15
I was now proud to be master of my moods, slipping from homicide to home without dropping a stitch. I was also proud to be the smooth comforter and conveyor of information to those present at but repulsed by post-mortems. In fact, I had come to regard myself as a five-star, fully competent controller of emotions. Until I met relatives of the deceased.
Relatives, with their burden of shock, horror, grief. Relatives, looking at me for answers to the often unanswerable (‘Did he suffer, Doctor?’). Relatives, wanting to know the truth but greatly fearing the truth. Relatives’ emotions filled rooms like a huge and unstable spongy mass, absorbing all the available oxygen, while the relatives themselves sat awkwardly on hard chairs, passing tissues around, mouths open, eyes wet, heads shaking. Waiting for me to speak. Relatives, with their capacity to erupt into anger or hysteria or tears, frankly scared me.
This was something I had to learn to deal with, and the first lesson came, strangely, when a case taught me there was something much worse than relatives. And that was no relatives.
It was winter and I was called to the house of an old lady whose body lay naked and huddled under the table. The police were treating this as a crime scene and it certainly looked as though someone had been searching for valuables: cupboards and drawers were open, their contents spilling everywhere. Some of the lighter furniture had been shoved on its side.
‘Cold in here!’ I said to the police officer. The weather had warmed up over the last day or so but the large old house was still chilly.
‘Damp,’ he agreed. ‘That makes it colder.’
‘Didn’t she have the heating on?’ I asked.
He shook his head. ‘No central heating.’
A detective overheard this.
‘Probably intended to light a fire but the intruder must have got in before she had a chance.’
We looked around at the high-ceilinged room. The hearth had been swept and there had been no attempt to start a fire. There was an ancient two-bar electric heater in one corner. It was not plugged in.
I stared again at the fallen shelves, their contents – books, medication, knick-knacks, cards – all over the floor, the small chair on its side, newspapers that had clearly once been piled now smeared unevenly across the rug. I looked at the hunched, defensive body of the woman. She was pitiably thin. The scene was pitiable.
‘What do we know about her health?’ I asked.
‘Nothing yet, Doc.’
‘Has anyone spoken to the neighbours?’
‘Yeah, they don’t know much about her, kept herself to herself. Next door said they thought she was going a bit doolally.’
The police officer nodded. ‘The cleaner said she was definitely losing the plot.’
Doolally. Losing the plot. Forgetful. Doesn’t know what day it is. So many euphemisms.
In the kitchen, stale bread. An unopened tin of sardines. A tin opener. A jar of marmalade. A bread knife. Curious marks around the lid of the marmalade indicating perhaps that someone had tried to slice it with the bread knife, open it with the tin opener. Letters, most of them circulars or official looking, in the fridge.
No more euphemisms. I said, ‘Dementia.’
‘Expect she thought the intruder was a long-lost son or something,’ said the detective. ‘She probably answered the door and threw her arms around him. There’s no sign of a break-in, no sign of a scuffle in the hallway.’
‘Who found her?’ I asked.
‘Cleaner.’
‘Yeah, she couldn’t get in this morning and called us. Said the old girl was one sandwich short of a picnic and didn’t realize she was in here: thought she might have wandered.’
‘How often does the cleaner come?’
‘Once a week but she’s just been on holiday for two.’
A scenes of crime officer put his head round the kitchen door.
‘OK by us now if you want to move the body, Doc.’
‘Got anything much?’ the detective asked him.
‘Nah, lots of her fingerprints, can’t find any prints from the intruder. Must have worn gloves.’
I turned to the detective.
‘In my opinion, there was no intruder.’
He blinked at me.
I said, ‘Only the cold.’
By now there were four officers in the room. They said nothing.
‘I believe she died of hypothermia. I think she may have lost the mental capacity, or maybe even the physical ability, to switch on the heater, let alone light the fire.’
The detective started to shake his head vigorously.
‘Now, come on,’ he said. ‘It’s not that chilly!’
It is a myth that, in order to die of hypothermia, you have to be outside the house on a mountainside in freezing temperatures. We know that the old and vulnerable (and actually the young and vulnerable) can die indoors in air temperatures that are as high as 10°C – and that even higher temperatures can be lethal if there is a chilling wind outside or a strong draught inside.
