Monthly Archives: September 2011

LIGHTS OUT – AND THE DRESSING-UP BOX:

Killer Nurses – and Failed Governance

Part 3: The Evidence Gets Worse.

This is Part 3 of an investigation into the failure of the rule of law in Jersey.
In Parts 1 and 2 we have considered in detail the case of a rogue male nurse – and some of the evidence concerning his conduct, and the concealment of that conduct by the Jersey authorities.
I’m publishing below four, brief ‘up-date’ reports written by an expert witness.
The reports are so damning – and alarming – the Jersey authorities have done everything they can to try prevent them from becoming known to the public. Before explaining the context of those reports, here are a few quotes from them: –
From ‘Up-date 1’:
“I do not consider that the statement in paragraph 11 of the Review Officers witness statement is supported by the evidence. In my opinion the evidence is that examination of the clinical aspects of possible suspicious deaths on Corbiere ward was not thoroughly pursued.”
“In my opinion the investigation was terminated prematurely as clinical matters had not been thoroughly investigated.
“With regard to statement 19, in my interim report and addendum I have pointed out there were qualifications to this statement “all patients were seriously ill and their deaths were unsurprising” of the Clinical investigator. In addition, a report by the Clinical expert on 7th July stated that the death of a patient ‘could have been hastened’.
“That is a euphemism for the fact that the patient could have been killed. It is of note also that as I stated in my interim report, there is uncertainty as to the number of reports the clinical expert had completed when he made that statement.”

From ‘Up-date 2’:

 

“However it is difficult to make a plausible narrative of events between 25th June 1999 and the 7th July 1999.

 

“To explain, on 25th June 1999 the clinical expert had identified suspicious circumstances in the death of patient J. There had been serious irregularities in the administration of opiates, Nurse M appeared to have been at the centre of this. A doctor raised concerns at the time, and the clinical expert now raised concerns. (When his written report eventually produced he used a euphemism “hastened” death to suggest the patient may have been killed.) The police then prepared themselves to interview the doctors involved and anticipated that dead patient’s relatives may be contacting them. In effect all systems were readied to intensify the investigation as of 29th June 1999. Then just over a week later a review was held and the investigation was stopped.”
This new information serves to strengthen my previous conclusion that the police investigation was dropped prematurely. 

“I continue to consider that the clinical experts did not have the appropriate medical expertise, and that this was of considerable significance, and that the plan of subjecting the clinical expert’s concerns to a 2nd opinion should have been followed. 

 

“However, the new information suggests that further factors may have hindered the police investigation.”

From ‘Up-date 3’:
“The level of statistical analysis carried out on the data collected in operation Regent was very simple and used no statistical tests. This was very regrettable because with more skilled investigation considerably more valuable information and therefore evidence could have been extracted. For example the probability of the cluster of 7 deaths in February occurring during a period of Nurse M’s night duties could have been accurately measured.”
“The decision to compare the data for death rates per hours worked of Nurse M against the other nurses was a sound way to proceed, but again when the data showed that Nurse M’s rates were much higher than others, the data should have been analysed with statistical tests to draw accurate inferences from it. There were also further analyses that could have been done if statistical tests had been used.

 

“In my opinion, the opportunity to get valuable evidence from the data collected was missed.”

From ‘Up-date 4’:
“If the mathematical statistics had revealed the cluster of deaths was unlikely, then a cause for those deaths could be sought. An obvious one would have been that Nurse M had caused them. Again inferential statistics could have given a probability that he had not caused them.

 

“If reasonable statistics had been done the outcome of the meeting on 20th May 1999 could have been very different, and certainly the discussion would have been more enlightened. For example, one decision made at the meeting was that Nurse M was released from prison to home the next day. At the very same time a major homicide investigation of him was opened.”

Opiates, such as diamorphine and morphine, are not naturally found in humans and so their presence in someone who had not knowingly taken the drug would be very significant. Diamorphine is unstable and rapidly breaks down to morphine, but morphine lasts for many years. So the quoted statement is markedly misleading. Opiates were the type of drug probably used by Harold Shipman in most of his murders. Morphine was found in the bodies of several exhumed bodies and this fact was important in several of the guilty verdicts. The bodies were exhumed several months after burial. As far as I am aware opiates such as morphine are detectable in bodies, depending on the soil in which they are buried, over 100 years after burial. The comment regarding terminally ill depends on the definition used of terminally ill. Many of the patients reviewed in Operation Regent would not have been labelled terminally ill, and several were not prescribed opiates.”
The reports I quote from above – which are reproduced in full below – were prepared by an expert witness for use in my defence against being prosecuted for  whistle-blowing on the cover-up involving nurse M.
Nurse M is a rapist – and almost certainly a clinical serial-killer.
If that sounds an unlikely scenario, I recommend you read the two earlier postings. In Part 1, I published some brief quotes from twenty different cases in which different nurses were convicted for murdering and attempting to murder their vulnerable patients. I had no real idea before I began researching this subject just how common it is for killers to be found in the nursing profession. In many ways, it is the “perfect” occupation for those with the text-book psychopathy symptoms that cause them to have the urges to harm and kill others.
In Part 2,  I published some of the shocking evidence which shows how seriously the case of nurse M should have been taken – yet how startlingly defective were Jersey’s authorities in investigating the case.
Key amongst that evidence was the main report written by my expert witness for use in my defence case, when those same Jersey authorities were prosecuting me for exposing their failure in 1999 to investigate nurse M properly.
That main report was titled “Interim Medical Report: Attorney General V Stuart Syvret”. It was an ‘interim’ report – because to have been able to complete my defence case, we required further evidence to be disclosed by the prosecution. They refused to disclose all of that evidence; but a few, additional items were disclosed. This additional evidence enabled my expert witness to produce four, brief ‘Up-Dates’ to his main interim report.

 

It is those four documents I am publishing below.

 

In ‘Up-date 1’ – the expert witness assesses a witness-statement made by a Metropolitan Police officer who was involved in producing a 2009 ‘review’ of the 1999 investigation by the Jersey authorities. A number of the assertions by the reviewing officer are shown to be profoundly flawed. As is, indeed, the ‘Met Review report – which the expert witness addresses in ‘Up-date 4’, also published below.

 

In ‘Up-date 2’ – the expert witness assesses a statement made in 2009 for use in the prosecution against me. The statement in question is by the man who was the Police Senior Investigator in 1999, who, at that time was leading the investigation into nurse M. In this report, the expert witness shows how poor the 1999 investigation was – and how problematic are the attempts to try and defend it – ten years later – by the same man who is recorded in the minutes of 1999 as objecting to the fact the investigation was terminated – before  any of the doctors were interviewed.

In ‘Up-date 3’ – the expert witness offers a brief observation on claims made by the 1999 Police Senior Investigator concerning the statistical analyses of patient death-rates relied upon in 1999. Further criticism of that aspect of the 1999 investigation is included in the next report. 

 

In ‘Up-date 4’ – the expert witness provides a detailed critique of the 2009 ‘Review’, by the Metropolitan Police of the 1999 investigation of nurse M by the Jersey authorities. 

 

All of the evidential reports prepared by the expert witness are damning.

 

Damning of the performance and conduct of the Jersey authorities in 1999 – and, in many important ways – even more damming of the lengths the Jersey authorities have gone to, with external assistance, in 2009, and to the present day, in their efforts to prevent the truth emerging.

 

The work of the expert witness is so powerful and significant – that the Jersey authorities could produce no answer to it when it was submitted to court as my defence case against their charge of breaking the Data Protection Law by exposing the 1999 cover-up and the threat posed by nurse M to vulnerable people. 

 

In total, the expert witness produced five reports – the main document, and the four ‘Up-dates’. In many ways – it is ‘Up-date 4’ – his critique of the 2009 ‘Review by the Metropolitan Police – that is the most damning and most serious.

 

The Jersey authorities were conducting a malicious prosecution against me – to try and silence me – and punish me for whistle-blowing – for exposing their past failures and cover-ups. Their prosecution was based upon their claim that the public interest safe-guards in the Data Protection Law, which allow whistle-blowing, did not protect me, because – so they claimed – there was nothing wrong with the 1999 investigation of nurse M – and therefore nothing that needed exposing in the public interest.

 

The reports of the expert witness – as the public can now read for themselves – utterly destroyed that prosecution claim – and established my innocence.

 

The response of the Jersey prosecution and judicial establishment to the expert witness reports was to suddenly decide to have my entire public interest defence case deemed “inadmissible” – after three months of the proceedings  – and my work on the case.

 

What prompted such corrupt, oppressive behaviour will be clear to any thinking person who reads the evidence I publish below; the evidence the Jersey courts refused to hear.

 

In Part 4 of this series of articles – having established the evidenced facts in Parts 1, 2 & 3 – we will be turning to a close consideration of the conduct of Jersey’s prosecution and  judicial establishment; we will be examining some of the key decisions that have been made against me – and contrasting those decisions with the actual law. We will be examining the personal conduct of several of the key figures involved – and we will be asking ourselves – ‘just how much can the general public actually rely upon these people to protect us with the law?’

 

“Are the people depicted in the photograph below, and others like them, actually on our side?”

Until then – read for yourselves the evidence that so exposed the Jersey oligarchy – the evidence that they had no answer to. 

 

Evidence so shocking – that the Jersey authorities even went to the length of illegally denying me my right to a fair trial.

 

Stuart.

Up-date 1 to Interim Medical Report:

 

Attorney General V Stuart Syvret

 

12th October 

 

“This update is subsequent to my reviewing recently available information in the Folder AG v Syvret Disclosure: Unused Material 9/10/2009. In it were Documents 70, 71, 72, 73. 74, 75

 

Of particular relevance to my instructions was document 70, the witness statement of the Review Officer who was commissioned in April 2009 to review Operation Regent, the name given to the police investigation of possible homicide by Nurse M. 

