Unnatural Causes

by Dr Richard Shepherd

  ‘That’s the one. Anyway, they gave resus and some stuff to, er …’

  ‘To dissolve blood clots.’

  I was sorry at that. It was certainly the right thing to do but it didn’t save the patient and it certainly hadn’t helped the pathologist. Because, if there had been a blood clot for me to find, now it would be dissolved.

  ‘We were waiting for her to get better to discuss the GBH charge against the son-in-law and when we rang the hospital to ask if we could question her, the nurse says, “Oh, we forgot to tell you, she’s dead.” So suddenly it’s not GBH, it’s manslaughter.’

  I finished my tea. Now this had become a strange case. I’d just been presented with five possible causes of death, and it still might be something else entirely. Only her body could tell us why she had died and it was waiting for us now. I stood up. I was curious about this mystery.

  ‘Right. Let’s take a look at her.’

  On the way into the post-mortem room, I said to the detective, ‘This is your department, not mine, but you haven’t got a lot of evidence that the son-in-law pushed her. If she was drunk she could have fallen over and injured herself before she even arrived at his house.’

  ‘We’ve got the girlfriend, actually. She’s split up with him. And now she’s changed her statement. Says she saw him push the woman over and push her hard.’

  Hmmm. No jury is impressed with witnesses changing their statements by 180 degrees.

  ‘And,’ he added, ‘we have CCTV footage of the deceased about five minutes before she went to the son-i n-law’s and she had no problems walking then. So what we really need in order to prosecute is your evidence, Doc.’

  I would look for that evidence. But with a constant awareness that there was a manslaughter charge and the possibility of a prison sentence hanging over the defendant. I must be absolutely sure I was right before I could give the police my statement.

  The woman was fifty-six and looked ninety-six.

  ‘Are you sure we’ve got her age right?’ I asked.

  The police officer nodded.

  I examined the exterior of her bloated body. It was peppered with abrasions and scars, as the bodies of alcoholics often are. Each would have to be measured and described. I made my notes and kept the photographer busy.

  ‘What quality of image do you set on the camera?’ I asked him.

  He looked at me, surprised.

  ‘The lowest, Doc.’

  I was fascinated. ‘Why the lowest – surely you want the best-quality images possible?’

  ‘True,’ he said, ‘but the police computer system can’t cope with big files and so we have to use low quality.’

  There was no answer to this acceptance of inaccuracy, and I could hear no apparent distress in his voice. It was from his point of view a simple and sensible conclusion, given the poor computer system. It didn’t seem to matter that the photos he took would be used to convict hundreds of people. And had nearly finished off my career. I just sighed. What else could I do?

  Then it was time to make my first incision. I stood at the patient’s right side, PM40 in hand. It felt like many long years since the last time I had stood by a naked, dead body. Did I really want to do this? Store up more bad memories in that hideous scrapbook inside my head that could still open, without warning, at any time?

  I gradually exposed the body, entering the abdominal cavity using a unique cut. Unique because I had invented it. Let’s call it the Shepherd cut. Instead of slicing the muscles down the midline, I cut along the bottom of the ribs and down the sides of the abdomen. Then I fold down the muscles of the abdominal wall, like opening the lid of a box. Neat, effective. And I found here, around the fractured pelvis, extensive blood in the muscles and tissues.

  ‘Looking promising!’ said the detective happily.

  ‘She was certainly haemorrhaging,’ I agreed, baling out the blood and then looking at the body’s internal organs lying in the chest and abdominal cavities, ‘but none of it looks recent.’

  As I stared and lifted and poked, the roadmap of her life lay before me.

  ‘Is that her liver?’ asked a police officer, pointing to a small, grey organ lying across the top of her abdomen. Even a layman could tell this had not been a healthy organ for a very long time. ‘Looks like a dead parrot.’

  ‘You won’t need to pickle it, Doc, she’s already pickled it for you,’ said another.

  The detective was shaking his head. He said, ‘Doc, please don’t tell me her liver killed her.’

  I said, ‘I agree it looks awful, but I’ll know exactly how bad when I can get it under a microscope … her lungs don’t look too good either. Quite a bit of emphysema here.’

  The deceased had spent her life by a very busy main road or she had worked in a dirty factory or she had smoked heavily. Her lungs were dark, quite black in areas, and they were pitted by numerous big holes.

  ‘I don’t want to hear her asthma killed her either,’ said the detective gloomily. ‘And if you say she had a heart problem too, I’ll cry.’

  ‘She probably did with this little lot. I’ll have to get her heart out to look at it properly.’

  ‘Doc, don’t give me natural causes. I’d really like to nick him. This woman may only be fifty-six but she looks really old and frail and he’s a big bloke and he shoved her over hard and she broke her pelvis in five places and then she died. He shouldn’t get away with it.’

