2. Mrs Rosemary Gallagher

MRS ROSEMARY GALLAGHER (sworn).

Questions From Counsel to the Inquiry

Ms Blackwell: Is it Ms or Mrs Gallagher?

Mrs Rosemary Gallagher: It’s Mrs.

Counsel Inquiry: Thank you.

Mrs Gallagher, thank you for the assistance that you have so far given to the Inquiry and thank you for coming to give evidence today.

Please keep your voice up, speak into the microphones so that the stenographer can hear you for the transcript. If I ask you a question that isn’t clear, please ask me to repeat it and I will.

If you need a break before our usual time of breaking – which I think will be 1 o’clock today, my Lady?

Lady Hallett: Or maybe 1.15, depending on how we go.

Ms Blackwell: Or maybe 1.15 – thank you – then please just say so.

Is it correct, Mrs Gallagher, that you are the professional lead for Infection Prevention and Control, or IPC, and nursing sustainability lead at the Royal College of Nursing, a role that you have held since 2009?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: Thank you. In terms of your professional career to date, you were a senior nurse in infection control at Stoke Mandeville Hospital from 2002 to 2008. In 2009 you represented the Royal College of Nursing as a member of the Pandemic Influenza Clinical and Operational Advisory Group, dealing with the H1N1 swine flu pandemic, and from June to October of 2015 you assisted the World Health Organisation on behalf of the RCN with the MERS outbreak in Saudi Arabia. Between 2014 and 2016 you led the RCN response to the Ebola viruses disease outbreak in West Africa, and in November 2018 you joined the emergency preparedness, resilience and response (EPRR) clinical reference group of NHS England at the request of its director, Stephen Groves.

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: You have provided two witness statements. May we put up first, please, INQ000177809. Can you confirm that that’s your first witness statement, Mrs Gallagher?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: Thank you. Now INQ000183414.

Thank you. Is that the second statement that you’ve provided?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: Thank you very much.

My Lady, could we have permission for those to be published?

Lady Hallett: You have.

Ms Blackwell: Thank you. We can take that down.

I’m going to begin, please, by asking you to describe to us the role and function that you hold at the Royal College of Nursing.

Mrs Rosemary Gallagher: So I am a registered nurse –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – and I provide strategic leadership on behalf of the Royal College of Nursing on matters relating to infection prevention and control. I provide specialist infection prevention and control advice to the college, to our members and our stakeholder organisations that we work with. My role is a UK-wide role, and I’m one of a team of about 13 professional leads that work together to cover many areas of nursing practice.

Counsel Inquiry: Right, and it being a UK-wide role, how do you ensure a tailored approach to the particular needs of each of the devolved nations, for instance?

Mrs Rosemary Gallagher: So the RCN has – covers the four regions of the United Kingdom, and my role often involves both proactive and reactive work. With the proactive work, we engage with the four countries, the four regions of the Royal College of Nursing, and as far as possible with our relevant organisations in the countries as well. For reactive work, we would respond according to the need and what it was that I could support them with.

Counsel Inquiry: Thank you.

Moving then to your role with the EPRR clinical reference group, a role that, as we’ve established, you’ve held since November of 2019. Could you provide us with an overview of what that group does, and in particular what your role is within that group?

Mrs Rosemary Gallagher: I was asked to be on the group as a nurse.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: Not specifically in relation to my experience with infection prevention and control, though that was thought to be advantageous in terms of some of the discussions that took place in the meetings, and I shared that role with a colleague who represented public health nursing.

As a member of the EPRR we were there to represent our discipline of nursing and to provide nursing input and advice on discussions that were on the agenda at that time.

Counsel Inquiry: Right, thank you.

At paragraph 17 in your witness statement, you tell us that:

“Pandemic preparedness [with the group] focused only on influenza and was not a significant regular agenda item at meetings of [the group] …”

And that:

“The need to consider other potential infections with pandemic potential was made public by the Chief Medical Officer … for England in July of 2019 and this position was supported by the RCN due to the experience that it had gained through its planning to support Saudi Arabia with [the] MERS CoV [outbreak].”

You also say, Mrs Gallagher, that, additionally, Disease X was added as a new category to the World Health Organisation’s emergency priority list in 2019, but that the UK continued to focus on influenza, despite the experience of MERS in the Middle East, and Severe Acute Respiratory Syndrome, SARS, and the potential for a new coronavirus to emerge.

So the Chief Medical Officer had given advice in July 2019, the World Health Organisation had made Disease X – given it a place on the emergency priority list in the same year, and yet the group upon which you sat was giving pandemic influenza only a priority in its discussions, and even that wasn’t a regular agenda item.

Were you concerned about that?

Mrs Rosemary Gallagher: The overarching pandemic planning did not feel as if it reached into the EPRR group, whose agenda focused on much more recent incidents, and our response and our learning from those. So it was an ad hoc agenda item but not a regular item, and I’m unsure exactly how the EPRR group fed directly into the governance systems for pandemic planning.

Counsel Inquiry: Did you personally have any concerns prior to January of 2020 that the focus within the group was too narrow, given as it only appeared to consider pandemic influenza?

Mrs Rosemary Gallagher: The RCN had raised concerns regarding the opportunities for other organisms with pandemic potential that we needed to consider. The – if I recall the discussions, it was more of an agenda item rather than an opportunity to feed back, it was more feedback on where the pandemic planning was going.

Counsel Inquiry: The Inquiry has heard an explanation or justification from those who were focused, perhaps too narrowly, on pandemic influenza that in fact plans could be and should be adapted?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: So the fact that pandemic influenza led to a certain level of planning was able to be seized upon and used during the course of the Covid pandemic.

Do you agree that clinical preparedness plans are capable of being adapted for different infectious diseases?

Mrs Rosemary Gallagher: I believe that if you have the principles right in relation to pandemic planning, that you can use those as a platform to adapt as situations evolve. It won’t – you cannot have a specific plan for every specific organism, but it’s important that we get the foundation structures right.

Counsel Inquiry: Thank you.

The Inquiry has heard from Professor Dame Sally Davies, former Chief Medical Officer, and in her witness statement to the Inquiry she has said:

“I have previously expressed the view that whilst the [World Health Organisation] has said the UK was well prepared for a pandemic, those preparations assumed a pandemic of influenza. This reflected a longstanding bias in our preparations in favour of influenza and diseases that had already occurred, with, we now know, an underestimation of the impact of novel and particularly zoonotic diseases.”

