Transcript of Module 2B Public Hearing on 06 March 2024.
(10.00 am)
Lady Hallett: Ms Jung.
Ms Jung: My Lady, the first witness today is Dr Quentin Sandifer.
Lady Hallett: I’m sorry that you I think came yesterday and then we had to ask you to go away. I’m sorry to muck you about.
The Witness: I’m very grateful, my Lady, that you’ve allowed me to start this morning, rather than yesterday.
1. Dr Quentin Sandifer
DR QUENTIN SANDIFER (sworn).
Questions From Counsel to the Inquiry
Ms Jung: Good morning, Dr Sandifer, thank you very much for coming again to assist the Inquiry.
Could you start by giving us your full name, please.
Dr Quentin Sandifer: Quentin Sandifer.
Counsel Inquiry: Thank you. And is it right that you have provided a witness statement to assist this module, which is at INQ000267867, dated 4 September 2023?
Dr Quentin Sandifer: That is correct.
Counsel Inquiry: You also provided a corporate witness statement in Module 1 at INQ000192266; is that right?
Dr Quentin Sandifer: That is correct.
Counsel Inquiry: You also gave evidence in Module 1.
Dr Quentin Sandifer: Yes.
Counsel Inquiry: Thank you. Are both of those statements true to the best of your knowledge and belief?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: Could I start, please, by asking you about your qualifications. Is it right that you qualified as a medical doctor in 1985, and that you’ve been a fully registered medical practitioner since 1986?
Dr Quentin Sandifer: That is correct.
Counsel Inquiry: You’re also a registered specialist in public health medicine and have a Master’s degree in public health from the University of Wales, Cardiff?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: You hold a certificate in leadership in multi-agency emergency response and recovery command and co-ordination, following completion of an exercise gold in March 2015?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: You also hold other degrees, awards and fellowships that I won’t go into.
Is it right that, as far as your past career is concerned, that you trained in general practice in the UK, you worked in Canada as a family practitioner between 1990 and 1992, you then returned to the UK and undertook public health training in Cardiff?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: Between 1997 and 2004 you worked for a health authority local health board in Swansea, first as a consultant in public health medicine, and then as a director of public health?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: Between 2004 and 2012, you worked for strategic health authorities, primary care trusts and local authorities in south east England and London in public health leadership roles?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: You then returned to Wales in October 2012 to take up the post of executive director of public health services and medical director at Public Health Wales?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: And you were in that role from October 2012 until 27 November 2020, which is when you retired?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: During the pandemic, were you also the lead strategic director in Public Health Wales?
Dr Quentin Sandifer: I was, yes.
Counsel Inquiry: And it’s right that after you retired in November 2020, you didn’t have any more involvement in the response?
Dr Quentin Sandifer: That is right.
Counsel Inquiry: For completeness, is it right that following your retirement that you were re-approached by Public Health Wales and that since January 2021 you’ve been working as a part-time consultant, with the title Consultant Adviser on Pandemic and International Health?
Dr Quentin Sandifer: That’s correct, and you will see in my statement that I’ve explained what each of those roles involved.
Counsel Inquiry: Thank you, Dr Sandifer.
I would like this morning to deal mainly with the initial few months of the pandemic, going into the detail of what was happening in that crucial period.
Before I do, there’s just a couple of short matters I’d like to ask you some questions on.
You say in your statement that you attended very few decision-making committees, groups or forums dealing with or impacting upon the Welsh Government’s response to Covid-19. You also say that you attended very few ministerial meetings during the pandemic.
Dr Quentin Sandifer: That’s correct. Oh, sorry.
Counsel Inquiry: Sorry. So the question is: bearing in mind your role as lead strategic director leading an unprecedented response to this pandemic, do you think you should have been more involved in decision-making forums and have attended more ministerial meetings?
Dr Quentin Sandifer: I don’t. I think the important point to remember is that I had direct communication and very regular communication throughout the pandemic response with the Chief Medical Officer, and where relevant I was brought into discussions. For example, in May, about the setting up of the Test, Trace, Protect programme, which might have been attended by ministers, or, for example, the meetings that took place in September and early October about local restrictions.
Public Health Wales is separate from the Welsh Government, it’s not a part of government, it’s not an executive agency of the Welsh Government. So it is entirely appropriate that I should provide my advice through someone like the Chief Medical Officer, rather than directly to the minister, unless the minister expressly asked me to do so.
Counsel Inquiry: But in a pandemic such as this, do you see any benefit in either yourself or the chief executive of Public Health Wales having a direct line to ministers, sitting around the table with them answering questions as and when they arise?
Dr Quentin Sandifer: Well, the chief executive, as she explained yesterday, does have a direct line of communication to ministers, usually in the company of the chair. So – but to answer your question, I don’t think that’s absolutely necessary. I make the point that my responsibility, as I saw it, was to give strategic leadership, professional strategic leadership, within Public Health Wales to the response and to communicate my advice accordingly to Welsh Government, and the appropriate forum for doing that was through the Chief Medical Officer.
Counsel Inquiry: Thank you.
We heard through Dr Cooper yesterday that a lot of the communications with the Chief Medical Officer were in the form of informal quick catch-ups, I think she said about half an hour, and that those were not always recorded. Do you think that there should have been a more formalised structure for your meetings with the Chief Medical Officer for Wales?
Dr Quentin Sandifer: Well, as you are seeking to understand exactly what was happening in those early weeks, allow me to just share some context.
So the meetings that Dr Cooper referred to that you’ve just referenced were purposely intended to be informal quick catch-ups, and they were established from Monday 27 January, held two or three times a week, and it was essentially an exchange of information: where were we, what were we going to do next, and how could we, Chief Medical Officer, assist you?
But I was in direct communication with the Chief Medical Officer right from the very beginning.
Now, to come to your particular point about recording of those, well, of course it would always be preferable, if we could, to record the discussions that were taking place. But by the end of January I was in my office at 7 o’clock in the morning and, with most of my team, rarely left before about 9 or 10 o’clock at night. It was absolutely frantic, and I barely had a moment to stop and take breath. I simply didn’t have the time, myself, to record and, to be honest, there was so much going on I didn’t think that it was the most appropriate use of people’s time for me to re-direct staff that we were already mobilising for other activities in order to simply take notes. That’s not to diminish their importance, but to try to communicate across to this Inquiry the extent of the work and the activities we were undertaking.
Counsel Inquiry: In relation to that, whilst it’s understandable that you were seeking to deploy resources as best you could, is it right that the Public Health Wales emergency response plan did envisage that there would be a logger who would make a record of all key decisions and discussions?
Dr Quentin Sandifer: That is true, and we applied that loggist, that’s the correct title, to our silver group and, indeed, to our incident management team that we established from the 23rd. And those were the meetings that I felt were the ones that we really needed to record.
Counsel Inquiry: Thank you.
Can I ask you about the Health Protection Advisory Group, please. This was another vehicle through which you had contact with the Welsh Government that we didn’t cover with Dr Cooper yesterday.
Is it right that this group was a non-statutory committee that was established and chaired by the Chief Medical Officer for Wales?
Dr Quentin Sandifer: It was, yes.
Counsel Inquiry: Is it also right that that group went into abeyance and then was re-established during the pandemic?
Dr Quentin Sandifer: Yes, and I clarified the reasons for that in my Module 1 testimony, but for the record we had a change of CMO in 2016, the then CMO retired and Dr Frank Atherton was appointed in the August. The HPAG, the Health Protection Advisory Group, which the CMO had established many years earlier, simply was suspended and then when Dr Atherton had, I think, fully established himself in his role, he recognised the need for it and re-established it in 2018, as we describe in my statement.
Counsel Inquiry: Is it right that members of HPAG, prior to the pandemic, included officials from the Welsh Government, health boards, local authority, Public Health Wales, the Health and Safety Executive, and other bodies?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: When it reconvened during the pandemic, the membership expanded, didn’t it?
Dr Quentin Sandifer: It did. It’s worth perhaps noting that it was reconvened on 7 July 2020.
Counsel Inquiry: That’s right. Do you think that, bearing in mind what was happening prior to that date, that it should have been reconvened earlier?
Dr Quentin Sandifer: I’ll be honest with you, I was surprised that it wasn’t reconvened earlier. We held a meeting on 17 December, 2019 that is, and I would have normally expected it to have met again in about three months’ time, but I don’t know why it wasn’t reconvened, but that was a surprise to me.
Counsel Inquiry: We heard yesterday about lots of different groups that Public Health Wales and the government were involved with. What did HPAG add to the other structures?
Dr Quentin Sandifer: Well, what it added – what it could have added is it would have brought together a wide range of statutory partners with a common interest in public health protection, not just the emergency response but public health protection broadly, around the table for a discussion. The fact that it didn’t meet until 7 January, I don’t think in any way impeded our response through those first six months.
