Timestamps, PC Clock, Metadata are Unreliable in Any Court: R v Dr. Harold Federick Shipman (United Kingdom)
Transcript for Trial Day 21
Wed 10 Nov 1999
[COMMENT1] No. T982105
THE HIGH COURT OF JUSTICE
Preston Crown Court,
Wednesday, 10th November, 1999
THE HONOURABLE MR. JUSTICE FORBES
R E G I N A
HAROLD FREDERICK SHIPMAN
MR. R. HENRIQUES, Q.C., MR. P. WRIGHT, Q.C. and MISS K. BLACKWELL appeared on behalf of the prosecution.
MISS N. DAVIES, Q.C. and MR. I. WINTER appeared on behalf of the defendant.
Transcribed from the Stenotype notes of
Cater Walsh & Co.,
Official reporters to the Crown Court at Manchester.
P R O C E E D I N G S
I N D E X
JULIE EVANS, recalled
Cross-examined by MISS DAVIES .. .. .. .. .. 2
Re-examined by MR. WRIGHT .. .. .. .. .. 41
JOHN ASHLEY, recalled
Cross-examined by MR. WINTER .. .. .. .. .. 54
Re-examined by MR. WRIGHT .. .. .. .. .. 67
ROBIN ADRIAN BRAITHWAITE
Examined by MR. WRIGHT .. .. .. .. .. .. 70
Cross-examined by MISS DAVIES .. .. .. .. .. 79
Re-examined by MR. WRIGHT .. .. .. .. .. 83
STEVEN BERNARD KARCH
Examined by MR. WRIGHT .. .. .. .. .. .. 88
Wednesday, 10th November, 1999.
MR. JUSTICE FORBES: Yes, Mr. Wright.
MR. HENRIQUES: My Lord, once Mrs. Evans has been recalled I have discussed matters with my learned friends this morning and there are no other matters that I would seek to elicit in examination-in-chief at this stage. There may be matters in due course that may require her to be recalled but on a different point entirely.
MR. JUSTICE FORBES: Right. Are you content to start your cross-examination now?
MISS DAVIES: Yes, thank you my Lord.
MR. JUSTICE FORBES: Mrs. Evans, if you would come back into the witness box please.
MR. WRIGHT: Furthermore, there is the schedule now, there is a schedule now available and will be distributed.
MR. JUSTICE FORBES: Thank you.
MISS DAVIES: My Lord, overnight we have prepared a schedule which deals with, in respect of each of the 9 exhumations, the date of death, the date of exhumation, whether or not each body was embalmed, the postmortem interval both in weeks and days, and the finding so far as Mrs. Evans is concerned, be it thigh alone or liver and thigh. I have shown it to my learned friend. He agrees it as a document and perhaps I could then hand it in.
MR. JUSTICE FORBES: Thank you very much.
MISS DAVIES: Can I also say during the course of the questioning of Mrs. Evans I will want to refer to some of the liver weights, we have put those into a chart, and also an extract from a textbook relating to weights of livers and skeleton muscles. These documents I hope Mrs. Evans received yesterday. Therefore, to avoid any delays in cross-examination perhaps I could hand all those documents in now.
MR. JUSTICE FORBES: Yes. Very well.
MISS DAVIES: My Lord, perhaps as we have now produced them they can go into the defence bundle, probably the easiest position be at the end of the defence bundle.
MR. JUSTICE FORBES: Into the front of which bundle?
MISS DAVIES: I was going to suggest the end but I don’t feel strongly, the defence bundle my Lord.
MR. JUSTICE FORBES: Yes.
JULIE EVANS, recalled
Cross-examined by MISS DAVIES
Q. Mrs. Evans, the position in the Autumn of last year was this, that you were carrying out your analysis over a period of time as samples were being produced for analysis?
A. That’s correct, yes.
Q. Because as a matter of fact bodies were exhumed over a period of time between August and the latter part of last year and as bodies were exhumed samples were taken and were sent or brought to you and you began and indeed continued your process of analysis?
A. Yes, that’s correct.
Q. And is it right to say that as you gave your evidence to the Court yesterday, beginning with the case of Mrs. Grundy and ending with the case of Mrs. Grimshaw, that represented your chronological process of analysis, save where you might go back to a case for further investigation?
A. Approximately, yes.
Q. When you began with the very first case, which was Mrs. Grundy, that was an analysis done on its own, it was the first exhumation and it was one exhumation and one exhumation alone?
A. That’s correct.
Q. In respect of that very first sampling you attempted to analyse 3 types of samples, one was blood, one was liver and the other was thigh muscle?
Q. And was that in accordance with what would be perceived as good practice, namely to obtain a number of samples so that you can use them for comparative purposes?
Q. Insofar as the blood was concerned you told the Court yesterday that there you encountered difficulties because the blood was solid clotted material which in your opinion had been caused by the embalming process?
A. I think that was the most likely explanation, yes.
Q. And therefore of the 3 samples that you received only one you could actually test and the testing was so limited that in fact you could take it no further at all?
A. That’s correct, yes.
Q. And is it fair to say this, that following your attempt to sample the blood on Mrs. Grundy there was no further blood sampled on any of the other bodies?
A. That’s correct yes.
Q. Then moving on to the first 4 cases, do you have a copy of this chart Mrs. Evans?
A. No I don’t.
Q. Let me give you one. It would be easier for you. I will hand you two documents to save time. It is the top document. Members of the jury, I am working off that long schedule. Mrs. Evans, what you can see there simply in chart form are the names of the various women whose bodies were exhumed, the date of birth, the date of exhumation, whether or not each body was embalmed, the postmortem interval in weeks and days and the total morphine findings both in thigh and liver, yes?
Q. And I will say at once that the total morphine findings are from your reports and your evidence?
Q. We can thus see that in the first 4 bodies, Mrs. Grundy, Mrs. Pomfret, Mrs. Mellor and Mr. Melia, there you did sampling of both thigh muscle and liver?
A. I did, yes.
Q. And in the remaining 5, Lomas, Quinn, Turner, Lilley and Grimshaw, you sampled only thigh?
Q. Is my understanding of your evidence yesterday thus, that although you were able to analyse the liver in the first 4 cases, in the remaining 5 the state of the liver was such that you could not analyse it?
A. I could have attempted analysis but any interpretation would have been very much flawed, the decomposition was so far.
Q. So that by the time you get to the last 5 cases you have had to abandon two means or bases of analysis, namely blood and liver, and you have to rely on thigh muscle alone?
A. Yes. There were other tissues which we could have sampled but again because interpretation would have been difficult that was not attempted.
Q. When yesterday you were speaking of your decision not to sample liver in certainly Mrs. Lomas and Mrs. Quinn, in respect of Mrs. Lomas you said of the liver the extensive decay would not give a reliable result and in respect of Mrs. Quinn you said the decomposition would make meaningful interpretation extremely difficult?
Q. Could you help please, why would extensive decay produce an unreliable result?
A. Just in that we could not be sure of which areas of the lobes we were sampling. You do get variations across livers anyway. There was a lack of tissues, tissue areas that were amass, there were holes evident within that liver tissue.
Q. And in respect of decomposition, for example in Mrs. Quinn, where you said it would make meaningful interpretation extremely difficult, how does a certain degree of decomposition make meaningful interpretation extremely difficult?
A. Meaningful interpretation of any liver, even a relatively fresh liver, is difficult because the differing lobes of the liver can have differing levels of a drug in them. The liver can act as a storage site. This isn’t going to apply to especially exhumed bodies, it could apply even to fresh bodies. So, given that we have these problems to deal with anyway it was felt that it was better to rely on the thigh muscle.
Q. Can I then please just for the moment and deal with the first 4 cases and your readings in respect of the liver?
Q. What we have done, and it is the second document that I have handed to you Mrs. Evans, it is the shorter of the two documents, is extrapolate from the reports of Dr. Rutherford, the Crown’s pathologist, the liver weights in the cases of Mrs. Grundy, Mrs. Pomfret, Mrs. Mellor and Mrs. Melia. You see there the liver weights for the 4 cases?
Q. I very much hope that you have the third document that I have handed in this morning. It is a publication the back sheet of which says that it is Current Methods for Toxic Practice. It is published in 1979 and of particular note for this part of the questioning, Mrs. Evans, is that part on the very first page, page 677, where we have percentiles of weights of normal liver. Do you have that?
A. I am afraid I don’t have it to hand.
Q. But you have seen it?
A. I have seen that one, yes. Sorry, I have not seen this one, this isn’t the document.
Q. My apologies?
A. Yes I have. It is just that it is stapled. Thank you.
Q. And it is the very first page I wanted to look at, page 677, percentiles of weights of normal liver, yes?
Q. And if we look at that it is the second part of the page where we see there various columns where we can see the age of persons and the observed maximum and minimum weight, yes?
Q. And if we look at the very final entry in that column in terms of age we see there age 70 to 79?
Q. And we see there a maximum weight of 1,595 grams and a minimum weight of 1,100 grams, yes? Just going to the far right hand column, Mrs. Evans?
A. Right, yes.
Q. Those are the observed maximum and minimum weights and obviously there is a range between the two?
Q. If we then look at the liver weights in the cases of the first 4 women, we can see that the livers of Mrs. Pomfret and Mrs. Mellor, Mrs. Pomfret let me say at once is 49 and therefore her liver weight would in fact be in the range 2,130 to 1,250,, she is in any event within the range, but one can see both in respect of Mrs. Grundy and Mrs. Melia that both those weights are lower than the normal liver weights?
Q. Does that surprise you?
A. Not tremendously. I didn’t do any dehydration measurements on the livers of Mrs. Grundy and Mrs. Melia. It is possible that there could have been some dehydration of those tissues, some degradation. That is one of the reasons why we abandoned the liver testing.
Q. When you say some degradation what do you mean by that?
A. Any changes, breakdown in cells, loss of water putrefaction.
Q. You have spoken of loss of water, you have spoken of breakdown of cells. You have used the phrase putrefaction. That is rotting really, isn’t it?
Q. So what you have in, let’s take the liver, there can certainly be loss of water can’t there?
A. There could be, yes.
Q. But there is also another process going on, namely the rotting process?
Q. And one result of that rotting process is not simply loss of water, it is a reduction in mass?
Q. And as a proposition would you accept that it is likely that certainly the reduced liver weights in Mrs. Grundy and Mrs. Melia reflect precisely that degradation, rotting process, and resulting loss of mass?
A. That is a possibility.
Q. If we then look at the correlation between the morphine finding in the thigh and the liver, while there appears to be a reasonable correlation between Mrs. Pomfret and Mrs. Mellor, 0.6 to 1 and indeed 0.7 or .9 sampling the thigh and the morphine being in the middle between the two, there is in fact as between Mrs. Grundy and Mrs. Melia in the order of a four-fold variation in the morphine reading as the between thigh and liver?
Q. And those are precisely the two livers that are under weight and where you accept the possibility of degradation and rotting?
Q. Just take Mrs. Melia and what again we have done is to go to the reports of Dr. Rutherford, the Crown’s pathologist, as to his findings as to the state of decomposition. As you would no doubt expect, Dr. Rutherford carried out the visual examination but also carried out a microscopic examination and histology. In respect of Mrs. Melia he attempted histology but found that decomposition was such that a full assessment could not be made. In respect of his overall examination he said all internal organs were affected by moderate decomposition with associated shrinking of organs. Now again would that be consistent with that low liver reading in Mrs. Melia of 332 grams?
A. It could be but I would suggest that would be better directed at Dr. Rutherford.
Q. In this particular case, as in others, that is Mrs. Melia, you found the amphetamine type substance which you attributed, in fact, to the process of putrefaction?
Q. In other words the rotting process?
Q. So what there appears to be in this case on your chemical findings the rotting process has produced results?
Q. And on Dr. Rutherford’s visual findings the decomposition has resulted in shrinking of organs?
Q. To be fair to you, Mrs. Evans, when you were giving the figures in Melia you put it this way, that the levels are a reasonable estimate but do not necessarily represent an accurate figure?
Q. Is that because of that four-fold variation between the thigh reading and the liver reading?
A. It wasn’t because of that, it was that there was evidence of decay. You can get considerably higher levels in liver than in muscle tissue.
Q. Then just looking again at this table where we see quite clearly the different correlations, would you accept this, that Mrs. Grundy and Mrs. Melia, standing out as they do, this fourfold variability in reading, it is more likely than not that that variability is due to the process of decomposition?
A. It is certainly a probability.
Q. It being probably that it is due to that process, it must raise questions as to the reliability of any such reading?
A. In the livers, yes.
Q. And that is something which you have acknowledged in your answers?
Q. Can I ask you this, you must have known having come to the end of those 4 cases that you had, certainly 2 out of 4, this fourfold variability. Was that a factor when you moved onto the next 5 which you took account in deciding, and I am not at the moment criticising you, in deciding that it wasn’t appropriate to attempt sampling in the liver?
A. Yes, it was part of the consideration.
Q. So was it really then a twofold consideration, one you had decomposed livers because in fact the liver in the next lady, Mrs. Lomas, was of very much the weight of Mrs. Melia, it was just in the 300 grams, was it a twofold consideration, one you had the decomposed organ and, secondly, you knew from your previous experience such decomposed organs were giving you difficulties in reliability of your analysis?
Q. Right. So then you are left in effect with the thigh muscle?
Q. Again this is not remotely a criticism, Mrs. Evans, you have tried the first line which is blood and have not been able to succeed. You have tried the second line which is liver and you have found, and properly found, it wasn’t reliable, and you have no choice but to rely on the third, which is the thigh muscle?
A. Yes. There were alternative samples, as I said earlier, but again I felt we would have had the same problems as we were encountering with the liver and given that data had been published on thigh muscle I felt that was the best course of action at this stage.
Q. Probably the greatest difficulty you faced in carrying out this analysis was the length of time that these bodies had been in the ground?
Q. Because again if we just look at the longer table, the very first table, the shortest was the very first exhumation which was Mrs. Grundy. That was 38 days. In respect of Mrs. Pomfret it was 287 days; in respect of Mrs. Mellor it was 134 days; Mrs. Melia 101 days; Mrs. Lomas 501 days; Mrs. Quinn 332 days; Mrs. Turner 852 days; Mrs. Lilley 566 days; and Mrs. Grimshaw 512 days?
Q. You were embarking on somewhat novel territory, weren’t you, in having to carry out this analysis on bodies exhumed for this period of time?
A. Yes. There has been very little done in terms of studies on exhumed bodies. There are relatively few exhumations for toxicology purposes anyway.
Q. And that did not make your considerable task any easier?
Q. Because as a matter of fact morphine levels in dead bodies are generally taken from the blood if that is possible?
A. Yes. The majority of research would give you a blood level as opposed to a tissue level.
Q. That is why at first try you go for the blood because that is where the research has been done, that is where comparable levels have been produced as a result of studies and research?
A. In fairness I wouldn’t expect blood from an exhumed body to give reliable results anyway.
Q. Is that because of postmortem redistribution?
Q. But in fact the whole issue of postmortem redistribution really was being talked about in the late 80s and it was only at that point there was this realisation that the readings in blood in exhumed bodies was difficult if not impossible to interpret, is that right?
A. There are great difficulties if the means of sampling is not known and a lot of the data published can now be actually deemed to be unreliable.
Q. And so for scientists like yourself working in the field, let’s take it from the late 80s, there has been this growing realisation, certainly over the last 10 years, of the unreliability of blood readings and indeed research is going on even as of now, isn’t it?
Q. Were you present in Dublin when Gisela Scopp presented her paper in the summer of this year?
A. No I wasn’t.
Q. You have read it haven’t you?
A. I am aware of it.
Q. It is yet another paper that highlights the difficulty of postmortem redistribution in blood levels and morphine readings thereafter?
Q. By reason of this case, Mrs. Evans, I have had to learn about postmortem redistribution but it may not be the first phrase on everybody’s lips. Could you tell us quite shortly what is meant by postmortem redistribution process?
A. In very simple terms it is the way in which drugs move around the body after death. Although the heart has stopped pumping that does not mean that everything within the body has stopped. In the same way as you can have a liquid where you have a concentrated area at the bottom, leave that to stand and it can diffuse around so that you end with a more even distribution. That can happen in a body, particularly if there is an organ close to a blood vessel that carries a high concentration such as the liver. If you were to take a blood sample close to that there is a possibility that you are not only going to draw blood from the liver but are also have an elevation of drug levels if only by simple diffusion, but that is not the whole story.
Q. It is a pretty complicated story isn’t it?
Q. And it is a story in which research is going on and if anything it is throwing up more problems as to the difficulty with interpretation?
Q. Notwithstanding those difficulties of interpretation, blood is still the first sample of choice?
A. It is, especially if you know the site from which blood was taken.
Q. But as we know that was a choice that simply wasn’t available to you?
A. That’s correct.
Q. So you had to move forward on the muscle tissues. The particular difficulty you faced was the absence of scientific studies on morphine levels in muscle tissue?
A. There was relatively little data on any tissue samples.
Q. And indeed such data as existed was not the result of controlled scientific studies, it was purely anecdotal?
A. That’s correct. There have been no controlled studies into this phenomenon.
Q. Because they cannot be done?
A. That’s correct.
Q. So the most one is left with is anecdotal reports of fatalities?
Q. You yesterday cited the paper produced by Phelby. I think that was 1974, wasn’t it?
A. Yes, Soren Phelby.
Q. And that cited 10 cases where there was death which was attributed to morphine?
Q. You told the Court yesterday that there was no report of the route of administration?
A. In the work of Phelby it says there it is intravenous, but because it is purely anecdotal I don’t think you can have 100 percent confidence in that as being the route of administration. It is the suggested route.
Q. Indeed, and that is the difficulty, isn’t it, it is anecdotal, it is not in a controlled study?
Q. And in fact in the Phelby study, although there were 10 cases cited only 6 muscle readings were given of the 10 cases relied on?
A. I think you will find there were 7.
Q. I don’t doubt you are right, Mrs. Evans?
A. It wasn’t in all 10 the muscles were measured.
Q. Of the 10 cases relied upon, because some were not relied upon because other drugs were found, of the 10 cases relied upon, 6 of them gave muscle readings. There was a 7th muscle reading but there was evidence there of another drug being found?
A. That’s true, yes, there was another drug present.
Q. So confining it, because there were 14 cases in all weren’t there?
Q. 4 were eliminated because other drugs were found in the blood?
Q. Of the 10 cases remaining, only in 6 of those were there muscle readings given?
Q. And as you told the Court yesterday the most that one can extrapolate from that is that it was a muscle but there is no information as to which muscle in the body it was?
