|
Archived Transcript for 1 October 2001:
Pages 1 to 50
1
1 Monday, 1st October 2001
2 (10.00 am)
3 THE CHAIRMAN: Good morning, everyone. Just before we get
4 going, could I again ask people just to check their
5 mobile phones, please? Thank you very much indeed.
6 Mr Garnham?
7 MR GARNHAM: Sir, good morning. Before we start, I gather
8 Ms Boye has a point to make.
9 THE CHAIRMAN: Right, Ms Boye.
10 MS BOYE: Sir, I wonder if there is a matter I could raise
11 formally. I have spoken to counsel to the Inquiry about
12 this already. Mr and Mrs Climbie have today said that
13 they had incredible difficulties with the interpreter on
14 Friday. They are speaking to our interpreter today, and
15 the difficulty, as I understand it, seems to be this:
16 the interpreter who came speaks very academic French,
17 whereas the French that they speak is African French,
18 and is pidgin French, really. They feel he was not
19 translating accurately a lot of what they were saying,
20 and also the sections -- the grouping of the questions,
21 as it were, was that he was really paraphrasing the
22 essence of what was being asked by counsel to the
23 Inquiry, rather than saying exactly what was being
24 asked, and putting the responses accurately as well.
25 They had particular concern -- and this is something
2
1 that would have been better raised by my leader, who is
2 not here today, but who speaks French, of course, who
3 discussed this with them: the particular difficulty
4 arose in your questions, sir, in relation to the jumping
5 to attention point, where what Mr Climbie -- the way it
6 was translated to him was he thought this was something
7 about a respect issue, i.e., "How do your children
8 behave when people come to your home, are they unruly?",
9 that sort of thing, and he was attempting to respond to
10 that, but he feels his response was not translated
11 accurately.
12 I do not know the best way in which this ought to be
13 dealt with. Clearly, the problem is that our
14 interpreter, although he speaks African French is not an
15 accredited interpreter. I do not know whether it may be
16 that either something should be put in statement form or
17 people would want Mr Climbie recalled on a day when the
18 accredited interpreter could come back, and maybe our
19 interpreter could be here as well, and we will have to
20 have a battle of the translators as it were.
21 THE CHAIRMAN: Mr Garnham?
22 MR GARNHAM: Sir, Ms Boye is, if I may say so, right to
23 raise the matter. She mentioned it to me just before
24 you came in and it is clearly something to which we will
25 have to give some thought. It may be that rather than
3
1 battle with the translator, we ought to find someone who
2 is both accredited and fluent and competent in whatever
3 dialect of French is spoken by Mr and Mrs Climbie. We
4 will attempt to make those enquiries over the coming
5 days. If Mr and Mrs Climbie are in a position to make
6 a further statement on this matter, then I would ask
7 them to do so, and to let us have that, and we can
8 distribute it, and then we can decide the best way to
9 handle the matter once we have that, and have found an
10 alternative translator.
11 But for the moment, sir, I think you have to proceed
12 on the basis of the evidence you have heard, until we
13 have some other evidence to put in for you to consider
14 as well.
15 THE CHAIRMAN: Mr Garnham, I am grateful to you, and
16 Ms Boye, I am grateful to you for raising this. I think
17 that perhaps everyone realised at this particular
18 juncture the other day that I was uncertain about
19 whether or not the question had been understood, and had
20 been answered in the way in which Mr Climbie would have
21 wished to have answered it.
22 I think it is important that we actually get this
23 right, and that we get clear what is the practice on
24 this point, and I am happy to follow Mr Garnham's
25 suggestion, and I wonder if you would also agree to
4
1 Mr Garnham's suggestion?
2 MS BOYE: Yes.
3 THE CHAIRMAN: We will proceed on that basis. Mr Garnham?
4 MR GARNHAM: Thank you, sir. Our first witness today is
5 Dr Nathaniel Carey.
6 DR NATHANIEL CAREY (affirmed)
7 MR GARNHAM: Dr Carey, good morning. Would you give us your
8 full name, please?
9 DR CAREY: Yes, it is Nathaniel Roger Blair Carey.
10 MR GARNHAM: And your qualifications?
11 DR CAREY: Master of Arts of the University of Oxford,
12 medical graduate of the University of London. I hold
13 a doctorate by thesis in medicine. I am a Fellow of the
14 Royal College of Pathologists and I hold a diploma in
15 medical jurisprudence.
16 MR GARNHAM: And I think, Doctor, you are now based at Guy's
17 Hospital?
18 DR CAREY: That is correct, I am on the Guy's Hospital
19 campus of King's College London.
20 MR GARNHAM: You are a Home Office accredited pathologist?
21 DR CAREY: That is correct, yes.
22 MR GARNHAM: Sir, Dr Carey produced a series of statements
23 for the Crown Prosecution Service which we regarded as
24 adequate for this Inquiry, and we did not therefore
25 trouble him to make another statement. His CPS
5
1 statements begin in volume 7 of the green bundles at
2 page 37. I hope, Dr Carey, a copy of that has now been
3 put in front of you.
4 Sir, Dr Carey also gave evidence at the trial, and
5 for your note, the transcript of his evidence is in
6 volume 52 of the black volumes, pages 164 to 221, and
7 226 to 255.
8 Dr Carey, I think it is right that you carried out
9 a post mortem examination of Victoria on 26th February
10 at Westminster Public Mortuary.
11 DR CAREY: Yes, that is correct.
12 MR GARNHAM: You provided in your first statement
13 a provisional diagnosis as 1A hypothermia.
14 DR CAREY: Yes, that was in relation to the cause of death,
15 that is correct.
16 MR GARNHAM: Could you explain first the convention by which
17 a cause of death is given at different levels, starting
18 at 1A?
19 DR CAREY: Yes, 1A -- under the standard nomenclature of
20 death, 1A is the immediate cause of death. There may be
21 underlying factors that give rise to that, and they will
22 be listed under 1B or 1C, the link between the two being
23 due to or as a consequence of, but in this case, we had
24 clear clinical evidence of hypothermia in life.
25 MR GARNHAM: That was your provisional cause of death, given
6
1 after an initial examination of the body?
2 DR CAREY: Yes.
3 MR GARNHAM: On what was that based?
4 DR CAREY: I was heavily reliant on the fact that a very low
5 body temperature had been measured in life, but there
6 were some nonspecific findings at autopsy that would be
7 typical of hypothermia; very small ulcers in the stomach
8 and a change around the pancreas, which is in the
9 abdomen; the change is known as fat necrosis.
10 MR GARNHAM: The final cause of death was given only after
11 examination of body tissue.
12 DR CAREY: Yes.
13 MR GARNHAM: And what was the final cause of death, in your
14 opinion?
15 DR CAREY: It really remains one of hypothermia. There is
16 no change, essentially. There were many other aspects
17 to the case that I am sure we will be covering, but in
18 terms of the cause of death, it was one of hypothermia.
19 MR GARNHAM: So that remained 1A?
20 DR CAREY: Yes.
21 MR GARNHAM: Was there a 1B or a 1C?
22 DR CAREY: Certainly in relation to my main cause of death
23 given in my statement, that is what stood. I am not
24 aware of a 1C in any of the other statements.
25 MR GARNHAM: Thank you. You estimate Victoria's body weight
7
1 at 24 kilograms.