Lady Hallett: 7 July?
Dr Quentin Sandifer: Sorry, 7 July, my Lady, I apologise.
Lady Hallett: Okay.
Ms Jung: So prior to that date, then, was there a different forum in which all of those statutory partners could come together in a similar way?
Dr Quentin Sandifer: Yes. So, again, I explain this in my statement. We convened the Public Health Wales public health strategic co-ordinating support group – I know it’s a rather clunky title, but –
Counsel Inquiry: Yes.
Dr Quentin Sandifer: – what I agreed back in 2014 during Ebola represented the best characterisation of its intent.
Now, the purpose of that group was effectively to enable us to bring together all the strategic partners involved in an emergency response, who would otherwise be convening in separate strategic co-ordination – co-ordinating groups, bring them all together in one room and then we could discharge the responsibilities and the requests of us in one place rather than in four places.
The practicalities for a small public health team of servicing four strategic co-ordinating groups in the midst of an emergency of the scale that we were dealing with just meant that it was untenable by even the middle of March for us, by which time all four SCGs were in place, to have supported them properly as individual organisations.
The Welsh Government were entirely happy for us to reactivate a tested process that we’d used during Ebola and that’s what we did from 23 March.
Counsel Inquiry: Thank you.
Can we move on, then, please, to the initial period of the pandemic.
Can we display INQ000147237, please.
Is this the first briefing that Public Health Wales sent out in relation to, at the time, an unknown pneumonia from Wuhan City, and this was based on a similar briefing that had been received from Public Health England; is that right?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Can we see there the intended audience included Public Health Wales protection teams, CDSC consultants, scientists, and microbiologists, health board directors of public health, medical directors and also – that was for dissemination to emergency departments and leads of infection prevention and control, and, at the bottom, also the Welsh Government.
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Was that briefing circulated to everyone on that list?
Dr Quentin Sandifer: Yes, it was.
Counsel Inquiry: Can we see, then, below, please, in the background information section, that:
“On 31 December 2019, [the World Health Organisation] was informed by the People’s Republic of China of cases of pneumonia of unknown microbial aetiology associated with Wuhan City … China … At the last report to WHO on 03 January 2020, there were 44 cases of which 11 were reported as severely ill.”
In the next paragraph we can see that on 5 January 2020, 59 cases were reported, including seven critically ill patients, but no deaths:
“The first case became unwell on 12 December 2019 [with] the onset date of the last case [being on] 29 December 2019.”
And it says:
“Current reports describe no evidence of significant human-to-human transmission, including no infections of healthcare workers.”
What was the significance, if anything, of that?
Dr Quentin Sandifer: Okay, well, I think the key point is the absence at that time of evidence of significant human-to-human transmission. So we had a new infection, unknown aetiology, and it had not, apparently, transmitted from one person to another.
Counsel Inquiry: It also says that:
“… influenza, adenovirus, SARS CoV and MERS CoV [had] been ruled out.”
But it says:
“It [was] possible that this cluster [represented] the emergence of a novel pathogen.”
What was the significance of that, please?
Dr Quentin Sandifer: Well, clearly in East Asia, with its past history of infections, particularly avian influenza, SARS-CoV-1, MERS, those were the obvious candidates that needed to be investigated first, and of course those had been, by that time, ruled out.
Investigations, as it says, into other pathogen causes were ongoing, and that suggested that the emergence of this new cluster was caused by a new pathogen.
Counsel Inquiry: The fact that it may have been a novel pathogen, did that mean that it was possible that we wouldn’t have any existing medication or vaccinations available for it, and that it was likely that there wouldn’t be any existing immunity in the population?
Dr Quentin Sandifer: That’s correct. I mean, we had at that stage yet to characterise what that new pathogen was, but a working assumption is that if you don’t know what it is, it is a new pathogen, then it is very likely that existing therapies might not work, that you won’t have a vaccine and that the population could be naive to this pathogen.
Counsel Inquiry: Thank you.
Over the page, please, is it right that whilst the cluster was not thought to be avian influenza, that had been reported in the region, and so there were some recommendations of how to treat cases if avian influenza risk factors were present. But below that, it says that if those factors were not present, that:
“The patient should be managed in respiratory isolation, using the local personal protective equipment protocol for airborne infections, incorporating a fit tested FFP3 mask and eye protection.”
And it goes on to say testing was to be undertaken in containment level 3.
So is it the case that from the very beginning, whilst it was not known what kind of virus this was, out of an abundance of caution it was being treated as if it was an airborne high-consequence infectious disease?
Dr Quentin Sandifer: Yes, and that’s what you would expect to be the case. And what you see there is a clear statement, what we would expect in infection prevention and control terms from any NHS organisation in the UK – this was obviously taken from a Public Health England document – anywhere in Wales and the UK, should that – should this disease present itself.
Counsel Inquiry: In Module 1 we heard that pre-pandemic Wales did not have, itself, any isolation units. As at 8 January, can you tell us, had that situation changed?
Dr Quentin Sandifer: Sorry, just to make absolutely clear, we did not have in Wales a high-consequence infectious diseases –
Counsel Inquiry: Thank you.
Dr Quentin Sandifer: – unit. All our acute hospitals had isolation facilities, but, as you will also recall from my Module 1 evidence, an audit conducted in 2017 had suggested that not all of those isolation units satisfied our expectations.
So I guess the key point here is we were treating this as a new high-consequence infectious disease, and we would respond accordingly within Wales, which meant that we would normally move the patient, if that was our suspicion, to a unit in England.
Counsel Inquiry: So just to be absolutely clear, Dr Sandifer, is it the case that, as at 8 January 2020, first of all there were no HCID units within Wales?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: And secondly, that there were no satisfactory isolation units in Wales?
Dr Quentin Sandifer: No, that second point is not correct. What I’m perhaps not saying very clearly is we had isolation facilities in all acute hospitals, but our audit had suggested that further work was required in some of those settings to achieve, for example, a level of negative pressure isolation within the room that one would expect.
Counsel Inquiry: So, just to amend my question in that case, there were no isolation units that were satisfactory to be able to house HCID patients?
Dr Quentin Sandifer: I would put it this way: that we would not – that we might temporarily place a patient in an isolation unit in an acute hospital in Wales, but with the expectation that they would move to an appropriately equipped high-consequence infectious diseases unit elsewhere.
Counsel Inquiry: And how many level 3 containment laboratories were in Wales at that time?
Dr Quentin Sandifer: The exact number I’m not sure, but containment level 3 was in most of our principal laboratories, so I know that for certain Cardiff, Swansea and Rhyl in North Wales had containment level 3 laboratory facilities.
Counsel Inquiry: Page 3 of this document provides further information about Chinese New Year falling on 25 January. I don’t believe that information was contained in the Public Health England briefing. Why did you think that that was significant enough to include in the Public Health Wales briefing?
Dr Quentin Sandifer: Because I was well aware, personally, and I think it’s generally well known, that within China you will see a very large movement of people returning home for the Chinese New Year, and that likewise could also be associated with very large international travel.
Counsel Inquiry: Thank you.
Can we move on to 9 January, please, and display INQ000147259, please.
Is this an email that you received, Dr Sandifer, from Dr Giri Shankar, who was the professional lead consultant for health protection at Public Health Wales, and this email included a summary of an incident management team meeting convened by Public Health England that he had attended earlier that day?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Did that email set out the main points arising from that meeting, which I’ll just take you through? At paragraph 1b is it right that WHO had reported that morning that a novel coronavirus had been isolated from one of the affected cases?
Dr Quentin Sandifer: Yes, that was the new information, and we now understood that this novel virus appeared to be of the coronavirus family.
Counsel Inquiry: And it was potentially zoonotic?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: At that time there was still no evidence of human-to-human transmission or evidence of transmission to healthcare workers; is that correct?
Dr Quentin Sandifer: That’s right.
Counsel Inquiry: At paragraph 2, can we see that Public Health England had decided to respond to this as an “enhanced incident” because of it being a novel coronavirus, with as yet unknown consequences?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: And it says that the agent and incident was being managed as a high-consequence infectious disease –
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: – which I think you say was an appropriate approach?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: Just pausing there, so we have now the identification of a novel coronavirus. The Inquiry heard in Module 1 that coronaviruses generally were known to cause mild respiratory illness, also known as the common cold, however it’s right, isn’t it, that there had been two past global outbreaks caused by coronaviruses, SARS-CoV-1 and MERS CoV, which had caused severe disease which was transmissible from person-to-person and which were both classified as HCIDs; is that correct?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: So how much of a concern was it to you to learn that a novel coronavirus had been identified?
Dr Quentin Sandifer: I think I just simply noted what the situation was at that time. Clearly I was thinking: well, is this a variant of the SARS or a MERS? We were all thinking that. But I don’t actually think that would have fundamentally changed any of the decisions or actions we were taking then. What we were doing is reporting what we were observing. It should be said we were still dealing with something in one city in one province in China, reporting that, here, in the context of the United Kingdom, and specifically here in Wales.
