Unnatural Causes

by Dr Richard Shepherd

  You might take this as an oversight. You might take it as an indication of poor record-keeping. But, in a case like this where every tiny event matters, it can give rise to many more questions about sampling sites, labelling of bottles and security of transfer – and it certainly fuelled the accusations that these weren’t Paul’s blood samples anyway. Residual blood in the samples was tested and proved to be Henri Paul’s but that did not end the matter because there were missing samples, spilt samples, samples that had been shared with other labs … leaving enough room for doubt for those who really wanted to raise questions.

  It was for the jury to decide the significance, if any, of the evidence I gave to the inquest. This was a large-scale affair, presided over by Lord Justice Scott Baker, who had been appointed coroner specifically to this inquest. He was represented by three barristers, Mohammed al-Fayed by three, there were two for the Ritz hotel in Paris and two for the family of Henri Paul. In addition, the Metropolitan Police was represented by three barristers and the Intelligence Service and Foreign Office by two. Other interested parties, including Diana’s sons and her sister, also had lawyers at the inquest.

  Although, of course, there was considerable media attention at certain points, most days the lawyers heavily outnumbered the totality of both press and public.

  Questioning of the witnesses, as usual at an inquest, came first from the coroner’s barrister – but there was often cross-examination from one or more of the others. Every tiny detail of that night and the months leading up to it was examined. My own contribution was minimal but, I think, important to the outcome. I was asked what my overall impression of the events was. My conclusion? A simple, high-speed, alcohol-related, road traffic accident.

  The jury’s final verdict astonished no one and satisfied many:

  Unlawful killing, grossly negligent driving of the following vehicles and of the Mercedes. The crash was caused or contributed to by the speed and manner of driving of the Mercedes, the speed and manner of driving of the following vehicles, the impairment of the judgement of the driver of the Mercedes through alcohol.

  I wish that Professor Lecomte had not been so resistant to Shepherd’s charm offensive and had talked a little more: her silence does mean that, pathologically speaking, there is a slight lack of clarity. But that doesn’t mean I can credit conspiracy theories. I do not believe that what happened in the mortuary that mad night was part of a wider plan to murder a woman in such a haphazard way and then hide the evidence. Simply, Professor Lecomte made small errors under pressure, which, in a case without so many seeking fodder for their theories, would not have been significant. I entirely concur with the jury’s verdict.

  33

  In 2006 Tony Blair was still prime minister, there was a summer heatwave and CSI was named the world’s most popular TV programme. Chris was almost a vet and Anna halfway through medical school. On the Isle of Man, Simpson’s Forensic Medicine, Twelfth Edition had been not just finished but published. My pride in it was tempered by the sense of finality the book’s completion gave me. Reading the third edition had started my career. Was the writing of the twelfth edition a sign my career was ending?

  I still had plenty of work: sitting on committees, giving opinions on complex cases and evidence at public inquiries. But life was very different from that busy world I’d known before, a world that always had at its centre a body, demise unexplained, name perhaps unknown.

  Occasionally I began to experience a sense of ennui as I walked the hills with the dogs and stared at the sea. What was it? It took a while for me to recognize something I have barely experienced in the whole of my life. Boredom. Or was it loneliness? I hardly knew what that was, either.

  Alone together after some buzzing social event, Jen and I didn’t seem to have much to say to each other. There was no need to discuss the children like we used to now they were grown, and the cottage renovations were finished so there was nothing much to say about that either. Jen bought some sheep and started to learn how to manage her flock. I tried to develop an interest in sheep, too. But the fact was, much as I loved our home overlooking the sea, it had begun to seem very silent. I even welcomed the noisy storms that banged on the windows and battered the roof, because they made the house feel so alive.

  When we moved to the island we had both thought there would be some part-time work there, perhaps for me in the mortuary and surely for Jen in a dermatology clinic. But this proved closed to us due to island medical politics and Jen ended up spending one week a month working at a clinic on the mainland. In 2006 I was offered forensic work as a weekend locum in Liverpool. And I took it.

