Mr Robin Swann: It’s a very valuable service and I think has saved many lives in the past, yes.

Counsel Inquiry: Given you don’t remember that, I’m going to move on to a different topic, to look at emergency departments.

Why are the waits so long, emergency departments in Northern Ireland?

Mr Robin Swann: My Lady, this isn’t specifically due to Covid. Unfortunately, it’s a challenge that has faced the Health and Social Care in Northern Ireland through quite some period of time.

I think why they are so long is actually due to the flow of patients through our entire hospital system. So it’s not just moving patients from the emergency departments and to available bed capacity within wards but it’s also the onward movement of people who are in the wards, actually moving them back into community settings as well. So when I came back in as minister in February 2024, I put in money into social care to improve that flow through and actually that support of getting people out of hospital, so we can get people – if you can get them out of hospital, you can get them from ED and to wards, and that improves the flow throughout the entire system. Because no part of our system in Northern Ireland, or indeed across Health and Social Care, can be looked at in isolation in regards to the challenges.

Lady Hallett: Same problems we have in England, isn’t it?

Mr Robin Swann: Yes, it would be, my Lady.

Mr Scott: But to indicate the scale of the problem, I think it’s right that the Northern Ireland hospital statistics emergency care from 2022-2024 recorded that between 2018-2019 and then 2022-2023, the number of patients spending longer than 12 hours in emergency department increased from 25,326 to 106,990. So that’s a fourfold increase.

Mr Robin Swann: Yeah.

Counsel Inquiry: Why aren’t the times getting any better?

Mr Robin Swann: Because we haven’t been able to sustain that investment in the transformation in health that we’ve wanted to throughout that entire period of time. And again, my Lady, it’s down to the topics we’ve covered previously, in regards to not having a functioning Executive for five out of the last eight years, having single non-recurring budgets year on year since 2016, so the investment in health and social care and domiciliary care hasn’t been as robust as I think it should be. It’s several steps I took when I was there as minister, and again, my Lady, the difference being is the domiciliary care in Northern Ireland is part and responsibility of Health and Social Care and not devolved to the local authority.

Counsel Inquiry: Did Covid-19 break emergency care or just exacerbate an existing weakness?

Mr Robin Swann: I think it exacerbated the weakness that was already there, but it added additional numbers as well. The intention is well-being, that our Covid centres would have diverted some of that pressure away as well. So in regards to the numbers of people who may have been presented to ED with Covid symptoms could – actually went to Covid centre instead. But definitely the Covid pandemic highlighted and exacerbated the weaknesses we have in health and social care across Northern Ireland, not just in ED but across the entirety of our system, by the additional pressures that were put on our health and social care staff as well.

Counsel Inquiry: I understand that you say that the primary way, maybe the only way, to fix it is investment, but what steps had you taken within the resources available to you, so absent any additional funding, in 2020, 20201, 2022 to try ton improve the waiting times within emergency departments?

Mr Robin Swann: Well, it is about the additional monies. As I said, my Lady, the additional monies that were put into domiciliary care, so we could provide actually more packages, more – more hours to get the flow through hospital actually better, so we get more people out of wards and off beds so that we could get them from ED in – that’s the additional investments that were made in GPs as well, so that people could actually be seen at a GP rather than the need to go to the emergency departments as well.

Counsel Inquiry: Because it’s right that two urgent care services, so phone first, which I think is where you call an emergency department – or, slightly lower, minor injuries unit, is the word I was groping for, and then urgent care centres, that were introduced in late 2020, were aimed to assess patients needs before arrival and ensure they received the right care at the right time and in the right place, outside emergency departments if appropriate.

Has either service actually worked?

Mr Robin Swann: Well, they’re beginning to work. There’s also the introduction of ambulatory units as well, where people could actually be taken to a specific speciality in regards to when they do present in EDs as well. It’s about the whole package. It’s not just simply about looking at EDs, as I keep on referring to. We need to improve our domiciliary care packages and support, we need to improve our flow through hospital, we need to get people actually seen quicker at the right point and the right time. And I think some of steps that have been made – and our transformation from our elective care strategy, through the introduction of day care procedures unit, elective overnight centres, you know, these are all things that, my Lady – and, honestly, if they had been introduced as part of Bengoa, post 2017, would actually have made the introduction of red and green sites or the flow through our hospital systems in Northern Ireland actually in a better place coming into the pandemic rather than where we are now.

Counsel Inquiry: You’re talking about this being part of the piece, it’s about the whole system working, so I just want to ask you about non-emergency departments, about what the department has done to effectively restart services in the pandemic.

I think it’s right there is a headline comment from the Elective Care Framework that was produced by the department in July 2021 which reports that in March 2019 it was reported that a person in Northern Ireland is at least 48 times as likely as a person in Wales to wait more than a year for care. This is despite Wales being the worst performer otherwise in the UK. That’s something you recognise?

Mr Robin Swann: I think it’s actually part of my opening statement for the elective care strategy. It was produced at that stage. My Lady, can I say that was flowing on from an elective care strategy that was actually published in 2017 that was never built on or never enacted due to the fall of the Executive.

Counsel Inquiry: And I think the 2020 regional service delivery model for day case selective talks about how that the reasons, the fundamental reason why the current levels of waiting lists is because demand is increasing due to demographic change and its demand for care is steadily outstripping the ability of the system to meet it.

Prior to the pandemic, for how long had demand been outstripping the ability of the system to meet it?

Mr Robin Swann: I think for a number of years in regards to that, possibly from 2016, 2017, if I recall the figures from my time in the department. As I say, when I went into the department and took on the role in January 2020 the biggest challenges or the two challenges were industrial action and the state of our health service in regards to ever-increasing waiting lists.

Counsel Inquiry: I think it’s fair to say that the fundamental problem of demand outstripping and lack of investment wasn’t something that was fixed during your time as health minister?

Mr Robin Swann: Not during the pandemic years, as well, between January 2020 through to when the – the Executive actually fell, my Lady, in February 2022, ministers were then retained in post up until October 2022, without Executive meetings, without access to being able to formalise or actually having a political decision in regards to budget, that was something that was brought in by direct rule. So did waiting lists get better during any tenure? No, but we were faced by a pandemic through that time as well and then at that point the Executive fell again in October 2022.

Counsel Inquiry: It wasn’t intended to be critical that question, it’s a factual statement that it hasn’t resolved in your time as health minister.

Mr Robin Swann: No.

Counsel Inquiry: Is there anything more that you think that you could have done as health minister to improve the situation?

Mr Robin Swann: During the two periods that I was in the first, as I say, the intention was about how we actually developed and delivered the recommendations from Bengoa, my Lady, in regards to the transformation that we could have delivered and we should have actually been pre-delivered prior to 2020. The pandemic then set us off course in regards to how we reacted, how we were firefighting against a global pandemic but also working with a system that was already under pressure. I wasn’t able to do that during that time, but I think coming towards the end, when we looked to the development, as I say, the day case procedure units, the elective overnight centres, post-anaesthetic care units as well. There were those measures that were being taken, were being introduced, but again – and I know it was something that was said in the witness statements – do require that commitment of sustained recurrent funding to enable those transformation projects actually to continue.

Counsel Inquiry: The Inquiry’s looking at four non-Covid conditions, ischaemic heart disease, hip replacement surgery, colorectal cancer, and inpatient mental health services for children and young people. Just putting aside the mental health services for one minute, in relation to ischaemic heart disease, hip replacement surgery and colorectal cancer, are the challenges faced in restoring those services to what you think you would consider an acceptable waiting list, do all of them have exactly the same answer?

Mr Robin Swann: They do, and I think it refers to about how we bring about that transformation, just as how we look to those specialised centres across Northern Ireland that currently is happening, or is something that my successor is currently looking at, at how we look to specialised centres that can do high-number volumes of those specific procedures, surgeries, diagnostic tests, rather than looking to each trust possibly doing a few so we can actually bring that about and, again, come back to elective overnight centres or day case procedure units, that’s what those are all intended to do.

Counsel Inquiry: I am very shortly going to look at some of those responses in 2020 and 2021. Just one point I want to ask you about is targets. We see throughout a number of the departmental statements and frameworks that have been produced, discussion about targets, so waiting lists for no longer than 9 weeks and no patient waiting longer than 52 weeks. What’s the point of those targets?

Mr Robin Swann: It’s to set that challenge to those who deliver, those who support, those who call for investment in health and social care, actually, to see what can be achieved, what we want to achieve, and I don’t think by moving or removing those targets would actually improve the service because I do believe anybody working in health and social care in Northern Ireland has a genuine desire to meet those targets.