A. That’s correct.
Q. Is it fair to say this, Mrs. Evans, that by reason of reliance on literature such as Phelby’s article, the most one can do is to make broad generalisations?
A. That’s correct, but my conclusions weren’t just based on the work of Phelby.
Q. But notwithstanding, I am willing to broaden it but is it fair to say that by reason of reliance on literature the most when it comes to levels one can do is to make broad generalisations?
Q. And indeed yesterday you gave us a range, did you not, and that is extrapolated from the literature?
Q. Specifically in respect of morphine levels found in muscle there is no good scientific evidence upon the interpretation of morphine levels found in muscle postmortem in an exhumed body?
A. Not under controlled conditions, no.
Q. The science behind the finding is not known, and by that I mean what is not known is the process both in the drug and the muscle which leads to the final conclusion?
A. I don’t understand.
Q. Processes go on in the dead body notwithstanding the fact that it is dead?
Q. You come to a body days, weeks, months, in this case years, after the death?
Q. As a scientist you will be aware of processes which can go on?
Q. As a matter of fact in each of those bodies you cannot say what process and to what extent it went on?
A. That’s correct, yes.
Q. So therefore in respect of any finding of yours, although you can recognise as a scientist the processes exist, you cannot say whether that particular process went on and if it went on to what extent it went on?
A. That’s correct, yes.
Q. Another difficulty which you faced is that because no studies, scientific studies I am talking about now, have been carried out, you do not have a control group and therefore no scientific comparators against which you can interpret the levels you found?
A. No. The only interpretation that can be placed is on levels that have been found in previous muscle tissues.
Q. There is no data available on the disposition of diamorphine or morphine and their metabolites in tissues from experimental studies in controlled conditions, that’s right isn’t it?
A. That’s correct.
Q. There is no data available on the stability of morphine and morphine glucuronide in muscle tissues?
A. That’s correct.
Q. There are no studies available on residual glucuronide activities in postmortem muscle tissues?
A. There are some limited studies.
Q. And insofar as, are those the studies you referred to as Stephen studies which refer to 28 days?
A. Yes. That is the one that does some morphine in livers.
Q. That is morphine in livers?
Q. So it is not even in muscle tissue?
Q. And in fact it is outside the period in all these cases because the shortest period we have here is 38 days?
Q. So as a matter of fact there are no studies on residual glucuronide activities in postmortem muscle tissues?
A. Yes, in glucuronides, yes.
Q. I have just been asked if I would ask you to explain what a residual glucuronide is?
A. Glucuronides are these breakdown products that the morphine goes to. In getting the total you are measuring morphine glucuronides and morphine.
Q. As a matter of fact the long-term stability of morphine and diamorphine in postmortem muscle tissue has not been scientifically investigated?
A. Not adequately.
Q. There is no data available on the effect of embalming and specifically the effect of formaldehyde on muscle tissue and/or morphine?
A. That’s correct, yes.
Q. There is no data available on the taking of morphine in life and how it is converted into levels subsequently found in muscle?
A. That’s correct.
Q. Crucially there is no data available as to the muscle morphine concentration produced by a therapeutic dose of morphine in life?
A. That’s correct. You could not take tissue, muscle tissues from someone in life.
Q. You, to be fair Mrs. Evans, have acknowledged the difficulties you faced in attempting to interpret such levels and you said in your report, at pages 1187 FR, that caution must be used in interpreting the levels found. Is that something you stand by now?
Q. And you also added a further caveat to that in respect of the caution because you said that in respect of the data at which you had looked on which some conclusions were based, that data was in the main from relatively fresh samples?
Q. As matter of fact as a scientific, Mrs. Evans, you have actually been breaking pretty new grounds in this analysis that you have been carrying out, haven’t you?
Q. So you are left with some anecdotal studies which do not give you evidence upon which you can safely rely as to the route of administration?
Q. You are left with anecdotal studies which at best tell you it is muscle tissue?
A. Yes. They say it is skeletal muscle tissue.
Q. And you are left, and it was a phrase you used a number of times yesterday, that it was the opinion or that the cause of death was attributed to the use of morphine?
A. No, that the levels fell within a fatal, within the range previously reported. I haven’t speculated it is actually the cause of death.
Q. I was going to the actual anecdotal studies. In respect of the anecdotal studies you said that the cause death was attributed?
A. Yes, in the studies it has been attributed.
Q. And you used that word a number of times yesterday, attributed. What one was left with as a result of reading those studies was in effect relying on the opinion of those who had played a part in the investigation?
Q. Another word you used yesterday was excessive in terms of dose?
Q. Would the position be this, that looking at those anecdotal studies you are inferring that the levels you have found here relate to an excessive dose because in those studies those levels have been attributed to death?
A. Not just in doing that. In those studies they also did comparisons to blood levels which given, we do have doubts on the reliability of blood levels anyway, so we have the first pointer that these were fatalities so they were indicating excessive doses from the anecdotal information. In addition to that the studies tended to show that thigh muscle tissues, muscle, skeletal muscle tissues, are generally in reasonable agreement with what you might expect from a blood level. Though they are not exact, the range could take them up to give you around 3 to 4 times actual level. Basing some very loose calculations on that it would suggest that these are not the sort of levels that you could get from somebody taking a normal over the counter preparation in a normal dosage regime.
Q. Which was evidence you gave later?
Q. Can I move on now please to the way in which you calculate or the basis of your calculation because your unit of measurement is the mass of drug per unit mass of muscle, is that right?
Q. There is no criticism as to your method of measuring and analysing but you are having to contemplate certainly 3 possibilities, because in all of these cases there is a significant period between death and your sampling procedure?
Q. You have to contemplate what if anything could have changed between death and when you carry out your analysis?
Q. The first thing that could have changed is the drug?
Q. The second thing that could have changed is the muscle mass?
Q. And the third are factors which could alter the concentration as between drug and muscle mass?
Q. Let’s deal with the very first decomposition. You have already alluded to it, it being one the reasons you did not in fact proceed with your liver sampling. Can I ask you this, have you ever seen a decomposed exhumed body?
A. Not frequently, no.
Q. All these bodies showed some signs to a greater or lesser extent of decomposition?
Q. In Mrs. Grundy the liver, and can I tell you I am obtaining this from Dr. Rutherford’s report, in Mrs. Grundy the liver showed some signs of the effects of embalming?
Q. In Mrs. Pomfret decomposition had taken place and the liver showed signs of significant decomposition?
Q. In Mrs. Mellor there was decomposition, the liver demonstrated significant decomposition. In Mrs. Melia exactly the same thing, decomposition, the liver demonstrating significant decomposition?
Q. In Mrs. Lomas in respect of the thigh there was extensive decomposition. That is Dr. Rutherford’s finding?
A. I haven’t actually seen Dr. Rutherford’s finding in relation to that.
Q. In Mrs. Quinn there was some decomposition and there was decomposition in the left thigh muscle, were you aware of that?
A. I wasn’t aware but my visual examination suggested decomposition.
Q. In that particular body, Mrs. Quinn, Dr. Rutherford said the body was in a state of poor preservation and disintegration and in fact the disintegration of soft tissue was most marked in the left thigh, skin, ankle and foot?
A. As I say, I have not seen that.
Q. In Mrs. Turner and indeed Mrs. Lilley there was extensive decomposition and in Mrs. Grimshaw there was some. Now, as you have earlier accepted, the effect of decomposition is not just the loss of water, it is also a reduction in mass?
A. A loss or reduction in mass is due to dehydration of tissues and rotting but if you are rotting it, the mass that you take would still be the same. If you have got a hole there and you took one gram of it you would still have one gram. The hole wouldn’t weight anything. It is dehydration that accounts for a lot of the shrinkage of these organs.
Q. But it does not account for all of them, does it?
A. No it doesn’t account for all.
Q. So what you have is the loss of water, you have a chemical process going on which breaks down low volatile compounds?
Q. You have loss of low volatile compounds?
Q. And you have just a loss of mass?
Q. Can I take the sort of example that I suspect I can more easily understand, a piece of meat. Just look at the times these bodies have been in the ground. If one put a piece of meat in the fridge, take Mrs. Grundy, for 38 days, I am sure in this Court we would all be able to, if not visualise, understand that the rotting process is not just water, it affects the whole piece, doesn’t it?
A. Yes, microbial activity breaks tissues down.
Q. And so what you are having is a shrinkage to a greater or lesser extent of that piece of meat?
Q. So if there was something in that piece of meat, let’s say a drug, and there was that shrinkage, that concentration of that mass, that would increase the level of the drug wouldn’t it?
A. Only if, only in terms of, in taking one gram the area might be a bigger area if there was holes in it. You don’t actually get a shrinkage in weight. I actually have measured out one gram.
Q. But one gram might have been 2 grams but you don’t know because that shrinkage process has gone on?
A. Some shrinkage could have gone on.
Q. And the effect of shrinkage is to concentrate the mass isn’t it?
A. Parts of it, but given the water content of these, whether it was purely water or putrefactives, amounted to around what I would have expected in life. It didn’t suggest to me that there was significant shrinkage in terms of increasing that, the concentration of drug from the experiments I carried out. I can’t exclude it completely but—
Q. The other difficulty you have is that none of these bodies were weighed?
A. That’s true, yes.
Q. It is known that there is loss of weight from skeletal muscle?
Q. So you have no in life comparator do you?
A. That’s correct.
Q. And you have no at time of death comparator have you?
Q. So you acknowledge there would be loss of water you have attempted to quantify?
Q. But in addition to that loss of water there has to be some loss of mass due to the process of decomposition?
Q. The problem you have is you cannot quantify it can you?
A. That’s correct.
Q. And what that process of concentration will do is to increase any drug in that mass, the level of the drug in that mass?
A. To some extent, but from my visual examination I wouldn’t, it would suggest to me there wasn’t extensive concentrations. There could have been some concentration I will accept.
Q. And you also accept that if there has been some concentration the very fact of concentration would elevate the drug level in that mass of muscle it?
A. Could elevate it, yes.
Q. And whatever calculation you have done on loss of water is not the complete answer to that concentration of muscle and the resultant level of drug rising?
Q. Have you also, speaking of decomposition I hope, because I did actually ask it be given to you yesterday, Mrs. Evans, have you been given an article headed Time Since Death and Decomposition of the Human Body, Variables and Observations in Case and Experimental Field Studies by Mann et al?
A. Yes I have.
Q. Have you had an opportunity to read that?
A. I have had an opportunity to read the majority of it, yes.
Q. Can I give you a copy. My Lord, I am more than happy that this be circulated. It is a short point and unless anyone wants me to for the time being I won’t. What in fact that was looking at was the findings and observation of 8 years of research which may clarify some of the questions concerning bodily decay, yes?
Q. Turning to page 108 of that paper, in fact Mrs. Evans, quite inadvertently it has been marked so you probably can see the point I am going get to anyway, it is under embalming?
Q. “Embalming does greatly slow the decay rate of the body Further, the pattern of decay is different in an embalmed body from one that decays naturally. For example, unembalmed bodies usually show the first signs of decay in the face whereas embalmed bodies first show decay in the buttocks and legs perhaps as a result of insufficient penetration of the embalming fluid in these areas.” Yes?
Q. Do you have any reason to disagree with this article, which I know has subsequently been taken up in other textbooks, as a proposition as to the process and areas of decomposition?
A. Certainly it is a proposition. I would question just how reliable it is seeing as it is based on a single body buried, it would appear, directly into soil, but yes, I would accept that this is published and has been accepted in other works.
Q. So you accept that this has been published and accepted in other works and following from this it certainly suggests that in embalmed bodies the first sign of decay is in the buttocks and legs?
Q. And we know, because you have told the Court, that in respect of the muscle that came from the thigh, ie the leg?
Q. And if again we look at our chart again we can see that of the 9 bodies that were exhumed 6 of them were embalmed, Mrs. Grundy, Mrs. Pomfret, Mrs. Mellor, Mrs. Lomas, Mrs. Quinn, Mrs. Turner and Mrs. Grimshaw. I don’t think there is any dispute about that, is there Mrs. Evans?
A. There is no dispute, only that in some of the cases I didn’t have the full details about the embalming.
Q. Very well. My Lord, I am entirely in the hands of the Court. I am conscious these are not the easiest of topics, and you indicated yesterday that we would stop at appropriate moments. I am going on to a separate topic now. I am more than happy to continue with but if it is appropriate I should stop now I will do that.
MR. JUSTICE FORBES: It is a matter for you, Miss Davies, really. How long is this next topic going to take roughly?
MISS DAVIES: I can take this in about 5 minutes.
MR. JUSTICE FORBES: Right.
MISS DAVIES: Let’s just deal now please with embalming, because you told the Court yesterday that embalming fluid contains as its main active ingredient the chemical formaldehyde?
A. Formaldehyde and methanol, yes.
Q. Forgive me, you gave both. And you have already accepted that there is no research on the effect of formaldehyde on morphine levels found in muscle tissues?
A. That’s correct.
Q. The effect of formaldehyde is that it may chemically change one drug to another and by reason of that affect the concentration of the drug ultimately detected?
A. With some drugs yes, that does happen.
Q. A drug concentration determined in formaldehyde affected tissue cannot be taken at face value as the real level of the drug in the tissue before formaldehyde was added is not actually known?
A. That’s correct.
Q. The effect of formaldehyde can be different depending on whether it is in the tissue itself or in the surrounding tissue?
Q. If the formaldehyde is in the tissue it can increase the mass of the tissue because basically it is adding liquid?
A. Yes, diluting out effects.
Q. However, if it is in the surrounding tissue it has a dehydrating effect doesn’t it?
Q. And what it can do is extract the water into the surrounding tissue?
A. Yes it can.
Q. And therefore it would increase the concentration of the muscle mass?
A. That is the theoretical possibility. However, of the works that I have seen done with embalming fluid the majority suggest that embalming has a dilution effect, it actually is increasing mass more than decreasing it. But I would accept that if it is not actually penetrating that tissue there is a possibility that formaldehyde could draw water away.
Q. As a matter of fact in the 6 bodies that were embalmed the most you can say is that formaldehyde was used as part of the embalming process but you cannot say in any one of those samples what effect formaldehyde had on the sample you tested?
A. That’s correct.
MISS DAVIES: My Lord, could I stop there now please?
MR. JUSTICE FORBES: If that is convenient?
MISS DAVIES: Yes.
MR. JUSTICE FORBES: Very well, members of the jury, I will give you a short break for 10 minutes before we move on to the next part of the evidence.
MR. JUSTICE FORBES: Yes, Miss Davies.
MISS DAVIES: Mrs. Evans, we have insofar as some questioning is concerned come thus far, it is accepted that in all of these bodies there is a greater or lesser degree of decomposition?
Q. Which is wholly to be expected given the period of time between death and exhumation?
Q. The process of decomposition brings about changes in the deceased’s body affecting various parts of it, including muscle, tissue and levels that can be found therein?
Q. In respect of a muscle, that muscle can become more concentrated, ie can shrink down, by reason of rotting, putrefaction, call it what you will?
Q. And the process of that concentration can elevate any subsequent drug level found in that piece of muscle?
A. To some degree, yes.
Q. And the difficulty that you and any other scientists like yourself have is you cannot quantify the degree to which that elevation has occurred?
A. No. Other than measuring water content there is no other means to determine that.
Q. But the water content only tells part of the story because what you cannot quantify is the loss of other compounds, materials, whatever?
Q. So that for example you could have that 2 gram piece of tissue that would have been present at the time of death but when you go to carry out your sampling, by reason of this process of rotting or decomposition that 2 gram piece of tissue has shrunk down to a one gram piece of tissue?
A. That could happen, yes, but what must be remembered is that the drug isn’t just distributed in the tissue area, it is also distributed in the water content as well.
Q. But the problem that you have is that because you do not know the weight of the original tissue, and by no proper means could you know that, you have to deal with the tissue as you find it at sampling?
A. That’s correct.
Q. And you have to deal with it and you really did have to deal with these in quite difficult circumstances didn’t you, given the decomposition?
Q. So we are left with this, that you are doing your professional best to analyse decomposed material and produce a level when by reason of the processes which have occurred in that tissue you do not know whether the level accurately reflects the level it would have obtained at the time of death?
A. That’s correct.
Q. Can I now please just deal with one example and it is the longest period, it is Mrs. Turner. If we look at our chart Mrs. Turner died on the 11th July 1996. The postmortem interval was 852 days and in fact it was in, I am sorry?
A. It is okay. I have my own table anyway.
Q. In respect of Mrs. Turner that gave the highest level of all your morphine readings, the reading in the thigh muscle being 1.4 to 1.6?
Q. When you carried out your analysis of water content Mrs. Turner was the lowest, wasn’t she?
A. Yes, she was. There was around about a 7 percent reduction from what you would normally expect.
Q. I think it was 67 percent when you gave the average reading as being 74 percent?
Q. Insofar as autopsy findings were concerned, I am now going to Dr. Rutherford’s report again Mrs. Evans, he describes the decomposition there as moderate and characterised by fatty tissue turning to soap. There is in fact a particular description of that, is there not?
A. There is. I am afraid I can’t recall exactly the term at the moment.
Q. I think it is adiposae but I may not be pronouncing it correctly?
Q. He also found patchy parchmentation affecting the skin and subcutaneous tissue and the internal tissue?
Q. Were you aware of that?
A. I was aware of that.
Q. And another word for patchy parchmentation would be drying?
Q. He found drying of the skin, subcutaneous and internal tissue?
Q. Were you aware that when Dr. Rutherford attempted histology on the body of Mrs. Turner he found that the degree of post mortem degenerative changes precluded meaningful interpretation?
Q. In toxicological terms it was found that it was suggestive of extensive decomposition?
Q. Given that in Mrs. Turner’s case we have one of the longest intervals between death and exhumation, on your analysis of water content it is 7 percent below normal, on Dr. Rutherford’s findings there is decomposition, there is drying affecting internal tissue and degenerative changes precluding histological interpretation, do you think it is simply coincidence that the reading you have there found is the highest morphine reading?
A. I think in part there was dehydration to account, so that is going to have devaluated it possibly by some 10 percent but I would still put it above 1, especially given that I took the areas deep within the muscle tissue where there was some reddening so I deliberately targeted where there was less decomposition. There obviously is going to be some contribution from the decomposition, the extent of which I can’t measure, but I couldn’t say that entirely accounted for that being the highest level.
Q. And we have this don’t we, we have the highest level which you say firstly is likely to be affected by the reduced water content?
Q. You accept that decomposition would affect that reading but you cannot quantify the extent?
Q. And can I just deal please with your point on the decomposition. You went in to try and find a deeper level of tissue, is that right?
