You might remember that the first death in custody I encountered caused by restraint had left me feeling some discomfort at the coroner’s verdict. That patient had both pneumonia and sickle-cell trait and so was deemed to have died of natural causes aggravated by lack of care. From that day, I had been concerned about the methods sometimes used by enforcers of the law: it was obvious that some simply didn’t know how to restrain people safely.
And restraint – indeed, death from restraint – was definitely on the increase. Joy Gardner was restrained so that she could be deported. Other deaths were caused when the police tried to apprehend suspects, particularly if those suspects had sickle-cell trait. But most deaths we were seeing caused by restraint now were due to another factor: the spiralling use of just one drug. That drug was, of course, cocaine.
Cocaine blocks the brain’s uptake of neural transmitters and the blockage can give continual, pleasurable stimulation: it gives confidence, euphoria and energy. Cocaine users can talk for hours, have heightened responses to physical stimuli, so sex is more enjoyable, and they have little need for food or drink. It can, however, lead to a greatly stimulated heart rate, agitation and psychosis. So, if restraint is required for a cocaine user, it is usually because he appears to be suffering from uncontrolled psychosis.
My first cocaine death came at about this time, and it was an early marker in Britain’s rising cocaine use. A very large and muscular drug dealer (who was also himself an addict) was arrested, having just bought a large quantity of cocaine, and at once began to punch the two police officers detaining him. An officer stuck an arm around his neck but that was just one manoeuvre in what was pretty much a fight. The fight ended with the dealer’s death. But how had he actually died?
A highly regarded neuropathologist confirmed that the dealer did not sustain a head injury in the fight, so that was not a cause of death. He may have been asphyxiated by the arm around his neck, but he showed only one of the three classic signs of this: insufficient to give asphyxiation as a cause of death. He had consumed a lot of cocaine, but his blood sample put him below the fatal level, so he probably did not die of an overdose.
Finally, I gave a combination of causes: the stress on his heart generated by his fight with the police, coupled with the fundamental stress caused by his cocaine use. Although a young man, he suffered from an inflammation of the heart muscle. Now this is recognized in cocaine users and sometimes called ‘cocaine myocarditis’.
Charges against the two police officers were later dropped. But this was another case that left me with a sense of discomfort I could not ignore. There were simply too many deaths when police officers restrained people. They surely believed that they were simply doing their duty, and they certainly had no intention of killing anyone. But people were dying. I knew I would have to do something, but it wasn’t clear to me yet what I could do.
While we waited to see if anyone would be arrested for Joy Gardner’s death, headlines everywhere announced an arrest for Rachel Nickell’s murder. It came as no surprise to me. I had been aware of the police’s suspicions about a man called Colin Stagg. I knew that, in the absence of forensic evidence, they had set up a honey trap on the advice of a psychological profiler. They recorded intimate sexual conversations between Stagg and an undercover policewoman, hoping Stagg would reveal himself as Nickell’s murderer. He did not, but the Crown Prosecution Service thought that what he did say was incriminating enough. I answered a number of questions about the murder from the team targeting Colin Stagg and my reconstruction of events that day on Wimbledon Common was used as evidence for the prosecution. I was expected to appear as a witness at the trial the following year.
With Britain’s most notorious murderer now believed to be safely on remand and awaiting trial, I was surprised to be called, in the autumn, to the body of another young woman. She had been the victim of an even more deranged attack than that on Rachel Nickell.
Jack the Ripper, who killed at least five women in East London in 1888, is still the stuff of film, fable and countless guided walks daily around Whitechapel. I suspect that the public is so fascinated by his gruesome crimes because they happened long ago. Samantha Bisset’s name, and that of her killer, are barely known, I believe because she was the victim of such a truly shocking Ripper-type murder that the press, for once, was reluctant to inflict on readers the horrific information unfiltered by time’s lens. I feel the same reluctance and do not here give details of this homicide.
