Transcript of Module 2B Public Hearing on 01 March 2024.
(9.59 am)
Lady Hallett: Good morning on a rather damp St David’s Day here in Cardiff.
Mr Poole: Can I call Dr Chris Williams, please.
1. Dr Chris Williams
DR CHRIS WILLIAMS (sworn).
Questions From Lead Counsel to the Inquiry for Module 2B
Mr Poole: Could you please start by giving us your full name.
Dr Chris Williams: Christopher Julian Williams.
Lead 2B: Dr Williams, thank you for attending the Inquiry today to give your evidence. Can I just remind you to please keep your voice up so that we can hear you but also so that your evidence can be recorded. If I ask you a question you don’t understand, please do ask me to rephrase it. There will be breaks, but if you do need one, let us know.
Your witness statement to this module is at INQ000251938. That was signed and dated on 17 August, and is that statement true to the best of your knowledge and belief?
Dr Chris Williams: It is.
Lead 2B: Now, Dr Williams, in terms of your professional background, I understand that you have worked as a consultant epidemiologist in Public Health Wales Communicable Disease Surveillance Centre, the CDSC, since 2013, and you have been involved in public health responses to communicable diseases since 2001; is that right?
Dr Chris Williams: Yes.
Lead 2B: You are a medical doctor, you completed your medical training and trained as a medical registrar with NHS England, following which you trained in the European fellowship for intervention epidemiology in Germany; is that right?
Dr Chris Williams: Roughly, there’s – some of the organisations have changed names, but yeah.
Lead 2B: Between 2008 and 2013 you worked as a consultant in communicable disease control, with responsibilities for outbreak control and surveillance, and you had involvement I think in the 2009 swine flu pandemic, and in addition you’ve worked for the World Health Organisation as an epidemiology consultant; is that also correct?
Dr Chris Williams: That’s correct, yes.
Lead 2B: Now, Dr Williams, going back to January 2020, and setting the scene, at the time you were one of only three consultants in the Communicable Disease Surveillance Centre; is that right?
Dr Chris Williams: Yes.
Lead 2B: Can you briefly tell us what the CDSC was and perhaps explain its importance and significance in that period January to March 2020.
Dr Chris Williams: So we have a responsibility for surveillance of infectious diseases, also advising on outbreak management and research, teaching, those kind of activities.
In the early part of the pandemic we moved from hearing about the first case from the WHO at the end of 2019 to starting to get briefings, mainly through colleagues in Public Health England, about this new infection, new disease that was affecting people in China, and there were a series of meetings on that, which in general Public Health England led, and we were just – we were picking up on what was going and I was disseminating it through my organisation.
Lead 2B: We will come to look at that in a bit more detail and break that period down in a moment, but I understand that in March 2020 you became one of three incident directors to Public Health Wales. What did that role involve?
Dr Chris Williams: So that was more day-to-day decision-making, attending particular groups with respect to the response within Public Health Wales, and, you know, monitoring the situation. So there was quite a few tasks associated with that, but essentially it was the tactical response on the day. I was one, as you say, of three, and then I think there were four later.
Lead 2B: I’m right in saying that you were also involved with the Technical Advisory Cell and the Technical Advisory Group that we heard a bit about from Dr Hoyle yesterday; is that right?
Dr Chris Williams: That’s right, yeah.
Lead 2B: What was your primary contribution to the Technical Advisory Group?
Dr Chris Williams: So at the beginning I was involved with my role as an epidemiologist and passing on some of the information I was getting through the briefings and other mechanisms. I think the majority of the time I was there to give reports on the surveillance and the unfolding epidemiology of the infection in Wales.
Lead 2B: Would it be a fair summary to say that you were fairly heavily involved, then, with Public Health Wales and the Technical Advisory Group’s pandemic response in that early period, January, February, March 2020?
Dr Chris Williams: I think that’s fair to say, yes. Probably more Public Health Wales because that was my main role, but I was also involved in TAG and worked with the Chief Scientific Adviser for Health.
Lead 2B: So you were working closely with Dr Orford. Were you also working closely with Dr Atherton, the Chief Medical Officer?
Dr Chris Williams: Less so with Dr Atherton, it was more Dr Orford.
Lead 2B: Of the group of scientists at that time that were working and advising, was it only you that had an academic background in epidemiology and communicable diseases?
Dr Chris Williams: I can’t recall all of the qualifications of everyone in TAG, but certainly Welsh Government colleagues were more health and health policy and other aspects of science. There aren’t a huge number of infectious disease epidemiologists in general and in the UK.
Lead 2B: And am I right in saying that you undertook this work in an independent capacity insofar as you were not employed by the Welsh Government; that’s right, isn’t it?
Dr Chris Williams: Yes.
Lead 2B: Now, when did you first become aware of the pandemic?
Dr Chris Williams: So I can’t recall exactly, but I think I would have seen news reports of the WHO report at the end of 2019. I think it was 7 January when there was a briefing just after the Christmas period from Public Health England about a new pneumonia syndrome coming out in Wuhan in China, and there was sketchy information at that time, but there were continual meetings, repeated meetings, and then we started to learn more.
Lead 2B: Following that 7 January Public Health England meeting, what role did you assume regarding the outbreak?
Dr Chris Williams: Within CDSC, we tended to get involved when there was a briefing or some kind of communication about something that came through nationally, so I wrote a briefing note, I think it was the next day, based on the initial briefing, I informed other colleagues, and I think there were further briefing notes that came out from England that we then read and adapted and added to.
Lead 2B: Now, the Inquiry understands that there was a devolved administration update on 15 January that was also hosted by Public Health England. Did you attend that meeting, can you recall?
Dr Chris Williams: I’d have to check my evidence pack. Probably I would have done.
Lead 2B: What was your perception of the risk posed by Covid-19 at that time, so we’re talking mid-January 2020?
Dr Chris Williams: I honestly can’t recall what my perception is. What I do remember was that, towards the latter half of January, as there were reports of more and more cases coming from China, I was attempting to work out how fast the infection was spreading using some very rough, you know, mathematical techniques, so I must have had – been aware that there was a possibility of much wider spread.
Lead 2B: At this point in time, so still in sort of mid to late January, what body was responsible for providing expert epidemiology and scientific advice to the Welsh Government in a sort of day-to-day de facto sense?
Dr Chris Williams: That would have been Public Health Wales. Public Health England, because of their – they had a larger respiratory department and international department and other links, they tended to get information, you know, earlier or from different sources to us. Obviously we could access the media and other published sources, but a lot of the time we were taking information that was given to us by them, interpreting it, seeing what the context was for Wales and then disseminating it within our organisation and also to Welsh Government.
Lead 2B: Now, on 23 January 2020, there was a Public Health Wales briefing entitled “Update on Wuhan novel coronavirus”, I don’t intend to bring it up on the screen, but I just want to understand, did you play a role in authoring that briefing?
Dr Chris Williams: Yes, I would – I would have written that, but, again, adapted, probably, from a Public Health England briefing.
Lead 2B: Understood.
Now, that briefing note confirmed the likelihood of human-to-human transmission, and just to read a passage from it, it says:
“Due to the enlarging geographic area affected, and evidence of human to human transmission, it is increasingly likely that suspected cases (those with an appropriate clinical picture and travel or contact exposure) will be identified in the UK, including Wales.”
Did that 23 January briefing change the pandemic response in any way in Wales?
Dr Chris Williams: Once again, I can’t remember the exact sequence of events regarding the stepping up of various emergency response activities within Public Health Wales, but we were – certainly that briefing will have gone to key individuals within Public Health Wales and we made sure that people were aware of the risk.
Lead 2B: Can you tell us how Public Health Wales was monitoring and advising the Welsh Government on the spread of Covid-19 at this time, so we’re still at the back end of January 2020.
Dr Chris Williams: Again, my recollection is not strong from this time, but where we would have had information from the England briefings and the – by that time – daily meetings regarding the situation, I would have sent – I and sometimes colleagues would have sent out an email that also included, I believe, Welsh Government colleagues at the time. If it wasn’t directly to Welsh Government colleagues, then someone more senior to me would have disseminated that.
Lead 2B: Was there an understanding amongst your colleagues and those advising the Welsh Government at this time that this had pandemic potential?
Dr Chris Williams: I think we were – we were beginning to realise it had pandemic potential once – particularly once there were more widespread cases in China. You don’t necessarily get to hear about all of the cases and all of the transmission, so you can probably assume that if there are actual official reports from a country such as China that there’s probably quite a lot of transmission going on, and there was still international travel.
Lead 2B: Did you or any of your colleagues at this point think it worthwhile to review the Wales pan flu response plans and look whether they would be sufficient for a coronavirus pandemic?
Dr Chris Williams: I can’t recall whether we looked particularly at the pandemic flu plans. We were – we would have been aware of them. As I said, I was involved in the 2009 pandemic, so I’m sure I’d have looked at them at the time. But the plans tend to – you have to adapt based on the circumstances that are coming, and I think this needed a different response.
Lead 2B: Just on that point, then, were you given, can you recall, any instructions at any point at this period of time to perhaps begin reviewing population-wide NPIs to deal with a virus spreading such as this, as was instituted in China?