2 DR CAREY: Yes.
3 MR GARNHAM: That was only an estimate because the mortuary
4 scales were not sufficiently precise, or what?
5 DR CAREY: Unfortunately, with quite a low weight, I was not
6 satisfied we were getting a terribly accurate reading.
7 In contrast, we had a reading that was taken in life on
8 the Paediatric Intensive Care Unit, which I felt was
9 a more accurate reading.
10 MR GARNHAM: And that is what you based your estimate of
11 24 kilograms on?
12 DR CAREY: That is correct, yes.
13 MR GARNHAM: And you measured her height at 3 feet 10.5
14 inches or 1.18 metres.
15 DR CAREY: Yes, that is correct.
16 MR GARNHAM: That height and weight, were they normal of
17 a child of eight?
18 DR CAREY: It is always difficult to put those into precise
19 context. I think the height would certainly be
20 a reasonable height within the sort of variation you
21 would expect. I think she was definitely underweight.
22 The problem is that young children can be very thin
23 anyway, but at my examination, there was clear evidence
24 internally that she was undernourished, and in a way,
25 that is a more helpful marker.
8
1 MR GARNHAM: Thank you.
2 DR CAREY: One of the things that can happen is when you are
3 in a very poorly condition, such as she was in her
4 latter days, you may retain fluid, so that can make the
5 weight go up again, even if you are nutritionally in a
6 very poor state.
7 MR GARNHAM: I wonder if the witness, please, could be shown
8 volume 3A from the black files; it is page 150, for
9 those who want to follow it.
10 That I think is a body plan showing Victoria's body.
11 DR CAREY: Yes.
12 MR GARNHAM: I wonder if we could have that on the screen,
13 please. I hope they have come up on the screens; it has
14 not come up on mine. It may be just that mine is
15 defective.
16 Can I then ask you, Doctor, to look at page 3 of
17 your second statement where you list the signs of old
18 injury.
19 DR CAREY: Yes.
20 MR GARNHAM: You note multiple both pigmented and
21 depigmented scars; can we just check we know what those
22 expressions mean? Pigmented?
23 DR CAREY: Yes, sometimes when you have scarring on the
24 skin, there may be an increased amount of pigmentation
25 in relation to the scarring and sometimes there may be
9
1 a decrease. This will make the scarring more obvious,
2 one way or another.
3 MR GARNHAM: What accounts for the alternatives?
4 DR CAREY: I think there is no particular reason why you
5 might get increased pigmentation or decreased; it
6 reflects the fact there is damage to the pigment
7 producing cells, and they may be overstimulated or they
8 may be damaged in such a way as they do not produce so
9 much pigment in the area of scarring.
10 MR GARNHAM: Thank you. You record pigmented scars and
11 depigmented scars over the face, the neck, the trunk,
12 the upper and lower limbs; is that right?
13 DR CAREY: Yes, that is correct.
14 MR GARNHAM: You begin first of all by listing the marks to
15 the face; on my count it is 15, because you identify
16 them individually.
17 DR CAREY: Yes.
18 MR GARNHAM: Then there are a series of scars that you note
19 at the front of the neck.
20 DR CAREY: Yes.
21 MR GARNHAM: And then a number of scars over the chest, the
22 abdomen, the loin, the back, the shoulder blades and the
23 left hip.
24 DR CAREY: Yes.
25 MR GARNHAM: Next you describe extensive skin breakdowns and
10
1 abrasions over both buttocks.
2 DR CAREY: Yes.
3 MR GARNHAM: And you say on page 6:
4 "This skin loss appears to be in a background of
5 lichenification and scarring."
6 What does that mean, please?
7 DR CAREY: That is where the skin becomes rather leathery;
8 this in essence, although she is obviously much older
9 than a baby, but this is like the most severe form of
10 nappy rash that you occasionally see, when the nappy
11 area is just not properly treated for weeks on end.
12 MR GARNHAM: So it is the consequence of the skin lying in
13 faeces and urine, is it?
14 DR CAREY: Yes.
15 MR GARNHAM: You also note excoriation and abrasion down
16 both buttocks.
17 DR CAREY: Yes.
18 MR GARNHAM: Cause?
19 DR CAREY: That is the same effects, really. There may have
20 been additional injury to the buttocks, such as through
21 being beaten, but much of the change present really
22 reflected this terrible state in which she was kept,
23 with, as you say, faeces and urine contaminating the
24 skin.
25 MR GARNHAM: Can you say for certain that there was beating,
11
1 or is that just one of a number of possible causes?
2 DR CAREY: Given the amount of skin breakdown anyway,
3 I think it would not be possible to be certain that
4 there was beating, and in many ways, it is not really
5 relevant, given the number of sites of obvious beating
6 elsewhere on the body.
7 MR GARNHAM: Next the arms; multiple circular scars you
8 note.
9 DR CAREY: Yes.
10 MR GARNHAM: Can you say what the cause of those could be,
11 or causes?
12 DR CAREY: The circular ones are likely to be healed
13 lacerations, those are blunt force splits of the skin.
14 MR GARNHAM: Caused by?
15 DR CAREY: Probably being hit with weapons more than
16 anything else.
17 MR GARNHAM: Numerous other scars over both arms; is that
18 right?
19 DR CAREY: Yes.
20 MR GARNHAM: Including a roughly circumferentially
21 orientated area of ulceration around both wrists.
22 DR CAREY: Yes.
23 MR GARNHAM: I wonder if you could describe that a little
24 more for us?
25 DR CAREY: Yes, this was a combination of both old and
12
1 recent change, in other words the ulceration is
2 relatively recent, that is damage to the integrity of
3 the skin in a bracelet type fashion, but then there were
4 clearly scars reflecting the same process having gone on
5 before, really characteristic of the wrists having been
6 bound together for a prolonged period.
7 MR GARNHAM: Bound together or bound to a third object?
8 DR CAREY: It could be either. What it illustrates is that
9 the bindings have either been so tight that they have
10 cut into the skin themselves, or obviously in attempts
11 to loosen the bindings or to break free, there has been
12 damage to the skin.
13 MR GARNHAM: There was evidence at the criminal trial that
14 the police discovered masking tape of some sort.
15 DR CAREY: Yes.
16 MR GARNHAM: I think you told the criminal trial that that
17 would have been material of a sort that could have
18 accounted for these injuries?
19 DR CAREY: Yes, that could well have done. One imagines
20 masking tape or other forms of packing tape as being
21 flat, but, of course, anyone who has pulled that out
22 knows that it is very easy for the whole thing to get
23 twisted up and actually to form quite a thin binding,
24 and I think that is very likely the origin of the marks
25 present around the wrists here.
13
1 MR GARNHAM: Again you note areas of lichenified skin;
2 cause?
3 DR CAREY: That is a general feature of irritation of the
4 skin on a chronic basis.
5 MR GARNHAM: On Victoria's legs, you found scarring to both
6 hips, both thighs, both knees, both calves and both
7 feet.
8 DR CAREY: Yes.
9 MR GARNHAM: There is a reference in your description to the
10 shins, to injury to the left leg, but then there is
11 another reference in the description of the left leg to
12 the right shin.
13 DR CAREY: Yes.
14 MR GARNHAM: Is that correct, or is that a typographical
15 mistake?
16 DR CAREY: That is a typographical mistake. I think that
17 was corrected in the criminal trial.
18 MR GARNHAM: So we should have seen references by you to
19 injuries to both shins?
