Unnatural Causes

by Dr Richard Shepherd

  The unfairness of this possibility made me sit up in bed. I was being accused of poor judgement on the basis of poor photos. Injuries on the lips and healed cracks in the posterior ribs could be evidence of old abuse but there had been no injuries to the lips and the fronts of the ribs that couldn’t be explained by resuscitation, and no cracks at the backs of the ribs at all. I was sure of it, Ellie was sure of it, the radiologist was sure of it. We had said in our report that, although the injuries to the front ribs were probably caused by resuscitation, we could not exclude the possibility that they had been caused deliberately. But then, of course, we had given SIDS as the cause of death.

  Surely, surely, it was impossible that I would be struck off for such a thing?

  When at last I slept, my dreams were a strange jumble of courtrooms and babies. The next day my night thoughts still shrouded me. Without thinking about the court case directly it nevertheless informed my every action. In my stomach, the patina of dread. In my head, a sense of crisis. Sitting at my desk that afternoon, tortured by inexplicable anxiety, I stopped fighting. I knew what was going to happen. It had started to happen flying over Hungerford recently. Then again after the Paris bombings. I had learned to clench my fist and with a supreme force of will almost keep myself away from the abyss. But now it opened right in front of me.

  I shut my eyes. It was waiting for me. The bodies, piled high, the stench of decay and heat, young people who had been dancing when the bomb went off, when the boat went down, young people without hands, children exhumed in their coffins, babies’ tiny bodies bearing helpless testament to man’s inhumanity, charred bodies, drowned bodies, bodies severed on the railway track. A deep, deep pit of human suffering.

  I looked up again. I blinked. I looked around my office. Computer, desk, pictures, files, dogs. All normal. It had been another of those quick trips to hell again, as sudden and shocking as an epileptic fit.

  And anyway, I was back in the present now. I was going to get on with my work. Which was to write to the Home Office reporting the judge’s comments about me in the Baby Noah case.

  A short while later, the Home Office replied. They were already aware of the case and said they had been for some time. Although they hadn’t bothered to let me know. The police officer involved in the case had reported me to them and they had decided to pass the file to the General Medical Council. I might, they said, wish to discuss the matter with my lawyer.

  I most certainly did. She was reassuring but I was not reassured. At night my dreams were hideous. In the day, awake in my office, I fought with nightmares.

  At last, a letter arrived. I opened it with shaking hands. I wanted it to tell me that the whole thing had been dismissed and that it was over.

  It said I was under investigation by the General Medical Council. My competence had been called into question because of the cause of death given in Baby Noah’s post-mortem report, signed by me.

  Then, all joy stopped. And those events that I had not been calling panic attacks? Well, even I had to admit that’s exactly what they were.

  I have spent my entire working life reviewing cases. Now I was a case. Now I was under review. The GMC is essentially a private court that investigates at its own pace and behind closed doors. It gives no information about the length of time it will take to resolve issues and does not communicate on the matter other than to issue edicts – to which I had to respond within a very short time frame.

  I knew the GMC was quietly contacting colleagues, coroners, police officers, anyone who had worked with me, for their opinions of me and of my skills. The GMC did not say whether or when it might refer my case to the next level, the tribunal. I would be informed when that referral was made.

  The tribunal is the Medical Practitioners Tribunal Service, which is independent of the GMC and adjudicates cases sent to it by the GMC. It hears evidence on oath, with examination and cross-examination by barristers, and they return a verdict on whether a doctor is fit to practise. Or not. It is, effectively, a court.

  All this because another pathologist who worked for the Family Court suggested I made mistakes, that I missed obvious injuries and gave a cause of death for Baby Noah that he considered incorrect. Pathology is a combination of facts, experience and judgement. But the tribunal could ignore this and conclude from the accusations made that I was not trustworthy to determine how a child had died and therefore whether siblings were at risk. They could decide I should be ‘struck off’. That is, removed from the register of doctors considered fit to practise.