  Maybe I had limped away from London to the Isle of Man feeling battered by my working life. By its politics, its administrative responsibilities, the interpersonal complexities of the new world of private pathology. Only now did I realize what I missed: the very heart of my work, that is, the dead and their mysteries. Standing in the Liverpool mortuary in my scrubs, with my PM40 sharp in my hand, I even felt renewed professional excitement for my first patient, one smelly and drunken knife victim who had been found in a rubbish chute. This was standby forensic work for the police and I stayed in a hotel for one weekend a month in order to do it. Sometimes I was called out to a stream of homicides and sometimes, to my great disappointment, nothing happened at all.

  I hadn’t been away from hands-on work for long, just about two years, but we seemed to be in a new era of forensic pathology. The changes weren’t dramatic so much as a continuation of developments I had first begun to notice in London.

  Bodies were and are changing. Body fat has increased exponentially in the population, so that unless a patient is homeless or has died of cancer or is so old or poor they could not eat, few are the same shape as the dead of the 1980s when I started practising. Looking back at forensic photos from that era I am astonished at how thinness was then the norm.

  Bodies also look different because they are so much more ornate: once tattoos were for fighting men and sailors. Now it seems that the majority of mortuary admissions have piercings or tattoos. In addition, self-harm was almost unknown then and now I am amazed at the number of bodies, particularly the young, which arrive in the mortuary with old, self-inflicted cuts and lacerations: it tells me about their life and about changing society but nothing about their death, the causes of which are generally not directly related to self-harm.

  For the pathologist in the 1980s, HIV and hepatitis were becoming the acknowledged enemy, and they still are. But by the time I returned to work from the Isle of Man, TB was an occupational hazard for anyone working in a mortuary and I knew several pathologists and mortuary staff who had caught it. TB is much more prevalent than you would guess and, not uncommonly, even at post-mortem, we have no idea that we are about to be exposed to a highly infectious disease which every other doctor has mistaken for a simple pneumonia.

  Post-mortem reports have changed too. When I started, three pages was considered adequate. When I returned, I was criticized for producing anything less than ten, and they were expected to be discursive, explaining the workings of the human body at length.

  Back in the 1990s, DNA started to make a significant contribution to forensic work, and forensic science soon overtook forensic pathology as the field’s major contribution to crime-cracking. Before I left, the police had begun to ask us to wear gloves at the scene of a crime. By the time I came back, it was gloves, boots, white Tylex suit (hood up), and a face mask too. DNA analysis had become so much more sensitive that now we knew just breathing, just talking, sprays saliva with DNA everywhere. Gone are the days of the pathologist and senior investigating officer walking around the scene in their office clothes discussing the case. The white suits are certainly not designed for ease of dressing, nor for comfort, and it’s always embarrassing to try to put one on when the world’s press is filming you. But it is so good to take them off at the end of the scene examination and put them in an evidence bag – yes, even the suits are kept
for trace evidence now.

  In court I had for years noticed how cases for the prosecution were becoming less meticulously researched and organized. Now, case conferences with counsel are a thing of the past. There is never a phone call: not from the police, the Crown Prosecution Service or even counsel. If I am lucky, I’ll get ten minutes with the QC before I go into the witness box. More often, barristers don’t have a clue what answers I’m going to give when they stand up and start to question me. Often, they don’t even allow me the chance to tell the jury who I am and why the years have particularly qualified me to discuss this subject: ‘Dr Shepherd, you’re a registered medical practitioner, tell me what you found on your examination of the body.’

  The days of the thundering, bombastic QC were already ending when I left London: that defence QC who gave me such a hard time over the rent boy’s all-over bruising was already a relic from the past and now such barristers are almost completely gone. Presumably for economic reasons, the Crown Prosecution Service seems to use junior barristers rather than much more expensive QCs. Of course, experienced, although not so overtly thundering, QCs are still out there, and they are nearly always working for the defence.