20 DR CAREY: Yes, all the right stuff follows in order, and
21 then all the left stuff.
22 MR GARNHAM: You note, paragraph 4.13, scars around the
23 circumference of the right ankle.
24 DR CAREY: Yes.
25 MR GARNHAM: And at 4.26, an area of deep laceration around
14
1 the left lower calf.
2 DR CAREY: Yes.
3 MR GARNHAM: Likely cause?
4 DR CAREY: Exactly the same as what has been going on around
5 the wrists. This is indicative of binding.
6 MR GARNHAM: Higher up on the left side than the right?
7 DR CAREY: Yes, exactly.
8 MR GARNHAM: Any significance of that?
9 DR CAREY: It may simply reflect an asymmetry of binding.
10 It could reflect the position she was in, in a fetal,
11 curled up position. It is difficult to speculate. It
12 may reflect that she was tethered to something else that
13 involved that asymmetry.
14 MR GARNHAM: We see from the plans that we have on the
15 screen, that first one we see is simply the front of
16 Victoria's body, and there are scars, it seems,
17 virtually all over her. Was there any part of her
18 spared?
19 DR CAREY: That is correct. There really is not anywhere
20 that is spared. Obviously when you look at the
21 abdominal area it perhaps has rather less scars than the
22 limbs, but essentially, there is scarring all over the
23 body.
24 MR GARNHAM: If we look at the next plan, please, I think we
25 see the reverse side of Victoria, and a pretty similar
15
1 picture.
2 DR CAREY: Yes, absolutely.
3 MR GARNHAM: The marks that we have just gone through,
4 doctor, are marks of old injuries, in your words.
5 DR CAREY: Yes.
6 MR GARNHAM: You then go on, at 4.28, to describe marks of
7 recent injury.
8 DR CAREY: Yes.
9 MR GARNHAM: What does "old" and "recent" mean in this
10 context?
11 DR CAREY: In terms of the binding marks, they were both, if
12 you like, they were ongoing marks, but recent injury
13 would reflect something proximal to death by a few days
14 at the most really.
15 MR GARNHAM: How, when you are examining a body, do you
16 distinguish between new and old?
17 DR CAREY: Well, the old injuries in this case were quite
18 obvious scars, whereas the recent injuries amounted to
19 areas of bruising or superficial skin loss, and so it
20 was quite apparent that the bruises were relatively
21 fresh.
22 MR GARNHAM: Recent injuries; there was bruising to the left
23 elbow, the right thigh, the left foot.
24 DR CAREY: Yes.
25 MR GARNHAM: Doctor, before turning to your conclusions in
16
1 that first statement, can I ask you to turn to your CPS
2 statement of 31st October of last year, which is at
3 page 59 in that volume. You describe there further
4 injuries detected after the head was shaved.
5 DR CAREY: Yes.
6 MR GARNHAM: Can you describe those for us, please?
7 DR CAREY: Yes, there were a number of further scars on the
8 shaved head which are apparent within the scalp.
9 MR GARNHAM: Not apparent until the hair was removed?
10 DR CAREY: Not until the hair was removed, that is correct,
11 and these were elongated scars, curving and irregular,
12 up to several centimetres in length, typical of healed
13 lacerations, that is blunt force splits.
14 MR GARNHAM: Blunt force splits?
15 DR CAREY: Yes, such as would occur if hit by some form of
16 weapon.
17 MR GARNHAM: I think it is right that you were also shown
18 photographs of Victoria taken at the North Middlesex
19 Hospital, showing scalding injuries.
20 DR CAREY: Yes.
21 MR GARNHAM: You say in your evidence that the appearance
22 there was consistent with injuries caused by weapons of
23 different types.
24 DR CAREY: Yes, that is correct.
25 MR GARNHAM: You talk about blunt objects, a training shoe
17
1 and a belt buckle.
2 DR CAREY: Yes.
3 MR GARNHAM: Can I ask you about the belt buckle? Did you
4 ever see a belt that could have caused such injury?
5 DR CAREY: I did not, no. It is possible sometimes with
6 these sort of marks on the skin to fairly precisely
7 match the causative object, but we did not have the
8 opportunity to do that.
9 MR GARNHAM: So you did not do a match between the marks
10 that you could see in the photographs and a particular
11 object?
12 DR CAREY: No, that is correct.
13 MR GARNHAM: That is true, you tell us, in respect of the
14 belt marks. What about the suggested mark of the
15 trainer?
16 DR CAREY: The mark of the trainer is a fairly
17 characteristic collection of little blocks of injury to
18 within the skin, and such an injury is fairly typical of
19 impact with a patterned object such as a trainer.
20 Again, we did not have the opportunity to match
21 a specific trainer, but the appearances would certainly
22 do for the kind of patterning you see in the skin when
23 a trainer strikes the skin.
24 MR GARNHAM: So in respect of the trainer injury, you can be
25 fairly confident that it was such an object which caused
18
1 those injuries, but again you did not have a particular
2 shoe to match it with?
3 DR CAREY: Yes, exactly. The important feature with all
4 these injuries is they were due to weapons rather than
5 fists or some natural cause.
6 MR GARNHAM: Back to your conclusions, please, Doctor, at
7 page 17 of your main statement. I think it is right
8 that it is your view that both the clinical history and
9 the evidence at autopsy pointed towards hypothermia as
10 the cause of death.
11 DR CAREY: Yes, that is correct. That is what took her into
12 hospital, and I mean, there is undoubted evidence of
13 hypothermia because her body temperature was measured as
14 being very low, in the region of 27 degrees centigrade.
15 MR GARNHAM: And what was the autopsy evidence of
16 hypothermia?
17 DR CAREY: The fairly nonspecific evidence I have already
18 mentioned really. The small ulcers in the stomach and
19 this change of fat necrosis around the pancreas.
20 I should say though there is another very important
21 finding at autopsy, and that is the lack of any other
22 obvious cause of death. Hypothermia is the sort of
23 diagnosis where one would want to exclude other possible
24 causes.
25 MR GARNHAM: Did you in fact have any differential
19
1 diagnosis?
2 DR CAREY: I wondered about some sort of toxicology, if some
3 administered substance had been involved in the cause of
4 death, but, of course, that could also be involved in
5 precipitating hypothermia.
6 MR GARNHAM: And?
7 DR CAREY: All screens, including samples that were taken in
8 hospital prior to her death, I think were negative.
9 MR GARNHAM: While we are dealing with the toxicology
10 results, was there anything to suggest poisoning by
11 bleach?
12 DR CAREY: No, there was not. Bleach is quite a corrosive
13 substance, and I would expect to find evidence of injury
14 around the lips and the mouth, or further down in the
15 gullet or in the stomach lining.
16 MR GARNHAM: And there was none?
17 DR CAREY: There was not. Of course, that does not exclude
18 it having happened some time previously and having
19 healed up.
20 MR GARNHAM: Were you conscious of any smell of bleach about
21 Victoria's body?
22 DR CAREY: By the time I carried out the autopsy obviously
23 she had been in hospital for some time, but I am
24 certainly aware that there was a smell of the premises
25 and obviously in a case of this kind, I spoke to scenes
20
1 of crime officers, and we discussed the scene in some
2 detail, and I know that bleach was discovered at the
3 premises.
4 MR GARNHAM: Nothing to suggest it contributed to her
5 condition?
