Unnatural Causes

by Dr Richard Shepherd

  The detective glanced, reluctantly, at the old man’s neck. I pointed to the thin, superficial lines of blood on either side of the large slash wound and explained hesitation injuries to him. ‘We don’t know exactly why people do this: perhaps they’re just building up their courage. Preparing for the pain. Or trying to find the right place. But hesitation injuries are strong indicators of suicide.’

  The detective still looked sceptical.

  ‘Those lines always mean it’s suicide?’

  ‘In my experience that is usually the case.’ My experience at the time was not so very extensive, but I didn’t plan to tell the officer that.

  ‘If he cut himself out there …’ The detective indicated the pool of thick blood in the parking area. ‘… and died just here, how much time would he have had to dispose of the knife?’

  I thought.

  ‘Up to a minute.’

  Not that he would have been able to hide the knife after losing all that blood. He might have been able to throw it but he had almost certainly just dropped it.

  The detective, who really seemed to want a homicide to brighten up his Sunday, said, ‘Someone could have knifed him and run off with the weapon.’

  ‘Well …’

  ‘It’s possible, you admit the possibility, that his wound was inflicted by someone else?’

  I hesitated. Of course it was possible, anything was possible. But it was my job to collect and present evidence, not to speculate on every wild theory.

  I said, ‘It’s unlikely. But it’s possible.’

  The detective looked triumphant.

  ‘However, I believe that the knife must be here,’ I said. ‘And in a fairly obvious place.’

  The team looking for the knife heard this. They paused. Some put their hands on their hips, others stood straight, staring at me. They had been searching for a while now and didn’t want to hear they had missed something obvious.

  I went out through the little back door, past the bloody wellington boots, past the greenhouse and the old clay flowerpots, past an ancient tin bath that lay on its side, following the blood trail to its source.

  ‘He lost a lot of blood and he was losing more fast as he moved back towards the house, I really think he would have just dropped the knife somewhere near this spot rather than throwing it,’ I said. ‘Perhaps the daughter …?’

  ‘Says she hasn’t touched a thing.’

  When there is a suicide, often a relative or friend suspects it has taken place. Perhaps Mr Garland had threatened suicide or maybe he had just seemed very depressed. I tried to imagine the middle-aged daughter arriving at speed in her red car, heart beating, scared of what she might find. The first thing she would have seen was the pool of blood. Her car had screeched to a halt just short of it, and, leaving the vehicle askew across the parking area, barely even shutting the door, she would have jumped out and run into the house to find her father.

  ‘No knife, no suicide,’ stated the detective firmly.

  ‘Could you reverse her car, please?’

  Everyone looked at everyone else and the detective went to ask the daughter for the keys, then came out and slowly backed the car away from the parking area.

  Beneath the wheel’s original position lay a bloody, bone-handled bread knife.

  The detective can have had no idea of the relief I felt at having my theory confirmed. I had probably sounded very sure of myself. And I was very sure. But deep down I have, since childhood, recognized that life is a series of unexpected twists and turns. This knowledge enslaves me. Although it is my job to be certain, I was unable that day, and am still unable, to escape a greater certainty: that there are always other possibilities.

  20

  By now I was beginning to suspect that my attempts to reconstruct homicides from the track of stab wounds might just be eclipsed by a technique which had recently appeared on the distant periphery of forensic work. People had started to talk about DNA testing. DNA, they said, would be a better means of identification than fingerprinting or any of our other current methods. We discussed it in the pub during one of our raucous office Friday lunchtimes, our debate leaking into the afternoon, the secretaries and technicians all joining in. Was DNA the future? Or one of those technological advances which would have no workable application for years and years?

  The new developments did make me wonder if my special interest in the track of stab wounds would soon be so old-fashioned it would help no one. My fascination with the idea did not abate but it happened that at around that time another specialization seemed to find me. At first I tried to ignore it, but somehow it managed to kick me hard in a vulnerable place I scarcely knew I had: my social conscience. I did think I already worked for society: forensic pathologists helped families and state to understand the dead and so find justice, didn’t they? I was rather slow to take on board the idea that I personally might have a more direct role to play in bringing about social change.

  Working closely with the police at the scene of a crime was a part of my job. Their professionalism and camaraderie made the chaos, blood, filth and human tragedy of the average homicide a lot easier to deal with. When I had a good relationship with the officers involved they sometimes kept me informed as their investigations progressed, and I valued that.

  How hard it was, then, to bear witness to another sort of policing. One that had little in common with the dignified, serious men and women I encountered.

  On arriving at a hospital mortuary for a post-mortem one night, the information I was given at the briefing was a bit sketchy. I soon gathered why. The patient had died while in the care of the prison system. I noticed that there was no banter or small talk as we changed and walked into the post-mortem room to examine the body.

  The deceased was a twenty-eight-year-old Nigerian. An external examination revealed abrasions on the front of his nose and around the lips. I saw he had recent bruising to his arms and particularly around his wrists, as well as on his abdomen.