 

A general comment is that the Review Officer looked at the form of the clinical aspects of the investigation but did not look in detail at the conduct of the clinical investigation, probably because he did not have the expertise to do so. My opinion is that the conduct of the investigation was unsatisfactory for reasons I have detailed in my interim report. In that report I also detailed the evidence that an important part of the structure of the investigation was also unsatisfactory, in that the requirement for a 2nd opinion on cases where the clinical expert raised concerns was not followed. Therefore, for that and other reasons given in my interim report, I do not consider that the statement in paragraph 11 of the Review Officers witness statement is supported by the evidence. In my opinion the evidence is that examination of the clinical aspects of possible suspicious deaths on Corbiere ward was not thoroughly pursued.
With regard to statement 14, in my interim report I have covered in some detail why I consider that the choice of clinical expert appeared to be flawed, despite the fact that Good Practice was followed by the Police. In addition I have pointed out that there were in fact two clinical experts, and the fact that the expertise of the second expert has not been detailed, despite the very important role that she played in the investigation. 

 

With regard to statements 15, 18, & 20 I repeat my view from the interim report that for a thorough clinical investigation the doctors should have been interviewed. This was the plan of the Police investigators, and as mentioned in my interim report the Police Senior investigator was minuted making this point strongly at the meeting of 7th July 1999. These are quotes attributed to him on that day. “I feel there is a chance of obtaining something remote but serious, for example the anaesthetist was angry that the notes were missing. A doctor may have encountered something which isn’t on the notes.” He also said on 7th July 1999 “I personally would have liked to have done the doctors and nurses.” And the note from the Police file of 24th June 1999 stated “Two police officers to have full access to the medical record of Patient J. To ensure the thorough investigation of the circumstances surrounding his death and allow the investigators to raise points raised by Dr Sd with members of the medical profession at the General Hospital.” In my opinion the investigation was terminated prematurely as clinical matters had not been thoroughly investigated.
With regard to statement 19, in my interim report and addendum I have pointed out there were qualifications to this statement “all patients were seriously ill and their deaths were unsurprising” of the Clinical investigator. In addition, a report by the Clinical expert on 7th July stated that the death of a patient ‘could have been hastened’.
That is a euphemism for the fact that the patient could have been killed. It is of note also that as I stated in my interim report, there is uncertainty as to the number of reports the clinical expert had completed when he made that statement. 

With regard to Statement 22, in fact several of the patients had died within a few months of the Police investigation. Of great importance is the fact that it was documented that a Forensic Pathologist linked to the investigation. Was the Pathologist’s opinion ever sough on these matters, and if so what was it?

 

With regard to statement 23, with regard to ongoing management of risk of this man, it is of note that the Police Senior investigator continued parts of the enquiry even after it was officially closed. 

 

With regard to Documents 73 above they allow me to give further information on the Mental Health assessments of this case. This was Part 10 of my interim report, and in my final report this Part will be fully amended. However, I consider that an initial update is timely. In 1999 Nurse M had apparently been given a diagnosis of Post Traumatic Stress Disorder related to time he spent in the Gulf War. This diagnosis probably was given in separate reports of a Consultant Psychiatrist and Forensic Nurse produced in August and October 1999. This supports my view that Nurse M’s full forensic history was not revealed to the report writers, but I would need to be able to see the reports before being definite. The UKCC in 2001 was reported in the H&SS committee meeting of 5th September 2001 as having accepted medical evidence that nurse M was not a risk to the public. 

 

According to HISS committee meeting minutes of 6th March 2002 a further Psychiatric report was completed by a different Consultant Psychiatrist, based in the UK, on 26th February 2002, with a supplement on 4th March 2002. The report referred to the fact that Nurse M’s Post Traumatic Stress Disorder was ongoing, but that Nurse M felt he could cope with the symptoms. The Consultant Psychiatrist felt he was fit to practice professionally as a nurse, operate a nursing agency, and run a nursing home. He commented there was a risk of relapse of depression but felt this risk could be reduced by regular antidepressant medication. 

 

It was noted during the meeting that Nurse M was being investigated for a serious breach of professional conduct in a local nursing home. I consider that this was probably the case I referred to in my interim report in Part 7, which I stated has taken place around 2003.

 

In my view the report again suggests that this man’s full forensic history had not been revealed to the Psychiatrist, and so an accurate Mental Health assessment was not carried out, particularly in relation to a personality disorder. I would need to see the actual report to be certain.”

Up-date 2 to Interim Medical Report:
Attorney General V Stuart Syvret

 

12th October

 

“Further to my interim report of 7th October 2009, I have reviewed the bundle of documents in the file labelled “AG v Syvret Material disclosed at Court 07/10/2009.” 

 

I examined the recent statement of the person who was the Police Senior Investigator of Nurse M in 1999, and the Major Crime Policy File of the Police from the investigation. Both documents had information relevant to the assessment and management of risk to others by Nurse M. 

 

The ex- Police Senior Investigator gave a witness statement to the police on 29th September 2009 which contains information of considerable importance to the Medical aspects of the case which I detailed in my report of 7th October. He refers to Nurse M having worked in a specific Jersey residential home post 1999. This residential home is different to the one in which I was already aware he had worked, as described in Part 7 of my previous report. Therefore to my certain knowledge he has worked in at least two Jersey residential homes post 1999. 

In paragraph 9) of his witness statement the ex- Police Senior Investigator described his action of initiating at his own insistence a further less formal continuation of the investigation following the official closure of the investigation on 7th July 1999.
This adds considerable weight to my previously expressed concern that the Clinical part of the police investigation was prematurely stopped. If there are any notes or further detail about his informal investigation, it would be helpful if I could review them. 

In paragraphs 6) &7) the Police Senior Investigator describes what I would label as a Risk Management Strategy and actions. In my previous report I identified concerns with how this man’s subsequent risk was managed. The Police Senior Investigator obviously reached the same concerns and acted on his own initiative. It would be helpful if I could see any relevant documentation on this matter from the Police Senior Investigator and from the Health Services.

On reviewing the major crime policy file which tabulates decisions taken by the Police investigating team and their reasons from 18th April 1999 to 9th July 2009 there are a number of relevant items. I have documented selected extracts.

 

Be aware these are not the complete notes, but those part notes I consider relevant to my task. I have not included all the dates or in all cases the complete notes made on those dates. Also the emphases are mine. I make comments in italics. 

On 14th May 1999 It is noted “Secure the most suitable expert to advise on the medical evidence collated in this case. Medical evidence will play a key role when interpreting medical opinion.” 

 

On 24th May 1999 It is noted that “medical expertise on the treatment of patients will be imported from the UK to avoid a conflict of interest”
On 27th May 1999 It is noted “Weekly meeting of Police Senior Investigator and deputy arranged with hospital representatives. The hospital will be invited to nominate a senior nursing officer to assist in the investigations…. A Nursing Officer appointed to the case could facilitate an understanding of ward procedures and practice.” (There is no record in the bundles to suggest that this happened.)

 

27th May 1999 It is noted Police Senior Investigator “to provide a concise briefing note wkly to distribute to the seniors.” 

 

1st June 1999 It is noted “From the review of the notes the focus of attention will be on the nurses. Doctors mentioned will be interviewed in Phase 2. The nursing staff tends to spend a high degree of time with the patients doctors spend very little time with the patient although we recognise they may have evidence and information which will need to be collated.” 

3rd June 1999 It is noted “Engage the expert Dr Sd. Expert opinion required on the cause of death and treatment of patients at the General Hospital.” 

 

8th June 1999 It is noted “Concern re missing documents. Concern re level of care of patients on Corbiere to be raised on completion of the study. Investigation severely hampered by missing docs
14th June 1999 It is noted “The hospital in the form of [Chief Executive G J] has asked that living patients are not approached to avert any distress to them. If suspicious activity is identified on the patient notes the situation will be reassessed.” 

22nd June 1999 It is noted that Nurse M’s legal representative is to be informed that Nurse M is “to be told he will be interviewed further concerning the current investigation”. (I believe on this date Dr Sd and Mrs Sd began their investigation of the records. However, the controlled drug book was not available to them until 24th June 1999 which hampered their assessments.) 

24th June 1999 It is noted “today 2 deaths have been identified which give cause for concern. The need to assess each file carefully is paramount.” (This comment probably relates to Dr Sd’s investigation.) 

 

24th June 1999 It is noted “The investigation teams to interview all Nursing Staff identified as having contact with 8 patients highlighted by Dr Sd as requiring further investigation. The documentation or speed of death, or conflicting documentation give cause for concern and the observations of staff will be essential to assess the situation effectively.”
24th June 1999 It is noted “Attempt to identify any suspicious behaviour on the part of Nurse M or any other member of staff to account for the deaths of the 8 deaths highlighted by Dr Sd.” 

 

25th June 1999 It is noted “Two police officers to have full access to the medical record of Patient J. To ensure the thorough investigation of the circumstances surrounding his death and allow the investigators to raise points raised by Dr Sd with members of the medical profession at the General Hospital.” (I referred to Patient J several times in my interim report. The report on Patient J was completed on 7th July 1999 and so was probably not available to the meeting that day at which the decision to stop the investigation was made. It was certainly not completed by when Dr Sd wrote his summary letter of 5th July 1999. Dr Sd wrote in his report of Patient J “in my view the death was from natural causes but, however it could have been hastened.” That is also the case referred to in the first meeting of 7th July 1999 when the Police Senior Investigator argued in favour of interviewing doctors as minuted “I feel there is a chance of obtaining something remote but serious, for example the anaesthetist was angry that the notes were missing. A doctor may have encountered something which isn’t on the notes.”)
(I believe Dr Sd and Mrs Sd arrived in Jersey on 21st June 1999 and returned to the UK 3 to 5 days later.)
29th June 1999 It is noted “In the event of the patient’s relative contacting the incident room inquiring about a person subject to investigation the SIO, deputy SIO or nominated person will call on them personally to explain the circumstances surrounding the Police interest in their dead relative

 

The entry in the next note page is not readable at all as the content of the page is blocked out by a typed note placed over it of the decision of 7th July 2009 of the Deputy Chief Officer of Police to stop the investigation. The typed note has a stamp that it was signed on 14th July 2009. The written entry of that page is therefore completely covered and not readable. There are also typed minutes of the meeting at which the decision was taken to stop the investigation which give identical reasons. The reasons in the typed note and the typed minutes are “Decision has been made to terminate the investigation at this point. Despite exhaustive enquiries with nursing staff no further evidence has been gained. Despite the employment of an expert no firm evidence has come to light in relation to the patient deaths. There is circumstantial evidence of death rate and anecdotal evidence of” Nurse M’s “behaviour, there is no corroborative evidence on which to base further investigation. Given the chances of finding that evidence are utterly remote it has been decided that the enquiry be put on hold.” In the typed minutes additional comments include that the Deputy Chief of Police stated “There is a risk in terminating the enquiry now but given the lengths we’ve gone to in the last 8 weeks, I don’t feel we are in a position to be criticised.” He also commented “the enquiry has not been helped by outside organisations.” (There is no explanation of which organisations these are or how they have not helped the Police enquiry)
On 8th July 2009 there is a note that refers to the presumably hand written decision on the covered page It is noted “The decision has been made to bring the investigation to a halt, the actions which have been discontinued comply with the policy decision 75.”