  Once the GMC investigation began, I started to experience, with renewed and alarming frequency, more panic attacks. Sequences of heart-stopping, heartbreaking images completely took over my mind.

  I tried to adopt a detached, medical view of this. So, these ambushes had started when I was flying over Hungerford one day. Why exactly had they started, why exactly had they stopped? Obviously the GMC investigation had triggered their ugly and forceful return. Had this public doubting of a man who is supposed never to be wrong opened up a chasm of hidden fears? And were these fears now out of control?

  There were no answers. Only images that inhabited my head suddenly and totally at the most unexpected moments. All I had to do was put some ice in Linda’s drink and I was back in Bali, staring at the young bodies rotting beneath their bags of melting ice. There was no question of my opening any of the files piled in my office. Because inside them lurked pictures. And there were already too many pictures inside my head to manage. A sense of dread immobilized me. I was filled with a horror that I can only call unquenchable. The stench of death never left me.

  Each ambush robbed me of sleep, stripped me of pleasures, tormented me with worry, filled me with self-doubt. The loss of my ability to rest was soon followed by the loss of my ability to read. Because I couldn’t make the decision to pick up a book, or to open it. I couldn’t make any decision at all. Would I like a cup of tea? I had no idea. I barely knew whether to get up in the morning, let alone bother to get dressed. The future? It didn’t exist. Everything I thought I had known or cared about suddenly had no meaning. Much of the day I simply concentrated on trying not to blink, since I had noticed the images that hovered over me, waiting to kidnap my mind, were quick to pounce when I closed my eyes.

  One hot summer morning my mind was pursued by rotting body fragments. There were intestines. Spongy livers. Hearts that did not beat. Hands. Here was one wearing a wedding ring. I had to prise it off to read the inscription so that I could find out whose hand it was. The clawing stench of decay took my breath away.

  I thought it was better to die than live like this.

  But how?

  Railway lines are quick but they are selfish. People who appear in front of trains cause trauma for the driver and create an unforgettable mess which will torment loved ones for ever. Hanging might not work, or not very quickly. A gun would be good, but how could I get one? Driving my car off a cliff seemed like a clean option. I’d have to find a suitable, accessible cliff, though. Difficult when I barely felt able to change out of second without crashing the gears.

  I don’t know what I was doing or saying because I could only see the world from inside my head, and it was not a world in which anyone would want to go on living. My actions, whatever they were, greatly alarmed Linda. I was taken, unprotestingly, to A&E, where I was referred to a psychiatric team. Sane, sensible, senior pathologist Dr Richard Shepherd sat and quivered as a psychiatrist gently asked him to share the images he was seeing. I tried to describe them. But no words came out.

  It wasn’t a difficult diagnosis. I dare say every person reading this book has already diagnosed post-traumatic stress disorder. Apparently, I was alone in not recognizing its symptoms.

  My PTSD is not caused by any particular one of the 23,000 bodies on which I have performed post-mortems. And it is not caused by all of them. It is not caused by any particular disaster I have been involved in clearing up. And it is not caused by all of them. It is cau
sed, in its entirety, by a lifetime of bearing first-hand witness to, on behalf of everyone – courts, relatives, public, society – man’s inhumanity to man.

  The result of this diagnosis?

  The summer of 2016 off work.

  Two cures: talking and pharmaceutical.

  And this book.

  I was scheduled to return to post-mortems in the autumn, but I did not see how I could ever work again. I did not see how I could cut arteries into tiny sections again, or lift brains out of skulls again or examine the insides of faces again or stand in the middle of an overflowing mortuary after another disaster with a queue of the dead waiting for me. Again and again and again. My future as a forensic pathologist was unimaginable.

