LETTER REGARDING CO-PROXAMOL

This letter, from a retired anaesthetist - published in the Daily Telegraph on 24th August -speaks of the inconclusive nature of one of the secondary averred causes of Dr Kelly's death: co-proxamol poisoning.


'the fact that the blood level of Dp was so low as to be below that necessary for cardio-respiratory dpression suggests that not many tablets ever arrived in the stomach.'

Sir

If David Kelly (Letters, August 23) did not die from ulnar artery blood loss, then can we be sure that death was even due to cardio-respiratory depression after ingesting co-proxamol?

The drug contains dextropropoxyphene (Dp) and paracetemol. Paracetemol overdose can cause death but only in excess of three days after ingestion. Dp can cause death within one hour but usually within a mean of five hours.

As a retired anaesthetist with training in pharmacology, I noted that the stomach was empty of capsules, which indicates the Dp was totally absorbed. But the fact that the blood level of Dp was so low as to be below that necessary for cardio-respiratory depression suggests that not many tablets ever arrived in the stomach. An empty blister pack is not proof of ingestion.

Wrting as a citizen of this country, I feel that there are enough untidy ends in this sad saga to justify a coroner's inquest in which scene-of-crime officers and specialists in pharmacokinetics, forensic pathology, toxicology and vascular surgery can explain inconsistencies.

Dr David Rutter
Romsey, Hampshire

PISS AND WIND:
DAVID AARONOVITCH ON THE DEATH DAVID KELLY

Tim Wilkinson's lively critique of David Aaronovitch's article in
Saturday's 'Times' (14 August 2010)

'There is no mystery over David Kelly's death' proclaims the headline. Well, in one sense you might say that: no mystery, no esoteric ineffables, no transcendent unknown. Of course that is not the sense in which the headline is supposed to be taken - not officially - but it sounds a lot more plausible that 'no room for doubt', 'no stone left unturned, or 'no unresolved issues'.....

KELLY'S DEATH: INACCURACY IN MEDIA

by Rowena Thursby

According to a recent report in the Independent, a frog-like jump across the lilly pad has transmuted the cause of Dr David Kelly's death from "haemorrhage" (Hutton Inquiry) to "heart attack" (Independent): "Kelly had heart attack, says pathologist" blares the headline.

Dr Jennifer Dyson, a retired pathologist, tells an Independent reporter, "there seem to have been a lot of pills in his stomach". I am not sure she has paid close attention to the forensic reports given to the Hutton Inquiry. Possibly her words reflect a common assumption: that Dr Kelly ingested all 29 of the tablets missing from the three blister packs beside his body - but did he?

Other than the existence of three blister packs with 29 pills missing found at the death scene, there is no real indication that Dr Kelly took all 29 pills, voluntarily or otherwise. There is more evidence that he did not.

• At the Hutton Inquiry, forensic toxicologist Dr Richard Allan, clearly stated that he found only a fifth of one tablet in Dr Kelly's stomach. He did not find the residue of anything approaching 29 pills.


• Dried regurgatative material was found in a line from both corners of Dr Kelly's mouth to his ears - more was distrbuted on the ground beside his body. This suggests that a substantial amount of any drug ingested would have been ejected.


• Although Dr Allan found the amounts of the two components of co-proxamol in Dr Kelly's blood to be possibly consistent with an ingestion of 29 pills, he seemed puzzled that this quantity represented significantly less - more than half - than the amount that would normally cause a fatality.


• Dr Robert Forrest, Home Office forensic toxicologist at the University of Sheffield, points out in a BMJ article that after death, concentrations of a drug increase - sometimes up to tenfold. If that is the case, Dr Kelly may need only have ingested two or three pills for Dr Allan's findings to make sense.


• US army interpreter Mai Pederson, a close friend and colleague of Dr Kelly's towards the end of his life, maintains that he had a medical condition: "unexplained dysphagia" - a condition that makes it very difficult to swallow pills, while food is taken without any problem.
  

The Independent further records Dr Dyson as saying: "my suspicion would be that he had a coronary attack, brought on by the circumstances he found himself in and the stress that that entailed".

So is that to say, Dr Kelly was found dead in the woods, with wounds to his wrist, pill packets and a knife beside him, but that was just coincidental - he died of a heart attack, nothing to do with poisoning or blood loss? Or does Dr Dyson mean the combination of blood loss and poisoning probably caused a heart attack? Only the latter is plausible - but is it so?

