Unnatural Causes

by Dr Richard Shepherd

  ME: It may.

  QC: And, if he has suffered some physical trauma – blows – that will not improve matters, will it?

  ME: Well, I think that depends on the blows he has received.

  QC: Now, Dr Shepherd, you said the deceased had received about a hundred blows, is that right?

  ME: (very carefully now) That is … an approximation.

  QC: Now follow this through as a logical thought, would you please. You are a doctor, called to a flat on the ninth floor. You have been told and you can see a man has had … let us take your evidence at full strength … 105 blows. He says, ‘I want to walk down to the third floor. I know I had a drink.’ There are seventy-four steps and eight and a half landings. Would you say, ‘All right, old boy, get going. I’ll see you at the bottom?’

  If I hadn’t been under oath and giving evidence, I might have laughed. Would the QC, on finding himself on the ninth floor of a block of flats with a drunken young male prostitute, really address him as ‘old boy’? But the real concern for me was: where was this going?

  After an endless series of further questions about if, how and why I would help a drunken rent boy down the stairs in the middle of the night, the QC exploded in a manner oddly reminiscent of my father.

  QC: Can I come straight to the heart of the matter and not pussyfoot around answering and questioning? You would have wanted to make sure he did not fall down the stairs – seventy-four of them – would you not?

  ME: That would be one of my concerns, yes.

  QC: Yes. Because if a man had been subjected to the number of blows you indicated, he might fall?

  ME: Clearly, anyone in that circumstance might fall.

  QC: Thank you. If he fell on uncarpeted stairs, he might injure himself?

  ME: Certainly, a fall onto the lower stairwell I saw could result in injury, yes.

  QC: Yes!

  Good heavens. Surely the defence was not going to argue that the 105 injuries were virtually all caused by the victim falling downstairs? Surely he would not try to persuade the jury that this was not a murder with the metal bar but just an unlucky series of falls? The idea was absurd.

  Counsel asked me to describe the stairwell in minute detail, although in fact the jury had been given pictures of it. I lost count of the number of times he repeated how many stairs there were. I think everyone in court must have dreamed about the number 74 that night. And a fall down these seventy-four concrete stairs, he kept insisting, could be very serious. I was unable to contradict him. But I didn’t believe the deceased’s injuries, or at least the fatal ones, resulted from falling downstairs.

  Then he went back to the injuries. Individually. Again. All 105 of them. One by one, he asked me to prove they had not been caused by the deceased’s alleged fall, and one by one he challenged each answer.

  This cross-examination amazed me. The deceased had been a drifter who had lived most of his childhood in and out of care, had probably spent at least some of his subsequent time living on the streets and had recently been released from jail. The defendant’s background was very similar. If either one had ever received a fraction of the public money, care and interest which was devoted to this trial then I doubt there would have been a murder.

  As for the defence barrister, it was good he was working so hard to defend a client who was clearly from the margins of society. Had he ever passed the lad huddled in a doorway, I don’t expect learned counsel would have looked at him, let alone thrown a coin in his cup. But now the young man was on trial for murder, legal arguments about him consumed the barrister. I wished he could do his job without attacking my reputation as an expert witness. But I knew that in another case and with another jury we might be on the same side and then, instead of excoriating me, he would be praising my experience and skills.

  The cross-examination continued for the rest of the day and then carried on the next morning. And the next afternoon. And the following morning. Now the defence QC wasn’t just arguing that the injuries were caused by falling downstairs but that the cross-hatching from the surface of the iron bar reproduced on the victim’s skin was actually simply caused by the warp and weft of his cotton T-shirt.

  Then, many tea breaks later, as I returned to the witness box ready for a few more rounds with my back against the ropes, I watched him bounce in, a spring in his step and his eyes darting dangerously beneath his wig. I knew the tiger was planning to pounce.

  QC: Alcohol, I suppose, if you are affected by it, will make you, perhaps, slightly more liable to bleed than would otherwise be the case?

