Public scorn at the failure to apprehend Stephen’s attackers reached such a pitch that at last it really began to seem that demands for a public inquiry into the Met’s investigative failures would be met. I was personally delighted by this strong move for change which was now forcing a rethink in official and police culture. It had not escaped my notice that so many of the deaths in custody or under restraint I had been dealing with were the deaths of black people, and, put simply, the potentially increased vulnerability of some individuals through sickle-cell trait certainly did not explain this disparity. I could see change was necessary, but I could not imagine how change might come about. It never occurred to me when I examined the body of Stephen Lawrence that precisely those knife wounds would, over the next twenty years, be the precipitating factor in that change.
26
After about eight years at Guy’s, I had itchy feet. The wing of Iain West had become more smothering than sheltering and, despite our friendship and his many promises to promote me, he had not done so. I applied directly to the medical school dean behind his back for a senior lectureship and was immediately promoted. But Iain really didn’t want me or perhaps anyone else to become his deputy. As for his possible early retirement to embrace fully his country-squire lifestyle of huntin’, shootin’ and fishin’, well, Iain made it clear that was not even on a distant horizon.
I looked quietly for other openings and continued with my work. By now, approaching the mid-1990s, both my children were at secondary school and occasionally I could glimpse in their young faces the adults they would become rather than the small children they had once been. It had always been hard to carry out post-mortems on children who were the same age as my own kids: this was probably the one time my hand wavered – momentarily – over a body. And now that they were growing up, there seemed to be more cases involving children. Had I been avoiding them before? Or were they really on the rise?
One day I was called to examine a baby who had died in his mother’s arms at ten months. I found him to be well nourished and well grown. There had obviously been resuscitation attempts but there were no other marks on him, and certainly no sign of violence or trauma. The internal examination was just as unrevealing: there was not one indication of abnormality.
I waited for the toxicology, virus and bacteria test results but decided that if they were all clear I would have to give sudden infant death syndrome as the cause of death. The police were not too happy that I was thinking SIDS and promptly handed me a bundle of background notes. Ah. Now the case had a context, and what I read seemed to change things.
Officers had arrived at the mother’s flat in response to her 999 call. She was twenty-two years old and lived alone after receiving death threats from the baby’s father. Those threats – but also the mother’s drinking habit – had placed the ten-month-old baby on the at-risk register. To protect them against the father, an attack alarm had been installed in the home.
When the mother phoned the emergency services at about 9 p.m. she sounded drunk and referred to a ‘death in the family’. The attack alarm rang too, but only as police were actually on their way to the flat.
The police were concerned because, only a month before, this young mother had been convicted for being drunk in charge of her child. This is an offence that carries a fine and rarely a custodial sentence: its main purpose seems to be either to humiliate mothers into sobriety or to alert social services to the possibility of neglect or abuse.
On arrival, only seven minutes after her call, the police rang the bell. No one came to the door. They peered through the letterbox and could see the mother pacing up and down the hallway with the baby in her arms.
She was not panicking and there was no obvious threat, so they did not break in. They gently persuaded her to open the door, although she had great trouble doing this because she was so drunk. When eventually the police were able to enter, they found that the baby she had been cradling was dead.
All attempts were made at resuscitation. The mother was angry, aggressive and, of course, upset. A couple of hours later a blood sample was finally taken, and from this it was possible to extrapolate her blood alcohol level at the assumed time of the baby’s death: that is, when she dialled 999. The level was 255mg/100ml of blood. It is illegal to drive above 80mg in England and Wales (now 50mg in Scotland) and for a less hardened drinker 255mg/100ml could possibly be a fatal dose. So we can conclude that, although she was clearly accustomed to alcohol, the mother was very drunk indeed.
The sample revealed no evidence of any drug use. However, she was too drunk to explain whether the child had died in her arms or in his cot or on the sofa or her bed. And she was unable to say where she had been at the time.
Perhaps your sympathy for the bereaved parent is now strained. Perhaps mine was. I had the baby’s blood tested for alcohol and drugs. By now we had begun to recognize that some parents who drink or take drugs, in order to keep their children quiet while they do so, administer to them the same substances they enjoy. And sometimes they administer a fatal dose. However, when the toxicology report came, it revealed that this was not the cause of the baby’s death.
There are fads in illnesses, as in most things. Their popularity waxes and wanes according to our perceptions. Sudden infant death syndrome, where an apparently healthy baby dies for no evident reason, gradually entered the public consciousness during the 1970s and 1980s and by the early 1990s it had become statistically significant, peaking at two per thousand live births.
SIDS was a welcome diagnosis for many pathologists. It seemed to explain the unexplainable and it cleared parents or carers of any blame. SIDS says that the baby did not die of any unnatural cause and so the assumption must be that it died of natural causes. But SIDS was not universally acceptable – there were some police officers and non-medical coroners who were sceptical.