  Courts are much more interested in expert witnesses giving what is now called ‘evidence-based’ testimony rather than experience-based, no matter how much experience we have. Judges have occasionally stopped me answering important questions fully with a curt, ‘Just give us a yes or no, Dr Shepherd.’ Often when I am responding to a long and detailed question from counsel.

  The essentially self-employed structure of forensic pathology in England and Wales that was introduced as I left London has removed almost completely the possibility of forensic research. Most of us do not now work or teach at universities: forensic medicine no longer even has a place on the medical-school curriculum. Research has anyway been effectively neutered by the Human Tissue Authority’s insistence that families of the deceased give consent before samples, even minute samples, can be used for research purposes. How then, you may ask, can the answers we give to the courts be ‘evidence-based’?

  There will always be homicides and suicides and accidents, but now the routine forensic caseload will, increasingly, include negligence and ‘safeguarding’ issues in nursing homes. It will certainly include a large number of deaths from drug overdose. And, shamefully, there are many more deaths in custody, which speaks volumes about our jails: 316 in the year to March 2017, of which ninety-seven were suicides. In the same year, there were in jails over 40,000 incidents of self-harm and over 26,000 assaults. And these figures are rising alarmingly year on year.

  The most shocking change I noticed on my return is that forensic pathologists are called to investigate a death less often. The cost and administration of opening an inquest seems to encourage some coroners to overlook an element of doubt. If there ‘might be’ a natural cause and a doctor ‘might be’ willing to sign a form, many coroners will accept that without too much inquiry. Sadly, the need for the police to pay a standard fee, admittedly several thousand pounds, to a forensic pathologist, may be enough to persuade them that a death (especially, it sometimes seems, one close to the end of the financial year) really is not so suspicious after all and can be dealt with by a local, non-forensic pathologist instead of one of the forty or so specialists registered by the Home Office.

  Most people would agree that a civilized society should endeavour always to find, no matter what it costs, the true cause of death. The cost of the trials, the inquest and public inquiry into the death of Stephen Lawrence should serve to remind anyone in any doubt that it is far, far better and far, far cheaper to do all things properly at the start.

  I found that I enjoyed being back at the coalface in Liverpool, different though it looked. I was sometimes invited to lecture on the mainland by medical bodies or other professional groups, and I enjoyed that too. At the end of these lectures, interested people usually came forward to ask me questions. After one lecture in London, a forensic paediatrician chatted to me about my work. A forensic paediatrician can expect to see cases of child abuse, both physical and sexual, and this was, in fact, the paediatrician’s specialization: not death, but the protection of the living. She asked me questions about bruising and we agreed that, with our combined knowledge, we really should write an academic paper on the subject. Our work overlapped in that problem area between my research into whether a child had died naturally and her research into whether living siblings were in danger, and we met several times to discuss the paper on bruising during my subsequent trips to the mainland.

  On the Isle of Man, our house became more and more silent. Jen shepherded her flock. I studied my papers.

  One day, she said, ‘We really ought to discuss our marriage.’

  And I said, ‘What marriage? It hardly seems to exist.’

  That was how it ended. One night in February. Not with a bang but a whimper. With little talk. But much pain. After thirty years.

  How quickly, in comparison to its length, the marriage unravelled. Perhaps every entity has a limited lifetime. Perhaps senescence is built into relationships just as it is built into the human body. It seemed to me there was simply nothing left of this marriage of ours but it was impossible to say this, to think it, without inflicting pain and engendering fury. There was the past and there were two children and a shared property and that, of course, all had to be discussed, often acrimoniously, always with much pain on both sides. But we shared so little else that I was sure, when the shouting was over and the hurt receding, that better lives lay ahead for both of us.

  Jen issued papers to divorce me and the process was complete within one year.