If the body’s core temperature falls below approximately 32°C then heart rate and blood pressure fall and there is a dulling of consciousness. If the body’s temperature falls below about 26°C then death must almost certainly follow, although there is a famous case of someone who reportedly recovered – albeit mutilated by frostbite – from a body temperature of 18°C. (In forensic medicine it is amazing how often you find just one exceptional exception. Followed always by a defence barrister trying to make it sound commonplace.)
Hypothermia is, surprisingly, a not at all unusual cause of death. Its victims may have fallen in the sea or other cold water, or they are drunks who have dropped off to sleep in the park or they are young children who have been neglected. The great majority of victims, however, are elderly. Perhaps they think they cannot afford heating – and perhaps they really cannot – or perhaps physical or mental disability prevents them from switching it on. Sometimes hypothermia is simply the final step in a tragic pattern of depression and apathy towards eating, heating and personal care.
In this case, the homicide team simply refused to believe that no one had broken into the house.
‘Look at the state of the place, Doc! God knows what he took, he’s gone through everything!’
‘And why’s she got no clothes on? I’m just hoping you don’t find the bastard’s interfered with her …’
I said, ‘I believe she undressed herself.’
‘Because she was cold!’
‘And you think she threw all her own stuff around, I suppose?’
But this looked to me like a classic case of hide-and-die syndrome. The old lady had almost certainly given in to that strange counter-intuitive urge that can arise in those who are dying of cold. They take off their clothes. Survivors have described feeling very hot as their temperature dropped and really thinking that stripping off was a completely sensible thing to do. This is a common response to hypothermia. Less common, but another recognized syndrome, is the way some victims hide. In corners. Under tables. And, in doing so, they frequently pull over furniture or empty the contents of low-level drawers and bookshelves on themselves.
The team was sceptical about hide-and-die syndrome. The detective insisted that I would find evidence of homicide at post-mortem and, in fact, I knew it might be hard to prove my theory. Hypothermia can be difficult to diagnose in a body after death because dying of cold and the cold of the dead can have very similar appearances. Sometimes there are tell-tale external signs, like pinky-brown skin discoloration around the knees and elbow joints in white-skinned people. And the crucial diagnostic finding is the presence of numerous small dark ulcers in the stomach lining.
In this case, to my relief, I found both these clear indicators. Death had certainly been caused by hypothermia. I was pleased to have my theory confirmed but strangely upset by the truth. The old lady, living and dying alone, felt like a caricature of my grandmother and my aunts and their friends, all women whom I remembered living alone in the north of England. When I had holidayed there as a child, the world of older single women had seemed part of a firm structure of friendship, family, community and support. If they could no longer cope alone, they lived in care and remained part of a community. But the deceased woman had lived alone without any such structure. She had effectively died of neglect. Perhaps self-neglect, but still there had been an absence of care – from friends or family or community – which had allowed this to happen. From the pictures on the bureau she seemed to be someone’s mother or aunt or grandmother. Where was that someone? Where were these relatives who did not seem to bother themselves about her? Would they care now that she was dead?
I found it hard to cope with the emotions of relatives of the deceased but now, for the first time, I actually wanted to meet a few relatives. I wanted to explain to this woman’s children exactly how their mother had died. They made no attempt to contact me. Nor did they show up at the inquest. After gathering further information about the deceased, the coroner gave a verdict of accidental death, accepting my cause of death: Hypothermia with precipitating dementia. There was only me, a junior police officer and the coroner in court to hear this verdict. What a sad and lonely ending to a life that was.
When the next opportunity to meet some bereaved relatives arose, I dreaded it but reminded myself that coping with their emotion was better than contemplating the cruel isolation of the uncared-for. Which didn’t entirely eliminate my dread. At the thought of these relatives I felt something like nausea and even considered saying I was too ill to attend. But I knew there was no escape. I would have to engage with the pain of their loss. Which, I now admitted to myself, meant recognizing the resonance of my own, long suppressed pain.