Do you agree with that?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: Yes.

In his evidence to this Inquiry, Jeremy Hunt has said that in his view there was a groupthink that the United Kingdom knew that this stuff, as he described it, the best, and that we had no need to look further afield to other countries in order to try and learn from their experience.

In particular, he said:

“… I don’t think people were really registering particularly Korea as a place that we could learn from.”

Did you observe this type of groupthink as described?

Mrs Rosemary Gallagher: I did.

Counsel Inquiry: Yes, and did you raise your concerns in relation to that with anybody or any organisation?

Mrs Rosemary Gallagher: In response to the work that we did with Saudi Arabia, and also in relation to the work we did on Ebola, we raised significant concerns around the different needs, for example, for personal protective equipment that may differ from influenza. So the concerns that we raised came out of our experience supporting other incidents and were fed directly back to those involved.

Counsel Inquiry: Right, well, I want to ask you about your personal involvement with incidents representing the Royal College of Nursing.

In your witness statement, you tell us that the Royal College of Nursing was invited to be part of the Pandemic Influenza Clinical and Operational Advisory Group, or PICO, and that was as part of the response to the H1N1 swine flu –

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: – in 2009. Tell us about your experience in that group, please.

Mrs Rosemary Gallagher: So as part of the pandemic response in 2009, the college was approached to provide representation to the PICO. It was a clinical subgroup that I understand provided advice to SAGE at the time. Other members of the PICO included other medical royal colleges and those with other relevant areas of expertise.

We discussed situations or drafts of guidance that were being developed, and we met weekly. I shared that role with two colleagues within the Royal College of Nursing to ensure that we provided the correct level of representation, that included my colleague who led on health and safety, and the professional lead for community and primary care at that time, so we considered all care settings.

I found the PICO an excellent group. It allowed for multi-professional discussion and scrutiny of proposed guidance. The end result of that discussion would be agreement on a specific position, or to approve the guidance moving forward.

Counsel Inquiry: So you would describe this as an example of clinical stakeholder engagement working well?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: What you tell us, Mrs Gallagher, at paragraph 40 in your witness statement is that:

“We were able to feed in our expertise and intelligence and represent the needs of the [Royal College of Nursing’s] membership to inform the development of clinical guidance and guidelines concerning the response to pandemic flu.”

Then you go on to say:

“This was a very different experience to the approach taken by the [United Kingdom] government during the Covid-19 pandemic.”

How so?

Mrs Rosemary Gallagher: My experience in the early stages for Module 1 is that the opportunities for engagement of stakeholders from my position, from the Royal College of Nursing, was extremely limited, so this was a very – it had the perception of a very hierarchical response. Given that it was a command and control situation, however, we had the experience of knowing that stakeholder engagement could be implemented and worked very well in previous pandemics.

Counsel Inquiry: Well, indeed, Dame Deirdre Hine in her review following the swine flu outbreak, at paragraph 6.60 in her report, says:

“Further engagement is needed between health departments, professional bodies and employers to further develop clinical advice and provide support to staff during a pandemic.”

Is it your experience, Mrs Gallagher, that that lesson was or wasn’t carried forward and incorporated into preparedness planning for the Covid-19 outbreak?

Mrs Rosemary Gallagher: So the Royal College wasn’t specifically involved in pandemic planning. Our experience does not reflect stakeholder engagement. And I would just like to add that it’s not just the development of clinical guidance or guidelines that requires stakeholders to be involved. Nursing is the largest part of the healthcare worker workforce, and actually we have a key role in implementing guidance and guidelines. So it’s absolutely vital that we are around the table to be able to identify opportunities or risks to that proposed guidance.

Counsel Inquiry: But that didn’t happen?

Mrs Rosemary Gallagher: No.

Lady Hallett: Sorry, when didn’t it happen?

I’ve got a feeling that you were moving on to when the pandemic really was acknowledged as having hit, so in other words response rather than –

Mrs Rosemary Gallagher: So I was referring to the very early days, up until the middle of January, because I’m aware Module 1 only covers that short time period.

Ms Blackwell: All right, but in relation to pandemic planning –

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: – there was a lack of engagement with the Royal College of Nursing?

Mrs Rosemary Gallagher: That’s correct, yes.

Counsel Inquiry: You tell us in your witness statement about playing a clinical advisory role during the Ebola viruses disease outbreak?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: Can you tell us what that involved, please.

Mrs Rosemary Gallagher: So the Ebola epidemic in West Africa was extremely challenging, and a request was made for UK nurses to go out and support the delivery and action in West Africa. This request, from a nursing perspective, was led by the public health – by Public Health England.

Counsel Inquiry: Yes?

Mrs Rosemary Gallagher: – and I was asked to provide professional support to the nurses that were leading that response.

This was really about where the RCN could add value, as somebody put it, at a time when everybody was running towards the fire. We are able to sit back and reflect on what is needed from a professional and regulatory and indemnity perspective, and to support those nurses who may be interested in going to West Africa under those conditions to really understand what it is that they need to do and the level of competency and capability that is needed to do that sort of role.

Counsel Inquiry: Was it possible, in your experience, for lessons to be learned by the government in pandemic planning from the time of the Ebola viruses outbreak until Covid-19 hit at the beginning of January 2020?

Mrs Rosemary Gallagher: Yes, one of the most useful lessons for us, unfortunately, occurred when a healthcare worker in Spain acquired Ebola virus disease as a result pf caring for a patient in hospital in Madrid. Now, that healthcare worker was not involved in providing direct care. There were many, many lessons that were identified as a result of a European nursing summit with – through our relationship with the European Federation of Nurses, to identify lessons around how we can best protect healthcare workers from what we call high-consequence infectious diseases now, such as Ebola.

Now, we were not preparing for a pandemic of Ebola, this was very much a local situation, but it highlighted significant lessons around how infection control policies were written and the need to engage with clinical staff. It identified lessons around what – not just what type of personal protective equipment was needed but how we support staff to be educated on how to put these on and take these off safely. It also highlighted many lessons around confidence and communication and transparency that was needed by the healthcare workers.