  It was not obvious to me at this time that I would fall in love with the forensic paediatrician I had been meeting to discuss our work on bruising, let alone that she would become my future wife, but I was never able to persuade Jen of my innocence in this. It was true I was spending time with someone whom I knew to be of special warmth, empathy and intelligence, but there had been no further planning on my part. Nor on Linda’s. She had been widowed when her three daughters were very small and for some years now she had been in a relationship. That relationship and my marriage both ended with mess and fury.

  Despite her determination to divorce me, Jen suffered greatly. Our separation caused considerable unhappiness to our children, too, who also, I think, wrongly suspected that I had simply found Linda and dumped Jen. Anna, almost a doctor herself now, during the period when her mother’s pain was greatest and her anger red hot, declared that one thing she would never become is a pathologist like her father.

  I am glad to say that Jen did find happiness with a new partner. And in September 2008 Linda and I were married. This added another family to mine and I found myself back in the world of teenagers as well as busy, elderly parents. No matter how loving and welcoming a new family, relationships between each individual, between the two families, must be built slowly, over years. We have applied ourselves to this and the result, I hope, is a strong and loving extended unit.

  Since that time, I have lived and worked as a forensic pathologist in the north of England. Life here is rich and varied: stimulating work, a warm and loving home, interesting holidays, surprise expeditions, a shared aeroplane to fly, five children between us and, for me, two grandchildren now.

  My son, Chris, is a vet, specializing in horses. He now lives abroad, where the landscapes and perhaps the mindscapes are wider. Anyway, he has certainly escaped poor pay and dark mornings. And he is following me in one way: by learning to fly.

  Anna is a consultant histopathologist and, yes, she does have a keen interest in post-mortem and forensic medicine and even works for some of the coroners I worked for years ago. We chat often about cases: I seek her advice on ‘newfangled’ tests and she seeks my opinion on causes of death. She changed her name when she married and no one can say that her father’s name is connected in any way with her achievements. But probably no one would, because
she is obviously very much her own person. Anna doesn’t find herself torn between modern practice and a desire to be Keith Simpson. No, Anna’s world is much more complex and accountable than the one I knew at her age. I see that world as less colourful. But she doesn’t. She never knew Simpson’s limitless horizons.

  I would say that my knowledge of death has helped me appreciate the importance of life’s small pleasures and I bask in them: a loved child running excitedly through a carpet of red and yellow fallen leaves, or tracing a finger with deep fascination along the wrinkles on my face, a fire ablaze while rain throws itself against the window, a dog hurtling towards me to welcome me home, a gentle hand placed lovingly on mine. I am no stranger to joy. I know that joy can be truly experienced only by those who have known adversity. And adversity is an inevitability.

  34

  One morning the phone rang and an angry voice cried, ‘Have you read this crap? Have you?’

  The voice was instantly recognizable as Ellie’s. She is a paediatric pathologist with whom I’d worked on the occasional case. And the crap she was referring to? We’d together performed a post-mortem on a baby named Noah eighteen months ago and given SIDS as the cause of death. I’d noticed there was something new about this case in my inbox, waiting to be opened.

  Ellie was unstoppable.

  ‘How can we have missed lip injuries and fractures on the posterior ribs too? How? The lips were resuscitation injuries or I’m Naomi Campbell! And we looked and didn’t see any posterior rib fractures and neither did the radiologist. How is it that this person can just look at the photographs and find suffocation injuries and old fractures? Tell me that, Dick!’

  The parents of the late Baby Noah now had another baby. Social services evidently felt there was enough doubt hanging over the earlier SIDS death to safeguard the new baby by removing her from the parents’ care. Their application to do so was heading for the Family Court. Recently the court had asked for copies of our report on Baby Noah, our notes and the post-mortem photographs. And evidently, all this had now been reviewed by another pathologist who specialized in working for that court. I clicked on the email. Yes, here were his comments.