6 DR CAREY: No.
7 MR GARNHAM: Could you tell us your opinion, please, Doctor,
8 as to the cause of the hypothermia in Victoria's case?
9 DR CAREY: Firstly it has to be put in the context that
10 hypothermia in a child of this age occurring in a
11 domestic circumstance must be incredibly unusual, if not
12 unique, but the reason for that is that the
13 circumstances in which she was kept, I think, were very
14 unusual, to say the least. She was malnourished, she
15 was in a very damp environment, and her movement was
16 limited through being bound up. All those would act to
17 prevent the body being able to maintain its temperature,
18 and if you then combine that with a cold and damp
19 environment, such as you would get in a bath, wet
20 clothing, you have an effect that is really very similar
21 to being lost on the hills with no food, running out of
22 hills and getting what is called exposure in those
23 circumstances.
24 MR GARNHAM: So do you think that the combination of
25 malnutrition, inadequate clothing, low ambient
21
1 temperature and dampness, perhaps from lying in her own
2 urine, plus the binding, could account for a drop of
3 body temperature to 27 degrees centigrade?
4 DR CAREY: Yes, I think -- I mean, that is a very dramatic
5 drop, because obviously the body temperature should
6 normally be 37 degrees centigrade, and your body will do
7 everything in its power to maintain body temperature,
8 and it will go on fighting as your temperature drops.
9 The problem here is there would have been nothing to
10 fight with. With no calories, no large amounts of
11 subcutaneous fatty tissue to mobilise reserves, she
12 would not have been able to fight the low temperature of
13 her surroundings. It was not that low, it was probably
14 in the region of 10 degrees centigrade, but it is well
15 recognised that that is capable of causing hypothermia.
16 The other thing that may happen is, of course, once
17 you start to become hypothermic, your body systems do
18 not work very well at all, so when the body temperature
19 drops to 32, she may well have got into severe medical
20 difficulties, her heart would not necessarily have
21 behaved normally, and this could then compound the
22 effect and allow the hypothermia to develop to a greater
23 degree.
24 MR GARNHAM: The necrosis that you detect around the heart,
25 pancreas and liver on internal examination; does that
22
1 amount to the body burning up its own tissue?
2 DR CAREY: No, that is actually more a manifestation of the
3 pancreas, which is an organ that produces digestive
4 juices. It produces enzymes, and in fact one of the
5 effects of the old injury on the pancreas is to cause it
6 to release the enzymes into the surrounding tissues.
7 The release of those enzymes into the fat around the
8 pancreas causes literally self-digestion to occur, so
9 that fatty tissue breaks down under the influence of the
10 enzyme responsible for breaking down fat.
11 MR GARNHAM: A drop in temperature in a child to 27 degrees
12 is extremely unusual, is it not?
13 DR CAREY: It certainly is, yes. It is obviously described
14 in relation to children who have been immersed in ponds
15 and I am sure in children who have been out on the hills
16 with no food for a prolonged period of time.
17 MR GARNHAM: It might be thought to be quite extraordinary
18 in the case of a child who is indoors, even in the sort
19 of conditions that you have described.
20 DR CAREY: I think this is a very unusual case, but then, it
21 must be quite extraordinary for this combination of
22 features to have arisen before, and I think that may
23 explain it really.
24 MR GARNHAM: Let me ask what is going through my mind, so
25 you can put me right about it: could it be that this
23
1 child was exposed to something more, such as immersion
2 in cold water?
3 DR CAREY: I certainly cannot exclude that possibility.
4 MR GARNHAM: But on the other hand, you cannot say that the
5 absence of such an explanation is unbelievable.
6 DR CAREY: We, she was certainly damp, and the ability of --
7 I mean, if you have damp clothing on, or you are in
8 contact with damp surfaces, obviously evaporation can
9 occur and cause cooling, and that is quite a potent
10 effect, even if you are not fully immersed in water. We
11 all know how useless damp clothing is at keeping the
12 warmth in.
13 MR GARNHAM: Thank you. The scars you saw, you say, were
14 entirely consistent with repeated systematic abuse, is
15 that right?
16 DR CAREY: Yes.
17 MR GARNHAM: Consistent with anything else?
18 DR CAREY: Not really. I think -- I would rather not use
19 the term "consistent", I would rather use the term
20 "indicative of" in fact. It is not really, "Could there
21 be any other explanation?"
22 MR GARNHAM: And abuse using a weapon?
23 DR CAREY: Certainly some of the wounds have shapes that
24 indicate a weapon has been used.
25 MR GARNHAM: A weapon, or different weapons?
24
1 DR CAREY: Given the variety of shapes and sizes of scars,
2 and the fact that some of them formed lines and curving
3 lines suggestive of sharp weapons, I think we have
4 a combination of sharp and blunt weapons.
5 MR GARNHAM: Again, are we talking about consistent with or
6 indicative of?
7 DR CAREY: Indicative of weapon injury for many of the
8 scars.
9 MR GARNHAM: Are you able to help us, Doctor, as to the
10 timescale for the sustaining of these injuries?
11 DR CAREY: I think that is quite a difficult question,
12 because there could be episodes of immense numbers of
13 injuries, or there could be a few injuries occurring
14 perhaps on a daily or an alternate daily basis. There
15 would not be any difference in appearance between those
16 two sorts of occurrence.
17 MR GARNHAM: And what about the age of the oldest injuries?
18 DR CAREY: Well, we know a little bit about that, of course,
19 because like many others, I saw a photograph of her when
20 she first arrived in this country, and it was quite
21 apparent from that that on the visible skin, she
22 certainly did not have any scars to speak of then. We
23 have some photographs taken at the North Middlesex
24 Hospital which show, although there are some obvious
25 scars and injuries present there, I do not think all the
25
1 injuries which were found at autopsy were apparent then,
2 so we have two separate time windows. We have when she
3 came into the country, and we have when she was
4 photographed at the North Middlesex.
5 MR GARNHAM: If we look at the period from July, and the
6 admission to North Middlesex, through to the time of
7 your examination of Victoria's body, are you able to say
8 when during that period these injuries might have
9 occurred, or can you simply say that they would have
10 occurred in that period, based on the evidence of
11 comparison with the photographs?
12 DR CAREY: That is the best evidence. Obviously they had
13 had the opportunity to heal and scar, so that would put
14 the time back from the autopsy of at least a few weeks.
15 MR GARNHAM: But simply from the autopsy evidence, you
16 cannot do more than that?
17 DR CAREY: No, that is correct.
18 MR GARNHAM: In your last CPS statement, this is page 61 in
19 that volume 7, you draw together your conclusions about
20 the injuries you saw at the autopsy, and the injuries
21 photographed at the NMH. You say that firstly, the vast
22 majority were not caused accidentally.
23 DR CAREY: Yes.
24 MR GARNHAM: And you can be positive about that, can you?
25 DR CAREY: Yes, I can. It would be quite bizarre, really,
26
1 to imagine that anything like this could occur
2 accidentally.
3 MR GARNHAM: The vast majority not caused by skin disease?
4 DR CAREY: Yes, that is also correct. The possibility was
5 raised, certainly during the clinical trial, of the
6 possibility of insect bites, but again, I think the vast
7 majority of these scars are not insect bites.
8 MR GARNHAM: At the clinical trial, you mean the criminal
9 trial?
