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.
‘Ellie, he’s surely not saying that we missed …’
‘I’ll look at the pictures and call you back.’
I felt sick. Was it possible that I had examined a dead baby who had been abused and murdered and failed to spot the evidence for this? And actually given SIDS, exonerating the parents and endangering any future babies they might have? And had the evidence been so obvious that eighteen months later another pathologist could pick it up just from the photographs?
I dug out the file. Baby Noah was many cases ago. I tried to remember that day.
I had been called to the mortuary by the police because the mother had found her baby dead in the morning. Waiting for me in the lounge area next to the inevitable mortuary fish tank was Ellie – the post-mortem of a child whose death is suspicious must be carried out by two pathologists, one forensic, one paediatric. Ellie is good to work with: witty and wise, she demonstrates a 100 per cent certainty about her own conclusions that I secretly envy.
Now I flicked through my notes. The mother gave Baby Noah a bottle at 8 p.m. and, since he was sniffling, also some paracetamol. He went to sleep but had woken twice in the night. The first time, at about 2 a.m., the father had rocked him back to sleep. The second time was at 5 a.m. and the father was waking up anyway, since he was on an early shift. He settled the baby and left the house at 6 a.m. without really waking the mother. At 7 a.m. she had found the baby dead. She ran, screaming, into the street. A neighbour, who had seen resuscitation techniques demonstrated on EastEnders, ran in and attempted to revive the baby until the ambulance crew arrived to take over. Without success.
Pictures of the home had shown the disorder one expects to find where there is a new baby. There was little furniture because the place was dominated by large, plastic toys of the kind Grandma buys at Argos. The fridge was nearly empty except for milk and leftover takeaway cartons. Upstairs the bedroom was almost filled by the bed and cot: there were piles of baby clothes on the remaining floor area.
Most notable for us as pathologists was the temperature of the place. We saw pictures of the boiler thermostat downstairs set to thirty degrees and pictures of the bedroom radiators on max. The police had commented on how hot the house was. There is, of course, a strong association between SIDS and overheated babies.
Some time after we had completed our post-mortem report, a number of anomalies and untruths emerged. Moslem neighbours were shocked to find their bins full of empty alcohol bottles and mentioned this to the police. Noah’s parents later admitted that they had disposed of these bottles in the night. Toxicology extrapolated the father’s blood alcohol level at the time the baby was supposed to have first woken at 200mg/ 100ml, two and a half times the drink-drive limit. And the same tests revealed that both parents had been smoking cannabis.
The father had an old GBH conviction after a fight, but there was no history of domestic violence. The baby had an old shoulder injury, but this could easily have been caused by his very difficult birth. The police were clearly suspicious of this couple but could not really articulate why – although they did find out that the house was so hot because there was a small cannabis farm in the loft. The ambulance crew strongly suggested that the baby had been dead for a few hours, not just one as the mother insisted. But they weren’t sure. And all the marks on Baby Noah’s body could be explained by the untrained resuscitation techniques of the neighbour and the subsequent prolonged attempts of the ambulance crew.
Ellie and I had to agree on a cause of death. As the paediatric pathologist, she was going to write the report and I would make any corrections and then sign it.
Ellie was sure she knew what she wanted to say.
‘SIDS, Dick. It’s SIDS.’
‘But there’s too much about it that’s not quite right. I’d rather give “Unascertained”.’
‘We’re not here to pass judgement on them for having a few cannabis plants in the attic, for heaven’s sake. Or for liking a drink. They’re obviously not a chaotic pair of addicts. The father has a regular job, the baby was healthy and well cared for, they turned up for all their health-visitor appointments and vaccinations, there was a supportive wider family – the grandma, the sister. No, don’t let’s leave “Unascertained” hanging over a young couple who’re simply poor and doing their best.’
SIDS it was, then.
Except now another pathologist had looked at the post-mortem pictures and decided it wasn’t.
I put the pictures up on the screen. Here were the baby’s lips. They were redder than I remembered and the marks on them were more prominent, but there was no swelling or bruising. These were injuries caused during resuscitation. I then looked for the serial pictures of the inside of the chest showing the baby’s ribs. Sure enough, I could see some whitening in some areas. Which might indicate old fractures. Or was it just the glare from the photographer’s flash?
I phoned Ellie back: ‘The lips look redder and more marked in these pictures than they really were and there are actually some areas that look white on the back of the ribs –’ I could hear her exploding so I went on quickly. ‘We know that’s not how it was. If you look at the pictures closely enough, you’ll see some of the other organs are odd colours and there seem to be flash reflections littering the images. It’s the photos.’
‘Who took them?’ she roared. ‘Who took these rubbish pictures?’
I remembered how a SOCO had stepped forward rather shyly with the camera. Had it been his first ‘proper’ job? He had asked his senior for advice several times and then the auxiliary flash had stopped working, and he eventually had to rely on the camera’s own built-in flash.
When I looked through the rest of the photos I saw their quality was so poor that Baby Noah’s white nappy had a distinct blue hue. Why hadn’t I noticed this earlier?
