Unnatural Causes

by Dr Richard Shepherd

  The pathologist, he who had examined both babies, changed his cause of death in one of them and apparently withheld test results, was found guilty by the GMC of serious misconduct. He was suspended from carrying out Home Office post-mortems for eighteen months.

  David Southall had been a commentator on, rather than a direct participant in, the Clark brothers’ case but Sally Clark’s release now catalysed the inevitable backlash against his views and against the growing child protection movement. He may have furthered our understanding of the medical and moral complexities of infant mortality in general, and SIDS in particular, but angry pressure groups were formed by parents under suspicion and others who sympathized with them. (And don’t we all sympathize with the outrage of those who claim to have been unjustly accused?)

  The groups complained to the GMC about Professor Southall. The GMC took their protests to its Medical Practitioners’ Tribunal Service. He was judged unfit to practise and struck off. It took him many years and a Court of Appeal decision to overturn this verdict. His condemnation by the GMC received wide coverage: his subsequent complete exoneration went almost unreported.

  The Sally Clark case perhaps charts the history of our relationship with SIDS. Fashions in thinking should have no place in the world of scientific truth, but they certainly do. Ten years earlier she would have been regarded as simply a tragic figure for losing two babies. By the time her first son died, SIDS was declining but still a widely given cause of death. By the time her second son died, thinking had progressed further and any pathologist in the land would take into account the full circumstances of the case. The cause of death actually given was that the baby had been shaken, and this reflected the topicality of shaken baby syndrome at that time. Overall, the case revealed our deep new suspicion of mothers when their babies died suddenly. Her successful appeal may have reflected a public reconsideration of that level of suspicion.

  In fact, although the pathologist involved certainly made errors of recording and disclosure, the medical evidence was extremely complex and controversial and huge numbers of experts lined up to disagree with each other in court on almost every aspect of both children’s deaths. The truth in the Clark case, as in so many, proved to be not solid but a rather unpredictable liquid. The courts wanted honesty and truth and then chose to be selective and make their own assessments of highly complex medical issues.

  No one emerged unscathed from the tragedy of the Clark case. For forensic pathologists, it was certainly a horrible reminder of the huge responsibilities of our profession.

  32

  Much as I loved life on the Isle of Man, after a couple of years I began to miss the cut and thrust of day-to-day forensic pathology. I missed the camaraderie in the mortuary and at crime scenes, the sense of a close-knit team working together. I recalled the great humanity of all involved, while the startling evidence of cruel, murderous inhumanity lay before us.

  Committee work began to fill that gap. In particular, I was involved in producing guidelines to help the police and other authorities deal with a new challenge which was caused by the growing use of crack-cocaine. This drug can produce an extraordinary mental state in some users which makes them as strong as an ox and twice as dangerous. How to restrain these powerful, dangerous people to safeguard the public – without actually killing them? Helping to solve this problem was worthwhile, good work, but it was not like solving a problem at the mortuary. Now, I always seemed to be once removed from the body, from the scene of the crime, from the coalface.

  Then, in 2004 I became engrossed in one of the most interesting and high-profile public inquiries underway at that time. It arose from events seven years earlier and many miles away.

  I had not been the Home Office pathologist on call on the weekend of 31 August 1997: that fell to my colleague at St George’s, Rob Chapman. In the early hours of that morning, the Princess of Wales and Dodi al-Fayed died in a road traffic accident in a Paris tunnel, he at the scene and she in hospital after an operation. The bodies were flown into RAF Northolt the same day and the then coroner for West London, John Burton, who by chance also happened to be the coroner for the Royal Household, assumed responsibility for them. That evening, surrounded by high-level police officers, evidence officers, a crime-scene manager, the coroner, Met police photographers and mortuary assistants, and with still more officers holding back the public outside, Rob carried out the post-mortems in Fulham. Both had died from injuries sustained in the accident.

  The questions over those two deaths have never gone away. In a bid to stem the inevitable tide of conspiracy theories, a police inquiry was opened in 2004. It was led by Sir John Stevens, then commissioner of the Metropolitan Police, later Lord Stevens, and its aim was to establish whether or not there were grounds for treating the deaths as anything other than a road traffic accident. The new coroner to the Royal Household, Michael Burgess, suggested I act as forensic pathologist to this inquiry. Of course, both bodies had been long buried, and so it was my job to review the evidence my colleagues had produced in 1997.

  There has famously been much speculation about the cause of the accident, but I don’t think there is any doubt about the fact that Dodi and Diana left the back door of the Ritz in the hotel’s Mercedes driven by Henri Paul and, crossing Paris at speed, pursued by photographers, their car hit the thirteenth concrete pillar in the Alma Tunnel at over 60mph.

  If a car comes to a dead stop after such an impact, unless restrained by seat belts, the bodies of the people in the car don’t stop with the vehicle. They continue forward and hit the windscreen, the dashboard or the people in front of them. Diana and Dodi, in the back seats, were not wearing seat belts. Nor was the driver. He hit the steering wheel and his injuries reflected that but, microseconds later, he was also hit from behind by Dodi, who was a big man and who was still travelling at over 60mph. Henri Paul effectively acted as Dodi’s airbag and he died instantly. So did Dodi.