10 DR CAREY: Sorry, the criminal trial.
11 MR GARNHAM: It was put to you, I think, during that trial
12 that there might have been infection with scabies.
13 DR CAREY: Yes.
14 MR GARNHAM: You obviously cannot say what the clinical
15 picture was in July, but when you saw the body in
16 February, was there any evidence then of scabies?
17 DR CAREY: There was not evidence then of scabies, and, of
18 course, although clinical diagnoses of scabies may be
19 made, the only sure way of diagnosing scabies is to get
20 the scabies mite and see it under the microscope, and
21 I do not think there was a diagnosis established at that
22 level.
23 MR GARNHAM: Could any of the marks you saw have been the
24 end result of a scabies infection?
25 DR CAREY: I do not think so. Some of the lichenification
27
1 described and the excuriation of skin might have been
2 the result of itching of scabies infected sites, but to
3 me, this is not a case of scabies, this is a case of
4 repeated weapon injury.
5 MR GARNHAM: Are you able, from the standpoint of your
6 autopsy examination, positively to exclude scabies as
7 being present back in July?
8 DR CAREY: No, but as I say, the evidence for its presence
9 in my view is certainly not cast iron, in that my
10 understanding is that the organism that causes scabies
11 was not seen. Also it is, of course, of a highly
12 infectious nature, and therefore one might expect other
13 members of the household to have it, and require
14 treatment for it. There may be evidence in relation to
15 that.
16 MR GARNHAM: We may have some evidence in relation to
17 Mrs Kouao that we will hear about later.
18 There were some smaller scars which you say, in
19 those conclusions, could have been caused by cigarette
20 burns.
21 DR CAREY: Yes.
22 MR GARNHAM: "Could have"; is that the right word?
23 DR CAREY: Yes, that is right. There is nothing really
24 characteristic about any of them. They were small
25 circular scars of the kind that you do get with
28
1 cigarette burns, but you cannot be certain about that
2 sort of diagnosis.
3 MR GARNHAM: You say that the possibility that the vast
4 majority were self-inflicted could be dismissed.
5 DR CAREY: Yes.
6 MR GARNHAM: That by implication suggests that it is
7 possible that there may have been some that were
8 self-inflicted?
9 DR CAREY: I suppose it is theoretically possible, but
10 again, you do not really have to look for
11 self-infliction when you have evidence of obvious
12 infliction by third parties, and the obvious evidence
13 that I would draw attention to in this case is the
14 involvement of the back, involvement of the scalp by
15 wounding, and the symmetrical involvement elsewhere on
16 the body. If you think about it, if you are looking at
17 self-infliction in the very broad context, most
18 self-infliction will be asymmetrical; most
19 self-infliction will not involve the back; and most
20 self-infliction will tend to spare the head.
21 MR GARNHAM: We have the head being shown there. You end by
22 commenting on the evidence of malnutrition. In your
23 statement you said either a short period of severe
24 malnutrition or a longer period of inadequate nutrition
25 or both, but then in the criminal trial you say that it
29
1 probably was both.
2 DR CAREY: Yes.
3 MR GARNHAM: That is your preferred option, is it?
4 DR CAREY: I think so, yes. I think there is probably
5 a background of never really having -- never being
6 properly fed, but there may well be episodes of having
7 no food at all for periods of time.
8 MR GARNHAM: Last question, please, Dr Carey: we heard on
9 Friday from Mr Climbie that when Victoria left the Ivory
10 Coast, she had a full set of teeth. She is, however,
11 eight years old; there was noted to be one incisor tooth
12 missing, perhaps two teeth missing. First of all, did
13 you notice any damage to dentition at the time of the
14 autopsy?
15 DR CAREY: No, I did not. This would be a difficult area,
16 because obviously children lose their teeth at various
17 stages.
18 MR GARNHAM: And at eight would be a natural time to lose
19 milk teeth anyway?
20 DR CAREY: Obviously some of them would have gone before or
21 would go after that, but I would not wish to suggest
22 that the absence of a tooth necessarily means that
23 trauma is involved, because it is all too common for
24 young children to have that period of being rather
25 gappy, because their milk teeth have gone.
30
1 MR GARNHAM: Did you find any positive evidence of damage to
2 the mouth?
3 DR CAREY: I would have to look back at my original
4 statement. There were certainly a lot of scars on the
5 face in the vicinity.
6 MR GARNHAM: I think the only one you note is damage at the
7 junction of the lip and the gum.
8 DR CAREY: That is right.
9 MR GARNHAM: Tell us a bit about what that is.
10 DR CAREY: That is the sort of injury that is regarded as
11 being strongly suggestive of non-accidental injury.
12 This is a web of mucosa that spans between the lip and
13 the gum margin and the reason it is so strongly
14 suggestive of non-accidental injury as opposed to some
15 form of accident is it requires a sideswiping effect to
16 tear that, so it is a very typical injury arising from
17 a slap which will move the lip across the gum. On the
18 other hand, it is unlikely to have an accident to get
19 that sideswiping. You can imagine a child falling
20 forward and banging the lips directly, as they indeed
21 do, and get small bleeds from the lips, but you will
22 tend not to get this tearing effect which requires
23 sideswiping.
24 MR GARNHAM: I was interested whether that said anything or
25 not about the loss of the tooth, whether that is likely
31
1 to be related or whether that is entirely independent.
2 Can you help us with that?
3 DR CAREY: One could not exclude that possibility. Of
4 course, there is evidence of use of weapons all over the
5 body, so it certainly would not be surprising if
6 a weapon came into contact with a tooth, but you may
7 well get fracturing of the tooth then, of course, so you
8 will see the residue rather than what appears to be just
9 a gap.
10 MR GARNHAM: But at autopsy, you saw no distinct evidence of
11 damage to teeth?
12 DR CAREY: No, that is correct.
13 MR GARNHAM: Doctor, thank you very much indeed.
14 THE CHAIRMAN: Dr Carey, thank you very much indeed. Just
15 a couple of questions if I may. First of all, you refer
16 on 07/039 to a puncture in the lung, the left lower lung
17 to a depth of 2 centimetres.
18 DR CAREY: Yes.
19 THE CHAIRMAN: Could you cast any light on that, as to what
20 significance that may have, how it may have been caused?
21 DR CAREY: Yes, it is not uncommon unfortunately for chest
22 drains to accidentally puncture the lung when they are
23 put in in patients who are in extremis. We find that
24 not infrequently at autopsy, but it certainly does not
25 have bearing on the cause of death.
32
1 THE CHAIRMAN: I am grateful to you. Later on, you refer to
2 the scalding incident, the evidence of scalding. Do you
3 have any view, as you indicated in the question from
4 Mr Garnham, about the difference between accidental and
5 non-accidental injury? Would this be a most unusual
6 non-accidental injury?
7 DR CAREY: I would regard scalding as being one of the
8 findings in a child where you would always be concerned
9 to exclude non-accidental injury. Burns are obviously
10 one of the ways in which children are abused, and so
11 I would have had a high index of suspicion that a child
12 had sustained such an extensive area of scalding injury
13 accidentally, and I would want to be satisfied that
14 there was a good accidental explanation. Obviously
15 rather younger children may pour pans of hot water or
16 kettles over on to themselves, and indeed freshly made
17 coffee may be pulled over. That tends to be rather
18 younger children. By her age, they are not so
19 vulnerable to that sort of accident.
