Unnatural Causes

by Dr Richard Shepherd

  In mass disaster management, false identification is the biggest fear. This is obviously hideous for everyone, especially if a family later begins to suspect they may have buried the wrong body. The coroner rightly wanted the most secure and accurate identification methods that were possible. Now we have the option of DNA analysis but, although the subject of much pub discussion, DNA identification was just not available to us then. The two most secure means were still fingerprints and comparison of teeth with dental records.

  The problem with dental records is that you, of course, have to know the name of the missing before you can begin to search for their dentist, and only when the name of the dentist is known can you request their records. And then that request can take a very long time to fulfil. This is especially true if records must come from other countries. And by now we knew that the partygoers on the Marchioness were a high-flying crowd from all over the world. That was clearly going to cause problems and delays.

  As a result of all this, fingerprinting was the first choice of identifier. Fingerprinting plus dental records would be ideal. Absolute accuracy can be a time-consuming business, but the coroner took the view that accuracy was more important than speed. Which is surely correct, although I can understand this is very frustrating for anxious relatives.

  Those who are trying to cope with the possibility of sudden bereavement after a mass disaster often cannot understand why the relatives are not simply invited into the mortuary to walk through the lines of fatalities to claim their loved one. Many relatives of the Marchioness victims, believing that identification must be easy, did in fact suggest that, if they could just be allowed into the mortuary, they could find their family member. I understand their need and their logic, but it is false. And it would have been utterly inhumane to allow this.

  People find it hard to believe that, in mass disasters, visual identification is unreliable, especially so when death has been traumatic or the body has been immersed in water. But even the uninjured and undecomposed dead are often simply not recognizable to those who knew them as animated individuals. Without life, facial expression, movement, robbed of our essential selves, our bodies can look very different. And this is certainly the case when the dead have been held by the Thames for hours or days.

  The fact is that relatives, even immediate family, when they are under great stress, are very likely to make mistakes. They may identify a body that isn’t their relative. Or they may not correctly identify a body that really is their loved one. These are known as false positive or false negative identifications, and they happen more often than you might think. Later, perhaps much later, the identifying relatives sometimes worry they were wrong. And then change their minds. This can occur long after burial or cremation, when our ability to review the identification is lost. Add to the difficulties of identification the immense emotional trauma of having to look at many, many bodies in the mortuary to find the one you think may be your relative. With all my experience of death and dying I know I couldn’t walk between rows of victims and reliably identify my own wife or child or parent.

  I should say that being called on to see a body for identification purposes is quite different from seeing that body once police and pathologists are sure that the correct identification has taken place. I personally believe every relative who wishes to do so has an absolute right to see the body of their deceased. It is cruel to deny – for whatever reason – a family this chance to say goodbye personally. But the reality is that bodies may be injured, decomposed and smelly. We can do a lot with reconstruction, but we can’t perform miracles. So it may take many hours of talking and discussing, of initially showing photographs of the body, before we can move into the room where the body lies. And then maybe more time again before the relatives will actually look at the body. Spending this time with families is crucial. So is care and compassion. We must do nothing to add to the trauma.

  As unreliable as visual identification is the use of ‘mobile’ or moveable indicators, such as clothing, jewellery or wallets. These may be treated only as clues to identity because people swap jewellery or look after friends’ wallets. And to use clothing, we would have needed to know exactly what the victims were wearing on the night of their death, relying on descriptions from others when such descriptions are seldom either accurate or available.

  Despite this, the coroner was inclined to accept visual identification and mobile indicators – but only from those bodies recovered from the wreck of the Marchioness itself, and only as long as they showed no decomposition. In all other cases, the coroner instructed that mobile means of identification were not dependable.

  The coroner’s conclusion, when we discussed identification, was that fingerprinting of each body was essential. As a list of the suspected missing was compiled, police were despatched to homes (unless they happened already to have fingerprints on their database) to collect personal items on which fingerprints might be found, so that these could be used to match those taken in the mortuary.

  Our problem was that these were drowned bodies. They were likely to be damaged, either by aquatic predators or by contact with rocks, bridges, boats or other underwater obstructions. Drowned bodies show all the discolouration and bloating of normal decomposition plus some much earlier skin changes. Even if retrieved from the water within a few hours, those inevitable ‘washerwoman hands’ can make fingerprinting difficult, and when there is a complete loss of the skin from the hands – elegantly called ‘degloving’ – well, then it can be extremely difficult or almost impossible to take fingerprints from the deeper layers of skin, the dermis.

  At first this disaster seemed easier than Clapham because there was no severe mutilation of the bodies. As time went on, however, bodies arrived in worse and worse condition and decomposition became our nemesis.

  Once again, each body travelled through a system. First, we described in detail clothes, jewellery and general appearance. I then helped remove the clothes and performed an external examination, describing tattoos, scars and anything unusual that might assist identification. Police officers made notes and the body was photographed and refrigerated.