Counsel Inquiry: I wanted to ask you about the culture of transparency and learning. What do you say, in relation to that, should have been carried forwards and perhaps wasn’t?

Mrs Rosemary Gallagher: We fed the lessons back from the experience of that meeting in Madrid directly. At the time I was part of a Department of Health communications group that actually worked very well, again with other stakeholders around the table, where we were able to feed in both intelligence from within the UK around how some vulnerable groups were feeling stigmatised, as cases started to be imported into the United Kingdom, but, on this occasion, more importantly, about the lessons we learnt from Madrid.

So that worked very well. However, I have no knowledge of what happened with those recommendations and that report after it was delivered.

Counsel Inquiry: All right, thank you.

Moving forward to MERS CoV, could you outline your role, please, during the outbreak in the Middle East in 2015.

Mrs Rosemary Gallagher: Yes. A request came in to Public Health England through the global – through GOARN, which was a global network, requesting support in Saudi Arabia, particularly in relation to the spread of MERS CoV within hospitals. There was real concern that healthcare workers were becoming infected with MERS, and MERS did have some sustained transmission between people at that time. We were asked to effectively identify nurses that would go – that would be willing to go to Saudi Arabia to support education and training on infection prevention and control.

We undertook an assessment of the situation and were actually very concerned about potentially just going out to seek nurses to respond to this, and we asked if it would be possible to undertake an assessment in person so that we could identify whether it was appropriate for nurses to be – to go there, number one, but also to identify what risks might be present, both culturally, clinically, you know, a holistic view, and it was on that basis that we were asked to visit – when I say “we”, myself and a colleague in Public Health England – to visit and undertake that assessment, and the subsequent ask, given our expertise, was then to look more widely at potential transmission of MERS CoV and how infection prevention and control might support that.

Counsel Inquiry: Right, and you tell us at paragraph 36 in your witness statement that you believe, in your extensive experience of that outbreak:

“… significant lessons should have been learnt from the experience with MERS CoV. For example, the Gulf Co-operation Council’s IPC guidance specifically addressed the airborne spread of MERS CoV and the requirement for the use of RPE.”

Mrs Rosemary Gallagher: Yes, that’s correct.

Counsel Inquiry: You go on to say in a following paragraph:

“The Covid-19 pandemic has shown that there was too much of a focus on preparing for a flu pandemic and not enough consideration was given to how such plans would need to be adapted to deal with a respiratory infection pandemic, where the primary mode of transmission was not necessarily via ‘traditional’ droplet transmission.”

And:

“… that airborne transmission needed to be properly factored into IPC Guidance concerning the level of PPE required for health and care workers exposed to patients with Covid-19.”

Mrs Rosemary Gallagher: That’s correct. We had the experience of MERS CoV in Saudi Arabia and we additionally had the South Korean experience as well, both of which showed that transmission within healthcare facilities was entirely possible in addition to community spread of infection.

Counsel Inquiry: What is the difference between PPE and RPE?

Mrs Rosemary Gallagher: So RPE stands for respiratory protective equipment, and it is one form of personal protective equipment. Personal protective equipment is a broad term that in healthcare would cover items such as gloves, aprons, respiratory protective equipment, for example.

PPE is designed to protect the wearer from a hazard, so in the case of a pandemic of whatever cause, that would be the infectious agent or the biological hazard that is present at that moment in time.

Counsel Inquiry: Are there lessons that you believe could have been learned from countries dealing with MERS CoV regarding the stockpiling and use of RPE?

Mrs Rosemary Gallagher: Yes. To – when you’re – in my view, if you are planning for a pandemic, we need to consider all eventualities. So we need to consider both potentially the use of surgical masks, but they are not personal protective equipment, and consider the need for respiratory protective equipment for an infection that is spread through the respiratory route predominantly. Not exclusively but predominantly.

It’s my view that there was inadequate consideration given to not just the use of respiratory protective equipment for a prolonged period of time but exactly which elements of the health and care system would need to use respiratory protective equipment if we had widespread infection.

Counsel Inquiry: Right. So not just for hospital settings?

Mrs Rosemary Gallagher: No, the NHS is more than buildings, so the NHS considers – the NHS has hospitals and healthcare facilities but also community teams, community nurses, district nurses, GP practice nurses, for example; all make up part of the NHS. So NHS care goes beyond hospitals.

Counsel Inquiry: Right, thank you.

I want to ask you now about the level of engagement that the RCN had in the preparation of Exercise Cygnus, which we know began to be prepared in 2014 but in fact didn’t take place until 2016.

Was the RCN involved in any sense in either the preparation or the carrying out of that exercise?

Mrs Rosemary Gallagher: Not to the best of my knowledge.

Counsel Inquiry: Do you know whether or not the RCN was invited to be involved in the preparation or carrying out of the exercise?

Mrs Rosemary Gallagher: No.

Counsel Inquiry: Corporate memory. You tell us in paragraph 34 of your witness statement that you have concerns about the loss of corporate memory.

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: You say:

“There was … a palpable change in culture, in the years immediately preceding the Covid-19 pandemic, brought about by the successive administrations. This seemed to manifest in an attitude where engagement with stakeholder organisations seemed to be less of a priority.”

Can you expand upon that, please. What did you mean by a “palpable change in culture”?

Mrs Rosemary Gallagher: So as I’ve described, our experience supporting the incidents of MERS and Ebola were very positive experiences in terms of the engagement and the value that professional nursing was held in, so far as we could support that. At the time, around 2017, we were also part of an antimicrobial resistance programme board that was managed by Public Health England, that, again, had a variety of stakeholders, including the RCGP, the Royal Pharmaceutical Society, around the table.

Once that was disestablished, about a year later, stakeholder engagement was significantly reduced and really remained that way until the pre-pandemic period.

Counsel Inquiry: All right. Just taking that into account and moving back for a moment to Exercise Cygnus, do you believe it was a mistake for the Royal College of Nursing not to be involved in that exercise?

Mrs Rosemary Gallagher: Yes, but I would go further and say it was a mistake not to involve other professional organisations alongside ourselves as well.

Counsel Inquiry: Thank you.

May we put up, please, a paragraph of the report that’s been provided to the Inquiry by Dr Claas Kirchelle. Thank you.