Counsel Inquiry: The Inquiry heard that very few cases of SARS and MERS reached the UK during those outbreaks. Are you able to assist us as to how many cases, if any, reached Wales?
Dr Quentin Sandifer: I don’t think there were any SARS-CoV-1 cases in Wales, I’m not absolutely sure on that point, I wasn’t working in Wales at that time.
With the 2015 outbreak of MERS CoV in South Korea, and indeed through the period since MERS CoV was first identified, I think from memory we had two contacts, suspected contacts, in Wales during those years, and those I believe were ruled out as confirmed cases.
Counsel Inquiry: Thank you.
At paragraph 6 of this document, can we see there under “Diagnostics” it says:
“PHE’s Respiratory Virus Unit have a well-developed and well-tested Pan-coronavirus assay that should detect most coronaviruses.”
Am I right in understanding that your evidence is that Wales did have at this time level 3 labs which would also be able to test for coronaviruses –
Dr Quentin Sandifer: Yes.
Counsel Inquiry: – once PHE had developed that assay?
Dr Quentin Sandifer: Sorry, so we just need to separate out. PHE had the assay at that date –
Counsel Inquiry: Yes.
Dr Quentin Sandifer: – 9 January. We had laboratories that could conduct this test, but we didn’t have the assay for this – for coronavirus here in Wales at that time.
Lady Hallett: Could you just explain what you mean by assay?
Dr Quentin Sandifer: So this is the test itself, if you like, the diagnostic test, my Lady.
Lady Hallett: Thank you.
Ms Jung: Over the page, can we see there a reference to the situation being “rapidly evolving”?
“… there will be lots of changes to guidance, [advice], documents etc. [Public Health England] have asked for co-operation from [the devolved administrations] on this and offer quick turnaround on issues that require 4 nation agreement.”
Is that right?
Dr Quentin Sandifer: That’s right. And it might be just worth us all – me just reminding us here, Public Health England were designated the national focal point for the UK Government under the International Health Regulations (2005), so they would have received any notification to the WHO, and they, therefore, would have taken the lead in sharing that information and any immediate action that arose from that within the United Kingdom.
Counsel Inquiry: Thank you.
Can we then display, please, INQ000147262.
This was the briefing note on 10 January 2020 where Public Health Wales was relaying the information that had been passed on the previous day by Dr Shankar; is that right?
Dr Quentin Sandifer: That’s correct, yes.
Counsel Inquiry: On page 2, the last paragraph, can we see there the advice on what to do with patients with respiratory symptoms and the reference to transferring them to a single occupancy room, preferably a respiratory isolation room, ideally under negative pressure.
So is it right that, as at this date, patients were being transferred to England to be held in HCID units? Do you think that the briefing at this time should have advised health boards to start preparing their own isolation units which would have been sufficient to house HCID patients?
Dr Quentin Sandifer: Sorry, could I just correct something you said?
Counsel Inquiry: Yes, of course.
Dr Quentin Sandifer: The UK Government was not asking for patients to be transferred from China. What this statement –
Counsel Inquiry: No, no, sorry, this is in relation to patients from – in Wales.
Dr Quentin Sandifer: Yes.
Counsel Inquiry: So you are advising, aren’t you, that if there are any patients in Wales who have symptoms –
Dr Quentin Sandifer: Yes.
Counsel Inquiry: – that they should be held in isolation units, preferably negative pressure ones, and you’ve told us that those patients would have had to have been transferred from Wales to England –
Dr Quentin Sandifer: Yes.
Counsel Inquiry: – is that right? So my question was: do you think, at this time, you should have been advising health boards to start getting ready to have their own satisfactory units to be able to house HCID patients?
Dr Quentin Sandifer: So this briefing was intended to alert the health boards to the fact that the isolation rooms which would have met the requirements we were asking for, that they ought to take notice of what was happening and be aware that they might need to use those isolation rooms.
Counsel Inquiry: Is it right that the – sorry – the first suspected case in Wales was on 16 January 2020?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: You provided a briefing note to the Public Health Wales board on that day. In fact, I think – sorry, let me just correct that: the suspected case was on the 15th, and you reported it on the 16th; is that right?
Dr Quentin Sandifer: That’s correct, and at that time –
Counsel Inquiry: Yes, and that patient was a 67-year old female Welsh resident in North Wales whose husband worked in Wuhan City, and she was in fact transferred from a hospital in Wales to specialist facilities in Liverpool; is that right?
Dr Quentin Sandifer: She was transferred, yes, to a specialist facility in Liverpool.
Counsel Inquiry: And you’re right to say that that was negative.
Dr Quentin Sandifer: The test was negative, yes.
Counsel Inquiry: Yes.
You had or Public Health Wales had its first meeting with the Chief Medical Officer of Wales on 21 January 2020. That was 12 days after the novel coronavirus had been discovered. Do you think that was soon enough?
Dr Quentin Sandifer: So just to wind back a little bit, the UK IMT, established and chaired by Public Health England from 9 January, was attended by members of my team, Dr Giri Shankar, whom you’ve referred to, as well as a senior medical officer from Welsh Government. We were having daily conversations at that and from that time with the Welsh Government senior medical officer and other senior officials in the Chief Medical Officer’s team, and those were happening on a daily basis.
Now, I can’t remember the first time I spoke to the Chief Medical Officer about this, but in case there’s any misunderstanding from your question, there was regular daily communications already taking place between my senior team and the Chief Medical Officer’s team.
Counsel Inquiry: Thank you.
It’s right, isn’t it, that on 22 January 2020 Public Health Wales invoked its emergency plan at an enhanced level?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: We know that Public Health England had been responding to this at an enhanced level since 9 January. Do you think that Public Health Wales should have moved to that sooner?
Dr Quentin Sandifer: No, I don’t think necessarily. Public Health England, you know, in the face of a potential high-consequence infectious disease alert, it was entirely correct that they would immediately go to an enhanced level. As I say, we were in daily contact, not just – we were in – attended the daily IMTs, the incident management teams, with Public Health England, and the reason we stood up our public health emergency response plan on the 22nd is because the sheer volume of work that had by then arisen from that engagement as a member of the four nations IMT necessitated us to start thinking beyond the immediate resources of our public health protection service.
Counsel Inquiry: The Public Health Wales response plan had envisaged a silver group being established at the same time as –
Dr Quentin Sandifer: Yep.
Counsel Inquiry: – an enhanced level response being invoked. Why wasn’t that done on the same day?
Dr Quentin Sandifer: So, I don’t think that there’s – any particular significance should be attached to a six-day difference. What we were doing, as I say – apologies if I keep repeating myself – is we were in daily contact with Public Health England, we were in daily contact with the Welsh Government, work was building up, we necessitated therefore additional – well, envisaged additional resources would be required to support us, we invoked the emergency response plan, we established our own IMT on the 23rd, again at enhanced, consistent with Public Health England, but we could see that that group itself would necessitate additional tactical level support. And so, you know, we were talking about, over the period of the weekend, bringing together additional support, and that was established in the form of the silver group.
So the fact that silver group didn’t actually – wasn’t established until Tuesday, as far as I’m concerned, had no material impact on our response. We were delivering the response. The silver group was an additional element that would assist us with that, and it was better to make sure that we could establish that.
And just to be clear, when you establish something like a silver group, it’s not just a case of convening a meeting, we have to put human resource behind that, and that resource has to be rostered in a way that it’s sustainable for it to be able to deliver the functions set for that group. So this was not just the case that, “Oh, we just better convene a group”, it doesn’t work like that.
Counsel Inquiry: You mention there the Public Health Wales IMT, which was established on 23 January, and is it right that that was set up to assess and manage the information and consequential actions arising from the Public Health England-led IMT, and to undertake Welsh-specific surveillance and risk assessment and to provide public health technical advice on plans for responding to possible cases in Wales? Do you think that it would have been helpful to set up this Wales-specific IMT prior to 23 January, and had it been, would there have been a bit more of a head start on making Wales specific plans?
Dr Quentin Sandifer: No, and no to both, to be quite frank. The point that I’m repeatedly trying to make is that we were undertaking all the actions that I think were required, and that an IMT in due course formalised, right from the beginning. So I don’t think it would have made any difference to have declared an IMT at the same time, for example, as Public Health England. We were doing what we needed to do already.
Counsel Inquiry: Thank you.
Can we look at another briefing that was sent out on the same day, 23 January.
This is INQ000147265.
We’ll just wait for that to come up.
Can we see there the intended audience, as well as the previous intended recipients, this time also included GPs, health boards, the Welsh ambulance service trust and port health authorities, as well as the Welsh Government? Can you see that?