This case was a difficult one. The family’s misery was acute because their elder daughter had walked into her fifteen-year-old sister’s bedroom one morning to find that the girl had died in the night – for no immediately apparent reason. Alannah had been a keen ballet dancer, sweet-faced and lovely. Her parents and siblings were baffled, shocked, devastated by her death, and their GP, or perhaps the coroner’s officer, had therefore arranged for them to see me to discuss it.
I met them in the relatives’ room at the mortuary. This had been decorated sympathetically in soft colours. Lighting was subdued and the room was soundproofed from the clangs of trolleys and any inappropriate whistling by the staff. I ran in, the keen young pathologist who had just given a lecture and was shortly scheduled to rush off and carry out another post-mortem, then get home to his children. As I opened the door I was wondering how quickly I could get this over with.
Before me sat one entire family in shock. Mother of the deceased. The deceased’s father. Her brother. Her sister. The sheer physical presence of their great grief brought my own life to an abrupt halt. Stop all the clocks.
I desperately wanted to be kind to them. I opened my mouth to speak. And then closed it again. Their suffering was unbearable. I felt it begin to soak into me, like some indelible dye. Misery engulfed me. What kindness could I offer, what could I possibly say? A sob escaped the brother. The sister’s head was in her hands. Tears ran down the father’s cheeks. Suddenly I wanted to cry with them. And I never cry, never, ever, certainly not since, or perhaps even when, my mother died. I have no recollection of crying as a teenager or as an adult. I have not cried, not once, at the cruelty and sadness that parade endlessly through my professional life. Just ask my wife. I don’t cry. But now I wanted to. As if I had to witness someone else’s tears in order to unleash my own.
Except, of course, that professionalism required I did nothing of the sort.
So, they waited patiently until I was able to mumble my way through my condolences. Then there was an excruciating silence.
At last someone spoke. It should have been me but it was the deceased girl’s mother, a woman whose face revealed her devastation but who retained her composure.
‘Are you all right, Doctor?’ she asked. Her voice, suffused by grief, was kind and generous. Generous because she was looking at me with something like compassion.
I assured her, rather shakily, that I was fine.
‘Can you … can you shed any light on Alannah’s death for us?’ she prompted.
Of course! That was my role here. She had reminded me. They didn’t need me to share their grief. They didn’t require my tears for the beautiful daughter taken from them.
Snap. I moved into professional mode. I had a knowledge of their daughter that they lacked; knowledge of how her body worked, of what had happened that terrible night. She had, in effect, spoken to me. Bodies do. An examination tells me so much about the deceased’s lifestyle, perhaps even their personality, but most of all about their death. In the case of a homicide, what the deceased says to me, as long as I listen carefully enough, can help bring a perpetrator to justice. In the case of Alannah’s death, I could comfort her family with what I had learned from her.
This was certainly not my first meeting with relatives but it was here that I finally understood the obvious. Families who ask to see the pathologist want just one thing. The truth.
Alannah suffered from epilepsy and had been prescribed the appropriate medication. I explained that, as expected, toxicology had established there were no other drugs or alcohol in her blood. Crucially, it had also been established that she had taken the correct amount of medication for her condition. No overdoses, no forgetting. Nor had she been asphyxiated by bedding during a fit.
My external examination ascertained there were no marks on her body indicating a struggle with another person or interference of any kind. My internal examination confirmed there was no congenital heart problem or other obvious cause of death. And there was no evidence that Alannah had died during or after a seizure in the night.
‘Then why? Why?’ sobbed her father.
I asked them for Alannah’s medical history. Of course, I had read it, but I wanted to make sure there was nothing that had slipped through the notes. When they finished speaking, I knew that, in the complete absence of other explanations, the cause of death must be her epilepsy.
Nowadays we know about SUDEP – sudden unexpected death in epilepsy. We know it is something that can happen without warning to those who suffer from epilepsy, usually in the night and not necessarily after a seizure. We still don’t exactly know how or why SUDEP occurs – and back then the evidence for SUDEP was even more anecdotal.