20 I think it was also suggested, though, that this
21 might have been self-inflicted in order to alleviate
22 itching from scabies, and I find that a bizarre
23 suggestion, particularly in the context of numerous
24 inflicted injuries. When put in that context, I would
25 say that there is a very strong likelihood that in fact
33
1 the scalding was one of the types of inflicted injury.
2 THE CHAIRMAN: Could you enlarge, if you can, on why you
3 would regard the suggestion of deliberate scalding as
4 being bizarre?
5 DR CAREY: What, by her? Well, I have never heard of
6 a similar case of a child scalding herself to deal with
7 the itching of scabies. I mean, maybe there are others
8 here who have, but I have not come across that
9 phenomenon. I have not come across the phenomenon of
10 people scalding themselves in general to deal with some
11 medical condition.
12 THE CHAIRMAN: Thank you very much indeed.
13 Just as a lay question, if I may, that kind of
14 scalding: how hot does the water have to be to have that
15 effect?
16 DR CAREY: This is actually quite a difficult question,
17 because the hotter the water, the shorter the period of
18 time it has to be in contact with the skin to cause
19 burning. One might expect -- had the water been very
20 close to 100 degrees centigrade, in other words boiling
21 point, one might have expected there to be more scarring
22 as a consequence, particularly if there was a large
23 volume of water. The problem here is we do not know the
24 volume of water that was involved, and we do not know
25 the period of time for which it was in contact with the
34
1 skin. Both those are very important in determining how
2 hot the water would need to be.
3 Given that it scalded at all though in what is
4 likely to be a contact with the water running off,
5 I would expect the water to be hotter than 55 degrees
6 centigrade, probably hotter than 60 degrees centigrade.
7 THE CHAIRMAN: Just one final question, Dr Carey: you have
8 answered Mr Garnham very clearly and very helpfully,
9 thank you very much indeed for that, about the extent
10 and nature of the injuries that you recorded.
11 DR CAREY: Yes.
12 THE CHAIRMAN: You have obviously had many years experience.
13 Where would you place this in your experience?
14 DR CAREY: I think it was widely reported in relation to the
15 criminal trial, I regard this as -- all non-accidental
16 injuries to children are awful, and difficult for
17 everybody to deal with, but in terms of the nature and
18 extent of the injury, and the almost systematic nature
19 of the inflicted injury, I certainly regard this as the
20 worst I have ever dealt with, and it is just about the
21 worst I have ever heard of really.
22 MR GARNHAM: Sir, just a couple of questions arising out of
23 your questions, if I may.
24 In relation to the scalding injuries, Doctor, you
25 said that viewing the history of this case, and in the
35
1 light of what you had seen at autopsy, you find the
2 scalding as a self-inflicted injury to be highly
3 unlikely.
4 DR CAREY: Yes.
5 MR GARNHAM: Those who were examining this child's scald at
6 the time however would not have had the benefit of
7 seeing all these other injuries.
8 DR CAREY: Indeed, and it is easy to be wise in retrospect.
9 MR GARNHAM: Viewing the scald injury alone, are you of the
10 same or of a different opinion with regard to the
11 likelihood of it being self-inflicted?
12 DR CAREY: I would always be very concerned about burns
13 injuries in children, and my starting point personally
14 would be that this could well be non-accidental injury,
15 and we have really got to try and positively establish
16 that it is not, and the way to do that is to analyse the
17 alternatives objectively.
18 MR GARNHAM: It was said by Victoria and her alleged carer
19 that the boiling water was applied to relieve itching.
20 That might have been either the itching of the scabies
21 bug itself or itching resulting from dermatitis caused
22 by overtreatment of the scabies, might it not?
23 DR CAREY: Those are possibilities.
24 MR GARNHAM: Because both of those things cause itching?
25 DR CAREY: Yes, they certainly could do.
36
1 MR GARNHAM: Does hot water relieve itching from either of
2 those causes?
3 DR CAREY: I am not quite sure how to answer that. I think
4 most people would realise what the answer is going to
5 be. It gives you an alternative sensation in the same
6 area, of intense pain.
7 MR GARNHAM: Yes, thank you very much, Doctor. Unless you
8 have any further questions, sir?
9 THE CHAIRMAN: No. I am extremely grateful to you,
10 Dr Carey. You have been most helpful, thank you very
11 much.
12 (The witness withdrew)
13 MR GARNHAM: Sir, our next witness is Dr Alsford, please.
14 DR LESLEY ALSFORD (sworn)
15 MR GARNHAM: Please have a seat. Your full name, please?
16 DR ALSFORD: Leslie Joyce Alsford.
17 MR GARNHAM: And your professional qualifications?
18 DR ALSFORD: Bachelor of Medicine, Bachelor of Surgery,
19 Fellow of the Royal College of Paediatrics and Child
20 Health, Fellow of the Royal College of Physicians.
21 MR GARNHAM: And at which hospital are you based,
22 Dr Alsford?
23 DR ALSFORD: North Middlesex Hospital.
24 MR GARNHAM: Sir, Dr Alsford has provided a statement for
25 this Inquiry which is found in the green volumes at
37
1 volume 6, page 9. Dr Alsford's CPS statement is also in
2 our bundles, the black files, volume 46, at page 3. We
3 have the transcript of her evidence to the Central
4 Criminal Court in volume 51, page 156.
5 Dr Alsford, you were on call on 24th February last
6 year when you received a phone call from your registrar,
7 Dr Pahari?
8 DR ALSFORD: Yes, that is correct.
9 MR GARNHAM: Have I said his name right?
10 DR ALSFORD: Yes.
11 MR GARNHAM: Were you in the hospital at the time?
12 DR ALSFORD: No, I was at home.
13 MR GARNHAM: What were you told?
14 DR ALSFORD: I was told a child had come in, an eight year
15 old child, who was severely cold. I was also told that
16 it had been noted that she had injuries, and that
17 Dr Pahari was very concerned as to the nature of the
18 injuries, and how she could have got so cold.
19 I was given a summary of the medical treatment that
20 was being given as well at the time.
21 MR GARNHAM: Dr Pahari was your registrar, was he?
22 DR ALSFORD: Yes.
23 MR GARNHAM: Would you normally have come in on a report of
24 that sort, or was that an unusual report?
25 DR ALSFORD: That was an unusual report. I would come in
38
1 with that report, because it was unusual.
2 MR GARNHAM: The temperature that was detected in Victoria
3 was I think 27 degrees.
4 DR ALSFORD: Yes.
5 MR GARNHAM: Is that unusual?
6 DR ALSFORD: Yes, it is very unusual.
7 MR GARNHAM: Have you come across it before?
8 DR ALSFORD: I have done, but only in children that have
9 been in incidents of drowning in cold water, or near
10 drowning incidents in cold water.
11 MR GARNHAM: I think you went into the A&E Department?
12 DR ALSFORD: Yes.
13 MR GARNHAM: And you there examined Victoria?
14 DR ALSFORD: Yes.
15 MR GARNHAM: I wonder if the witness, please, could have
16 volume 38, page 19. We have there your notes. We can
17 see from the top left hand column that you carried out
18 an examination of Victoria at 00.30 on 25th February; is
19 that right?
20 DR ALSFORD: I believe that I examined her before then.
21 I did a brief examination when I first arrived, which
22 was around midnight.
23 MR GARNHAM: I see.
24 DR ALSFORD: Then I did several examinations between my
25 arrival at midnight and between about 2.30.