‘Don’t worry, Ellie,’ I said. ‘It must just be a technical problem with the flash and it’s been made worse by the low resolution they’ve used to store the images.’
‘I’m not worried,’ she told me coolly. ‘Nope. I’m very, very angry. This pathologist who’s criticized us doesn’t do post-mortems himself. And he certainly wasn’t present at this one. The other forensic pathologists who looked at the body on behalf of the family agreed with us, didn’t they? How dare he challenge us when –?’
‘Because … well, have you read the rest of the file yet?’
‘No I have not!’
‘Because they’ve now found out all sorts of things about the parents. Stuff they didn’t know before. Which gives a different picture. We thought they were young and struggling and trying to make ends meet with their little cannabis farm in the loft … but now it turns out that the father already had a baby with someone else, down south somewhere. About four years ago. And it died. SIDS was given as the cause of death.’
That silenced even Ellie for a moment.
I said, ‘It doesn’t help that he’s a former heroin addict who until quite recently had a methadone script. I wish they’d told us all that.’
‘Oh, go on. Just victimize a man when he’s doing his best to get clean. Was he on methadone when the baby died?’
‘No.’
‘There you are, then.’
‘When he met the mother and had the baby he was really trying to live a better life; that’s how I read his police interviews.’
‘Exactly, and if we took every baby away from every recovering heroin addict, there wouldn’t be any children left in some parts of town.’
‘Listen, Ellie, we’ll go to court, give our evidence, explain that the photos are faulty and we’re sure the child did not have old fractures, explain that the radiologist agrees with us, and that will be an end to it.’
‘It won’t be so simple. We’ve given SIDS and they don’t want to hear that. I think they just want to take the next child away. It’s quite clear they believe Baby Noah was killed.’
‘Courts are briefed to find the truth, not what they want to hear.’
There was a loud noise halfway between a laugh and a snort and then she was gone.
The court case really didn’t worry me. In fact, I was quite curious. The Family Courts have retained their mystery for me as for everyone else because until now only my written evidence had been used. These courts deal with such personal, sensitive issues that they are absolutely closed to press and public: no one without a direct reason to be there is admitted, not even close relatives of the deceased or their family.
Ellie was waiting for me outside. She looked nervous.
‘You should see how many people are in there.’
‘How? Virtually no one’s allowed in apart from lawyers and witnesses.’
‘There are a trillion lawyers. The mother has a solicitor, a junior barrister and a QC. So does the father. So does the local authority. So does the new baby! Not three months old and she already has three lawyers! So that’s twelve of them for starters, then there are loads of officials. Dick, now they’re cutting back legal aid for criminal cases, lawyers must be into the Family Courts like vultures. Cases last for weeks here!’
I thought she was probably exaggerating.
‘Just as well there’s only one judge, then,’ I said. ‘Sounds as though there wouldn’t be room for a jury too.’
But once inside the courtroom I saw that the place was indeed thronged with lawyers. No one was technically on trial, of course. The defendant’s box was empty. It was one judge’s job to decide whether a baby should be taken into care or perhaps safeguarded in some other way. There were lots of factors he would take into account but whether, on the balance of probabilities, a parent had injured or killed Baby Noah was the central question. No trial then, just an investigation into the truth. But with a full adversarial presentation, barristers each questioning, cross-examining and arguing their clients’ case. I recalled that, as Aeschylus allegedly said, the first casualty of war is truth.
I was allowed to sit in the courtroom during Ellie’s testimony and so was able to see both parents. They sat separately and did not look at each other. They had a new baby but they seemed not to be together: of course, their legal teams would each now be playing the blame game.
The mother was angry. Overweight, barely moving, her face large as though swollen, she managed to create a sense of noise around her, swearing into the ear of her solicitor and sometimes out loud into the quiet courtroom. The father was very thin and he sniffed and fidgeted constantly as though the proceedings were keeping him from something more important. Like a fix. If they had really killed Baby Noah they were not to be pitied. But if they hadn’t … they looked like two unhappy, unloved people who perhaps had struggled to learn to love their baby.
In the witness box, Ellie was losing her cool. I watched with growing concern as barrister after barrister attempted to question her competence in giving SIDS as Baby Noah’s cause of death. When they had finished mauling her, I knew what was coming next.
Almost as soon as I had taken the oath, the first barrister began by pointing out that the baby had in fact been wearing a blue Babygro with green rabbits on it – annoyingly, Ellie had reversed the colours in the post-mortem report and I had failed to notice that the rabbits weren’t blue when I checked it. She had also made one small mistake over a date, reversing the month and day, which I had, once again, failed to notice. Not major errors but it was the usual quibbling at the start of an examination designed to challenge my competence and undermine my confidence before the big fight. And the big fight was, of course, going to be the baby’s lip injuries and the alleged fractures to the posterior ribs.
‘Dr Shepherd, do you agree that old, now healed, fractures to the baby’s back ribs would be a strong indicator of abuse over his short lifetime?’