It’s at INQ000205178, and we’re looking at paragraph 112.

I want to seek your opinion on this paragraph, please, Mrs Gallagher:

“There were also ongoing concerns about [Public Health England’s] ability to act as an independent advocate for public health from within the Department of Health (from 2018 Department of Health and Social Care …). In 2014, the British Medical Association … warned that ‘the requirement to adhere to civil service rules and regulations is having an impact on [PHE staff’s] ability to do their work. Particular concerns have been raised about ( … ) the ability to publicly discuss or criticise public health policies’. In surveys, local authorities noted that PHE could do more to ‘acknowledge the pressures and constraints facing Local Authorities in its work with them’ and ‘be more vocal around issues such as welfare reform and austerity and what this means for the health of our nation’. A later witness seminar also highlighted that the increasingly rapid turnaround of civil servants across government departments had created a lack of specialist interlocutors and understanding in Whitehall.”

In your view, Mrs Gallagher, did Public Health England become less able to effectively advocate for public health and public health budgets in the period preceding January 2020? Are you able to give us your opinion on that?

Mrs Rosemary Gallagher: What I can say is that the Royal College of Nursing was very concerned around the reduced funding for Public Health England and the impact that that was having on local authorities and local health protection teams to support population health initiatives in that time.

From my perspective, obviously from an infection prevention and control position, the conversations continued in terms of business as usual, but not necessarily in relation to how we could move – work forward to increase population health and respond to incidents at pace.

Counsel Inquiry: All right, thank you. We can take that down now.

Finally on the issue of stakeholder engagement, before we leave this topic, please could we display INQ000148405, and it’s page 5, paragraph 15 of Professor Kevin Fenton’s witness statement, he being the president of the Faculty of Public Health.

If we could look over the page, please – in fact let’s look at paragraph 15 on page 5. Thank you. Could we highlight that, please:

“Generalist specialists in public health, particularly those working in health protection at regional and local levels, have been under-represented in the development of national pandemic policy, strategy and guidance and there is opportunity for this to be addressed in the future through the UKHSA-hosted Centre for Pandemic Preparedness. There was a significant missed opportunity for broader engagement in planning across local resilience forums and local health resilience partnerships which require closer working and mainstreaming of planning, training and exercising of pandemic response arrangements.”

From your viewpoint, working within the Royal College of Nursing, do you agree with those sentiments?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: Thank you very much. We can take that down, please.

By early 2019, is it your view, Mrs Gallagher, that there were sufficient structures in place for raising, escalating and addressing concerns on behalf of frontline staff amongst the UK preparedness bodies?

Mrs Rosemary Gallagher: I don’t think I can answer that question, because we weren’t specifically involved in preparedness.

Counsel Inquiry: All right. So because of your lack of involvement at all, it’s not possible for you to comment on that question?

Mrs Rosemary Gallagher: No. Could you repeat the question again for me, please.

Counsel Inquiry: Yes. It was whether or not you considered that there were sufficient structures in place for escalating and addressing concerns on behalf of your frontline staff, with the United Kingdom preparedness bodies.

Mrs Rosemary Gallagher: No, that wasn’t in place, we weren’t able to contribute to that.

Counsel Inquiry: All right, and indeed, as you’ve already said, there was a complete lack of engagement with the Royal College of Nursing in terms of preparedness, so there was no option or potential for –

Mrs Rosemary Gallagher: No.

Counsel Inquiry: – raising those issues on behalf of your frontline staff?

Mrs Rosemary Gallagher: No.

Counsel Inquiry: You tell us in your witness statement that, in terms of your role at the Royal College of Nursing – and indeed you’ve confirmed this this morning – that it was as part of a UK-wide organisation.

Did you have any concerns in relation to how EPRR had been dealt with in any of the devolved nations in terms of the frontline staff there?

Mrs Rosemary Gallagher: No. I – I only attended the EPRR group which was based in England.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: However, we did, if it was available at the time, take intelligence or feedback from our members in relation to what was relevant to feed in to the EPRR group. To the best of my knowledge, the agenda items that were discussed, the lessons there would have been learnt, would have been shared with the four countries.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: But I wasn’t party to those discussions.

Counsel Inquiry: All right.

I want to come on to discuss workforce resilience issues which are crucial to a pandemic. What is the relationship, Mrs Gallagher, between the resilience of health systems and the resilience of the workforce within healthcare and social care?

Mrs Rosemary Gallagher: So the resilience of the health and care workforce is absolutely essential in order to be able to deliver healthcare services that meet the public’s needs. We know that we went into the pandemic with a significant shortage, we were about 50,000 nurses short before we went into the pandemic, and therefore that immediately put us at risk when we needed to surge capacity to support patients who were infected, either at home or in hospitals.

Counsel Inquiry: Had the RCN, in your view, consistently highlighted over a number of years the absence of effective workforce planning for nursing?

Mrs Rosemary Gallagher: They had.

Counsel Inquiry: What was the reaction of the government to that being highlighted?

Mrs Rosemary Gallagher: The RCN has campaigned and lobbied for many, many years around what we now call staff safe – safe staffing for effective care. The RCN has participated in significant research with our European counterparts around the impact of insufficient numbers of registered nurses, for example, on patient care and the implications for patient safety. The RCN has responded to all the consultations and also comprehensive spending reviews highlighting the importance of investment in the nursing workforce.

Counsel Inquiry: Has this been handled differently across the different nations? What I’m coming to is asking you about the fact that the Welsh Government have implemented the Nurse Staffing Levels (Wales) Act, which was passed in March of 2016, and does that mean that health boards and NHS trusts in Wales must have regard to the importance of providing appropriate numbers of nurses in all settings?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: In Scotland, the Health and Care (Staffing) (Scotland) Act of 2019 has been passed, setting out requirements for safe staffing across both health and care services, but the implementation of that, in fact, was delayed due to Covid-19?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: So is that still pending, as far as you’re aware?

Mrs Rosemary Gallagher: As far as I’m aware, but I’m not leading that piece of work, so –

Counsel Inquiry: All right.

You also tell us in your witness statement that in Northern Ireland members took industrial action in December 2019 and January 2020 over safe staffing and pay.

Mrs Rosemary Gallagher: Yes, they did.

Counsel Inquiry: So just immediately going into the pandemic?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: All right.