  ME: In the chronic alcoholic whose damaged liver may have blood-clotting problems, yes. But I found nothing to suggest that is the case here. I believe alcohol would have a very minimal effect.

  QC: Do you know anything about that as a clinician?

  ME: No, I do not.

  QC: Not aware of that?

  ME: Not particularly.

  QC: What do you mean, not particularly? Are you aware of it?

  ME: I am not aware, throughout my experience, of anyone who has suffered significantly more bruising when they are under the influence of alcohol than someone who is sober.

  That was not the answer counsel wanted to hear. He argued and argued with me that alcohol dilated the tiny blood vessels on the surface of the skin – which I agreed with – and therefore that drinkers were much more vulnerable to bruising – which I did not. I lost count of the number of times he took me, step by step, through his logical but erroneous deduction that the victim was covered in bruises simply because he had been drinking. I really began to doubt who had been beaten by an iron bar, the victim or me, but I stuck steadfastly to scientific fact. Finally, the QC exploded.

  QC: Where do you get this from? Can you do some research overnight?

  ME: I can consult the preclinical medical textbooks about the effects of trauma on the skin.

  QC: What book do you suggest I consult overnight?

  ME: I would suggest you consult any molecular biology book, I’m afraid I cannot give you a name.

  QC: Aren’t you familiar with any?

  ME: Perhaps a textbook by Guyton will help, I cannot tell you which edition is current, I think the third or fourth edition. Or any haematology textbook will cover it.

  QC: Any haematology author you can name?

  ME: Not specifically, no.

  JUDGE: How many pages is counsel likely to have to read, Dr Shepherd?

  ME: I’m afraid I cannot help you with that.

  QC: It is beyond me, but I shall still have a look.

  JUDGE: Yes, and pass it to me afterwards, please, Counsel.

  QC: I will, M’Lud.

  By now I hated both the QC and the judge and suspected that they were members of the same chambers, or at least the same London club. Once, when the judge showed impatience with the defence, the QC asked to speak to him without the jury present. The jury, press, public and I filed dutifully out of the courtroom. When counsel and judge are talking in this way it usually means that a point of law is being argued and, on returning, there is a distinctly chilly atmosphere in the court, with one barrister smiling and the other sulking. But these QCs and this judge were all smiling happily when we returned, like pals at a fireside.

  The defence was trying to explain away the horrific beating the dead lad had received by persuading the jury he had fallen downstairs (did I mention that there were seventy-four stairs?) and in the course of this he had become so badly bruised because he’d had a few drinks. I spent the evening feverishly phoning friends to discuss bruising and searching the hospital library for that textbook.

  The next day we were at it again. It was all I could do to contain my own homicidal feelings.

  Defence QC: You referred me and the court to a textbook. Guyton.

  ME: Indeed.

  QC: Have you got it with you now?

  ME: I have a copy now.

  QC: Do you have the passage you relied upon?

  ME: I have marked the
page that deals with what happens in the body following damage to a blood vessel.

  QC: You’ve got it there?

  ME: Yes, in this particular edition it is chapter 36.

  QC: Which edition?

  ME: I believe the eighth.

  QC: Hmm. You had, of course, referred us to the third or fourth edition.

  ME: I think I said I did not know which edition is most current.

  QC: May I see it?

  But I think he had already seen a copy. He asked me endless questions about platelets and clotting in an attempt to prove his point until the jury was nodding off and even the judge interrupted.

  JUDGE: Please forgive me, but what I would like to ask Dr Shepherd is: this chapter you referred to – is there something in there which actually says alcohol increases bruising?

  ME: It is the absence in that book, M’Lud, and in other books I have consulted, of anything saying alcohol causes increased bruising. It is the absence of those facts.

  JUDGE: Because, if this was a sustainable proposition, you would expect to find it in that book, at that chapter?

  ME: I would indeed, M’Lud.