  Then, there was a change, small at first. I started to talk. I remembered how Jen and I had sat together in the counselling room in Clapham all those years ago, how my mind had wandered but my mouth had stayed, for the most part, closed. Now, in a quiet room with a sympathetic professional, I allowed my mind to wander – just a little bit at first – and then told the professional where I’d been. It was a dangerous game, letting my mind stroll off where it would. Because God knows what it would get up to if I didn’t keep it firmly under control. But with a professional in attendance I, very slowly, week by week, controlled the release of my thoughts. And I found that, by reporting on my excursions to hell, they became fewer. Bit by bit.

  One day, quite recently, I began to feel better. There was still no word from the GMC and I really had no idea where the summer had gone or how it had become autumn but suddenly, almost as suddenly as that first panic attack over Hungerford, my acute anxiety lifted. The massive boulder that was going to roll over me any minute lost momentum. The dread that had weighed so much that my feet could not walk and my mind could not think, rose up and floated lightly away like a radioactive cloud.

  It was replaced by an intimation, perhaps the ghost, of my former pleasure in life. I knew this couldn’t last, that it was just a glimpse of normality, but it was enough for now. I wanted to grab the moment, get in a plane and fly it, to feel the thrill of take-off, to rise above the small, the mundane and the everyday. But of course, after my summer of madness, I had been forced temporarily to surrender my pilot’s licence.

  I burst in on Linda, who was working at her desk, frowning slightly over a child-abuse case that was soon due in court.

  ‘Let’s go for a walk!’ I yelled. Too loudly, perhaps. She looked at me strangely but stopped typing at once.

  And so we put the old dog and the new puppy in the car and it seemed to me that the autumn sun was burning more intensely than it had all summer. The brilliance of the countryside astonished me, as if I had never been out of town in my life before. When we arrived in a wild place, the leaves were so gold and rustling they looked like lamps on the hillside. The puppy ran round and round in excited circles, barking, and even the old dog scampered a little. The world was lovely, it was dressed magnificently, as though for a party. All summer it had been wearing its finest clothes and all summer I had rudely failed to notice or admire it.

  Linda said, ‘You look …’

  ‘Better?’

  She nodded and I saw her face alter without moving, as if, according to some secret rule and very subtly, each cell had just changed position. She didn’t even have to smile to look happy now. How hard PTSD is for those who have to watch it.

  I tried to absorb the hillside and the leaves and the dogs and Linda and the world’s beauty, to guzzle it the way some men guzzle beer, consume all I could before the darkness closed in on me again. Because I knew it must. Cured is not, unfortunately, a word in the PTSD lexicon. But that glimpse of a world without sickness – it must have lasted two, maybe three hours – was enough to make me long for more, to give me the energy to reach for more. The next intimation of normality would last longer. Eventually, one lasted a whole day. Gradually the world of colour and beauty began to reform itself around me, like a jigsaw.

  There were (and still are) many regressive moments, of course. If Linda had a drink she made sure she put the ice in it herself. Any communication from my solicitor about the GMC investigation, even just saying there was no news, left me incapable of action for a day, as though she had physically pushed me over. In the office, there were some files I knew I still had to avoid, containing images I could not see. Even this book, which I had been writing on and off for a year or two and finally put to one side, still had chapters I preferred not to revisit for now. But the summer taught me that I wanted to finish it, that I did not want my life’s work, forensic pathology, to be a ghostly, ghastly secret from the public. Because talking about the things a civilized society requires civilized people to do makes all of us healthier.

  Then, one day, the phone rang and it was my solicitor. She hadn’t received the letter yet but she had been told it was on its way. The case against me had been dropped. Suddenly. Without consultation or explanation, as it had begun. It had not even got anywhere near the tribunal.

  I can’t call this really a champagne moment. I had travelled too long and too painfully for that. But a weight did lift. The world did look clearer, sharper, as if someone had refocused my lens. For a few minutes, I didn’t know what to feel. GMC investigation or no, a deep fissure had opened up in my psyche which would always be there.

  When I told Linda the good news, the relief and happiness on her face reflected back at me and I began to feel something of her joy and then perhaps a little of my own. So many years of service were not going to end in a welter of unjust accusations. I could carry on. If I wanted to.