Dr Chris Williams: So we had the example of China. I don’t recall considering those for – for the UK. The climate of thinking was not necessarily to start with NPIs, because they’d never really been done at that level. That took a bit longer for that thinking to come through, I think.
Lead 2B: What about scaling up surveillance and contact tracing capacity, was that something that was – thought was given to at this point in time?
Dr Chris Williams: We were certainly scaling up surveillance activity. There were the First Few 100 epidemiology forms that we would sign to complete where we’d got suspected cases. And in terms of contact tracing I think I did – it might have been February by that time – I think I did write something on that.
Contact tracing per se isn’t necessarily the responsibility of CDSC, but we would have been involved in the surveillance, and maybe advising on that kind of response.
Lead 2B: To your recollection, was there any work being done to prepare care homes and hospitals for numerous cases and the risk of nosocomial infection?
Dr Chris Williams: I can’t recall any – any particular preparations along those lines, but we did make sure that all of our briefings went to the health service in Wales. And nosocomial spread of infections, respiratory infections is always a risk and … yeah.
Lead 2B: Now, Dr Sandifer has told the Inquiry in his written evidence that, with the exception of the CMO and his staff, he did not see the same awareness of and urgency about Covid across the rest of the Welsh Government. He has said what he thinks was missing in these first few weeks, namely 8 January, when he first became aware of Covid, to 20 February, which was the first meeting of the Welsh Government HSSG Coronavirus Planning and Response Group, he says what was lacking was national strategic leadership and co-ordination from the Welsh Government.
Do you have any comments on those observations of Dr Sandifer?
Dr Chris Williams: Between sort of mid-January up to sort of late February, early March, I didn’t have an awful lot of direct working with the Welsh Government, so I’m not really able to comment on their level of preparedness.
Lead 2B: Now, the Inquiry’s heard in Module 2 that the approach to the pandemic response in accordance with the UK influenza pandemic strategy was one of containment. What did you understand by “containment” and how was that implemented by Public Health Wales?
Dr Chris Williams: The idea behind containment is that you would identify every single case that came into the country, you would trace their contacts, gather some information about them and their contacts, and put into place isolation and quarantine of those contacts to ensure that there were no secondary or further cases. That was – that had been the response also in 2009, as – “containment phase”, as they called it.
Lead 2B: Now, the Inquiry also understands that in January 2020 there were several direct flights each week to Wuhan City from London Heathrow and other indirect flight routes. We know also that the common symptoms of Covid-19 were fever and a cold, so the kind of symptoms that might mirror a common cold might not give cause for concern.
Knowing all of that, what was your view on the likely success of a containment strategy?
Dr Chris Williams: Again, I don’t know exactly what my thoughts would have been at the time, but I had my experience of the 2009 pandemic of influenza which showed that containment really isn’t very feasible in a country with lots of international connections, with infections that are highly contagious, rapidly spread, and, you know, spread through multiple mechanisms.
Lead 2B: Was it your view, then, with that prior experience, that Wales needed to really start preparing for mass community transmission?
Dr Chris Williams: I suppose that’s the implication, yes, that that was probably on the way, when we were doing – as I say, I wasn’t directly doing the contact tracing, but when we were responding to that surveillance-wise, I think we were aware that it wasn’t going to be successful.
Lead 2B: And perhaps with the benefit of hindsight, do you think that containment was the right approach for Wales in February 2020?
Dr Chris Williams: I think it was, because even if you think you’re eventually not going to succeed, it’s worth trying the best you can. It will at least slow – especially in the first – first few cases, you can genuinely slow the infection. But as more and more people travel, you get, you know, cases that you’re not aware of, that are then transmitting, then that’s when it becomes untenable.
Lead 2B: As we move into late February, how did the epidemiological picture in Wales develop?
Dr Chris Williams: So I checked my notes before. The first case I think we reported was on 28 February in somebody that had returned from northern Italy, and then – we should also remember that before that there were a number of suspected cases reported, so people with appropriate symptoms and who had travelled to China or the changing list of countries, who were then identified, isolated, tested and found to be negative. But this was our first positive case, and from then on, you know, the case numbers did increase through March.
Lead 2B: A week or so before that first case, there was a SAGE meeting on 20 February. Were you and your colleagues at Public Health Wales appraised of what was discussed at that SAGE meeting, can you recall?
Dr Chris Williams: I don’t recall that particular one. I don’t think I was able to have any contact through SAGE meetings until either late February or early March via Welsh Government colleagues.
Lead 2B: So after that SAGE meeting of 20 February, Dr Orford emailed Dr Atherton and some other senior figures in HSSG about those SAGE discussions. Now, you aren’t copied in to that email. It says:
“From cruise ship – 30-50% asymptomatic-mild;
“Likely that UK testing has missed 40% of positives, due to delay in testing versus detectability of virus.”
Are those figures, and especially that point about testing missing 40% of positives, something that you were made aware of at that time?
Dr Chris Williams: I think I would have heard about the results of the cruise ship testing through some of the other professional briefings and, yeah, the fact of there being some asymptomatic cases probably wouldn’t have been a huge surprise.
Lead 2B: If 40% of positive cases had been missed, does it not follow that containment measures would effectively be obsolete?
Dr Chris Williams: That is the difficulty with containment. You just – I remember writing things at the time saying if we’re not catching all the cases then you’re only getting whatever effectiveness you get from the cases that you do know about.
Lead 2B: So being aware of this figure of 40% of – 40% being missed of positives, did you or any of your colleagues advise the Welsh Government of the difficulty that this presented with a containment strategy?
Dr Chris Williams: I don’t recall any advice I gave on that respect. The containment strategy, in my recollection, was a kind of UK-led strategy, so we were following the UK strategy, which started with containment.
Lead 2B: But if by 20 February you’ve got Dr Orford emailing Dr Atherton and noting in particular this worrying data about missed 40% of positives, should Wales have still been following the UK Government’s containment strategy, if effectively it was a doomed strategy by this point in time?
Dr Chris Williams: I would say that if you take the counterfactual, if Wales had decided that we would stop contact tracing, stop trying to identify new cases whilst that activity continued in the other nations of the UK, I don’t think that would have been particularly helpful to the response. I think you have to try, even though it’s very difficult and essentially impossible after a while.
Lead 2B: Can we, please, have a look at INQ000309714.
This was a presentation that was delivered, as we can see on the screen, by Dr Sandifer to the HSSG planning and response group on 28 February. It provided an update as to the progression of Covid-19 in Wales.
Did you have any input into that presentation, Dr Williams?
Dr Chris Williams: I don’t recall, but it’s likely that I would have done through some of the update slides that we’d send round.
Lead 2B: If we could please have page 16 of this presentation. The second – sorry, the third and fourth bullet points read:
“• Estimated 10 fold increased demand with further widening of geographical area within Europe.
“• Estimated 100 fold increased demand to account for historic cases that will then meet possible case definition.”
In this case what does “demand” refer to? Is this the demand on Public Health Wales to conduct surveillance and containment on all likely Covid-19 cases?
Dr Chris Williams: I can’t recall exactly, but I think there was discussion about resources needed for contact tracing around this time and that may have been playing into this. The contact tracing is very resource-intensive and with a sort of exponential increase in cases, it becomes quite difficult.
Lead 2B: Did you agree that there was likely to be a tenfold and then a hundredfold increase in cases that needed to be contained?
Dr Chris Williams: I can’t recall this exactly. This – the second statement seems to be about changes to the – retrospective changes to the case definition, so yeah, I’m not sure that – I can’t remember the implication of this.
Lead 2B: At this point would it be fair to say it was almost certain that community transmission would become widespread, in the event it wasn’t already?
Dr Chris Williams: Yeah, I think that’s fair to say. And, as I say, through my experience from 2009, I didn’t think that containment and contact tracing was some – was a possible early means of containing an infection like this, particularly in a country such as the UK, and when we had continued travel and, you know, continued movement within the country.
Lead 2B: We can, please, look at the next page, page 17. So on this following slide it reads:
“Healthcare providers response.
“Future challenges.
“• Step change in magnitude of response required.”
So did you see the need for a step change in the magnitude of response once it was clear that containment would not last?
Dr Chris Williams: Yes. It was going to be a huge demand on the NHS, regardless of the impact on individuals, also just – just the isolation, testing, those kind of demands.
Lead 2B: Could we, please, have INQ000252365. Thank you.
This is an email thread on 29 February, so the day after the presentation we’ve just been looking at, regarding Public Health England modelling work. We can see that from the subject title.
Now, it’s an email chain between yourself, Andrew Jones, Deputy CMO, Quentin Sandifer, and Dr Orford.
Can we please look at page 2, and the bottom email is from Andrew Jones, who worked for Public Health Wales, to Dr Orford, and it says:
“Dear Rob,
“We have just come off the PHE IMT.
“PHE have reported, through Yvonne Doyle MD, that work on the modelling to inform scenario planning, ‘next stage guidance’ including on containment strategy, has been accelerated and will commence today.”