There are several further notes relating to the process of winding up the investigation, the final note being dated 9th July 2009.
Comments on this new information

 

I consider this further information adds considerable support to my opinion that the police investigation was terminated prematurely. In addition I consider that a more experienced Medical investigator could have given more definitive advice to have assisted the Police’s very difficult decision, and thereby provided a more authoritative assessment of risk. 

However it is difficult to make a plausible narrative of events between 25th June 1999 and the 7th July 1999. 

 

To explain, on 25th June 1999 the clinical expert had identified suspicious circumstances in the death of patient J. There had been serious irregularities in the administration of opiates, Nurse M appeared to have been at the centre of this. A doctor raised concerns at the time, and the clinical expert now raised concerns. (When his written report eventually produced he used a euphemism “hastened” death to suggest the patient may have been killed.) The police then prepared themselves to interview the doctors involved and anticipated that dead patient’s relatives may be contacting them. In effect all systems were readied to intensify the investigation as of 29th June 1999. Then just over a week later a review was held and the investigation was stopped.
Something significant seemed to have happened in this period to change the whole direction. The Police Senior Investigator, his deputy, the clinical investigator were unhappy with the decision, and even the Deputy Chief Officer of Police, with his comments about risk and hints of outside interference, was uneasy.
Conclusions

 

This new information serves to strengthen my previous conclusion that the police investigation was dropped prematurely. 

I continue to consider that the clinical experts did not have the appropriate medical expertise, and that this was of considerable significance, and that the plan of subjecting the clinical expert’s concerns to a 2nd opinion should have been followed. 

 

However, the new information suggests that further factors may have hindered the police investigation. 

 

I must point out that in my declaration of interest about this case, and in my interim report I referred to Mr. G having mentioned to me around 1999 that he was under pressure to agree to the exhumation of the bodies of patients in relation to the investigation of a Nurse. There is no mention of this in the bundles I have seen, but there is reference to a Forensic Pathologist having been involved in the investigation. It would be helpful to know who that person was, and whether he gave advice around this time.”

Up-date 3 to Interim Medical Report:

 

Attorney General V Stuart Syvret

 

12th October 2009 

 

“Comments on the witness statement of the ex-Police Senior investigator in relation to the Statistical investigation on of the Data collected in 1999 in relation to Deaths on Corbiere ward.

The level of statistical analysis carried out on the data collected in operation Regent was very simple and used no statistical tests. This was very regrettable because with more skilled investigation considerably more valuable information and therefore evidence could have been extracted. For example the probability of the cluster of 7 deaths in February occurring during a period of Nurse M’s night duties could have been accurately measured. There is an inference in the intuitive analysis that the investigators carried out, that the cluster was not particularly remarkable. However, a more skilled statistical analysis could have produced an accurate figure of the probability of this cluster having arisen by chance. In my view from the raw figures I would anticipate that the probability of this being a chance finding would be very low, and that it would have strongly suggested that some of these deaths were not natural. This could have helped the clinical investigation as it appears that 3 of the 7 cluster of cases were not reported on by the clinical expert.

 

The decision to compare the data for death rates per hours worked of Nurse M against the other nurses was a sound way to proceed, but again when the data showed that Nurse M’s rates were much higher than others, the data should have been analysed with statistical tests to draw accurate inferences from it. There were also further analyses that could have been done if statistical tests had been used.

 

In my opinion, the opportunity to get valuable evidence from the data collected was missed.”
Update 4 to Interim Medical Report:

 

Attorney General V Stuart Syvret

 

A consideration of the 2009 Metropolitan Police Review.

 

19th October 2009

 

“This update is subsequent to the part of my update 1 in which I considered the witness statement of the Review Officer who was commissioned in April 2009 to review Operation Regent, the name given to the police investigation of possible homicides by Nurse M. The report was entitled “A Review of the States of Jersey Police Investigation in 1999 known as Operation Regent.”

This review is of the original report, a copy of which I was shown a few days ago. I refer below to selected extracts of the report related to my task as outlined on the title page. In bold type I make comments. The paragraph numbering is from the original document, and my comments should be referred to that document.

 

In 2.8 of the report are detailed the reasons that while in the police force Nurse M “failed to satisfactorily complete the probationary period, the four reasons being given as irrational behaviour, consistent failure to seek advice, consistent failure or refusal to follow advice given and regular indications of mistrust between him and his peers.”
This adds information to the psychiatric assessment giving details of personality and conduct disorder which are suggestive of psychopathy.

 

In 2.9 it is commented that medical reports from Nurse M’s GP and also a Psychiatrist indicated that he has suffered from post traumatic stress syndrome. “In January 1999, his GP diagnosed depression…”
It may be of relevance that on 1st January 1999 there was a suspicious incident with a drip in relation to patient D, which could have had lethal consequences, and led to a serious complaint being made against Nurse M. It is therefore possible that the depression was linked to stress around the investigation of the complaint.

 

2.23 Efficient control methods were in place to monitor the issue of controlled drugs i.e. morphine It was therefore not possible to draw any inferences, even less glean any evidence from this line of inquiry.
Unfortunately this important passage is wrong. The management of controlled drugs was very poor as was repeatedly stressed by the Clinical expert, Dr Sd. Also morphine is just one of several controlled drugs. 

2.24 & 2.25 Dr G F, a home office Pathologist was asked to give an opinion by the SIO on exhumation and he “concluded that it would be extremely unlikely that the relevant drugs (e.g. insulin, potassium chloride) would be traceable in any of the bodies.”
Unfortunately the Review does not make clear what form this advice took. Was it a written report, was it advice over the phone. Also the Review does not indicate the timing of the advice. As some of the case reports related to the possible misuse of controlled drugs by Nurse M, if Dr F was not asked about the possibility of detecting opiates such as diamorphine in the bodies then that was regrettable. Also there was other evidence that could have been obtained from a post mortem, such as detecting whether the cause of death on the medical certificate could be confirmed. It does seem likely that in fact Dr F’s opinion was sought very early in the police investigation, before the clinical expert’s review of the case notes had commenced. This would explain why no opinion was attributed to the Pathologist regarding how to proceed when abuse of opiates was suspected by Dr Sd’s investigation.

 

4.1.4 Refers to Nurse M performing violent rapes and assaults.
This again points towards psychopathy.

 

4.1.12 The Chief Officer of Health was not persuaded by the analysis of the death rates and when we discussed this with him he considered them “fanciful notions” pointing out that using data in such a way could be very misleading.
The Chief Officer of Health appeared to have little understanding of statistics.

 

4.1.15 There was only seen to be “limited evidence” of wrongdoing.
In my view this was a lamentable mistake. Bearing in mind my limitations in statistics previously detailed, I feel I must illustrate simply how inferential statistics could have identified the probability of the sort of clusters of deaths found in Corbiere Ward occurring by chance. Bear in mind that natural deaths tend to have an equal chance of arriving any day of the week and any hour of the day. It is stated that there were on average 4.5 deaths per month in Corbiere Ward. Therefore if to markedly simplify the illustration, we can assume there can only be one death per day. Then every day there is approximately a 1 in 6 chance of a death/event. It is like rolling a dice. If a 6 means there is one event that day, then when there has been one 6 rolled there is a one in 6 chance there will be an event the next day.

 

We can see the chance of a cluster of 6’s thus

2 events in a row – 1 in 6

3 events in a row – 1 in 36

4 events in a row – 1 in 216

5 events in a row– 1 in 1296

6 events in a row – 1 in 7776

 

This is not a perfect model because more than one event can occur on one day which alters the calculation and could increase the chance of clusters, but the maths is much harder to follow. But it is a good illustration of the powerful information that can be gained from data using more ―mathematical‖ statistics.

 

Another good way of analysing the statistics is one that was used in the Shipman investigation. If the question was whether Nurse M was killing patients, then patients would be more likely to die when he was there or in the hours afterwards. If the day was divided into quarters there would be the least deaths in the quarter just before he came on duty. In addition Nurse M’s pattern could be compared with other nurses. 

 

Statistics usually only show the probability of an event happening by chance, they don’t prove that it was not chance. In the model above a cluster of 6 events would occur by chance about once every 20 years. 

 

If the mathematical statistics had revealed the cluster of deaths was unlikely, then a cause for those deaths could be sought. An obvious one would have been that Nurse M had caused them. Again inferential statistics could have given a probability that he had not caused them.

 

If reasonable statistics had been done the outcome of the meeting on 20th May 1999 could have been very different, and certainly the discussion would have been more enlightened. For example, one decision made at the meeting was that Nurse M was released from prison to home the next day. At the very same time a major homicide investigation of him was opened.

 

4.1.26 When referring to the poor state of the records the reviewers suggested there should have been a comparative “dip-sample of other medical records.
The SIO had requested this but the Hospital would not cooperate.

 

4.1.33 Nurse M was discharged from the army in 1986 for “found in improper possession of medicines, AWOL for 7 days, found in possession of an offensive weapon (flick knife).
This is more evidence of psychopathy. 

