12 May 2022: Pickles - B

On to “clinical freedom” as a foundational principle of all things doctoring; a “given” according to the witness. The matter was being discussed at the time across the medical profession, for example, in relation to NICE and the potential of that body to restrict clinical freedom by its decisions.

As part of her additional role, Dr Pickles attended the meeting of the AIDS Group of Haemophilia Directors. She was not aware of the questions being raised about the suitability of Haemophilia clinicians being responsible for leading on their patients receiving, for example, AZT as a treatment. It would not ordinarily be seen as within their purview as clinicians.

Almost gossip-like, we hear there had been a robust debate with Edwina Currie, because as Minister she wanted to tell infected haemophiliacs that they could not have sex with their wives. Dr Pickles was arguing against such a stark instruction. Dr Pickles resisted saying anything negative about Currie due to the nice things the former Minister has said about her in relation to the BSE episode. It was noted how there was a fairly frequent turnover of Ministers (and civil servants). The witness said this could be an opportunity to re-focus activity. With respect to that interpretation, it could alternatively be said that the frequent change of personnel, both ministerial and officers, was a way of keeping control.

In relation to the safety of blood treatments, Dr Pickles could not speak about the biological aspects. In general, safety was not a matter of specific, written down, criteria. Each case was considered separately. Some drugs were inherently “unsafe” such as certain leukaemia treatments, but the need for them in the face of the consequences of the condition itself would justify allowing their use. The Advisory Committee on Dangerous Pathogens (ACDP) took the most structured a role in relation to things like the risk of viral hepatitis in treatments. The considerations included not just the pathogen itself, but also the possibility of risks associated with errors and blunders. Dr Pickles again referenced the BSE Inquiry report for its useful discussion of risk assessments in this type of context. In relation to transmission routes, Dr Pickles does not recall there being a particular focus on how such related to AIDS or Hepatitis.

Flagging issues up to Minsters was a matter of their being either press or Parliamentary interest, or there being financial impacts. Some Ministers were very interested in their brief (for example, Stephen Dorrell) while others were more interested in what was being said in the Daily Mail (no example was offered).

On Crown Immunity, Dr Pickles said it was “above my pay grade” to influence or have an opinion on any haggling over the application of Crown Immunity. Clearly, this was exclusively a top-level prerogative which even very senior civil servants avoided being associated with as much as possible. Hopefully, the heat in that potato will rise when former senior Ministers come to be roasted.

Transfusion policy and blood products was recommended to become part of something called “medical audit”, but that was a new initiative at the time and not well resourced until a couple of years later. This led on to a question about the received wisdom, or not, of single unit blood transfusions. It seems this was quite common, but not recommended indeed condemned by medical leaders. However, the use of a survey to understand the issue better was not favoured. Medical audit was generally considered as a “local issue”, even hospital level. Central Research and Development might be a medical audit issue for the DH, but not in general.

Randomly again, the big sigh incidents from this witness seems to coincide with an occasional document being displayed. The sighs are accompanied by grins and nods. It is as if a document, or the memories associated with it, are like unexpectedly bumping into an old friend. Still strange.

In relation to the HIV Haemophilia Litigation, a claim against the Yorkshire Regional Transfusion Centre was the first flag up Dr Pickles had of a potentially bigger problem. She had commented that Dr Rejman had handled it well on behalf of their branch of the DH. The possible practice of alternative site testing by individual was raised as a problem, in the same way false positives from screening was a relevant problem. Switzerland was cited as an example, but Dr Pickles did not know enough to say how certain the evidence from there was in reality. People around the world were looking to the UK to provide a lead in responding to the issue of viruses in blood. That was surely a misplaced trust. Sir Brian interjected to build on one of his questions to Dr Rejman. He is obviously concerned to discover if there was, or yet is, an accepted explanation for the gap between a test being identified and it being used.

Documentation demonstrated the detailed level of discussion at the time when the Government was seeking to come up with a line on potential negligence claims. Dr Pickles did not want to see a situation of peoples’ professional reputations being tarnished, including haemophilia clinicians, or of money being “screwed out of the Treasury”. She did not review the documents from before her time so as to speak from actual knowledge (because she “didn’t have time”), but she knew many of the people who could have been implicated and saw them as honourable, professional people. She could not see how it was possible they should be held accountable in a negligence claim. Dr Pickles, the CMO and others appear to have wanted to convince themselves of the security of the Government’s position, and so not be liable to losing a negligence case.

“I was never involved with communicable diseases in general” said Dr Pickles, then casually added, “I had AIDS, and then the blood side, with a bit of BSE thrown in,” as if these are not significant communicable disease issues. Go figure. Dr Pickles appeared to be increasingly discomfited. Her words became less audible, less coherent, far less sure. Then, out of the blue, Dr Pickles felt to stand up for Dr Rejman and put on record her view he was dedicated and conscientious. She thinks the targeting he has experienced has been completely misplaced. This appeared to be an odd time to interject on this matter when she herself was potentially being exposed to criticism at that very moment. And given her loyalty in defending past colleagues (friends?) without actually reading the history, her defence of her subordinate was perhaps lacking credibility. Jenni did not acknowledge the defence of Dr Rejman, she just went right on with the dismantling of the witness in front of her, the witnesses’ employers too, and her not-too securely elucidated storyline.

Counsel is tapping into a rich vein of vulnerability and the witness is struggling to keep her head above water. Dr Pickles was not in favour of providing money to haemophiliacs, but quickly added “it was not just me”. It was a group (-think) decision. Where have we heard this defence? Oh yes, Dr Rejman. However, when pressure mounted, the groupthinkers managed to find a way to justify, in carefully chosen words, the making of payments when the drive to do so became irresistible. However, Dr Pickles said AIDS was not special, even though it was caused by the NHS, because lots of people suffer as a result of NHS treatment. That was from her perspective as a clinical pharmacologist. So, Jenni sought to clarify if the witness thought the Department had done anything wrong. “No, that was not my thinking at the time”, was the reply. That turn of phrase is familiar too, but from where I couldn’t possibly say. Ok, it was Dr Rejman again. A pattern is emerging again. Maybe by coincidence they are being advised by the same lawyer. When Council sought clarity liability if the meaning was not so much about negligence, but before Jenni could finish the question, the witness generously suggested it was about the possibility of them “screwing up”. Under that more technically worded definition, the situation probably was that the DH could be exposed.

This witness has been comprehensively cornered; she knows it, she knows Counsel knows it, she likely knows we know it, and she has nothing left to offer in her own or her bosses defence. Is it morally right to glean some (guilty?) pleasure from watching the layers of the Pickle being slowly peeled back? Who cares?