In this case, the police suspected that the drunken mother’s hand had been involved in the baby’s death. This was reasonable in the circumstances, except that there was simply no evidence at all to support it. Therefore, having excluded all other possible causes of death, I was left with SIDS. There were many changes in my life immediately after this. And I was to look back on the cause of death I gave in that case just one year later and feel some surprise.
This was, in fact, my last case at Guy’s. I had learned of the forthcoming retirement of Dr Rufus Crompton from my alma mater, St George’s Hospital in Tooting. He was my former teacher and mentor, who now headed a department of which he was the sole member of staff. The opportunity to replace him was really exciting. St George’s was willing to grow the department and if I got the job I’d be able to expand it along the managerial lines that I was always suggesting to Iain and which he completely ignored.
One grey day I asked Lorraine if Iain was free and then walked rather nervously into his office. It was a large room, filled with utmost chaos. Stacks of files and other papers teetered on the desk, on every shelf, on the floor and on the huge table at the centre of the room, which was used for meetings. When one was scheduled, Lorraine would move all the piles of paper off the table, finding some corner of the floor for them, and take away the overflowing ashtrays and the old cigarette packets. When the meeting was over, it would all start again. Judging from the clutter on its surface, I estimated that it had probably been over a week since the last meeting.
Iain was sitting at his desk and did not immediately turn his huge jowls towards me when I came in. This was perhaps not the best time to approach him, because I knew he was tired. Yesterday he had been shouting, which always meant that, whoever he appeared to be angry with, he was actually angry with himself, generally because he had failed to do something. Although of course he blamed Lorraine: she had not reminded him to produce that report on time. The report had almost certainly been sucked into the vortex of other files on his office floor but the court had been unsympathetic and ordered him to produce it by this morning at the latest. So he and Lorraine had
been in the office until late last night, he dictating, she abandoning her shorthand pad and typing directly into the computer.
Now he sat with a menthol cigarette between his fingers. Another, forgotten, burned in the ashtray by his microscope. And a third lay, smoke spiralling from it, to one side of the room next to the flickering screen of his huge desktop computer.
I said, ‘Iain, you’ve probably heard that Rufus Crompton is retiring …’
He raised his eyebrows. It had long been understood between Rufus, me and Iain that one day I might like to go back to St George’s.
‘I’m planning to apply for the vacancy,’ I said.
He lit another cigarette from the end of the one he was finishing, looked around for an ashtray, or anyway one that wasn’t already full, failed to find such a thing, and stubbed out the spent cigarette on the packet.
‘I suppose you’ll be needing a reference,’ he said.
He smoked even more furiously than usual but did not betray emotion in any other way. He was cordial and wished me luck in my application and we agreed that, if we were both to run departments, we would not be rivals but highly co-operative with each other. I’m not sure either of us meant it, though. We were rivals already and now that we were to be equals in different hospitals that rivalry was unlikely to cease.
Leaving busy Guy’s with its famous departmental head and plethora of fascinating cases to leap into the unknown was scary. I took a break that summer from post-mortems as I moved to St George’s and began to set up the new department. It was essential for the police to recognize us and call us out, so, tedious though it was, I had to create a sound management and financial structure.
After a few months of this, I was surprised to find myself missing the mortuary, where I could use the skills I’d honed over so many years. When a pathologist friend on the south coast went on holiday I agreed to fill in for his routine coronial post-mortems. It was the school summer holidays. Anna and Chris were teenagers now. Anna was still at school but Chris had just finished his GCSEs and was hanging around at home, so I offered to take him with me. If he waited while I did a few quick routine post-mortems for the coroner – no homicides here, just sudden, natural deaths which required an explanation – then afterwards we could go for a walk along the clifftops. Chris was a relaxed sort of boy who was up for anything, so he was happy to sit reading in the car while I went into the mortuary to work.
I put on my kit. The mortuary staff had lined the bodies up on tables and prepared them for me: in those days that meant the bodies were still opened up, with the ribcages removed, and skulls opened too.
There was the usual small talk with the coroner’s officer, during which I happened to mention that my son was waiting for me, reading in the car.
The coroner’s officer clearly saw this as borderline neglect.
‘I’ll bring him to the office, he’ll be more comfortable in there,’ he offered. ‘He can have a cup of tea.’
I was busy over an open body, PM40 in hand, when in the corner of my eye I saw Chris. He was walking through the post-mortem room with the coroner’s officer. He seemed unperturbed. I, however, was extremely perturbed. I wanted to shout, ‘Get him out of here!’
But I knew that would make the mortuary seem even more shocking for an unprepared teenager so, with a supreme effort of will, I winked at him from behind my mask and waved my PM40 jauntily. To tell the truth, I felt unmasked. All these years I had shielded my children from the reality of my work, without actually lying to them or misleading them, and now Chris had been unexpectedly exposed to it.
As we walked along the clifftops afterwards, there was a sort of mumbling between father and son.