A. Yes I did.
Q. The process of decomposition is caused by bacteria, is it not?
A. That is one of means of decomposition, yes, bacterial invasion.
Q. And the bacteria would come from the lower abdomen?
Q. It would work from the inside out?
A. Assuming that the skin surface was intact. We know that some of the skin surface was not intact, therefore you would get microbial invasion from the surface as well, but yes.
Q. Therefore when you are going into that deeper tissue you are actually going deeper to the path of bacteria that is coming out, aren’t you?
A. Only if you are also tracking upwards. If we were just tracking down, all I looked for was the areas that looked most like you would normally expect to encounter in a fresh sample, so yes, they went deeper into it in that I have a skin surface and then I just tracked down. That does not necessarily mean that it was closer to the abdominal cavity.
Q. You cannot say?
A. I can’t say.
Q. And to be fair to you again you are trying to do your professional best but this wasn’t a scientific finding, it was a visual finding?
A. It was.
Q. But you accept the process of bacteria would be working from that lower gut out?
Q. Insofar as you carried out again your water content calculations, the two where you found reduction in the heart were Lomas and Quinn, were they not? I think you found a 29 percent reduction in each?
Q. Mrs. Quinn, together with Mrs. Grimshaw, was the lowest morphine reading, it was 0.3 to 0.4?
Q. Given that you had found reduced water content in the heart which again can affect the concentration of an organ, can’t it?
A. It can affect?
Q. The concentration of an organ, the reduced water content?
A. In the heart, yes.
Q. The only other sampling that you dealt with in Mrs. Quinn was that of the thigh?
Q. Insofar as you carried out this analysis of water content you said in your report, page 1187 FK, it was the paragraph after you cited your percentage findings, you said, “The water content of muscle tissue is generally regarded as approximately 74 percent. Thus my findings suggest that little dehydration had taken place in the tissues used in the morphine determination in these 9 women. It is, however, by no means certain that the water present in the muscles was that present at the time of death. It may be that some exchange has occurred.” What has happened, Mrs. Evans, in that process?
A. In that a lot of these were in very watery ground, some of the coffins were actually water filled. I can’t be sure that the water I was determining was the water that was present at the time of death. It is, of course, possible there was some dehydration but then you have tissues sat in a watery solution and rehydrating from the water surrounding the body.
Q. So if we have one fluid coming in and moving around, yes?
Q. Drug would be in fluid form, wouldn’t it?
A. The drug from the body could have gone out into the liquid in the coffin and then subsequently been reabsorbed, yes.
Q. So as you have this exchange of water fluid there could also be movement of drug fluid, couldn’t there?
A. There could if the drug has gone out into this solution, which is a distinct possibility. It could then be reabsorbed in the muscle tissue. But it had to have come out of the body in the first place to be reabsorbed.
Q. That creates another uncertainty as to the level of drug subsequently found?
Q. And within the fatty tissues in the muscle there can be pooling of blood, can there not?
Q. It can drain muscle of blood?
A. As I understand it, yes.
Q. And it can go the other way and congest it by adding to the blood in the tissue?
Q. Because all the time a body is in the ground there is this physical process of diffusion going on?
Q. So again that can effect any subsequent reading in muscle?
Q. Within the muscle is fat, isn’t there?
Q. The morphine is a highly fat soluble drug?
A. Relatively speaking it is fat soluble, yes.
Q. As a matter of common sense the amount of fat in any one person varies?
Q. And therefore the amount of the fatty streaks in the muscle is going to vary person to person?
Q. And therefore in those fatty streaks there could be different concentrations of a drug?
A. That is a possibility, yes.
Q. It is accepted, isn’t it, that within one person, taking drug levels in muscle there is muscle variability?
A. From one muscle to the next yes there is. There don’t appear to be significant variations within the same muscle as long as it is a remote skeletal muscle, such as the thigh muscle.
Q. There are some variations?
A. There are some variations, I think as much as a fourfold variation has been reported, but I did take 2 different areas and did have good correlation suggesting there wasn’t significant variation within the muscle tissue I was sampling.
Q. You took two samples?
A. In the cases, yes, I took two samples of muscle tissue.
Q. But the difficulty is this, isn’t it, that within that sample procedure, and I am not criticising you Mrs. Evans, please don’t think that, accepting that there is this muscle variability even within one piece of muscle, you cannot be confident that a third or fourth reading would have produced a different result?
A. I would doubt that it would within the muscle tissues I had. I suspect partly as a result of the fact they had been deep, they had been in the ground so long that an equilibrium had been established. It may be a factor that these bodies had been in the ground so far that we weren’t seeing significant variation across the muscle tissue, as opposed to some of the studies where they have seen these differences which were in relatively fresh samples.
Q. This issue of variability, the muscle variability, is another aspect of the process which can be affected by postmortem redistribution, isn’t it?
Q. And the most you can proffer, and properly proffer, is an opinion that the muscle tissue is less likely than blood to be affected by post mortem redistribution, but it is still susceptible to it?
Q. And the difficulty that you encounter is that, accepting that a postmortem redistribution will affect that tissue, you do not know to what extent because you have not been able to carry out any trials prior to your sampling?
A. Correct, in the same way as the people who conducted the original studies couldn’t know that.
Q. That is a difficulty which any scientist in your position would face?
Q. Can I now please deal with the drug. We have already seen that within the body. Let’s just take the first 4 cases. There are differences in levels. I mean the starkest example are two of those cases where there is a fourfold difference?
Q. As you have already accepted, notwithstanding the fact that a body is dead and indeed buried, there is still diffusion within that body?
Q. And as you have accepted there is, for example, diffusion of blood, there is also diffusion of drug?
Q. And again one of the difficulties that you would have encountered is that although as a scientific you know that that diffusion will have taken place, in respect of any specific body you do not know the nature or the extent of that procedure in any one body?
A. That’s correct.
Q. Putting it very shortly, Mrs. Evans, you do not know as a matter of fact where and at what level any drug was in the body at the time of death?
A. That’s correct.
Q. The most you have been able to do, and properly been able to do, is achieve a level which you believe to be, as you described it yesterday, representative?
A. The most representative level that we would expect in tissues of these types.
Q. But the major difficulty is you cannot say as a scientist that it accurately reflects the level of the drug at the time of death?
A. That’s correct.
Q. Would you just allow me one moment. One of the other difficulties that you encounter, or it may be you don’t even have to apply your mind to this, tell me if that is the case, is that although you find a level you are not able to say whether that represents one dose or more than one dose?
A. I can’t say.
Q. What I would like to do now, Mrs. Evans, is just move on to the individual cases please and just deal with some of the factors that arose within them. If at any time you want to look at any more documentation please don’t hesitate to say so?
A. Thank you.
Q. In respect of Mrs. Grundy, I am going to take them in the order that you gave evidence to the Court, in respect of Mrs. Grundy you were aware, were you, that according to the pathologist the liver showed some of the effects of embalming?
A. I was not aware at the time of the analysis but I have subsequently been made aware of that.
Q. And we have already dealt with the effect of formaldehyde and I am not going to go through that again. You said in this case, as you did in others, that you did not undertake testing for all drugs?
A. That’s correct. It is impossible to test for every drug anyway.
Q. And again, I am not putting that as a criticism, it is a fact you go so far and you stop?
Q. It was a further finding by Dr. Rutherford that in respect of the internal organs of Mrs. Grundy all were affected to a greater or lesser degree by embalming. Were you aware of that?
A. Yes I was.
Q. Now after you carried out the analysis of the samples obtained from the body of Mrs. Grundy you were asked then to analyse one particular tablet which was found near a bedside table?
Q. And you found that in fact to be nitrazepam?
A. Yes, a 5 milligram nitrazepam tablet.
Q. Which is a sleeping tablet?
Q. And you were asked about that and about the overdose produced by the taking of too many of those tablets and you described certain symptoms. As a matter of fact have you ever had to treat or deal with anyone suffering from nitrazepam overdose?
A. No, my comments were based on literature reports.
Q. In other words you went to the textbooks?
Q. Because your field is that of science, you are a chemist you are not a doctor?
Q. In your report, and indeed in the evidence that you gave to the Court yesterday, you said that in respect of nitrazepam it is not stable in biological specimens which are not stored under refrigerated conditions?
A. That’s correct, yes.
Q. As a matter of fact Mrs. Grundy, obviously her body was not stored in refrigerated conditions. You accepted in the report that you made to the Court the possibility that any nitrazepam present at the time of death may have been lost?
Q. That is because of the basic instability of the drug in unrefrigerated conditions?
Q. In respect of Mrs. Pomfret there decomposition had taken place. In respect of Mrs. Pomfret’s liver there were signs of significant decomposition. In respect of Mrs. Pomfret your finding was positive for opiates, benzodiazepine and amphetamine type substance, and this was probably the first of the cases, wasn’t it, where you attribute the initial finding of the amphetamine type substance to the process of putrefaction?
Q. You were subsequently asked in the case of Mrs. Pomfret to consider the issue of lithium?
Q. I don’t know how much you know about this lady’s medical history. Were you aware there was a rather lengthy psychiatric history and she been in receipt of medication?
A. I was aware of medicines she was in receipt of over a period. In terms of her actual medical conditions I could only surmise from the medicines prescribed that that was the case.
Q. Were you aware that when this lady died her treating psychiatrist, Dr. Tait, got in touch with Dr. Shipman because he had a fear that she may have committed suicide?
A. I have only recently been made aware of that, yes.
Q. And you were asked to consider whether or not this lady had died from a lithium overdose?
Q. Does it follow from the answer you gave in respect of nitrazepam that you have never seen nor indeed had to treat any person suffering from a lithium overdose?
A. That’s correct.
Q. Does it follow that any evidence that you gave as to any such symptoms comes, as in the previous case, from textbooks or medical literature?
A. Yes it does.
Q. As a matter of fact you did not analyse to see if lithium was present, did you?
A. I didn’t, no.
Q. Lithium is an element, one of the most basic forms of chemical, isn’t it?
Q. It would not have deteriorated so if you so tested you would have been able to discern whether it was there or not?
A. Yes, but the levels wouldn’t have been interpretable given that we were looking at thigh muscles. Again we are back to how do you interpret what you find anyway.
Q. Is that why you did not carry out that particular procedure?
Q. Can I turn please to Mrs. Mellor. Again the liver, significant decomposition, again here was another body where you found the putrefaction, the chemical evidence of putrefaction on that initial screening of an amphetamine type suggestion?
Q. And again, like Mrs. Grundy, again not a criticism, such testing as you carried out was not exhaustive, not all drugs were excluded?
A. That’s correct.
Q. Mrs. Melia. We can probably do it this way, Mrs. Evans, do you have pages 423 and 424 in our bundle of your statement of the 26th October 1998? If it is easier for you to deal with it in this way it is pages 4 and 5 of your statement of the 26th October 1998?
A. I don’t actually have your bundle at all. This is my own.
Q. Let’s make sure you have those 2 pages. I will tell you at once it is to do with the medication found in respect of this lady. Do you have your statement in respect of Mrs. Melia of the 26th October 1998?
A. I do.
Q. Then let’s just turn to that. Have you got it in front of you?
A. I have.
Q. Do you have pages 4 and 5?
Q. At page 4 of your statement, page 423 of our bundle, you there set out the medication which you were given, your understanding being it was medication found at the home of Mrs. Melia at the time of her death?
A. All I knew it was passed to the police by a relative.
Q. I see, and then it was subsequently passed to you?
Q. And there you list the medication. The first is amoxicillin?
Q. And you there say, “This bottle contained 6 small red tablets whose appearance was not consistent with that of amoxicillin tablets. Preliminary testing of these tablets suggested them to be prednisolone and their appearance was consistent with this identification.” Amoxicillin is an antibiotic isn’t it?
A. What is prednisolone?
A. It is a steroid type drug.
Q. Used for what?
A. I am afraid I am not exactly sure without just checking.
Q. Very well. Putting it very shortly, the wrong tablets were in the wrong bottle?
Q. And when you did your preliminary testing what testing did you do?
A. They were identified on the basis of their appearance and their markings.
Q. The sort of markings that we all of us have seen on tablets?
Q. What were the next tablets you found or were given to you?
A. It was a bottle labelled as being metronidazole.
Q. Do you know what they are?
A. There are an antimicrobial drug.
Q. And you did not carry out any specific testing, you worked on the basis of similar markings, is that right?
Q. And then some more amoxicillin was given in a bottle and again you dealt with appearance without specific testing and you found those to be amoxicillin?
Q. Then penicillin was found in a bottle and again you dealt with appearance but not specific testing?
Q. Quiet life, I think these are probably herbal preparations, aren’t they?
A. Yes they are.
Q. And again you dealt with appearance but not specific testing?
Q. Calms, that is a natural plant remedy, yes?
Q. You found 94 white tablets there. You did not test them, again you went on appearance?
Q. And what was the next one please, Mrs. Evans?
A. It was a box has was labelled theophylline.
Q. What exactly is theophylline?
A. It is a bronchodilator. It can be used in the treatment of things like asthma.
Q. You found tablets in foil blister packs. Again no testing, you went on the appearance?
Q. And the final box was ferrograd. Do you know what that is?
A. Ferrous sulphate used in the treatment of iron deficiency.
Q. Again you went on appearance, no specific testing?
Q. That is all I want to deal with. I just wanted to identify the drugs that certainly had been handed to you. Now in respect of Mrs. Melia this was the one body where you found morphine in the stomach?
A. It was the only one we actually had stomach contents.
Q. I see, it was the only one where you had stomach contents?
Q. Because what in fact you found in Mrs. Melia, just allow me one moment, you found in the stomach a viscose green brown liquid, yes?
Q. Does it follow from the answer that you have given that in respect of the other bodies you examined the stomach contents but there are none?
A. In the majority no stomach contents were submitted to the laboratory. Presumably the stomachs had been washed anyway in the embalming process.
Q. I see. So insofar as you have been able to carry out an analysis of these stomach contents, you were precluded from doing any other cases because none were for, warded to you?
A. Yes, presumably none being available.
Q. In respect of those stomach contents you said that they were a viscose green brown liquid. There was no obvious tablets or is it particulate matter?
A. Particulate matter.
Q. And what is particulate matter?
A. Any sort of solid material, whether it being just granules as opposed to whole tablets, so it could be a tablet that had broken down or even a granular preparation of drug.
Q. So what you were analysing was this viscose liquid?
A. Yes. There wasn’t a lot of it and it did actually resemble bile.
Q. Because of the colour?
Q. Greeny brown?
A. Yes, but at the same time it could just have been some food that had putrefied in the stomach.
Q. On your finding you found 2 milligrams of morphine, yes?
A. Very approximately. It wasn’t accurately determined but yes, approximately 2 milligrams.
Q. 2 milligrams of morphine in this greeny brown liquid?
Q. Are you aware of the colour of certain forms of oral morphine?
A. I am not exactly sure in terms of what they would look like once they have reacted with stomach acid.
Q. Are you aware of a form of morphine known as cervadol?
A. I have not actually seen that preparation no.
Q. Are you aware of its existence?
Q. Are you aware that it is pale green?
A. I have seen in the literature there are reports of it being pale green. How pale that green is I don’t know.
Q. This Court has heard on more than one occasion of MST tablets. They are used certainly for pain relief and certainly for those suffering from particularly painful illness?
Q. Are you aware that MST tablets are green?
A. I think some of them can be green, yes.
Q. Are you aware of capsules known as MXL capsules, oral morphine, particularly high dosage, 120 milligram capsules?
A. I am not actually aware. I have never actually seen one of those preparations.
Q. Are you aware of their existence?
Q. Are you aware that they are green?
A. I wasn’t, no.
Q. In respect of this finding of morphine in the stomach you postulated two scenarios, one was that it was the result of what you describe as enterohepatic recirculation?
Q. But you also said you could not entirely exclude the possibility of it being residual from an orally administered dose of morphine?
A. That’s correct, yes.
Q. Can we in the first instance please deal with this procedure, that is the wrong word, this concept of enterohepatic recirculation?
Q. Could you please explain to the Court what that procedure entails?
A. In part it is as blood goes round the body it goes to the liver and from the liver you have the gall bladder, inside the liver there is the gall bladder. Any blood that is circulating within the system can subsequently go into the bile that is contained in the gall bladder and subsequently back into the stomach. Alternatively you can get reabsorption of drug from blood vessels surrounding the stomach back into the—
THE SHORTHAND WRITER: Sorry, can you slow down a little please?
MISS DAVIES: If I were you, Mrs. Evans, I would start again. I think we are giving the shorthand writer quite a difficult time and I hold myself responsible.
MR. JUSTICE FORBES: Start that answer again if you would please, Mrs. Evans?
A. As the blood goes around the body and a drug has been absorbed into it, whether it be from the stomach itself, from intravenous administration, or an intramuscular administration or any other route, to have an effect it must go into the blood. Then the blood in circulating around the body calls into the liver and the liver has within it the gall bladder and the gall bladder contains bile. This bile can then subsequently have drug within it and bile feeds back into the stomach. There is, also there are vessels surrounding the stomach itself. These leak back into the stomach and thus put drug back into the stomach. Drug that may not ever have been in the stomach originally just as a result of circulation can end up in the stomach.
MISS DAVIES: So what you are saying is that for this process of enterohepatic recirculation to have taken place the drug in question has to move from the blood, it moves into the gall bladder, yes?
A. Yes, that is one route, yes.
Q. It concentrates in the gall bladder, yes?
Q. And it then has to move from the gall bladder into the small intestine, yes?
A. The gall bladder can actually by means of the hepatic portal vein feed back into the stomach or into the small intestine.
Q. And then from the small intestine it can go back into the stomach?
Q. Are you aware of the effect of morphine and the sphincter in the gall bladder?
Q. You don’t know that one effect of morphine on that sphincter is to constrict it?
A. No I didn’t.
Q. If you would accept from me that that effect is one of constriction, that would slow up such a process, would it not?
A. Yes it would.
Q. If you cannot answer this next question because it is simply beyond your expertise please don’t hesitate to tell me. On this process of recirculation as you describe it, how long are we talking about?
A. I couldn’t accurately determine that. It is outside my field.
Q. In respect of the quantity that you found, 2 milligrams, that is a not insignificant quantity, is it?
A. It is not insignificant. It could amount to a therapeutic dose of a drug.
Q. Can I move on then please to Mrs. Lomas. Mrs. Lomas, by reason no doubt of the period between death and exhumation, her body was decomposed and in respect of the thigh there was extensive decomposition, is that correct?
Q. Again this was one of these occasions where you found chemical evidence of the putrefactive process?
Q. This was a case where you tested positive for opiates, benzodiazepine and what was found to be the chemical evidence of the putrefactive process?