So, I could give them this evidence but I couldn’t give a detailed explanation of the exact mechanism of Alannah’s death. Perhaps faulty electrical wiring in the brain, an electrical discharge or neurone storm that stops the heart? SUDEP is a mystery. They accepted what I said but there were other things they needed to hear.
They needed me to say, ‘It wasn’t your fault. She took the right medication for her epilepsy in the right doses.’ This was the truth. I said it.
They needed me to say, ‘She isn’t dead because you failed to hear her cry for you in the night.’ This was the truth. I said it. And I added, ‘It is most unlikely that Alannah cried out at all. But IF she did, and IF you had heard, and IF you had rushed in, there was still nothing you could have done.’ That phrase is important to so many of the bereaved. One of the normal phases of grieving is guilt. There was nothing you could have done won’t magically wipe away guilt, but it may allow it to pass more quickly. I hope so.
So that is what I gave them. The truth as I understood it. Unvarnished by phrases designed to save them from it. Beautiful in its simplicity. Unfiltered by the rawness and violence of the emotion a death causes. Allowing myself to become involved in their feelings had added a complication to the truth that could help no one, and I determined never to let it happen again.
I watched as Alannah’s sister unwound herself from the strange, defensive contortion she had adopted. The brother stopped sobbing. The father dried his tears. Not for long, perhaps. But somehow the truth seemed to help them.
That interview changed the way I received relatives and, to some extent, took away my horror at dealing with them. I stopped trying to save the bereaved from their misery and now tried to deliver only the truth as kindly as possible – while accepting that the truth is not always simple and singular. It can be a fractured, fragmented beast. I may not see all of it. And truth can be different things when viewed from different viewpoints – which means some families say they want the truth then simply refuse to believe it when it doesn’t fit with their preconceptions or expectations.
Not this family, though. But they did have other questions, and I have been asked those same questions by many families many times since.
The brother, in a low voice, almost whispered, ‘What is it like to die?’
Answer: I don’t know.
I can comment that, even if it occurs in the most violent of circumstances, death is finally an experience of supreme release and relaxation. Therefore, with no scientific evidence and based purely on my own instincts and my experience of seeing people die in A&E departments and on the wards, I’ve come to the conclusion that, while few people actually want to die, when it happens, death itself is probably actually pleasurable.
When I said this, the surviving daughter of the family, who had been the one to find her sister’s body in the morning, blurted out, ‘She looked so peaceful! As if she was having a nice dream!’
I have very often heard that phrase: ‘She looked so peaceful!’ In fact, the facial expression of the deceased does not, in my view, necessarily mean that death was peaceful. The calm composure of the dead is simply the result of, I believe, the total relaxation of the facial muscles after death. Given the comfort that look of peace can bring the living, this is one truth I distribute economically, although, if asked, I will stick to my policy of honesty. But the dead girl’s sister was making a comment, not asking a question. The lines of Pope my father gave me at school came back to me:
’Tis not enough, your counsel still be true,
Blunt truths more mischief than wise falsehoods do.
Death may bring a pleasurable release, but whatever immediately precedes it can, of course, be terrible. Now the girl’s father, in a hoarse voice, asked a classic question: ‘Did Alannah suffer, Doctor? I hope she didn’t suffer for long!’
Pathologists are asked this question so many times. And in answering it, the facts can become very grey as the need to comfort the bereaved stumbles against the hard rock of truth.
Many choose to tell the relatives of those who die in violent circumstances that the patient would have passed out or become unconscious quickly and then died peacefully. Even when they are not sure this is the case. In fact, it is very hard to assess suffering or how long the body can bear it before dying. I can review injuries and diseases and make some guess at the level of pain they would have caused. And I can suggest how long death may take in some circumstances. But, from the body itself, there are seldom absolutely clear indicators of death’s speed.
There is a myth that finding a lot of fluid in the lungs – pulmonary oedema – is an indicator of a slow death. This oedema is a common part of the dying process for most people: as the heart beats less and less efficiently, normal physiology means that fluid leaves the blood vessels and fills the lungs. So, people who have their heads chopped off will show no oedema in the lungs at all because their death has been so fast. But the opposite isn’t true: a lot of fluid in the lungs does not necessarily point to an agonizingly slow death.