In recent days The Times has published a letter (reproduced below) from nine eminent medical specialists - one of them, Sir Barry Jackson, ex-president of the Academy of Forensic Sciences and past surgeon to the queen. They aver that, absent a clotting abnormality, it is 'extremely unlikely' that anyone would bleed to death from a single severed ulnar artery. In recent television interviews two of them have maintained there is a strong consensus on this point across the medical profession.

Venturing opinions, especially medical ones, without reference to the facts of a case seeds false ideas which take root in the public mind. In fairness to Dr Dyson, she did not baldly state, as the headline claims, that Dr Kelly had a heart attack. The reporter turned her opinion into an assertion.

Lord Hutton's conclusions on how Dr Kelly met his death are unsafe. Even the forensic pathologist to the Hutton Inquiry, Dr Nicholas Hunt, told the news-team at Channel 4 News that he would be 'more comfortable' with an inquest.
Today's Daily Mail reports that only one person in five believes Dr Kelly committed suicide. This was no ordinary death - Dr Kelly was at the centre of a political furore which threatened to bring down the British government.

The medical details surrounding Dr Kelly's death and the circumstantial details are complex. The many facets of the case need to be gathered and forensically analysed with care by independent experts in a public forum. Witnesses must be supoenaed, give evidence under oath and be cross-examined. That didn't happen at the Hutton Inquiry; a full inquest is essential.

DR KELLY WAS A BRILLIANT MAN WHO DID HIS BEST FOR HIS COUNTRY. WE OWE IT TO HIM AND TO OURSELVES TO DISCOVER THE TRUE CAUSE OF HIS DEATH.

In this powerfully argued article, doctor and barrister, Dr Michael Powers QC explains why justice demands an inquest is held.

Since his untimely death in July 2003, questions have continued to be raised about the circumstances of Dr David Kelly's death. Many wonder whether he really killed himself and speculate that he was murdered. His sudden death shocked the nation - how could it have happened?

As a specialist practioner in law and medicine, I feel a responsibility to the two professions to air my doubts about a case that bridges both worlds.

Any question of suicide or murder has to follow the determination of the cause of death. To do otherwise risks putting the cart before the horse. It would, for example, be scientifically and logically unsound to assume suicide and then to set about finding evidence to prove it.

Before asking whether the deceased himself or a third party put the bullet in the head, it is necessary to determine first that there was a hole in the head and secondly that the deceased died because of it.

For 1,000 years, coroners have been investigating sudden, violent and unnatural deaths. They have got good at it. Suicide used to be a crime and a finding of self-murder is an unhappy reflection on the victim and his family and friends.

That is why suicide has to be proved to the same high standard as murder. It has to be proved beyond reasonable doubt that the deceased did the act which killed him with that intention in mind.

The normal inquest process in the case of David Kelly was interrupted by the order of the Government. Lord Falconer, the Lord Chancellor at the time, exercised a rarely-used power to require the Oxfordshire coroner to adjourn his investigation and to give that responsibility to Lord Hutton.

The coroner had the power to compel witnesses to attend and to give evidence on oath. The Government which took our country to war with Iraq chose not to give these considerable powers to Lord Hutton.

Although there were 24 days of evidence taken over two and a half months, the whole of the medical evidence took no more than a half day. The evidence of the pathologist, toxicologist and forensic biologist can be read in 30 minutes. No one could say this was a detailed investigation into the death.

I was trained as a doctor and during my years in medical practice I often had to pass catheters into the radial artery in the wrist. This is where medics usually feel the pulse. It can even be seen pulsating in many people.

Dr Kelly's wrists were not slit. Neither radial artery was cut. This alone is a strange finding in someone who intends suicide by this method.

Deeper in the wrist on the side of the little finger lies the ulnar artery. It is not used for catheterisation because it is too small. Yet Lord Hutton, on the unchallenged evidence of a single pathologist, concluded that Dr Kelly bled to death from the severance of this single small artery in the left hand.

No courtroom drama would be complete without critical witnesses being challenged through the cross-examination process.

Like all barristers, I received a rigorous training in advocacy and, because of its enormous importance, I take time from my practice to train barristers in this art. A skilful cross-examination is often the key to ascertaining the truth.

None of this happened in Lord Hutton's inquiry and witnesses were simply led through prepared evidence. Reading the transcripts, far from providing any sense of satisfaction, leaves me with feelings of frustration. Opportunity after opportunity was lost to pursue answers until every avenue had been thoroughly explored and every "escape route " closed.

At the very end of his evidence, Dr Nichaols Hunt, the pathologist who had conducted the post-mortem, was asked: 'Is there anything else you would like to say concerning the circumstances leading to Dr Kelly's death?'