Dr Quentin Sandifer: I can, yes.
Counsel Inquiry: If we look at the last paragraph of that page, we can see there 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.”
Is that right?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: On page 2, can we see a section titled “Recommendations and actions”:
“Health boards should ensure their preparedness for a possible case of [this novel coronavirus], including provision, training and appropriate use of personal protective equipment, and isolation facilities. The current guidance is for assessment in an airborne isolation unit in hospital, followed by testing and a period of isolation (at home or in hospital) whilst awaiting the results.”
Was this the first time that Public Health Wales had formally asked health boards to start preparing these isolation facilities in Wales?
Dr Quentin Sandifer: I go back to my previous comment, with reference to the briefing on the 10th, by drawing attention to the need for any patients with – suspected of having this infection to be cared for or housed in, as you put it, an isolation room. We were already signalling that intent two weeks earlier. All we were doing is providing additional clarification to that.
Counsel Inquiry: At …
Dr Quentin Sandifer: I mean, could I just again reference my Module 1 – remind you that we had conducted training, an update refresher training for the health boards and the ambulance trust in September 2019, on managing high-consequence infectious diseases and the use of personal protective equipment. And so, if you like, this paragraph is just simply to remind them that there were a large number of people in health boards that could deal with these cases, pending their transfer, of course, to another facility, and to start to prepare themselves accordingly.
Counsel Inquiry: Could I just refer back, please, to your evidence in Module 1.
If we could bring up the transcript at PHT000000 – I think it’s eight 0s – PHT0000000014. It’s the transcript from 4 July 2023, at page 78.
Can we see there that you say that:
“… in January 2020, as it became clear to us in Public Health Wales the novel coronavirus represented a very serious threat, we as an organisation entered into discussions with the Welsh Government and – with one of our local health boards, to discuss how we could establish very quickly a high-consequence infectious disease unit at that hospital, in advance of and in readiness for potential patients if novel coronavirus came to Wales.”
So in your Module 1 evidence you were saying that you had entered discussions with one health board; is that right?
Dr Quentin Sandifer: That’s right, the University Hospital of Wales, just down the road from here.
Counsel Inquiry: Can we turn to your statement in this module at page 35, paragraph 145, three lines up from the bottom you say:
“… I was acutely aware that we lacked the authority to direct the NHS in Wales … to establish capacity and capability to support initial assessment and sampling of suspected cases.”
Then at page 38, paragraph 157, you refer to:
“Rapid scaling up [requiring] a system response under national leadership, with authority to direct, supported by access to reserve workforce, including volunteers, that can be mobilised quickly.”
Is it right that, without the national strategic leadership in place at this time, that Public Health Wales was not in a position to direct the NHS or local health boards to prepare in the way that they needed to be doing?
Dr Quentin Sandifer: I mean, let me just start by stating that paragraph 157 is obviously a reflection after the event, so this is me looking back and summarising what I strongly believe now, but even at the time.
The challenge we were facing, the previous point that you highlighted, the “authority to direct” comment, was with reference to the fact that during the week beginning 27 January we were asking, asking directly, health boards to begin to prepare themselves so that if we had a suspected case they were able to appropriately sample, assess and sample that patient, hold them whilst the sample was taken, tested by our laboratories, and then if we confirmed the infection we would have arranged for the transfer of that patient to a high-consequence infectious disease unit.
Now, in order to do that, we were having discussions and we were asking them to do that, but at that stage by the end of January we were becoming very, very concerned, we’d had by then a second suspected case, also tested negative, and I was looking for some urgency. And quite frankly I can’t tell the chief exec of a health board or an NHS Trust in Wales what they must do, and what was in my mind was that that was a function that the director general/chief exec of the NHS in Wales could have done, and that is what I’m referring to by national leadership, is from the Welsh Government’s Health and Social Services Group.
Counsel Inquiry: Thank you.
Can we look at INQ000147264, please.
This is a written report that was presented in private session to the Public Health Wales board the day after the briefing that we looked at before. At page 4, paragraph –
Dr Quentin Sandifer: I’m sorry, if I could just correct that.
Counsel Inquiry: Yes.
Dr Quentin Sandifer: A quirk of the Word processing software is that it was actually written on the 22nd for the board meeting on the 23rd, but unfortunately, by the time it was captured by my board secretary, it had auto-dated to the 24th in the top right of the document. So just to be clear –
Counsel Inquiry: I see, so it’s written on the 22nd –
Dr Quentin Sandifer: For a board meeting on the 23rd.
Counsel Inquiry: Thank you for that clarification. So this was presented to the board on the 24th. If we look at page 4, please –
Dr Quentin Sandifer: On the 23rd.
Counsel Inquiry: On the 23rd, sorry.
On page 4, paragraph 5, can we see there that there’s reference to there being no confirmed cases in the UK, but there had been five possible cases in the UK, including Wales, at that time; is that right? Two had tested negative and three, the tests were awaited for?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: So when the briefing went out, then, the day after you had written this, to the Welsh Government, why didn’t you include the information that there had already been five suspected cases including some in Wales? Do you think that that information would have been significant information to include in the briefing to the government?
Dr Quentin Sandifer: The government already knew that, we were in discussion with them at the time.
Counsel Inquiry: What about the NHS and the health boards?
Dr Quentin Sandifer: I guess we could have added, I don’t think there was a – quite frankly, I’m not quite sure what the additional significance of adding that in, but clearly we – if we didn’t add it in then that’s an oversight, but I don’t think it was a material matter.
Counsel Inquiry: Do you think that they might have acted with any more urgency if they thought that there were already cases in Wales that were suspected?
Dr Quentin Sandifer: So there was one case, suspected case, that had already been tested negative as of this date. The second case was on the 25th, so after this date. I don’t think it would have made any significant difference. I mean, as I said, we were meeting with the health boards the following week, and we were trying to explain to them what the – what we then thought they should be doing, and I don’t think that simply adding that line in would have made any difference to those conversations.
Counsel Inquiry: Thank you.
Dr Quentin Sandifer: We didn’t hold any information back, to be absolutely clear here, we didn’t withhold any information from the health boards.
Counsel Inquiry: Thank you, and I’m not suggesting that you deliberately withheld any information.
Is it right that on 24 January 2020 there was the first confirmed case in Europe?
Dr Quentin Sandifer: Yes, in France.
Counsel Inquiry: And if we display INQ000147245, please.
On 24 January 2020 you received an email from a Welsh Government official, David Goulding, who was the health emergency planning adviser; is that right?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: And at the bottom of page 1, can we see there that he says:
“Public Health Wales is part of the LRF structure and have in the past arranged a Wales briefing of LRF partners, facilitated by Quentin. This was at the height of the EBOLA risk and I don’t think we are at that point. If necessary, [Public Health Wales] could consider a similar approach to briefing LRF representatives.”
At the top of the page, can we see another email where he says:
“Hi Quentin
“See attached emails. I don’t think we are at the point of needing a meeting, similar to what you did before but thought to alert you to the possibility.”
Following this email, did you have a meeting with the local resilience forums?
Dr Quentin Sandifer: Okay, so we just need to unpack a few things and what was happening at the time.
So first of all, this email from David Goulding was prompted by an approach that I – my deputy made to him at my request. My deputy was acting as a direct liaison between Public Health Wales and Welsh Government. Essentially I asked him to embed himself part-time in Welsh Government so he could, in real time, keep them abreast of what we were doing and feed back to us in turn what Welsh Government, Chief Medical Officer’s team were doing.
As of the 24th, as you correctly pointed out, France had reported the first case in Europe, and it occurred to me that we might want at that stage to start thinking about public health emergency planning, using civil contingencies. So my deputy had approached David, and I got a response back, as you see in this email.
Now, that paragraph in bold at the bottom references the structure that we talked about earlier, the Public Health Wales public health strategic co-ordinating support group, which we did establish in due course, as I explained.
We were already briefing the LRF co-ordinators directly, however, by this time.
Counsel Inquiry: Thank you.
If we look at page 2, can we see there it says:
“The 4 nations is treating this as an enhanced public health incident and arrangements are in hand for dealing with potential cases and the NHS has plans for high consequence infectious disease. The risk to the UK is assessed as low.
“I don’t see this event as it is currently moving from being in the public health outbreak management space and into civil contingency/multi-agency emergency response.”
Did you agree with Mr Goulding’s view that this event was unlikely to move into becoming a civil emergency?
Dr Quentin Sandifer: Well, as I say, this email was prompted by the fact that I was asking him, as the health emergency planning lead, whether, in light of the events elsewhere in Europe, we ought to start thinking about civil contingencies and emergency response, and this was his opinion.
I think it was at 8.04 in the morning on 24 January, we could have had a debate around that, but, you know, my mind was already in the space of perhaps we needed to start thinking about civil contingency, and this is the response he gave me. I don’t think it was as black and white as: okay, there’s a case in France, stand up our emergency plans in Wales.