‘I agree that, if there had been healed fractures, abuse would be one possible explanation.’
‘Did you look for such fractures?’
‘All the ribs were examined extremely carefully …’
I pointed out that the photos were poor and did not represent what we actually saw. This was brushed aside: ‘We can all see that the back ribs were previously fractured in the photos, Dr Shepherd. So why can’t you?’
We had the same conversation about the lip injuries.
‘Just look at the photographs, Dr Shepherd! The presence of injuries is obvious!’
I explained that, because of the way the images were stored, transmitted and then printed on a poor quality printer, they could not be relied upon. It was clear, though, that I wasn’t making any progress. They could see what they could see. I was either blind or stupid not to accept that and – if I was either – I was obviously deliberately obfuscating to avoid the fact that I – we, Ellie and I – with seventy years of pathological experience between us, had dismissed suffocation injuries as resuscitation injuries.
There followed as demanding an afternoon as I have ever spent in the witness box of any court, including the Old Bailey. And, in a way, it was worse – instead of one hostile barrister, there were many, representing all sides, each attacking me from a different angle. I managed to hold my ground, acknowledging the possibility that we could have been wrong but saying it was highly unlikely that two experienced pathologists would have missed such clear evidence of abuse.
‘Are you an osteopathologist, Dr Shepherd?’
‘No, I am not.’
‘But you were concerned about the baby’s ribs, the evident fractures at the front?’
‘Concerned that the fractures were open to interpretation, yes, but aware that violent resuscitation by an untrained neighbour had –’
‘You were concerned, but not concerned enough to submit the ribs to an osteopathologist for his specialist comments?’
‘It did not seem to me that he could shed any further light on the ribs. We had seen which ones were broken and we knew that –’
‘You thought you knew as much as the specialist, is that it?’
‘The radiologist said, in her opinion, there were no fractures at the back of the ribs. We had easily seen the fractures at the front. I felt the further knowledge of an osteopathologist would add nothing.’
‘Wasn’t that rather arrogant of you, Dr Shepherd?’
‘I do not consider myself an arrogant person. I am sorry if I appear that way.’
Alexander Pope’s lines appeared in my head as if my father had just inserted them there.
But you, with Pleasure own your Errors past,
And make each Day a Critick on the last.
‘Do you admit the possibility that you were wrong to give SIDS?’
‘Assessment of a cause of death in these cases is always very difficult, there’s a very fine line. On the evidence we had when we wrote our reports, SIDS took precedence. Had we been given fuller information about the circumstances of the baby’s life and death, I believe we would probably have chosen “Unascertained” instead.’
The surprise of my afternoon at the Family Court was not just the attacks on me professionally, but personally. The second surprise was the written judgment. It arrived some weeks later. I learned from it that there had been a series of witnesses in court over the weeks of the case who gave examples of how neglected Baby Noah had been by his parents. The mother had now emerged as an alcoholic, the father as a frequent drug abuser. The mother’s sister and an aunt had been stepping in to help with Baby Noah, inadvertently promoting a false impression of the mother’s competence to the health visitor and others. According to the judge, it was they who had ensured the baby was looked after and taken to his appointments and vaccinations.
He said that Baby Noah had been neglected and he was shocked by the refusal or inability of the two pathologists who examined the body to accept that they had missed such obvious and glaring marks of abuse – which could be seen in the photos by anyone. Indeed, he said the pathologists still seemed to think that SIDS might well be the cause of death. The judge did not make any mention that the photos were of, at best, variable quality. Nor of the lack of information provided to us about the parents on the day their baby died when we had carried out the post-mortem. Nor of any failure to update us as further information about the family was uncovered.
He went on to say that, on the balance of probabilities – which was the test he had to apply – he concluded that the father had killed Baby Noah. Under cross-examination it had been revealed that, on the night of the baby’s death, large quantities of drink and some drugs had been consumed and when the baby cried, the father had responded. The judge supposed that he probably did this by pressing down on the baby’s chest, and possibly his face, asphyxiating him and perhaps breaking his ribs. There was evidence, he said, from the baby’s posterior ribs, that something like this had in fact happened before. On this occasion, the mother had asked him to do anything to stop the baby crying and, although she was aware that he was behaving harshly to Baby Noah, she did nothing to intervene. Therefore, no other child should be left in the care of either parent. Their new baby was to be taken from them for adoption.
I cannot imagine how the parents of Baby Noah felt on receiving that judgment. I was so crushed by it that I believe I actually gasped for breath. It was impossible that harsh words from a judge about a Home Office pathologist would not cause considerable repercussions. I had reached the age of sixty and had tried hard to work through medicine in the interests of justice all my life. And now it seemed that balance and justice were being withheld from me.
That night, I could not sleep. I could barely breathe. Such critical comments must require investigation and, as a Home Office pathologist, I must report them to the Home Office. Would the Home Office then investigate me? Refer me to the General Medical Council? The GMC can take away from doctors the right to practise if they are found guilty of serious misconduct.
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 caused, 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 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.’
‘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.