Then if we can just go up to the next email in the chain, so it starts at the bottom of page 1, it’s an email from Dr Orford in response:
“Thanks Andrew, this is very helpful. Please let me know if there is anything that you need from me in the interim. Happy to call if this is easier?
“We will continue stetting up a STAC and work on better sharing of intel. We will write to SAGE early next week informing them as such, including those involved. Once we have the secure shared drive and mailbox in place we will forward details.
“Have not received read-out from Thursday’s SAGE yet which concerns me!”
Then the next email in the chain, the next one above, is from Dr Sandifer, in the middle of that page:
“We should avoid calling it a STAC – it isn’t – and what we need is the same level of urgency as it seems is happening in PHE/DHSC.”
Now, do you agree, Dr Williams, that parts of Public Health Wales, HSSG, were not responding to the Covid pandemic with the same level of urgency as in Public Health England?
Dr Chris Williams: I don’t think that was necessarily the case. You say Public Health Wales, HSSG, so HSSG is a subgroup of the Welsh Government is my understanding. But, yeah, we were working certainly in the CDSC with a lot of urgency, and a lot of our work was directed towards – towards this.
Lead 2B: As we move into March, there was a COBR meeting on 2 March in which it was announced that contact tracing for the source of the last two cases of Covid in the UK had been unsuccessful and that there was sustained community transmission in France and Germany. So at that point was it not guaranteed that containment had failed?
Dr Chris Williams: Yes, I imagine so.
Lead 2B: Now, there’s nothing of this in the TAC minutes of 2 March. Does that suggest that TAC had either not been made aware by its counterpart scientists on SAGE before that was announced in COBR?
Dr Chris Williams: I don’t recall the discussions in TAC. My recollection from the time is that particularly up until the first lockdown we were really, as a UK, including Scotland, Northern Ireland, following a sort of UK Government and PHE-led response, so contain was part of the overall response. We could have had debate about – internally about whether it was working, whether the contact tracing was working, but there wasn’t really a sense that that was something amenable to change. This was the response. And even – you know, even now, I think that was fair. I think a UK response was the right thing at the time.
Lead 2B: So just going back to one of my earlier questions, when I think I asked you from your experience on the ground who had overall ownership of pandemic response in this early period, and I think you answered Public Health Wales, in light of what you’ve just said, would it not be fair to say that effectively ownership of pandemic response was being led by Public Health England, with the devolved administrations – we’re obviously focusing on Wales and Public Health Wales – sort of effectively following suit; is that fair?
Dr Chris Williams: For most of the major decisions I think that was fair, but of course we had to plan within the context of a Welsh NHS and our own systems, and I know my colleagues in the laboratory, for example, were working on testing, et cetera. So there were elements that were Wales-specific, but the overarching plan I think was a UK one.
Lead 2B: I now want to turn to a SAGE report. It’s INQ000224070. It’s entitled, as we can see on the screen:
“Low critical care capacity and high severity of Covid-19 mean there is little functional difference between successful ‘flattening the curve’ and ongoing containment.”
This was presented to SPI-M and SAGE. It’s, I think, first produced 9 March but then updated on 16 March.
If I can, please, ask for page 6, final paragraph, to be brought up.
I’m going to start reading from the end of the second line:
“The model results here do no more than reinforce the findings of the WHO China Mission and validate the strategy adopted by Chinese health authorities in or around the 23rd of January 2020; and then subsequently by Hong Kong, Singapore, Japan, and South Korea. We suggest that they are strong evidence with which to abandon mitigation strategies, justified in any way by the possibility of a short epidemic. Governments need to devote the entirety of their attention and resources to creating viable ongoing solutions to the presence of this virus. We suggest that the first step is to adopt stringent fixed-term social distancing so as to give time for detailed planning the rapid development and any accompanying technology.”
Were you made aware of this SPI-M paper, and if so when were you aware?
Dr Chris Williams: I don’t recall exactly when I was aware of it, but I can recall it was within a few days or maybe even the same day. My recollection is this represented a kind of shift in thinking in terms of the academic papers being brought to SPI-M from a strategy of mitigation, which was the flattening the curve, to a recognition that mitigation would actually be an untenable and catastrophic situation, and actually would probably result in the same sort of social distancing that a planned extreme social distancing by mandate would have done.
So I think this was – this Riley paper was the first one that really – in my recollection, that said we had to lock down, essentially, and soon, and that mitigation wasn’t really a viable strategy.
Lead 2B: So this was significant in shifting the opinions within TAG; is that right?
Dr Chris Williams: I think – I don’t – I can’t say for, within TAG as a whole group, but I think within – I had some indirect access to what was going on in SAGE and, I think, SPI-M at the time, and this shifted the viewpoints there.
Lead 2B: If we can, please, have INQ000251994 on the screen, please.
This is a TAC document titled “Covid – Technical Advisory Cell: Briefing on Behavioural and Social Interventions”. It was circulated on 11 March 2020. Looking at the second paragraph, first, please:
“There are a range of behavioural and social interventions that are evidenced as having been effective in responding to past epidemics. These interventions are well understood by the public and have been enacted in other countries.”
Then in the third paragraph:
“Applying behavioural interventions could be helpful in containing an epidemic to some degree or changing the shape of the epidemiological curve …”
Just pausing there, why “could be”?
Dr Chris Williams: Yeah, I have reviewed this document, it does come a few days after the Riley paper, although before the 16 March update. I don’t think the sentence is entirely clear. I don’t recall to what extent I would have had any contribution to that, but it’s …
Lead 2B: But you would agree “could” seems slightly odd in this paragraph?
Dr Chris Williams: Yes.
Lead 2B: If we can skip down to the sixth paragraph, please, at the bottom of this page:
“SAGE considered that measures relating to individual isolation will likely need to be enacted within the next 10 to 14 days to be fully effective, and those concerning household quarantining and social distancing of the elderly and vulnerable 2-3 weeks after this. However, the triggers for individual and household isolation could be met earlier depending on the progress of the outbreak in the UK.”
Then if we can go over the page, please, to paragraph 9:
“Modelling suggests that the stringent interventions introduced in Wuhan from 23 January … may have reduced the reproduction number to below one. However, there are differing views across the scientific community about whether other factors were involved in this.”
Just, again, pausing there, what was your view about the efficacy of the measures that had been implemented in Wuhan?
Dr Chris Williams: So I think measures in Wuhan and, to an extent, in northern Italy showed that it was possible to enact extreme social distancing to drive the reproduction number below 1 and actually suppress the wave, so I think it was empirically possible.
The debate that I can recall was around the modelling and scenario planning as to what might be possible within the UK, and, as I say, the thinking moved on from flattening the curve to realising that actually it was not only possible to enact a lockdown but actually it was necessary, to avoid terrible loss of life and an impact on wider society.
My impression of this document is it was – it was – it’s maybe a few days behind some of the – that SAGE thinking, but I couldn’t give you a day-by-day account of how those things went on.
Lead 2B: Just have a look at a couple more paragraphs, if we may, in this document. Paragraph 10 next, please:
“Hong Kong and Singapore are undertaking extensive contact tracing as well as a raft of social distancing measures such as school closures and self-isolation, but not to the same level of stringency as seen in Wuhan. There is also anecdotal evidence of extensive self-isolation by the general population. The roughly linear increase in the number of cases in Hong Kong and Singapore suggest that this approach has held the reproduction number around one.”
Then if we can, please, go over the page, to page 3, and look at the second bullet point:
“Home and work based distancing interventions have a greater individual impact. When combined self-isolation, household quarantine and social distancing of vulnerable groups and over 70s is predicted to lead to a 37% reduction in infection related deaths.”
Then finally, please, paragraph 13 at the bottom of this page:
“A combination of these measures is expected to have a greater impact: implementing a subset of measures would be ideal. Whilst this would have a more moderate impact it would be much less likely to result in a second wave. In comparison, combining stringent social distancing measures, school closures and quarantining cases, as a long-term policy, may have a similar impact to that seen in Hong Kong or Singapore but this could result in a large second epidemic wave once the measures were lifted.”
Just, again, pausing there, it’s right, isn’t it, that Hong Kong and Singapore had experienced their own coronavirus pandemic in the last 20 years, so they had experience of multiple waves; yes?
Dr Chris Williams: The SARS-CoV-1 – I suppose it was a pandemic but not in the same sense as, say, the 2009 pandemic, but they had experience of having to step up contact tracing and, you know, those sorts of interventions rapidly.
Lead 2B: Had they not modelled the impacts of second and third waves as well?
Dr Chris Williams: I don’t know what modelling they’d done at the time.
Lead 2B: Going back to this document we’ve just been looking at, over the page, page 4, paragraph 14, please:
“The timing of interventions would be critical.”
Then paragraph 16, please:
“These interventions assume compliance levels of 50% or more long periods of time. This may be unachievable in the UK population and uptake of these measures is likely to vary across groups, possibly leading to variation in outbreak intensities across different communities.”
Can you help us, where did that assumption come from, namely that a compliance level of 50% may be unachievable in the UK population?
Dr Chris Williams: I don’t know where that would have come from. As I say, the arguments you presented here in this paper are sort of a mixture of the pre-Riley paper about flattening the curve, there’s the point about not putting in too many interventions, otherwise you’ll get a second wave, but then the one above that you presented shows about the ICU surveillance figures, which was actually part of the mechanism for the repeated lockdowns that Riley was advocating and then Ferguson’s paper after that.