Counsel Inquiry: This email in the first line refers to the four nations treating this at this stage, 24 January, as an enhanced public health incident.
Do you think that if Public Health Wales at this stage had escalated it to a major incident, as far as Public Health Wales was concerned, that the government might have taken it more seriously?
Dr Quentin Sandifer: I don’t think so. I think Dr Cooper addressed this question yesterday. A Public Health Wales response plan directs our internal Public Health Wales actions. If we had gone to a major incident, we were just simply saying we desperately need to mobilise more resources internally. Well, we were doing that anyway, and I don’t think that that would have signalled to anyone outside the organisation that they in turn ought to take different action. I think it would only simply have confused the situation.
We were responding, consistent with Public Health England, at enhanced level, mobilising rapidly within Public Health Wales, engaging with, directly with Welsh Government, and engaging, by then, also with health boards. I’m not sure it would have made any difference.
Counsel Inquiry: How would it have confused the situation?
Dr Quentin Sandifer: Well, because if one organisation, at this stage, with one case, that might not actually be generally known to people, one case in Europe, confirmed that earlier in that same day, they would have perhaps asked themselves: well, what’s Public Health Wales doing suddenly activating its emergency response plan at a major incident level? What I needed really was, if you like, a clearer signal that what we were discussing already with them, that they were taking the necessary actions, as we’ve discussed in reference to the paper the previous day before the briefing that I had sent out.
Counsel Inquiry: Thank you.
The very next day there was the second suspected case in Wales; is that right? At that time, was the testing for that being done in England or in Wales?
Dr Quentin Sandifer: It was in England at that stage. All the test samples were going from Wales to Colindale laboratory in North London.
Counsel Inquiry: So by this stage Public Health England had the assay; why wasn’t it being done in Wales at this time?
Dr Quentin Sandifer: Well, as has, I think, already been covered, but I’ll happily just remind everyone, we got the genomic sequence for this virus, new virus, in late January. We also ordered primers and probes, which are the necessary elements that you need, my Lady, to make a test.
We ordered those on 16 January and the laboratory in Cardiff was already starting to develop a Welsh assay, and that process continued through till the 31st, by which time we were then using that as a test alongside the Public Health England test, so at the same time as we were sending a test to Colindale we were undertaking the same test in our laboratory.
But the previous week we had approached the Chief Medical Officer and said: look, we’ve started to develop a Welsh test, it’s not clear to us how quickly the UK test will be rolled out across the UK, turnaround times for getting test results was now approaching about 48 hours, so therefore could we use this test that we have developed – which was giving us the same results by the way, as we applied it, from the end of January, to those received from Public Health England – could we start to apply that?
And as the Chief Medical Officer explained on Monday, he sought some assurances from us. Some of those assurances were basic actions that we would have taken anyway. We produced a full set of standard operating procedures, we would do that for any introduced new test. But we agreed and indeed did submit a paper to NERVTAG, which was considered on 3 February, and then by the end of that week, 7 February, the Chief Medical Officer was satisfied that the Welsh test was okay, and he approved it in a letter to the Chief Medical Officer, and we therefore stopped sending tests to England at that point, and immediately our turnaround time fell from 48 hours to a few hours, depending on how quickly the sample got to the lab.
Counsel Inquiry: So from 7 February you were conducting tests in Wales?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: In your view, could that process that you’ve just described have been done any faster?
Dr Quentin Sandifer: Not really. I mean, there’s an awful lot of work starting from a sequence provided by the World Health Organisation to developing the actual test itself, and our consultant clinical scientists who led this I think did an absolutely cracking job pulling this together in less than a fortnight.
Counsel Inquiry: Thank you.
Sticking to 25 January for now, on this day the World Health Organisation issued a statement outlining the importance of being ready at local and national levels for detecting cases, testing samples and clinical management. From your point of view, how ready was Wales at the local and national levels?
Dr Quentin Sandifer: Sorry, at what date are we now?
Counsel Inquiry: This is 25 January.
Dr Quentin Sandifer: At 25 January we were, as an organisation, Public Health Wales, you know, fully engaged in the preparatory work for this, and we had – and the following week we were, as I say, engaged in the discussions. So if a case had arrived we would have managed it, I am very confident, in an appropriate and effective way. But as regards to the overall state of readiness, that was still work in progress.
Counsel Inquiry: Thank you.
Can we move on to 26 January, please, the next day.
And INQ000252016.
These are the minutes from a meeting that Public Health Wales had with the Welsh Government on this day to agree strategic aims and actions; is that right?
Dr Quentin Sandifer: Yeah, this is Sunday 26 January, and I suggested to the Chief Medical Officer that we got together now and agreed our overall strategic approach to what we were observing elsewhere still at this stage. I emphasise that last point. So he brought a couple of his senior colleagues, I had a couple of my senior team, and we sat round the table and asked ourselves: well, what were the strategic aims we should be aiming for at this stage?
Counsel Inquiry: Thank you.
If we look at agenda item 2, we can see that at this time there had been 52 cases tested in England, all negative, and two tested cases in Wales, also negative. Is that right?
Dr Quentin Sandifer: That’s right. The second negative case result had only just come through that morning.
Counsel Inquiry: If we look at page 2, in the first section, can we see there that there was a discussion about a proposal being circulated for the case definition to be amended to expand the affected geographical area? So was it anticipated that that would increase significantly the number of suspected cases in Wales and in the UK generally?
Dr Quentin Sandifer: Yes, so the case definitions are discussed at a UK level, led by Public Health England, and that in turn, on the basis of information that was coming out of the WHO. So, yes, the answer to your question is every case definition invariably expanded the potential numbers of people that could present as suspected cases.
Counsel Inquiry: Thank you.
At page 5, at the top of the page, can we see that:
“Any confirmed case would be expected to be managed outside of Wales as guided by the Imported Fever Service to HCID units.”
So at this time any positive cases were still being sent outside of Wales?
Dr Quentin Sandifer: Would have been sent, any confirmed cases would have been sent outside of Wales to an HCID unit in England.
Counsel Inquiry: Can we see in the middle of the page it says:
“Cross Government not meeting over [the] weekend.”
Bearing in mind that this was a rapidly evolving situation, you’ve told us the hours that you and your colleagues were working, do you think it was appropriate for that meeting not to have taken place over the weekend?
Dr Quentin Sandifer: I think this is a matter, as you say, it’s an update from Welsh Government, it’s a matter for Welsh Government to answer.
Counsel Inquiry: Page 6, item 6, can we see there that it’s stated that this is an “NHS incident at present … can be strategically managed accordingly and doesn’t currently require Civil Contingencies response”? So at this stage the government still did not think that it was a civil emergency?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: At page 7, action log item 2, which was in relation to testing and isolation capacity and so on:
“Agreed to remain with reactive approach.”
Do you think that at this stage the decision to remain with a reactive approach was the right one?
Dr Quentin Sandifer: I mean, with hindsight and reading these notes again, I’m not quite sure I understand what we’re saying. I’m assuming what this refers to is that we need to be alert to and respond to suspected cases in the way that we had already been doing for a fortnight by that – almost a fortnight by that stage, and I’m assuming that is what we’re referring to.
I mean, I had already enquired, as you know and we’ve discussed, with Welsh Government whether we ought to start thinking about civil contingencies, and I – as we’ve already discussed – had received a response.
Counsel Inquiry: Do you think you and the government should have been more proactive at this stage?
Dr Quentin Sandifer: So, absolutely, my point being that we were proactive. There is nothing else that Public Health Wales could or needed to have done at this stage. The decision to have activated civil contingencies was a decision for Welsh Government.
Counsel Inquiry: It’s right, isn’t it, that on 27 January 2020, and this is after you say the momentum had started changing, that two additional backup strategic directors were appointed and you became the lead strategic director at that stage, and it was the next day, 28 January 2020, when the silver group was established? You’ve told us that you don’t think that would have – establishing that any sooner would have made any difference; is that right?
Dr Quentin Sandifer: That was, if you like, an action that we needed, that we took internally in order to support – tactically to support the response that we were already mobilising within the organisation. The fact that we got that process in place, properly established, at that date, I think is neither – you know, even with reflection, I don’t think it would have made any difference if we had simply convened that immediately when we invoked the plan.
Counsel Inquiry: It’s right, isn’t it, that on 30 January the World Health Organisation declared a public health emergency of international concern, and the UK had its first two cases of Covid-19, which were announced on 31 January?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Can we look at, please, INQ000147267.
This was you updating the board about the WHO declaring a PHEIC, and the UK risk level being raised from low to moderate, and you were expecting the case definition to change; is that right?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: If we look at section 2, the first paragraph, can we see that it was agreed, it’s towards the bottom of the first paragraph:
“It is agreed that, at the present time, this is a ‘health led incident’ and Public Health Wales, alongside Welsh Government, is leading the response.”