  That didn’t really stop the defence. The QC made his false point in a variety of ways, once, twice, three times more, that alcohol increases capillary blood flow and so bruising must be more likely.

  A whole week after I took the witness stand, I was allowed to go. What a relief.

  This case illustrates that there are facts – and there are the conclusions that can be drawn from them. In the adversarial cauldron of that courtroom, truth had turned into an individual, nuanced, malleable commodity, and that is why as an expert witness I was pressured to interpret facts in ways I found uncomfortable. Advocacy – the art of a lawyer making his case – need have no conscience and any Bar school would agree that some good cases are lost by poor advocacy and that some poor cases are won by good advocacy. Overall, the balance of justice relies on a concept that has served our society well for centuries: that twelve people drawn randomly and with no special training can listen to and form a judgement based on all the evidence they hear.

  In this case, the jury found the defendant guilty of murder and he went to jail. I wonder if he had as many sleepless nights as I did. But at least it was over.

  Except it wasn’t. After his client had spent a couple of years in jail, the barrister sought leave to appeal against the conviction because he had new evidence. The new evidence was that I had failed to produce any textbook in court which would contradict the QC’s theory that alcohol intake was responsible for the deceased’s bruising after he fell downstairs. And he listed a number of other ways in which I had allegedly been incompetent.

  Now I certainly began to wonder who was being tried: me or the convicted murderer. But I did have time to muster some support. A very senior haematologist read the trial transcript and wrote a report, which concluded: ‘Alcohol-induced skin capillary flow would have played at most a trivial role in the skin haemorrhage (bruising). This spectacular red herring was pressed hard by the defence in the name of common sense but the image conjured up, of vessels bloated with blood, is misleading.’

  We spent quite a lot of time hanging around the Court of Appeal before the defence’s case was heard. Then it was all over in an instant. The spurious ‘new evidence’ had been seen by their lordships for what it was and leave to appeal was not granted.

  I admire the persistence of that QC in fighting for his client, a very disadvantaged young man. If I were ever accused of murder, then I would want him defending me. As an expert witness in his firing line, however, I felt he had shown a remarkable ability to ride roughshod over medical facts which did not favour his case.

  Since then, if I am in court and the going gets tough, my coping mechanism is Alexander Pope. The lines my father wrote so painstakingly for me in that dictionary all those years ago instructed me to speak diffidently even when sure I am right, to readily admit the possibility that I may be wrong, to examine my errors and admit to them, to teach or correct others with generous regard for their feelings, never to agree for politeness’ sake with concepts I know are wrong and to accept correction when it is appropriate. Despite the aggression and single-mindedness our adversarial system fosters, and its frequent disregard for the truth, I try to hold to Pope’s principles.

  29

  Just thinking about the Hyde area of Manchester always gives me a warm glow. It was here that my mother had been brought up, it was here that her family and friends had lived. It was a place of happy visits when I was small and a place of pilgrimage all my life, too, because my mother was buried here.

  It pleased me to think of the old ladies who came from Hyde – my grandmother, my aunt – who were so unlike the isolated, undernourished elderly people whose bodies I sometimes saw. They always welcomed me with warm and caring arms, drawing me into their busy lives and polished homes. They were noticeably an intrinsic part of a wider community.

  In 1998 I received a call from a defence solicitor asking me to perform a second post-mortem examination on just such a lady from just that area. Mrs Kathleen Grundy had been known to my mother’s family as a friend and schoolmate of my aunt. She had died on 24 June and on 1 July she had been buried in the same cemetery as my mother.

  In August, however, she had been exhumed and now I stood over her body in the mortuary of Tameside General Hospital.

  She was eighty-one but appeared to have been in exceptionally good health. There were no signs of a struggle. And, unusually for anyone her age and for the next generation too, her arteries showed only minimal atheroma.

  But toxicology told a different story. Although I could find no injection site on her body, she had evidently consumed a substantial dose of morphine or diamorphine in the hours leading up to her death. I gave as its cause: overdose of morphine.