  Diana was slightly more fortunate because the al-Fayeds’ bodyguard, Trevor Rees-Jones, was sitting on the right of the driver, in front of her. Bodyguards don’t usually wear seat belts as they restrict movement, but evidently Rees-Jones, maybe because he was alarmed by Henri Paul’s driving or maybe because he realized an impact was likely, put on his belt at the last minute. Belts are designed to give gradually while they restrain. So he was held by the belt and partially padded by the car’s airbag, which by now had inflated, as Diana’s body catapulted forward from the back seat. She was much lighter than Dodi and Rees-Jones’s belt would have absorbed some of the extra force. This slightly lessened the energy of the impact for her and so, more protected than Dodi, she actually suffered just a few broken bones and a small chest injury.

  Since Dodi al-Fayed and Henri Paul were clearly dead when the ambulance arrived, the paramedics rightly turned to the injured. They did not recognize Diana, who is reported to have been talking. Trevor Rees-Jones had taken the double whammy of his own weight forcing him forward and Diana’s weight hitting him from behind and he seemed much more seriously hurt. Of course, he was therefore taken out first. Diana was anyway effectively trapped behind the front passenger seat until he was removed.

  Rees-Jones, as the more seriously injured party, was put in the first ambulance. Diana was then extracted from the car and taken to hospital as an emergency. No one knew that she had a tiny tear in a vein in one of her lungs. Anatomically, this site is hidden away, deep in the centre of the chest. Veins, of course, are not subject to the same high-pressure pumping as arteries. They bleed much more slowly, in fact they bleed so slowly that identifying the problem is hard enough and, if it is identified, repairing it is even harder.

  To the ambulance services, she initially seemed injured but stable, particularly as she was able to communicate. While everyone focused on Rees-Jones, however, the vein was slowly bleeding into her chest. In the ambulance, she gradually lost consciousness. When she suffered a cardiac arrest, every effort was made to resuscitate her and in hospital s
he went into surgery, where they did identify the problem and attempted to repair the vein. But, sadly, by then it was too late. Her initial period of consciousness and initial survival after the accident is characteristic of a tear to a vital vein. Her specific injury is so rare that in my entire career I don’t believe I’ve seen another. Diana’s was a very small injury – but in the wrong place.

  Her death is a classic example of the way we say, after almost every death: if only. If only she had hit the seat at a slightly different angle. If only she had been thrown forward 10mph more slowly. If only she had been put in an ambulance immediately. But the biggest if only, in Diana’s case, was within her own control. If only she had been wearing a seat belt. Had she been restrained, she would probably have appeared in public two days later with a black eye, perhaps a bit breathless from the fractured ribs and with a broken arm in a sling.

  The pathology of her death is, I believe, indisputable. But around that tiny, fatal tear in a pulmonary vein are woven many other facts, some of which are sufficiently opaque to allow a multitude of theories to blossom.

  The conspiracy theorists, particularly Dodi’s father, Mohammed al-Fayed, believe the crash was no accident but had been arranged. The most widely held proposition is that the couple were killed because Diana was about to embarrass the British establishment by announcing a pregnancy. Since I did not carry out her post-mortem myself, I cannot categorically say that she was not pregnant. Rob Chapman has been examined and cross-examined on this point and he has explained that there was no indication of pregnancy: bodily changes would have been detectable perhaps two but certainly three weeks after conception, even before she herself would have been aware of pregnancy.

  Some people have asked me whether Rob could have been persuaded to lie. The answer is an emphatic ‘no’. He would never dispense with the engrained methods of a lifetime and agree to obscure the truth from a post-mortem (and neither, for that matter, would I).

  The conspiracy theories, however, did not rest entirely on Diana’s alleged pregnancy. Any number of reasons have been proposed to explain why the car crashed that night and the theories have been fuelled by the various anomalies of the case.

  First, there was the presence of a second car, a white Fiat Uno, which appears to have collided initially with the Ritz’s Mercedes before the Mercedes hit the pillar. However, no one has ever discovered what happened because neither the car nor its driver – despite extensive searches throughout France and Europe – has ever been found.

  Then there is the anomaly concerning the chauffeur, Henri Paul. His blood samples revealed him to be drunk, but this was hotly disputed by his family and by some of those who were with him shortly before the crash. There were accusations that someone else’s blood had replaced Paul’s, partly because his sample contained traces of a drug used to treat intestinal worms in children. Paul had neither worms nor children. However, the drug is also commonly used to ‘cut’ cocaine – although Paul had clearly taken no cocaine, at least not that night or even for a few days earlier. In addition, carbon monoxide levels were exceptionally, although not lethally, high in Paul’s blood, and no one could satisfactorily explain that either.