So even after Covid-19 has been declared to be a public health emergency of international concern, is it right that the government was still seeing this as a health-led incident and was not taking charge of leading the national response?
Dr Quentin Sandifer: It is the case that Welsh Government was considering this a health-led incident, and that the principal leadership, as I could see it, was coming from the Chief Medical Officer.
Counsel Inquiry: How seriously do you think the Welsh Government was taking this threat at this time?
Dr Quentin Sandifer: I think 31 January, even at the time, it really felt like a seminal moment. I mean, the Chief Medical Officer of the United Kingdom standing up and saying “We’ve got the first two cases in the UK” just about a month after it was first reported by China to the WHO, it just felt to me like this was an inflection point in the whole, as we would subsequently call it, the pandemic, in the emergence of this outbreak.
And I personally was starting to get very concerned now about the extent to which I could see, beyond the Chief Medical Officer, a response from Welsh Government.
Counsel Inquiry: You’ve told us that the testing in Wales was established on 7 February –
Dr Quentin Sandifer: It was approved on the 7th.
Counsel Inquiry: Sorry, approved on the 7th –
Dr Quentin Sandifer: We were already applying the test from 31 January in parallel with the test in –
Counsel Inquiry: Thank you, so after that date it was done exclusively in Wales?
Dr Quentin Sandifer: After 7 February it was done exclusively in Wales.
Counsel Inquiry: And in your statement you say that at that point the challenge then returned to community sampling. Could you just briefly explain what that challenge was, please.
Dr Quentin Sandifer: Yeah, so I think Dr Cooper described this really well. It’s an end-to-end process, somebody has to take a sample, a microbiological sample, our laboratory would conduct the test, and then that result needs to get back to the clinician who ordered the test.
Now, that front end requires clinicians in health boards to take a sample, and, as I’ve already said in my evidence this morning, we had begun that discussion earlier in that week, the week commencing 27 January, with health boards, in order to try to get them to take on that responsibility.
Now, the significance of that is that the first two cases or suspected cases, sorry, to correct myself, the first two suspected cases were attended by senior staff from the health protection service in Public Health Wales. And indeed, whilst we were having those discussions with health boards, the whole of Wales, the whole geography of Wales, was dependent on a handful of senior consultants from my team being able, in response to concerns about a suspected case, attending the patient, anywhere in Wales, clinically assessing them, taking a sample, and getting that sample back to Cardiff.
It was that front end of the process – which was unsustainable. You know, a handful of people could never do that if this was to start now increasing in any numbers in Wales. And we had no idea how quickly this might spread, even at that stage.
So that’s the reference that I made before and now to the mobilisation of testing – sorry, sampling capability.
Counsel Inquiry: Thank you.
Is it right that on 10 February 2020 the Chief Medical Officer for Wales issued a letter to health board chief executives requesting that every health board develop community assessment and testing plans, and that each health board must have coronavirus testing units separate from emergency departments, and that those arrangements were to be operational as soon as practically possible, and by no later than Friday 14 February?
Dr Quentin Sandifer: Yes, and that was in response to our frustration and concern at the pace at which the health boards were putting together their sampling capacity. And, if you like, the Chief Medical Officer’s letter represented the direction which I thought he had the authority to give rather than me.
Counsel Inquiry: Should that have been issued earlier than it was?
Dr Quentin Sandifer: It might have been helpful if that had been issued at the beginning of February. Or even, if I had decided not to bother to try to have a conversation and see if we can get this by negotiation with the health boards, we could have done it the previous week. But I think, frankly, that would have been inappropriate. Certainly after the 31st, when we’d had the first two cases, I think that did represent a turning point, and maybe the following week, some direction at that stage would have been really helpful.
Ms Jung: Thank you.
My Lady, would that be a convenient point?
Lady Hallett: It would, certainly. 11.30-ish, 11.31.
(11.16 am)
(A short break)
(11.31 am)
Lady Hallett: Ms Jung.
Ms Jung: Thank you, my Lady.
Dr Sandifer, could I start, please, with a correction. When we were discussing the meeting that took place between you and the Chief Medical Officer for Wales on 26 January, do you remember we looked at the minutes for that meeting?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: And I put to you that the action in relation to testing and other things was to remain with a reactive approach. I’m told that that specific action was in relation to communications, but the agenda item also related – also was in relation to diagnostics and case management. Do you know what the actions were in relation to those?
Dr Quentin Sandifer: So, thank you for that clarification. That would make sense, reactive communication, and I’m assuming that the second part is with reference to the fact that our laboratories were ready to respond to test any suspected cases.
Counsel Inquiry: Thank you.
Is it right that the gold group was set up on 25 February, and that was two days before the first confirmed case in Wales?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Do you think that should have been set up earlier?
Dr Quentin Sandifer: I don’t think so, at the time, as strategic director, it’s the discretion of the strategic director when to establish the gold group. The reason that I hadn’t was that I was discharging all the functions of the strategic director sufficiently without necessitating convening a gold group. But by 25 February, the sheer scale and volume of the actions and activities we were involved in prompted me at that stage to convene the group when I did. So I didn’t think it was necessary beforehand because I was pretty well doing that full-time anyway.
Counsel Inquiry: Thank you.
Can we look at INQ000252365, please.
This is an email thread that was put to Dr Chris Williams last Friday, and it’s an email thread regarding PHE modelling work between Dr Williams, Andrew Jones, yourself and Rob Orford.
Can we see there it says, in the middle of the page, this is in fact you saying:
“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.”
What did you mean by that?
Dr Quentin Sandifer: Okay, so the first part is, I’m afraid, me being a little pedantic. STAC stands for a scientific technical advisory cell. It’s a construct described in emergency planning guidance to support strategic co-ordinating groups. Those were being established at this time, but what I understood Welsh Government was doing was establishing what came to be known as TAC and TAG. So I was being a little pedantic in making that –
Lady Hallett: Like myself.
Dr Quentin Sandifer: The second part is probably the more relevant here. Below that you will see reference to work that was being undertaken in Public Health England, and I just felt that the response that I was seeing in Wales at that time to the specific actions that Public Health England were taking was not commensurate and that we needed more urgency.
Ms Jung: Thank you.
Can we look at INQ000309871, please.
This is an email that you sent to Dr Rob Orford and Dr Tracey Cooper on 23 March 2020 regarding testing, and you said:
“Above all else I am really worry that National politics could trump public safety and need in Wales and we end up losing out badly in Wales.”
What did you mean by that? What was your concern about national politics trumping public safety?
Dr Quentin Sandifer: So this was around the time that we were in discussion with Public Health England about access to tests from Roche. I had been party to some of the discussions with Dr Cooper, and I had been copied in to most of the emails, and at this date I had thought that there was an agreement for 5,000 tests to come to Wales. However, as a little bit further down you’ll see, we didn’t have that in writing.
Now, my concern at this stage was that we were going to lose those tests, which of course subsequently events showed we did and we got about 500 tests, and I was probably stepping out of line by speculating whether there was anything at UK Government level that might be behind that, and emphasising my concern about the implications of losing that test capacity on public safety and need in Wales.
Counsel Inquiry: Thank you.
Could I ask you about the Emergency Coordination Centre (Wales), please. Is it right that you asked the Welsh Government in January 2020 whether they were going to stand one up?
Dr Quentin Sandifer: Yes, on 24 January, we’ve discussed that point, we would have been the first signal that perhaps they were invoking civil contingencies.
Counsel Inquiry: Can we look, please, at INQ000255778.
On 3 March 2020 did you receive this email from Andrew Jones which sets out:
“This is not a civil emergency situation but ECC(W) is operating in support of the health agenda. This is being kept under review and any change in activation arrangements will be shared as a matter of urgency.”
This email was then forwarded to you and Dr Shankar the same day, and it said the same thing; is that right?
Dr Quentin Sandifer: Yeah, I was astonished at this. I mean, we’re at the beginning of March, and Welsh Government resilience team were telling us that they didn’t think we were approaching, if we weren’t already there, a civil emergency.
Counsel Inquiry: Do you know why they were taking that approach?
Dr Quentin Sandifer: I think that question needs to be directed to Welsh Government. What they will point out, because I’ve read others’ statements, is that they had convened the – a Civil Contingencies Group on 4 February. We hadn’t received notice of that meeting in advance, but Dr Jones – sorry, Mr Jones, who was my liaison, just happened to be there when that invitation came in, and he joined Chief Medical Officer’s staff at that meeting. So we knew that there had been a first meeting, which would have suggested a level 1 activation of the pan-Wales response plan.
We subsequently learned that ECC(W) apparently had been stood up, although over time, through February, it appeared to us that appeared to be operating more as a health desk and not in terms of the functions, as I read them, in the pan-Wales response plan, and the purpose for that email chain was that I asked Andrew to go back and say: hang on, are we in? Are we actually using civil emergency powers at this moment? And here is the response.