Counsel Inquiry: So were they actually more to inform people outside the health service about the state of the health service rather than people inside it?

Mr Robin Swann: No, there’s balance for both in regards to people outside the service actually knowing what the health service targets are and in regards to the supply of that information, it is something I believe is now available on a central website or a central database across all the trusts, so it’s available to the general public as to what state or where the waiting list is in each specific specialisation in each trust area as well. One of the steps that my successor has taken is people are able to move across trusts as well should there be available ability to do that.

And we were looking at that in regards to how we actually utilise the whole of the health estate across Northern Ireland and that patients aren’t simply restricted to the geographical trust that they live in.

Counsel Inquiry: And that comes about through an overarching strategy that’s imposed by the department rather than leaving it to the individual trusts; is that right?

Mr Robin Swann: That’s correct.

Counsel Inquiry: And is that not something that could have been brought in at a much earlier stage rather than your successor looking at in now?

Mr Robin Swann: Well, no, there is the Elective Care Strategy, I think we actually quoted in their section as well, there’s a cancer strategy, there’s a mental health strategy in regards to how you set about all those specific pieces of transformation. We also, I suppose – I’m sorry, the department also employed GIRFT, getting it right first time, assessments in regards to our orthopaedics, in regards to EDs, you know, in regards to how we actually bring about those changes.

Counsel Inquiry: I want to look briefly at CAHMS. The Department of Health’s statement on data at paragraph 53, says:

“During the relevant period, the Department did not routinely collect data that in relation to the number of people referred for inpatient mental health services …”

How can there be an effective commission of services if you don’t know how many people need them?

Mr Robin Swann: It’s a weakness that was in the system and I know it’s something that I and my special adviser have actually raised within the department on a number of times as well. You mentioned, I think a moment or two ago, the mental health strategy. There actually is a target within the mental health strategy in regards to additional investment in regards to CAHMS, because it was something that was identified by us as needing work done on it, it was something that was discussed at the Assembly level through the health committee as well.

Counsel Inquiry: But isn’t it simpler than making sure there is a mental health strategy, isn’t it simply, doesn’t the department need to know how many –

Mr Robin Swann: It does, yes. That data wasn’t – no, I do recall it was a specific that we did challenge.

Counsel Inquiry: It says:

“… the department has overseen the introduction of the … Acute Managed Care Network … which became operational in February 2022. Work is currently being taken forward by [that network] which will, when complete, enable the department to undertake routine monitoring with the number of inpatient CAHMS referrals …”

That suggests that the department still doesn’t hold that data even though the network has been in place two years?

Mr Robin Swann: That would be my reading from that statement as well, but as I say, not – when the Executive and the First Minister resigned in February 2022 there was additional pressures that we were putting on it. Again, it was something that we were specifically asking for within the department was that additional investment and recognition of CAHMS because I knew it was an area we were lacking in.

Counsel Inquiry: Is there a fundamental difficulty with the department being able to access the data that it needs and it’s taking multiple years in order to get that data?

Mr Robin Swann: I think there has been a general recognition that the number of databases and points of collection have been outstripped by the need of what is accessible and what is concurrent and what is needed by the department to formulate those responses. And I think, my Lady, I hope, my Lady, in regards to that is why the department invested so heavily and the introduction of encompass so that we could have a single point or a single data system that would cover eventually all five trusts.

Counsel Inquiry: I want to look then briefly at the independent sector. You say in your statement that you expected 120 to 135 procedures would be carried out per week across a range of red flag and urgent cases. Could you define red flag cases for us, please?

Mr Robin Swann: Red flag is cancer or specific medical cases that the GP has indicated that need urgent and timely assessment.

Counsel Inquiry: And you say that was a reduced number of procedures but the best possible in the circumstances. So are you satisfied that no greater use could have been made of the independent sector to either provide additional capacity to carry out treatments or to support HSC in the actual provision of staff or beds to treat Covid?

Mr Robin Swann: From the questions that were made by, I think, between the trusts and the Health and Social Care Board contracting and contacting the independent providers in Northern Ireland, which we have a very small independent sector in Northern Ireland, I think it was in the region of 130 beds across the three providers, so it’s not comparable to what was here in England or Wales or, indeed, Scotland. But from the feedback that I was getting from those department officials and from the Health and Social Care Board, I was being assured we were making best use of what was available.

Counsel Inquiry: When you say best use, do you mean maximum use?

Mr Robin Swann: Yes, maximum use, yes, and I think there’s also the concern – sorry, there’s also the added challenge at that stage our independent sector in Northern Ireland didn’t have critical care capacity either.

Counsel Inquiry: But, again, it’s about using the tools available to you as the health minister even though they are the independent sector but making sure you’re using the maximum capacity across all sources of capacity; is that right?

Mr Robin Swann: That’s correct, and my understanding is that’s what the Health and Social Care Board and the trusts were doing.

Counsel Inquiry: I want to look now, just briefly, at three frameworks about rebuilding services. The first is June 2020 which was called the Rebuilding HSC Services to Treat it Framework. What was that framework meant to achieve?

Mr Robin Swann: It was meant to show how the system was preparing to get back to the level of delivery that we had prior to the first wave.

Counsel Inquiry: And what was the role of the department in restarting services?

Mr Robin Swann: Produce that framework, produce the overarching policy, and then to challenge the Health and Social Care Board and the trusts to deliver.

Counsel Inquiry: So in this instance isn’t the policy: we need to be rebuilding our services, and then it was over to trusts to decide how to implement that?

Mr Robin Swann: Yeah, but there was also that co-production and co-working with the Health and Social Care Board and the trusts to actually do that.

Counsel Inquiry: Did the department take a firm enough grip about making sure there was a regional response to rebuilding services?

Mr Robin Swann: I think in regards to the challenge of the Health and Social Care Board whose remit it would have been to challenge the trust, I think we were being that challenge function, the establishment of the regional prioritisation organisation group in regards to –

Counsel Inquiry: The prioritisation group came in in January 2021; this is June 2020.

Mr Robin Swann: Yes. And again, there was that challenge there in regards to what each trust was delivering again, because those documents were public facing and publicly available.

Counsel Inquiry: Did that framework actually achieve its aims?

Mr Robin Swann: I think that framework was actually probably superseded by the second wave.

Counsel Inquiry: I want to look at one specific example under it. At paragraph 2.31, so page 14 of that framework, it says:

“The downturn in red flag demand through April and into May means that all Trusts outside of Belfast currently report that all parties who are suitable to be listed for surgery have a scheduled date, either locally, or within the Independent Sector facilities secured by HSC.”

That was probably the best position that Northern Ireland had been in for years, is that correct, about people having dates for cancer treatments?

Mr Robin Swann: It wasn’t the best position in regards to the number of people who were probably coming forward for treatment or who had been identified for red flag in regards to that. The fact that at that point we were able to meet need didn’t mean to say we were delivering the service we should have been.

Counsel Inquiry: Yes, because that’s what I want to go on to next. So the paper to the Executive and the Department of Health on 17 December sets out there’s been an increase in the number of patients on the 62-day cancer pathway and then it sets out that at 1 October 2020, 3,500 patients are waiting longer than 62 days compared to 1500 or so on 11 March 2020, an increase of 125%.

So, is it the position that even though you’d managed to reach a point where need had been met, I think to use your words, the demand completely outweighed the ability of the service to provide?

Mr Robin Swann: To look at those – I suppose maybe not to challenge looking at those two specific points in time as being absolutes, it was, I think, the overall demand prior to – what was presenting prior to the pandemic and when we saw the realistic demand of full presentations coming through GPs and EDs.

Counsel Inquiry: And again, I’m probably going to get the same answer but was the way to actually address that, the restructuring, the funding, the investment?

Mr Robin Swann: It is, and then I think, my Lady, there’s – quite a number of the questions I could answer today is about funding and investment and recurrent budgets in regards to the health service and what it actually needs in Northern Ireland but I was taking the direction by counsel at the start that that shouldn’t be the answer to everything today.

Counsel Inquiry: And again, is this the same position in relation to the regional service delivery model for day case elective in July 2020, that you put out in place –

Mr Robin Swann: No problem.

Counsel Inquiry: That you put in place those centres to deliver. You handed them over to the South Eastern Trust or the Belfast Trust but actually there hasn’t been the breakthrough in terms of waiting list reduction that you’d look for?

