Unnatural Causes

by Dr Richard Shepherd

I felt I had to extinguish the television news with its reporters discussing Hungerford excitedly and so urgently. The Hungerford dead had no excitement or urgency any more. Here were men and women simply slaughtered as they went about life’s business, business they thought important and pressing until it was brought to an abrupt halt. There was nothing important for them now. There was nothing pressing.

Despite all our years of training on the macro- and microscopic appearances of the organs in thousands of diseases, just looking carefully at the body before us is often the most vital part of the post-mortem.

Shock has no place in the work of a pathologist. We must seek the truth with clinical detachment.

Maybe I did need to discuss this with a professional after all. A priest, perhaps? Some person, anyway, whose job it is to receive our weaknesses and offer us strength.

How is it that I remember so much from that time about my grandmothers, my brother, sister, father, aunt … but there is a void where she should be? And I suppose there always will be.

Perhaps I wanted to view that horrifying thing, the worst that could happen, that thing called death, through the detached, clinical, analytical eyes of the great Simpson.

These bodies would stay with us throughout our Anatomy course for eighteen months until we knew more about them physically than they could ever have known themselves – but less about them personally than any stranger who had shared a bus ride and seen their face in motion or heard their voice.

I stared at the dead man’s face, a blank testament to its owner’s long absence. What had he seen? What had he known? He had been a part of the same world as us but in the year since his death that world had changed and moved on and he had not.

among those of us left, there was a new closeness. By dissecting a dead body, we were becoming professionals together. We were joining a very small group, a sect, a tribe. We were initiated. And for me, this maiden flight with the scalpel confirmed my great hope: I belonged here.

I was going to cut into her pink flesh. Run a knife right down her torso and then open her. Surgeons, of course, do just that, but for surgeons there’s a good reason, at least in theory: they are trying to save a life or improve its quality. I could make no such claim. At that moment, I wondered if I didn’t have more in common with a homicidal maniac than a doctor.

I’d always wanted to do this. I’d worked hard to arrive at this point. But now, suddenly, my ambition to become Keith Simpson and specialize in forensic pathology to help solve crimes seemed a schoolboy fantasy. The woman lying motionless on the porcelain table in front of me was the reality. Whatever had possessed me? I must have been insane to want to do this.

It is hard to believe how much like the carcases hanging at the butcher’s the human body looks when stripped down to the bone, and how like a steak human muscle can appear.

The meeting introduced me – or, perhaps no introduction was necessary – to the awful collision between the silent, unfeeling dead and immensity of feeling they generate in the living.

Jen had a miscarriage. We were both devastated. I had no idea how to deal with my overwhelming feelings of loss, my sense of the child that could have been, the life that might have been lived, nor what to do with the love that should have belonged to that baby. My pain was an enormous, invisible thing I carried awkwardly around. Where on earth was I to put it?

I’d been overwhelmed because there was no baby. Now I was overwhelmed because there was a baby. And so was Jen, even though she was by now an experienced health visitor. As for me, I was a doctor with a stint in paediatrics behind me. But we were both taken aback by the weeping, the sheer dissatisfaction with which our little prince responded to our efforts to please him. And all the time we were awash with a love for him which was so deep and passionate it shook me to the core. And his apparent lack of appreciation of our efforts perhaps shocked us both.

But how hard it was for keen, young Dr Shepherd to push in the old public mortuaries for the newfangled practices he had been taught.

Truth is based upon knowledge. So, of course, it can be compromised by incomplete knowledge. As a doctor I sought truth through facts. As a pathologist I was now learning that truth could be directly affected by choices I made, by how many facts I chose to study. It was the first step in what was to become a lifelong examination of the nature of truth.

Once the lad had been formally identified I was able to use his name, but apart from that certainty I experienced self-doubt over every fact as well as over my deductions.

My heart sank. Especially at the word ‘exactly’. That’s the question everyone asks first. That’s the question everyone thinks we can answer. That’s the question which reveals the huge gap between the public perception of pathologists and the truth. I blame those TV cop shows. The fact is, it is very hard indeed for us to determine with any accuracy when a death occurred.

I think the system would be most effective if we could all sit down together when a case is difficult and complicated – the police and the CPS with the pathologist, the forensic scientists, the blood-spatter specialist, the toxicologist, the ballistics expert – and discuss our facts together. But we seldom do that any longer.

I reminded myself that I became a forensic pathologist to be a seeker of the truth. That meant I must stand up for the truth whatever pressure I was placed under to massage it. I see now that this is just the sort of noble thought a keen young man of limited experience might have. I had not worked on enough cases to know how malleable a concept truth is for some people, nor how open to interpretation, instinct and inclination are all truths, even those that appear to be scientific fact.

I was still deluding myself that it was always possible to find a moral pathway that everyone would recognize as clear and correct.