Lead 2B: As a summary, by 11 March 2020, would it be fair to say the following things: the timing of an NPI would be critical, as is stated in this paper; you would agree?
Dr Chris Williams: Yes.
Lead 2B: Early intervention led to quicker results?
I’m afraid if you nod, we can’t pick up your answer.
Dr Chris Williams: Yes.
Lead 2B: Thank you. A combination of stringent NPIs, so home and work-based distancing interventions, self-isolation, household quarantine, social distancing of vulnerable groups, was likely to result in a 37% reduction in deaths?
Dr Chris Williams: Again, that came from the pre-Riley assumptions. I think that was not sufficient actually to suppress the epidemic, so this isn’t suppression, that’s a flattening the curve statistic in my recollection.
Lead 2B: I understand. Lockdown in Wuhan was effective?
Dr Chris Williams: Yes.
Lead 2B: Stringent NPIs in Hong Kong and Singapore also were effective?
Dr Chris Williams: Yes.
Lead 2B: The ideal outcome would have been to flatten the curve and push the epidemic into the summer months?
Dr Chris Williams: I’m not sure. Are you asking whether I think that now or whether that’s an implication of the paper?
Lead 2B: Whether at the time that would be – that would have been something that could have been safely assumed or thought.
Dr Chris Williams: I’m sorry, I can’t – I can’t really answer that.
Lead 2B: Bearing this in mind, and what we can see from this paper, why was lockdown not recommended by TAC at this point? So this is 11 March 2020.
Dr Chris Williams: So, again, this is on my recollection, but I have gone back and read some of the papers and done some further thinking, so it is with the benefit of that. My recollection, as I’ve said before, is that the overall strategy that we were following was a UK strategy, that the chief medical officers had made an agreement that they were going to attempt to do the same thing at the same time, except where there were specific reasons for a different response, because of differences in the NHS structure or whatever. So we were following a UK response.
My recollection – and TAG would have reflected the discussion and the thinking within SAGE. My recollection that the 13 March SAGE meeting, there was a consensus that lockdown was necessary. There may be need for repeated lockdowns, et cetera, but actually that there needed to be extreme social distancing to suppress the epidemic and prevent really severe impacts on the population.
And my recollection that after the previous papers about flattening the curve, that certainly by that 13 March meeting, that there was a consensus within SAGE, albeit although I wasn’t a member, so you maybe better ask people within SAGE, but that’s what they were recommending at that time, and I would have thought that TAG and the Chief Scientific Adviser would have echoed those views because that’s the way that we were operating.
Lead 2B: Now, I’ll – we’ll come on to that 13 March meeting in a moment. Just, though, hearing what you’ve said, that effectively it would have been impossible to have locked down without UK Government co-operation; is that fair?
Dr Chris Williams: I mean, I can’t say exactly how it would have gone, but I don’t think it would have been feasible.
Lead 2B: Do you not still think TAC should have at least considered locking down and advised the Welsh Government on locking down, leaving aside the practicalities or the relationship with the UK Government and what had been agreed at CMO level?
Dr Chris Williams: I suppose we could have considered doing that as a group, but recalling that the change in the thinking within the SAGE and modelling groups that we were relying on was only happening around this time.
Lead 2B: Could we please have INQ000271443 displayed. Thank you.
This is TAC’s briefing on behavioural and social interventions. We understand this to be dated 11 March.
If we have a look at point 4, please:
“The objectives of these interventions could be to:
“• Contain the outbreak so that it does not become an epidemic (note – this is [likely] to be [unachievable]).”
Was considering the possibility then of containment completely unrealistically about this date, namely 11 March?
Dr Chris Williams: Yes, I think that’s – that’s how it would be.
Lead 2B: Looking then at the next paragraph, paragraph 5, please:
“Any intervention would need to be Government policy for a significant duration (2-3 months) in order to see the benefit, as removing and/or relaxing the intervention too early could result in a new outbreak and potentially extend transmission of the virus into Winter 2020.”
Am I right in thinking that what this is saying is: go too early and the peak of infections might simply be displaced to a worse time of year?
Dr Chris Williams: So the first part of the sentence is correct, that any serious intervention would need to be done for significant duration. It’s also true that removing, relaxing it could result in a new outbreak. Reading it now, it looks like a mixture of the two forms of thought at the time, but essentially for a lockdown to work you have to implement it for a sufficient amount of time so that you know you’ve suppressed the virus and then you can then be sure that the levels are low once you’ve finished. What then happened after that is something that modelling might predict, but you don’t really know at the time.
Lead 2B: I understand. But does –
Lady Hallett: Mr Poole, just before you go on, I’m really sorry.
You said – am I right in thinking your question was: am I right in thinking that what this is saying is “go too early and the peak of infections may simply be displaced to a worse time of year”?
That’s not how I read it. I read it: because any intervention has to be two to three months long, then you don’t want to go too late because otherwise you risk going into the winter months.
That’s how I read it. So I read it the opposite way from you.
Mr Poole: Well, my Lady, perhaps we can put that to Dr Williams.
Lady Hallett: Which is the correct reading?
Dr Chris Williams: I have to confess I’m slightly confused by this paragraph, because it seems to be a mixture of flattening the curve and suppression, which was then moved on to.
The problem with the – was thought at the time was that suppression would work, so you put in interventions for two to three months, you would stop the epidemic for that time, but then after a while you would get a second infection and then you would either have to lock down again or you would get a further wave.
My also recollection is from the Riley paper and others that they predicted that it would come back every two to three months, actually even more frequently than that, which wasn’t actually the case in summer of 2020, so it took a longer time for the second wave to come around than they predicted.
Mr Poole: Is it right that this is predicated on the fact of there being sort of, effectively, only one lockdown? It doesn’t contemplate, does it, two or three successive lockdowns at specific intervals?
Dr Chris Williams: So as I’ve said, the Riley paper from the 9th was starting to contemplate the idea of repeated lockdowns or at least the first lockdowns. I can’t remember when the second paper came out but it actually did model repeated lockdowns. But this was around the time that that thinking was changing, so that might be the reason that this document is maybe a mixture of those views and was still reflecting the ideas of kind of flattening the peak, and also being concerned about not suppressing the peak because then you would get another peak but it would come in winter, when we would have the flu and other things at the time. I think the idea of lockdowns was quite far from practice in people’s minds and the idea of repeated lockdowns was even – even further away. So maybe that’s why the thinking was along those lines.
Lead 2B: If we can, please, have a look at, I think it’s page 6 of the document we’ve got in front of us, we can see there some of the modelling that was done, and I want to look – it’s not – certainly if you’re colour blind you won’t be able to follow this but I think you can just about see it, it’s – I’m looking at the grey dashed line.
Dr Chris Williams: Yeah.
Lead 2B: Is it right that that represents, looking at the key, school closures, case isolation, household quarantine and social distancing of the entire population?
Dr Chris Williams: Yes.
Lead 2B: So it is the scenario most like what we saw enacted over a week later, which we’re coming on to in a moment. Yes?
Dr Chris Williams: That’s right, yes. So the SD is the additional social isolation.
Lead 2B: Yes.
Dr Chris Williams: And it shows a flatten – it’s suppressed the first peak completely, but then you get a much larger peak, it predicts, actually into the summer.
Lead 2B: Is that because, as you’ve just described, a sort of reduction in case rates by mid-May and then suddenly a number of cases sharply increasing, is that because the model assumed that the set of restrictions would be lifted effectively all at once and then case numbers would increase in the population at that point?
Dr Chris Williams: I can’t remember the exact assumptions but there would have been something relatively simple like that, but yes, we assumed that – restrictions in place for X amount of time and then either gradually or immediately removed.
Lead 2B: Can you recall, did anyone ask about – going back to my previous question – multiple lockdowns or the staggered releasing of restrictions, or were those questions that were not being asked at this time?
Dr Chris Williams: I think the staggered release of restrictions – I can’t recall exactly what the modellers did, but they would have probably tried to put simple on/off things within the models, at this stage certainly. They – I think they were modelled later with staggered restrictions. And the idea of repeated lockdowns was I think the paper after this, when – again, I can’t recall exactly but I’m sure there were papers from Riley and papers from Ferguson, probably Edmunds’ group as well, showing what would happen if you lock down for a period and then you used good surveillance to watch until there were a certain number of cases emerging, I think in intensive care, and then you locked down again based on that number. So those were the models they were starting to run a little bit after this paper.
Lead 2B: Now, on 12 March the UK Government announced that from the following day, 13 March, those with coronavirus symptoms, either a new continuous cough, high temperature, should stay at home for at least seven days, and all those over 70 and those with serious medical conditions also advised against going on cruises.
Now, obviously that announcement fell short of a mandated lockdown. What warning were you given, Public Health Wales given or yourself or TAC given, ahead of that announcement by the UK Government?
Dr Chris Williams: I beg your pardon, is that 13 March?