Mr Robin Swann: Well, there hasn’t been the large-scale breakthrough in regards to overall reductions to a significant level but it’s also about the plateauing of the level of demand against what we can actually supply before the health service as it currently starts to meet the need and actually start to eat into those waiting lists. But again, my Lady, in respect to where the service currently is, I think it’s something the department could probably address those issues.

Counsel Inquiry: Was sufficient use made of elective hubs to ensure that diagnosis and/or treatment for non-pandemic conditions could continue uninterrupted in a future pandemic?

Mr Robin Swann: I think the establishment and, again, it was the call even from Royal College of Surgeons as well about the establishment of red and green surgical hubs were of a benefit. I think prior to the pandemic that work hadn’t been completed in Northern Ireland but with the establishment of our day case procedures units or elective overnight centres, there is an ability now to designate those, should there be another pandemic, as those green pathways to service.

Counsel Inquiry: And then finally and briefly, the elective care framework of July 2021. The experts instructed to look at hip replacements gave evidence and they said that:

“… the blueprint … which recommended elective care … the recommendations were fairly non-specific and I don’t think were well adhered to. There certainly wasn’t a financial incentive.”

There was:

“… a review in February 2022 by GIRFT programme which was initially an NHS England initiative that went to visit Northern Ireland and made a series of recommendations which were much more about having more focused central organisation of care for orthopaedic waiting patients.”

Do you agree with that assessment?

Mr Robin Swann: Actually GIRFT was commissioned by the department to come in and look at orthopaedics in regards to that robust challenge as to what was actually needed in regards to that and I think one of the recommendations actually wasn’t even down to the management of who managed Musgrave Park in regards to what trust it should actually be held in and it was managed by Belfast Trust, and I think one of the GIRFT recommendations was that if the Musgrave Park facility didn’t get up to the required number of procedures by a certain date, that the management of that site should be taken over by another entity or trust.

So the GIRFT report, I think, was much more detailed and forensic in regards to what it was actually saying.

Counsel Inquiry: But was the outcome of that effectively about having a more focused central organisation of care?

Mr Robin Swann: Yes, in regards to the GIRFT report recommendations.

Counsel Inquiry: That seems to be a recurring theme, that’s from GIRFT, that’s from the military assessment about critical care, that there needs to be a greater grip taken to ensure that there’s a regional approach; do you accept that?

Mr Robin Swann: I do and I think part of the, I suppose, the restructuring and the moving of Health and Social Care – the closure of the Health and Social Care Board into SPPG within the department should bring about that focus because it’s now in the house in regards from a departmental point of view in regards to where that challenge actually sits.

Counsel Inquiry: I am going to move on to a different topic, and it’s about paediatric pathology.

Did you hear the evidence of Catherine Todd about the experiences with her son Ziggy when he was sent for the post mortem?

Mr Robin Swann: I have. And, my Lady, in regards to that I think it’s not just in regards to the evidence that was given, my son was in Birmingham hospital at 8 months old for his first open heart surgery, we actually met a couple from Lisburn in regards to a child who was over there for medical treatment, they passed away, and regards were actually left, and a similar situation in regards to being able to bring the child home at that point as well. So again, my Lady, I don’t think I can underestimate the evidence that has been given from individuals in regards to what can be done, what should be done.

In regards to the paediatric pathology, I think there is an opportunity, actually, that we can develop an all-Ireland solution in regards to paediatric pathology, it’s something we’ve actually been able to do through paediatric cardiology and something that has worked very well. So there are solutions that are there but the challenges that we currently face with not having a commissioned service in Northern Ireland, I think are the outworkings of stories like Ziggy’s.

Counsel Inquiry: Isn’t it right that effectively that’s been the situation since January 2019 when the paediatric pathologist retired?

Mr Robin Swann: That is correct and we’ve been able to – unable to recruit a paediatric pathologist for Northern Ireland and, unfortunately, some of those workstreams, my Lady, fall, when there’s no Executive in place or push to do that because the establishment of an all-Ireland approach would be something that would require a ministerial decision, something I can assure you, my Lady, that I was fully supportive of, I would be fully supportive of and I know my successor is.

Counsel Inquiry: Can I move on to shielding.

The department statement says:

“By 25 March 2020 letters were being issued to the Clinically Extremely Vulnerable population by a combination of General Practitioners and Health and Social Care Trusts. In practical terms it required a number of weeks for all these letters to be issued.”

I believe when Ms Hargey gave evidence to Module 2C, she talked about it taking a couple of months, two months, and additional, because of seeking to access 500 databases for each of the general practice surgeries and that took the additional period of time. Could it have been shortened, when I say “it”, could the period of time to communicate to those who should shield that they needed to shield have been shortened?

Mr Robin Swann: Not with the functionality that we actually had at that point in time and I think the exact figure was in the region of 370, different databases, that actually had to be sometimes manually trawled across Northern Ireland actually to identify those who met the criteria that was necessary for shielding as well. And again, I think that’s why the investment in encompass is worthwhile at this point. But also rather than just stopping the development of it, the access to it by the five trusts that decide to look at it, but going further into general practice or even community pharmacies.

Counsel Inquiry: Has anybody run a test on encompass to see whether it would be able to actually deal with an issue such as notifying people who should shield?

Mr Robin Swann: Not that I am aware of.

Lady Hallett: Sorry, I failed to catch the first part of your question, as did the stenographer.

Mr Scott: Has a test been run to see whether encompass can deal with an issue such as notifying people?

Mr Robin Swann: I’m not sure but I know that was one of the selling points that was presented to me that we would have a single system across Northern Ireland that would be accessible, but it does involve it being across all five trusts and accessible to a point of where that functionality can be actually introduced.

Counsel Inquiry: Do you know how many people in Northern Ireland were shielding?

Mr Robin Swann: I don’t have a figure, no.

Counsel Inquiry: Do you think the department knew?

Mr Robin Swann: I do, in regards to the cumulative number of letters that they were asking to be issued.

Counsel Inquiry: Because the briefing paper on 18 June 2020 says there are more than 95,000 people who have been advised to shield but the notes of the Executive meeting on 5 January 2021 talks about up to 200,000. Does that jog your memory about how many people there may have been?

Mr Robin Swann: If those figures were reported to the Executive, yes.

Counsel Inquiry: Was there clarity about what support should be provided to people in Northern Ireland who were shielding?

Mr Robin Swann: Again, that was the intention of the letters going out rather than the reliance on electronic or access to websites, or anything with regards so those specific individuals who required notification would receive it and I think there were a number of letters sent out during the pandemic.

Counsel Inquiry: But that support wasn’t actually provided by the Department of Health was it?

Mr Robin Swann: No –

Counsel Inquiry: It was provided by the Department for Communities.

Mr Robin Swann: Well, there was cross-Executive response in regards to that and I know there was cross-wording across a number of departments in regards to how that would be supported.

Counsel Inquiry: And then I believe it was on 18 June a briefing paper was put to you about pausing the shielding advice from 31 July; is that correct?

Mr Robin Swann: That’s correct.

Counsel Inquiry: Are you able to explain why the view was taken on 18 June that people should no longer shield from 31 July?

Mr Robin Swann: I think it was due to the number of falling cases that we had. I also think it was around that time that we had 14 consecutive days with no deaths due to Covid and it was also in response and to keep in step with the rest of the United Kingdom who were taking the same action at the same time.

Counsel Inquiry: Because I think you were publicly saying that you didn’t want anyone to shield for one minute longer than was necessary?

Mr Robin Swann: That’s right.

Counsel Inquiry: Are you satisfied that’s what happened?

Mr Robin Swann: I am but, again, and I think that’s why we issued the letters with that lead-in time as well in regards to what was actually necessary. We had, my Lady, commissioned through the Chief Medical Officer commissioned the Patient and Client Council in regards to doing an assessment of those who were shielding and the impact and the effect that it was actually having on them and did they find it useful in regards to that and I think there were concerns that were raised by that cohort of people in regards to what it actually meant to them both physically but also mentally as well.

Counsel Inquiry: After 31 July, did you hear concerns from people who had been shielding that they didn’t have sufficient support after that point?

Mr Robin Swann: There was concerns in regards to the supports that were then available but, as I indicated, and this isn’t meant as a derogation of anything we were doing, but it was the support mechanisms that were there through the Department of Communities and through the Department of Finance, as financial supports, letters to employers, and things like that as well.

Counsel Inquiry: I’m going to move to Long Covid. It was known at the start of the pandemic that it was likely that there would be long-term effects caused by the virus. At the start of the pandemic were you made aware of that potential impact?