  I said, ‘Her family might have a case against the first hospital for sending her away with just paracetamol when she had five pelvic fractures. Unless, of course, she fell at her daughter’s afterwards and got the other four …’

  ‘The daughter’s not saying, but we’ll get the X-rays from the first hospital checked,’ said the detective, making a note. ‘I’m not really interested in cases against hospitals, though. She got the fracture in the first place because he pushed her.’

  ‘How could she die of a broken pelvis anyway?’ asked another officer.

  ‘An indirect cause of death from a broken pelvis would be a pulmonary embolism: she’d been lying in a hospital bed for days and that means a blood clot could easily have developed in her legs and found its way through the blood vessels into her lungs. Unfortunately, the hospital gave her medication during resuscitation to break up any clots so I’m unlikely to find that – if it was ever there.’

  ‘Oh God,’ said the detective. ‘We need evidence.’

  ‘Well, another common cause of death after a fracture is a different type of embolism called a fat embolism. We don’t know how this happens. Maybe fat from the bone marrow at the fracture site finds its way through damaged blood vessels and into the lungs. Once it’s there it can be carried through the lungs and then it can get to the heart, the kidneys, the brain … it’s often fatal. Odd thing is that it takes about a week from the trauma to death.’

  ‘Ah!’ The detective’s face was brightening. ‘When will you know if she’s got that?’

  ‘She’s probably got it to some extent, a lot of people do after a fracture, after all sorts of things. It’s a question of degree … I need to know just how many fat emboli she has, and if that number is significant, before I can say that’s the cause of death.’

  ‘When will you know, Doc?’

  ‘About a week, but of course we’re waiting for toxicology anyway.’

  The detective looked at me. He said, ‘I told you it was a strange case.’

  I grinned back at him. ‘Yes,’ I agreed, ‘it is.’

  I thought about the case a lot. But not the next day. Because I had just got my pilot’s licence back and now I went flying. Alone, I was suspended by nothing in the middle of nothing with the amazing feast that is the English countryside spread out below me and, in the distance, the deep, sombre blue of the sea. The plane soared. I soared. My thoughts were as gloriously uncluttered as the sky, as the sea.

  A week or so later I met the same detective again at another post-mortem. Another strange case.

  A
man had come out of the pub and later been found dead in a river. His family were convinced that he’d been knocked out by an assailant and then chucked in the water.

  ‘Well?’ said the detective from across the post-mortem table. ‘Had any luck yet finding the cause of death for the drunken woman who got pushed over?’

  I was running an eye over the man from the river. I had a theory about him.

  ‘I’ve been agonizing over it. That woman really was a complex case. I did find quite a few fat emboli in her lungs and brain but, according to the research, not quite enough to be one hundred per cent sure they were fatal.’

  He groaned.

  ‘I’m going to give as cause of death the fractured pelvis with haemorrhages and fat emboli. For part two – that’s the associated findings of course – I’m going to add the cirrhosis, diabetes, etc. as underlying conditions.’

  He stared at me.

  ‘So! It was the fractures!’

  ‘What I give is my opinion about the cause of death. Others may disagree and in the end it’ll be up to the CPS to decide if they want to prosecute. I think they should. But, knowing the CPS nowadays …’ I rolled my eyes. ‘Of course, finally it’s up to a jury to decide if that’s beyond reasonable doubt or not.’

  ‘They can’t decide if he’s not been prosecuted. Thanks, Doc. I tell you, I’ll be arresting that son-in-law for manslaughter.’

  ‘The CPS will only let you do that if they’re sure they can win the case, and right now they’re not sure.’

  ‘What’s stopping them?’

  ‘They want me to give more weight to the pelvic fractures.’

  He looked at me narrowly.

  ‘Well, can you, Doc?’

  I stared back at him over the drowned body.

  ‘I’ve gone as far as my conscience allows.’

  ‘But –’

  ‘My cause of death says it all. She died from complications of her pelvic fractures but she was already an ill lady with several chronic diseases. You take your victims as you find them, right? If some minion at the CPS can’t understand what I’ve written – and I don’t think they can – and they’ve point-blank declined my request for a meeting so I can explain my findings and reasons, what more can I do?’

  ‘Doc –’

  ‘I’ve been fair. That’s my job, to be fair.’

  At this point detectives can get very annoyed with pathologists, so I concentrated on the body in front of me. I had a suspicion that this was going to be one of those cases of death by urination. We know that drunks can be unstable and wobble. Not normally too much of an issue, even when urinating, although it does make for messy bathrooms. However, wobbling can become an issue if drunks stop on the way home to relieve themselves in a river or a lake. Then, if they wobble a bit too far, a treacherous combination suddenly occurs: they are both staggering drunk and immersed in cold water.