  It was frightening to return to work. I agreed the date, but as it approached I felt that I really could not do it. The psychologist reminded me that I had been learning to manage bad memories. She was right. I could get them out and review them when I wanted to and then put them back in the drawer when I wanted to. They wouldn’t go away. But they could be managed. I would return to work.

  As I walked into the mortuary on my first day back there was a moment when I smelled the place, when the door closed behind me, a moment in which I lost momentum.

  I stopped still.

  I could not go forward. And I could not go back. It was unbearable to enter, unthinkable to run away. I hovered, my mind clouding. And at that moment, the police officers arrived.

  ‘Hello, Doc, good to see you again, how are you?’

  I couldn’t turn back now. But I didn’t have to move on either, we were going to greet each other and talk right here. I stayed put.

  The detective was a man I knew and liked. He said, ‘Got a very strange case for you today, looking forward to seeing what you make of it.’

  A very strange case, eh? It must have been those words that propelled me forward. Five minutes later I was sitting on a sofa with a mug of hot tea in one hand and a biscuit in the other.

  The detective looked through his notes.

  ‘Deceased is in her fifties, a complete drunk and a bit of a handful, frankly. Her son-in-law borrowed some money and then left her daughter and never gave back the money, so one day this lady has a few and decides to go to his house and confront him. Lots of shouting and swearing. He says he was steering her gently off the premises but she was so drunk she fell. She said he pushed her. Either way, she ends up on the ground.’

  This wasn’t sounding strange at all. It happens all the time in my world.

  ‘And did he push her?’ I asked.

  ‘We think he did. Although initially his new girlfriend said he didn’t – and she’s the only witness.’

  Nothing strange yet.

  I could hear the clangs of the fridge doors as bodies were rolled in and out of them. I swallowed. The sound evoked many disasters, many bodies. I tried to concentrate on the detective.

  ‘The question for you, Doc, is: if he pushed her over, is that what killed her?’

  ‘So how long after the fall did she die?’

  ‘Days and days. She’s on the ground and
she can’t get up. He calls an ambulance. The hospital tells her she’s got a fracture in her pelvis and there’s not much anyone can do about that. Just keep taking the painkillers. That’s the normal treatment. And the fact is, she was shouting and swearing at the staff in A&E and they couldn’t get rid of her fast enough …’

  Was this going to turn into a medical negligence case? I took a sip of tea. It was beginning to get interesting.

  ‘She goes to stay with the daughter, where she’s given lots and lots of her favourite tipple. But she’s in agony and no amount of booze and painkillers help. Finally, a few days later, the daughter calls an ambulance. Different hospital this time. They say she has not one but five fractures of the pelvis and needs to stay in. But she’s gasping for breath and the orthopaedic team decide that she should go to a medical ward because her asthma’s so bad.’

  ‘And the medical team agreed? More fool them. So she’s an asthmatic alcoholic with a badly broken pelvis?’

  ‘I think she’s epileptic as well, actually …’ The detective passed me the hospital notes and continued while I glanced at the file. Osteoporosis. Asthma. Alcoholism. Epilepsy …

  ‘Oh, and diabetes too,’ I said.

  ‘This woman was a death waiting to happen,’ said one of the police officers. ‘She sounds like a medical dictionary.’

  The detective was quick: ‘But that doesn’t mean she died of natural causes.’

  ‘It doesn’t,’ I agreed. ‘So, what happened next?’

  ‘Well, on the medical ward they notice that she has extreme coughing fits and they treat her for asthma and a chest infection. She coughs and coughs, apparently until she faints. After about five days she has another one of these massive coughing fits. Only this time she collapses and dies.’

  ‘What did the hospital do?’

  ‘Resus, of course. They thought it was … er … pull … pull …’

  I said, ‘A pulmonary embolism? Pelvic fractures and she’d been lying in bed for days, it’s the obvious diagnosis.’