 

4.1.40 “It was noted that he did not like taking orders and continually blamed others for his shortcomings”.
This is more evidence of psychopathy. 

 

4.1.43 “numerous members of staff spoke of bizarre behaviour and of concerns for their welfare”.
These were police staff.

 

4.1.49 & 4.1.50 some staff found him “uncaring, unprofessional and a potential danger to patients but there were those who found him pleasant to work with and considered him a good nurse.”
This divisiveness is indicative of a personality disorder. 

 

4.1.50 “There were many who thought of him as a sexual predator and there was evidence that he was over familiar with young female patients and relatives.”

 

One nurse gave evidence “of an indecent assault while she attended to a patient.” This is more evidence of psychopathy.

 

4.1.52 to 4.1.78 The Review team reviewed the clinical assessments of the patients by Dr Sd and drew their own conclusions about the cases.
In my view the Police Officers did not have the expertise to be making these assessments. They should have been carried out by a doctor with suitable experience of the type of cases he was reviewing.

 

4.1.80 This relates to the discussion of the cluster of deaths on Corbiere ward and the marked increase in the death rate, From 1st March 1998 to 31st March 1999 there was an average of 4.5 deaths per month, but in February there were 7 deaths in 4 days when Nurse M was on duty and 5 deaths in March when Nurse M was on duty or shortly afterwards. It was thought they could have been explained by a serious bout of flu in the hospital at the time or foul play. The Chief Officer of Health pointed out there had been a bout of flu at the hospital at the time.
Did Dr Sd identify these patients as dying of flu? Was it on the medical certificates? Was there an increased death rate in the two other medical wards at the same time? I feel the most likely answer to these questions is no, otherwise mention of flu would have appeared elsewhere in the records. 

 

The Chief Officer for Health “added that his own wider research had not found any particular deviances in death rates at this time.”
As it stands this sentence is meaningless.

 

4.1.90 Of the 16 deaths, ten had been cremated and of the 6 burials none had been the subject of a post-mortem examination. Only two of those cremated had received a post mortem.

 

4.1.91 The SIO had considered exhumations but felt the lack of evidence did not justify that course of action. The review team strongly support that decision and had seen no evidence that would support a change of position in respect of this. They refer to paragraphs 4.2.18. to 4.2.24 to support this claim.

 

4.1.92 45 members of staff were seen by police and a questionnaire and/or statement was obtained.
It would have helped in the understanding of the process if figures were given for the number that gave statements and the number who solely filled in questionnaires. 

 

4.1.94 – 4.1.99 detailed allegations of extremely violent and sadistic behaviour against a woman over a period of time which took place in England. The complaints were not investigated in England as the woman was unwilling to participate.
This is evidence of psychopathy.

 

4.2.19 – 4.2.20 The Review team evaluated the decision made not to exhume bodies 6 months after the death (presumably in 1999) and then 10 years after the death (presumably in 2009) . They sought expert opinions from two doctors with appropriate experience. “Both gave identical opinions that given the circumstances there was little or no likelihood of detecting insulin and potassium chloride in the bodies after 6 months or 10 year internment. One doctor stated it was almost impossible to detect potassium chloride within 24 hours of death,”
This is a critical part of the review with regard to the clinical part of the investigation. Therefore it is disappointing that the reviewers have not been more explicit about how they obtained their information. Was it by phone or letter? What questions were they asking? Did Forensic experts approve this paragraph?

I do not have the expertise to state whether insulin would be present 6 months or 10 years later, but some of the relevant deaths in the 1999 investigation had occurred less than three months previously. 

I provide a link to a newspaper report which states that Morphine and Insulin were found in exhumed bodies.

 

This comment is unattributed. The impression in the report though is that this also the opinion of the experts, one an accredited Home office Pathologist, and the other an experienced toxicologist. If this is the case the manner in which the opinion was obtained was not apparent. Opiates, such as diamorphine and morphine, are not naturally found in humans and so their presence in someone who had not knowingly taken the drug would be very significant. Diamorphine is unstable and rapidly breaks down to morphine, bur morphine lasts for many years. So the quoted statement is markedly misleading. Opiates were the type of drug probably used by Harold Shipman in most of his murders. Morphine was found in the bodies of several exhumed bodies and this fact was important in several of the guilty verdicts. The bodies were exhumed several months after burial. As far as I am aware opiates such as morphine are detectable in bodies, depending on the soil in which they are buried, over 100 years after burial. The comment regarding terminally ill depends on the definition used of terminally ill. Many of the patients reviewed in Operation Regent would not have been labelled terminally ill, and several were not prescribed opiates.

 

4.2.22 The Review team “expressed the opinion that given the circumstances at the time the decision not to exhume the bodies in 1999 was correct and there would be no evidential benefit to the investigation to do so ten years later”.
But what was the opinion of the Forensic experts? Did they not ask them?

 

Even in the unlikely event of the presence of any of the relevant drugs in any of the bodies, proof that the drugs had been administered by Nurse M would be at best circumstantial.)”
It is of note that neither Dr Shipman nor Nurse Colin Norris, both convicted patient killers, were witnessed administering the drugs that killed their patients.

 

4.2.26 The Review team commented that the Police Senior Investigating Officer in 199 “sought the advice of Home Office forensic experts and other renowned forensic practitioners. This gave him access to the forensic interpretation of the medical records, the psychological background of the suspect and the issues around exhumation.”
It would be helpful if the names of these could be documented. The only Home Office Forensic expert involved in 1999 that is mentioned by name is Dr Fernando referred to in 2.24 and 2..25. There is no record I have found that any Forensic expert was consulted with regard to the detection of opiates, in particular diamorphine, by exhumation.

 

The information on psychological background of the suspect seems to have originated from Richard Walter which has now shown to be of dubious value. In my view it is regrettable that it appears that the opinion of one of the local mental health practitioners was not sought. None of the local mental health workers seem to have been aware at the time of this investigation. In particular, the prison Psychiatrist who probably looked after Nurse M in the prison and during his treatment in the Psychiatric ward under bail conditions seems to have been unaware of these allegations. I will be able to make more comments on this matter if I have sight of the relevant Psychiatric records.

 

The Forensic interpretation of the medical records would in my view have been much improved if the clinical experts appeared to have had a reasonably up to date experience of practising in an acute medical admission ward as that is where the suspicious deaths occurred. The plan outlined in the police strategy document of providing a 2nd opinion when that clinical expert had concerns was not followed. 

4.5.4 This reports that the SIO submitted “a report to his Chief Inspector requesting 4.5.4 This reports that the SIO submitted “a report to his Chief Inspector requesting deployment of an undercover operative at a local nursing home to work alongside Nurse M.
This demonstrates continuing concern about the risk posed by Nurse M. There is no comment on what happened to this request.

 

4.5.5 “In 2002 intelligence was received …that Nurse M was no longer working at the nursing home as he had been sacked for having consensual sex with a patient suffering from multiple sclerosis.” As a result he was being investigated by the Medical Officer of Health.

 

4.5.6 & 7 & 8 The review team detailed evidence that Nurse M was a sexual predator on vulnerable women, he was a “control freak”, and he regularly passed himself as a more senior nurse than his rank.

 

4.5.9 & 10 & 11 The Review team considered that Nurse M was unlikely to change his behaviour and recommended that SOJP carry out an up to date risk assessment around Nurse M with a view to prevention of offences against vulnerable members of the Jersey community.

 

5.3 As part of their conclusions the Review team stated “While exhumations were considered and the advice of a leading pathologist obtained, the evidence did not support this.”
The Review team did not present sufficient evidence in their report to support this statement. In particular it would be relevant to know when the advice of the Forensic Pathologist was sought, what questions were asked, what information was available to him, and what form did his response take?

 

5.5 The Review team were satisfied that there are no potential new lines of enquiry that would be relevant.
Important comment by the author of this report (Update 4 to the interim report)

I repeat again that the inferential Statistics I have shown are just illustrative and are not a perfect model for this case. They are simply given to show the power of inferential Statistics and why they should have been carried out in this case. 

 

Comments 

The notes above are highly selected by me in relation to the précis of my instructions on the title page. The full Review report is 53 pages long. In my up-date 1 to the interim report I have commented on the witness statement of the police officer who led the Review which is the subject of this update. When I produce my final report I intend to merge the information in to one Report. However, I keep being given further bundles, and there are regular hearings for which the Defence is instructing to produce additional reports. Therefore I am not as yet able to integrate the interim report and the 4 Update reports.

 

In Update 1, I stated “Of great importance is the fact that it was documented that a Forensic Pathologist linked to the investigation. Was the Pathologist’s opinion ever sough on these matters, and if so what was it?” These questions are only partially answered in this full Review, and if they represent the sole input from the Forensic Pathologist in 1999 I consider that was far too limited to have been of much assistance to the clinical aspects of the Police investigation. Indeed, there is no evidence that the Forensic Pathologist’s input was more than one phone call early on in the investigation in response to the finding of stolen charged insulin syringes and vials of potassium chloride. No evidence is presented that he was involved in decision-making after the clinical expert had examined the case notes and found marked irregularities in the use of controlled drugs? In particular was the Forensic Pathologist ever asked to advise whether bodies be exhumed to examine for opiates? No evidence is presented that he did.

 

With regard to the recent Police Review, I consider that the opinions of the Forensic Toxicologist and Forensic Pathologist were crucial to the accuracy of the conclusions drawn. They should have been asked to give written attributable reports. There is no evidence in the Review that they were. At the very least if their views are given subsequent to a conversation, there should be an indication that they have accepted that what is written accurately accepts their views. There is no such evidence. 

 

The opinion in 4.2.21 is critical in assessing the Pathological input. It is however patently misleading. It is very regrettable that the ownership of the views expressed in that paragraph is vague. In my view it is incredible that the Forensic experts could have subscribed to the views expressed. 