Counsel Inquiry: Can we look, please, at a document that was produced by Public Health Wales, INQ000147246.
This is called “Covid-19 as a ‘major (health) incident’: Points to consider”. If we look over the page, we can see that at the top it says:
“This paper summarises the current situation of Covid-19 in Wales and provides an evidential summary of considerations to guide Welsh Government in any decision on the declaration of a Major Incident for Health in Wales.
“In preparing this paper and before declaring a major incident two essential questions need to be answered and this paper considers each in turn.
“1. Why declare a ‘major incident’ and why now?
“2. What would we expect from making a declaration of a ‘major incident’.”
You go on, don’t you, in this paper, to deal with three questions? We can see the first question there: why declare a major incident and why now? And you set out the factors that need to be considered.
Firstly, the current epidemiological situation, and you set out that the summary of confirmed cases in Wales as at 9 am on 11 March 2020 was that there was 19 cases confirmed from five different health boards. Two, a summary of contact tracing/monitoring as at the same time and date:
“109 individuals were under contact monitoring …”
Over the page. And of the 13 cases in Wales who have contacts under surveillance, the mean number of contacts per case was six, but this ranged from zero to 27.
Then factor 2, characteristics of the population exposed, you set out there that, in terms of demography, Wales has a higher proportion of the population aged 65 or over compared to the UK.
Over the page:
“Wales has a slightly higher proportion of the population aged 85 [or over] compared to the UK …
“Wales has 30,000 men aged 85 [or over] and 52,400 women aged 85 [or over].”
In terms of health status:
“Wales has a higher proportion of Census respondents reporting their health to be NOT good or very good compared to England …
“Wales has a higher proportion of Census respondents reporting having a limiting long-term illness compared to England …
“Wales has a high proportion of patients on a number of QoF registers including asthma and COPD, diabetes, coronary heart disease and stroke compared to the UK as a whole …”
Economic status:
“Wales has a lower proportion of people in employment compared to the UK as a whole …
“Wales has a higher proportion of people on short and long-term sickness absence compared to the UK as a whole …
“Wales has a higher proportion of people in Wales employed in service or sales roles compared to the UK as a whole …
“Wales has a higher proportion of lone parent families compared to the UK as a whole …”
And then dependency:
“Wales has a higher proportion of the adult population that provide care compared to England …”
Over the page, you say:
“This gives rise to an important question: Is the Welsh population more vulnerable than comparator populations that would necessitate earlier/different interventions?
“Objectively the demographic characteristics of the Welsh population and specifically the age profile of the population over 65/75, health and economic status, and dependency responsibilities are such that Wales may experience disproportionate levels of impact from Covid-19.”
Is that right?
Dr Quentin Sandifer: That’s correct.
Counsel Inquiry: Factor 3, you deal with, later on in that page, state of the health system in Wales to respond to Covid-19, and you say in the last paragraph:
“The predictions for the population of Wales are for over 1.5 million symptomatic cases … with 200,000 requiring hospital admission … An estimated 18,000 will require mechanical ventilation at some point … with 25,000 predicted deaths.”
Over the page:
“Older people and those with comorbidities have higher estimated hospitalisation and mortality proportions, so the estimates for Wales referred to above may be higher than the above under the [reasonable worst-case] scenario.”
You go on to say that:
“Behavioural interventions are planned, including home isolation and household quarantine and cocooning of vulnerable people.”
And in the next paragraph:
“Nevertheless, and quite apart from any consider of a major incident declaration, given the demography and health status of the population of Wales, Public Health Wales strongly advocates early implementation of these three behavioural interventions and specifically commends urgent attention directed at the elderly population cared for in residential and nursing homes in Wales.”
Can we see that below that, on the same page, you go on to ask the second question:
“What would we expect from making a declaration of a ‘major incident’?”
You go on to give the definition of a major incident under the Civil Contingencies Act; is that right?
Dr Quentin Sandifer: Mm-hm.
Counsel Inquiry: Over the page, you say:
“Declaration of a major incident in Wales would lead to the establishment of the Emergency Committee (Wales) and the establishment of 4 Strategic Coordinating Groups … across Wales.”
You explain that:
“At the time of writing all LRFs have started to form SCGs and Public Health Wales has attended or will attend all meetings arranged during the week commencing 9 March …”
Then you set out, don’t you, the benefits of declaring a major incident in response to Covid-19, and explain that:
“A recurring theme of lessons identified in multi-agency debriefs is that Major Incidents are not declared soon enough. Timely/early declaration would apply previous lessons.”
2, you say that in the middle of that paragraph:
“The response structures that support SCG decision making, [would be] made available. Examples include Tactical Coordinating Group, Multi-Agency Media Cell, [the] Mass Fatalities Coordinating Group, Logistical Preparedness Group and Recovery Coordinating Group. All these supporting structures and groups can benefit the response to COVID-19.”
Formal decision logs of actions would be kept, that’s paragraph 3.
And 4:
“SCGs would be able to make multi-agency decisions and use partnership networks on key areas such as ‘Communications’ and ‘Mutual Aid’ in a more effective manner than existing arrangements.
“Specific areas could include …”
And then you give some examples, such as domiciliary care and care of the vulnerable, closures of specific schools and events, consistent and effective use of PPE across agencies, and managing public anxiety, addressing any panic buying.
Over the page:
“Ensuring multi-agency consistency of communication/messaging on health, welfare, prevention and delay of the spread of COVID-19.”
At the bottom of this section:
“Set against this there are costs and consequences of setting up the above support infrastructure, which will require resource capacity … and may deflect or impact on the undertaking of necessary actions. It is assumed that the necessity to declare a major incident overrides these considerations.”
Then in conclusion, you say:
“Wales … is confronted by a pandemic … The known characteristics of Covid-19 and the known characteristics of the population of Wales suggest that the impact in Wales could be significant. Considerable preparatory work has occurred in Wales in the ‘containment’ phase but as we approach the ‘delay’ phase this will need to be expanded and accelerated.”
So does that document set out why Public Health Wales thought that the government should be treating this as a civil emergency?
Dr Quentin Sandifer: Yeah, I mean, we wrote this paper. It might be just helpful to just make a couple of points just to locate this in the narrative here.
So the WHO declared a pandemic on 11 March. Following our first case, on the 27th, announced on 28 February, we began to see case numbers rise, and by this week, of 11 March, those case numbers were rising exponentially.
What I didn’t know, I don’t think any of us knew, in fact I’m pretty sure none of us knew at that time, is that COBR had discussed the legislative basis for the response by then, I think on 2 March, and had decided against using civil contingencies legislation in favour of public health legislation. That quickly became apparent to us in the coming days, as we saw the Coronavirus Bill being developed, but at this stage, and in response to what we had been told by Welsh Government in the email we referred to earlier, I just felt we need to put our – lay our cards on the table and say to Welsh Government “This is how we see it, are you going to use emergency legislation?”
Counsel Inquiry: Was this your way of trying to persuade the Welsh Government to take its own course?
Dr Quentin Sandifer: Yes.
Counsel Inquiry: Is it right that the feedback that you received from the Welsh Government was that such a declaration would not be helpful?
Dr Quentin Sandifer: That was given to me verbally via Dr Tracey, who had I think received a communication from Welsh Government.
Counsel Inquiry: Thank you.
Can I ask you, please, about the development of local plans.
Dr Quentin Sandifer: Mm-hm.
Counsel Inquiry: Is it right that Public Health Wales was asked to produce some guidance in relation to those, and those were received on 21 August 2020?
Dr Quentin Sandifer: We’d sort of asked ourselves. I mean, what I was looking at during the summer was at the state of preparedness of the health boards for what we could expect in the autumn and the winter. And I personally felt there was a mixed level of preparedness, so I put it to the Chief Medical Officer: we probably ought to ask the health boards for these prevention and response plans, and we’ll write the guidance for you. Which is what we did.
Counsel Inquiry: So in your view they were not all satisfactory?
Dr Quentin Sandifer: They were not all satisfactory. Some – there were a couple who actually, doing a very good job. But there were a few that were causing us concern.
Counsel Inquiry: And is it right that the Welsh Government had said that they would write to the health boards in relation to those plans, and then you were surprised to read a letter from the government.
Which is at INQ000147256.
Dr Quentin Sandifer: Yep, so this is about seven weeks later. So Welsh Government wrote out, asked for the plans, we received the plans in mid-August. At the Health Protection Advisory Group on 24 August my deputy presented – I and my deputy had reviewed those plans, he presented our findings to that HPAG meeting. It was quite clear that further work was required, by all of the health boards, some much more than others, and so I was surprised then, you know, three weeks, four weeks later, that apparently the Welsh Government seemed to have stepped away from that plan –
Counsel Inquiry: From – and we can see that – I’m sorry.