Lead 2B: This is the announcement on 12 March, with the restrictions coming into effect the following day. What warning, if any, were you given about that announcement?
Dr Chris Williams: I don’t recall being given any warning.
Lead 2B: Were you surprised that an announcement like that would be made without your input and without any prior warning?
Dr Chris Williams: I can’t recall if I was surprised or not. I think I was surprised that it wasn’t a more – a more complete lockdown.
Lead 2B: At this point, so we’re now 12 March, was the scientific consensus in Wales in favour of restrictions being imposed only and no further, or in favour of an immediate lockdown, to your recollection?
Dr Chris Williams: My recollection, as far as it goes, was that we’d thought that – given all of the preceding papers, that by that 12 March that there would be a UK-wide mandated full lockdown, given the sorts of warnings that were given in the Riley and the Ferguson papers.
Lead 2B: Given that that was your view and, I think I’m right in saying, a sort of scientific consensus view by 12 March, and you were surprised that the 12 March announcement hadn’t gone further, did you speak to anyone about this? What did you do?
Dr Chris Williams: I can’t recall exactly my verbal or written communications at the time. As I say, my – my understanding at the time was that we were working as a four nations, as a UK-wide response, and it would have been very difficult to lock down in Wales and not lock down in England, and certainly we found subsequently – you know, there’s a lot of movement across the border – it only really works properly if there’s a UK-wide intervention.
Lead 2B: You’ve said earlier that you worked quite closely with Dr Orford, the Chief Scientific Adviser for Health in Wales, I mean, at this stage, did you raise your concerns with Dr Orford, can you recall?
Dr Chris Williams: I don’t recall whether I raised them in a written format. I think it’s probable that if we’d had any telephone meetings or similar at the time that I would have expressed surprise that that was the response.
Lead 2B: I think it would be fair summary to say that between this date, 12 March, and 20 March, those on TAC were becoming increasingly concerned about the approach being taken in Wales to the pandemic. If I can just anchor that in perhaps a point in time, on 15 March TAC authored a paper for the SAGE meeting that was to take place the following day – I don’t want that paper pulled up, please – it’s TAC’s recommendations for the Welsh Government, and the executive summary reads:
“TAC group recommends that unless the requisite resources [resources for the NHS to prevent it becoming overwhelmed] are identified in the next seven days, with a clearly defined plan to implement them in a timely manner a policy of more stringent interventions should be considered for Wales.”
Why was that your advice or TAC’s advice at that time?
Dr Chris Williams: I think that was to do with the NHS capacity, that it would need to be greatly augmented if we were going to have a big wave.
Lead 2B: So was there a concern that unless more stringent interventions were immediately put in place, then the NHS in Wales risked being overwhelmed?
Dr Chris Williams: Yes, that was a concern at the time.
Lead 2B: Do you think, looking back, that that advice was – went far enough?
Dr Chris Williams: I suppose even after – even at the time I did wonder whether we, including myself, could have done more to argue for an earlier lockdown, given that the UK-wide lockdown didn’t happen when we thought it might have done. The only other thing I would say is that we were ever so slightly behind the epidemiology in England, so actually the case numbers were maybe a week or something behind the numbers in England, and there was – you know, there was rationales for timings of lockdowns, but yes, I was – I have wondered about whether we – I should have argued harder for something to be done, but I’m not sure it would have made an awful lot of difference.
Lead 2B: Doesn’t being, epidemiologically, a week behind, doesn’t that, in fact, give Wales sort of effectively a head start, it would allow Wales to get ahead of the curve?
Dr Chris Williams: You need to time the lockdown so that you don’t – I think – I recall, you know, John Edmunds’ testimony is you don’t go into lockdown when there’s just only one case, because that’s clearly too early, but then when there are too many cases that’s too late, so somewhere between one and the other. And the papers were arguing for earlier lockdowns. I don’t know exactly how that timing would have worked for Wales, but, as I say, at the time, it – just wasn’t aware that it was an option.
Lead 2B: Now, five days later on 20 March TAC was asked to commission a paper on lockdown measures and then a TAC advisory paper was published on 23 March, which again advised on – it was entitled “Lockdown and release strategy”. So that appears to be the first formal interrogation by TAC into national lockdowns; is that right? Is that your recollection?
Dr Chris Williams: I would have thought, given that there was the feedback between SAGE meetings and TAC, that some of the other papers and repeated lockdown papers would have been discussed within TAC but maybe that’s the first time it was formally put down on paper.
Lead 2B: Was TAG and TAC consulted on the ultimate decision to lock down on 23 March?
Dr Chris Williams: I don’t recall the discussions being of that variety, but yeah, I just – I don’t recall, you’d have to ask them about the minutes.
Lead 2B: In your view, should Wales have locked down earlier in March 2020?
Dr Chris Williams: So my view is that the UK should have locked down earlier, and ideally, you know, on 12 March or possibly even earlier than that, because of – partly because of what the modelling was saying in terms of the timing of a lockdown in relation to the impact, and also partly because we had evidence that it would work, from, you know, Wuhan and Italy.
Lead 2B: What would the impact of an earlier lockdown have been on later waves?
Dr Chris Williams: It’s very difficult to answer that. I think it would have reduced the impact on the first wave in terms of hospitalisations and deaths. However, it might have been that there would have been a rebound effect over the second wave, and we did see that to an extent, that we were actually slightly less impacted relative to population in the first wave but then slightly more in the second wave. This is from some of my subsequent reading of the figures from the time. So there was an extent to which what you don’t get in one wave you do get later on, unless it’s a very well enacted and early suppression the second time.
Lead 2B: Now, Dr Williams, I just want to change topic, if I may, and ask you some questions about asymptomatic transmission of Covid-19. Again, I want to try to take this chronologically, if I can.
What did you know about asymptomatic transmission in early January 2020?
Dr Chris Williams: So, again, I’m not sure it would have been something that I thought about greatly, but I can say that professionally I would have assumed that there was likely to have been asymptomatic infection, and this is just from my experience of other respiratory viruses. I know SARS-CoV-1 didn’t generally have asymptomatic infections but SARS-CoV-2 does and influenza certainly does. Whether those asymptomatic infections were detectable by testing and whether they were transmissible is a separate question.
Lead 2B: I think on 29 January you and your colleagues at Public Health Wales received an email from Public Health England attaching a paper on asymptomatic transmission. Again, I’m not going to ask for it to be displayed, but that paper, if you recall it, outlined early credible evidence of asymptomatic transmission from an individual in Germany who appeared to have been infected through her asymptomatic parents. Do you recall this paper that I’m talking about?
Dr Chris Williams: Yes.
Lead 2B: And the paper concluded that “The currently available data is not adequate to provide evidence for major asymptomatic/subclinical transmission of 2019-nCoV”, but that there was evidence of small-scale anecdotal asymptomatic transmission.
Was it your view as an epidemiologist that it is better to keep an open mind about transmission possibilities?
Dr Chris Williams: I think in general, it is. What you don’t know is to what extent they play a role in terms of the transmission of the infection, so something may be possible but not a major factor or it may be possible and a major factor, and it’s hard to tell, particularly early in the phases.
Lead 2B: Was it your view that the best approach would be to assume that asymptomatic transmission was taking place?
Dr Chris Williams: I can’t really answer that. You have to think about also the implications of assuming asymptomatic transmission, which would – given the case definition at the time was “travel from China or Wuhan with symptoms”, you’d then quite quickly shift that to “anyone who’s travelled from China”, which I don’t think would have been very feasible in terms of follow-up, and probably you would have then had to think about, you know, what would the next step be. So maybe that’s the light in which it was considered.
But yes, it’s always worth considering on the precautionary basis what might be transmission routes.
Lead 2B: Moving forward chronologically, then, so that was a paper that was shared with you on 29 January. On 17 February 2020, the Diamond Princess asymptomatic cases were discussed in a SAGE meeting. Do you recall discussing the evidence of asymptomatic cases on the Diamond Princess in TAC?
Dr Chris Williams: I don’t recall those discussions in TAC. I’m sure there would have been – we’d got reports from the Diamond Princess through the PHE meetings, I’m sure there would have been some at least information on that, but I don’t recall discussions in TAC.
Lead 2B: If we can, please, have INQ000119469 on screen.
This is minutes of a NERVTAG meeting of 21 February 2020.
If we could, please, have page 6, at paragraph 3.4. Thank you.
“NF noted that there were a few modelling groups estimating a higher infection rate when comparing case populations in Singapore, South Korea and Japan, this suggests that at least a third have been missed. JE commented on this after the meeting taking into account the issue of asymptomatic cases, where the evidence suggests that 40% of virologically confirmed cases are asymptomatic.”
Do you recall being informed of this?
Dr Chris Williams: I don’t recall that particular – I wasn’t on NERVTAG or received the minutes from NERVTAG, but I’m sure the figure of the – from what was happening in the Diamond Princess was probably reported elsewhere.
Lead 2B: So by late February, were you and your colleagues aware that asymptomatic transmission was taking place, and the extent of asymptomatic transmission could be as great as 40%?
Dr Chris Williams: As I say, I can’t recall, but I’m sure it would have been part of the thinking.