 

This is a quote from Pounder DJ. Department of Forensic Medicine, University of Dundee, American Journal Forensic Medical Pathology. 2003 Sep, 24(3):219-26

 

“….Shipman was convicted murdering 15 of his patients by administering lethal doses of diamorphine (pharmaceutical heroin). Investigations indicate that, during his working life, he killed about 220 to 240 of his patients. The bodies of many victims were cremated. Twelve victims were exhumed, and 9 of these deaths were included in the indictment. Most victims were elderly and had histories of natural disease. Autopsies confirmed known natural disease but showed no evidence of acute lethal events. Analysis of skeletal muscle disclosed significant quantities of morphine, to which the deaths were attributed. Circumstantial evidence was strong, as illustrated by the convictions in 6 deaths without autopsy or toxicology, because the bodies had been cremated. Organic compounds are remarkably stable in buried bodies. Even so, detection and quantitation of morphine in exhumed bodies may become problematic after burial for 4 years or more.” 

 

Recommendations as regards future risk management 

I strongly recommend that a Forensic Pathologist and Forensic Toxicologist with suitable experience be instructed to provide reports, preferably written but clearly attributable about relevant matters in this case. They should be provided with appropriate information about the clinical aspects of the investigation.

 

I recommend that a Statistician is asked to review the data related to deaths and their timing in 1999 to attempt to as accurately as possible assess the probability of Nurse M not having murdered patients.”

LIGHTS OUT – AND THE DRESSING-UP BOX:

Killer Nurses – and Failed Governance

Part 2: Read Evidence the Jersey Courts Covered-Up.

This is Part 2 of an investigation into the failure of the rule of law in Jersey.

In Part 1, we considered the background to the case of ‘nurse M’- who came to the attention of the Jersey authorities in 1999, because of very serious concerns he may be a clinical serial killer.

The Jersey authorities – in particular the Attorney General – decided not to investigate that case properly. Like so many other serious crimes in Jersey, they preferred a cover-up – in order to avoid any ‘bad publicity’.

In 2009, I exposed the rogue nurse, and the cover-up which occurred in 1999. Since then, the Jersey Attorney General has misappropriated approaching  £400,000 in public money in an unlawful campaign to silence and oppress me.

This unlawful campaign – which I have had to fight  against – has included such measures as: –

Having me illegally raided by a squad of ten police officers  – and my home searched – without a search-warrant;

The private data of hundreds of my then constituents being stolen and copied in that raid;

Those actions against me being ordered and directed by a personally conflicted Attorney General, William Bailhache;

Having my entire defence case and the supporting evidence -deemed “inadmissible” three months into the proceedings – and three days after they received my expert witness reports – because the prosecution realised they had no answer, and their case against me had collapsed;

Refusing admissibility of the defence witnesses I wished to call;

Allowing the prosecution to run a case – that the defence had been specifically prevented from mounting an argument against;

Refusing to disclosure the identity of the third-parties who helped the magistrate write the judgment;

My appeal being heard by a judge – Commissioner Pitchers – who had been hand-picked and appointed for the task – by the current Bailiff, Michael Birt, who was the Attorney General in 1999 who I had exposed for preventing the police from investigating  nurse M properly;

The same judge, Commissioner Pitchers, who eventually admitted under questioning from me that he – “also on one occasion had dinner in a restaurant with the present Bailiff and Deputy Bailiff.”

So – the judge hearing my appeal admitted – eventually – that he has been wined and dined by Michael Birt – the man who’s 1999 cover-up of the nurse M case I had exposed – and William Bailhache – who had until recently been the Attorney General who decided to undertake the malicious prosecution and repression  against me;

And if all the above were not bad enough – during the prosecution  against me – and the subsequent appeal – Jersey’s judicial authorities were aware of the existence of a witness who proves the validity of my public interest disclosure defence – but those authorities did not tell me.

The existence of that witness was deliberately concealed from me. I only discovered the person’s existence, by happenstance – three weeks ago.

I wonder how much of that £400,000 of misappropriated tax-payers’ money was spent on the dinner?

But readers need not wonder about my defence case evidence that the courts refused to hear. The first, major part of that – is being published below.

I’m publishing it because it remains in the public interest that we get to the full truth concerning nurse M.

It could be  the case – to this day – that he may have murdered and attempted to murder many vulnerable patients.

The families of those who may have been victims  don’t know of this possibility. The Jersey authorities made a deliberate decision to not tell them, nor to interview them as potential witnesses.

With that startling fact in mind – can I remind readers of the poll I am running, on the upper right, which asks whether those people should have been informed?

When researching this issue, I was shocked to discover that murders and attempted murders by rogue nurses are so widespread – that people have written PhD’s on the subject.

In Part 1, I quoted briefly from no less than twenty – yes, twenty – different cases. Those cases feature convicted nurses who, between them, have killed unknowable numbers of  people. For example, in one case, that of Charles Cullen, authorities in New Jersey estimate he may have murdered over four hundred patients.

Another very common characteristic of many of those cases is that it took the authorities far longer to stop the killers than it should have done – because of a wish by colleagues, managers, employers and institutions to avoid scandals and controversies.

Just like Jersey’s authorities.

It’s worth repeating a quote I reproduced in Part 1:

“But possibly the biggest reason that some nurses kill is that they can. They have access to patients who are often very sick, very old or very young — and access to drugs powerful enough to kill unobtrusively through an intravenous tube. And they work at institutions with an inherent aversion to litigation and publicity.

“Katherine Ramsland, a forensic psychologist at DeSales University in Centre Valley, Pa., has worked with FBI profilers. “ Some hospitals don’t want the public to know they had someone like this, so they sort of shove the problem aside” with a dismissal, she said. “But then the nurse gets a job somewhere else.”

Public authorities, such as prosecutors and judges are supposed to be our ultimate protectors. For if investigating, preventing and punishing such crimes was left up to politicians, most would go unexposed and unpunished. Politicians do not like scandals; they like the departments they are responsible for, to appear as though they are marvellous, efficient – and safe.

But in Jersey – those authorities who are supposed to enforce the law impartially and effectively are contaminated with politics. They sit with the legislature and the executive; they are tangled-up with them; they support them – they are responsible for legally advising them – and- as in the photograph below – they remain at the heart of power in Jersey.

In the background in that photograph – between the Lieutenant Governor and the then Bailiff, Philip Bailhache – is Michael Birt. He is presently the Bailiff – but at the time of the nurse M episode, in 1999 – he was the Attorney General; the sole prosecution authority in Jersey.

And as Attorney General, he was head of the department that was also responsible for giving legal advice to the Health & Social Services Department.

Back in May 1999 – the day after Michael Birt had been in a meeting with police where it was decided to initiate an investigation into the strong possibility that nurse M is a clinical serial-killer, Michael Birt decided not to oppose bail – so nurse M was let out of prison.

The suspect then began to intimidate some of the key potential witnesses.

Michael Birt also decided that the investigation the police wished to carry out into nurse M  – for example, by interviewing the witnesses – was “far too wide”. That can be seen in the file-note written by Michael Birt, which I published in Part 1 of these articles.

So not one visitor – not one relative – not one patient – and not one doctor – were interviewed by the police.

That is so extraordinary, you couldn’t make it up.

It was a cover-up.

As I wrote in Part 1, there were, broadly, two reasons for the failure to properly investigate the matter. Those were:

1: The authorities were incompetent in investigating suspected clinical serial-killing.

2: There was profound reluctance on the part of some high-ranking public officials to see the investigation progressed.

So, having failed in something so serious as to investigate a suspected outbreak of clinical killings by a rogue nurse – it’s easy enough to understand why the authorities – such as the Office of Attorney General – would get very angry  – and very afraid – when someone like me exposes the matter – makes a public interest disclosure all these years later.

Because – make no mistake about this – the failures and cover-ups concerning nurse M makes the survival of the conflicted power-apparatus in Jersey as presently structured, impossible. The complete absence of an Independent Director of Public Prosecutions now has to be addressed.

The implications for the present position of Attorney General – essentially the very heart of the Jersey establishment’s power-base – are so serious, they had to crush me. They had to strive to depict my public interest disclosure as somehow being “bad” and “wrong” – they had to make an “example” of me, to scare other whistle-blowers. They had to con the public into believing that the authorities had investigated the nurse M case correctly, back in 1999 – and that vulnerable people can rely upon the protection and oversight provided by  Jersey’s authorities.

Hence the repressive and anti-democratic actions taken against me.

And so desperate and extreme have those actions been – they’ve even involved the overt politicisation of the judiciary.

To the quite breathtaking extent that the Jersey courts prevented my defence evidence from being heard.

You simply couldn’t make up this kind of thing.

But – unable to use that evidence in court – for the first time I am publishing the key parts  of that evidence below.

It will leave you speechless.

The evidence you are about to read  proves my public interest defence – but more significantly, proves how inadequate the 1999 investigation was – and how the public interest has been betrayed by those who work in Jersey’s prosecution and judicial apparatus.

I begin with some quotes from the report I originally published.

I then turn to some further relevant quotes – taken from some of the other documents that were disclosed to me in 2009, to use in my defence, before the prosecution and judiciary realised that evidence was damning to their case against me, and they decided to bar it.

And then – in particular – I reproduce most of  first report prepared by my expert witness. It was that  report – in particular – and four brief ‘Up-dates’ that I will be publishing in Part 3 of this series of articles – that the Jersey oligarchy were so desperate to suppress – they even denied me my right to a fair trial.

When reading this material – any thinking person will be able to see – and understand – exactly what this – what the repression against me – has been all about.

These are public authorities who should have protected us – but who failed to protect us. They should have investigated the nurse M case properly – but they chose not to – in order to avoid the bad publicity. And then – when I exposed the truth – Jersey’s authorities set about crushing me, in an attempt to hide their disgraceful failures.

But their failures were laid bare – exposed even more – by the work of my expert witness, who’s main report, you can read below.

So bad was the 1999 cover-up – Jersey’s authorities didn’t even take sufficient steps to have nurse M removed from the nursing register; instead – he remained able to work as a nurse during the next 13 years.

Think about that.

And what the implications could be.

In Part 3 of this series of articles, I will publish some further analyses by my expert witness.

That material is – in many ways – even more damming than what you are about to read.