Not only was Samantha killed and sexually assaulted, but also her four-year-old daughter. Whose body was then tucked into bed with her toys so that the first police officers on the scene harboured hopes, soon dashed, that she had safely slept through the murder of her mother.
I was called in by the coroner, my interest in knife crime now widely acknowledged, to carry out the second post-mortem on the bodies of Samantha Bisset and her daughter. This second post-mortem was not for the defence, since no one had been charged with the murder, but for the coroner so that the bodies could be released.
It had fallen to a colleague to visit Samantha Bisset’s flat, where these crimes had taken place. Therefore I saw the scene only through the photographer’s lens. I could imagine the terrible silence, how the usual camaraderie, the exchange of pleasantries, inquiries about families or holidays, the workaday stuff we use to remind ourselves of normal life when we are confronted by a homicide, how even that must have been impossible for all investigators in the home where these acts of cruelty and mutilation had occurred.
As I carried out the post-mortem, it became clear to me that the killer had been, like Jack the Ripper, something of a trophy-hunter.
I said to the police officers attending, ‘If I didn’t already know you’ve got Colin Stagg, I could really think this was carried out by the same bloke as Nickell’s murder.’
The senior officer shrugged.
‘No way; we’ve got Stagg and he’s as good as confessed.’
‘It’s not that similar,’ pointed out his colleague. ‘No one mutilated Rachel Nickell.’
‘Maybe he would have done if he hadn’t run out of time. Maybe he wanted to enjoy himself killing her but he was in a public place and he just couldn’t do that without getting caught. Killing a woman slowly in her own home probably would have been the next step for him, too.’
‘Yeah, well, he’s inside and he’s staying there for the rest of his life,’ said the officer. And soon the same could be said of the man who killed Samantha Bisset. Robert Napper was a twenty-eight-year-old warehouseman with a history of violence and mental illness. He had often been brought to police attention but somehow, perhaps due to poor record-keeping in those days before the widespread use of computers, he had always slipped under the radar. Now his fingerprints in Samantha Bisset’s flat connected him to this crime.
On his arrest, the police were confident that they had taken two ruthless murderers, Stagg and Napper, off the streets. So it was a very great shock when, in September 1994, Colin Stagg was acquitted.
The case was thrown out by a judge who said that the police operation was nothing more than entrapment and that, because Stagg had been lured into talking to the undercover policewoman, anything he said was inadmissible evidence. I was as astonished as everyone else: the police had worked with many professionals on the case and it had not occurred to me to challenge their absolute certainty that Colin Stagg had killed Rachel Nickell.
Colin Stagg was released – but into a different sort of jail. He only had to walk outside his front door to be subjected to immense cruelty. The police, press and, most of all, the public, were still convinced that Stagg had murdered Rachel Nickell and somehow got off on a legal technicality. This belief was so widespread that it didn’t even occur to me to draw attention once again to the similarity between Nickell’s killer and Bisset’s. I had learned only too well that expert opinion is marginalized by the system and, despite my brief foray into crime reconstruction, I was now firmly back in my box
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25
The relatives of those who died when the Marchioness went down had doggedly been pursuing their case all these years. Now they won a victory. When their attempts to persuade the coroner to reopen an inquest had got nowhere, they had turned to the Court of Appeal, which agreed that, by refusing them an inquest, the coroner was ‘in real danger’ of showing unfair, though unconscious, bias. As a result, an inquest was finally held by another coroner. Six years after the disaster, in 1995, the inquest jury agreed nine to one that the victims were ‘unlawfully killed’.
There was no one to prosecute now, since two attempted prosecutions of the Bowbelle’s master had failed, but the verdict fuelled the relatives’ belief that there should be a public inquiry. An action group continued to push for one. Their efforts were resisted by the authorities because there had been a complete overhaul of river safety as a result of the accident and it was argued that there would be nothing now to be gained by a public inquiry. The action group did not agree. Although it must have taken a great personal toll on them to continue their fight, the relatives insisted there was more to learn from their suffering and that a public inquiry was the best forum.
