Unnatural Causes

by Dr Richard Shepherd

  After that, we researched neo-natal milk allergy and Jen stopped eating and drinking dairy products. Chris became almost immediately a different child. He slept. He even smiled. But I am grateful for all I learned from that wailing baby. Thank you, Chris, for giving me this understanding of the great pressure some parents face.

  8

  Two years later, we had another child, Anna. She was lactose-tolerant and a much easier baby; or maybe it was we, her parents, who were easier now we had some experience.

  By the time Anna was born, my first post-mortem was far behind me and so were many more. As soon as I’d passed the initial part of my specialist pathology exams, I gathered speed, understanding and skill by working in mortuaries throughout London, from Wembley to Finchley to Tooting.

  I’d arrive for a morning’s work to find the dead waiting patiently for me on a line of tables. These were not suspicious deaths. Most were believed to have died of natural causes, which it was my job to ascertain.

  Many such causes are immediately obvious. Something looking like a blob of redcurrant jelly in the brain? That’s a stroke. Severe heart disease? That one is rapidly settled by dissection of the coronary arteries to find them crackly with plaque, or opening up the heart sac to discover a blocked valve or the soft shadow of oxygen-starved heart muscle. You can see and assess the kidneys quite quickly, also the lungs, spleen, liver, biliary tree, gall bladder, pancreas, stomach and bowel. The heart does take a bit longer and so do the throat, neck, trachea and bronchi.

  This was a time of great change for those of us carrying out post-mortems. The average length of time it took my predecessors, including my hero Professor Simpson, to carry out one post-mortem and ascertain cause of death where no crime was suspected might shock today’s pathologists: often just fifteen minutes. That was partly because mortuary staff saved time by preparing the bodies and removing the internal organs for examination even before the pathologist arrived. That practice was still the norm when I started. It had also been usual – and still was in places – once the cause of death had been found, to move on to the next patient with only a brief recording of the rest of the organs. Old-school pathologists argued that when there was clearly a heart problem, there was no need to waste time weighing the kidneys. And the coroners’ own pro-forma report, published by the government, seemed to confirm this, because it was just one page long.

  Of course, this led to whispered tales of pathologists who just looked at the heart and, if they found it at all diseased, declared heart disease the cause of death, bothering to look no further and ignoring the fact that most people in the Western world have some degree of atheroma (furred-up arteries) and many may be walking around with that same degree of heart disease. No one knew how many quick-fire pathologists were practising, but there was a strong suspicion that their excessive diagnoses of heart disease distorted government cause-of-death statistics.

  Those days had all but passed before I became fully established. It wasn’t just that I had been trained to examine bodies more thoroughly, but also because inside me there was always a forensic pathologist bursting to get out. I was keen and curious to see if a death was more suspicious than it at first appeared. I was also anxious to establish not just the immediate cause of death but anything relative to it.

  But how hard it was for keen, young Dr Shepherd to push in the old public mortuaries for the newfangled practices he had been taught. These included external examination of a body before it is touched by mortuary staff, weighing and study of each organ, samples taken for toxicology or histology, detailed recording of findings … even just brighter lights. The staff didn’t like any of this. Their mortuaries were often set at the back of some dark cemetery, and the elderly staff had worked there for years and were used to the old ways of carrying out post-mortems. I didn’t have to listen very hard to hear mutinous mutterings wafting from their offices about ‘new boys’ and ‘the good old days’. Sometimes, if I insisted on showing a particular interest in a case they considered routine, they got really annoyed and denied me my cup of tea. A cruel punishment which seldom lasted long.

  I did, however, learn something from the old-school thinking. Those charlatans who were only too ready to name the first irregularity they encountered as cause of death introduced young Dr Shepherd to truth’s elasticity. Truth is based upon knowledge. So, of course, it can be compromised by incomplete knowledge. As a doctor I sought truth through facts. As a pathologist I was now learning that truth could be directly affected by choices I made, by how many facts I chose to study. It was the first step in what was to become a lifelong examination of the nature of truth.

  Carrying out large numbers of post-mortems as scrupulously as I could, and always on the look-out for homicide, I came to know the human body and its many weaknesses as well as I knew the Tube map – better, perhaps. In those years, I was constantly busy: studying, teaching medical students and, of course, performing post-mortems. Death had become a way of life, and in the next phase of my training I had to be more or less dragged out of mortuaries to spend more time staring at those dreaded microscope slides of human disease.

  Disconsolate, I sneaked away from the hospital path labs whenever I could to sit in the office of my great friend and mentor, the forensic pathologist Dr Rufus Crompton. He had helped pilot my career and now he let me study piles of police photos, read reports and immerse myself in all things forensic: scenes, injuries, excuses and explanations of the accused, witness statements, everything. Just to remind myself what lay waiting for me when I no longer had to stare at end-to-end disease slides. And, eventually, I did begin to carry out, under supervision, post-mortems on sudden or suspicious deaths, the sort of deaths coroners would open inquests for and the police would investigate.