  In fact, she had died at the hands of her trusted family doctor, and it was through her sudden death that Harold Shipman was finally revealed as a serial killer. He was highly regarded by his patients, discussed and admired in that community I remembered with such fondness. Many described him as the nicest doctor in the area. He was especially loved by the elderly because he was happy to make home visits and, having worked in Hyde for some time, when he set up his own practice in 1992 he was inundated with patients by word-of-mouth recommendation.

  Suspicions about him were aroused by Kathleen Grundy’s sudden death just days after her will had apparently been changed to favour him. He had certified her cause of death as: ‘Old Age’.

  Further cases were immediately opened and more exhumations followed. I attended five of these post-mortems. The next I saw, a seventy-three-year-old, had very mild coronary disease and mild emphysema. She cannot have had pneumonia, as claimed by Shipman on her death certificate. She did, however, have morphine poisoning. The next body told the same story. They all did.

  It seemed frankly incredible that a family doctor could have killed six of his patients. In a letter I wrote afterwards I said:

  It is clearly essential that the source of the morphine is identified and the possibility of contamination must also be considered … given the delay between death and post-mortem examinations and the numerous events and actions that have surrounded these bodies, the possibility of contamination needs to be positively excluded … I would suggest that advice is sought from a chemist to see if it is possible for chemicals used in the manufacture of embalming fluid, coffin wood or coffin furniture to be contaminated by substances containing morphine whilst buried … finally, the possibility of other links between the bodies should also be explored (embalmers, undertakers, staff).

  Of course, I thought every other possibility should be investigated not just because I was pathologist for Shipman’s defence (yes, even serial killers are entitled to a defence) but because I was, we all were, resistant to the idea that a doctor had systematically killed his patients. A few years later, when Shipman had been imprisoned for the murder of no fewer than
fifteen patients, it was hard to stomach the conclusions of Dame Janet Smith’s public inquiry – that he had, over more than twenty years, certainly killed 215 people and there were hundreds more cases for which it was impossible at this stage to ascertain the facts.

  His reasons are unclear. Generally, his victims lived alone. Generally, but not always, they were elderly. Generally, but not always, they were women. Anybody hoping that Shipman would eventually reveal the reasons for his actions – and perhaps confirm how many of the 494 deaths which had occurred on his watch he had actually caused – had their hopes dashed a few years later, in 2004, when he was found hanging in his cell.

  Hyde changed for me after the exhumations. Instead of being a place I associated with my mother’s family warmth and bustling old ladies, it became a place where old ladies lay dead at the hands of a serial killer they had trusted to take care of them.

  When I returned to London from the exhumations, still half disbelieving that small part of Shipman’s crimes we then suspected, I had another unpleasant experience: I crossed swords with Iain West. To my amazement, he had retired from Guy’s. After all those years of swearing he would never stop, he had done just that. The rumour was that Iain was unwell but, of course, it was impossible for him to disappear from the London murder scene and just tend his garden in Sussex. He popped up frequently in the mortuary and in court, and when I returned from Manchester, brooding over the unfolding truth about Shipman, I found that he was to be my adversary in a knifing case.

  We disagreed fundamentally: not by meeting face to face but by writing strongly worded, contradictory reports. His rebuttal was, as usual, extremely robust. Although it did occur to me at the time, and not just in retrospect, that his prose was a little less robust than it used to be.

  The case centred on the perpetrator’s account of how the knife entered the heart of the victim. Such accounts are often highly creative and by now I think I had heard every excuse in the book for the presence of a blade in another person’s body. The most common is the claim that ‘he ran onto the knife’. This is not always easy to prove or disprove and I need as many witness accounts as possible to help me reconstruct the attack. On this occasion, there were none. A woman and her husband had argued, the outcome was his death, and we only had her word to go on. The senior investigating officer actually phoned me for advice before interviewing her, a rare enough event, but he knew the entire case did rest on her exact description of what happened.