Q. You, as I understand it, did not attempt to identify the benzodiazepines which led to the positive testing, am I correct as to that?
A. That’s correct.
Q. Insofar as the other findings were concerned you mentioned that pholcodine had been prescribed. We know in fact it had been prescribed on the 16th May 1997 and Mrs. Lomas had died on the 29th May of that year so it had been prescribed in the month of her death?
Q. As a matter of common sense, and I put it no higher Mrs. Evans, although you were working out the supply of pholcodine no-one in this Court knows to what extent and when Mrs. Lomas took the pholcodine tablets?
A. That’s correct, and it is also available over the counter as well.
Q. You are aware that pholcodine can break down?
Q. And it can break down into morphine?
A. Under extreme conditions, yes.
Q. As a matter of fact morphine can, I beg your pardon, as a matter of fact pholcodine can break down totally into morphine?
A. Under very extreme conditions yes, but not under the conditions I would expect within the bodies.
Q. In the case of Mrs. Lomas your finding in the thigh muscle was 0.9 percent, yes – 0.9, I beg your pardon.
Q. As a matter of fact you are unable to say whether that level represents in part or in whole any of the breakdown of pholcodine?
A. There may be a very small contribution from pholcodine. Testing that I have done as a result of this case, I have actually had samples that have been spiked up with pholcodine and have been allowed to putrefy for the last 12 months and in that 12 month period no detectable morphine has been detected under naturally occurring conditions. If we treat those samples with a concentrated acid then we can get conversion.
Q. Acid can be produced in the body, can’t it, when the body is in the ground?
A. It can, yes, same as with any decomposing tissues, and these tissues have been left to decompose.
Q. So therefore there would have been this agent present which could in whole or in part have broken down pholcodine to pure morphine?
A. I would not expect it to go entirely to morphine, I would expect to find some pholcodine.
Q. As a matter of fact the agent was present which could convert some of the pholcodine to morphine?
A. Acidic conditions do exist in these bodies, yes.
Q. As a matter of fact those acidic conditions could have broken down the morphine in whole or in part and converted the pholcodine into morphine?
A. I would expect in part. In my opinion I would not expect it to go to completion.
Q. If you accept in part that there could have been this conversion process, it follows doesn’t it that of that finding you have made of 0.9 you cannot say what part of that represents the breakdown of pholcodine to morphine?
A. I would say there could be some contribution to that from pholcodine, yes.
Q. But as a matter of fact you cannot quantify that contribution?
A. From the experiments I have done I would suggest it is a small part.
Q. But as a matter of scientific fact you cannot say of that 0.9 level what is represented by the break down of pholcodine to morphine?
A. That’s correct.
Q. The next lady please, Mrs. Quinn. This was a body described by Dr. Rutherford as being in a state of poor preservation. The disintegration of the soft tissues was most marked in the left thigh, skin, ankle and foot. As a matter of fact, Mrs. Evans, your sample came from the left thigh muscle?
Q. And therefore the area identified by Dr. Rutherford as demonstrating the most marked disintegration?
Q. Therefore we have decomposition probably at its most active in this particular part of Mrs. Quinn’s body?
A. With the exception that again I sampled the areas where there was still considerable reddening so therefore it was minimal.
Q. You say that, but one, that is only reddening to your eye isn’t it?
Q. And you have accepted that in going in you are moving further into that area where bacteria are moving inside out?
A. I am moving deeper, I am not necessarily moving closer to the abdomen, but yes, the decomposition process is where they were present.
Q. They were more than present, the decomposition processes rendered this body in a state of poor preservation according to Dr. Rutherford?
Q. Mrs. Quinn represents, together with Mrs. Grimshaw, the lowest of the levels that you found, 0.3 to 0.4?
Q. And this is a body where the effects of decomposition appear certainly on the face of it to be at their highest?
Q. You simply cannot say in that badly decomposed sample that you were doing your best to analyse what the state of that sample was at the time of death?
Q. It follows, doesn’t it, that from the very low reading that you have obtained there, and I am saying low in the range that you have told the Court of, you simply cannot say what any such reading would have been at the time of death?
Q. This was a lady who 11 months prior to her death had been prescribed co-codamol?
Q. In respect of the next lady, Mrs. Turner we have dealt with when I was dealing specifically with the liver and I don’t need to take up your time or this Court’s time any further on that particular case. Can I move on then please to Mrs. Lilley. ere again was a body where there was extensive decomposition noted by Dr. Rutherford. This was where you found chemical evidence of the process of putrefaction, yes?
Q. And by reason of such findings you said that the levels do not – I won’t pursue that. I am concerned I have not accurately recorded what you said. It was a case insofar as Dr. Rutherford was concerned where the liver was too degenerate for meaningful appraisal?
Q. And there was obvious degradation apparent in the tissues?
A. Yes, even on my visual examination.
Q. Even on your visual examination?
Q. And in the case of Mrs. Grimshaw again we have decomposition present?
Q. And this again, like Mrs. Quinn, was the lowest of the readings produced by yourself, 0.3 to 0.4?
MISS DAVIES: Mrs. Evans, would you allow me just one moment please. I have no further questions thank you.
Re-examined by MR. WRIGHT
Q. So far as you are concerned is there any problem in the reliability of the evidence that you have given as to the finding of morphine within the body by the fact that the sample has been obtained and analysed from the thigh?
A. No, morphine is definitely present in these samples.
Q. So far as the choice of the thigh muscle in order to perform your analysis in each of these 9 cases, was there a distinct preference or order of preference that you undertook?
Q. And which, please, is the preferred site of sample in each of these cases?
A. Preferred site would still be the thigh muscle. It is a peripheral muscle.
Q. And in general please, so far as the body is concerned and the preference by way of sample site generally, what would be the preferred site?
A. In cases of exhumed material I would still say the thigh muscle.
Q. Is there anything in the literature that causes you to consider that that may be wrong?
Q. In fact, is there anything in the literature that may confirm your opinion?
A. The reported levels in terms of stability, the reported stability suggests that thigh muscle is the one least susceptible to microbial invasion and therefore the best specimen of choice.
Q. Is there any dissent among this field of expertise?
A. Not that I have come across.
Q. Is there any dissent in the material that you have considered in relation to this enquiry?
A. Not that I am aware of.
Q. Has any report of any form been drawn to your attention that may seek you to cause to reconsider your view?
Q. Is it so far as you are concerned appropriate to infer that the thigh was the third option?
A. The third option?
Q. The least favourable of the 3, blood, liver, thigh?
A. In an exhumed body, no, I wouldn’t say it was the third option. I would still say it would have been a sample of choice.
Q. And so what is the purpose in seeking to analyse liver and blood?
A. Just to show that there was additional support for its presence in the thigh muscle, that it was in the general circulation and in other areas of the body, and that what we were looking at was maybe an injection had been given into a thigh muscle after death and therefore this was just present there for no other reason.
Q. So how many different areas of the thigh did you then seek to obtain samples from?
Q. How deep within the thigh did you seek to obtain the sample?
A. Until I found areas of reddening. In most cases that was quite deep. We were looking at a few inches below the surface.
Q. A few inches below the surface?
Q. Were you aware of the concept of postmortem redistribution in blood at the time that you performed these tests?
A. Yes I was.
Q. And therefore did the concept of postmortem redistribution in blood affect your preferred source of sample?
Q. Why is that?
A. The only reason that affected the decision was that of the reports that are available concerning postmortem redistribution. These suggest that the femoral, which is the vessel in the leg, is the one least susceptible to change.
Q. Do continue?
A. Thus in deciding on a skeletal muscle to choose I chose the one that was nearest to a vessel that would give the representation if we were looking at a fresh autopsy.
Q. Does the concept of postmortem redistribution in blood effect the total level of morphine?
A. If we were looking at blood, yes.
Q. Does it affect the total level in the sample of thigh tissue?
A. Theoretically yes it could, because it depends on how reliable data is but as I am comparing like with like, I was comparing muscle to muscle, I take those to be minimal considerations.
Q. So far as the total level is concerned, is it possible by postmortem redistribution to increase the total level?
A. Only by—
A. Only by way of concentration and in my opinion there was no significant concentration effects evident in these muscles.
Q. So consequently the converse of that is whether it may effect a decrease in the total level?
A. There is a possibility of a decrease, yes.
Q. So there may be a decrease from death but the increase is in the terms, the potential for increase is in the terms in which you have explained?
Q. And that is of what extent?
A. That is a negligible consideration.
Q. So is the problem of postmortem redistribution a problem with the reliability of the findings of morphine or with an interpretation of the level found?
A. The problems are with the interpretation of the level found. Morphine was present.
Q. So far as the deep thigh is concerned and postmortem redistribution being by blood, yes?
Q. Then in the deep thigh muscle itself, how approximate is that to the major blood vessels?
A. In all the reported literature on comparisons of muscle to blood they give an average of 1, ie that the blood is approximately equal to that in the tissues. The range goes from .4 to 3.3. But I didn’t seek to do a comparison to blood because of the problems of postmortem redistribution and the unreliability of data. I merely looked to compare thigh muscle tissue to other muscle tissue.
Q. It is put that by the process of decay you can get considerably higher levels in liver to muscle tissue?
Q. And you would accept that?
A. Not just because of the decay, you can get higher liver levels than muscle tissue.
Q. Tell us why that is please?
A. The liver is effective a storage organ. Drugs can actually accumulate within the liver?
Q. Is the thigh muscle a storage organ?
A. It is not a storage organ for drugs.
Q. Is it really an organ?
Q. You were asked to consider the report of Phelby, yes?
Q. Soren Phelby. Morphine Concentrations in Blood and Organs in Cases of Fatal Poisoning?
Q. Is that an article with which you are familiar?
Q. It was put to you that that was anecdotal by way of study?
A. It is anecdotal in terms of these were people that died but they were not under controlled conditions, therefore they were reliant on information provided to them either by the police or witnesses to the death that the mode of death was from morphine.
Q. Does the literature also include the range indicating whether these deaths were in the morphine naïve or in the morphine user?
A. In the study by Phelby he suggests that most of them had some degree of addiction.
Q. And that the range incorporating that detail was one within which these individual deceased with which we are dealing fell?
Q. And the lowest end of the scale, the end of the range was what please?
Q. And so in dealing with a figure of 0.3 as being the lowest here in the cases of Mrs. Grimshaw and Mrs. Quinn, what number fold increase in the level of morphine does that actually indicate?
Q. A threefold increase in the level?
Q. Would it be fair to deal with that in terms of percentage as being a 300 percent increase?
Q. In the actual level of morphine?
Q. And this is in an anecdotal report of the deaths of intravenous morphine users?
Q. Whilst you were asked about the anecdotal nature of that particular report, have there been any animal studies into this particular field?
A. There have but most of those have been on rats and they are not reliable results for a small animal.
Q. So far as the long-term stability of diamorphine or morphine in muscle tissue is concerned, have you yourself performed any control tests in that regard?
A. I have for the preceding 12 months had samples spiked not with diamorphine or morphine but with other drugs that could be considered potential drugs that morphine could be produce from, ie pholcodine, codeine, and in that 12 month period I have found no measurable morphine, just the parent drug. I have also spiked those same things with embalming fluid as well and I have still not detected any free morphine from those.
Q. Did you spike them with the embalming fluid of the type used in each of these individual cases?
A. Yes I did.
Q. In which the deceased were embalmed?
A. Samples that were submitted that were of the type used in some of these, yes.
Q. Any morphine?
Q. Dealing with the pholcodine point and the conversion of pholcodine to morphine, you accept as a proposition that pholcodine may in certain circumstances be converted to morphine?
Q. And converted in its entirety?
A. In laboratory conditions, yes.
Q. That is what I wanted to ask you about, laboratory conditions. Firstly, what does that involve?
A. It involves adding a strong acid, such as hydrochloric acid, at a very low pH to those samples and allowing them to stand in the presence of that acid for a period of time.
Q. Now hydrochloric acid, very strong acid, for a very long period of time?
Q. You were asked specifically in relation to Ivy Lomas about the pholcodine point?
Q. Firstly, does embalming fluid contain hydrochloric acid?
Q. Secondly, was Ivy Lomas even embalmed?
A. From the records I have then, no.
Q. From our schedule, no. Therefore, so far as the presence of hydrochloric may be concerned, or an acid of similar strength, is there anything to indicate from your analysis of the tissue in the case of Ivy Lomas that there was present hydrochloric acid?
Q. You say that pholcodine may be so converted over a lengthy period of time?
Q. What sort of length of time are you talking about?
A. We are only talking about a few hours in the presence of that under laboratory conditions.
Q. In hydrochloric acid?
Q. Insofar as acids produced by any putrefactive process post death, are there any acids produced by that process that are akin to hydrochloric acid?
A. Not within the putrefactive process. Hydrochloric is present in the stomach, so if that was to come into context then there is a possibility, but as the stomach does not directly contact the thigh muscle….
Q. It was a point I was going to investigate with you. Hydrochloric acid in the stomach, your sample was from the thigh?
Q. Furthermore, so far as pholcodine is concerned what percentage, if you can deal with it in those terms, is the active ingredient of codeine, sorry morphine?
A. Of pholcodine.
Q. How then does pholcodine convert to morphine?
A. It is by processes involving acidic breakdown.
Q. In your view how likely is the prospect of pholcodine converting entirely to morphine?
A. Extremely unlikely. In my experience you cannot actually get the tissues to degrade pholcodine to morphine.
Q. Why is that?
A. Because the acidic conditions developed during the decomposition are not strong enough to convert it.
Q. Did you find any pholcodine by way of parent drug?
Q. As far as the levels that you found of total morphine within the tissue samples analysed by yourself, you said this, these are not the sort of levels you could get from an over the counter regime?
Q. Could you explain what you mean by that please?
A. If someone was to purchase for instance kaolin and morphine or any of the over the counter preparations and take them as the dosage indicated on the bottles, then you could not achieve levels like this.
Q. I will return to that topic briefly when asking you about an analysis of the stomach content a little later, but dealing with analysis of the thigh tissue and the state of decomposition of the bodies, what please was the state of decomposition of the samples taken from the thigh of these 9 respective deceased?
A. There was some evidence of decomposition in the majority of them but the samples I actually took were the ones where there was reddening and the least amount of degradation, although there would be some degradation.
Q. Where does the decomposition manifest itself?
A. In the ones I examined the greatest amount of decomposition was closest to the skin.
Q. Your sample was, as you told us, that number of inches away from?
Q. Having regard to the matters brought to your attention so far as decomposition is concerned and the analysis that you undertook upon the thigh muscle, thigh muscle that you obtained, have you any cause to reconsider your opinion?
Q. Does anyone suggest that morphine occurs naturally as a decomposing product?
Q. Have you considered the literature available in this case?
A. I have, yes.
Q. And have you considered various reports served for your consideration?
A. I have, yes.
Q. Is there anything that causes you to reconsider that particular expressed opinion?
Q. Dehydration. On the tests that you performed a degree of dehydration in the organs was revealed?
A. In the heart and lung, yes, negligible in the muscle tissue.
Q. Negligible in muscle tissue?
Q. Therefore, does that factor of dehydration cause you at all to review your opinion?
Q. Or to reconsider it?
Q. Does the concentration of morphine, total morphine, in the thigh tissue by dint of any dehydration, negligible or otherwise, does the fact of dehydration affect the concentration of total morphine?
A. If the tissue was dehydrated then yes, it would raise the level, but I found no evidence of dehydration.
Q. So you accept the principle?
Q. And did you apply it in practice?
Q. And are you therefore able to consider and reject the prospect of that having affected the calculation?
A. I did consider it in drawing my conclusions and I did reject it.
Q. Now you were also referred to the literature from the Journal of Forensic Sciences, a report by Robert Mann and others, Time Since Death and Decomposition of Human Body, Variables and Observations in Case and Experimental Field Studies?
Q. And you were asked to consider paragraph 12 of that particular report at page 108?
Q. And the effect of embalming?
Q. Firstly, that particular paragraph and the report upon embalming, how many bodies were involved in that particular study?
A. It would appear one.
Q. Do we know anything about the circumstances in which the embalming took place?
Q. Do we know how that embalming was undertaken?
Q. Was the body of the deceased in that particular case buried in a coffin?
A. On the basis of what is here it would appear that it wasn’t.
Q. Was the body of the deceased in that case buried to any noticeable or considerable depth?
A. No, it says it was in a shallow depression.
Q. Is that particular anecdotal report so far as you are concerned of any assistance in the matters that were undertaken by you?
Q. Or in the considerations that you have in giving your opinion?
Q. Formaldehyde and embalming. Does morphine, forgive me, does formaldehyde have any component constituent chemical that is susceptible to conversion to morphine?
Q. So far as the levels of total morphine ascertained by yourself as being present in the thigh muscle of each of the deceased is concerned, insofar as there may be any variable or any variation from the matters that have been drawn to your attention, could the total level at death have been higher?
A. Yes, it is a possibility that it was higher at the time of death than that I found during my analysis.
Q. Could the level have been lower?
A. I think it unlikely.
Q. Why is that?
A. Because if a drug is unstable it is going to breakdown, it is going to be lost, but there is no reports of spontaneous production of morphine in tissues so it is not being produced within the body, there was no measurable dehydration in these muscle tissues to suggest that we were getting a concentration effect. So in my opinion there is nothing to suggest that these levels may have been lower, though it is conceivable that they were higher.
Q. Muscle variability please. You are aware of the literature in relation to that particular concept?
Q. And also the tests reported by, is it Professor Pounder?
Q. Did he test for morphine when dealing with muscle variability?
Q. So far as the first 4 cases are concerned, Grundy, Pomfret, Mellor, Melia, you were asked to consider the difference in levels present in the thigh?
Q. What may explain the difference in levels?
A. It may be that different doses were administered, it may be that because the older bodies were showing the lower levels that, as I suggested, maybe the drug does become unstable after very prolonged periods and therefore you get a reduction.
Q. A reduction?
Q. But not an increase?
Q. You can go down but you cannot go up?
A. In my opinion, yes.
Q. Speaking of those that had been buried for longer of course, and looking at our schedule briefly, Mrs. Turner was 852 days, the longest?
Q. Yet her reading in the thigh was 1.4 to 1.6?
Q. How many fold is that increase from the level of 0.1 referred to in Phelby?
A. A 15 fold increase.
Q. 15 fold increase?
Q. Is that 1,500 percent increase?
Q. Nitrazepam please. I am going to turn, and I hope very briefly my Lord to the individual cases. Nitrazepam, Mrs. Grundy, sleeping tablet?