So does this still remain a concern of high priority for the RCN across the four nations?

Mrs Rosemary Gallagher: Yes, absolutely. I mean, there are clearly differences across the UK in terms of how workforce and the need for an appropriate workforce level is implemented across the UK.

Counsel Inquiry: Right, thank you.

I’d like to display, please, the witness statement of Jeremy Hunt, please, just to underline this point, page 15, paragraph 66. Could we highlight this, please.

“As I have written elsewhere, one of the things I learned in my time as Health Secretary and wish I had understood better at the outset was the importance of workforce planning. This was not something I implemented while Secretary of State because it took me some time to appreciate the full picture. I was also not advised to place more emphasis on this because the NHS had a longstanding habit of relying on immigration to fill any gaps. However, with a two million shortage of doctors globally according to the World Health Organisation, this was not a sustainable position in the long term.”

Now, the former Secretary of State for Health and Social Care doesn’t mention nursing there –

Mrs Rosemary Gallagher: No.

Counsel Inquiry: – he uses the shortage of doctors as an example, but would you say, Mrs Gallagher, that the issue was just as important in relation to nursing and workforce planning?

Mrs Rosemary Gallagher: Absolutely. We know we have a global shortage of nurses, as identified in the triple impact report, so this is a global problem, and the reliance on overseas nurses is a real cause of concern for the Royal College of Nursing.

Counsel Inquiry: Thank you.

Lady Hallett: I think, Ms Blackwell, we are going to pause there, because we have a strange noise that I know –

Ms Blackwell: Oh dear.

Lady Hallett: – may need fixing. I don’t know if you are conscious of it. Initially I thought it was thunder, but …

Ms Blackwell: Right.

Lady Hallett: Forgive us, you’re going to have to come back this afternoon, Mrs Gallagher. I hope it’s not too inconvenient for you. I shall return at, I’m being told, 1.45.

Ms Blackwell: Fingers crossed. Thank you.

(1.03 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: I’m assured the problem has been resolved.

Ms Blackwell: I do hope so. Thank you, my Lady.

Mrs Gallagher, just before we broke, we were discussing workforce resilience issues and the importance of workforce planning, and I’d like to turn now to look at public health and local infection control.

At paragraph 65 in your witness statement, you tell us that:

“Funding for public health services and interventions (ie the frontline public health services funded by local authorities) in England has not been consistent and has suffered under austerity measures.”

And you say that:

“The public health grant has been cut by more than a fifth (22% [in fact]), since 2015/16. Consequently, this has meant that local authorities are unable to provide vital functions that promote well-being and prevent ill health and the reductions in outreach services such as smoking cessation [and other health matters] which impacts population health and chances.

You go on to say that:

“It is the [Royal College of Nursing’s] contention that this historic underfunding of public health [has] undermined the capacity of local public health teams to effectively improve health and reduce inequalities and respond to the Covid-19 pandemic.”

From a nursing perspective, then, how does a reduction to the public health grant and public health spending affect pandemic preparedness at the local level? Is it just a matter of resilience, or are there other effects to the cutting in the budgets?

Mrs Rosemary Gallagher: In terms of population health and having a population that is as well as it can be to not suffer unnecessarily from the impact of an infectious disease, population health is absolutely vital, and throughout the life course. So, for example, we know we have far fewer health visitors at the moment that support mothers and also support young children, and that is vital in terms of local communities.

In terms of operational management of the pandemic, that’s – that, at a local or regional level, would be supported by the health protection teams, and they are absolutely vital in having good relationships, collaborative relationships with provider organisations such as NHS trusts, but also in supporting care homes.

Now, health protection teams came under Public Health England, they’re now under the UKHSA, and their roles have continued but, with the changes in the landscape, those roles and relationships have changed over time. So it’s a bit of both, if you like.

Counsel Inquiry: All right, thank you.

Professor Philip Banfield from the British Medical Association has provided a witness statement to the Inquiry in which he says that reforms to the public health system in England in particular led to a fragmented system and that the 2012 Health and Social Care Act fractured in many places the links between public health specialists and NHS colleagues, which in turn impacted upon pandemic response.

Do you agree with that?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: All right.

What role does community infection prevention and control have to play in pandemic planning and emergency response?

Mrs Rosemary Gallagher: So the role of community infection control teams has changed over time. When I was in clinical practice we provided support from the acute trust to our community partners and provided them with an infection control service, but in other areas they have dedicated infection control teams. So there is variation across the system on how advice is provided.

We know that when the Lansley reforms, the changes to the NHS – the Health and Social Care Act was implemented, that we lost many community infection control teams as staff moved under the umbrella of local authorities away from their original employers, and that gap, if you like, placed increased pressure on health protection teams, but also had an effect on local relationships and resilience locally.

Counsel Inquiry: May we put up, please, the statement of Professor Kevin Fenton at paragraph 11, pages 3 to 4, and highlight that, please. Thank you.

Here he says:

“Health protection teams, which moved from the Health Protection Agency … to [Public Health England] … saw successive reductions in funding and capacity over the pre-pandemic years and lack of investment in regional emergency preparedness, response and resilience … teams. A direct result of these changes was a reduction in the amount of professional exposure that the public health specialist generalist workforce had to health protection duties and continuing professional development outside of PHE. There was also a reduction in the exposure that NHS staff in general had to important public health issues associated with health protection, especially in community settings. This is likely to have contributed to a poor understanding of the role of the wider public health agenda around pandemic preparedness, and more specifically the role of local authority public health teams and wider system partners in pandemic preparedness and response. Community infection prevention and control … is a key element of pandemic planning and local health protection more generally, but guidance is unclear on commissioning responsibilities, funding streams, and standards for high-performing local integrated services. It is largely understood that provision for community IPC was a significant casualty of the 2012 reforms and the Faculty considers the creation of Integrated Care Systems, with local authority Directors of Public Health and UKHSA as key partners, an opportunity to rectify the current problems. The use of Contain Outbreak Management Funding … during the pandemic to temporarily increase IPC capacity in many systems provides proof of concept of what can be achieved through concerted effort and funding enhancements.”

Do you agree with Professor Fenton’s suggestion that guidance on commissioning responsibilities, funding streams and standards for high-performing local integrated services is unclear?