How, then, to answer this family’s – any family’s – questions about suffering and speed of death? I decided to follow the hunch I had developed into a technique in the post-mortem room: offering knowledge to alleviate painful emotion.
I said, ‘Most people misunderstand death. They see it as an instant event. You think that one moment your daughter was alive. And the next … gone. But death just isn’t like that. Humans only switch off completely, in one moment, like lights, if they’re vaporized in a nuclear explosion. In all other circumstances, death is a process.’
Death is a process. I’ve used that phrase so many times now. During this process, each organ of the body shuts down at a different rate according to its own internal cellular metabolism. And then this in turn triggers further processes which eventually lead to the decomposition and natural disposal of the body. Dust to dust.
The simple process of death that many of us recognize from a bedside may last only seconds – or it can last tens of seconds or even minutes. Technically, it lasts hours as the body dies cell by cell. Some cells, skin and bone, can remain ‘alive’ for as much as a day: these cells continue to metabolize without oxygen until their reserves are finally exhausted. In fact, these cells can be removed and then grown in a laboratory for some days after a body has been certified dead.
For a few hours there might be random heartbeats. Digestion may continue. White blood cells can move independently for up to twelve hours. Muscles may twitch. But that’s not life. There may be exhalation. But that’s not breathing.
Various definitions try to pin down death, but each definition is a struggle; morally and scientifically. When the individual will never again communicate or deliberately interact with the environment, when he is irreversibly unconscious and unaware of the world and his own existence: that’s death. Of course, that may define someone in a deep sleep or under a general anaesthetic – conditions that are reversible. It may also define someone in a coma or persistent vegetative state. But these patients do have heartbeats and show at least some brainstem activity: that’s not death.
When there is no heartbeat, no breath, and the ECG shows a flat line, that’s real death. Occasionally people have told me that they knew the exact moment, sitting at a bedside, when a relative died. But they are almost certainly wrong. They are referring to the time that breathing and heartbeat stopped. They witnessed a somatic death. Cellular death takes longer.
The bereaved family listened to my explanations without sobbing. There was silence as they tried to knit the knowledge I had shared with them into the particularity of their own, tragic, experience.
‘I can’t tell you how long it took Alannah to die, but the anecdotal evidence is that sudden unexplained death from epilepsy is swift. I can’t tell you how much she suffered but there is no evidence from her body that she suffered at all.’
‘She may not even have woken up? She may not have known she was dying?’ asked the father hopefully.
The temptation was to agree wholeheartedly. But that would not be entirely truthful.
‘We can never know exactly what Alannah experienced. I can only say that there is no evidence of distress. And repeat that death is a process during which life is gradually wrapped up and put aside. And that I believe this to be a pleasurable process.’
The family looked ready to leave the room calm, engaged, relaxed. However, then the father said, to my astonishment, ‘It’s really helpful to hear all this. But … I just can’t stand the idea that you’ve cut my daughter up into pieces.’
At that, the mother, who until now had been so strong and composed, burst into tears.
‘We would have liked to have seen her one last time. But we can’t! Because you’ve cut her up!’
The son choked. The surviving daughter’s face crumpled. The father started to cry again.
It had never really occurred to me before then that for most people I am the dark figure of death cloaked in Halloween colours who has ‘cut up’ their loved one. And it was the first time I encountered the false assumption that we pathologists turn beautiful corpses into mangled meat. Although I’ve met it often since.
Many people – and, I am sorry to say, this includes police officers and sometimes even coroners’ officers (who really should know better) – wrongly advise relatives who wish to see a body after post-mortem that they should not do so. Because of ‘what the pathologist has done’. People who cannot bear the idea of a post-mortem, even those who are theoretically professionals but who may never have visited a mortuary or seen a body after post-mortem, simply should not impose their own feelings on relatives at such a sensitive time. No doubt they hope to offer support. Instead they can inflict deep and long-lasting scars on those who want and need to say a last goodbye.