A. Not present within nitrazepam and wouldn’t break down to give morphine.
Q. Mrs. Pomfret, benzodiazepine, susceptible to conversion to morphine?
Q. Lithium, susceptible to conversion to morphine?
Q. Mrs. Melia, amoxicillin, susceptible to conversion to morphine?
Q. Any of the tablets or the capsules that you were supplied with and asked about by my learned friend susceptible to conversion to morphine?
Q. Stomach content analysis please of Mrs. Melia. Viscose liquid that resembled bile?
Q. Did you find any tablets or particulates within that liquid?
Q. Enterohepatic recirculation. From the material that you have considered in the case of Mrs. Melia is there anything that leads you to conclude that the residue, that the liquid found within the stomach and containing 2 milligrams of morphine, was the residue of morphine tablets, capsules or syrup?
A. I can’t exclude the possibility.
Q. Is there anything that has been brought to your attention by way of report or document that leads you that conclusion?
A. The only thing I can say is that I found nothing in the medical records to suggest that she was on anything morphine related.
Q. Furthermore, you say that the 2 milligrams is not insignificant, it could amount to a therapeutic dose of the drug?
Q. That would be the 2 milligrams found in the stomach content?
Q. Of Mrs. Melia?
Q. Then what please of the 0.7 to 0.9 total morphine found in the thigh?
A. They are greatly in excess of what would be expected from therapy.
Q. If there are 2 milligrams in the stomach how does the total morphine get to the thigh?
A. Could be from another route of administration, from injection.
Q. Mrs. Lomas, I have dealt with, touched upon, the pholcodine point. Just one matter. We know that she was not embalmed in any event and the acidic conditions that are required you have dealt with so far as hydrochloric is concerned?
Q. Are you also aware of any report by a Professor Forest?
A. I am aware of a number of reports by Professor Forest.
Q. And as to the alkaline or acidic state of any cadaver?
Q. What please is the situation so far as the alkaline or acidic state of a cadaver is concerned?
A. In terms of Professor Forest’s reports I would prefer if I could actually relate to that report as opposed to doing it from memory.
Q. Whether I need to pursue it further, may I at 2.15. Otherwise that concludes the matters I would seek to raise by way of re-examination.
MR. JUSTICE FORBES: Subject to that then we will break off now, members of the jury, and resume again at 2.15. Mrs. Evans, you still remain giving your evidence until after the lunch break. If you would like to go with your usher, members of the jury.
MR. JUSTICE FORBES: Yes, Mr. Wright.
MR. WRIGHT: I am sorry, forgive me, I did convey the message that it is not a point I wish to explore further. There is no re-examination of Mrs. Evans, I have no further questions thank you.
MR. JUSTICE FORBES: Thank you very much. Thank you, Mrs. Evans. You are free to go. Thank you very much.
MR. WRIGHT: Would you forgive me just for a moment whilst I just confirm something. May we now turn to computer evidence by the calling for cross-examination of Detective Sergeant Ashley. I acknowledge that it is interposed during what is a complex area, but there are reasons why it is not possible for Detective Sergeant Ashley, or indeed anyone representing the interests of the defendant so far as this field is concerned, to be both here at court on any other day.
MR. JUSTICE FORBES: Yes very well. Let Detective Sergeant Ashley be brought into court.
JOHN FREDERICK ASHLEY, recalled
MR. JUSTICE FORBES: You are still under oath you understand?
A. Yes my Lord.
MR. WRIGHT: Would you wait there, there may be some questions for you.
Cross-examined by MR. WINTER
Q. Detective Sergeant, before I ask you some questions might I just explain, my Lord, the device that has appeared in the right hand corner of the court, so that the witness understands what has happened and so that your Lordship and the members of the jury can follow. Detective Sergeant, what you see to your right is, as you will probably immediately recognise, a lap top computer. It is connected to a projector just to the side of his Lordship which is projecting upon that screen what you would ordinarily see appear on the screen of the computer. The screen of the computer is in fact blank and you will therefore be asked to look at the screen in due course rather than the screen of the computer. And the programme that has been loaded on that lap top is the programme and the patient histories that was seized by you, in other words copied from the surgery computer, in the way in which you described when you gave your evidence. Do you follow? So a copy of what you removed has been placed upon that computer and we now have access here to the same Microdoc programme?
A. So this is the record on the day that I seized it?
Q. That’s correct. Do you follow that?
Q. Before I ask you to access that programme I would like to ask you one or two questions about the nature of Microdoc because you have given evidence both orally and the jury has heard a number of statements of yours read to them, wherein you describe the finding upon the computer in relation to the specific patients with which we are concerned, entries which appear to have been backdated?
Q. Now the Microdoc programme is designed, is it not, specifically to enable that to take place?
A. The Microdot programme is designed as a computerised medical records data base.
Q. But intrinsic with it is an ability to make an entry at any time within a patient’s history details?
Q. And it carries with it what is known as an audit trail whereby it records the time at which that particular entry was made?
A. That is attached to each record, yes.
Q. And that is an intrinsic feature, isn’t it, of the programme?
Q. Details of how one does that and how one would view the audit trail are included within the manual to the programme?
Q. So, for example, if one makes an addition, we will do this shortly, to a patient’s record, and dates that addition some years previously or sometime previously, let’s say a year previous to the time it is being entered, the entry itself becomes part of the patient history chronologically. In other words if you make it for the 10th December 1997 it would work its way into the patient’s history at that time?
Q. And you would then by simple procedure be able to analyse the audit trail part of the programme in order to be able to establish when that entry was placed upon the computer?
Q. Have you seen a copy of a report prepared by Mr. Jonathan Beck?
A. I would need to see the report. I have seen a report.
Q. I am just going to ask you one short question, I hope, about it. Did you also receive with that a rather large volume of printout patient codes?
Q. Which was a print out of the total number of backdated entries for whatever patient that were recorded within that computer?
A. I believe that was what it was supposed to be, yes.
Q. Did you perform any checks on it?
Q. Do you have any reason to believe other than, as Mr. Beck states, that that is a printout of every backdated entry on the computer?
Q. It does not matter as to specifics but there are a very large number of those entries, aren’t there?
Q. Probably in excess of 20,000?
A. Possibly yes.
Q. I am grateful to my learned friend, just over 19,000, 19,206. The programme has to be entered by way of a code?
Q. And perhaps if you would turn to the computer now and assist us because do we see on the screen that the very first screen that one finds when one has logged into the Microdoc one is about to embark upon entering patient histories?
A. That is a screen, when the computer, the server, has been powered up that is the screen that, when it has gone through power up process you are faced with. You are not actually into the Microdoc system as yet, that is the menu that allows you to go into it.
Q. This is the menu to gain access and one can see the third entry Microdoc, so would you be kind enough to enter that. It tells us it is loading Microdoc and appears, there two spaces with the flashing cursor. That is where one needs to enter the code?
Q. There was in fact, do you understand, in effect only one code used by all the staff in the surgery?
A. I believe so but that is not a matter of fact to me. I have not spoken to anybody about that.
Q. That is from your understanding, it is not something you have been able to understand from the computer itself?
Q. That is agreed. I am very grateful. And I hope this will work, if you enter HFS ACP222?
A. The way I normally enter the system is by a super user pass word, not his way.
Q. There are two ways of gaining entry, that is the way the normal user would gain entry but there is a super user which is the word “Bowls?”
Q. Whichever route you prefer. Having therefore entered Microdoc, entered the user code, the first page that you see is a page that states in the centre of it the date?
A. Today’s date as picked up from the computer.
Q. I am going to come back to this in a little more detail but the way that computers work is that they don’t have an understanding of what today’s actual date is, they are told by the user what the date is?
A. I can enter any time and date on there I wish. The date and the time we are seeing is actually picked up from the computer itself. So there is a record within the computer of what today’s time and date is now.
Q. But that has come from it having been entered into the computer at some earlier stage?
A. Probably at manufacturer.
Q. Quite possibly. But the computer will calculate today’s date from the date that has been entered into it either by the manufacturer or by some other person?
Q. In other words, if the manufacturer entered the wrong date for some reason, we would not be seeing today’s date, we would be seeing a different date?
Q. At the bottom of that it clearly states, does it not, an ability to change the date by using D, to change the time by using T, and once having done that to confirm that it is correct by pressing enter?
Q. Would you for the moment confirm we are at the 10th November and move to the next page. The next page is the main menu?
Q. For the particular part of the programme in Microdoc that would be of use to a doctor in a general medical practitioner’s surgery?
Q. And one can see there a list of the various possibilities available. If one goes to M?
Q. M, one sees Medical Summaries. Would you press that please. And comes up a refined menu so one is narrowing the field, is that correct?
Q. And on that summary menu there are 4 choices on the left and a cohort histories choice on the right, but of the 4 one can see there is Histories, Medical, Summary, and then an entry for removing summary. Do you understand, don’t press this button because it takes a very long time to do it but do you understand if you were to press R you would remove a particular patient’s summary completely from the programme?
A. Yes. You would be required to input the patient’s registration number or identity and then you could remove that patient’s whole summary.
Q. Exactly. So that would be a way of going about removing someone completely from the practice, for example if they left the practice?
Q. Could you, however, press M again please for medical summaries. I am sorry, I have gone wrong already, I knew this was going to happen. Could you press escape to go back and press H for Histories. We need the full histories. This is now inviting the user to enter a particular patient’s history and obtain access to that set of records?
A. The patient’s registration number, that is what it is waiting for.
Q. Would you please enter the registration number for Mrs. Pomfret which I shall tell you is number 31082. It immediately comes into her record and also flashes that she is deceased?
Q. So would you please press escape to enter her full history. Then do we see access as you have described, and we have seen photocopies of these records in our bundle. We have entered the particular history of Bianka Pomfret?
A. It is. This is not the way that I normally enter by reference to my statements.
Q. I appreciate that but as a user following simple steps through the operation of the Microdoc programme this is a route to gain access to the summary?
A. Yes obviously, yes.
Q. It has highlighted, has it not, in fact for the 11th December a particular entry?
A. That will be the last entry, I presume, of the record, yes.
Q. If you press the arrow keys you can go up to select a particular entry so would you perhaps select the first one for the 10th December. In order to look in greater detail as to that entry one goes simply to Display, doesn’t one?
Q. Or F6 makes the same route. Just before you do that can I point out through you that at the top of the page just under where it has the patient number and Mrs. Bianka Pomfret there is a box under the heading “Patient history” which has various possibilities listed horizontally?
Q. The first is Add, by which one would simply add an entry. The second is Display, by which one enters a specific entry in order to analyse it further. The third is Correct, if one wishes to make amendment to an entry. The fourth is Remove if one wished to remove a specific entry. Do you agree that here set out in very easily understandable terms intrinsic to the programme is the ability to amend, to add, to remove, to deal with as you see fit entries in that patient’s history?
A. What you are referring to there is a drop down menu system. We can actually go to that menu and display all the options that appear under each of those words. So yes, basically what you have said is correct. There may be other functionality available within that drop down menu.
Q. Precisely. That is the route in to remove an item, for example?
A. That is one way, yes, definitely.
Q. Would you kindly enter the display part of that. I think that is F6. So by pressing that button one then gets the full entry in this case for the 10th December?
A. The Display History Details yes, in that central box.
Q. And would you confirm, I will show you the manual if you need to but it may be that you know this in any event, all of this is set out in the user manual?
Q. If the user wanted to know when that particular entry had been made one can see that it is dated on the left the 10th December 1997, but if one wished to discover when that particular entry had been made, it is a very simple step isn’t it?
Q. One simply goes into Info that we see on the second box down under Display History Details?
Q. So would you perhaps do that please. You pressed, did you press “I” for Info?
A. Yes I did.
Q. And we can see that was created, as we see there, on the 10th December at 15.52. So do you agree with this suggestion, not only is it very straightforward to analyse a particular entry, it is equally straightforward and an intrinsic part of the programme to discover when that entry was made?
Q. Would you please return to the main history menu by pressing escape. I am grateful. Could you please be shown the first volume of the jury’s bundle and might I invite your Lordship and the members of the jury’s attention to the first bundle. Under the flag for Mrs. Pomfret, maybe you have got the second, may I invite attention under the divider for Mrs. Pomfret to page 721.
MR. JUSTICE FORBES: Can I have the reference again?
MR. WINTER: Page 721 which is towards the rear of the divider labelled “Pomfret.” Before we come to refresh our memory of this and another related document, can I just ask you this. You said when you gave your evidence to my learned friends who prosecute that it was quite possible in your view that the user of the computer would not know that a particular entry was being timed. Can you remember? It is a long time ago. Can you remember saying that?
Q. Well, that might be the case but it would only be the case of a user who had not (a) read the manual and (b) looked in Info as we just did on the computer?
A. The manual being, I would estimate, in excess of 300 pages.
Q. It is a very very lengthy, I agree?
A. Not the easiest thing to read.
Q. And not the easiest thing to read, but in the paragraph that tells you how to make an entry, that very paragraph goes on to explain how you can examine through the Info button when that entry was in fact created?
Q. So you might not read the entire 300 pages but if you looked in order to discover how to make an entry, all of this information is included at that part of the manual?
A. It exists in the manual.
Q. And as we have just seen even a mildly curious user would be able to access that information?
A. If you looked in that section you would find the answer, yes.
Q. Can I just refresh the memory of the ladies and gentlemen of the jury. At page 721, do you have that there?
A. I do.
Q. We have an entry dated 28th April 1997 with an end date of the 10th December and if you look at the previous page that was created on the 28th April but removed on the 10th December. It is page 721 and 720?
Q. If you turn now to page 691?
Q. We see an entry again for the 28th April 1997, this time with no end date, which over the page is said to have been created on the 10th December 1997?
Q. And what is said by the prosecution is that page 721 was removed on the 10th December and in its place page 691 was put on the machine?
Q. If you look please at the times involved, so at page 691 the time of that entry if you move over the page is 15.59 and 8 seconds on the 10th December?
Q. That is precisely the same time, is it not?
Q. At which the entry for page 721 was removed?
Q. You find that at page 720, 15.59 and 8 seconds. What happens is this, if a correction of any form is made to an entry the computer regards the process that has taken place as the removal of one entry and the replacement of it by a new entry?
A. Yes, I am aware of that.
Q. Do you agree with that?
A. Yes I am aware of it, I agree with it.
Q. In effect what is happening is that an entry is simply replacing another entry?
A. In this case the entry on the 28th of the 4th existed within the record and on the 10th December at 15.59.08 that entry was altered. The original entry was placed into the removed section of the data base and it was replaced with the entry that was created at that time on the 10th of the 12th.
Q. Exactly. The point being this, that even if you were to go in and correct a spelling mistake, for example, the computer regards the entry which was corrected as having been removed and a new entry as having been put in its place?
A. That is correct.
Q. The previous entry, as you say, goes into a list of entries that have been removed from the computer and can be accessed as we will see in due course?
Q. And that explains, doesn’t it, why on the occasions when the date and time are precisely the same, what has happened is that some form of amendment has taken place to an entry?
A. Yes, definitely.
Q. For example, the top of the page you see the word filters?
A. This page.
Q. Yes, forgive me, top of the screen?
Q. You see the entry for filters immediately under Histories in the top box?
Q. Would you be kind enough to enter Filters. By going into that entry do you see the 4th entry down you have got, Read, Code, Date, Range, Context, Show, Remove. If you access that you go into a list of entries that have been removed. So do you agree again with this proposition, that it is an intrinsic function of this computer that when an entry is amended the previous entry is there stored in a list of entries that have been at some point either removed or amended?
Q. And we can see there the relevant entry, it is the second one down, “28th April 1997, Seen in GP’s surgery.” That is the entry which we saw at page 721 as being amended in some way and therefore the original entry has simply been placed in a list of entries that have been amended or removed? You agree with that?
A. Yes, I agree.
Q. Yes. Would you return please to the main menue. Escape I believe. Sorry, I didn’t mean you to do that. Can you enter Mrs. Pomfret’s number again, 31082. Right. Can you now show us what happens please when one wants to remove an entry. So one accesses Remove. The entry which has been previously highlighted is there, and it is thereby possible simply by pressing the Remove word on the left of that box – do you want to do that please? Have you done that?
A. Yes. I presume you want to go to the Filters menu.
Q. Now we need to go to the Filters to see that it has been removed and you can see there the entry which you have just removed. So in pretty much two very simple steps you can remove any entry of your choice?
Q. Could you now please press the Add function.
A. You can’t from this screen. You have to go back to the Main History.
Q. I think if you go back to Filters. It is 31082. Now can we go to Add please. So if somebody has, for example, come into the surgery and it is necessary to make an entry, by pressing Add this box appears. And this is the box that prints out in the form that we have seen for example at page 721, when it is completed, the printout, the information is coming from this box?
A. The information probably is coming from there. This isn’t any function I have ever done with this data base. I wasn’t required to add records to it.
Q. Can we just have a look at it please. Now the first that is highlighted is Term keys. Do you understand within the programme there are a very large number of short cut routes into making an entry?
A. Yes. We can list them at this point if you wish to.
Q. Would you just do that so that we can see. There are various headings under which you might want to have a look. So would you go to one of those, it does not matter which. And you have got Administrations at the bottom. Can you then display a list of possibilities under Administration Detail?
A. I am not sure.
Q. It is easier if I do it this way, type in the word “seen,”
S-E-E-N, and enter that. Right. Different form?
A. I can’t understand why that is.
Q. Try if you would 9N1?
A. Do you want me to try something else?
Q. Try 9N1. Sorry, forgive me, you have to press F9 first to show the Read codes.
MR. JUSTICE FORBES: Have you read the manual?
MR. WINTER: I have my Lord?
A. It is complex.
Q. It is very complex. Just F9. Yes. Can I just summarise it in this way?
A. Please do.
Q. There are an awful lot of Term keys like 9N1?
A. I believe you.
Q. Which will come out at the end of the day as saying things like “Seen in own home,” “Seen in surgery,” “At hospital?”
A. Abbreviations would be a better word.
Q. Which are short cuts into placing for example “Seen in GP’s surgery” into the computer?
A. Time saving lists.
Q. Precisely. The Comment, which is the next box down, is a box which must be completed by the user. It is very faint at the moment. Can you go down to it. Don’t worry about entering it?
A. You have got to put something in the Code field.
Q. Precisely, but under comment the user simply makes whatever comment is appropriate and there he has to make an entry if he wants anything to be recorded?
A. I don’t know.
Q. Right. The next entry down is Date and again any particular date can be entered by the user?
Q. The next entry down is End Date and again the user can place a date there, for example if someone has had an illness for a specific period of time but has come to an end, that particular part of the entry can be concluded by putting a date in at that point. Review is simply you might want to ask the computer to pull up this patient in the future if she needs to come back, for example, for a 3 monthly check, is that right?