Mrs Rosemary Gallagher: From my experience, yes.

Counsel Inquiry: Do you also consider that the provision for community IPC was a significant casualty of the reforms? I think as you’ve just referred to.

Mrs Rosemary Gallagher: Yes, I do.

Counsel Inquiry: All right.

Towards the end of that paragraph, Professor Fenton suggests that the use of the COMF during the pandemic to temporary increase IPC capacity demonstrates the concept of what can be achieved; do you agree with him in that regard?

Mrs Rosemary Gallagher: I do. In order to sustain the benefits that have been achieved through this, however, I would also focus on a need for standardised training as a foundation, a cornerstone for health protection teams, because there is no standardised education currently for health protection practitioners.

Counsel Inquiry: How would that best be achieved?

Mrs Rosemary Gallagher: There are a number of ways in which education can be commissioned and delivered. For me, the starting point would be to identify the needs of health protection practitioners, who are not all nurses at all, many do not have a nursing background, and to support them to identify what is needed in order for them to deliver their role in practice.

Counsel Inquiry: Thank you.

Lady Hallett: Just before you go on, may I interrupt.

Can you explain, I appreciate it’s not your expression, Mrs Gallagher, “specialist generalists” sounds a bit contradictory to me.

Mrs Rosemary Gallagher: Sorry, that’s me.

Lady Hallett: Is it? Oh, no, I think it’s in this report as well.

Mrs Rosemary Gallagher: Oh, I see.

Lady Hallett: What is a specialist generalist?

Mrs Rosemary Gallagher: I’m not quite sure actually.

Lady Hallett: Right.

Ms Blackwell: We will provide a definition for my Lady.

Lady Hallett: Thank you. I hope it makes sense. At the moment it doesn’t.

Mrs Rosemary Gallagher: I think I know what it means, but I wouldn’t like to say.

Counsel Inquiry: Right.

In terms of the problems created in public health provision, the Inquiry has heard from Professors Marmot and Bambra that those difficulties that arose, those highlighting of inequalities that developed, hit certain areas of the country hardest and hit people who were suffering from particular inequalities even harder, living in those areas.

Is that something that you recognise, and if so, is the difficulty with inequalities, and that caused by funding or lack of workforce planning or some of the issues that we’ve looked at, is that something that the Royal College of nurse was alive to prior to the onset of the pandemic?

Mrs Rosemary Gallagher: Certainly in relation to the impact of the pandemic, we’re very aware of the effect of inequalities both on our nursing workforce but also on those that required care or were most affected by the pandemic.

The second part of your question, in relation to workforce –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – could you just repeat that for me, please.

Counsel Inquiry: Yes, what I’m asking is whether or not the fact that inequalities hit in particular areas, as Professors Marmot and Bambra have told the Inquiry, and whether or not that was exacerbated by either workforce issues or public health funding cuts or a combination of both, and if that is something which the Royal College of Nursing recognises, was that something that was apparent prior to the onset of the pandemic in 2020?

Mrs Rosemary Gallagher: Certainly the Royal College is very aware of the impact of inequalities, from a public health perspective. Then, obviously, whatever impacts on our public health ultimately affects our hospitals and the demand for hospital services, so the two are very closely related.

The issue of black and ethnic minority staff in terms of their experience in the workforce is well documented by the Royal College of Nursing.

Counsel Inquiry: Is that something to which the Royal College of Nursing was alive prior to the pandemic?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: The onset of the pandemic.

Mrs Rosemary Gallagher: I would – yes.

Counsel Inquiry: All right.

Moving on to social care, please, you describe in your statement at paragraph 48 that there was not a whole systems approach to pandemic planning, particularly with regard to social care, and you say that from your perspective:

“This was evident at the start of the pandemic, during efforts to rapidly scale up acute capacity, when some community staff were being redeployed into the acute sector without sufficient thought being given to the services that needed to continue in the community. For example [and this is an example that you give in your statement], the [Royal College of Nursing] heard reports that community nursing staff were being asked to go and work in hospitals when community services needed to be augmented at the same time to ensure essential services such as child protection and end of life care, could continue.”

You identified this as a problem. Was this a problem that had persisted prior to the pandemic or was this something that came to light only when the pandemic hit and the staff, as you say, were being pulled from hospitals into the care sector and back again and vice versa?

Mrs Rosemary Gallagher: Certainly you would expect to need to move staff in a case of need –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – in the case of a national incident. The pandemic highlighted, really, the impact of doing such actions, and there was real concern regarding how we would maintain care for our patients in the community, and we have many more patients in community settings than we do in hospital settings, for example.

The RCN has raised concerns over a number of years around a reduction in the community nursing workforce and the implications for that, not just in terms of community care but the knock-on effect of care in hospitals.

Counsel Inquiry: Right. As far as you are aware, was there any planning in terms of the movement of staff from hospitals into adult social care and workforce planning in any of the pandemic planning that was undertaken?

Mrs Rosemary Gallagher: As I recall, as we took place – part in Operation Pica around 2018, the need to consider the movement of staff and the different demands in different care sectors at different times was on that agenda.

To the best of my memory, I don’t recall in-depth discussions on what the real impact of that might mean, particularly from a nursing perspective.

Counsel Inquiry: In your view, was there adequate operational guidance in place for managing a pandemic within the social care sector prior to Covid-19 hitting?

Mrs Rosemary Gallagher: I’m not aware of any, but we weren’t involved in the pandemic planning.

Counsel Inquiry: Yes, of course.

Mrs Rosemary Gallagher: Yeah.

Counsel Inquiry: Certainly none was brought to the attention of the RCN –

Mrs Rosemary Gallagher: Not that I recall.

Counsel Inquiry: – nor was there any invitation given to the RCN to involve itself in any such guidance being prepared?

Mrs Rosemary Gallagher: Not that I recall.

Counsel Inquiry: All right.

I’d like to ask you now, please, about the value of healthcare-acquired infection operational guidance, which you deal with at paragraph 53 in your witness statement.

Now, there was the publication in 2012 by the Health Protection Agency of certain guidance, and you recall that the guidance was updated in 2016, I think, as an internal document but that that update wasn’t published; is that right?

Mrs Rosemary Gallagher: Yes, that’s a verbal report that I had. I’ve not seen the 2016 updated guidance.

