The Vale of Leven Hospital Public Inquiry report was published on 24 November. At least 34 patients had been killed by Clostridium difficile in 2007 and 2008 in the hospital in Alexandria, a small town at the foot of Loch Lomond. The report tells one horror story after another about bad nursing, ignorance about infection and management incompetence. The failings beggar belief.
When one of my children was born at the Vale of Leven in the late 1970s it was a well-run small district general hospital with more than 200 beds. The view from the maternity ward of Ben Lomond was magnificent. But by the millennium the hospital was deemed too small. Many committee meetings were convened. There was paralysis by analysis. New hand basins were bought to replace old cracked ones but no funds were allocated to install them. The hospital decayed.
After the report came out, media attention focused less on its findings than on its cost: more than £10 million. But public inquiries are expensive. They involve lawyers. They have to, because lawyers are trained inquisitors.
Having chaired a public inquiry myself, I wasn’t surprised to read about the difficulty they had getting documents from the NHS in Glasgow. The first request was made in October 2008. There was a slow dribble. By January 2010 the inquiry chair was obliged to issue an order compelling the production of documents. More than a year later, many laboratory reports about C. difficile test results still hadn’t been supplied. The photocopying of patient records was very poor. Dates were obscured, items were missing and records were out of chronological order.
Not long after he became a judge, Stephen Sedley developed his ‘Laws of Documents’. He published them in 1996. Twenty years later they are still in full operation: the first states that ‘documents may be assembled in any order, provided it is not chronological, numerical or alphabetical’; the fifth that ‘any important documents shall be omitted’; and the seventh that ‘as many photocopies as practicable shall be blurred, truncated or cropped.’