Lead 2B: Did TAG or TAC formally advise the Welsh Government at this point, in late February, about the potentially very high rates of asymptomatic transmission?
Dr Chris Williams: Again, I can’t – TAG – as I’ve mentioned earlier in my statement, TAG was one of the things that I was involved in. My role was mainly to give epidemiological updates, and my main role was within Public Health Wales, so I don’t recall absolutely all the discussions in TAG at the time unfortunately.
Lead 2B: Dr Williams, I’m going to change topic again and talk to you next about, first, discharge of patients from hospitals to care homes and also then testing of care home staff.
Now, as I’m sure or you may be aware, there is a later module of this Inquiry that is going to be looking at the care sector, but within this module we are looking at high level core Welsh Government decisions that might have impacted on the care sector.
Were you involved in providing any advice about discharging patients from hospitals to care homes in February to April 2020?
Dr Chris Williams: February to April … not … not that I can recall between February and end of March, no.
Lead 2B: Is it right that you have subsequently worked with colleagues to address the question of transmission to care homes from these discharges, so namely discharges from hospitals to care homes?
Dr Chris Williams: Yes.
Lead 2B: That work, am I right in saying, has largely confirmed that transmission to care home residents was driven by their exposure to the community through staff rather than from hospital discharges; is that right?
Dr Chris Williams: That’s the broad conclusion. I just want to caveat that by saying that of course it’s possible for care home residents from discharges, particularly early in the pandemic, to have then gone on to cause transmission within those homes, I’m not arguing at any point that that wasn’t a possibility. We just felt that there was a bigger risk, and an ongoing risk, from the community to staff to the care home, and that was something that was potentially amenable to change, and that’s why we did this work.
Lead 2B: So from the point of view of care home outbreaks, the testing regime of care home staff and residents was important in terms of saving lives, possibly more important than the policies around discharge from hospitals; is that fair?
Dr Chris Williams: I think it was – I think it’s the whole package of what you would do around care homes, how you would support the staff, how you would support the work within – the infection control and things like that within the care home, rather than simply the testing policy versus – within staff versus the testing policy on discharges.
Lead 2B: Can we, please, have INQ000228309 displayed. Thank you.
Now, this is an email chain, it covers 31 March through to 1 April. It’s between Dr Thomas Connor, yourself, Dr Orford and other members of TAC.
Just by way of context, Dr Connor has circulated a paper on nosocomial outbreaks and, given the spread of outbreaks observed in a hospital in late March 2020, the issue was raised as to how effectively you could test healthcare workers to ensure that positive cases of Covid were caught.
So just with that context, if we can go, please, to page 2 of this email chain – I’m grateful – at the bottom email.
It’s an email from Dr Connor, yes, on 31 March, 22.41. Then over the page, it goes to page 3, paragraph 4, I’m grateful, yes:
“Just thinking in terms of timescales the potential for routine testing to have picked this up is very contingent on how that testing regimen is designed. In this case we have a cluster of 50-70 cases who all flagged positive within 7 days of the suspected index case. That to me suggests that one implemented something like weekly testing would be critical in catching something like this early. I would think that if a portion of staff tested every day then detection that there is a problem on a ward might be possible. But, say, testing everyone once a week could conceivably have missed basically all of the transmission here. So to me the message is to design routine testing well, taking into account the observed timescales in AB and understanding that such testing has to be rapid to be useful.”
AB being the hospital that I referred to when giving context to this email chain.
Then if we can, please, go at page 2, to the top email.
This is your reply of – on 1 April. I’m looking at the second paragraph, five lines down, starting:
“On regular testing I was thinking of a different scenario, whereby healthcare workers could be infected at home rather than the ward. Agree that only daily testing would be secure, but weekly testing would help to give routine reassurance and also set up a rhythm and acceptance of testing and self-consideration of symptoms. Of course you can be unlucky with this too and miss a whole week, but I think it could work and I think have seen that it’s been used elsewhere (will check).”
Now, you say there “self-consideration of symptoms”. Did you consider the role of asymptomatic transmission when considering this advice, Dr Williams?
Dr Chris Williams: I believe so, yes. So this was the email – the outbreak that Tom refers to was one in Aneurin Bevan that actually my team had investigated initially and we found this number of cases and then Tom had added on to that with a genomic analysis to try to work out what the chains of transmission were, and this was then leading into a discussion about how healthcare worker testing might help mitigate the transmission in hospitals both between staff and patients, patients to staff, but also to staff at home. So we started to discuss the timing of that, and how you would optimise it.
You also have to remember about the performance of tests and things like that.
Lead 2B: Would it have been more prudent to advocate for testing more frequently than once every seven days, as Dr Connor has done?
Dr Chris Williams: I think we were both arguing – I think we were both discussing whether weekly testing would work and how many it would miss and what pattern you would use, rather than that he was arguing for daily testing and I was arguing for weekly.
Again, the – because – I think it was in the understanding of the asymptomatic cases, and the fact that healthcare workers do tend to carry on working even if they’ve got mild symptoms, or sometimes with severe symptoms, and actually I think what I was trying to say here was that giving people the test and then it turned out to be positive maybe before symptoms would at least give them the rationale that they would not then go to work whilst infectious. So there’s quite a lot of things going on here.
Lead 2B: Was it your view that there needed to be some routine testing, then, of healthcare workers at least once every seven days?
Dr Chris Williams: That’s my recollection, is these email chains would allow me(?) time to argue for that.
Lead 2B: On the same day, about two hours later, you email Dr Orford.
If we could, please, have INQ000224062 on the screen. Thank you.
You emailed Dr Orford – this was a CDC study about the high proportion of healthcare workers testing positive for Covid-19, and care homes, who were asymptomatic.
As we see there, the email at the top of this page:
“Will try to discuss this offline with Robin. Whilst it is true that the NPV of the test is low, it is also true that potentially a high proportion of those testing positive (and therefore likely shedding) are asymptomatic (see below in context of care homes). It is also true that HCW will continue to work whilst symptomatic despite guidance.”
Then email from Dr Orford slightly above that one, please, says:
“It would be good to understand if there is more data out there on higher intensity testing of HCWs. Also it is a risk based approach to mitigate nosocomial outbreaks – whilst it may have a low pick-up it might have a ‘marginal gain’ and also a psychological barrier for HCWs.”
What did you understand by Dr Orford’s response? What did you understand that to mean?
Dr Chris Williams: I think I was – I think I was arguing for routine testing of healthcare workers so you could pick up both pre-symptomatic, mild symptom and asymptomatic infections, and Rob is just asking if there’s more evidence on this. I don’t know about the “marginal gain”. The negative predictive value point is that, when there’s little infection around – well, there’s a lot of infection around, that negative tests might not necessarily mean that that person is negative, so it might provide false reassurance, but I don’t know exactly what he means in that second sentence.
Lead 2B: Perhaps to summarise then what was known, what you knew by 1 April, you knew it was essential to routinely test healthcare workers to avoid transmission to patients; yes?
Dr Chris Williams: I wouldn’t say I knew it was essential but I was suggesting that might be a means of preventing transmission, yes.
Lead 2B: I understand. Symptom-based screening alone would fail to identify Covid-19 cases?
Dr Chris Williams: That’s what I thought, yes.
Lead 2B: So routine screening of everyone, so symptomatic and asymptomatic, was really the only effective way to avoid transmission of Covid-19 from staff bringing community infections into a care home; is that right?
Dr Chris Williams: I think that was part of my thinking. I mean, it’s a very complex area, but yes, to pick up those asymptomatic infections you needed a test.
Lead 2B: If asymptomatic transmission accounted for up to 40% of Covid cases, testing symptomatic individuals only could miss up to 40% of outbreaks on any one day; is that –
Dr Chris Williams: Yes.
Lead 2B: And if some healthcare workers would continue to work whilst symptomatic, even more infections would obviously be missed; is that right?
Dr Chris Williams: If they were symptomatic they wouldn’t necessarily be missed, someone would know about them. But, yeah.
Mr Poole: I’m grateful.
My Lady, I’m not going to quite finish this topic, so this might be an appropriate time for a break.
Lady Hallett: Certainly. 11.30.
(11.13 am)
(A short break)
(11.30 am)
Lady Hallett: Mr Poole.
Mr Poole: Dr Williams, we were just talking about the position as at 1 April. I just want to move forward a few weeks to 17 April, and there was a Public Health Wales Strategic Coordinating Support Group meeting on that date.
You provided an update on the situation in care homes. You said 300 care homes are reporting Covid-19 activity, roughly 25% of care homes in Wales. Then your colleague from Public Health Wales provided some further information and said:
“To date 322 of 1,302 registered care homes in Wales have reported Covid-19 activity. A total of 153 cases have been confirmed. Since 9th of April, Public Health Wales have been offering testing of symptomatic and asymptomatic staff. There is a 62% positive iterate of staff tested.”
Was this a policy that had been rolled out across all care homes in Wales, to your knowledge, with mandatory testing, or was it being offered – provided only to care homes as and when outbreaks emerged?
Dr Chris Williams: My recollection, it was for outbreaks.
Lead 2B: A 62% positivity rate for staff tested must have been very concerning?