  At last, sixteen years after I started my medical training, my son now aged six and my daughter four, I qualified. I was a forensic pathologist. That goal I had fixed on since encountering Simpson’s book as a teenager had been achieved. But of course, it was only the beginning.

  I landed my first job at Guy’s Hospital. My boss was to be Iain West, the man who was top dog in our profession. After any homicide or disaster, his department was the go-to place for the police, coroners or solicitors. And, even more exciting, this was the very place where my hero, Professor Keith Simpson, had worked.

  There were four pathologists, and we were always technically ‘on call’ – but we could pass the work round among ourselves. Less interesting cases, that is, those which were medically or forensically straightforward, usually went down the pecking order. And as the newly qualified arrival, I was at the bottom of that order.

  When there was no homicide to examine we were teaching and lecturing to medical students or more professional audiences such as police or coroners’ officers. The students were mostly in the fourth year of their general medical training and, for many of them, this was their introduction to a world their comfortable homes had not exposed them to before. Rapes, murders, assaults; they lapped it up and the lecture hall overflowed. There were students sitting in the aisles and standing at the back. They learned not just about life but about how stupidity and inhumanity leads to fatal injury, and I hope they learned a little about recognizing when a death is suspicious.

  It was a pleasure to hold forth to enraptured rooms, but we spent a great deal less time lecturing about homicide than we did looking at it. Because London seemed to be awash with murder, or at least sudden and suspicious deaths. We had meetings in our offices, poring over photos, arguing about cases, and then we continued the discussions in the pub, sometimes with barristers or the police. The place just buzzed.

  Of course, I treated my earliest cases, simple though they were, with great concentration and seriousness, working with guidance from Iain and other colleagues. But the day had to come when I went out alone to my first homicide as a lecturer in forensic medicine at Guy’s and, because we were so busy, it came quickly. It is hard to describe how proud I felt as I heade
d towards a dull block of flats in Croydon where a body awaited me. Proud, and not a little nervous.

  It was a weekday, mid-morning. My heart was beating hard, perhaps with the effort of trying to look like a pathologist who had been called out many times before.

  Ringed by a physical and human barrier of tape and police officers, and beyond them press and neighbours, a young white man lay in a roadside gutter. A Metropolitan Police photographer was already busy but paused as I bent to examine the body.

  The deceased was lying on his back and nothing more serious than a few cuts and abrasions were visible on his face. But I knew a lot more was happening than that because beneath his upper body was a pool of blood.

  I reached out. He still felt warm to my touch. He was not yet stiff, although his muscles were already tightening, most notably around the neck and jaw and in the fingers.

  I rolled him over. His thick jacket had a stab hole at the back. That’s where all the blood had come from. I let his body return to its original position.

  As the photographer worked I made more notes for my post-mortem report. In it I would have to describe the scene and what I had found there, then I would give details of my full examination of the body at the mortuary, and finally a conclusion about the cause of death. The last part would, hopefully, be straightforward, since there was still blood dripping from the stab hole in the young man’s back. But there was a lot of work to do between now and my final conclusions.

  The victim had not yet been identified, so for now he was simply recorded as Unknown Young Caucasian Male. He looked about eighteen. He was slim and some might describe him as handsome. I made a diagram of what I saw, especially noting the position of bloodstains in the road and on the adjacent pavement. I also scribbled notes about the scene, the deceased’s clothes and the position of the body. The notes were to re-emerge later in the post-mortem report as:

  Rigor mortis was established around the neck and jaw but was less marked elsewhere on the body. These findings are consistent with death occurring about 3 hours earlier.

  Still trying to sound authoritative, and not as though this was my first case, I asked the coroner’s officer to have the body removed to the mortuary. I followed it there, where I was joined by various police officers, including a detective superintendent. I read this in my report now with incredulity. There is no way a ‘super’ would turn out today for a street stabbing.

  At the mortuary there were further photographs, and I wrote detailed notes about the victim’s clothes before I even started on his body.

  Jacket: heavy blood staining on the left side of the back. Gravel from roadway also present. Three defects in the fabric. Defect one – 8cm to the left of the midline seam, approx 21cm from the collar. 8mm in length, approx horizontal. Defect two – 12cm right of midline seam, approx. 21cm from collar. 16mm length. Vertical. Defect three – 3.5cm below the same approximately on the lateral midline of the right sleeve. 18mm in length. Horizontal.

  Sports shirt: blood staining on the back and left side. Three defects in the fabric …

  Blood staining on the back of the waistband of the jeans, boxer shorts and underpants. Blood splashes noted on the back of the lower half of the legs of the jeans …

  When I had scribbled several pages about the clothes, we removed them, putting each one in a separate evidence bag, which was taken and labelled by a police officer.

  Once the patient lay naked on the table for post-mortem, I could see how extensive his wounds were. Three stab wounds in his back, one of which had clearly been the fatal wound, and nine additional significant injuries to the abdomen and face. In my notes are body charts – blank outlines of bodies – and on these I drew details of the injuries, numbering them, and then wrote notes:

  Five injuries to left side of face:

  (i) 3mm diameter contusion immediately above lateral margin of left eyebrow.