And as you read this evidence – bear in mind that those people involved in Jersey’s prosecution system and judiciary have striven – in every way they can  – to try and prevent you from learning the truth; even to the point of stealing £400,000 of your money to spend on repressing whistle-blowing opposition politicians.

Stuart.

List of Documents Quoted Below:

Document 1: Quotations from a May 1999 initial police report into activities of nurse M.

Document 2: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities. Quotations from a July 1999 police minute of a meeting at which the decision was made to terminate the nurse M investigation prematurely.

Document 3: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities.  Quotations from a  July 1999 memo by DCI MG in which he records difficult meeting with the Chief Executive and Chief Pharmacist of Health & Social Services.

Document 4: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities.  Attorney General V Stuart Syvret; Interim  Report by defence expert witness.

…………………

Document 1: Quotes from May 1999 initial police report into activities of nurse M.

The police report of May 1999 is the document I originally published.

I quote some key passages from it:

“On Thursday, 1st April, 1999, Police Officers attended the home address of a female who disclosed that Nurse M , a Staff Nurse on Corbiere Ward, had stolen and stored drugs at her home address. The female, an ex-lover of Nurse M produced to the officers, drugs in the form of Valium and Hypnoval, together with a syringe containing clear liquid and several packets of Coproxamol. These have since been identified and their content verified. Hypnoval is more commonly known as a ‘date rape’ drug. Enquiries confirmed that the drugs were from the hospital and indeed had been sent from the Hospital Pharmacy to Corbiere Ward, where Nurse M worked.

A check on the Firearms Register held at Police Headquarters, revealed that Nurse M had possession of several firearms, and that his Firearms License had expired in October, 1998. The female who handed the drugs to the Police confirmed that Nurse M had attended at her premises with a loaded firearm.

Nurse M was arrested on returning to the Island on the 17th April, 1999, and, armed with a Warrant, his home address was searched. During the search, the following property was recovered.

1. One lump of brown cannabis resin, tablets and scales.
2. Knuckle-duster.
3. A Police Philips radio (in working order).
4. Bag containing various medications.
5. Eleven syringes with a clear liquid within, and other medication, including
two bottles of potassium chloride.
6. Six firearms, with large quantity of ammunition.
7. One expired Firearms Certificate.

Nurse M was interviewed concerning the medication found, and at first suggested that the insulin in the eleven syringes was intended as an aid to body-building. He later changed this story, in that he intended to kill himself with the medication, by marching down to the Cenotaph in military dress, where he would inject himself with a lethal dose of insulin and potassium chloride.”

The report continues:

“Police Surgeon Dr. Michael HOLMES first expressed concern when he viewed the drugs recovered, in that a combination of insulin and potassium would be very difficult to detect in the body. Added to this, the amount of drugs in the possession of Nurse M cast doubt on his account, in that he had several lethal doses of drug. If a person with a serious medical history were to be injected with the combination of drugs found in the possession of NURSE M, the cause of death would not be clearly apparent. His possession of such drugs was therefore regarded as suspicious.

“Enquiries have continued over the last three weeks, and have established that Nurse M has had several affairs with either patients or relatives of patients at the General Hospital.”

The report goes on to state:

“Incident 1 – an elderly male admitted to Corbiere Ward (name unknown) suffered a heart attack which was further complicated when his insulin levels became abnormal. He was placed on a glucose drip, which is the normal procedure. The drip had been inserted correctly, and was working fine when Nurse A checked the patient on the previous evening in question. Nurse M handed over to a nurse on the ward, just prior to Nurse a arriving for duty (the am. shift). On this occasion, Nurse M had not worked with Nurse A and the normal team. As normal, the nurse checked on her patient and discovered, to her horror, that the glucose drip had been disconnected from the patient, and a bung put into the base, preventing the substance from leaking. The patient was unconscious and close to death. The nurse reconnected the drip and the patient recovered within about ten minutes.”

The report further states:

Incident 4 – A young girl was admitted to Corbiere Ward, following an overdose. Nurse M found her attempting to hang herself in the toilet on the ward. The patient was transferred to the APU, where it is alleged that the young girl disclosed to a member of staff that Nurse M had offered to show her how to commit suicide correctly.”

In reference to a statement from a former girlfriend of Nurse M from the time when he worked at Basingstoke Hospital, the report says this:

“She explained that they had experimented with [sexual activities excised], with her permission. This had, however, progressed to Nurse M becoming very violent, and he had on one occasion, thrown her over his shoulder and placed his knee on her chest, asking her if she wanted to die. She suffered a fractured sternum on this occasion. She alleges that the violence progressed to rape, and on one occasion, she was tied up on a table, naked, when he put a poker in the fire, took it out, placed it in water and ran it along her body at the time. Nurse B is very scared of Nurse M, and she was spoken to by her line manager, after sporting a black eye and cut lip at work.”

………………..

Document 2: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities.

Quotes from July 1999 police minute of the meeting at which the decision was made to terminate the nurse M investigation prematurely.

Operation Regent – Presentation by DI BF

1400 hours – Wednesday 7th July 1999

Present:

Chief Officer RH LeB
Deputy Chief Officer RJ
Chief Inspector MG
Crown Advocate CW
Detective inspector BF
Detective Sergeant AS
Police Sergeant MR
Police Constable BT
Detective Constable EC

RJ: Why would you want to interview the doctors?

BF:  I feel that there is a chance of obtaining something remote but serious, for example the anaesthetist was angry that the notes were missing. A doctor may have encountered something which isn’t on the notes.

………..

RJ: If the enquiry is going to continue, I can see three sides to it and resources:
1) the amount of concern in the hospital.
2) BBC Southwest have it and are ready to run, could be public knowledge tomorrow.
3) The realistic chance of getting anything.

BF: I would be the first to accept that apart from the trend and a lot of concern re: missing documents and terminally ill people dying when he’s been around, we’ve got nothing to hang our hat on.

………….

16:40 hours: meeting resumes.

RJ: The decision has been made to terminate this enquiry and I have written out the reasons why, and you can put this in your policy book, which I will then sign. I want to thank everyone involved as it has been made difficult due to three areas:

1) the sensitive nature of the enquiry.
2) The worrying aspects of the enquiry.
3) The enquiry has not been helped by outside organisations.

…………….

1645 DCO RJ leaves.

AS: I would like it to be recorded that I believe that the nurses should still be spoken to as planned, as this would surely be the natural conclusion to the enquiry.

MD:  Mr Jones’ decision still stands.

1649 hours: CI MG leaves.

DI F:  I agree that it is natural to finish off with the nurses, perhaps that is something I need to raise in the morning. We’ve got to look at what we’re going to run with next week. I personally would have liked to have done the doctors and nurses.

AS:  Perhaps you could argue how difficult it will be to get hold of the nurses in five years time due to staff contracts, etc.

 1652 hours: end of meeting. 

……………………

Document 3: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities.

Quotes from a July 1999 memo by DCI MG in which he records difficult meeting with the Chief Executive and Chief Pharmacist of Health & Social Services.

Memorandum by Detective Chief Inspector MG

14th July 1999

Operation Regent

Paragraph 1

At 0930 hours on Thursday 15 July 1999, 1 attended at the General Hospital and met with Mr J (Chief Officer) and Mr G (Chief Pharmacist). During the course of that meeting, having established a contract of confidentiality, I provided a briefing concerning the investigation of Operation Regent.

Paragraph 3

I highlighted problematics that the enquiry team was faced with, and in particular the absence of certain medical records from files passed to us by the hospital authorities. I singled out for special mention the missing prescription charts and epidural chart of [a patient] and suggested that the absence of that document was in fact of concern to the hospital authorities (Anaesthetist) when recalled to the ward to prescribe further medication.

Paragraph 4

Whilst Mr J / Mr G acknowledged this to be fact, Mr J suggested that there might have been another explanation, other than the suspicion that Nurse M had deliberately accelerated administration of the dosage prescribed. He proffered the view that equipment may have been faulty and suggested that perhaps that possibility was not considered. I was unable to comment further in this respect but suggested that if faulty equipment was a causal factor then one might reasonably have expected that to have been noted within the medical records.

Paragraph 5

I highlighted the deaths that we had examined, and reiterated the thoughts of the medical expert employed to review those files. I suggested that the absence of key and relevant information to some extent thwarted efforts and thus the expert opinion we sought was inconclusive.

Paragraph 8

I presented the statistical analysis prepared by the enquiry team concerning relevant deaths. I demonstrated a pattern that reinforced the investigating team. Mr J was dismissive of that analysis and suggested that statistics can say anything you want them to. He made the point that the hours worked together with the eight hours following a period of duty left little time for persons to die and thus the statistics had little value.

Paragraph 9

I was able to show, and receive an acknowledgement from Mr J, that the investigation was not a fishing expedition. I was able to show that it was an investigation that had to be undertaken by the police and importantly one with which the Hospital Authorities were seen to have fully cooperated.

Paragraph 12

I advised that the UKCC (Nurses Governing Body) were aware of the charges preferred against Nurse M but were not aware of the enquiry we had conducted concerning the suspicion that he might have brought about the premature death of patients, albeit patients who were in any event terminally ill. (Emphasis added.)

Paragraph 13

Mr J advised that he was considering informing UKCC of that event and suggested that, ethically, we the police could do likewise. He acknowledged that it was a matter for us to consider.

Paragraph 14

To conclude, following discussion with Deputy Chief Officer J, it is considered that to correspond with UKCC in the manner suggested would be ill advised. The allegations against Nurse M, whilst thoroughly investigated (sic), were inconclusive. Any correspondence that might be received from UKCC arising from correspondence forwarded by the hospital authorities would need to be carefully considered. A policy decision has been made that in such an event correspondence will be referred to the Chief Officer.

Detective Chief Inspector MG.

……………….

Document 4: Stuart Syvret’s defence case: blocked from use in court by Jersey authorities. 

Attorney General V Stuart Syvret; Interim Medical Report by defence expert witness. (Some redaction.)