  The second phase was the full post-mortem, after which the internal organs would as usual be replaced in the body cavity and the body sewn up and made presentable for viewing by relatives.

  Finally, I submitted a report about each of the deceased for the coroner, concluding with the cause of death: drowning. If he was satisfied with all this, especially the identification processes, he would open an inquest and release the body.

  The first free-floating body was found in the Thames before 7 a.m. that Sunday morning. No more were found that day but in the afternoon the Marchioness was raised and when I reached Wapping police station, twenty-four had been found on board and arrived at Wapping in the warmth of an August day. They were tagged before being carried on to Westminster mortuary.

  This mortuary is run by Westminster City Council. At that time, it had six holding fridges, refrigeration for sixty bodies and a further six units for extra-wide bodies. It had freezing facilities for eighteen bodies.

  Whatever the outside temperature, bodies are refrigerated to a temperature of 4°C. This slows down the decomposition process but does not stop it completely. We do not freeze bodies until the post-mortem has been fully completed.

  During a disaster, we work in a world of constantly changing information, often helping to revise and then re-revise it. The key problem for those managing the Marchioness victims was that no one had any idea exactly how many people had been on board the boat, nor who they were. So, within a couple of hours, while the rescue operation was still going on and before the first body had been found near Vauxhall Bridge, a telephone bureau had been opened to process information from friends and relatives that might help us identify victims. And by that afternoon, as Westminster mortuary prepared for its influx of dead, relatives of some on board had started to appear at police stations with photos of their loved ones and descript
ions of what they might have been wearing.

  By the end of that first day, the police believed that there had been 150 people on the Marchioness, of whom sixty-five, including those twenty-four bodies taken from the wreckage, were considered missing.

  The next day I was back at the mortuary starting the long process of identification and post-mortem. We learned that eighty-seven survivors had identified themselves and we had twenty-five bodies, so we knew that if police estimates of the number of people on board were correct, there were a lot more bodies to come.

  Expecting so many further arrivals, we worked as speedily as accuracy would allow. It was an extremely intense week. To see so many young people here was not just unusual, it was shocking. I was aware, as though in my peripheral vision, of the intense misery of parents fearing the worst, waiting for news. Bodies were laid out one at a time on the six tables in the post-mortem room and we worked our way doggedly from one to the next, feeling the greatest service we could perform for the bereaved was to do our job as efficiently as possible.

  By eight o’clock that evening we had completed post-mortems on all twenty-five in the mortuary and, of these, thirteen had now been fully identified. The next day, Tuesday 22 August, we learned that the casualty bureau had received 4,725 calls from anxious relatives and had already amassed more than 2,000 documents on individuals believed to be on board. As we waited, a few more bodies were found in various places on the Thames, upstream and downstream of the disaster, and the police revised their estimate of the number of people on board the Marchioness down to 136.

  By the end of the day there were thirty bodies in the mortuary and the police thought there were twenty-seven more to be found. But by now, immersion time in the Thames was taking its toll. Waterlogged skin was falling off fingers and the officers were having trouble getting prints using the standard inking process. The coroner called for dental records to help confirm the identity of the remaining fatalities but this would take time and relatives were anxious for news. So attempts to fingerprint continued but, as the hours went by, conventional fingerprinting was failing. It was now necessary to use a specialist technique and more sophisticated equipment. This equipment was based in a laboratory in Southwark – which had no facilities to manage bodies.

  The routine process for individual bodies recovered from the Thames that could not be fingerprinted at the mortuary was to remove the hands, fingerprint them at the lab in Southwark, and then return the hands to the body. They were sewn back on to avoid distressing relatives, who, when the body is appropriately arranged, were unlikely even to see the stitches. The coroner allowed this and so the procedure was followed. Seventeen pairs of hands were removed.

  That evening more bodies were found between Westminster and London Bridge, and then another, far downstream past Wapping. The next day, eight more bodies were found. One, retrieved at Cherry Garden pier on the south side of the river at Bermondsey, was wearing uniform and strongly suspected to be the Marchioness’s captain, Stephen Faldo. Another was nearby, then four more were found near HMS Belfast, not far from London Bridge. Two more were on the other side of the wreckage, upstream around Westminster.

  That gave us a total of forty-four bodies. By now we had positively identified twenty-four of these. Of course, there was an assumption that every single body found on the river must be from the Marchioness, but this was unlikely to be the case: there are suicides and other deaths in the Thames almost weekly, and we had to be aware of this.

  By the following day there were forty-eight bodies and, although we had been working as hard as we could, six were still waiting for post-mortems. The police were saying they now believed there had been 140 people on board the Marchioness: eighty-four survivors and fifty-six lost or missing. The dental records of all the known victims had been requested, those from abroad via the relevant embassies. That night, Wednesday, the casualty bureau closed, saying it had gathered all the information about the missing it could.