  I said, ‘So was he wearing a body belt when he died?’

  They nodded glumly.

  A body belt is an unattractive contraption consisting of a thick, heavy, leather belt with handcuffs passing through a ring on each side. The belt, of course, goes around the abdomen and the wrists are attached to it by the handcuffs.

  When I examined the deceased internally I found that he had severe atheroma (furring up of the arteries) but only in one place: inside a carotid artery, the main artery in the neck that takes blood to the brain: very unusual in a twenty-eight-year-old. In a few years’ time that might well have become life threatening. But it certainly did not cause his death.

  Further tests showed that he also had sickle-cell trait.

  Sickle-cell disease is the UK’s fastest growing genetic disorder. It is carried by millions of people worldwide, mostly of African or Caribbean origin. Those who suffer from it are more likely to survive malaria (not very useful in metropolitan London). But that’s the end of the good news. It is caused by a mutation in the haemoglobin gene and haemoglobin’s vital function is to transport oxygen around the body. In healthy individuals with normal haemoglobin, these red blood cells are fat and round with a dimple in the middle – not unlike a ring doughnut. And, most importantly, they are bendy. The sickle-cell genetic mutation swaps one amino acid and this means that the haemoglobin folds differently. For most of the time that’s not a problem but when the haemoglobin molecule is not holding on to an oxygen molecule it can become stiff and fixed in an unusual shape. In this case, red blood cells can look like odd bananas – or sickles, hence the name of the disease. The result of the stiffness and strange shape is that, instead of flowing smoothly through the blood vessels, the blood cells tend to pile up, interlock and block the vessels – starving vital organs of oxygen.

  Pains in the joints and abdomen and often anaemia are just the start of the problems these blockages can cause. Sufferers were once virtually guaranteed a short life but increasing knowledge of the dise
ase and new drug treatments are changing all that, and maybe gene therapy will soon be available to help further.

  The full, severe, disease means that the individual has inherited the same faulty gene from both parents. This is called homozygous and, as a result, sufferers can only make the faulty haemoglobin. However, inherit one faulty gene from one parent and one normal gene from the other and sufferers are called heterozygous. They can make some normal haemoglobin as well as some faulty haemoglobin. These individuals will have the lesser form of the disease, which, not surprisingly in a genetic disorder of this sort, is even more widespread than full sickle-cell disease. This is called sickle-cell trait.

  Sickle-cell trait was for a long time thought to have no significant impact on those who had it (unless they caught malaria). Only in recent decades has it been recognized as a major risk factor in certain circumstances. And those are circumstances that in any way significantly deprive sufferers of oxygen. So, no climbing Everest for those with sickle-cell trait. In fact, sickle-cell trait sufferers should avoid all situations where there may be any threat of oxygen deprivation at all, so as well as climbing high mountains, that includes scuba diving, parachuting … and being forcefully restrained. Of course, the former are a matter of choice. But not the latter.

  This was the first case for me, although soon others followed, in which a black patient died under restraint and in whom I could find only a few sickle cells in the tissues when I looked down the microscope. This indicated that they did not have full sickle-cell disease but sickle-cell trait, and this could then be confirmed by specialist tests on their haemoglobin. Sadly, many probably did not even know that they were carriers.

  This particular patient also showed signs of hypoxia, which is a lack of oxygen. He had been forcibly restrained but none of his injuries was actually life threatening. Clearly, then, the police actions must have gone further than was indicated by the areas of bruising, all of which I noted carefully in my report.

  It was only later that I was given the full story. He was being held at a London jail awaiting trial for conspiracy to defraud. I’m not sure what he did for his behaviour to be described by prison medical officers as ‘strange’ enough for them to arrange his transfer to the hospital wing of Brixton jail. I think from that I would assume mental health problems, although none of the medical notes specifically said so. I didn’t think that this behaviour was drug-related since, although cocaine was found in his urine, it was very minimal.

  During transportation to the hospital wing at Brixton he became ‘agitated or aggressive, then unresponsive’. That description comes from notes taken by the doctor at the accident and emergency department when the patient was driven there later. According to the police’s own records, on arrival at Brixton Prison’s hospital wing ‘it was noticed that he appeared not to be breathing’.

  So he was bundled into the back of a van and taken to A&E. He was given CPR on the way but those resuscitation attempts were not successful. In fact, the A&E doctor’s notes added, ‘fingers stiff!’

  It seemed to me that he may have been held in a way that restricted his breathing and his oxygen supply – possibly face down, or maybe someone knelt on his chest. But the post-mortem showed that death was caused primarily by the fact that he had severe pneumonia.

  This was enough to slip him out of the suspicious death category. He had died from natural causes – a combination of pneumonia and sickle-cell trait. Although I felt and said that he might have survived pneumonia if he had been given proper treatment immediately and if he had not been restrained in a body belt face down, or in some other position that further restricted his ability to breathe.