  I examined the man’s body carefully for marks of the punch-up his family were convinced had killed him. A few minor bruises … a very few lacerations, which looked as if they had happened in the river. And the crucial findings – flies undone and penis exposed. I was just sure I’d find a full bladder when I examined his pelvis. And there was a lot of froth exuding from his mouth and nose, a classic sign of drowning. So, the man was alive when he entered the water, and then … I was concentrating so hard that I had almost forgotten the angry detective.

  ‘Doc …?’

  I looked up and blinked at him.

  ‘I really admire you.’

  I blinked harder. No police officer had said such a thing to me before. Ever.

  ‘You’ve done a job all these years that most people don’t even want to think about. And you’re still fascinated – I can tell by watching you. Here’s some idiot who pegged it, probably because he fell over peeing while pissed. That woman was a hopeless alcoholic who was at death’s door anyway. And you still care about them. No matter what, you care enough to be fair.’

  Behind us the mortuary clanged as wagons moved the dead around. Nearby, in the softly lit, pastel-painted bereavement room, a relative sobbed loudly. Around us the group of police officers waited, watching the knife in my hand. I looked at the body before me. Overweight, balding, fingers puckered and whitened, some skin slippage, a bit of decomposition, a lot of bad luck. My fellow man.

  I tried to respond to the detective’s words with a light-hearted, throwaway line. Something about how I still loved solving puzzles after forty years. But I couldn’t. Because I knew he was right. I did care. And I still do.

  Author’s Note

  It was difficult for me to take the decision to change names and identifying details in this book because I’ve spent a working life striving for accuracy. However, I’ve also spent a working life trying to alleviate the suffering of the bereaved and it would help no one to recognize a relative in these pages and revisit their darkest days here. So only the names of those who are so famous they are impossible to disguise are given. In all other cases I have changed details to preserve confidentiality while maintaining relevant facts.

  Acknowledgements

  I have been very fortunate to spend my career working in a profession which has fascinated me from the first moment I knew it existed. But it is only when I look back over forty fleeting years that I realize what a crucial part family, friends and colleagues have played. I remember them all but they are, of course, far too numerous to list, so here I thank just a few of them. Dr Rufus Crompton and Professor Bill Robertson – they created a job especially for me to study forensic pathology at St George’s Hospital and showed me the path ahead.

  The many coroners I have worked for and with, including Paul Knapman, John Burton, David Paul, Alison Thompson, Michael Burgess – they have helped me to give understanding and closure to so many devastated families.

  My colleagues at Guy’s Hospital, Dr Iain West, Dr Vesna Djurovic and Dr Ian Hill. And, of course, The Forensic Medicine Unit at St George’s: Dr Robert Chapman, Dr Margaret Stark and Dr Debbi Rogers, as well as the indefatigable Rhiannon Layne and the ever-cheerful Kathy Paylor.

  Not forgetting the staff in mortuaries all over the country for their immense skills so seldom recognized or praised and for their friendship, support and, of course, cups of tea! I have worked in courts of all sorts in the UK and abroad and the court staff have always been polite and helpful. I must mention in particular the staff at the Old Bailey, some of whom I’ve got to know well during the many hours I have spent waiting to give evidence. And I’ve always been grateful for their cheery smiles and encouraging words after the occasional mauling by a truculent barrister. The many police officers I have worked with, but particularly Steve Gwilliam: he was a wonderful colleague and we rather grew up together professionally in the early years. And it was he who taught me to fly and opened up a whole new world. The many solicitors, barristers and judges with whom it has been a pleasure to work. And then, of course, my family. First Jen, who was such a support to me as my career developed and whose determination in the years we spent together took her own medical career into areas she had never previously contemplated. I am inordinately proud of our children, Chris and Anna, and of my grandchildren, Austin and Iona. And Linda, my wonderful wife and the constant point in my life, who keeps my feet on the ground and who has taught me to love our garden. Without her love and support it would not have been possible at times to carry on. Plus of course the three ‘additions’ I am very pleased to say she brought with her – Rachael, Sarah and Lydia. Thank you, to all of my family, for your strenuous efforts to prevent me growing old and even the slightest bit pompous.

  It was the patience and support of Mark Lucas and Rowland White and all of his fine team, but especially Ariel Pakier, at Michael Joseph who steered the craft you now hold in your hands to a safe landing and I thank them wholeheartedly for this.

  Finally, my current Jack Russells, Archie and Bertie, and their predecessors who have been my ever-present companions, personal trainers a
nd totally tolerant confidants.

  THE BEGINNING

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  First published 2018

  Copyright © Richard Shepherd, 2018

  The moral right of the author has been asserted

  Designed by Andrew Smith

  Cover image © Alamy

  ISBN: 978-1-405-92355-2