Interim Medical Report:

Attorney General V Stuart Syvret

7th October 2009

From Part 2:

I examined the reports of the clinical experts, Dr Sd and Mrs Sd looking mainly for evidence related to the behaviour of Nurse M. These clinical experts had been selected by the Jersey police representatives on the advice of the UK Police National Crime Faculty. There are contradictory accounts of the exact form of their recruitment at several places throughout the above files. It was unclear to me whether they had directly recommended Dr Sd and Mrs Sd, or whether the recommendation was to recruit a medical expert, and Jersey police thought Dr& Mrs Sd were appropriate because Dr Sd was a medical doctor and Mrs Sd was a nurse.

From the Strategy document (1a-42) of the Police of 20th May 1999, the duties of the clinical expert, a Doctor, were to screen a variety of records and identify items of concern. These would be subject to a second opinion. The records would include –

(i) hospital notes related to deaths of patients on Corbiere ward between 23rd and 26th February 1999, (1a-48) a period when a suspiciously high number of patients (7) died when Nurse M was on night duty;

(ii) hospital notes as well as records of other suspicious deaths where evidence suggested Nurse M may have been involved in the premature death of a patient;

(iii) the clinical expert was also to examine incidents listed in the statements of two nurse colleagues of Nurse M, as well as –

(iv) examining documented allegations of nurses about Nurse M.

The Strategy document did comment that the actions could vary with the result of investigations as they were undertaken. However, in the papers that were available to me there was no documentation I saw that suggested the above part of the strategy had been deliberately changed before the Police investigation was put on hold on 7th July 1999. This Strategy was labelled as Phase 1 of the investigation.

The Phase 1 Strategy document appeared to have been produced following a meeting that took place that day, 20th May 1999 between representatives of the police, the hospital, and the law officers. There are notes made following the meeting, by the Attorney General and separately another law officer. The Attorney General noted “There was evidence” Nurse M “was potentially dangerous. We had to investigate the position thoroughly in order to ascertain whether there was anything in it or not.” (1a-38) The Crown Officer noted separately “The only responsible decision is to investigate – but in a measured sequence, followed by early review.” (1a-39) The police senior investigator had wished for the investigation to include the interviewing of surviving patients, relatives of patients, and other patients who had been on Corbiere ward at significant times. However, the decision of the meeting was that a less extensive investigation, Phase 1, would take place, and then be reviewed.

Phase 1 of the police investigation lasted just under 7 weeks. The results were then presented to relevant police officers, including the Deputy Police Chief and a crown advocate. Following that presentation the Chief of Police or his Deputy decided to stop the investigation. (1a 36, 37)

PART 3: MY CONCERNS ABOUT THE CLINICAL PART OF THE POLICE INVESTIGATION INTO NURSE M

Several aspects of the clinical part of the investigation cause me considerable concern that it was not effectively conducted and that this resulted in the investigation being prematurely stopped.

According to his Curriculum Vitae, (1a-61) the clinical expert Dr Sd did not appear to have the appropriate expertise to justify him operating as a clinical expert in this investigation. This is considered in more detail in Part 4.

No evidence was given that Mrs Sd had appropriate experience to be seen as a clinical expert in the appropriate nursing field. This is considered in more detail in Part 4.

Although the clinical experts raised concerns about Nurse M, none appear to have been subject to a 2nd opinion, in contradiction to the agreed Police strategy on 20th May 1999.(1a-42) I deal with this matter in more detail in Part 5.

No evidence was available, or was referred to, to suggest that the clinical experts had screened the concerns of the various nurses, nor that they had subjected them to a 2nd opinion. This was in contradiction to the declared Police strategy.

The clinical experts had not completed their investigations of the documents when the investigation was dropped. Dr Sd in a letter of 5th July 1999 (1a-52) had particularly wished to provide a report on one further patient. In addition he completed one patient report on the 7th July 1999, (1a-61) in which he raised the possibility that the death had been hastened (presumably by Nurse M). It seems probable that this critical information was not available at the meeting of the 7th July 1999 at which the decision to drop the investigation was made. See Part 6.

The clinical experts’ opinion was not properly represented at the meeting on the day when the decision to stop the investigation was made. See Part 5. This may have been because his letter of 5th July 1999 (1a-52) had not arrived.

The clinical experts did not seem to acknowledge that they were investigating a nurse with a history of marked sociopathic behaviour. They did not have the mindset that they might be dealing with a Nurse who was deliberately setting out to deceive, and who may have been altering records, and manufacturing records and file notes. Thus when there were numerous concerns over the accuracy and completeness of records, the clinical experts favoured the view that it was a mistake rather than some deliberate manipulation. For example, when there were doubts over the manner in which Nurse M altered the rate of administration of controlled drugs, they favoured a belief that the prescription had been written to allow for variance although that prescription was missing. (1a-61) Their minds seemed to be closed to the fact that they should have been suspicious and looking for wrong-doing on the part of Nurse M. It is of note that in the Shipman inquiry into the failings of the first police investigation, the Clinical expert was criticised for not opening his mind to the possibility that Shipman was killing his patients.

PART 4: DR SD AND MRS SD’S QUALIFICATIONS AND EXPERTISE

Obviously it is vital that any investigation and reporting is carried out by persons with suitable expertise. As the clinical investigators’ task was spotting the unusual, it would have been reasonable to expect that they had good experience of the usual. Given that all the deaths occurred to patients in a Medical Ward, and the importance of the use of opiate medication on such patients, the experts should reasonably have had up-to-date experience of working with acutely ill patients in medical wards.

The two experts were Dr Sd and Mrs Sd, husband and wife. Dr Sd in his Curriculum Vitae (1a-61) described himself as Principal of Westminster Medical ltd. I looked at the website for the company. The impression is that he and his wife are the sole employees and owners of the company.

Dr Sd’s medical Curriculum Vitae was not itemised in the “unused material” bundle. In fact it was filed inside item 61, which was the case report of Patient J. This report was not one of the initial 6 completed as per Dr Sd’s letter of 5th July 1999, (1a-52) and was dated 7th July 1999. Therefore it was probably not available to the Police until after they had decided to stop the investigation.

It is of note that the Shipman inquiry into the first police investigation which failed to identify him as a murderer, discusses in its conclusions the importance of having experts available with the proper expertise particularly as “Modern Medicine is highly specialised,” I do have considerable experience of Medical recruitment, and would say that Dr Sd’s CV was poorly constructed. This CV did not give the flow of Dr Sd’s medical career. He described his experience and some of the posts held, but did not always date their beginning and/or end. For example he stated that he was appointed Principle Police Surgeon in 1988 but gave no indication whether he was still in that post 11 years later. One part of his CV seemed wrong to me. He stated as part of his Casualty experience that he was a specialist registrar in intensive care and part of the resuscitation team, but this was in the 1970s, and as far as I am aware the specialist registrar grade was only created in the 1990’s.

Dr Sd has no medical degree. He spent 6 years, instead of the usual 5 years at medical school, but did not qualify. He qualified the following year by direct examination with the Royal Colleges of Surgery and Physicians. This was an unusual but legal way of solely qualifying as a UK doctor at the time, which is no longer available.

After fully registering as a doctor, Dr Sd worked for 5 years as an anaesthetist and in Casualty. He then gained membership of the Royal College of General Practitioners and worked as a GP for 7 years, mostly as a single-handed GP. He also did police surgeon work, and became a senior Police Surgeon in 1988. It is not clear from his CV what he had been doing throughout the 90’s, but it may well be that he was running a report writing company, Westminster Medical ltd. along with his wife Mrs Sd.

Dr Sd appeared to have done no posting in a medical ward since his full registration as a doctor in 1977. Indeed apart from some experience in an intensive care unit of indeterminate length and looking after a handful of long stay patients in a “cottage” hospital he has appeared to have not had any in-patient work at all. As the Shipman inquiry stated in relation to the recruiting of experts “an officer cannot use a directory effectively if he does not know in which field of expertise he needs advice. In some cases, the police will readily recognise what sort of expert they need but not in all cases. Modern medicine is highly specialised.” Dr Sd was apparently not specialised at all in the assessment of patients in an acute admission ward. He had no experience of this area of medicine since the time he registered as a doctor.

I have e-mailed Dr Sd to ask for further details that should have been included in his CV. I have had no response.

Dr Sd signed himself as a Consultant Forensic Physician. This may well have misled a non-medical person to consider that he had the accredited training and qualifications and status usually associated with a Medical Consultant, in particular a Consultant Physician. However the term Consultant is not a term controlled by any statute, and Dr Sd chose to call himself a Consultant. Some police surgeons call themselves Forensic Physicians, and some call themselves Consultant Forensic Physicians. So Dr Sd is not alone in doing this. But according to his CV he has no higher training or qualification in Forensic Medicine. In the last few years in England much of the police surgeon work is now being done by specially trained nurses. I did write to the President of Faculty of Forensic and Legal Medicine (London), and received this response to my question as to what were the qualifications for a consultant forensic physician. The response was from the Registrar to the Faculty “I do note the concern you have identified where we are aware of the issue in question in what remains a rather grey area in as much as the specialty of legal and forensic medicine has yet to develop a formal career structure with a CCT (Certificate of Completion of Training). Consequently, the vast majority of Members and Fellows (unless they are a NHS Consultant by virtue of their primary specialty) will not be consultants in the traditional medical sense. The understanding that I have on the subject is that a number of distinguished colleagues have entitled themselves in this way in that they have been consulted by a third party to provide an expert opinion and have felt it appropriate to use this designation in such circumstances.” I consider that Dr Sd could not by any reasonable stretch of the imagination define himself as a distinguished member of the Faculty, because he is not qualified to be a Member. NB this assessment was based on the CV available to me. It is possible that there was other information regarding his medical career and skills that was not available in the document I reviewed.

Mrs Sd worked with her husband, Dr Sd in providing the reports. She has been described as an experienced Nursing Sister. However, no Curriculum Vitae was provided, and so there is no information about whether she has ever been a nursing sister in a Medical Ward, when she last worked etc… Without this information it is impossible to weigh her expertise.

Therefore I believe that there is no evidence that the team preparing the reports can reasonably be considered to have the necessary expertise to do so. Therefore the value that can be put on their conclusions is not high.