Mr Robin Swann: It wasn’t something that was brought to my attention at the beginning of the pandemic. We were very much focused on those who were suffering from Covid rather than there actually being a further condition in regards to Long Covid or indeed some of the other –

Counsel Inquiry: Because in summer 2020 you asked the CMO to established a clinical working group to review the needs of those recovering from Covid-19 specifically following a hospital admission. What took you to make that request to the CMO?

Mr Robin Swann: It was actually through conversations being had at the Executive but also other indications from conversations, I think. We met, the four health ministers met regularly for conversations just in regards to what was happening across but there was a need there and I think it was actually something that was brought up at an Executive meeting as well in regards to what we could do, but also from correspondence and presentations that were being made to me as health minister.

Counsel Inquiry: So it wasn’t as a result of there being any tracking from the department or the trusts about …

As a result of that review, by the clinical working group, the report recommended that disciplines working on post-Covid recovery should be incorporated into a one-stop clinic and at that point in time there was such a clinic within the Belfast Trust?

Mr Robin Swann: That’s correct, yes.

Counsel Inquiry: And then I just want to look at the timeline. Because in December 2020, you agreed that HSCB should be asked to develop plans for a multidisciplinary clinic as part of the management?

Mr Robin Swann: Yeah.

Counsel Inquiry: On 9 June, approved proposals and the HSCB directed to commission the service and then the service was actually launched on 1 November 2021. How did it take from when the report came back, presumably in around autumn 2020, until 1 November 2021 to actually put in place these services that you believe should be in place?

Mr Robin Swann: Well, that was the request I made to the Health and Social Care Board who were the commissioning service in regards to that, as to how quickly and what they actually looked like as well and that was in their remit to do that.

Counsel Inquiry: Is there anything more that you think that you could have done to bring those on stream earlier?

Mr Robin Swann: Well, I could have put additional pressures onto the Health and Social Care Board but I think there’s a functionality across the department, as well, to doing that.

Counsel Inquiry: I just want to look, finally, then, at lessons learned. So you were health minister from 11 January 2020 to 27 October 2022 and, then again, February to May 2024. As far as you’re concerned, has Health and Social Care, the Department of Health, and yourself sought to learn all the lessons from the pandemic that occurred?

Mr Robin Swann: I think we have, my Lady, and I think that is part of the functionality of this area in regards to the engagement that we’re having both CMO, CNO and myself, in regards to that, as being asked have I learned all. There’s personal reflections, in regards to the decisions I took when I was health minister weigh heavily on me, my Lady. In regards to the challenges that I face and still think about in regards to even lines of not even the questions that were being raised today but some of the questions that I raised myself in regards to, you know, what could have been done, whether they were the right decisions, were they timely, in regards to what we knew then compared to what we know now.

In regards to the responses from the department itself, I think that is one the department would be best placed to answer, my Lady, as I stepped out as has been indicated and put out of post on October 2022 and then didn’t get the opportunity to return until February 2024.

Mr Scott: Thank you, Mr Swann.

My Lady, no further questions.

Lady Hallett: Thank you very much.

Ms Campbell, would you like to take us to the break.

Questions From Ms Campbell KC

Ms Campbell: Mr Swann, good afternoon. I have topics – five topics and about 20 minutes in which to ask you questions on behalf of the Northern Ireland Covid Bereaved Families for Justice.

Can we start, please, by revisiting a topic that you were asked about very briefly before lunch, and that is the issue of PPE. And you’ll remember that Mr Scott took you to a readout of a meeting on 24 March with the First Minister, deputy First Minister and, I think, the CMO and others, and that readout suggests that there had been something of a misperception about the problem with the PPE and perhaps all was not as bad as it seemed. You recall that document?

Mr Robin Swann: I recall that document, yes.

Ms Campbell KC: I want to then move forward in time by about ten working days, to 3 April 2020.

And can we look at a document, please, which is INQ000065719. And it’s underscore page 10. There we are.

These will be familiar to you not least from Module 2C, Mr Swann. They’re handwritten notes of Executive meetings, and this one is on 3 April. I wonder if we can look at the passage in the middle of the page that starts “DfE”, which I think is Department for the Economy, and perhaps Mrs Dodds; you can confirm if I’m right about that, and perhaps you don’t know –

Mr Robin Swann: I honestly don’t know. It could be the Department for Education.

Ms Campbell KC: I did wonder. In any event, the query you can see is in relation to:

“PPE – how [is it] distributed in [Northern Ireland] – not available when nurses need. How do we get to frontline staff.”

And the Department of Health seems to respond:

“[there is] enough for now, but [it] needs to get to [the] frontline …”

And if we can scroll down the page, please, to the next section where Mr Pengelly is noted – and Mr Pengelly at that stage was the permanent secretary to the Department of Health; isn’t that right?

Mr Robin Swann: That’s correct, yes.

Ms Campbell KC: It is an “Issue of concern”, it notes.

“[The] Paper circulated today – details of stock.

“Tend to focus on central stock – [but] asking them to check supplies with Trusts.

“Issue for Trusts – [it’s a] low level operational issue …”

And you can see at the very bottom of the page that chief executives are being asked to address.

Can we go to the next page, please. Because the question that I’m interested in comes in again from the DfE, and it seems to be – top of the page, the first two entries from DfE and RP, please, if we can highlight those.

The question seems to be is there a:

“Mechanism for Trusts to report back to [the Department of Health]? Re [the] level of PPE [and] distribution to facilities.”

And Mr Pengelly replies:

“No specific mechanism for report to us – ask CEO to fill in Returns. Every location has [its] own supply control system.”

So, the question really that we have, and focusing on the issue of that central element of control that you’ve been asked about on the part of the Department of Health, is it really the case that on 3 April 2020 there was no specific mechanisms for trusts to communicate with the department in relation to the availability of PPE on the front line?

Mr Robin Swann: I think that is – that specific point is in regards to the management of stock levels.

Ms Campbell KC: Yes.

Mr Robin Swann: If I take this document in regards to my understanding and my recall of that meeting was actually in regards to not the concerns of the front line but what stocks were being held in regards to either each ward or each trust. That’s my reading and my recollection of that actual engagement. It wasn’t the fact that concerns weren’t being raised.

As I mentioned in regards to – the evidence I gave to Mr Scott was in regards to how I asked the CNO to establish that PPE hotline so that any concerns that were raised or could be raised were actually coming directly into the department.

Ms Campbell KC: Of course you’ve got the PPE hotline which allows an opportunity for frontline staff to email the trust – the department if there are problems. But how does the department ensure that there aren’t problems if it didn’t have sight of what the stock levels are at trust level?

Mr Robin Swann: And I think that’s why Mr Pengelly there has asked the CEOs to fill in actual returns so that that documentation was coming back.

And again I think in regards to that answer that I gave to Mr Scott, was that Health and Social Care were so used of PPE being that item that was always there, in regards to when it was – when it was needed, in regards to, then, the change and challenge as to, I’ve said, distribution, supply chain, the just-in-time supply chains that actually presented the challenges to the distribution in the central management.

Ms Campbell KC: But can we focus for a moment, Mr Swann, on what control that your department had over this. The Chief Medical Officer has told her Ladyship in the course of this module that as of 27 January – and you’ll, I suspect, be familiar with this – health gold had been established, and then you had the gold, silver and bronze command, the purpose of which was to ensure effective oversight and engagement from top-level Department of Health to frontline staff. And PPE, as we’ve already seen, is an issue that has been of increasing concern throughout March 2020. So why is it that by 3 April 2020 you were asking CEOs to simply fill in returns without a direct mechanism of communication to the Department of Health?

Mr Robin Swann: And, again, that’s the statement of Mr Pengelly at that point in regards that no direct mechanism had been established, and that’s how the interim measure was being put in place, through the CEO of each trust to fill in those returns, and then that was superseded by the establishment and responsibility of what BSO was actually doing in regards to the overall management of PPE.

Ms Campbell KC: Putting BSO to one side, did the trust chief executives then, in April 2020, get to the point of filling in returns for them to be analysed by the department?

Mr Robin Swann: I assume they must have, because it wasn’t then, you know, followed up in regards to that, whether they were actually filling it in or somebody on their behalf was filling it in and returning it to the department, because that’s when that more centralised control in regards to the work that BSO was doing was actually started.

Ms Campbell KC: What did you learn – if we focus on the issue that Mr Pengelly was raising at this Executive meeting, one of the things that he said was that there was essentially no – every location has its own supply control system.