A. I don’t know.
Q. You don’t know. But Where, is the point I am getting to, you told the jury when you gave evidence earlier that Where related to where the entry had been made. Do you recall giving that evidence?
Q. What do you understand the Where to mean?
A. I understand that by default in this data base, as we see there, every record will have “Here (this practice)” unless anything else is entered there instead of.
Q. Precisely. The default entry means this, does it not, that unless you enter something specifically for that entry the computer automatically records “Here (this practice)?”
Q. So where we see for example on page 721 the words “Here (this practice),” that may specifically have been entered by the user or the computer may have entered it as its default entry because no other entry was put there?
A. I would suspect the computer has done it because it is identical to what we see on the screen now.
Q. Yes. It is therefore impossible from an analysis of the computer to know whether that entry was deliberately and specifically placed in or is simply there as a result of the functioning of the machine?
A. I think it is more important to look at the difference between the two entries as opposed to the timings perhaps. We know that the entry on the 28th April existed in the data base and on the 10th of the 12th was amended. So if we examine the contents of the 10th of the 12th as amended, we will see the alterations from the 28th April’s original record.
Q. Precisely. I am merely using this page as an example. You cannot say, can you, from this machine whether the entry “Here (this practice)” was specifically and deliberately entered in at the time the entry was made?
A. No, I suspect that is put in automatically by the system.
Q. Precisely. Now finally I hope, this, if I wanted to make an entry for the 10th December, for example today I want to make an entry for the 10th December, but I do not want the computer to record that I have made it today on the 10th November, there is a very simple way of going about that, isn’t there?
A. I don’t think so, no. Try and enlighten me.
Q. Would you go back please to the front of the computer where we saw the time page?
MR. JUSTICE FORBES: Do I understand this is a way of avoiding the audit trail?
MR. WINTER: Yes.
MR. JUSTICE FORBES: Thank you.
MR. WINTER: Would you enter your code please. Would you apply Change the Date, so press D, and put the date the 10th December 1997. Leave the day of the week, it doesn’t matter. Now apply please to change the time. Would you please type in 15.59. Would you confirm that please? Enter again the medical Summaries, the Histories, and the code 31082. Would you please apply now to Add an entry. Now press F9 please for the Read code and put in please 6144, just an example of a particular code. I promise you I wasn’t aware that was coming. Can you put a Comment now please, perhaps you would write “Test” and the date 10th December 1997. And save that as an added entry. So you press Add. Would you please return to the previous page. Do you see there that we have the entry you have just made for the 10th highlighted for the 10th December 1997 with the details and your word Test?
Q. Now please analyse to see when the computer thinks that entry was made. The computer thinks that entry was made on the 10th December 1997. Do we understand therefore by that, by the simple changing of the internal computer clock at the outset of the programme, one can completely alter the effective operation of the computer?
A. This data base was held on a separate server. The actual data base manipulation would take place at work stations throughout the surgery.
Q. Although it has a central server?
A. It could be done in the manner in which we have done it, but obviously all entries made thereafter would be incorrect. One would have to come back out of the data base and reenter the correct time for all the other entries then to pick up the right time. Quite in overall a lengthy operation.
Q. In order to put it back to where it was before one simply changes the date at the outset?
A. One comes back to the screen we were in, changes it back to the correct, and then, yes.
Q. If one wanted to create computerised records that purported to show that they were created at the time and date which is entered upon the patient’s history, that is, is it not, a very simple way of doing it?
A. That is a way to do it deceptively, yes.
MR. WINTER: Thank you very much.
Re-examined by MR. WRIGHT
Q. Using that particular illustration, what would happen thereafter whenever you then made a further entry?
A. Without going back and changing the time and date all further entries would follow on chronologically. That clock is now ticking. It is probably, at the moment it is 16.03 so any further additions would also be incorrect.
Q. So the clock on the computer would think that it is now the 10th December 1997 and it is 42 seconds past 4 o’clock?
Q. And so if then anybody within the practice was then to use the computer?
A. From any of the other work stations.
Q. From any other work station and enter in any details in relation to any other patient?
Q. Then the date and time that would be displayed upon that entry would be what?
A. Incorrect by the number of days we are amending it or whoever is amending it.
Q. And just to remind us, how many work stations were there please in this surgery?
A. Excluding the actual server there were 5 work stations.
Q. And including the server?
Q. What about if there are 3 successive late entries, each of different dates for example. How could that be done?
A. In an individual record?
A. It means that by that methodology one would have to go and change the clock 3 times.
Q. And then put it back to the correct time?
Q. In other words, once you have put in 3 entries for December 97, September 97 or April 98, you would then have to return to the correct time being the 10th November 1999?
Q. The user manual that you were asked about, the Microdoc programme user manual, does that set out how you are able to perform that exercise?
A. I would think it probably does. I can’t say specifically. I would think the user is probably explained the relevance of that screen where you are able to change the actual time and date. I am sure it is included in the software to provide the facilities to put it to the correct time and date should your computer’s clock be faulty, which does occur. I am sure it is not designed to be put in there to allow users to use it for this subterfuge.
Q. Furthermore, if we look please at the Bianka Pomfret entries for a moment, and using the schedule as we have it please ladies and gentlemen in our volume 1.
MR. JUSTICE FORBES: The A3 schedule?
MR. WRIGHT: The A3 schedule my Lord, yes thank you. And using the examples that were given to us earlier, so we look at the deletion and creation of the entry dated 28th April of 1997, yes?
Q. You were able to ascertain from an interrogation of the record information held within the computer the time of the creation of that entry and the deletion of the previous entry?
Q. At 15.59.08?
Q. We know that the body was found at 5 pm, that is 17.00 on that day. Now insofar as those entries are concerned is the time of the 15.59.08 a manual creation by the process that we have been having described to us?
A. I can’t say whether it was or it wasn’t. It could have been. The data base can be used in that fashion.
Q. So either the time that was ticking on the clock was the time that day, namely 2 hours, an hour and a half, no, an hour before the discovery of the body, or it was a time deliberately selected by manual entry in the way that we have just undertaken here?
A. One of the two, yes.
Q. And after that the computer itself was then reset?
Q. Does the user manual explain also that if the date is changed then the audit trail is also necessarily changed?
A. I don’t know. I think the computer manual is so lengthy, computer manuals are generally not anything that anybody particularly likes to read, particularly if one is not overly computer literate. And it may well be that even a regular user of this system would not be aware of all the facilities of the software and all that was contained in the manual.
Q. That with respect does not answer my question. It is more a comment really, isn’t it?
A. It is.
Q. What I am seeking to explore with you is whether or not, whilst the facility may be explained within the manual, is the consequence also likely to be explained within the manual so far as the audit trail is concerned?
A. I would doubt it is because that is not what it is intended to be used for.
MR. WRIGHT: I have no further questions.
MR. JUSTICE FORBES: Thank you very much Detective Sergeant Ashley, you are free to go.
MR. WRIGHT: My Lord, before return to t, oxicology is that a convenient moment?
MR. JUSTICE FORBES: Yes.
MR. WRIGHT: At that stage we can remove the screen and remove the various pieces of equipment.
MR. JUSTICE FORBES: That sounds like a very good idea.
MR. WRIGHT: And resume transmission, as it were.
MR. JUSTICE FORBES: Members of the jury, if you would like to go with your usher for ten minutes we will dismantle all this technology.
ROBIN ADRIAN BRAITHWAITE, sworn
Examined by MR. WRIGHT
Q. What is your full name please?
A. Robin Adrian Braithwaite.
Q. And what is your occupation?
A. I am a Consultant in Toxicology and Head of the Regional Laboratory for Toxicology which is based at City Hospital in Birmingham.
Q. Are you a Consultant Clinical Scientist in Toxicologist?
Q. And Director of the Regional Laboratory for Toxicology and Super Regional Assay Service?
A. Yes I am.
Q. Honorary Senior Clinical Lecturer in the Division of Medical Sciences at the University of Birmingham?
Q. Senior Research Fellow at the Institute of Occupational and Environmental Health?
A. Yes I am.
Q. Were you also trained in analytical, clinical and forensic toxicology at Guy’s Hospital, London?
Q. Do you have over 25 years’ experience in this field?
A. Yes I do.
Q. And have you held a variety of appointments involving medical toxicology, clinical pharmacology, clinical research both here and abroad?
A. Yes I have.
Q. And is an area of particular interest analytical and forensic toxicology and drug and substance abuse?
A. Yes it is.
Q. Have you also published a large number of papers concerning various aspects of human pharmacology and toxicology?
A. Yes I have.
Q. Is that something in the region of 160 such papers?
A. Yes I have.
Q. Senior adviser to the World Health Organisation?
A. Yes I am.
Q. Amongst other particular positions that you hold?
A. Yes that’s correct, yes.
Q. I want to ask you please firstly, and this is page 1187 GH, 1 is the starting point, my Lord.
MR. JUSTICE FORBES: I have it thank you.
MR. WRIGHT: I want to ask you please firstly general matters concerning the metabolism of diamorphine and morphine. This is little 4 within that section. GH(iv).
MR. JUSTICE FORBES: Thank you.
MR. WRIGHT: We heard described by Professor McQuay the arterial road map of the body?
Q. The motorway of the body?
Q. And using that as the description of the blood the system together with the approaches to the brain being the big city?
Q. Is that a particular analogy that you would accept?
A. Yes, I think it is attractive analogy to use.
Q. Diamorphine may enter the blood circulation by a variety of routes, may it not?
A. Yes, that’s correct, either by intravenous injection into a vein or injection into a muscle or by mouth, a variety of routes.
Q. Once it has entered into the body thereafter is diamorphine then rapidly converted?
A. Yes it is. It is rapidly converted to another product which has a long name of 6 monoacetyl morphine, or 6 MAM for short, which is then further converted relatively rapidly to morphine.
Q. That was the halfway stage that Professor McQuay spoke of?
A. That’s correct.
Q. And the time over which such a metabolism or conversion takes place?
A. Yes. Diamorphine will convert to 6 monoacetyl morphine within minutes and this intermediate product is relatively unstable and further converts to morphine in a period of maybe half an hour to an hour.
Q. Now we have heard reference to in this case on a number of occasions both what is called free and total morphine. I don’t propose to spend a great deal of time dealing with the distinction but could you just explain to us please what happens to morphine within the body as to how it is metabolised or conjugated?
A. Right. Morphine continues to be metabolised in the body so morphine is converted to what is called glucuronide metabolite and this largely takes place in the liver and—
Q. Just pause for a moment. Glucuronide metabolite?
Q. In other words that is morphine and its metabolites?
A. Yes, well the glucuronide is the metabolite so morphine is converted to another product which we know as morphine glucuronide. There are two different, slightly different forms of this but this is the next product which we call glucuronide metabolite. When we talk about total morphine generally this means morphine plus that morphine which is present as its glucuronide metabolite. So it is the total amount of drug that is present that is either as morphine or its metabolite.
Q. So would it be fair to put it in these terms, it is the total amount of morphine together with that part of the morphine that has been metabolised?
A. That’s correct, yes.
Q. What then please is free morphine?
A. Morphine, sorry, free morphine is the unmetabolised morphine so it is actually morphine itself. The molecule has not undergone that change so it is morphine which, as I say, is termed free morphine. It is the unmetabolised part of morphine before it is converted into this glucuronide metabolite.
Q. So putting it another way, squaring the circle, free plus metabolite?
A. Equals total.
Q. Equals total?
Q. You heard the evidence of Professor McQuay so far as the administration and the effect of various quantities of diamorphine and morphine administered either intramuscularly or intravenously?
A. Yes I did.
Q. Do you seek to dissent in any way from that?
A. No, I would fully support what he said.
Q. May I turn please to codeine, because we have had reference to codeine in this case. What is codeine?
A. Codeine is the sort of 3-methyl derivative of morphine so it is a chemical derivative of morphine that is commonly used in many over the counter preparations combined with paracetamol or aspirin. It is a well known over the counter pain-killer.
Q. But is combined with other chemical substances?
A. Very often. I mean, it can be used on its own but it is most commonly in medicines which are bought over the counter in a pharmacy. It is often combined with either paracetamol or codeine or it may be in other medicines where it is combined with other products.
Q. Is codeine known to convert to morphine in the body?
A. Yes, it is well known that codeine or part of the codeine will be metabolised in the body to produce morphine.
Q. But does it metabolise entirely into morphine?
A. No, it will go through other routes to produce other products, so part of its route is to produce morphine.
Q. And so as part of it produces morphine would you expect to find if codeine were administered and part converts into morphine, the presence of other substances?
Q. Within the tissue?
A. One would expect to find codeine and a smaller quantity of morphine.
Q. Pholcodine please?
A. Is a morphine like drug, sorry, it is a derivative of morphine that is used in cough medicines, so it is a chemical derivative of morphine that is widely used in a lot of over the counter preparations, particularly for treatment of coughs.
Q. When you say derivative, is it thought to convert to morphine in the body?
A. No, there is no good evidence to show that it is converted. It seems to be remarkably resistant to conversion to morphine in the body.
Q. So is the high water mark that it may convert?
A. It may convert.
Q. Is there any evidence of that?
A. There is no real evidence that it does actually convert to any significant degree.
Q. Dealing with conversion to any significant degree, what would you expect to find if there had been some conversion of pholcodine to morphine?
A. One would expect maybe to find a small trace quantity of morphine but a much larger quantity of the parent drug pholcodine also present.
Q. And why is that?
A. Because very little, from what we know of pholcodine, virtually none of it is converted to morphine. One would expect because it is really metabolised so little in the body that you would largely find unchanged drug pholcodine there in samples of tissue and other tissues and fluids.
Q. I am going to turn to page 1187 F X my Lord.
JUSTICE FORBES: It occurs to me, Mr. Wright, that the members of the jury may have a little difficulty from time to time understanding the names of the various drugs to which reference is made. I merely cast out the thought. Is that so, members of the jury, or are you following the names of these drugs? Very well, I was going to suggest perhaps just a list of the names.
MR. WRIGHT: We could provide a glossary of those terms.
MR. JUSTICE FORBES: Would that help?
MISS DAVIES: Certainly, my Lord.
MR. JUSTICE FORBES: Members of the jury, we will take steps to provide you with a glossary of the names of the drugs. Yes, Mr. Wright.
MR. WRIGHT: Did you receive a bundle of documents in July of this year concerning the forensic investigations carried out by Julie Evans?
A. Yes I did.
Q. And also by Dr. Rutherford?
A. Yes I did.
Q. And also various reports prepared by Dr. Grenville?
A. Yes I did.
Q. We also are aware of documentation concerning a Dr. Karch, the gentleman seated in the middle of the middle row here, from the United States, and also from Julie Evans?
A. Yes I did.
Q. And as a consequence of considering those particular documents did you then review these findings?
A. Yes I did.
Q. And did you prepare a report to that effect?
A. Yes I did.
Q. And from that report was a statement prepared?
A. Yes it was.
Q. And would you wish to refer to that statement whilst giving your evidence?
A. I can do, yes.
MR. JUSTICE FORBES: There is no objection so yes, Dr. Braithwaite, you may refer to it.
A. Thank you.
MR. WRIGHT: We are at page FY. It may assist if you turn, as it were, towards the ladies and gentlemen of the jury, Dr. Braithwaite, and use that part of witness box. Do you have it?
A. Yes. I will just find it.
Q. That should have been done for you by me. I am sorry about that. You have consider the conclusions drawn by Julie Evans and also Dr. Rutherford concerning the cause of death in each of those 9 cases?
Q. And do you dissent at all from the considered opinion of those two individuals?
A. No, I would support what they have said.
Q. Does there appear to be any other rational or feasible explanation?
A. Not that I know of.
Q. On the material that you have considered does there appear to be any other rational or feasible explanation?
A. No, I am not aware of any.
Q. You have been seated in court whilst Julie Evans gave her evidence?
Q. Matters were raised by way of cross-examination?
A. No, I would still agree with what I have written in the report and what other experts have said.
MR. JUSTICE FORBES: Can I just be sure, rational or feasible explanation for what, Mr. Wright?
MR. WRIGHT: For the death of the 9 individuals in this case?
A. Yes they, that they probably took or were administered a substantial dose of morphine or diamorphine shortly before death, which is what I wrote.
MR. JUSTICE FORBES: Thank you.
MR. WRIGHT: So far as dosage may be concerned, would it be fair to say this, it is not possible to seek to extrapolate any precise form of measurement from the figures that have been obtained and considered?
A. Yes, it is unwise to do that.
Q. But is there any general conclusion that you are able to give so far as dose is concerned from the figures that you have been made aware of?
A. From the postmortem tissue measurements one would surmise that a substantial dose of morphine or diamorphine had been given or had been taken by the deceased.
Q. And insofar as the range, the bracket that we are aware of the Phelby paper?
Q. Of deaths from morphine poisoning?
Q. Are you satisfied that these particular deaths fall within that bracket?
A. Yes, they fall within that range reported in that particular paper.
Q. And so in considering the nature and terms of the dose, what is your opinion so far as that is concerned?
A. Again a large dose, potentially fatal dose of morphine or diamorphine.
Q. Have you considered the method by which the samples were extracted by Julie Evans?
A. Yes. I have seen copy of her report and the methods which she has used and they are acceptable.
Q. And insofar as the, paragraph 7 my Lord.
MR. JUSTICE FORBES: Yes.
MR. WRIGHT: So far as the use of the thigh tissue is concerned, what is your considered opinion as to the use of that particular tissue above any other?
A. I think one would regard it as a recommended specimen to take in many cases and that it has many advantages over other specimen types such as liver or even blood.
Q. Does the fact of the taking of simply thigh tissue, albeit from two separate areas, two separate sites?
Q. In any way cause you to express any concern as to the reliability of the findings?
A. Well, I think samples were taken from separate sites and showed remarkably good agreement, so one draws the conclusion that what was measured was measured reproducibly and an accurate estimate of the amount of drug in that sample.
Q. Paragraph 11 of the report.
MR. JUSTICE FORBES: Thank you.
MR. WRIGHT: Postmortem redistribution. Is this a concept with which you are familiar?
A. Yes indeed.
Q. Is also a concept of the problems that are attached to it, also matters with which you are familiar?
Q. Is there in any way any restriction or confinement to the problems of postmortem redistribution that you are aware of?
A. In what respect?
Q. Do they apply equally on blood as they may do to thigh tissue across the gamut of specimens that may be obtained from the deceased?
A. They are a far greater problem with specimens of blood and this is widely discussed in the scientific and forensic literature about those problems. Problems can occur with other tissues but probably muscle tissue, to some extent the postmortem redistribution changes one has mentioned, are probably minimised or least effected in the case of muscle tissue in comparison certainly with blood specimens.