The result of this mythology is that, sadly, many relatives who are asked to agree to a post-mortem of their relative will not do so. Of course, they do not always have a choice: if death has been sudden, whether it is natural or accidental, the coronial system will usually take over, and the coroner will certainly demand a post-mortem if homicide is suspected. Society needs to know, and this greater good overrides the relatives’ wishes. Bearing in mind that a relative could be – and quite often is – the murderer.
The general horror of post-mortems only became completely clear to me when I read a statement a relative gave following a major disaster. She had learned that a post-mortem had been performed on her son without her knowledge. Since he was a disaster victim she thought the cause of death was already obvious:
In my view, it was wrong to carry out any unnecessary invasive procedure which disfigured the body and showed lack of respect for it and for my family’s emotional and religious needs. To me, he was still my son, and any unnecessary mutilation of his body was an unforgiveable intrusion.
I really do understand that it is hard, very hard, to recognize the finality of death. To understand that the son who was thinking and feeling and animated yesterday is not so today. To comprehend that yesterday he would have been in agony when I inserted my knife but today he cannot feel it at all. And perhaps the hardest thing is to see the insertion of that knife not as an intrusion but an act of respect and, yes, maybe of love.
Here are the words of the QC who was acting for the group of angry, bereaved relatives that included the mother I quoted above:
The care with which our dead are treated is a mark of how civilized a society we are. Much goes on for understandable reasons behind closed doors. For this reason, there is a special responsibility placed on those entrusted with this work and the authorities who supervise it to ensure that bodies of the dead are treated with the utmost care and respect. That is what bereaved and loved ones are entitled to expect and what society at large demands.
Who cannot agree with him? Except that he was representing relatives who, among other miseries, were angry that their loved ones had undergone a post-mortem.
For me, his words pinpoint why post-mortems are so important. When I perform one, I am thoroughly, efficiently and perceptively delivering to the dead not just ‘the utmost care and respect’ which a civilized society expects, but love for my fellow man. I am ascertaining the exact cause of death and in doing so it is very distressing to be regarded as a mysterious, cloaked butcher. I sincerely hope that those to whom I have spoken directly, or who have heard my evidence in court about the death of their relative, appreciate that I did my job with care. And, I believe, love for humanity.
Very gently, I tried to help Alannah’s sobbing family to understand that her body had not been brutally mutilated at post-mortem but respectfully investigated – for their sake, her sake and society’s sake. The world did not shrug its shoulders and say, ‘Oh well, there goes another fifteen-year-old girl.’ It demanded to know the truth.
I assured them that her body had been faithfully and beautifully restored after this process – as all bodies are – by my colleagues. Mortuary technicians are rightly proud of their skills. Alannah’s family should have no fears about seeing her. Indeed, they must do so. Seeing a loved one’s body is a way of saying goodbye, recognizing death’s finality and celebrating a life.
I made arrangements then and there for them to see Alannah. They thanked me quietly as I left. I knew how long and hard the grief road would be as it unfolded in front of them. Maybe I had made a few steps on it easier for them. For our different reasons, none of us there has probably ever forgotten that meeting.
Of course, I can’t personally feel grief for every one of the tens of thousands of people on whom I’ve carried out post-mortems. Grief is not an emotion I experience as I incise a body. It is something I experience when I see others suffering their own loss, either within the controlled forum of the coroner’s court or, more informally, at the mortuary or office. I’ve come to terms with the need to manage my response now. In the years since that meeting about Alannah I’ve even come to believe these contacts between pathologists and the deceased’s loved ones should be arranged far more often. Information, its very solidity and certainty, can provide not just clarity but support, relief and a sound basis from which relatives might, eventually, move on.
For myself, I would say I have spent a working lifetime respecting and understanding relatives’ pain – while trying not to internalize it. Analytical readers will by now be associating my reluctance at the start of my career to meet relatives with the death of my own mother so early in life. And at my subsequent willingness to engage with others’ grief they will say, ‘Aha! He couldn’t allow himself to experience the enormity of grief for his own loss! So, he experiences it again and again in manageable proportions through the grief of others. And, at the end of the meeting, he walks away from it!’
I accept that there is probably something in that theory.