  (ii) 10mm curved laceration with associated bruising on lateral margin of left upper eyelid.

  (iii) 20 x 22mm abrasion over lateral aspect of left zygomatic arch. Surface dried …

  Lacerations are different from the clean incisions of knife wounds. In a laceration, the skin is torn apart rather than sliced and this is caused by a blunt weapon. Not many people regard a road or a kerb or a building as a ‘weapon’, but if a body slams against it, then its effect is that of a weapon. In this case, I thought laceration could have been caused by the victim’s head hitting the kerb when he fell.

  Abrasions are scratches or grazes, which seldom penetrate below the epidermis – the skin’s outer hard layer. They don’t, therefore, actually bleed, but they can ooze blood, often as spots. They can be a feature of road traffic accidents because they are caused by sliding over rough surfaces. Of course, grazes are very common in life, but forensically they are interesting because they can also occur after death. Supposing the young man’s body had been dragged along the road: this might have caused the abrasions but it could be difficult to tell from them if he had been dragged before or after he was murdered.

  Contusions are bruises. Damage to the small veins and arteries causes them to break and bleed. Children have more resilient tissues so their skin can bruise less easily than the skin of older people which has lost its elasticity. Bruises can be deceptive, however, because their major component is blood, and this is both fluid and biodegradable. Result: bruises change over time and under the influence of gravity. Most notably, they change colour. That is because, once blood is outside the confines of a blood vessel, the body starts to break it down. Generally speaking, bruises go from purple to yellow to green to brown. There has been much research into dating a bruise from its colour and it would be very useful if any of the systems devised to do this were reliable; unfortunately, none is.

  It can certainly be disconcerting to find that bruises become more prominent after death and even that ‘new’ bruises have appeared days or even weeks later. This doesn’t mean the body has been injured at the mortuary. It is simply a sign that red blood cells have continued to leak from the damaged blood vessels – although pulled by gravity rather than pushed by blood pressure.

  It took a long time to write all the notes on the victim’s exterior injuries. When I had finished I looked up, blinking. The police officers blinked back at me. There was a pause while I remembered what to do next.

  These days I wouldn’t experience the slightest shame in pausing to think but then I so wanted to appear entirely in control that I had to pretend to scribble notes for a moment to buy myself time. I wished the staff would turn off Radio 1 but was too shy to ask them.

  Chris de Burgh was singing about a lady in red.

  I tried to concentrate. Of course. Swabs next. Of the genitalia, anus and mouth so the scientists could look for signs of a sexual assault.

  ‘Any chance you could switch that racket off?’ said the super.

  The staff weren’t very pleased; however, they did so, to my relief. But now the room seemed eerily silent as I took samples of the young man’s hair as well as clippings from his nails, which could be searched for skin or fibres or any other debris trapped there that might link him to an assailant or a place. At the end of the post-mortem, I would take samples of blood, urine, tissues for histology and anything else that might be relevant.

  The exhibits were all marked with my initials and a number (RTS/1). I wrote each label with a new boy’s pride. For thirty years that unique triplet of letters has signified my involvement in a case but on that day, the first time I wrote them, the letters looked stark and new, like a school uniform at the beginning of term.

  Everyone in the room – the coroner’s officer and the police officers – waited for me to start the internal examination. It is a little-known duty of police officers to observe post-mortems: their presence is an important part of the protocol. The super had, of course, seen quite a few in his time, but for the young PC who also witnessed the process it was a first. He had been looking distinctly miserable during the e
xternal examination and when I picked up my scalpel he turned deathly pale.

  ‘All right, lad?’ asked the super.

  The constable nodded grimly.

  I tried to think of something to say to make him feel better. But I couldn’t. I was too busy trying to look as if I had performed plenty of forensic post-mortems entirely alone.

  ‘Oh, you’ll soon get used to it,’ I said airily, to hide my own nerves.

  The PC swallowed. I attempted a reassuring smile but was so anxious that my muscles felt oddly stiff and the smile may have been more of a grimace because the PC did not return it but instead looked alarmed. Then, as I opened the body, I became aware that the young officer did not take his eyes off me. The way he stared at my face was so disconcerting that a couple of my cuts wobbled slightly. I glanced up at him and saw that he wore the fixed mask of sheer terror. Staring at my face was apparently his method of not looking at what my hands were doing.

  I would have liked to find a way to reassure and support him. But I was so tense that I was without the resources to help. Even the experienced super and the coroner’s officer, who had greeted each other like the veterans of many cases together, had now stopped talking and were watching me in deep silence. Usually the mortuary staff can be counted on to lighten the atmosphere with a quip or a comment but today they were oddly still. Why didn’t someone talk? Just say something? No one did. I even found myself wishing they would switch on the radio again. Although perhaps to a different station.

  They watched as I tracked the wounds internally. When I examined the victim’s facial wounds from the inside, the PC’s body shook suddenly and he rushed from the room, hand over his mouth.