  However, bodies were still being found and the police revised their estimates again. They thought there were eighty-three survivors and fifty-six lost or missing. But there was now a report, for the first time, of a fifty-four-year-old woman running the disco on the boat. This was followed by another report of a woman jumping into the Thames near HMS Belfast after a handbag full of bricks was found on the riverbank. As we carried out our post-mortems, some officers began to grumble at the way the casualty bureau had closed when so many inquiries were still outstanding. And by Thursday evening, there was a new development that pushed police estimates of the number of people on board up again: a group of gatecrashers at the party came forward to say they had survived the sinking – but a friend was missing.

  Meanwhile, back at the mortuary, a request was sent to the lab for the return of the seventeen pairs of hands as soon as possible so that they could be reunited with their owners. Another eight pairs of hands were delivered to the lab.

  There was not much more we could do now but wait. It was the Friday before the August bank holiday. Outside the mortuary, people were leaving hot London for the weekend. We were waiting for dental records to arrive, fingerprint information from the labs, or just more bodies: fifty had now been recovered. After all that frantic activity, the mortuary seemed almost eerily quiet.

  No new bodies arrived in the mortuary over the long weekend. On the Wednesday, the police attempted to name the people still missing. One of them was the party’s host, Antonio Vasconcellos, who had been celebrating his twenty-sixth birthday. Another was a Frenchman. And there was still one unidentified body in the mortuary, a man in his twenties: he may have been nothing to do with the Marchioness. Or he could be the gatecrasher, who had still not been named.

  By the end of the week, forty-six of the fifty bodies in the mortuary had been positively identified and the others partially identified, meaning that we still needed more information to make it positive. Except for this one anonymous young man. Who was he? Nobody had any idea. He fitted no description.

  Since he was carrying a distinctive key fob, the police photographed it and decided to release the picture to the press. So we had one person completely unidentified, and still two missing people: the Frenchman and Antonio Vasconcellos. We could stop worrying about the gatecrasher, though: he had shown up alive and well.

  On Friday there was a major step forward in the identification of the mystery man. The distinctive key fob was taken to the Frenchman’s flat and it opened the door there. Now only the party host was missing. That night the body of a young man was found downstream of the wreck, between London Bridge and Bermondsey, somewhere in that area broadly known as the Thames Upper Pool. We were fairly confident this was Antonio Vasconcellos, but after two weeks in the water we knew it would take some time to identify him positively. We were also confident that the other bodies in the mortuary were nothing to do with the Marchioness and the police were sure now that there were no more dead. The toll was fifty-one and there had been 137 people on board.

  We had worked hard and, I felt, had served the victims and their families well. Only afterwards did I understand that, while I had been immersed in my work at the mortuary, a lot more was happening inside and outside it than I realized.

  Everyone responds rapidly and wholeheartedly to an emergency. Everyone does their best at the time. So, although everyone, no matter how well meaning, should be held to account, it is hard to receive criticism afterwards for actions that may have been taken under extreme pressure in a crisis. The emergency and follow-up services, after many of the 1980s disasters I listed earlier, frequently found themselves on the receiving end of some very angry criticism. It is such anger that very often fuels reform. This is nowhere more true than after the sinking of the Marchioness.

  I learned that, although some relatives early on identified their dead at a special viewing room at the mortuary, many others were told, due to late recovery of the body and the extent of the decomposition, they could not, they were not allowed t
o, see their loved ones. Sad reunions of the living and the dead do not usually take place at the mortuary: more often the body is moved to the undertaker’s first. But undertakers, as well as the police, later claimed they had been told such viewings should be strongly discouraged and, even in the face of opposition, relatives should be refused access to the dead.

  I do not know who ordered this or why. When I learned of it, I assumed it was the result of misplaced compassion, because someone thought that seeing a son or daughter in a state of decomposition is traumatic. However, that person clearly did not know that not seeing them is even worse.

  One relative later wrote:

  We were never actually prohibited from seeing [our daughter] but were talked out of doing so at every stage … when I went to the undertaker’s expecting to see her, the coffin was already sealed … I could not sit in a room with a box and so walked out of the funeral parlour. I feel very strongly that I should have had the opportunity of time alone with her. [Her mother] … has since seen photographs of [our daughter] and from the photographs there really is no reason why we should not have seen her.

  Another wrote:

  On Friday 25 August I was told by the coroner’s officer that my son was not recognizable as a human being. On Thursday, 31 August, the undertaker phoned me to say they had collected [his body]. I went immediately to their premises and asked for the coffin to be opened. I wanted to make sure that I had found my son. The undertaker told me that he had been given orders not to let me view my son’s body. This made me extremely upset. I was never given the opportunity to see him, to touch him and to say goodbye to him. The undertaker told me that he had been an undertaker for twenty-five years and he had never before been told that relatives could not view a body. ‘I was told the coffin was sealed and it must be kept sealed,’ he said. Since it is the undertakers who place a body in its coffin and they are the ones to close it, this was clearly untrue.