Such a question gives the witness who is favourably disposed to the questioner an open opportunity to go further than his witness statement. It is NOT a question ever asked in cross-examination as it provides a free pass to an escape route.

Dr Hunt answered: 'Nothing I could say as a pathologist, no'. He is an experienced expert witness. What on earth did that answer mean? He was there to give evidence as a pathologist. He knew that. Everyone knew that. So why did he give that answer? It begged the question whether there was anything else he knew. Was he concerned about any other forensic or factual evidence? These questions were never asked.

Hutton focused on the so-called dodgy dossier and the conflict between the Government and the BBC which, at that time, was more in the public eye. Because it was taken from granted Dr Kelly had killed himself, the medical evidence was insufficiently explored.

In the absence of any bleeding tendency from a clotting deficiency (and there was no evidence of this) fatal haemorrhage from a severed ulnar artery is so improbable that more evidence was essential before such a conclusion could be reached.

If you want to know how much beer has gone from a full pint glass, it is easy. You can either measure how much has been poured out or measure how much remains. To be confident, you would measure both. The same approach should have been adopted in this case.

As it was not, there is no evidence as to whether there was sufficient haemorrhage from the ulnar artery to cause death. The inquiry fell into the trap of the circular argument: Dr Kelly died, therefore he must have lost sufficient blood.

'In my work as a barrister I meet many medics but I have never met a single doctor who has disagreed with the propostion that is is extremely improbable that haemorrhage from a single, severed ulnar artery would ever be a primary cause of death.'

Yet this extreme unlikelihood was never explored with Dr Hunt. Whatever the reason, this was a serious failure of the Hutton Inquiry. It has understandably led to a suspicion of cover-up. This could not have been the cause of death, the argument goes. If it were not the cause, then what did cause his death? Was it something Dr Kelly did to himself, intending to cause his own death, which has not yet been discovered? Was it part of some elaborate plan by others to end his life?

The only way to stop the many theories which abound is for there now to be a thorough and open investigation by way of a fresh inquest. Surely the Government realises that the way to foster conspiracy theories is to be secretive and to resist calls to disclose all the medical evidence.

We should pay tribute to Dr Kelly. He was a brilliant man who did his best in the service of this country. He deserves our gratitude and respect. We owe it to him and ourselves to ensure the true cause of his death is ascertained.

Dr Michael J Powers QC is a barrister specialising in medical causation and a Fellow of the Faculty of Forensic and Legal Medicine of the Royal College of Physicians to which he is an appointed examiner.

From the "Mail on Sunday", 15 August 2010

13th August 2010

VIDEO:
ITN - EXPERTS DEMAND FULL KELLY INQUEST

13th August 2010

TIME FOR A PROPER INQUEST INTO DR KELLY'S DEATH

Sir
Amid the continuing interest surrounding the death of the government weapons inspector, the late Dr David Kelly, we wish to express our concern about the conclusion as to the cause of death in the light of the information now in the public domain. It is extremely unlikely, from a medical perspective, that the primary cause of death would or could have been haemorrhage from a severed ulnar arter in one wrist without any evidence of a blood clotting deficiency.

This small artery, deeper in the wrist than the larger radial artery used to palpate the pulse, would have retracted on being severed and within a short time blood loss would be expected to have ceased.

Insufficient blood would have been lost to threaten life. Absent a quantitative assessment of the blood lost and of the blood remaining in the great vessels, the conclusion that death occcurred as a consequence of haemorrhage is unsafe.

The inquiry by Lord Hutton was unsatisfactory with regard to the causation of death. A detailed investigation of all the medical circumstatnces is now required and we support the call for a proper inquest into the cause of Dr Kelly's death.

DR MICHAEL J POWERS QC
Barrister, Medical Practioner and Examiner to the Faculty of Forensic and Legal Medicine, Royal College of Physicians

PROFESSOR JULIAN BION
Professor of Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham

DR MARGARET BLOOM
Barrister, Former General Medical Practioner and Fomer Deputy Coroner

DR NEVILLE DAVIS
Consultant Forensic Physician

DR ELIZABETH DRIVER
Solicitor and Fellow of the Royal College of Pathologists

SIR BARRY JACKSON
Past president, British Academy of Forensic Sciences

DR JASON PAYNE-JAMES
Consultant Forensic Physician and Honorary Senior Lecturer, Cameron Forensic Medical Sciences, Barts and The London School of Medicine and Dentistry

PROFESSOR JOHN FRANCIS NUNN

DENIS WILKINS
Retired Consultant Vascular Surgeon