Q. How does the absence of any good in-house data or research on muscle with which to compare these case findings affect your conclusions?
A. It does not affect them substantially. I think one would, it is very difficult to do such studies. Perhaps in a perfect world one might have the opportunity to do those sorts of studies but it does not affect the conclusions which I draw in terms of the significance of those values.
Q. So far as those values are concerned, acknowledging the limitations that may apply to them or attach to them, how do you view the calculations themselves and the figures obtained in relation to thigh muscle?
A. In what respect? The value, the magnitude of the values?
A. They are substantial, they are significant toxicologically and one would associate them with, as has been done in the Phelby set of data and other data sets, that they are consistent with the administration of a substantial dose of morphine or diamorphine and not inconsistent with death.
Q. We heard some evidence of the stomach content of Mrs. Turner?
Q. And a therapeutic dose of morphine?
Q. 2 milligrams. How do these compare at all with a normal therapeutic dose of morphine?
A. Probably on the low side. I mean 2 milligrams perhaps as compared with a therapeutic dose of morphine maybe of 5 milligrams to 10 milligrams.
Q. How do the figures by way of thigh tissue in relation to the deceased compare?
A. That the values from the thigh measurements would indicate a substantially greater dose than that.
Q. You considered the evidence of dehydration?
A. Yes, yes.
Q. In the various organs with which we have been concerned?
Q. And you have listened and considered the matters raised this morning?
Q. Do they cause you any concern?
A. No, I don’t think they are a substantial factor.
Q. Stability of morphine in postmortem material, that too is something that has been reviewed?
Q. In the evidence thus far?
Q. And was that also reviewed by you?
A. Yes. There is perhaps limitations on the amount of data available for thigh tissue. There is data available on blood and other materials, and broadly it appears to be relatively stable in postmortem material.
Q. So far as total morphine is concerned is there any observation you would wish to make on that particular topic?
A. As regards total morphine it would seem to be quite stable.
MR. WRIGHT: Thank you. Would you wait there.
Cross-examined by MISS DAVIES
Q. Dr. Braithwaite, your experience, and if I may say so looking at your statement your considerable experience, is in the field of toxicology?
A. It is, yes.
Q. And you have held a number of positions in that field at specialist centres?
Q. In the course of this case it is clear from your statement that you were asked to look at the reports of Dr. Rutherford, the pathologist?
Q. And you appear to have been asked to consider those reports. Would you hold yourself out as an expert in the field of pathologist?
A. Not forensic pathologist, no. I was aware of the reports and tried to take from them the major conclusions.
Q. Yes, and that is in effect what you were doing?
Q. Please don’t think for one moment I am seeking to minimise your expertise in your specialist field, but you were relying on the conclusions of another specialist in another field?
Q. And for reasons I am sure everybody in this court will understand you did not seek to challenge those conclusions, his experience being wholly different to your own?
Q. As no doubt he would defer to your conclusions in the field of toxicology?
Q. So far as Dr. Rutherford is concerned you relied on his conclusions in coming to the views you have expressed to the Court today?
Q. Can I please turn not at great length to your own field, that of toxicology. The greatest, I beg your pardon, one of the major difficulties of dealing with levels in muscle tissue is that there is no good scientific data to assist the interpretation of such levels?
A. I think it is very limited, it is limited should I say.
Q. By all means, limited. It is ground I went over this morning, I am not going to go through it at length now. The fact is that there are no controlled scientific studies, the best literature that can be produced is anecdotal?
A. Not necessarily anecdotal. I think in all of toxicology, particularly forensic toxicology, it is almost impossible to do controlled studies by the very nature of the subject.
A. One perhaps can only do control studies in animal studies.
Q. And therefore insofar as there is any attempt to interpret the findings in this case with anything in published literature, I think you have used on one occasion the word “consistent,” on another in your statement you have used the phrase “broadly comparable?”
Q. That really is as far as one can go?
Q. The other difficulty is this, that by reason of the period between death and exhumation in all of these cases, and by reason of the processes which would have continued in each of the 9 bodies, although there is a level that has been subsequently analysed by Mrs. Evans, one cannot say that level accurately reflects the level of the drug at the date of death?
A. No. I wouldn’t wish to state that it is inaccurate. It is an index of.
Q. It is an index of. And can I please deal just with one other separate point. You have raised the issue of dehydration, namely the loss of water content. You have heard me no doubt deal at some length this morning with the issue of concentration of the mass?
Q. Would you accept the proposition that during any process of decomposition there is a concentration of mass which is due not simply just to loss of water but, for example, to the low volatile compounds and other factors?
A. There may be loss of some volatile compounds but the actual concentration of the drug is perhaps not changed. If the water contents is broadly the same, one is still measuring the amount of drug in one gram of material. It is still one gram of material that one is taking.
Q. But the real difficulty is one does not know at the date of sampling what that one gram of material represented at the date of death?
A. There is some, there is likely to be change due to putrefaction within that tissue and, as you say, it may not be exactly the same gram of material, but it is again a representative amount of material—
Q. It is a, I do beg your pardon?
A. …that one is comparing with.
Q. It is a representative sample but as a matter of fact the person carrying out that analysis does not know if that sample represents the same weight as at the date of death?
A. I think the biggest problem is the loss of water and dehydration rather than loss of other materials.
Q. There is the loss of other materials as well isn’t there?
A. I think that is not quite so well documented as loss of water which would be the major factor that one would perhaps be concerned with.
Q. Can I please deal with something that arose this morning which you touched on briefly in your evidence, namely the finding of morphine in the stomach of one of the ladies, Mrs. Melia, where something in the order of 2 milligrams was found?
Q. Two propositions were put forward. One is it was the result of enterohepatic recirculation?
Q. Could you explain that please?
A. This is where a drug and metabolites is excreted in the bile from the liver and enters the small intestine. Then it can be converted by microorganisms in the gut, so in the case of the morphine metabolites that might release some free morphine which then can be reabsorbed back into the body. So it is a sort of recirculation, recycling process.
Q. Are you able to say over what period of time such a process would take?
A. Maybe over some hours.
Q. And that is what we are talking about, a period of some hours?
Q. And it would be a period of some hours in a living person?
A. Yes, yes.
Q. So that in order for the two milligrams of morphine to be subsequently found in the stomach of Mrs. Melia, for that process of recirculation to have taken place there would have had to have been a period of some hours in life during which that morphine could have been recirculated for it to result in being in the stomach?
A. It would also depend on the validity of that stomach sample and whether it is contaminated in some way or, you know, within the body.
Q. But if one explanation, and in fairness to Mrs. Evans she allowed for two, if one interpretation is the presence of the morphine in the stomach is enterohepatic recirculation, that has to take account of morphine in the body in life for some hours?
A. I wouldn’t want to put a very precise time scale on it. I am saying it is some hours.
Q. Indeed. The point I was seeking to make is we are dealing with hours as opposed to minutes?
Q. Dr. Braithwaite, as you were giving your evidence I was handed a tone which is entitled, The Disposition of Toxic Drugs and Chemicals in Man. It may be a tone well known to yourself and it is to do with the point on pholcodine and the breaking down into morphine?
Q. I have not had an opportunity to give you a copy of it, not at least because the evidence you have given is not in your report. I wonder in those circumstances it is probably much easier if I hand the book to you for one simple passage in it. I apologise to yourself and the members of the jury, it wouldn’t be the way I would normally do it?
A. Thank you very much.
Q. If I can hand this out on a limited basis. It is a short point. Is the book known to you?
A. Oh, yes indeed. It is probably the very latest edition. I haven’t actually seen it yet.
Q. And if we turn to page 705 of it we find the part that deals with pholcodine, yes?
A. Yes indeed.
Q. It deals with the occurrence and usage, blood concentrations and page 706 at the beginning of the second paragraph deals with metabolism and excretion and there are various diagrams which replicate diagrams you have produced for the Court?
Q. It would seem, would it not, that that certainly contemplates the breaking down or conjugation of pholcodine into morphine?
A. Yes, it does, it shows the structure of morphine down at the bottom left-hand side, yes.
Q. And the book to which I have referred you, it is very much one of the recognised books in the particular field of toxicology?
A. Yes. I mean, it is very much a review book and so the author takes, reviews work from all sorts of sources, so the original work might have been done by the somebody else, not the editor of the book himself. So I am not sure without reading it in more detail who he is citing there as the author of this metabolic plan.
Q. Dr. Braithwaite, I have literally shown it to you. If you want any more time to look at it—
A. No, no, it is fine.
MISS DAVIES: That being the case I have no further questions thank you.
Re-examined by MR. WRIGHT
Q. Does it necessarily mean when dealing with the stomach contents, this was Mrs. Melia?
Q. And the two milligrams of morphine found within the liquid within the stomach, does it necessarily mean that the patient was alive for that period of time, a couple of hours?
A. No, I wouldn’t want one to be categorical about that. I think it is very difficult to be precise.
Q. And this is considering the concept enterohepatic recirculation?
Q. Is that the only route by which the morphine may actually have been eventually distributed into the stomach?
A. No, it might have diffused from the blood.
A. And been trapped in that sort of fluid in the stomach.
Q. So it may have diffused from the blood. Would that involve also the problems or the problem area of postmortem redistribution?
A. It is part and parcel of that problem.
Q. So the quantity found within the stomach could be quantitatively identified through a process postmortem as opposed to premortem?
Q. In other words it could have occurred after death rather than before it?
A. Either, yes.
Q. Could it also be in the stomach from contact with the liver?
A. Yes. Again part of postmortem diffusion.
Q. So we have leakage from blood vessels, postmortem redistribution from the liver?
Q. As well as enterohepatic recirculation?
A. All those potentially.
Q. All of the above really?
Q. So is it possible say precisely how this morphine within the stomach may actually have arisen?
A. In honesty no.
Q. In terms of quantity is it of significance?
A. It is a small quantity.
Q. You were asked a few points on the factor of dehydration. Does that particular factor and the matters that have been raised cause you to review in any way your stated considered opinion?
A. Not at all.
Q. As to the cause of death in each of those cases?
MR. WRIGHT: I have no further questions.
MR. JUSTICE FORBES: Thank you, Dr. Braithwaite. You are free to go. Thank you very much.
MR. WRIGHT: I can’t now remember just precisely how many breaks we have had this afternoon. It has been one of those days I am afraid. The next witness I propose it call is Dr. Karch. It is a little different by topic although still essentially toxicological, but there are also clinical findings to be dealt with. Might we have a few moments just to stretch our legs?
MR. JUSTICE FORBES: Of course you may. Members of the jury, we will break off for a short while whilst Mr. Wright regroups and then resume again as soon as he is ready. I imagine 5 minutes.
MR. WRIGHT: No more than that.
In the absence of the jury
MR. JUSTICE FORBES: Yes I gather you want….
MISS DAVIES: Thank you for giving me time to address you. Tomorrow the prosecution propose to recall Dr. Rutherford for cross-examination.
MR. JUSTICE FORBES: Yes.
MISS DAVIES: As, my Lord, you know my learned friend Mr. Winter and I have effectively split the cases factually between us. I am conscious this is a somewhat unusual course but insofar as individual cases are concerning cross-examination of Dr. Rutherford, would you permit us to each deal with our individual cases each so that I would, for example, deal with those cases where I have cross-examined.
MR. JUSTICE FORBES: Of course.
MISS DAVIES: Thank you very much indeed.
MR. JUSTICE FORBES: Whatever is the way which most assists you in the conduct of the defence entirely meets with my approval.
MISS DAVIES: Thank you very much. Can I also say this, I would also be seeking your leave to do exactly the same thing with Dr. Grenville.
MR. JUSTICE FORBES: You need not ask me again.
MR. WRIGHT: May I raise one matter in the absence of the jury, that in the examination-in-chief of Dr. Braithwaite I elicited, in fact it had not sunk in with me at the time I elicited it, I had a discussion with my learned friend Miss Davies about it, I elicited a response from Dr. Braithwaite as to the administration of a substantial dose of morphine.
MR. JUSTICE FORBES: Yes.
MR. WRIGHT: Which he then went on to remark was shortly before death.
MR. JUSTICE FORBES: Did he?
MR. WRIGHT: Well, there we are. It is not our case that that is asserted by the Crown. It is a matter that there was discussion on and we have considered the reports of experts that have been served upon us. We have been steadfast in our approach to the calculations in this case and the use merely of total morphine as opposed to any ratio between free and total, and we do not in any way seek to elicit evidence as to rapidity of death. That remark, of course, is entirely on the point of rapidity of death. It is not the way the Crown put their case. It was elicited by way of a question to which the response itself was not anticipated would incorporate that particular phrase and I thought I had better raise it at this stage so that in due course your Lordship in summing up the case, when you will remind them of the evidence of Dr. Braithwaite, that particular factor is not a factor in this case the Crown seek to rely upon.
MR. JUSTICE FORBES: Thank you for drawing it to my attention so that I should not repeat the error in the course of the summing up. Do you require me to take any other action?
MR. WRIGHT: No. We thought it preferable to deal with it in open court because the press also have interest in the evidence as it has been elicited in this case. But may I say, for the avoidance of any doubt, that that particular feature is not a feature of this case that the Crown in any way seek to rely upon. There is clear authority upon the point from the experts that rapidity is a most unreliable topic and is not one upon which there ought to be any faith at all.
MR. JUSTICE FORBES: By rapidity you mean the speed with which or the duration of the time interval between the administration of the substantial dose of diamorphine by whatever means and ensuing death?
MR. WRIGHT: Yes, by any calculation from the figures so far as the total morphine within the thigh is concerned one cannot – we have the evidence of Professor McQuay as to the effects of the administration of morphine, that is the Crown’s case, and as to the on-set of any stupor, any sleep, any sleepiness on the part of the patient and thereafter death, but what we cannot do is seek to extrapolate from the figures that in any particular case there was from the figures alone such a rapid death.
MR. JUSTICE FORBES: Yes, I understand. Thank you for drawing it to my attention. I shall take appropriate steps to ensure I make no reference to it myself. Are you content that the matter should be left on that basis?
MISS DAVIES: My Lord, yes.
MR. JUSTICE FORBES: Very well. Thank you very much.
MR. JUSTICE FORBES: Let the jury come back.
MR. WRIGHT: Would your Lordship permit one other matter? Would your Lordship consider going one stage further and directing there be no reporting of that particular facet of the evidence of Dr. Braithwaite.
MR. JUSTICE FORBES: Pursuant to what power, exhortation to the press?
MR. WRIGHT: It would have to be exhortation to the press because I don’t consider that section 4 of the Contempt of Court Act would cover the situation.
MR. JUSTICE FORBES: I am sure the press have heard what you have said. They know what I am going to do or rather what I am not going to do in the course of my summing up with regard to this particular part of Dr. Braithwaite’s answer to a question and I am sure that they will be very co-operative and make no reference to it in any report of today’s proc, eedings which they intend to publish. And I would simply ask all representatives of the press to oblige me and oblige the process of the proper conduct of this trial by co-operating in that regard.
MR. WRIGHT: Thank you.
Members of the jury returned
STEVEN BERNARD KARCH, sworn
Examined by MR. WRIGHT
Q. My Lord, this witness’s evidence is to be found at page 1187 GI which is volume 2 of 2 of the expert evidence.
MR. JUSTICE FORBES: Thank you.
MR. WRIGHT: What is your full name please?
A. Stephen Bernard Karch.
Q. Dr. Karch, what are your qualifications please?
A. I have an MD from Tulane University.
Q. And are you then a Doctor of Medicine?
A. I am a Doctor of Medicine, yes.
Q. In the United States?
A. In the United States.
Q. Do you have other further qualifications?
A. I received my Bachelors degree in Philosophy from Brown University in Providence, Rhode Island. I did graduate work in cell biology at Stamford University. I was a fellow in neuropathology at the London hospital in London. I was a resident in Neurology at Stanford University. I did an internship in general medicine at Kaiser Foundation in Oakland, California and worked for 7 years in the cardiac pathology Laboratory at Stanford University doing resuscitation research and research on the effects of drugs on the heart.
Q. Are you also the author of a considerable number of publications?
Q. Including publications on drug abuse?
A. Primarily on drug abuse.
Q. Are you also involved in funded investigations, including the position of investigator in the World Health Organisation in a collaborative project for sudden cardiac death?
A. Yes. I just came here from the organisational meeting. We will be starting an international project to see if we can determine risk factors from analysis of hearts of individuals who died suddenly.
Q. And do your publications also include the pathology of drug abuse?
Q. Have you prepared a report in this particular case concerning the deaths of the 9 deceased exhumed in relation to this enquiry?
Q. And have you also considered the post mortem reports of Dr. Rutherford?
Q. The laboratory reports of Mrs. Evans?
Q. Also the report of Dr. Braithwaite?
Q. And of Dr. Grenville?
Q. And have you also considered the report of a consultant toxicologist from whom we will hear in due course Dr. Sachs?
A. Yes I have.
Q. Dr. Hans Sachs?
Q. Have you also considered a number of reports from other experts in the field concerned with this particular enquiry?
A. Yes. I received a packet of reports from experts for the defence.
Q. Have you examined any of the microscopic sections of any of the specimens from the deceased?
A. No, I have not had that opportunity.
Q. But have you considered the records of those particular histological findings?
A. Yes. My conclusions are based on Dr. Rutherford’s interpretations of the slides.
Q. I want to ask you this please, the very bottom of page GJ my Lord. In your opinion are the anatomic findings elicited by Dr. Rutherford, taken together with the findings of Julie Evans and of Professor Sachs, in your opinion sufficient to explain the deaths of the 9 deceased in question?
A. Yes, I believe they are.
Q. Have you also considered various matters drawn to your attention by way of the reports submitted to you from the defence?
A. Yes I have.
Q. Have you taken into account any abnormality as identified at postmortem examination in the hearts of any of the deceased?
A. Indeed yes.
Q. And considered whether they were sufficient to cause sudden cardiac death at any time?
MR. JUSTICE FORBES: Dr. Karch, would you be assisted by referring to your report whilst giving evidence?
A. Yes sir, my Lord.
MR. JUSTICE FORBES: Have you any objection?
MISS DAVIES: No.
MR. JUSTICE FORBES: Very well, you may.
MR. WRIGHT: May I ask then please a general point so far as any abnormality of the heart is concerned. What in your opinion please is the effect of the administration of morphine to an individual suffering such a defect?