  The deceased was of no fixed abode and he may, therefore, have been living rough and contracted pneumonia before his arrest, or he may actually have contracted it in custody. An inquest was held and a verdict of death by natural causes was given – aggravated, the coroner said in something of an understatement, by lack of care.

  This took place less than thirty years ago but in those days in general – and this is not true of all communities – the bulk of society thought criminals deserved what they got, and that the police were always, or at least usually, right. So, even without the natural and mitigating factors of his sickle-cell trait and pneumonia, there would have been no outcry at the death of a prisoner. And I am sorry to say that, the times being what they were, such indifference was especially true if the prisoner was black.

  Indifference from both public and police meant there was an almost total lack of training and understanding about how and when to restrain someone safely. Such training was not considered relevant or useful for the day-to-day work of a policeman or prison officer. It was acceptable for staff simply to rugby-tackle people, jump on them, wrestle with them, do whatever was necessary to get them under control – and ‘control’ meant ‘still’.

  Police and prison officers were trusted to do what was right and the nation was uncaring about the possibility that they might not. I, however, could not share this attitude. I saw a series of deaths in custody or under restraint. Many of the dead were black. This was not just a sickle-cell problem, although it was sickle-cell that had brought it to my attention. I felt that I had to do something. But what? I worked with the Met and good, supportive relations were essential at the scene of a crime and afterwards. I liked and respected many officers. A pleasant working relationship with them was essential to me and so I did not know how to call them on their behaviour. But I knew I had to, and as the deaths under restraint were more than occasional, I realized that I had to focus on this. I just wasn’t sure yet how to use my knowledge to improve the situation. After all, pathologists examine bodies and understand the cause of death. Our findings might contribute to the saving of future lives or the process of justice. But it wasn’t my job to change the world. Was it?

  21

  I could not ignore the problem of death caused by restraint but, intellectually and analytically, I remained committed to studying knife murders. As a bullets-and-bombs man, Iain West had specialized in a comparatively straightforward area. The perpetrators want someone dead and they shoot them, end of story. Stab wounds require perpetrator and victim to be up close and personal. Stab wounds often involve mixed motives. Stab wounds may have more to do with a sense of theatre than a definite wish to kill – particularly if the injuries are self-inflicted. But what really interested me was my theory that every wound track tells a story. I was still sure that the exact track a knife made into the body – and often victims are stabbed many times – could provide a sort of photograph of the homicide itself if one knew enough about wounding.

  At each knife murder I was anxious to learn anything I could from the wounds. Very soon after the suicide of the old man with the bread knife came another death by knife. It was an entirely routine homicide but it did show me that all those experiments with the Sunday roast were getting me somewhere.

  Winter followed quickly behind that sunny autumn day, and soon the first frost came. One morning, I was called to a body found by a canal in north London. I arrived at noon to find a young man in jeans and jacket lying face down in a grassy waste area, his arms beneath him. The temperature was still only 2°C and this did not help the usual problems determining the time of death. Body temperature was down to 20°C and the police photographs showed that there was frost still on the body when found. Rigor mortis was established but not fully fixed.

  All I could tell the police from this was that death had occurred at some time between midnight and 6 a.m. – eliciting the usual response of veiled frustration.

  The grass adjacent to the deceased’s feet was bloodstained and next to the body was a bloodstained kitchen knife. I turned him over and saw that the mouth, nose, hand and front of the chest were covered in blood.

  We moved him to the mortuary for a full post-mortem, where I confirmed that a single stab wound had penetrated first his clothes, then the cartilage of three adjacent ribs. The cartilage had de
flected the blade. Just a little, but that small deflection meant sadly that the knife went straight into the aorta. It had cut through the aorta to the trachea behind it. The track ended in the oesophagus. The total track length from the skin surface was 12cm. The incision went horizontally from front to back and slightly from right to left.

  The black-handled kitchen knife found nearby would certainly have been the right size and shape to cause this wound. The force used must have been more than moderate as it had cut through both clothing and the three ribs. There were also minor abrasions on the deceased’s face and various abrasions on the left arm.

  It looked like a straightforward stabbing. The police were trying to match it to the defendant’s story. The defendant and victim, both aged about twenty, had been drinking together and then went out for a walk. They were good friends but, as revealed during his police interview, the accused was secretly angry with his mate:

  Q: What did you talk about?

  A: Nothing really.

  Q: Were you armed?

  A: No.

  Q: Was he?

  A: Yeah, he always carries a knife.

  Q: On previous occasions have you both carried knives?

  A: Yeah, but mine was at home then.

  Q: I must tell you that you are still under caution. Do you know how he died?

  A: I think I do.

  Q: Please tell us.

  A: We reached the canal and he said he felt sick. So I stood there and waited for him and I looked down and saw my trainer was undone so I bent down to retie my lace and he said, what do you think of me going out with your sister?

  Q: Mary?

  A: Yes.

  Q: How old is Mary?

  A: Thirteen.

  Q: What did you say?