So, firstly, do you know what he means by every location? Was it every hospital, was it every trust –

Mr Robin Swann: From my understanding, and actually every location actually went down to – as I said in a previous answer, actually down to ward level in regards to how PPE was actually being managed or distributed at each location.

Ms Campbell KC: And did that change, so far as you know?

Mr Robin Swann: Yes.

Ms Campbell KC: And when did it change?

Mr Robin Swann: I’m not sure of an exact date but that was the outworkings of the mechanisms that were then later put in place in regards to how stock was managed, stock was delivered, and it was actually ordered via BSO through that central organisation system.

Ms Campbell KC: Would you accept that there seems to have been a problem certainly in March and April 2020 in terms of preparedness to understand what level of stock was available to frontline staff?

Mr Robin Swann: Yes.

Ms Campbell KC: And really the email address that you set up, and I think you had something in the region of 100 responses or emails, was of little comfort to staff if in fact they couldn’t be assured that the stock was reaching the front lines?

Mr Robin Swann: But it was of comfort in regards to they had an ability to directly contact the department and the Chief Nursing Officer in regards to issues in regards to supply, fit and best use, because I think when we looked at the breakdown of the responses that you speak to, there were a number of critical issues that were – been able to be addressed and again fed back to either the ward or the trust in regards to those queries that were asked.

Ms Campbell KC: I’ll move on and my next topic is the topic of DNACPR. Again, you had been asked some questions about that by Mr Scott.

I want to revisit that paragraph in your statement, it’s 307, in which you refer to questions coming in from MLAs and your response making it clear that orders based on age or disability were discriminatory and unethical and in which you state that the policy – sorry, media reports about a policy in Northern Ireland around DNACPR were ill-founded.

You understand, and I suspect you understood at the time, that you were responding to those MLA questions that there were increasing concerns amongst the bereaved and those who were yet to be bereaved at that point, that there had been a misuse of DNACPR orders in Northern Ireland. You knew that, didn’t you?

Mr Robin Swann: Not that there had been a misuse in regards to the specific – any specific instances, I don’t think –

Ms Campbell KC: My question was you knew that there were concerns –

Mr Robin Swann: Oh, yes, there were –

Ms Campbell KC: – about the use?

Mr Robin Swann: I know there were concerns, yes.

Ms Campbell KC: And you agree, don’t you, that from your position as the Minister for Health, it’s important not only to consider what a policy might be but how that policy is in fact being implemented within a healthcare setting?

Mr Robin Swann: That’s correct.

Ms Campbell KC: And you told us in your evidence that you were aware of the CQC report that emanated from England?

Mr Robin Swann: Yes.

Ms Campbell KC: And are we right that your understanding of that CQC report was that it also applied in the North?

Mr Robin Swann: Well, that they had looked at what had happened in Northern Ireland was my understanding as well.

Ms Campbell KC: Do you recall what gave you that understanding?

Mr Robin Swann: I think it was through the reading of preparation for this session.

Ms Campbell KC: Do you recall being aware of the CQC report and recommendations at the time when these issues were being raised with you?

Mr Robin Swann: I don’t recall those specifics at that point in time, no.

Ms Campbell KC: You see, the CQC report had an interim report in autumn 2020 and a final report I think in March 2021, contemporaneous in fact to the MLA questions that you refer to in your statement. Is your evidence that you weren’t aware or you can’t recall being aware of the report at that time?

Mr Robin Swann: I can’t recall it being brought to my attention in regards to that. As I said in referral to – an earlier answer in regards to those written statements or those written responses to MLAs, there would have been a subsequent information pack that would have been provided. But I don’t recall the full content of that additional –

Ms Campbell KC: Let’s leave the CQC report to one side if you weren’t aware of it when responding to those MLA questions. What assurances, in real practical terms, did your answer that orders based on age or disability would have been or were discriminatory and unethical – in what way was that meant to assure the population of Northern Ireland that their concerns about the misuse of DNACPR were misplaced or needn’t be as grave as they were?

Mr Robin Swann: Well, I think that was the intention of those – those answers in regards to the statements that were being made.

Ms Campbell KC: But how can you answer that, Mr Swann, without having carried out an investigation into what was happening at the ground level, at the front line?

Mr Robin Swann: Well, again, come back to, again, the additional information that would have been in the back of those written questions and written responses, my Lady. I think I also – and I can’t be specific in regards to the conversations that I had, around the issue with the Chief Nursing Officer again in regards to the issue of that concern.

Ms Campbell KC: Well, given that those were concerns and that we are at this point into 2021 and that the concerns were persisting, did your department consider that there should be an investigation carried out into those concerns about the inappropriate use of DNACPRs?

Mr Robin Swann: I’m not sure if the department considered that or conducted that.

Ms Campbell KC: Do you think it should have?

Mr Robin Swann: I think now there is an opportunity actually to retrospectively do that in regards to the recommendations in the work of this Inquiry.

Ms Campbell KC: Going back to the CQC report. Do you think you should have been aware of the recommendations and the conclusions of that report when it came out in March 2021?

Mr Robin Swann: Yes, I – of the final report, yes. But as I say, I’m not sure that it wasn’t in – mentioned in the briefing pack in regards to those written responses. I don’t recall nor have I seen them in the evidence bundle, nor, my Lady, unfortunately, did I ask them.

Ms Campbell KC: The CQC report has a number of recommendations, I think something in the region of 11 under three broad headings, including ensuring that health and care professionals have not only the knowledge to make ethical decisions but the skills necessary to have those sensitive and difficult conversations with patients and their loved ones. And particularly significantly for the Northern Ireland Covid Bereaved, they recommend ensuring improved oversight and assurance of the use of DNACPRs.

Do you remember any work under your tenure as minister of health that sought to implement those recommendations in Northern Ireland?

Mr Robin Swann: I think, my Lady, in regards to that, it was the start of the work in regards to advance care planning documentation and engagement piece that was conducted. I think I commissioned that towards October, possibly October 2022 in regards to work – I don’t remember the specific date but, again, it was the wider piece around advanced care planning that also would have covered and touched upon DNACPRs.

Ms Campbell KC: And that was October 2022, so I’m focusing in particular on the period throughout 2021 when these concerns were being raised directly with you. And the report was available to you from the CQC?

Mr Robin Swann: Well, the rules were being completed, I think, by the ethics forum as well.

Ms Campbell KC: Moving on to my third topic, and it’s end-of-life care, and it’s related because I suspect you will be aware, Mr Swann, that, in addition to the concerns about the use of DNACPR notices, there were similar concerns raised about decisions around end-of-life care, including concerns about the discredited Liverpool pathway, which I’m sure will be familiar to you, concerns about syringe drivers or particular drugs that were used that were believed – or that there were worries that they hastened death.

The same questions really apply. Looking at policies that were in place in relation to that end-of-life care is insufficient if there is not knowledge of what in fact is happening in practice; do you agree with that?

Mr Robin Swann: It would be if that was what was happening in Northern Ireland. Again, there is reassurances I think given by CMO and CNO in regards to that wasn’t either the policy or practice in Northern Ireland.

Ms Campbell KC: But in terms of investigation, is it right that no investigation was ordered or conducted during your tenure in relation to the concerns that had reached the Department of Health?

Mr Robin Swann: Not that I’m aware of.

Ms Campbell KC: And do you agree there was, and indeed probably still is, an opportunity to have that level of investigation?

Mr Robin Swann: I would agree with that line of questioning, I think as I said to the earlier question as well.

Ms Campbell KC: My penultimate topic is the issue of aerosol infection, and you’ll have followed, I’m sure, how the evidence in this module has unfolded before her Ladyship.

Do you recall when you first became aware that there was a – we can put it, a disagreement between scientists about the route of transmission, be it primarily droplet or aerosol?

Mr Robin Swann: From recollection, I think it was around May.

Ms Campbell KC: May which year?

Mr Robin Swann: 2020.

Ms Campbell KC: May 2020?

Mr Robin Swann: Yeah, from recollection. As I say, it’s not something I have any documented evidence from, but if it is, from a conversation in regards to …

Ms Campbell KC: And do you recall who that conversation may have been with?

Mr Robin Swann: It may have been with the CMO and the CSA.

Ms Campbell KC: The CMO’s evidence to this Inquiry was that there was nobody in Northern Ireland providing, if you like, any separate advice about routes of transmission and that he was, to a significant extent, reliant on advice taken from the UKHSA, and he accepted that advice and sought to implement it.

Was that your understanding of the position?

Mr Robin Swann: Yes.

Ms Campbell KC: Well, coming back to this conversation, if it is around May 2020, do you recall raising any concerns about the acceptance of that advice given the disagreement between the scientists?