Dr Chris Williams: That is a high rate, yes.
Lead 2B: Of those tested, more care home staff than not were positive for Covid, 62%?
Dr Chris Williams: It’s over 50%, yeah.
Lead 2B: Given the number of outbreaks in care homes across Wales at that time, coupled with what we’ve just discussed about your knowledge of asymptomatic spread, did you think that roll-out of mandatory testing of all staff and residents should take place at that time?
Dr Chris Williams: I don’t recall what my views were at the time. I think there was a meeting the following day that moved things on a little bit, but no, I don’t recall.
Lead 2B: Taking a look at what was happening in England, on 14 April the UK Chief Medical Officer’s advice was that testing within care home settings was a priority, following concern highlighted by a study of 29 care homes by Public Health England, and then on 28 April in England the Department of Health announced extending testing to all residents in care homes irrespective of symptoms.
There was a ministerial advice on the scaling up of testing in care homes that was provided to Vaughan Gething on 30 April.
It’s INQ000116607. Which is up on display, thank you.
Did you contribute to that ministerial advice?
Dr Chris Williams: I don’t recall that I did, no.
Lead 2B: Perhaps we can just have a look, then, at page 4, paragraph 16, under the “Impact of asymptomatic care home residents” reads, first bullet point:
“A pilot study recently undertaken by PHE in six care homes in London that reported an outbreak tested all residents and staff groups. Preliminary results from one care home with over 100 residents investigated at an early stage of the outbreak in the home, 75% of residents were positive for COVID-19 but only 25% were symptomatic. 50% of staff were positive but only 29% of these were symptomatic …”
Then if we can, please, go to page 5, paragraph 21. Paragraph 21, thank you.
“Discussions with colleagues in Welsh Government and PHW indicate that testing of asymptomatic (or reportedly so) care workers would help to prevent introductions into care homes, and also provide an estimate of community incidence of COVID.”
Then, please, paragraph 23, bottom of the page, thank you.
Under “The Options”:
“There are limited options. Do nothing is not [an] option. Expanding into asymptomatic individuals still lacks the evidence base to support this being the best use of testing capacity.”
So by this point, there was peer reviewed evidence in favour of routine testing in care homes from that CDC study one month prior. Do you agree with the statement that there wasn’t an evidence base to support mass testing that we see in this document?
Dr Chris Williams: I don’t think that’s – I don’t think that’s correct in this – (inaudible) the question. So the CDC paper found that there was asymptomatic infection but it didn’t necessarily advocate for routine testing of asymptomatic staff. I think a follow-up paper and then editorial in the New England Journal later in April, I think, before this but after the previous ones, started to advocate for regular testing. However, there wasn’t evidence, ie trial evidence, showing that if you took X number of care homes and tested all of the staff and residents and then you took some care homes and didn’t, that actually this would improve outcomes. So I wouldn’t say that there was strong evidence but on the precautionary basis I think I was advocating for some kind of routine testing of staff, through my sighting of the paper on 1 April and also some documents on the 18th.
Lead 2B: I understand.
Is it a fair interpretation that the reference here to the “best use of testing capacity” that there were capacity issues with testing and so the advice was perhaps to prioritise their use elsewhere, so in hospitals and for symptomatic key workers?
Dr Chris Williams: Having reviewed this document, which I don’t recall seeing at the time, but having reviewed this document, it does seem to make mention of capacity. I think there’s also a reference to 25,000 tests or something like that, in relation to residents and capacity.
Lead 2B: Just finally on this topic, annexed to this ministerial advice is a document titled “Summary of discussion on prioritising tests for care homes” – sorry, INQ000116607, if that could be displayed, please, page 10.
This document proposed prioritising blanket testing of symptomatic and asymptomatic staff in certain care homes, those with an outbreak, Covid-free homes, struggling homes. And in this annex it is noted, I think it’s page 11, paragraph 2 – if we can see that, please.
“FA [this is Dr Atherton] indicated that it would have been helpful to have this information earlier as it had caused enormous issues in Wales. Proved very difficult situation as the media had picked this up as a very significant divergent of policy.
“There was a 4 nations group on testing but Wales did not seem to be fully plugged in.”
In your view, insofar as you can answer, as you weren’t sighted on this paper at the time, was Dr Atherton fair when he said that Wales was not fully plugged in on this issue?
Dr Chris Williams: I wasn’t a member of the four nations testing group, so I can’t really comment on that.
Lead 2B: Dr Williams, changing topic and briefly touching on the question of face masks, face coverings, that was obviously one area where there was a difference of opinion between the four nations. I’d just like to ask you a few questions about this.
On 11 May the UK Government advised the public to consider wearing face masks in enclosed public spaces. And in terms of what we know happened in England (on 5 June, face coverings were required in hospital settings, on 15 June they were required on public transport, and then 24 June they were mandatory in shops and supermarkets), on the other hand face masks only became mandatory on public transport in Wales on 27 July and in shops and other public spaces on 14 September.
Now, there is a TAG advice dated 8 June 2020, I don’t need to go to it, but it did not explicitly advise that masks be mandated in public, and on that same date Dr Atherton advised the First Minister on this topic and he said:
“I remain of the view that the evidence of benefits does not justify a mandatory or legislative process and I still see dangers in taking such an approach in Wales.”
Did you agree with that advice?
Dr Chris Williams: I can’t recall at the time but not necessarily, no. I think I put in my witness statement that I thought that it might be worth a try, masks, even in the absence of good evidence, knowing that it’s very hard to get definitive evidence for an intervention such as face coverings.
Lead 2B: As you say, I think you say in your witness statement, on face coverings:
“… I can recall arguing verbally (in TAG) in favour of their use, even in the absence of evidence …”
That’s right?
Dr Chris Williams: That’s correct, yes.
Lead 2B: Moving then to another topic, again fairly briefly, just superspreader events.
The Six Nations men’s rugby match between Wales and Scotland, as we’ve heard earlier, was due to take place on Saturday 14 March 2020. Welsh ministers declined to intervene to stop that match and the Welsh Rugby Union ultimately took the decision to postpone the match at lunchtime on the day before, but by which time 20,000 Scotland fans had already arrived in Cardiff. There were also two Stereophonics concerts on 14 and 15 March held in Cardiff.
Now, your views, expressed in a briefing to TAC around 10 March, was that the modelling evidence did not show a major impact of mass events on overall transmission.
Do you stand by that advice?
Dr Chris Williams: I think that’s certainly what the modelling was showing at the time. I still think that mass events don’t generally have a huge impact on transmission, because there’s a lot of transmission going on elsewhere. But of course it doesn’t mean to say, as with my previous answer, that transmission can’t or doesn’t happen at mass events.
Lead 2B: Now, one of the reasons the Wales and Scotland match was not cancelled was, as I understand it, due to a concern about socialising displacement, so people going to more pubs and restaurants if the match was cancelled.
Now, in light of what we know about voluntary reductions in contacts and socialising in mid-March, do you think those concerns were well-founded?
Dr Chris Williams: I think the concern that transmission could happen better in closed environments like, you know, pubs and restaurants was correct.
Lead 2B: Are you able to assist at all with what might have happened to Covid-19 community caseload progression in Wales in March 2020 had those events not proceeded?
Dr Chris Williams: I couldn’t – couldn’t say how it would have changed things. I think evidence from some – some evidence of low effects from mass events and some evidence – I think there was one in Scotland where there was quite a large impact on transmission, but you have to look at the circumstances in the particular events.
Lady Hallett: There’s also the impact on public behaviour, isn’t there?
Dr Chris Williams: You could see it as part of a wider –
Lady Hallett: You allow a mass event to go ahead, it gives the public the message “Everything’s fine”.
Dr Chris Williams: I agree, and, yes, that should be a consideration.
Mr Poole: Dr Williams, finally, and again a slightly different topic, about school closures, if I may.
You briefly mentioned school closures in your evidence, and in your witness statement at paragraph 118 you say:
“Regarding schools I thought it was important to set the risks here in context given the relatively low severity and burden in children and the negative effects of school closures.”
What, in your view, were the risks to children in schools?
Dr Chris Williams: I think the risk of infection, severe outcomes in children was low, and that was reasonably well recognised at the time. I have children of my own and I know that the effect of them not going to school might have been damaging to their education and other parts of their social development, and I also knew that there were a lot of concerns about transmission in schools, both driving the epidemic and also within – across the workforce.
Lead 2B: In the passage I think we’ve got on the screen, in paragraph 118 of your statement, what do you mean by setting the risk in context?
Dr Chris Williams: I think in the context of what the risk was in the rest of the population, that I think I was concerned that maybe schools were seen as a sort of magic bullet to – you close the schools you can really nip some of the transmission in the bud, and that’s partly based on the experience of flu, where we know that children play a large role in transmission of influenza, and with other infectious diseases. But I think – I thought it ought to be balanced with the knowledge that the outcomes were generally pretty good in children.
Lead 2B: And how were the risks assessed for schoolchildren in Wales?
Dr Chris Williams: As I say, we set up a report to try to report on the numbers of cases in both schoolchildren and also in staff, to try to say what they were, and also compare them to the incidence and the indicators in the local authority population at the time, just to make that comparison.