Dr Quentin Sandifer: Apologies.
Counsel Inquiry: We can see that in the second paragraph, where they say that:
“Events have moved on rapidly since then. We had anticipated providing further feedback … however it has not been possibly to finalise that.”
Then it goes on to say:
“As such, we will not be providing formal feedback on your … plans. We are sorry for any inconvenience this might have caused.”
What’s the importance of having satisfactory local plans in the response to a pandemic such as this?
Dr Quentin Sandifer: Right. I’m not quite sure where I begin to answer that one, to be honest. I –
Counsel Inquiry: We’ve only got a few minutes left.
Dr Quentin Sandifer: Okay. Well, I think I’d already set the context in the summer. We were looking ahead to almost certainly a second wave in the autumn/winter. I mean, I think, to give some acknowledgement to Welsh Government, we were by then in the thick of it with all these local protection arrangements being put in place around Wales. But nevertheless, we were looking ahead, and I was just concerned that our health boards’ public health functions were not necessarily geared up for what might come in the winter.
Counsel Inquiry: In your statement, you say that what you think was missing in the first few weeks from 8 January until 20 February was national strategic leadership and co-ordination from Welsh Government. Do you stand by that?
Dr Quentin Sandifer: I do stand by that.
Counsel Inquiry: And are there any other reflections that you would like to tell us about?
Dr Quentin Sandifer: I don’t think so.
Counsel Inquiry: Is there anything else that you think Public Health Wales could have done better or earlier?
Dr Quentin Sandifer: I’m sure we could have done quite a few things better and earlier, and I set out some of my reflections in my statement, as do other – as has Dr Cooper. I don’t think I’ve anything to add to what I’ve already said.
Counsel Inquiry: In your statement you specifically mention the challenges that you faced in mobilising and expanding staff; is that right?
Dr Quentin Sandifer: That’s correct, and I was interested in the discussion – or, rather, the questions you were putting to Dr Cooper yesterday about that.
We are now in a much stronger position than we were, but I think this is more than just simply about resource in Public Health Wales, grateful as we are to Welsh Government for the additional investment; this is also about a system wide preparedness for the future. I allude to that in paragraph 157 with some reflection. I still think there’s more work to do to ensure that Wales and its system, public health system, is ready for a future pandemic.
Ms Jung: Thank you, Dr Sandifer.
My Lady, those are all my questions.
Lady Hallett: Thank you very much.
I think, Ms Foubister, you’ve got some questions, and then Mr Gardner.
Questions From Ms Foubister
Ms Foubister: My Lady.
Good morning, Dr Sandifer. I represent John’s Campaign and Care Rights UK. I’m going to refer to your witness statement, if it’s possible to bring that up.
That’s INQ000267867, and I’m going to look at page 12, paragraph 50.
You say in the bullet point in paragraph 50 that you chaired a gold meeting on 13 March 2020 to discuss stopping routine community testing, and closing down contact tracing in a managed way so as not to leave vulnerable people exposed.
Can I ask, what did you mean by a “managed way”?
Dr Quentin Sandifer: So those people that were already, if you like, in the system, that had been made known to us and we were conducting contact tracing, we needed to make sure we concluded that process for those individuals. As this is the containment to delay, and our response to the UK Government’s decision to move from containment to delay and what that practically would mean, essentially in response to the letter that the – or the link letter the CMO had produced on that.
Ms Foubister: And what factors were considered in relation to how this might impact vulnerable people?
Dr Quentin Sandifer: So, what we recognised is that, as we moved to hospital test – hospital testing, that we would therefore be stepping away from our community testing process and that we would therefore need to engage with the community through a broader range of activities through our professional communications, through the local health boards and their directors of public health, and of course we never withdrew contact tracing entirely because, in response to any local outbreaks or incidents, we would have responded to those as we would in any other public health – at any other time in a public health way.
Ms Foubister: I’m going to refer next to your paragraph 117, which is on page 28 of your witness statement. This kind of goes over towards the bottom. I’m going to look at the next page and paragraph 118 as well.
So in 117 you refer to a Public Health Wales advice note dated 24 October 2020, of which you were a contributory author, which was to inform Welsh Government decisions about steps to be taken after the firebreak.
Then over the page, looking at paragraph 118, you explain about halfway through this paragraph that:
“The … note acknowledged the harms from restrictions ([including] on personal mental health, [and] access to healthcare …”
So if we can turn to the advice note itself, which is INQ000147260.
And I’m going to look primarily at page 3 but it might be helpful to just look at the beginning of the section, which is at the bottom of page 2, if it’s possible to get the kind of split between those pages up.
Essentially, this note is talking about recommendations for post-firebreak, and what’s said at the bottom of page 2 is that whilst some regulation may still be required, this should only be used where, and then there’s three bullet points.
Looking at the final bullet point, this says:
“The harms arising from regulatory impacts on actions to health care, mental health, unemployment and consequent ill health and mortality have been calculated and the population health benefits of the regulations have been shown to exceed the harms caused on a Disability Adjusted Life Years … basis.”
So do you agree that this note recommends that further restrictions should only be imposed if those calculations have taken place?
Dr Quentin Sandifer: Yes, I mean, it’s worth I think saying at this point a range of people were involved in the drafting of this, including Professor Mark Bellis, whose name was mentioned by Dr Cooper yesterday, and at that stage we had established our Population Health Group within Public Health Wales, which was examining the wider impacts of Covid on the population, and this was, as I recall it, a suggestion from the work of that group that we should clarify our expectations around this.
Ms Foubister: And was there ever a thorough calculation of the harms caused by restrictions on those –
Dr Quentin Sandifer: I don’t know.
Ms Foubister: – needing care?
Dr Quentin Sandifer: To be honest, I don’t know, but that might have been undertaking by the Population Health Group, but I don’t know for certain.
Ms Foubister: And if we wanted to find out, who would you recommend asking?
Dr Quentin Sandifer: I guess we could get that information from within Public Health Wales, so I’m happy to take that away as an action from this Inquiry, if you wish.
Ms Foubister: Thank you.
Thank you, my Lady.
Lady Hallett: Thank you, Ms Foubister.
Mr Gardner.
Questions From Mr Gardner
Mr Gardner: Dr Sandifer, I ask questions on behalf of the Children’s Commissioner for Wales.
You briefly discussed your actions and the actions of Public Health Wales in the post lockdown, post first lockdown period, I just have two quick questions relating to those and to school closures and re-openings in particular.
So firstly can I ask: ahead of schools re-openings on 29 June 2020 what advice, if any, was requested and given by Public Health Wales?
Dr Quentin Sandifer: I’m not sure, I wasn’t closely involved in the work that, any work that Public Health Wales might have been doing in that area, so I don’t know, sorry.
Mr Gardner: I’m grateful.
The second one perhaps follows on from questions just being asked in relation to the firebreak. In the statement, in your statement, just ahead of that, at paragraph 116, I don’t need you to turn to it, but you note that Public Health Wales did give advice on the firebreak.
For the benefit of the Inquiry, that advice is dated 12 October 2020, and is INQ000147258.
In that advice, it appears that it is recommended that a number of actions are taken, but it doesn’t appear that it is recommended that schools are closed, just universities. Do you remember that advice?
Dr Quentin Sandifer: I remember that advice.
Mr Gardner: And can I ask, as schools were closed on 23 October 2020 for those Year 8 and above, would you suggest that that action was taken in line with Public Health Wales’ advice?
Dr Quentin Sandifer: I don’t know if we provided specific advice on school closures in respect of this advisory note. I note that that was the date of the start of the school half term, and I think that was a consideration that TAC or TAG had given in advance of introducing the firebreak. I’m not sure if Public Health Wales was asked or indeed gave any particular advice on that specific point.
Mr Gardner: I see, so it was simply just a – it wasn’t an omission or a deliberate address, it was –
Dr Quentin Sandifer: Not at all. The issue of the universities had been brought to our attention specifically with regards to – we had – a lot of students, obviously, had arrived in Cardiff, many of them perhaps as freshers, and, looking through the course of that term, what would be the position that we would recommend with regards to the universities, and that was what prompted us to put in the advice as set out in that advisory note.
Mr Gardner: I’m grateful, my Lady.
Lady Hallett: Thank you, Mr Gardner.
I think that completes the questions for you, Dr Sandifer. Thank you again for your assistance, and I do understand the long and very demanding hours that people like you spent trying to serve the public in responding to the pandemic, and please rest assured I shall very much bear the context in mind when I come to produce the reports.
But in the meantime, thank you again for all you and your colleagues did.
The Witness: Thank you very much, my Lady.
(The witness withdrew)
Lady Hallett: Yes, Ms Cowen.
Ms Cowen: My Lady, may I please call Shavanah Taj.