Mr Robin Swann: It was in regards to – I don’t recall the specifics of the conversation but there was a general conversations that were had with CMO and CSA in regards to different aspects of the pandemic.

Ms Campbell KC: And were those concerns – or that conversation, was it revisited?

Mr Robin Swann: It’s not that I – that I – I don’t recall in detail of that, or when those conversations were had, but I do know there was discussions around that.

Ms Campbell KC: Well, we know that there was a representative from the Public Health Agency in Northern Ireland on the UK IPC Cell, and we know about – we now know, certainly, about the concerns about the length of time the UK IPC Cell took to acknowledge the risk from aerosol transmission and to change advice.

Would you have expected that the individual from the PHA in Northern Ireland would have reported those concerns to you?

Mr Robin Swann: I would have expected – not maybe directly to me but I would have expected them to have been reporting that conversation either through the PHA to CMO or CSA, yes.

Ms Campbell KC: And do you recall that happening?

Mr Robin Swann: I don’t.

Ms Campbell KC: You see, one issue for those we represent is that the answer from the CMO in relation to being heavily reliant on advice coming from sources in England suggests that in a future pandemic Northern Ireland would be effectively powerless to prevent something like this happening again because we don’t have the capacity, domestically to replicate what the UKHSA can do or does – and you’re nodding in agreement with that.

But one outworking of that is that, from a Northern Irish perspective, there’s a limited number of lessons that be learned or changes that can be properly implemented to ensure that doesn’t happen again?

Mr Robin Swann: And I also – you know, and I think looking – I think it was M2C, in regards to Northern Ireland actually having that position at the table, should it be through that body or SAGE or anything else, we don’t have, in regards to the size of the population, the size of the department or the size of Public Health Agency, the ability to replicate all those bodies, and I think that’s – it’s also part of the benefit that I see of being part of those wider discussions as well, but also the ability, then, to be able to challenge within those bodies as well.

Ms Campbell KC: So, reflecting on lessons learned from your position or from the position of the department, what can be done to ensure a greater level of scrutiny from a Northern Irish perspective rather than acceptance of advice that’s coming our way?

Mr Robin Swann: Well, in regards to that, I think it is that operational functionality of CMO and CSA in regards to the involvement in how those decisions are being made and the question about – of what can be done.

I’m also aware, my Lady, that The Executive Office, within what is now the – used to be the Office of the First and Deputy First Minster have now employed their own CSA as well, so that they’re not solely reliant on the CSA within the Department of Health for advice as well. So there is, I suppose, a second good. I don’t know the full remit of that position, whether it can look across Health or not, because, again, unfortunately, I’m no longer in that position.

Ms Campbell KC: Final topic and it’s the topic of nosocomial infection.

In your statement – it’s at paragraph 233 – you identify the creation of a nosocomial support cell to address challenges arising from Covid infections in healthcare settings. And you refer to a report of that cell in relation to Craigavon Area Hospital. And one of the positives, if you like, that you take out of – from your statement is that the reports from the nosocomial support cell were a timely source of feedback for our trusts on their approach in relation to mitigating the impact of Covid-19 within the acute hospital sector.

You’re aware, are you, of the content of the Craigavon Area Hospital report from the nosocomial cell?

Mr Robin Swann: Yes, so – from what limited recall I have and access to bundles.

Ms Campbell KC: Would you have known about it at the time?

Mr Robin Swann: I do recall having engagements with both the trust chief executive and the board chair in regards to the challenges that were being specifically faced there as well. There was also an SAI instigated at – level 3 SAI at that stage, and I asked that the findings of that SAI be made public, something which isn’t normal, my Lady, in regards to that, but such, I think, was the concerns in regards to the workings of what had happened and what had occurred.

Ms Campbell KC: Well, one of the issues that the report found in relation to Craigavon Hospital was that effectively, although staff were doing their best, the problems were so significant due to the lack of ventilation on the site that they were – almost feel like insolvable.

So they found there was no mechanical ventilation in the wards. They relied totally on natural ventilation from opening windows. They raised the problems with that approach during the winter months. They refer to the recommended air change rate of being unachievable. They talk about the proximity of beds, a lack of sanitary facilities combined with poor ventilation mechanisms. And they say it is difficult to see what more the trust can do with the physical environment given the constraints of the existing layout and fabric of that hospital.

In essence, their recommendation was that the department should consider the trust master plan for redevelopment, which was apparently a programme that was going to take “several decades”.

Firstly, from the perspective of patients and visitors concerned about the risks of going to hospital and contracting Covid, would they or should they have felt safe attending that hospital had they known those findings?

Mr Robin Swann: Well, again, those findings came as a result of the investigation that was commissioned in regards to the concerns that were being raised and, unfortunately, the incidents that had occurred.

Ms Campbell KC: But do you accept patients and their visitors essentially were not safe in that environment, or certainly didn’t have any reason to feel safe?

Mr Robin Swann: Well, in regards to the mechanisms and the supports that were being put in place in regards to provision of PPE and other measures that were in place, I think the trust and the staff involved were doing all that they could within the resource that they had.

In regards to the investment of the site and specifically around Craigavon, my Lady, that is one of the sites that has been indicated for quite a long term in regards to capital investment.

Lady Hallett: Keep your voice up.

Mr Robin Swann: Sorry – capital investment and redevelopment, and I think that’s the key finding of those recommendations.

Ms Campbell KC: Well, it very much was, and therefore my question was, do you know if the Department of Health has approved that master plan of redevelopment and, if so, how soon it’s going to be implemented?

Mr Robin Swann: I haven’t been in possession now for a number of months in regards to the financial constraints that are currently on both revenue and capital. I’m unsure as to where that is. But I’m sure, my Lady, it’s something the department could respond to the Inquiry on.

Ms Campbell KC: In your dealing with that report and the nosocomial cell you talk about it being never too early to learn lessons. And your statement, at the end of your statement, does set out what lessons that you have identified with the benefit of hindsight.

Your statement mentions two broad lessons. Firstly, issues around staffing, including insufficient staffing and the need for an agile workforce. And, secondly, that the CMO at the time had too many roles. Those are the two issues that you identify in your statement.

Is that all?

Mr Robin Swann: No, there’s a number of other recommendations, my Lady, in regards to the completion of that report that I’ve thought on in regards to – some of them have already been touched in the question, about how we can look across the borders or across the island in regards to health and social care, something that we’ve been able to do with paediatric cardiology, in regards to the issue that was raised, paediatric pathology, or indeed ECMO, which was looked at – or hasn’t been touched in regards to today’s procedure, again, an all-Ireland response could be something that could be explored, the further development of our health and social care transformation projects, those elective overnight centres, the day case procedure centres, the further steps that we need to implement in regards to Bengoa, but, again, that is, my Lady, depending on long-term recurrent financing in regards to what we need to do, in regards to that as well –

Ms Campbell KC: The list is clearly long and a lot longer than the two lessons learned that you identified in your statement. From the perspective of the Northern Ireland bereaved, can you see why they may have expected more from you in terms of lessons learned?

Mr Robin Swann: In regards to this specific module – you know, there are more modules to come where I’d be able to make further recommendations in the outworkings of what is actually there in regards to what’s actually in the statement as to – in reflection and preparation for today, my Lady, there are others.

Lady Hallett: Thank you, Ms Campbell.

We’ll take the break now, I’ll return at 3.20, and then there is just under half an hour of questions left for you, Mr Swann.

The Witness: Thank you.

(3.05 pm)

(A short break)

(3.20 pm)

Lady Hallett: Mr Wagner.

Over that way, Mr Swann.

Questions From Mr Wagner

Mr Wagner: Thank you. Good afternoon. My name is Adam Wagner and I ask questions on behalf of the Clinically Vulnerable Families group.

In December 2020 there was a report published by the Patient and Client Council which reported the findings of a survey and one of the things that it concluded was that those who had been advised to shield, prioritised being kept informed with clear advice and guidance along with being given the scientific rationale for that advice. Do you recall that report?

Mr Robin Swann: I do, yes.

Mr Wagner: So once that report came out in December 2020 and it was known what those who were being advised to shield were saying, by that point it was obviously clear that the virus was continuing to circulate in the community and for the long term, you were in the middle of the second wave.

Do you think at that stage more could have been done to equip people who were at higher risk with that information they needed to empower them to understand the steps they could take to protect themselves and also what support the government was giving them to do so?