Embarrassment is just the kind of worldly concern which I believe the dying relinquish, often perhaps with relief.

Many people find the idea of decomposition repellent. It might help to remember that this is an important natural process that completes the life cycle of the human body and returns it to the chemical pool that is the earth. It is hard to imagine what our world would be like without the ultimately cleansing process of decomposition, smelly and ugly though it may seem to the living.

You might assume pathology is such a precise science that all reports on the same body must be identical. This is not the case. Wounds and injuries recorded identically may be interpreted differently. Interpretation can be influenced by many things, especially the information supplied concerning a case: the more information there is, the less likely that conclusions may be erroneous.

There is another, more personal, reason why defence post-mortems can be a challenge for newcomers trying to make their way in the world of experienced forensic pathologists. That’s the fear of taking an opposing view. Our court system thrives on these differences, but they do nothing for relationships within the profession, particularly if you are just a newcomer facing one of the giants of pathology.

No courage was required to contradict the findings of the prosecution’s pathologist for that case. But, beyond cowardice or careerism, is a deeper problem for both defence and prosecution pathologist. Neither party can ever – should ever – admit to being wrong. It is acceptable to admit that there may be other possible conclusions, but, in the absence of any new evidence, the pathologist should be sure enough of his or her view to stick to it.

It was alarming to understand at the beginning of my career that the pathologist is assumed to be right, whichever side he is working for. The day I became a fully qualified forensic pathologist was the day I turned from a not very sure trainee who still probably had a thing or two to learn, into an expert who can never put a foot wrong. Allegedly. So, if you have ever thrilled to the transformation of the insignificant Clark Kent into Superman’s invincibility, imagine what a disconcerting experience this must have been for Kent himself. Certainly, I have found the cloak of invincibility placed upon me a heavy burden.

But why is this? Why must I now always be right when it is the human condition to be wrong sometimes? Answer: because the adversarial nature of our criminal justice system has...

there is nothing more likely to bring great joy to the private life of the forensic pathologist as a new baby and nothing so likely to bring great misery to his professional life.

The belief that if the lungs of a dead newborn float then the baby must have breathed and had a separate existence has been proven a myth.

It is now known that the lungs of many stillborn babies will float, particularly where there are gases due to early decomposition if the baby has died a day or two before birth.

It would have been unbearable if she had been tried for murder on the basis of evidence produced under pressure but against my conscience.

Like so many institutions of death, it is discreet enough to oblige those who don’t wish to be reminded of the inevitable.

(In forensic medicine it is amazing how often you find just one exceptional exception. Followed always by a defence barrister trying to make it sound commonplace.)

There was only me, a junior police officer and the coroner in court to hear this verdict. What a sad and lonely ending to a life that was.

When the next opportunity to meet some bereaved relatives arose, I dreaded it but reminded myself that coping with their emotion was better than contemplating the cruel isolation of the uncared-for.

One of the normal phases of grieving is guilt. There was nothing you could have done won’t magically wipe away guilt, but it may allow it to pass more quickly. I hope so.

So that is what I gave them. The truth as I understood it. Unvarnished by phrases designed to save them from it. Beautiful in its simplicity. Unfiltered by the rawness and violence of the emotion a death causes. Allowing myself to become involved in their feelings had added a complication to the truth that could help no one, and I determined never to let it happen again.

I stopped trying to save the bereaved from their misery and now tried to deliver only the truth as kindly as possible – while accepting that the truth is not always simple and singular. It can be a fractured, fragmented beast.

while few people actually want to die, when it happens, death itself is probably actually pleasurable.

’Tis not enough, your counsel still be true, Blunt truths more mischief than wise falsehoods do.

‘Most people misunderstand death. They see it as an instant event. You think that one moment your daughter was alive. And the next … gone. But death just isn’t like that. Humans only switch off completely, in one moment, like lights, if they’re vaporized in a nuclear explosion. In all other circumstances, death is a process.’

Various definitions try to pin down death, but each definition is a struggle; morally and scientifically.

death is a process during which life is gradually wrapped up and put aside. And that I believe this to be a pleasurable process.’

his words pinpoint why post-mortems are so important. When I perform one, I am thoroughly, efficiently and perceptively delivering to the dead not just ‘the utmost care and respect’ which a civilized society expects, but love for my fellow man. I am ascertaining the exact cause of death and in doing so it is very distressing to be regarded as a mysterious, cloaked butcher.

For myself, I would say I have spent a working lifetime respecting and understanding relatives’ pain – while trying not to internalize it.

We didn’t have rows: we had seething and we had silences.

I realized that it was, in fact, perfectly possible to participate fully in family life while one’s mind was somewhere else completely. Did I do the same thing?

I was often amazed at how nondescript most murderers seemed. So many looked like that mild-mannered individual you barely notice sitting next to you on the train until he obligingly picks up your ticket if you drop it.