Lead 2B: Again, looking at this paragraph of your witness statement, what do you mean by the “negative effects of school closures”?
Dr Chris Williams: So, in addition to the effects on the students themselves, I think there was also a recognition that closing schools has a big impact on parents, particularly there was concern about healthcare worker parents and other sort of staff that then wouldn’t be able to go to work because the school was closed, so I think that was part of the wider considerations, but … yeah.
Mr Poole: Dr Williams, those are all the questions I have for you.
I think there are some Rule 10 questions, my Lady.
Lady Hallett: I think, Ms Heaven, you’re asking some questions.
Ms Heaven: Yes.
Questions From Ms Heaven
Ms Heaven: Good morning, Dr Williams, I represent the Covid-19 Bereaved Families for Justice Cymru.
Just two topics, please. I want to come back very briefly to face coverings and then the autumn firebreak.
So, my Lady, for your reference, I’m swapping round the two questions on which I’ve been granted permission.
CTI has just covered with you what you say in your statement, but can I just read it back to you and ask some targeted questions. So it’s 119 of your statement, don’t worry, you say :
“On face coverings I can recall arguing verbally (in TAG) in favour of their use, even in the absence of evidence, as I knew that there was evidence from SARS-CoV-1 that surgical face coverings had a protective effect in hospitals and also that they were likely empirically to be effective; and that a measure with low effectiveness deployed very widely can have a significant effect.”
So two things firstly, can I just check here, you’re obviously talking here about advocating for surgical face coverings. Are we talking here about fluid-repellant surgical masks? To give it its technical term.
Dr Chris Williams: I think so, yes. I mean, I just meant face coverings in general.
Ms Heaven: Okay, that’s helpful, because my next question was going to be: it seems that you are also talking about advocating for face coverings in the community, in TAG?
Dr Chris Williams: That’s my recollection.
Ms Heaven: Okay, now, you’re saying in your witness here – your statement – you’re “arguing verbally”, and that’s obviously your word, in favour of face coverings, and it would seem to be that you’re suggesting that, as an infectious disease epidemiologist, you were facing some opposition in TAG to your views. So is this correct, were you facing some opposition? If so, from whom?
Dr Chris Williams: I can recall there were arguments about other negative impacts of using face coverings in different groups. I can’t recall who in particular might have made them. Also on the case of things like face coverings and – you mentioned surgical face masks, that tends to be the purview of people with infection prevention and control expertise, and microbiologists, and that’s not my – generally my area of expertise –
Ms Heaven: Well, can I just prompt you, were you facing some push-back from Frank Atherton, CMO, on face coverings? Because we obviously know from the evidence that he was not in favour of them in the community for quite some time.
Dr Chris Williams: Frank Atherton wasn’t a regulator attender at TAG meetings so I don’t think that it would have been him.
Ms Heaven: Okay.
Second question then, please, is just generally you have given some views but I want to be absolutely clear on your view on the approach taken by the Welsh Government to face coverings. CTI has taken you through the dates. We know that on every measure the Welsh Government diverged and was later than all the other four nations in their approach to recommending and mandating masks.
Robert Hoyle, who was from a TAG subgroup, told the Inquiry yesterday the Welsh Government should have mandated masks much earlier. To be absolutely clear, do you agree with his view?
Dr Chris Williams: I think that would have been a reasonable approach.
Ms Heaven: You’ve also just been asked by CTI about the approach Frank Atherton took in May and I know you didn’t see the document. We know that Frank Atherton was giving advice in May that face coverings were essentially a matter of personal choice, directly contrary to the evidence we heard in Module 2 was being given by Chris Whitty to the UK Government.
Do you have a view on the Welsh Government’s approach in May 2020 to face coverings?
Dr Chris Williams: I don’t really have a view, no, not beyond what we’ve just discussed.
Ms Heaven: Okay.
Next topic then, firebreak, and again I’m going to read to you. It’s paragraph 117 of your statement you say:
“I was an advocate for lockdowns when rates were rising, given my experience from March 2020. In autumn 2020 surveillance data was used to guide local and regional levels of restriction, and I was involved in explaining these data to groups advising on these. On the firebreak, I recall verbally advocating for a long enough period to be significant, but I was aware that there were constraints in feasibility and also that an intervention not mirrored across the border would have more limited effects.”
So the first topic is on the timing of the introduction. Were you advocating for the firebreak to be introduced earlier, and if so to whom?
And if I can just ask the next one, because you can answer it together, please. Should the firebreak have been implemented sooner?
So did you want it at the time to be coming in sooner, and now, thinking back, should it have come in sooner?
Dr Chris Williams: I don’t recall that in particular. I know there’s other evidence from Public Health Wales advice on the firebreak intervention. All I can recall at the time is advocating for some kind of national restriction because the rates were rising, and also for a significant length of time because we knew it wouldn’t have much effect if we did it for a short period of time.
Ms Heaven: It doesn’t say in your witness statement when were you advocating. So when were you advocating for national restrictions?
Dr Chris Williams: Again, I don’t have records to – I have to say I don’t have records to say exactly what I was saying at the time. I feel that a prolonged firebreak at the time might have actually pushed the larger wave more towards when we had vaccinations, but I don’t think that was really a feasible option at the time unfortunately.
Ms Heaven: Okay, that was going to be my second question, is: should the firebreak have been longer? And I think you’ve sort of answered that, haven’t you, by saying you thought it probably should but that probably wasn’t feasible, to push the firebreak longer into when the more vulnerable groups had been vaccinated?
Dr Chris Williams: Yeah, you’d have to ask Welsh Government colleagues the reasons for feasibility. But you can still see the firebreak as a notch in the data, so it had some effect.
Ms Heaven: What about a four-week firebreak, was that something that you think perhaps would have been sensible? So not right into the December period but just four weeks.
Dr Chris Williams: I really can’t say what the difference was – would have been, I would have probably thought that would just have given a bigger notch.
In the event we had quite a prolonged period of lockdown after the December restrictions, that were actually a lot longer than any period that was advocated in the autumn. That’s just a reflection with hindsight.
Ms Heaven: Yes, okay. Thank you very much.
Thank you, my Lady, those are my questions.
Lady Hallett: Thank you, Ms Heaven.
Ms Foubister. Sorry, have I pronounced that correctly?
Questions From Ms Foubister
Ms Foubister: Good morning, Dr Williams. I represent John’s Campaign and Care Rights UK.
I’m going to ask a few short questions about your role regarding non-pharmaceutical interventions, I’ll refer to them as NPIs.
At paragraph 116 of your witness statement you note that your role in relation to NPIs was mainly to provide information to assist with decision-making. Was it within your role to provide information not just about harm caused by Covid but also to provide information about all relevant harms to health, in particular indirect harms resulting from NPIs?
Dr Chris Williams: So I do recognise that there are a number of indirect harms from NPIs, but I work in the infectious disease surveillance department, I felt it was my role to give the information about the epidemiology of infectious disease and that others were better placed to give data and advice on other harms.
Ms Foubister: I refer next to a document which I hope can be brought up, which is INQ000183846.
While I just wait for it to come up, this is a statement from Professor John Watkins, also a consultant epidemiologist, who worked, amongst other roles, for the policy modelling group feeding into TAG and the Social Care Working Group feeding into SAGE.
Yes, this is the document. And within that if we could go to page 16.
And under the heading “Wider Non-COVID-19 related harms to [NPIs]” there’s a paragraph under that heading, and about halfway down the paragraph Professor Watkins says that he:
“… highlighted, early on, that people with mental health issues may be harmed by lack of social contact, people with early stage cancer and CVD may not get the diagnosis and treatment they needed, children’s education and social development was being impact etc. Despite raising these issues I saw no attempt to quantify, or consider, these when restrictions were being imposed.”
Were you also aware of concerns of this nature?
Dr Chris Williams: I don’t recall what the discussions were in TAG, but I think the immediate problem was to avoid a huge health impact from a large wave of Covid-19, and I still don’t think that could have been avoided in any other way than a lockdown, despite the negative aspects to it.
Ms Foubister: And in 2020, was there an attempt to quantify or collect data or even consider the more indirect harms resulting from NPIs?
Dr Chris Williams: I don’t recall that from my own work or – it might be in other people’s evidence, but remember I’m a specialist – it’s in infectious disease epidemiology.
Ms Foubister: You may not be able to answer this, given what you’ve just said, but my final question is: to what extent were the adverse impacts of NPIs on people in care or those needing care analysed? To what extent was data or expert input obtained for the benefit of core decision-makers in order to be weighed against the benefits?
Dr Chris Williams: I can’t answer that, I’m afraid. I’m not part of that evidence.
Ms Foubister: Thank you.
The Witness: Thanks.
Lady Hallett: Thank you very much.
Thank you very much, Dr Williams. Thank you for your help.
The Witness: Thank you.
(The witness withdrew)
Mr Poole: If I can – I’ll wait.
Lady Hallett: Mr Poole, Ms Whitaker, don’t worry, the question wasn’t asked, so we’re moving on.
Mr Poole: Exactly, my Lady.
Can I call Dr Roland Salmon, please.