No one ever forgot the missing hands of the victims, and I was still held responsible for this. So, while I agreed with the reason the relatives wanted an inquiry, I dreaded it. Because the whole subject, including those hands, would surface yet again.
Pressure from the ground up on intransigent authorities was also evident in other important cases at that time. The investigations into the deaths of Joy Gardner and Stephen Lawrence, two years on, just seemed to be fizzling out. Except that there were many people who were not going to let that happen. First relatives, then whole communities, set out to mobilize public opinion by showing that, in the case of Stephen Lawrence, racism in the Metropolitan Police was hindering the investigation. In the case of Joy Gardner, they had to show that someone other than a court had decided to exonerate the officers involved.
At first, not much changed in the Lawrence investigation. However, to the astonishment of the Met, who insisted their staff had only been doing their job, prosecutors now charged three officers with the manslaughter of Joy Gardner.
At that trial, the QC gave me a cross-examination I shall never forget. Someone had leaked a copy of an early draft of my report on the case, and he pointed out that in my final draft there were over seventy changes. He dragged me through them, one by one, asking me to justify every word change, deleted comma or additional semi-colon. I felt my minor revisions (for instance, changing probably to possibly, or quickly to rapidly) made little difference to the overall case, but it was useless to say that in each draft I was refining and clarifying. The QC’s clear implication was that I worked closely with the police and had been leaned on to make them appear less culpable for Gardner’s death.
Our exchanges went something like this (and I am writing from memory since no transcript seems to have survived):
QC: Let us look at here … why did you revise the word ‘severe’ to ‘moderate’, Dr Shepherd? For that was certainly a dramatic revision.
ME: It seemed on reflection a more appropriate description.
QC: But why was it more appropriate?
ME: Well, I considered all the facts again very carefully and revised my opinion.
QC: Are you sure that revision wasn’t based on the receipt of further information?
ME: It was based entirely on my analysis of the case.
QC: But why would you make so extreme a change if you had no new information?
ME: I felt it was more correct.
QC: So … are you saying you … changed your mind?
ME: Indeed, I changed my mind.
QC: You simply changed your mind! Changed it on a, on a, on a mere whim?
I can see why he was suspicious. Of course, I regularly worked with police officers and it might have seemed a fair assumption that I was trying to please them. In fact, no one had leaned on me. Nor do I try to please. Yes, it might have felt awkward working with the Met if I had been instrumental in convicting three of its officers, that is the sort of dilemma I had always known a forensic pathologist must face occasionally. I had hoped that I would respond bravely to pressure and treat truth as my greatest ally.
Scandalously to many, all three officers were acquitted.
Personally, although I could not condone their actions, it was clear to me that the officers were, themselves, victims in a way: victims of an entirely flawed system. They had not been trained or informed how to restrain safely, they had not been warned about the possibly dangerous effects of their actions. They did not know the rights or wrongs of Joy Gardner’s deportation. It was their duty physically to carry out the orders of bureaucrats who made their decisions on behalf of the British people. They thought that by restraining Joy Gardner they were simply doing the unpleasant job they were paid for. The fact that they did it so badly, I felt, reflected on their employer’s bad practice.
Joy Gardner’s sad death was a catalyst for change. For me it was the last straw. I knew now what I had to do. I became an active and enthusiastic part of, indeed sometimes the instigator of, bodies set up not just to review restraint procedures but to train properly anyone whose job requires them to restrain: principally police, prison and immigration officers.
It is impossible to know what will later be the significance, if anything, of one’s own life: I’d like to think that in my case it will be my contribution to this change. It has largely been a question of making a nuisance of myself, running training courses, organizing conferences, writing reports, sitting on committees but, most of all, education.