  Rather unusually, Diana’s body had been embalmed. A French undertaker arrived at the hospital to do this and no one has ever really explained why he was called or by whom: certainly not by the pathologist at the hospital in Paris. Probably the explanation is that embalming is a usual procedure for a member of the royal family, but since the bodies were flown immediately back to the UK and Rob carried out post-mortems within twenty-four hours of their deaths, there was no real need for the French to introduce preservation fluids into Diana’s body. By doing so, they compromised all toxicology results. Some people saw this as suspicious action, but since neither Diana nor Dodi was driving it is very hard to see what significance any toxicology from them would have had.

  After a lot of diplomatic wrangling and armed with many questions we, the police team and I, went to Paris. The French authorities did not greet us warmly, or even very helpfully but we saw the crash site and eventually even the car itself. Other specialists were trying to explain the carbon monoxide in Paul’s blood and they immediately began to examine the airbag but my role, of course, took me to the mortuary.

  Here I met Professor Dominique Lecomte, the charming pathologist who had the misfortune to be on duty that night. She had carried out the post-mortem on Henri Paul. She spoke good English until I started to discuss the post-mortem and whether possible lapses in recording systems meant the blood samples could have belonged to anyone other than Henri Paul. At that point, she said little more and insisted on speaking only through an interpreter, and often looked for advice to the lawyer who sat next to her.

  I hope she understood how much I sympathized and empathized with her. A routine Saturday night in a big-city mortuary includes the odd road traffic accident, unlucky drunks, the victims of crime and brawls. In Paris, pathologists do not routinely deal with these over the weekend; they start performing their post-mortems on Monday morning. Professor Lecomte was therefore asleep at home in the middle of the night when she was dragged off into a situation of sudden and immense pressure. The world’s most photographed face had died in a car crash and her driver and boyfriend had also arrived at the mortuary. Outside, governments, family and the international press were howling for the professor’s conclusions.

  The general rule when presented with a high-profile death is to stop. Do everything slowly. Carry out all procedures correctly and in strict sequence. It is worth following these rules because a celebrity death means that your every action will be questioned for a long time afterwards in public and in private. During the event itself, you are under pressure to get things done right now. In half the usual time and with half the usual information. To give simple answers immediately to complex medical questions. I have learned the hard way that no one says thank you in these cases. Ever. The only comments that are made are critical – you either did something you shouldn’t have done or (more commonly) you failed to do something that, in retrospect, you possibly should have done.

  Unfortunately, pathologists in this situation sometimes do bow to the immense pressure placed on them to hurry, to cut corners, to accept ‘the obvious’. They do things out of sequence and may behave in an uncharacteristically haphazard way. I am not suggesting that Professor Lecomte carried out her post-mortem haphazardly. I think she did a good job, and, although I was later to uncover some errors, I have no criticism of her. And I can very well understand her defensiveness when a British pathologist arrived to ask insistent questions about how well she followed her own procedures after she was woken suddenly for a particularly demanding night’s work seven years earlier.

  The Stevens inquiry cost £4 million and resulted in a 900-page report, which was finally submitted at the end of 2006. It said, ‘Our conclusion is that, on all the evidence available at this time, there was no conspiracy to murder any of the occupants of the car. This was a tragic accident.’

  The report did nothing to stop the conspiracy theorists, certainly not Mohammed al-Fayed. In 2007, after much pressure, a full inquest was announced. I was called as an expert witness and this time the French were finally persuaded to produce more of their files. I had already seen Henri Paul’s full post-mortem report, of course. Then, in late September, very close to the start of the inquest, the French authorities finally released the post-mortem photos of Henri Paul.

  In 1997 police photographers used film cameras. The numbers on the negatives were reproduced on the back of the prints and this meant it was possible easily to follow the sequence of the pictures that were taken in the mortuary. The first of the photographs clearly showed that Paul had been placed face down at the start of the examination. In pathology you are taught to look at the whole of the microscope slide – there’s always the chance of a tiny bit of cancer at one edge. The same rule applies to photographs. Ignore the blindingly obvious to begin with an
d look at the background. So I looked at the background of the Paul photographs and they showed a row of empty glass bottles, lined up and waiting for his blood samples, on the sink beside the mortuary table behind the body.

  Professor Lecomte’s report described a huge area of bleeding in the back of Paul’s neck – probably caused by the impact from Dodi’s body. Nothing unusual about that. But it was very odd that I could see more of the blood bottles filling with each sequential picture. There were a number that were evidently full before the body was turned over ready for the chest and abdomen to be opened.

  That would have no great significance except that, in her report, Professor Lecomte states that the blood samples she submitted were taken from the heart. And not from the neck.

  Of course, she might first have taken samples from the neck as a precaution and then discarded them when she turned the body over and found she was able to take cardiac samples instead (cardiac samples are regarded as acceptable: in fact, femoral samples are the best). That would be good practice. But only if she recorded her actions.

  Or she may have labelled blood samples from the neck as being from the heart. It doesn’t matter so much where the samples are taken from. Saying where they are taken from does matter. The site of sampling can significantly affect the toxicologists’ interpretation of the results, and incorrect labelling can lead to great inaccuracies.