39
1 MR GARNHAM: Because presumably your first priority was to
2 start the vital first treatment?
3 DR ALSFORD: Yes, my first examination was not uncovering
4 her completely, because at the time, we were trying to
5 increase her body temperature, so that would have been
6 examining vital signs, and her breathing and
7 cardiovascular system.
8 MR GARNHAM: Was she dry at the time you examined her, or
9 was she wet?
10 DR ALSFORD: She was dry when I examined her.
11 MR GARNHAM: And she was in a warm hospital room?
12 DR ALSFORD: Yes.
13 MR GARNHAM: And her temperature, I think, began to rise
14 with the treatment Dr Pahari had given her?
15 DR ALSFORD: Yes.
16 MR GARNHAM: Up to 28.5 when you examined her?
17 DR ALSFORD: When I examined her, and then later up to about
18 32.7, something like that, at a later stage.
19 MR GARNHAM: Was Victoria conscious when you examined her?
20 DR ALSFORD: At one stage she was. She was not when she
21 initially came in, and at one later stage, she was
22 spontaneously opening her eyes at some stage, although
23 she was only moving when something was being done to
24 her, like when she was having blood taken, she would
25 flex a limb.
40
1 MR GARNHAM: Can you help us with your notes, please?
2 I confess I cannot read all of your handwriting. Is it
3 your handwriting in fact?
4 DR ALSFORD: On this page, yes.
5 MR GARNHAM: It begins "Admitted in July 1999 ...". This is
6 the history from the mother, as you understood the woman
7 to be?
8 DR ALSFORD: Yes, this was a history I took from Kouao.
9 MR GARNHAM: "Admitted in July 1999 ...". I wonder if
10 I could ask you to read on from there.
11 DR ALSFORD: "... with burns. Poured hot water over head.
12 In NMH. Following this, wetting and then soiling.
13 Didn't attend school. Seen by social worker. Appeared
14 active and otherwise well. Mother attended church, told
15 she had a bad spirit."
16 Then I have put the name of the church.
17 MR GARNHAM: We can see that.
18 DR ALSFORD: "Yesterday morning completely well, kicking in
19 the bathroom and hurt herself. Ate well yesterday
20 morning. Yesterday evening, refusing food, talking
21 slowly, confused and vomited after a drink. Only
22 coughed once. Slept all night, didn't wake up. Usually
23 wakes in the night. This morning didn't wake up, sleepy
24 and not responding. Woke up later, then slept again.
25 Went back [this is referring to Kouao going back] at
41
1 12.00, couldn't wake her up. Spoke to church at
2 3.00 pm, told she had a bad spirit and that she should
3 leave her. In the evening, tried to give her hot lemon
4 drink, couldn't drink it. Opening eyes but not talking.
5 Took her to the church this evening. Felt cold like an
6 ice block. Church told her to bring her to hospital."
7 MR GARNHAM: And then over to the other page.
8 DR ALSFORD: "Mother lives alone with her [I have put the
9 name of the mother] four other children in France
10 [I have put the ages]. Lives in a studio flat.
11 Landlord in the house, Carl Manning. Scratches herself
12 on hands and skin. Marks on wrist from a watch. Anna
13 has put elastic bands around wrists. Not taken any
14 medications except for holy water from the church. Puts
15 on her face and she drinks a little."
16 MR GARNHAM: If you pause for a moment, please, Doctor?
17 Presumably you are there simply recording what you have
18 been told; you are making no comment or judgment about
19 that.
20 DR ALSFORD: I was recording what I had been told, and some
21 of it would have been in response to specific injuries.
22 The last paragraph about her scratching herself, and
23 putting the -- getting injuries from the watch, and her
24 putting elastic bands around her wrists was as
25 a response to my asking her about the injuries that
42
1 I had noted on her arms.
2 MR GARNHAM: Did you form a view as to the truthfulness of
3 the account you were getting from Kouao?
4 DR ALSFORD: I felt it could not possibly be a truthful
5 account, on various accounts.
6 MR GARNHAM: But you have recorded verbatim or in summary,
7 as you hear it, without comment on its veracity?
8 DR ALSFORD: Yes, I have. I have recorded what she said at
9 the time.
10 MR GARNHAM: We then come on to your examination. You note
11 severe hypothermia.
12 DR ALSFORD: Yes.
13 MR GARNHAM: The next word I cannot read.
14 DR ALSFORD: "Now 28.7".
15 MR GARNHAM: Bradicardia.
16 DR ALSFORD: Bradicardia, which means a low heart rate, of
17 60 per minute.
18 MR GARNHAM: Blood pressure 90/40; how does that compare
19 with what it should be?
20 DR ALSFORD: That is a reasonable blood pressure considering
21 her age. As an eight year old, she would have a lower
22 blood pressure than an adult.
23 MR GARNHAM: Then if you would go on with the notes, please?
24 DR ALSFORD: "Opening eyes to pain and flexing to deep
25 pain."
43
1 That would be her response, for instance, when
2 somebody was taking blood from her or putting a line in.
3 "Otherwise no spontaneous movements. Respiratory
4 rate 30 per minute. Oxygen saturation 100 per cent."
5 MR GARNHAM: The significance of those?
6 DR ALSFORD: Respiratory rate of 30 is a little bit raised.
7 Saturation of -- oxygen saturation of 100 per cent is
8 normal, is the maximum.
9 MR GARNHAM: Yes.
10 DR ALSFORD: I think that says "bilateral prepitations",
11 which would be listening to her chest.
12 MR GARNHAM: Significance?
13 DR ALSFORD: She may have had something like some infection
14 in her chest, or some excess fluid in her chest.
15 MR GARNHAM: Is that a rattling sound in the chest?
16 DR ALSFORD: Yes, or it may have related to secretions in
17 her upper airways. Capillary refill 3 to 4 seconds; the
18 normal would be less than 2 seconds.
19 MR GARNHAM: So the significance of the fact that it is
20 slow?
21 DR ALSFORD: That is prolonged; it would reflect the
22 hypothermia, that it would be slow with the hypothermia.
23 The heart sounds were normal, no murmurs. Her abdomen;
24 I have put here "distended bladder". I changed my mind
25 on a later examination.
44
1 MR GARNHAM: Presumably she would be catheterised, would
2 she?
3 DR ALSFORD: She was not at this stage, but after my
4 examination she was catheterised.
5 MR GARNHAM: And the bladder emptied.
6 DR ALSFORD: The bladder emptied and she still had a very
7 abnormal distended abdomen, and I could at that stage
8 feel lots of hard faeces, so she was very severely
9 constipated.
10 MR GARNHAM: Yes.
11 DR ALSFORD: Pupils, 4 millimetres equal. Fundi not seen.
12 MR GARNHAM: Significance?
13 DR ALSFORD: Her pupils were normal, and at that stage I did
14 not look at her fundi, probably because she had swelling
15 around her eyes, so I did not look at her fundi at that
16 stage. Her skin, I have put:
17 "Swollen red hands and feet. Ligature-like
18 circumferential cuts around the left and right wrist".
19 MR GARNHAM: "Swollen hands and feet"; what does that tell
20 you.
21 DR ALSFORD: She had very red, very remarkably swollen hands
22 and feet.
23 MR GARNHAM: Would one not expect the extremities to be
24 blue, if she was cold?