Mr Robin Swann: And I do think when shielding was re-introduced in England in January of the following year we wrote out again to those who had been indicated to shield in regards to the additional advice and guidance that we were able to provide them at that stage, because coming out of that PCC report, taken from what you’ve said that’s what they asked for, rather than the reintroduction of shielding so that – I suppose that additional communication that was given in January was I think what you’re referring to.

Mr Wagner: Was it enough? Do you think people were given enough information to empower themselves?

Mr Robin Swann: I believe at that stage, as in regards to what were known, and I think that, my Lady, is one of the steps that by asking PCC to engage with those groups, I think we in Northern Ireland were maybe better engaged with the cohort than perhaps other parts of the United Kingdom.

Mr Wagner: I want to ask you about pausing shielding in 2020 in June. When the plan was announced to pause shielding you gave an announcement and you said – one of the things you said was that the difficulty shielding has presented would not just vanish because the need to shield has ended. Do you think that the transitional support which was offered at that stage was enough to meet the scale of the challenge?

Mr Robin Swann: In retrospect of – and, again, this is working across different departments, could we have done more? There’s always more that could have been done in regards to, I suppose, allowing people to come back into society in regards after being through a very challenging time where they were shielding as well. My Lady, I’m remembering some of the conversations we had with community pharmacy who we supported to actually deliver medicines directly to those who were shielding, the feedback that they got from community pharmacy when those drivers were delivering those medicines, it wasn’t just a matter of: here is your prescription, here is your medication, that they were actually being engaged in conversations because of the challenges they were facing, because of isolation and loneliness, as well. So we looked into those additional supports as well, but again, if the question is could we have done more, there’s always more we could have done.

Mr Wagner: What about mental health support? There were, I think, mental health support resources were made available online. Do you think those were sufficiently tailored to the particular needs of those who had formerly shielded?

Mr Robin Swann: Well, the additional online ones and, again, my Lady, there were also additionality and additional supports provided by community groups and other organisations, and as I say, we put 10 million into the mental health support fund which again supported communities and individuals across Northern Ireland, not only those who were specifically shielding as well but also those who had received – succumbed to those mental challenges due to the pandemic.

Mr Wagner: When the shielding programme was paused what was also ended was the automatic eligibility to Statutory Sick Pay that people who had been shielding were receiving. And the practical effect was that some clinically extremely vulnerable people had no choice but to return to work because they couldn’t afford to stay at home. You said in your announcement in June 2020 that shielding people could decide to do – decide what to do at their own pace. Do you agree that because of the removal of the – the, sort of, sudden removal of Statutory Sick Pay the reality was for some shielding people they couldn’t return at their own pace, they had to return, effectively, straight away?

Mr Robin Swann: I do agree with that statement although Statutory Sick Pay was not within the remit of myself at that point, or even the Department of Health, in response as to how long they paid for. I do recall engagements as well and I think, and I can be corrected in regards to this, but there were opportunities for those individuals to engage directly either with their GP or their medical consultant in regards to receiving that letter of support which would allow them to continue working from home.

Mr Wagner: Given at the time, June 2020, there was no vaccine yet and also wider, sort of, society-wide mitigations such as better ventilation were still not in place, not really even in place today, do you accept, looking back, that the effect of the pause was to expose some clinically extremely vulnerable people to high levels of risk, effectively a cliff edge from one day to the next?

Mr Robin Swann: In regards to, I think, the pausing of shielding, there was that, I think, a three-week lead-in, from my recollection, from the announcement being made until the actual date being brought about. But, again, going back to, I suppose, the original point that we were taking into cognisance the recommendations or the failings that had been brought about by the PCC reporting engagement.

Mr Wagner: Do you accept that after the shielding advice was paused, the shielding programme was paused, it would have been valuable to continue to engage with those who had been formally advised to shield just to, for example, more ongoing PCC surveys or similar that would help you understand the impacts that the pause, the sudden pause of the shielding programme, even with that three-week buffer, was causing, and also what support they would continue to need going forward?

Mr Robin Swann: My Lady, I do think there would have been value in further engagement via PCC because their initial engagement basically allowed to us make the decisions that we did and I think, as has already been intimated in the line of questioning, one of the strong recommendations was in regards to keeping those who were shielding better informed with reliable and up-to-date information.

Mr Wagner: But do you know why that wasn’t done?

Mr Robin Swann: I don’t, no.

Mr Wagner: Should it have been done?

Mr Robin Swann: It could have been done, yes.

Mr Wagner: And do you think that might have fed into other concerns that the PCC report had identified that the clinically vulnerable were forgotten or ignored as changes to guidance and restrictions for the wider population were announced?

Mr Robin Swann: I think that ongoing engagement would certainly have addressed those issues as well. And again, my Lady, I think that was the rationale for us actually engaging PCC at that stage to have that direct interaction with that specific group of individuals, and I know it’s something that didn’t occur to the same extent or the same depth elsewhere across the United Kingdom.

Mr Wagner: Something else that you said when the shielding was paused was, you asked for everyone to be as considerate – sorry – everyone to be considerate as people end their periods of shielding and you said, “We should all continue to social distance but in the coming weeks I want you to be particularly understanding of the fact that you might be encountering someone who has had to stay at home for many months. Please be aware of this, show respect and kindness to all and keep your distance.”

Now, at the time shielding was paused and after that, this is coming from a different direction because it’s not about information given to the shielded, or former shielded, it’s about information given to the rest of the public. Do you think enough was done to educate the general public about the ongoing risks posed by Covid-19 to the clinically extremely vulnerable and the clinically vulnerable?

Mr Robin Swann: I think that was the basis of that statement in regards to showing that additional respect without identifying those who had been clinically extremely vulnerable and making them actually step outside society, it was about integrating them back into society after what been a challenging period during that period of time.

Mr Wagner: But aside from just saying that during that – in that statement, was anything else done to educate the public about how to be respectful of and considerate towards clinically extremely vulnerable?

Mr Robin Swann: It wasn’t in regards to specifically the clinically extremely vulnerable. We did produce a “keep your distance” badge which was a small yellow badge that we circulated around the general public in regards to that just so people could identify. There was the lanyards as well, so that some people could identify – it allowed them to identify themselves as clinically extremely vulnerable to encourage people to be that bit more respectful.

Mr Wagner: Was anything else done apart from those badges and lanyards?

Mr Robin Swann: Not that I can think of at this point.

Mr Wagner: Do you accept that responsibility for educating the public falls ultimately on the government and that there is a possible problem in placing the responsibility for explaining why ongoing mitigations are required, so for example wearing a mask, without experiencing kickback and abuse from the public, do you accept that if that is, that burden of education is placed solely on or predominantly on the clinically vulnerable themselves that can become unmanageable?

Mr Robin Swann: No, I would agree there is a job for government collectively in regards to how that communication is actually given out to the wider general public without making people uncomfortable in regards to them having to explain their condition continually.

Mr Wagner: I want to ask you about DNACPRs. You have been asked quite a lot about this so I’ll just ask you one question. And it relates to do not attempt resuscitation orders being placed on clinically vulnerable people. Is there any basis that you could reassure this Inquiry that the clinically extremely vulnerable were not more likely to be the subject of a blanket DNACPR on account of their underlying health conditions?

Mr Robin Swann: I’m unaware of it being a blanket approach in Northern Ireland and I think I’ve given that previous answer in regards to the same line of questioning.

Mr Wagner: Would you support a recommendation by the Inquiry for there to be a systematic review of all DNACPRs, notices put in place from 2020 to date so – to get to the bottom of how many inappropriate notices there were, and also to make sure that clinically vulnerable people are not wrongly refused medical treatment in the future?

Mr Robin Swann: In answer to, I think, Ms Campbell’s questions from the Northern Ireland families, I think I have indicated that it would be something I would be supportive of although I’m not in the position, my Lady, to actually take that directly back to the department.

Mr Wagner: Thank you.

Thank you, my Lady.

Lady Hallett: Thank you.

Ms Sivakumaran.

Over at the back there. Could you make sure that your voice, because it does drop, you are softly spoken – think of shouting in the House of Commons.

The Witness: Thank you, my Lady.

Questions From Ms Sivakumaran

Ms Sivakumaran: Good afternoon. I ask questions on behalf of the Long Covid groups. My first topic is on pandemic planning and long-term sequelae. You said earlier that the risk of long-term sequelae was not something brought to your attention at the start of the pandemic.

Professor Sir Michael McBride, the CMO of Northern Ireland, has said in evidence to this Inquiry that he was aware of that risk. Just so we are clear, did he not advise you of that risk?