‘Er … were you all right with what you saw at the mortuary?’
‘Didn’t really bother me,’ he said. ‘But the coroner’s officer was an idiot.’
Whatever subject they’d differed over (football, I think), it was more memorable for Chris than the sights and sounds of a working post-mortem room. He and Anna had sometimes actually come to the mortuary with me when I was working, so they were familiar with the smells and the clangs and the general ethos of the place. If the bereavement room was empty they would sprawl over the chairs doing their homework beneath the fish tank while beaming staff plied them with tea and biscuits. They had never actually asked what I was doing there, out of sight.
I did hope, without voicing this, that Chris wouldn’t breathe a word at home about his expedition through the post-mortem room. And so, of course, he told Anna.
‘Can I come to a post-mortem?’ she demanded. ‘It’s not fair if Chris has been and I haven’t.’
‘I wouldn’t exactly call that coming to a post-mortem …’ I said.
And by now Jen had overheard.
‘You saw what?’ she asked Chris, throwing me an accusatory look.
‘I’ll have to get used to that sort of thing if I’m going to be a vet,’ said Chris bravely. ‘I’ll have to cut up dead things all the time.’
‘Well, I’m going to be a vet too,’ said Anna. ‘Or a doctor.’
Ours was a medical household and incidents and cases were routinely discussed, often quite candidly, although I still hid the case photos. If asked what their parents did, the children still answered, ‘They’re doctors.’ If pushed, they would say, ‘Dad cuts up dead bodies’ – which usually prevented any further questions. But, on the whole, it was much easier to explain that their mother was a GP who was specializing in dermatology than that their father was a forensic pathologist.
In a few years, Chris and Anna would both be off to university. It was hard to imagine them as independent people leading independent lives. It was hard to imagine they wouldn’t need me any more. I determined that, although my new job would certainly be demanding, I should try to spend as much time with them as possible before they left.
27
Once I had started up the department I was back in the mortuary, and this became a busy, productive period. Other staff arrived. Rob Chapman, a friend and excellent pathologist from Guy’s joined me, and two secretaries, Rhiannon Layne and Kathy Paylor. And so did two clinical forensic doctors, Debbie Rogers and Margaret Stark. They examined the living victims of crime, and they also looked after the medical needs of the people who had been arrested and detained in police cells. These were the first academic clinical forensic posts in the UK, a great asset to our embryonic department. In addition, we had a trainee pathologist. Very quickly, we became nationally and internationally recognized, and that meant we were busy almost at once.
Being boss gave me the chance, to some extent, to choose my cases. One very difficult area I would have liked to palm off onto my colleagues was the very area I’d been immersed in with my last case at Guy’s – babies. But I could see that wasn’t fair. Because now everything was changing in the pathology of child death, and this reflected society’s changing attitude to children. I realized that now I probably would have given a different cause of death for the baby of that drunken mother.
From the early 1990s, the number of SIDS deaths – or deaths diagnosed as SIDS – significantly declined, and that decline has continued (the most recent statistics tell us that SIDS now accounts for only 0.27 deaths per 1,000 live births).
The improvement was largely due to the worldwide campaign (called ‘Back to Sleep’ in the UK) which persuaded parents to stop putting their babies face down in bed, as this had been identified as a major risk factor in SIDS. Other factors we knew of included adults in the house smoking, adults sleeping on the sofa or in bed with the baby (which could result in ‘overlaying’ or rolling onto the child), alcohol- or substance-abusing parents, too much bedding and too high a room temperature. With all this knowledge, and an education programme for parents, the numbers fell.
Numbers also fell because perceptions of SIDS changed, and consequently the fundamentals of its diagnosis. It was now sometimes referred to as a ‘diagnostic dustbin’ and guidelines for pathologists were t
ightened up. The thinking was that, before diagnosing SIDS, we should examine very carefully first the history – both the child’s medical history and the caregiver’s story of events – then the scene itself and finally the pathology of the deceased child. There isn’t really any positive pathology for SIDS. It’s a question of confirming the absence of every other possible cause of death.
And why, really, were guidelines tightening up and people talking about SIDS as a ‘diagnostic dustbin’? Simply because many pathologists did not follow the criteria laid down for its use and gave it for any death they couldn’t explain – and often these deaths were under-investigated by both the police and the pathologist. SIDS had become such a catch-all that there were now unpalatable suspicions. Could it be that some so-called SIDS cases might be acts of adults rather than God?
Those uncomfortable suspicions were rooted in the pioneering child-protection work of Professor David Southall and his colleagues. In the light of evidence he produced, it was hard not to face facts. He was involved in studies which not only identified Munchausen syndrome by proxy – parents with this mental disorder deliberately make their children ill in order to receive attention and support – but also produced irrefutable evidence through covert video surveillance that some parents certainly do attempt to injure or even kill their children for reasons that are unclear.
Unnatural Causes Page 25