25 DR ALSFORD: Normally you would, but occasionally you can
45
1 get a cold injury, if you have been very cold for a long
2 while, and although it is not a subject that I know
3 a lot about, I believe you can get reddening of the skin
4 with that. I also wondered about things like sometimes
5 with certain infections, you can get vasodilatation and
6 you can get reddening of the peripheries, so I did
7 wonder about infection as well.
8 MR GARNHAM: You have mentioned infection twice now, once in
9 relation to the chest sounds and once in relation to the
10 hands and feet. Did you ever reach a conclusion as to
11 whether there was evidence of infection?
12 DR ALSFORD: We did some investigations to look for an
13 infection. At the time, we strongly suspected
14 infection. She had several markers that may have
15 suggested that infection was contributing.
16 MR GARNHAM: And on tests, did you find any?
17 DR ALSFORD: On her initial blood test, she did have --
18 there is something called C reactive protein that can be
19 increased with infection, and hers were very high.
20 However, it can be increased with other causes as well.
21 We did cultures to look for infection, which would not
22 have come back at that time, they take about 48 hours,
23 and they were subsequently negative. I believe
24 St Mary's looked for infection and never found any
25 infection, but we did give her -- we gave her three
46
1 different antibiotics and the reason for that was I was
2 seriously concerned that she might be septisaemic, that
3 she might have an overwhelming infection.
4 MR GARNHAM: Your conclusion now, with the benefit of all
5 the information you know, is that she did or did not
6 have infection?
7 DR ALSFORD: She still could have done, but we did not --
8 there was not any significant infection on culture which
9 would make it unlikely.
10 MR GARNHAM: Thank you. Can we go back to the notes?
11 Forgive me, I have lost where we were up to on your
12 handwritten notes.
13 DR ALSFORD: I have put "Numerous old scars all over body.
14 Numerous round scars on legs. ?burns". I was thinking
15 they look a little bit like scars from cigarette burns.
16 I have put "appears malnourished and wasted".
17 MR GARNHAM: Is the next word "problem"?
18 DR ALSFORD: "Problems". I have put:
19 "Severe hypothermia. ?septisaemia. Probable
20 neglect/abuse."
21 MR GARNHAM: Then you come on to deal with the treatment,
22 I think. Perhaps you can finish that now, if you would.
23 DR ALSFORD: I have put "management as above"; that would
24 mean the registrar would already have recorded the
25 management that was being given, and I have put she was
47
1 on Cefataxin and Metronidosol.
2 MR GARNHAM: Are those both antibiotics?
3 DR ALSFORD: Yes, and I wanted to add in Gentomycin, another
4 antibiotic. I wanted to recheck a blood gas. I think
5 she had previously had a blood gas.
6 MR GARNHAM: Are these wide spectrum antibiotics?
7 DR ALSFORD: Yes.
8 MR GARNHAM: Is the aim to hit anything that you can?
9 DR ALSFORD: Yes. I was thinking maybe there were sort of
10 gramme negative type of organisms, and that I wanted to
11 hit anything we could. I have put "discuss with
12 anaesthesia re" --
13 MR GARNHAM: Sorry, where is "discuss with anaesthesia"?
14 DR ALSFORD: It says, "Recheck ABG [which is blood gas];
15 discuss with anaesthesia re intubation and ventilation."
16 MR GARNHAM: Thank you. If we could leave the last note for
17 a moment, we will come back to that, but I want to ask
18 you a little about the temperature; the very low
19 temperature initially and the slight warming up by the
20 time you saw Victoria. You have told us that that is,
21 in your experience, very unusual. Do you think it could
22 be accounted for by the factors we have heard about
23 subsequently, namely malnutrition, physical injuries,
24 being kept in a cold room, in a bath, naked?
25 DR ALSFORD: Yes, I think it was probably a combination of
48
1 things. At the time I was very puzzled, because I do
2 remember recalling it was not a cold night, and I do
3 remember afterwards when I left casualty to go home
4 thinking I only had a thin jacket on, and how could she
5 have got that cold on a night that was not cold?
6 I strongly suspected that she could have been in
7 cold water, because normally we would not see a child
8 with a temperature that low unless they had been in cold
9 water. I also considered -- I strongly thought, had she
10 been drugged, because that could account for her reduced
11 level of consciousness, her cold temperature, and also
12 the fact that I thought that she looked like she had not
13 been moving for a long time, not just that day.
14 I think in retrospect, it was probably a combination
15 of things. She had severe muscle wasting, and she also
16 looked very malnourished, she had very little
17 subcutaneous fat, and that would combine to her being
18 able to develop a very low temperature.
19 MR GARNHAM: In paragraph 15 of your statement you suggest
20 three possible causes for the severe hypothermia: in
21 water for some time, alcohol or drugs, and infection.
22 They are the matters you have talked about just now.
23 I think it is right there is no evidence of alcohol or
24 drugs.
25 DR ALSFORD: No.
49
1 MR GARNHAM: You have told us your conclusions on infection,
2 that it is unlikely, although possible.
3 DR ALSFORD: Mm.
4 MR GARNHAM: Enough infection to produce that sort of drop
5 in temperature, if there was any?
6 DR ALSFORD: I think if there was infection to that degree,
7 it would probably have been a bacterial infection we
8 would have picked up with our cultures, or St Mary's
9 would have done with their cultures.
10 MR GARNHAM: Therefore the absence of that suggests that
11 infection is not the cause for this drop in temperature?
12 DR ALSFORD: Yes.
13 MR GARNHAM: Which leaves, on your analysis, immersion in
14 cold water. Let me explain why this matters, Doctor,
15 because this is an investigation, not a trial. We are
16 trying to discover whether there is something more here
17 that we ought to be looking for. Ought we to be looking
18 to see whether there was evidence that this child was
19 kept in cold water, or are you confident that we can say
20 that the conditions to which she was subject are
21 sufficient in themselves to explain this very low
22 temperature?
23 DR ALSFORD: I think if she had been -- if she had been
24 unconscious or semiconscious, not able to move around,
25 kept restricted, malnourished and in a damp environment,
50
1 wet clothes, she could have got that cold. I do not
2 think it is absolutely necessary that she was completely
3 covered in cold water. It may be that she was washed
4 down with cold water, for instance, before she came in.
5 MR GARNHAM: Yes, thank you very much. The heart rate, you
6 tell us, was very low; had been 44 beats per minute, and
7 when you examined her it was 60. Should be 80 to 90?
8 DR ALSFORD: Yes, around that.
9 MR GARNHAM: Cause for that low heart rate?
10 DR ALSFORD: That would go with the low temperature.
11 MR GARNHAM: You have told us about the swelling to the
12 hands and feet, and how that could be a reaction to
13 prolonged exposure to cold. You note cuts to the hands
14 and wrists; any view on the causes of those?
15 DR ALSFORD: Yes, I think also I felt that the swelling
16 could be due to restriction of the circulation with
17 having a ligature. The cuts to the wrists were
18 noticeable in that they spared the anterior aspect of
19 both wrists, and were round most of the outside, as
20 if -- I thought she may have had her wrists tied
21 together, and the inside was spared. Also it was quite
22 noticeable that the marks on the lower legs were very
23 similar. There was some sparing of the inner aspect of
24 the legs as if she may have had her legs tied together.
25 MR GARNHAM: Yes, thank you. That is helpful. Your
|