Mr Robin Swann: Not that I can recollect, as a specific issue at that stage in the earlier stages of the pandemic.

Ms Sivakumaran: Are you saying that you became aware at a later stage?

Mr Robin Swann: Yes.

Ms Sivakumaran: What stage is that, can you assist?

Mr Robin Swann: I can’t think give a specific date but in regards to the answers to Mr Scott, it was in regards – I think it was around June, July, at that stage, that I asked for the Health and Social Care Board to take forward the delivery of support.

Ms Sivakumaran: Professor Sir Michael McBride’s evidence was that the long-term impacts of Covid-19 were not tracked from an early stage in the pandemic and he’s added, “At present, there is still no system to monitor long-term effects in a future pandemic”, but he recommended there should be.

Would you also recommend that pandemic planning include provision for monitoring the long-term effects of a novel virus?

Mr Robin Swann: I would, yes. And, again, my Lady, I hope that, again, not building up the promises of what encompass can or will deliver, I hope that that’s something it can actually do as well and doesn’t resolve or resort to the Department of Health or Health and Social Care having to resort to the various databases that we had to previously.

Ms Sivakumaran: My next topic is about Long Covid clinics. You were asked about the 18-month delay between your commissioning or working group on the long-term effects of Covid-19 and the establishment of a Long Covid clinic in November 2021. The working group recommendations made clear that there was a need for specialist services which was not being met; do you agree?

Mr Robin Swann: I agree, yes.

Ms Sivakumaran: And it follows, doesn’t it, that the delay in providing dedicated Long Covid clinics in Northern Ireland left adults and children without access to the specialist care and support that they needed? Do you agree?

Mr Robin Swann: There was, I think as Mr Scott pointed out, there was clinics already established in the Belfast Trust, although not commissioned centrally across the rest of the region as well, and that’s why I had asked Health and Social Care Board to go forward and develop that as a commissioned model.

Ms Sivakumaran: Indeed. So there was only one trust that had it. Across Northern Ireland, there wasn’t provision of the services that were needed for people with Long Covid?

Mr Robin Swann: That’s correct.

Ms Sivakumaran: You were asked what more you could have done to progress work on the clinic and you said you could have put additional pressure. Why didn’t you put that additional pressure? Was there a lack of urgency in your mind in addressing the needs of people with Long Covid?

Mr Robin Swann: I don’t think it was a lack of urgency, I think it was in regards to what else was going on. I assumed, and whether rightly or wrongly, that that work was being progressed and, again, what I know now compared to what I knew then and what I was asking for then, you know, there is recollections and reflections. As I said earlier, would I do things differently now? Yes.

Ms Sivakumaran: You were provided updates and advice, you were told exactly when the clinics were going to be established. Do you now accept that you knew then the delays in the provision of that service?

Mr Robin Swann: I don’t recall those specific updates or dates in regards to a timeline.

Ms Sivakumaran: But can you see why for people with Long Covid who are struggling to get referrals to services or who have been bounced around from services, this delay was inexcusable?

Mr Robin Swann: Yes, and I’ve already said that in regards to how I wanted or should have now, in retrospect, been more vociferous in the delivery of those clinics across all trusts.

Ms Sivakumaran: And can you provide any recommendations to the Inquiry on how such an extreme delay in establishing necessary services could be avoided in future?

Mr Robin Swann: I think it is in regards to the changes possibly in regards, as I said, my Lady, the Health and Social Care Board was first indicated for closure in 2015. It wasn’t until the legislation actually come about, I think in 2022, that it was closed. So the functionality of the Health and Social Care Board is now subsumed them in part of the Department of Health within the SPPG, so there should be a greater focus and attention in regards to what that stream and streams of work are actually being commissioned and delivered.

Ms Sivakumaran: Okay. My final topic is about children and young people with Long Covid. There are no dedicated Long Covid clinics for children and young people in Northern Ireland. Professor Sir Michael McBride’s evidence was he thought there was much merit to the suggestion by Professor Brightling and Professor Evans that a Long-Covid hub for children and young people could deliver care through virtual multidisciplinary teams.

Would you agree with Professor Sir Michael McBride that there is merit to the suggestion?

Mr Robin Swann: I would, yes.

Ms Sivakumaran: And would you agree that the failure to create a dedicated Long Covid service for children and young people in Northern Ireland has left them without access to that specialist care that they need?

Mr Robin Swann: I do, but I also, in, I suppose, reflection of what Sir Michael said in regards to following the NICE guidance at that point in time was what many clinicians in Northern Ireland actually did. I think that was where we were and where we took that advice and guidance from was from NICE, but in regards to the recommendations coming from Sir Michael as Chief Medical Officer, I would be supportive of his approach.

Ms Sivakumaran: I just want to pick up this point about the NICE guidance. The NICE guidelines actually make clear, I believe at page 5 under the overview, that the guidelines apply to make recommendations about the care in all healthcare settings for adults, children and young people. They also go on to provide advice, at paragraph 5.8, that a practitioner should consider referral for 4 weeks for specialist advice for children with ongoing symptomatic Covid-19.

So the NICE guidelines actually do recognise the need for specialist care for children and young people. Would you agree with that? There’s nothing in the NICE guidelines to say there should not be specialist care?

Mr Robin Swann: That’s why I would be supportive of Sir Michael’s recommendation in regards to that, also working, I suppose, in conjunction with the Royal College of Paediatrics.

Ms Sivakumaran: So you accept the NICE guidelines do actually make provision for specialist services?

Mr Robin Swann: Yes, but not – I suppose it’s how they are accessed and available in regards to what we deliver – or sorry, what the Department of Health delivers in Northern Ireland and that’s why I say I would be supportive of Sir Michael’s recommendations.

Ms Sivakumaran: Just on that final point, when you say how they are accessed and available, then you agree that they’re not accessible – specialist services are not accessible and available for children and young people in Northern Ireland because there is no specialist provision?

Mr Robin Swann: There is no specialist provision, yes. But, as again, my Lady, unfortunately as I’m no longer in post as Minister of Health, it’s not a lever I have direct access to, but if the Chief Medical Officer is coming forward in regards to those recommendations I would be supportive, as an individual and as a previous health minister.

Ms Sivakumaran: Thank you, my Lady. Those are my questions.

Lady Hallett: Thank you.

Ms Polaschek.

Thank you.

Questions From Ms Polaschek

Ms Polaschek: Thank you. Good afternoon. I ask questions on behalf of 13 Pregnancy, Baby and Parent Organisations. You’ve already answered some questions about the visiting restrictions in general and the difficulties these caused patients and families, and a specific area of concern for women, pregnant people and their families were visiting restrictions in respect of pregnancy care in particular.

Was the Northern Irish Government made aware of specific concerns raised by maternity staff in Northern Ireland about the availability and adequacy of appropriate PPE?

Mr Robin Swann: Yes, in regards to across the work that was being led by the Chief Nursing Officer who had a chief midwifery officer within part of her team as well and, I suppose, in cognisance, my Lady, of the geographical and size and nature of health and social care in Northern Ireland.

Ms Polaschek: And would you agree that alternative mitigations such as PPE and testing would have been reasonable steps to investigate which might have avoided the particular harms which women, pregnant people and their families experienced from those visiting restrictions?

Mr Robin Swann: I think when – I think, due to earlier comments in regards to reflections as to the availability of testing, if we had the ability to test at the beginning of the pandemic the way we had towards the end of the pandemic I think we’d have been able to do things a lot more different.

Ms Polaschek: Thank you. And just finally, were you also aware that some women and pregnant people delayed or avoided attending hospital due to concerns about catching or exposing their unborn baby to Covid-19 and the requirement to attend hospital alone and, if so, what steps did you or the government take to respond?

Mr Robin Swann: I wasn’t aware of that being raised as a direct issue, my Lady, but I do know midwives in Northern Ireland were using telephones to be in direct contact with those expectant mothers that were in their care as well. It’s not an issue was raised specifically with me.

Ms Polaschek: Thank you, my Lady, those are my questions.

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

I think that completes the questions for you, Mr Swann.

Thank you very much for your help today. It must have been a very long day for you, I’m sure.

I’m not sure if I can say we won’t be calling on you again, but I promise you we’ll try to limit any burdens that we place upon witnesses like you that we keep coming back to.

So thank you for your help.

The Witness: Thank you, my Lady.

Lady Hallett: Thank you, Mr Scott.

Tomorrow at 10 o’clock.

(The witness withdrew)

(3.45 pm)

(The hearing adjourned until 10.00 am on Tuesday, 19 November 2024)