Counsel Inquiry: Right.

You say in your witness statement that the fact that this operational guidance wasn’t published, that’s the 2016 update, I think:

“… meant that NHS teams, as well as care homes and community settings, did not have up-to-date information on the roles and responsibilities of Health Protection teams, and this would have impacted directly on local, regional and national incidents, including responding to HCIDs such as Covid-19.”

Mrs Rosemary Gallagher: Yes. The – as I recall, the operational guidance was a recommendation that came out of the Stoke Mandeville report in 2016 – 2006, apologies, where there was criticism around the role of the Health Protection Agency local team at that time and how they intervened to support the NHS trusts.

The guidance is around roles and responsibilities, and relationships between health protection teams, acute trusts and community providers is really important for dealing with local or regional issues, and therefore, when it comes to a national incident, it’s absolutely essential.

The 2012 guidance focuses on healthcare-acquired infection because Stoke Mandeville was predominantly around clostridioides difficile healthcare-acquired infection.

However, for me this represents good governance and essentially having your house in order to have operational guidance in place that can be referred to and is already in place.

Counsel Inquiry: Has the RCN been vocal in expressing its concern about a lack of guidance in this area?

Mrs Rosemary Gallagher: I don’t believe we’ve written anything formally, but certainly questions have been asked over the years since it was developed and at a time when it would have been reasonable to update it.

Counsel Inquiry: Yes. One of the aspects that you bring to the forefront in your witness statement is the concern that has been regularly raised by the RCN at national fora, including the Care Quality Commission’s stakeholder group for non-hospital organisations, that the CQC had not delivered on its regulatory responsibilities in relation to IPC, to the extent of ensuring effective systems.

Is that something which has regularly been raised by the RCN over the years?

Mrs Rosemary Gallagher: So when I attended the CQC meetings on behalf of the Royal College of Nursing I did raise this at those meetings, and I also took the opportunity, I can’t recall which meeting specifically, but to raise this as part of concerted efforts to support the reduction in healthcare-associated infections that didn’t just focus on hospitals.

Counsel Inquiry: Right. In particular, I think, one of the concerns of the RCN was that a focused inspection was requested of the CQC in adult social care and to strengthen non-hospital-based IPC provisions. You say in your witness statement that:

“Despite [that], the RCN is not aware of consideration being given to providers, such as care homes, being assessed in pandemic planning with regard to meeting the fundamental requirements of the Code of Practice or their ability to escalate issues if required.”

Is that right?

Mrs Rosemary Gallagher: That’s correct. The theory behind our ask is that if care homes are well prepared for business as usual, then when it comes to an incident they are much better prepared to respond and consider how they will manage, should that occur.

Counsel Inquiry: Was social care non-compliance something that you’d raised with the Department of Health and Social Care before 2020?

Mrs Rosemary Gallagher: Non-compliance with regard to the code of practice –

Counsel Inquiry: Yes?

Mrs Rosemary Gallagher: – do you mean?

We raised concerns around the level of compliance, I would say, rather than non-compliance with the code of practice, which every provider of health and care has to meet in a proportionate way to their role. So there is a different expectation for care homes than there is, for example, to a large acute hospital.

The essential expectations around having good policies and procedures and education in place would be fundamental to their response in a pandemic.

Counsel Inquiry: Right, thank you.

We’ve touched upon PPE and RPE, and you tell us in your witness statement that, as far as the RCN is concerned, there was a lack of – or insufficient stockpiling of RPE that was needed. That’s also a reference, is it not, to FFP3 face masks, which I think you’ve already described to us, the critical nature of those?

You say that without a sufficient stockpile of that equipment, not only for hospital settings but also for community nursing, nursing staff are putting their own lives and the lives of their families and patients at risk.

But in addition to the availability of such PPE, is it also necessary for those who are going to be utilising it to know how to fit it properly?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: That involves staff training in fit testing.

From an RCN perspective, is there or indeed was there at the onset of the pandemic sufficient capability within staff who might need that PPE to be able to fit it properly? Had the training been in force and in place?

Mrs Rosemary Gallagher: If I might go back a little step –

Counsel Inquiry: Certainly.

Mrs Rosemary Gallagher: – briefly. The failure to consider a pathogen that had pandemic potential that would require the extended use of respiratory protective equipment was not duly considered, and it is my view that that had an effect on how large the stockpile was of respiratory protective equipment as opposed to face masks.

If you take that to the next degree, then I would have expected consideration of the need to cascade fit testing to be in place as part of pandemic preparedness.

When a pandemic or an incident first starts, it’s absolutely critical that we also take a precautionary approach to what it is we are dealing with until the science tells us otherwise, and that would also have implications for how much respiratory protective equipment we would need. It’s clear now that those systems for escalating fit testing, and also the system for having standardised respiratory protective equipment, was not in place, and by that I mean the demand for respiratory protective equipment resulted in many different types of masks being available, and masks fit people differently. So whilst your face may fit one type of mask, it may not fit the other. So this then necessitated multiple attempts or multiple – the multiple – multiple requirements to fit test staff on numerous occasions because of the numerous types of masks that were required.

So I don’t believe that the system was well set up to consider this as part of pandemic planning.

Counsel Inquiry: All right. So just to summarise your evidence, a lack of foresight in terms of the requirement for RPE, a lack of stockpiling for RPE, and then a lack of fit testing for the various RPE facilities?

Mrs Rosemary Gallagher: Yes, or having systems in place to cascade fit testing. You can, for example, introduce a train the trainer system, where you can cascade to staff. Most trusts would not routinely – well, I can’t think of any trust, actually, that would routinely educate or train all its staff to be fit tested all the time in RPE. However, we did learn from H1N1 and Ebola that there would be a need to expand and escalate fit testing and the use of RPE as part of those experiences.

Counsel Inquiry: In your witness statement, you discuss framing vulnerability as a clinical category in pandemic plans and guidance. In your view, were structural health inequalities factored into the government’s pandemic planning?

Mrs Rosemary Gallagher: No. I don’t believe so.

Counsel Inquiry: Why do you say that?

Mrs Rosemary Gallagher: So the structural health inequalities that I would consider of key importance to take into account would have included inequalities within the healthcare workforce, as well as the vulnerabilities and inequalities experienced by our population, and that has undoubtedly changed since the last pandemic.