A. Well, there are a number of different effects exerted by morphine and it would be very difficult at this stage to say which effect exerted, which property of the morphine exerted the greatest effect, but morphine does two things that would exacerbate the sort of heart disease that we see in several of these individuals. The first thing that happens is that, and some of you may have had experience with seeing drug addicts, seeing train spotting, that drug addicts, particularly heroin addicts, often have scratches and it is not because of bad hygiene but it is because when you inject heroin that releases histamine and histamine causes the skin to itch and addicts are often itchy and have scratches. One of the other things that happens when the histamine is released is that it can affect the heart beats and it can also dilate blood vessels. People who have a histamine reaction get red faced and that reflects dilation of blood vessels throughout the body. If the blood vessels in the body dilate, less blood goes back to the heart and if there is less blood going back to the heart that means that less blood is available to go through the partial obstructions that were present in a number of these patients.
Q. So please how would be administration of a significant dose of morphine, diamorphine, affect an individual with any, with a heart condition?
A. Even without a heart condition we know from studies, controlled studies in humans at surgery, that their blood pressure would likely go down, histamine levels would go up, blood pressure would go down. If blood pressure goes down then the heart is not profused. Not enough blood going to the heart muscle means the heart muscle becomes irritable and may fail either electrically, in other words have an arrythmia, cardiac arrest, or may fail pump wise, in other words not pump adequately or both.
Q. You see the lady with her eyes closed here trying to keep pace with what you are saying. If you could show down a little. I am the one that gets the look that tells me that you are going too fast. Any other effect so far as the administration of morphine, diamorphine is concerned? We have dealt with the effect on the heart or on the blood vessels please, any other area, any other topic?
A. Well, there is a very big one and that is that morphine given to individuals who are not tolerant will stop them from breathing and cause respiratory arrest and subsequently death. In this particular case we are very fortunate because we have hair to look at and hair is an indicator, as we have only known for the last year, of the degree of drug use. And in the cases of the individuals here analysis of their hair shows very low levels based on Dr. Sachs’s analysis, shows very low levels of heroin. In fact the levels are comparable to the levels that are seen in people that die of heroin overdose and this is information that only was published last year in Lancet.
Q. If I can just stop you for a moment, Dr. Sachs will be called in due course to give evidence of the hair findings, but insofar as your own opinion is concerned have you taken into account the hair findings of Dr. Sachs?
A. The hair.
Q. Professor Sachs?
A. Professor, the findings of Professor Sachs in my mind are extremely important because they establish drug naïvety.
Q. In whose cases?
A. Well, one case had a level of 11 nanograms.
Q. I am not going to ask you about precise figures of each of them but so far as each of these deceased are concerned have you considered the question as to whether these individuals may or may not have been morphine naïve?
A. Yes, and I think in every single case they were. One of the individuals had somewhat more morphine in the hair than all the others but compared to known heroin addicts the levels were generally very very low.
Q. Is there an explanation for that, an innocent explanation for it?
A. No, there is no innocent explanation, except they had not taken morphine in the past.
Q. They had not taken morphine in the past?
Q. Final general topic before turning to rather more specific findings. Any diagnosis of a stroke in the deaths here, for example in the case of Mrs. Quinn and Mrs. Grimshaw as entered on the death certificate? Can you help us please as to what the effect may be of the administration of a significant dose of morphine upon—
A. There are two kinds of strokes that people can have, one is a haemorrhagic stroke where there is bleeding into the brain and that is almost always associated with the either malformation you are born with or high blood pressure. Morphine would not raise the blood pressure so would not be associated with a haemorrhagic stroke. It seems extremely unlikely that could ever be the case. On the other hand, someone who is elderly and has atherosclerosis, furring up if you will, of the blood vessels in the brain, who has a large dose of morphine but sufficient to drop their blood pressure, might well sustain a stroke.
Q. So I would just like to ask about cause and effect really. Is the administration of morphine then necessarily connected if there were a stroke to such a stroke?
A. It might be connected to an infarction, a non-haemorrhagic stroke, but not to haemorrhagic stroke.
Q. Hydration within the organs, dehydration within the organs. You have considered evidence that has been elicited on that particular topic?
Q. Do you seek in any way to disagree with the expressed opinion of Julie Evans and Dr. Braithwaite?
Q. Do you consider that the total morphine concentration measured in each of these cases would be significantly altered by the degree of dehydration?
A. The total amount measured would be affected by the degree of hydration.
Q. To what extent?
A. Well, if dehydration were present the levels would go up but there is no evidence of dehydration, or only negligible changes.
Q. So far as the morphine levels found in the hair samples of the deceased, of which we can ask Professor Sachs in due course, do you find those levels at all an unexpected finding?
A. No. This is not a very well studied field, or as well studied as we would like it to be, but we do know that drugs end up in hair via several different routes. One way is through the little follicle that attaches the hair to your scalp but another way is from sebum and sweat secreted from your scalp. And the low levels seen here could be consistent with sweat and sebum containing drug because morphine appears very rapidly in the sweat and could have accumulated between the time the drug was given and the time the patient died. The other possibility that also exists, particularly in the one patient who has a slightly higher level—
MISS DAVIES: My Lord, I have great unease about this evidence because the primary evidence is not before the Court.
MR. JUSTICE FORBES: Sorry, I didn’t quite hear.
MISS DAVIES: I have an unease about this witness commenting on evidence when the primary evidence is not before the Court and has not yet been subject to any scrutiny.
MR. JUSTICE FORBES: How do we deal with that? There is a point there but on the other hand…
MR. WRIGHT: There is, but there ought to be, in my respectful submission, no bar to this witness giving evidence, considered as expert evidence, having regard to the reports that he has read in the case and the matters that are to be elicited by way of evidence. The mere fact that Professor Sachs has not given evidence in advance of this witness does not make his evidence on the topic inadmissible. But may I put it a different way, I don’t propose to explore it at any—
MR. JUSTICE FORBES: You are perfectly correct and in the ordinary way if I were sitting as a judge alone I would hear the evidence de bene esse and look at it again in the light of the way in which the later evidence develops, but I can’t have that luxury at the moment, so is there a way you can deal with this without asking Dr. Karch to develop his evidence too extensively on the basis of what he has read in a report of a witness who has not yet given evidence?
MR. WRIGHT: Yes.
MR. JUSTICE FORBES: If this causes any difficulty I will be sympathetic to you recalling Dr. Karch after Professor Sachs has given his evidence to give further evidence about it.
MR. WRIGHT: Thank you. There may be logistical difficulties in this regard, I think he is next headed to Sydney amongst other places, but I think it can be resolved by discussion between us as opposed to by ruling or by at this stage taking the matter any further.
MR. JUSTICE FORBES: Would you like opportunity to consider it overnight?
MR. WRIGHT: Please?
MR. JUSTICE FORBES: Does that meet with your approval, Miss Davies?
MISS DAVIES: My Lord, yes.
MR. JUSTICE FORBES: Members of the jury we will break off now and resume again at 10.30 tomorrow morning. Can I just check with you that you find the morning and afternoon, mid morning and mid afternoon breaks of assistance to you in concentrating on the evidence? I see you nodding. You don’t find it disruptive to your ability to follow the evidence in this case. Very well.
Members of the jury retired
MR. JUSTICE FORBES: Dr. Karch, I am sure I don’t have to tell you this but I must warn you that while you are still giving your evidence you must not discuss any aspect of this case with anybody at all without my permission do you understand?
MR. JUSTICE FORBES: Very well. 10.30 tomorrow morning.
|Birth name:||Harold Frederick Shipman|
|Born:||14 January 1946(1946-01-14)
Nottingham, Nottinghamshire, England
|Died:||13 January 2004 (aged 57)
HM Prison Wakefield, West Yorkshire, England
|Cause of death:||Suicide by hanging|
|Number of victims:||250+|
|Span of killings:||1975 – 1998|
|Country:||England, United Kingdom|
|Date apprehended:||7 September 1998|
Harold Frederick “Fred” Shipman (14 January 1946 – 13 January 2004) was a British convicted serial killer and former doctor. He is one of the most prolific known serial killers in history with 218 murders being positively ascribed to him, although the real number may be twice that.
On 31 January 2000, a jury found Shipman guilty of 15 murders. He was sentenced to life imprisonment and the judge recommended that he never be released. The whole life tariff was confirmed by the Home Secretary a little over two years later.
After his trial, the Shipman Inquiry, chaired by Dame Janet Smith, decided there was enough evidence to suggest Shipman had probably killed about 250 people, of whom 218 could be positively identified. About 80% of his victims were women. His youngest victim was Peter Lewis , a 41-year-old man. Much of Britain’s legal structure concerning health care and medicine was reviewed and modified as a direct and indirect result of Shipman’s crimes, especially after the findings of the Shipman Inquiry, which began on 1 September 2000 and lasted almost two years. Shipman is the only British doctor found guilty of murdering his patients.
Early life and career
Shipman was born in Nottingham, Nottinghamshire, the son of Vera and Harold Shipman, who was a council lorry driver. His working class parents were devout Methodists. Shipman was particularly close to his mother, who died during his teenage years. Shipman graduated from Leeds School of Medicine in 1970, and started work at Pontefract General Infirmary in Pontefract, West Riding of Yorkshire. In 1974, he took his first position as a general practitioner (GP) in Todmorden, West Yorkshire. In 1975 he was caught forging prescriptions of pethidine for his own use. He was fined £600, and briefly attended a drug rehabilitation clinic in York. After a brief spell as medical officer for Hatfield College, Durham, and temporary work for the National Coal Board, he became a GP at the Donneybrook Medical Centre in Hyde, Cheshire, in 1977.
Shipman continued working as a GP in Hyde throughout the 1980s and founded his own surgery on Market Street in 1993, becoming a respected member of the community. In 1983, he was interviewed on the Granada television documentary World in Action on how the mentally ill should be treated in the community.
In March 1998, Dr. Linda Reynolds of the Brooke Surgery in Hyde—prompted by Deborah Massey from Frank Massey and Son’s funeral parlour—expressed concerns to John Pollard, the coroner for the South Manchester District, about the high death rate among Shipman’s patients. In particular, she was concerned about the large number of cremation forms for elderly women that he had needed countersigned. She claimed Shipman was, either through negligence or intent, killing his patients.
The matter was brought to the attention of the police, who were unable to find sufficient evidence to bring charges; The Shipman Inquiry later blamed the police for assigning inexperienced officers to the case. Between 17 April 1998, when the police abandoned the investigation, and Shipman’s eventual arrest, he killed three more people. His last victim was Kathleen Grundy, a former Mayor of Hyde, who was found dead at her home on 24 June 1998. Shipman was the last person to see her alive, and later signed her death certificate, recording “old age” as cause of death.
Grundy’s daughter, lawyer Angela Woodruff, became concerned when solicitor Brian Burgess informed her that a will had been made, apparently by her mother (although there were doubts about its authenticity). The will excluded her and her children, but left £386,000 to Shipman. Burgess told Woodruff to report it, and went to the police, who began an investigation. Grundy’s body was exhumed, and when examined found to contain traces of diamorphine (heroin), often used for pain control in terminal cancer patients. Shipman was arrested on 7 September 1998, and was found to own a typewriter of the type used to make the forged will.
The police then investigated other deaths Shipman had certified, and created a list of 15 specimen cases to investigate. They discovered a pattern of his administering lethal overdoses of diamorphine, signing patients’ death certificates, and then forging medical records indicating they had been in poor health.
Prescription For Murder, a book by journalist Brian Masters, reports two theories on why Shipman forged the will. One is that he wanted to be caught because his life had got out of control, the other that he planned to retire at fifty-five and leave the country.
Trial and imprisonment
Shipman’s trial, presided over by Mr Justice Forbes, began on 5 October 1999. Shipman was charged with the murders of Marie West, Irene Turner, Lizzie Adams, Jean Lilley, Ivy Lomas, Muriel Grimshaw, Marie Quinn, Kathleen Wagstaff, Bianka Pomfret, Norah Nuttall, Pamela Hillier, Maureen Ward, Winifred Mellor, Joan Melia, and Kathleen Grundy, all of whom had died between 1995 and 1998.
On 31 January 2000, after six days of deliberation, the jury found Shipman guilty of killing 15 patients by lethal injections of diamorphine, and forging the will of Kathleen Grundy. The trial judge sentenced him to 15 consecutive life sentences and recommended that he never be released. Shipman also received four years for forging the will. Two years later, Home Secretary David Blunkett confirmed the judge’s recommendation that Shipman never be released, just months before British government ministers lost their power to set minimum terms for prisoners.
Shipman consistently denied his guilt, disputing the scientific evidence against him. He never made any statements about his actions. His defence tried, but failed, to have the count of murder of Mrs Grundy, where a clear motive was alleged, tried separately from the others, where no obvious motive was apparent.
Although many other cases could have been brought to court, the authorities concluded it would be hard to have a fair trial, in view of the enormous publicity surrounding the original trial. Also, given the sentences from the first trial, a further trial was unnecessary. The Shipman Inquiry concluded Shipman was probably responsible for about 250 deaths. The Shipman Inquiry also suggested that he liked to use drugs recreationally.
Despite the prosecutions of Dr John Bodkin Adams in 1957, Dr Leonard Arthur in 1981, and Dr Thomas Lodwig in 1990 (amongst others), Shipman is the only doctor in British legal history to be found guilty of killing patients. According to historian Pamela Cullen, Adams had also been a serial killer—potentially killing up to 165 of his patients between 1946 and 1956—but as he “was found not guilty, there was no impetus to examine the flaws in the system until the Shipman case. Had these issues been addressed earlier, it might have been more difficult for Shipman to commit his crimes.” H. G. Kinnell, writing in the British Medical Journal, also speculates that Adams “possibly provided the role model for Shipman”.
Shipman committed suicide by hanging in his cell at Wakefield Prison at 6:20 am on 13 January 2004, on the eve of his 58th birthday, and was pronounced dead at 8:10 am. A Prison Service statement indicated that Shipman had hanged himself from the window bars of his cell using bed sheets. Some British tabloids expressed joy at his suicide and encouraged other serial killers to follow his example; The Sun ran a celebratory front page headline, “Ship Ship hooray!”
Some of the victims’ families, however, said they felt cheated, as his suicide meant they would never have the satisfaction of Shipman’s confession, and answers as to why he committed his crimes. The then Home Secretary David Blunkett noted that celebration was tempting, saying: “You wake up and you receive a call telling you Shipman has topped himself and you think, is it too early to open a bottle? And then you discover that everybody’s very upset that he’s done it.”
Despite The Sun’s celebration of Shipman’s suicide, his death divided national newspapers, with the Daily Mirror branding him a “cold coward” and condemning the Prison Service for allowing his suicide to happen. The Independent, on the other hand, called for the inquiry into Shipman’s suicide to look more widely at the state of Britain’s prisons as well as the welfare of inmates.
Shipman’s motive for suicide was never established, although he had reportedly told his probation officer that he was considering suicide so that his widow could receive a National Health Service (NHS) pension and lump sum, even though he had been stripped of his own pension. His wife received a full NHS pension, which she would not have been entitled to if he had died after the age of 60. FBI “profiler” John Douglas asserted that serial killers are usually obsessed with manipulation and control, and killing themselves in police custody, or committing “suicide by cop“, can be a final act of control.
Shortly after Shipman’s death, Sir David Ramsbotham wrote an article in The Guardian newspaper, urging that whole life sentencing be replaced by indefinite sentencing. He said indefinite sentences would be better than whole life sentences because, while a prisoner might still never be released, they would always have the hope that they might.
In January 2001, Chris Gregg, a senior West Yorkshire detective was selected to lead an investigation into 22 of the West Yorkshire deaths. Following this a report into Shipman’s activities submitted in July 2002 concluded that he had killed at least 215 of his patients between 1975 and 1998, during which time he practiced in Todmorden, West Yorkshire (1974–1975) and Hyde, Greater Manchester (1977–1998). Dame Janet Smith, the judge who submitted the report, admitted that many more suspicious deaths could not be definitively ascribed to him. Most of his victims were elderly women in good health.
In her sixth and final report, issued on 24 January 2005, Smith reported that she believed that Shipman had killed three patients, and she had serious suspicions about four further deaths, including that of a four-year-old girl, during the early stage of his medical career at Pontefract General Hospital, West Riding, Yorkshire. Smith concluded the probable number of Shipman’s victims between 1971 and 1998 was 250. In total, 459 people died while under his care, but it is uncertain how many of those were Shipman’s victims, as he was often the only doctor to certify a death.
The General Medical Council charged six doctors who signed cremation forms for Shipman’s victims with misconduct, claiming they should have noticed the pattern between Shipman’s home visits and his patients’ deaths. All these doctors were found not guilty. Shipman’s widow, Primrose Shipman, was called to give evidence about two of the deaths during the inquiry. She maintained her husband’s innocence both before and after the prosecution.
In October 2005, a similar hearing was held against two doctors who worked at Tameside General Hospital in 1994, who failed to detect that Shipman deliberately administered a “grossly excessive” dose of morphine.
A 2005 inquiry into Shipman’s suicide found that it “could not have been predicted or prevented,” but that procedures should nonetheless be re-examined.
In 2005, it came to light that Shipman might have stolen jewellery from his victims. Over £10,000 worth of jewellery had been found in his garage in 1998, and in March 2005, with Primrose Shipman pressing for it to be returned to her, police wrote to the families of Shipman’s victims asking them to identify the jewellery.
Unidentified items were handed to the Assets Recovery Agency in May. In August the investigation ended: 66 pieces were returned to Primrose Shipman and 33 pieces, which she confirmed were not hers, were auctioned. The proceeds of the auction went to Tameside Victim Support. The only piece actually returned to a murdered patient’s family was a platinum–diamond ring, for which the family were able to provide a photograph as proof of ownership.
Shipman, a television dramatisation of the case, was made in 2002 and starred James Bolam in the title role. The case was also referenced in an episode of the television series Diagnosis: Unknown called “Deadly Medicine” (Season 2, Episode 17, 2003). Shipman’s activities also inspired D.A.W., an episode of the American TV series Law & Order: Criminal Intent. In it, the police investigate a physician who they discover has killed 200 of his patients.
Both The Fall and Jonathan King have released songs about Shipman. The Fall’s song is, “What About Us?”, from the 2005 album Fall Heads Roll, asks the question “what about us, Shipman?”—implying Shipman should have handed out free drugs to the author (for recreational use).
King’s song became controversial when, six months after its release, it was reported to be in Shipman’s defence, urging listeners not to “fall for a media demon”.
As of early 2009, families of the victims of Shipman are still attempting to seek compensation for the loss of their loved ones.
In September 2009, it was announced that letters written by Shipman during his prison sentence were to be sold at auction. However, following complaints from victim’s relatives and the media, the letters were removed from sale.