Detractors of the police may be surprised that I found most officers extremely keen to learn correct and humane restraint: they, more than anyone, were aware of the deficiencies in their practice. They, more than anyone, knew that it wasn’t just the families and friends of the victims who suffered, it was also officers’ lives and careers which could be completely changed by the events of a few minutes. However, it was many years before every single organization which can lawfully restrain, from the Border Agency to the Youth Justice Board, finally endorsed the set of principles for safer restraint that we succeeded in introducing to Metropolitan Police training after the Joy Gardner case.
I became a member of the Independent Advisory Panel to the Ministerial Board on Deaths in Custody. It is jointly sponsored by the Departments of Health and Justice, as well as the Home Office. Sounds bogged down in bureaucracy? It isn’t. That’s just how much elbow power we needed to ensure the set of guidelines I wrote would be approved and adhered to.
The guidelines recognize that restraint can have a significant psychological effect on everyone involved, including those who witness it. They set out the principle that restraint should be used only when it is necessary, justifiable and proportionate to the perceived threat. And they acknowledge the possibility that poorly applied restraint can lead to death. So only approved techniques should be used, and only by trained, authorized staff.
Once an incident is underway, management is essential. I like to think that the guidelines here were influenced by my flying experience. Where there are two pilots in a plane, only one is in full control and, when control is passed from one to another, both pilots must verbally acknowledge this.
PILOT 1: I have control.
PILOT 2: You have control.
This routine brings clarity in a crisis. So I had the idea of transferring aviation practice to the crisis which is a restraint situation. In this crisis, the person who is responsible for the detainee’s head, neck and breathing is the person in control. It doesn’t matter if it’s the lowest-ranking officer present, that person must take control by saying, ‘I now have control of this incident.’ The others must acknowledge with, ‘You now have control of this incident.’ Crucially, control gives the authority to order an immediate release and be obeyed.
There is more detail of course, involving me
dical monitoring, filming, records and debriefing. But the overall aim was to turn the rugby scrum of forcible detention into something used only when necessary, and in a well-managed and safe way. The result, I believe, has been a dramatic reduction in the number of restraint deaths by the authorities. In fact, it is now much more dangerous to be arrested by a fellow citizen or shop or nightclub security staff.
After the acquittal of the officers in the Joy Gardner case, there were calls for a public inquiry. Which were resolutely resisted. As for the Stephen Lawrence case, it was clear the police investigating knew some names and had suspicions. However, no prosecution followed and so Stephen’s parents and friends began a heroic and dignified struggle for justice. They pressed ahead with their own civil prosecution of three of the five alleged killers.
I was called as a witness at this trial. Michael Mansfield QC was acting for the family in the unaccustomed position of private prosecutor. But it was all to no avail. The world watched as the proceedings collapsed almost before they started for lack of evidence considered admissible by the judge. Worse, the double jeopardy law at that time meant that the three who were tried could never again be tried for the same crime and it seemed that all possibility of justice was lost for the Lawrence family.
However, they did not accept this. They now demanded an inquest. It seemed public opinion was fully behind them. Many had been shocked by the acquittal of the officers involved in the Joy Gardner case. Now people were beginning to believe that the investigation into Stephen’s case was hampered by the same sort of racism that had led to his death, and even a public inquiry – established only at the behest of a government minister and something considerably larger in scale and much more legally powerful than a coroner’s inquest – began to look like a real possibility.
The Lawrence family’s patience and persistence finally did lead to an inquest. The five suspects were ordered to appear. They did so, but refused, as was their legal right at an inquest, to answer any questions. The coroner, who is not legally allowed to actually name murderers, was helpless in the face of their rude silence. However, the jury found a way around that and cleverly concluded, in February 1997, that Stephen Lawrence had been ‘unlawfully killed in a completely unprovoked racist attack by five white youths’. They might as well have said ‘… by the five white youths sitting over there’. And the Daily Mail more or less did so, publishing pictures of the five, naming them, and inviting them to sue if the Mail was wrong.
Unnatural Causes Page 24