Counsel Inquiry: How has that changed?

Mrs Rosemary Gallagher: So we know that our levels of non-communicable diseases have increased, so diseases such as diabetes, obesity, for example, those have really escalated since the 2009 pandemic, therefore there have been shifts in our populations that we would need to keep considering as part of our pandemic planning.

Counsel Inquiry: All right.

Frontline workforce and planning for minority ethnic members of the workforce. Paragraph 63 of your report, you say that:

“In its written submission to the … Treasury Comprehensive Spending Review … [in] (September 2020) … the [Royal College of Nursing] highlighted the overrepresentation of BAME staff at bands four to six, which represent those professionals providing care on the frontline, warning that they may be at increased risk of exposure to the viral load of Covid-19.”

And you also highlighted the fact that:

“… as the pay bands increase, data shows larger increases in the number of white staff at each pay grade compared to the increase of in ethnic minority staff.”

Was the risk of a disproportionate impact on minority ethnic staff mitigated against within pandemic planning as far as the Royal College of Nursing is concerned?

Mrs Rosemary Gallagher: In my opinion, no, but as I’ve stated before, we weren’t involved in pandemic planning.

Counsel Inquiry: But you haven’t seen anything or had anything brought to your attention in your position to indicate that it was so considered?

Mrs Rosemary Gallagher: Not that I recall. The language used in most strategic documents tends to refer to at-risk groups –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – or, as you’ve said, other clinical vulnerabilities linked to medical conditions, but not inequalities as described by Professor Marmot, for example.

Counsel Inquiry: Thank you.

Finally, Mrs Gallagher, turning to lessons learned for future pandemics. You’ve mentioned stakeholder engagement earlier in your evidence this morning. What do you say is missing and what needs to be done in order to better ensure a level of preparedness, certainly so far as your organisation is concerned, with stakeholder engagement going forwards?

Mrs Rosemary Gallagher: I would say that we need to revisit what we think stakeholder engagement means. There may be assumptions that stakeholder engagement could be something as simple as sending out a draft document to review and comment on, but the view of the Royal College of Nursing is that meaningful stakeholder engagement would entail involvement at the beginning rather than being a recipient at the end of a long process.

We would also consider stakeholder engagement to be absolutely vital to allow us to really consider the impact of what we have learnt now in terms of vulnerabilities. So, for example, by engaging with other royal colleges or other organisations, which has been such a valuable lesson for us during the pandemic. So, for example, the inclusion of organisations such as the British Occupational Hygiene Society or speech and language therapists or others that can bring a combined view together with ours on how we operationalise or manage specific incidents or view guidance.

Counsel Inquiry: Thank you.

Finally, is there any recommendation that you would like to bring to the attention of the Inquiry so far as transparency is concerned?

Mrs Rosemary Gallagher: Transparency is absolutely vital to support communication. In my experience, I have found that healthcare professionals and the general public are very understanding that guidance and advice changes as an incident or a pandemic evolves, and they are very forgiving of changes in guidance and advice. But they need to understand why. So we are able to bring people with us if we can do that, and bringing in the public and our healthcare workers with us at a time of national crisis is absolutely vital.

Counsel Inquiry: So transparency and information provision?

Mrs Rosemary Gallagher: Yes.

Ms Blackwell: Yes, thank you.

My Lady, those are all the questions that I have. You have provisionally provided permission for Covid-19 Bereaved Families for Justice to ask a specific question around a meeting of the Chief Nursing Officers back in 2014, according to the sheet that I have.

May they ask those questions now, please?

Lady Hallett: They may. Ms Munroe.

Questions From Ms Munroe KC

Ms Munroe: Thank you, my Lady.

Good afternoon, Mrs Gallagher.

Mrs Rosemary Gallagher: Good afternoon.

Ms Munroe KC: In your witness statement at paragraph 29 – I should have said, my name is Allison Munroe and I ask questions on behalf of Covid-19 Bereaved Families for Justice.

In your statement at paragraph 29 – we don’t need to bring it up – you make reference to a meeting on 22 October 2014 between the Chief Nursing Officer and regional CNO nursing teams. It’s a meeting you yourself did not attend.

Mrs Rosemary Gallagher: That’s correct.

Ms Munroe KC: But you say that from discussions that flowed from that meeting, there were concerns about whether or not the voices of nurses were being heard, and that issue of stakeholder engagement that you’ve spoken about at length this afternoon and earlier this morning.

Can you assist us, please, were there wider concerns about the engagement with the Chief Nursing Officer and the RCN, and did you see any improvements following on from that meeting in 2014?

Mrs Rosemary Gallagher: The feedback I had as a result of that meeting, which I wasn’t present at, was that the information that was provided, and this was in relation to the Ebola outbreak, had been positively received and that there was … that it had been taken on board around the need for nursing to be engaged in this response.

I don’t – I don’t recall any issues in relation to relationships, there were good professional working relationships at that time, but clearly because this was in response to an incident that was occurring at a moment in time, the meeting was called at quite short notice, to the best of my memory.

Ms Munroe KC: You’ve said there were good working relationships. You have been referred to paragraph 34 of your statement again earlier, before the luncheon adjournment, where you speak about certain significant changes that happened in the healthcare system and the culture around about the time 2018 to 2019.

Now, with regards to the Chief Nursing Officer, Dame Ruth May succeeded Jane Cummings in January of 2019. To what extent did that change have an impact, if at all, on the pan professional working and communications between the CNO and the RCN?

Mrs Rosemary Gallagher: To the best of my knowledge, there was no detrimental effect at all when Dame Ruth May took over her position of CNO. Most of the – my experience before that had been to work to the Deputy Chief Nurse in Public Health England, who then held a strategic relationship with the Chief Nursing Officers team in the NHS. From my perspective, the change in CNO leadership didn’t cause any issues at all.

Ms Munroe: Thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Ms Munroe.

Ms Blackwell: That concludes Mrs Gallagher’s evidence.

Lady Hallett: Thank you very much indeed for your help, Mrs Gallagher.

The Witness: Thank you.

(The witness withdrew)

Ms Blackwell: My Lord, may I please call Professor Dame Jenny Harries. Would you take the oath, please.