PART 5: THE DECISION TO STOP THE POLICE INVESTIGATION

There is some contradiction about the process by which the investigation was stopped. This has probably resulted from fading memories with the passage of time rather than any attempt to deceive. There were, though, available in the documents available to me, minutes of two of the meetings of 7th July 1999 (1a-36) which clarify the process. There were three meetings. At the first minuted meeting the Police Senior Investigator presented the findings of the investigation. (1a-66) A discussion followed. That meeting was then adjourned and the deputy Chief Constable went to a further meeting, possibly with the Chief Constable at which the decision to suspend the investigation was made. In the bundles there are no minutes of that meeting. There was then a third meeting, which was minuted, at which the decision to suspend the investigation was presented to the investigating team. (1a-66) The minutes state that the decision had been that of the deputy Chief Constable. Two of the investigators, one of whom was the senior investigator wanted their concerns minuted. One felt the nurses should be interviewed and the other that the doctors and nurses should be interviewed. It is not minuted that Dr Sd’s view that further reports should be completed was part of the decision making. To make it clear, according to contemporaneous minutes –

a)    The decision to stop the investigation was not “a collective decision of all attendees at the meeting” but was an executive decision made either by the Chief Officer of Police or his Deputy.

b)    The decision was immediately opposed and criticised by two of the police investigators, including the Police Senior Investigator.

c)     Dr Sd had made clear in his letter of 5th July 1999 (1a-52) that he wanted the investigation to continue. He needed more time to complete his reports. It does not seem that this opinion was considered.

From my view point as a doctor the decision to stop the investigation was premature.

There is no doubt that the doctors might well have produced vital information. The dropping of the 2nd opinion for any concerns raised by the investigators as originally outlined in the Strategy was lamentable.

a)    No local doctor was interviewed as a witness at any time during the inquiry. This was despite the fact that one doctor was possibly being accused of making a negligent decision by taking no action when informed of a patient’s critically low blood sugar. (BF report 08/05/99 in SSS blog) One doctor had expressed considerable concern about the usage of opiates and lack of records in a patient that Dr Sd had felt concerned could have had their death accelerated by excess administration of opiates. (1a-61) That doctor’s evidence could have produced very important information. Indeed the senior police investigator argued on 7th July 1999 (1a-36) in favour of interviewing the doctors “I feel there is a chance of obtaining something remote but serious, for example the anaesthetist was angry that the notes were missing. A doctor may have encountered something which isn’t on the notes.”

b)    Nurse M was never interviewed. It is not minuted that the senior police investigator when told that the inquiry would be halted wanted to continue with the investigation by interviewing Nurse M. (1c- SIO witness statement 26/08/09 claims he wanted to interview Nurse M) However the police senior investigator was minuted at that meeting stating “I personally would have liked to have done the doctors and nurses.”

c)     Only 10 out of 28 nurses had been interviewed. It appears that a further 12 had been “interviewed” by returning a questionnaire that they had been sent/given, but to label that an interview seems misleading. (1a-36).

d)    Dr Sd & Mrs Sd had been asked to provide reports on 16 patients. It is unclear, see Part 6, how many reports had been completed and received by the police at the time of interview. It seems to have been between 6 and 10. Of the 7 patients who died on the 23rd – 26th February 1999 only 4 had been reported on. The deputy chief of police was minuted saying “*******  Sd I take it, can’t give us any evidence to base an interview with” Nurse M, to which the Senior Police Investigator responded “No”. (1a-36)

e)     Dr Sd wrote a summary of his findings to the Police on 5th July 1999. (1a-52) It is uncertain whether it had been seen by the time of the meetings on 7th July 1999. Dr Sd’s views were contradictory. He stated that “all patients were seriously ill and their deaths were unsurprising.” However he went on to say “Nursing records were ill-ordered with some missing. Time and dates on nursing reports were poorly recorded…..There were no Syringe Driver Checking forms……Syringe driver prescriptions were written poorly….. there were opportunities for unauthorised adjustment. Surplus drug disposal was not documented…..We could identify no specific incident of suspicious conduct but the overall lack of information causes concern…..We simply did not have time to complete detailed reports on all cases while in Jersey but feel this should be done for completeness……We have identified a further 5 patients who may have died in the period in question. One particular case….was directly concerned with the party under investigation.”

f)      Dr Sd wrote a case report dated 7th July 1999 (1a-61) which concluded “in my view the death was from natural causes, but it could have been hastened.” He also stated “this case was very difficult to review because of the appalling hotpotch of records, poor timing and dating of records and drugs.” It was this case where the anaesthetist expressed his anger referred to in sub-paragraph a, above.

PART 6: THE REPORTS OF DR SD

Dr Sd was selected as an expert witness, though the exact process of his selection is not clear. Dr Sd produced a letter dated 5th July 1999 (1a-52) which summarised his investigatory process. The contents of this letter should have been of critical importance in the assessment and management of Nurse M’s risk to others.

 Dr Sd seems to have been tasked to examine the hospital notes of 16 patients, but at the time of the letter of 5th July 1999 he implied that reports had been completed on just 6 patients. This appears to be inaccurate for the items 53 to 60 from the “unused material” (1a-53 to 60) bundle are 8 dated reports prepared by Dr Sd between the 22nd and 25th June 1999. The reports furthermore were labelled alphabetically by patient going from A to I, with the exception of D. From this it seems likely that he had also prepared a report on patient D. From other comments in the bundle patient D was the patient referred to in the police report of 8th May 1999 (exhibit AG/23/04/09/02 in the Data Protection Prosecution bundle) who had the bung placed in his drip. Dr Sd’s assessment of this case would have been particularly important in assessing risk. Given the importance of this letter of Dr Sd’s, its inaccuracy is regrettable and raises questions as to the reliability of the information he provided. It also raises the question of whether and when all the reports were received by the police, and what was the content of Dr Sd’s report on Patient D, assuming one had been completed.

In his letter of 5th July 1999 (1a-52) Dr Sd stated that he had screened out 5 of the 16 notes he had been given, stating of the patients that their “stay on the ward and subsequent demise occupied such a short time as to be unworthy of scrutiny”, although later suggested that they should be reported on for completeness. It would have been helpful if he had clarified his reasoning; for on the face of it, if his task was to look for suspicious activity these would be the sort of cases he should be reporting on. Of the 11 remaining notes Dr Sd claimed to have completed 6 reports, and later in his letter stated, “We have identified a further 5 patients who may have died in the period in question. One particular case Patient K was directly concerned with the party under investigation” As Dr Sd only had 16 case notes, these 5 were probably the remaining notes – (6 reported on, 5 of low priority, and these 5). However, Dr Sd had already prepared reports on at least 8 patients, therefore for the figures to add up he should only have 2 that he wished to report on plus patient D. So if Dr Sd had made a simple error in his letter by inaccurately saying he had completed 6 reports, he must have made a simple compensatory error in the number remaining to be reported. This is very unlikely to have happened by chance, and needs explaining by Dr Sd. The lack of clarity in Dr Sd’s letter is very disappointing, given its critical importance in the investigation.

Dr Sd, who was by now back in England, completed a further report on patient J on 7th July 1999. (1a-61) It is uncertain whether this report had arrived with or been read by the police before the key meeting that took place that day to decide on the progress of the police investigation. It is notable that Dr Sd stated in this report that “in my view the death was from natural causes but, however, it could have been hastened.” From the notes this referred to issues related to the speed of delivery of a diamorphine infusion pump. Dr Sd had manifest concerns about this case.

Dr Sd stated in the letter of 5th July 1999 (1a-52) “All patients were seriously ill and their deaths were unsurprising.” However, as mentioned above it is unclear how many cases he had reported on at the time, and certainly did not include his conclusions about Patient J.

Item 42 (1a-42) in the “unused material” folder documents the police strategy, reference Operation Regent, the name of the investigation. It was apparently prepared by the police on 20th May 1999 probably following a meeting earlier that day between police, hospital authorities, and law officers. One of the actions of the strategy was “Screen all such records by utilising the services of a UK clinical expert. Any items of concern identified by the Doctor will be subject to a second opinion.” Later in the document it was noted that actions “could vary in accordance with the results of the investigations.” However I can see no evidence that this specific action was deliberately varied before the Medical Reports were prepared.

The records for screening were defined in the strategy document and included the hospital notes relating to deaths of patients on Corbiere ward between 23rd and 26th February 1999, and the notes of Patient C and Patient J.

However, there is no evidence that Dr Sd, the UK clinical expert, was acting to these instructions.

He identified numerous areas of concern but gave no consideration to referring for second opinion. Given his probable recent lack of clinical practice, plus his very limited experience of acute medical inpatient wards, and presumably no up to date experience of the use of opiates in medical wards, this is remarkable. It strongly suggests that he was not aware that that option was open to him. My expertise to comment on this matter is limited. I am a qualified medical doctor, but after registration I worked my entire medical career in Psychiatry. In many ways my clinical knowledge of medical wards is similar to that of Dr Sd in that neither of us worked on an acute medical ward since we registered as a doctor. However, within these limitations I would venture to say that some of these deaths were suspicious, and they would have merited a closer look at by a doctor and nurse who had recent experience in working in an acute admission medical ward, in particular where controlled drugs were used.

PART 7: HOW SUBSEQUENT RISK WAS MANAGED

The police kept the file open, but suspended the investigation. According to notes of the Law Officer who appears to have attended the first two meetings on 7th July 1999, the decision was made that a final circular would be sent to the staff telling them “that this is the final opportunity to raise with the police any relevant information.” (1a-37)However, this no record in the files provided by the police as to whether this took place and if so what the outcome was.

A memo dated 14th July 1999 was prepared by a Detective Chief Inspector (1a-35). There was some confusion about the dates because much of the memo referred to a meeting that supposedly took place on 15th July 1999 between the Detective Chief Inspector and the Chief Officer of Health and Social Services and the Chief Pharmacist. (Note the Chief Pharmacist was the Directorate Manager of Medicine and was probably present in that capacity.) The Detective Chief Inspector advised the Hospital managers of the conduct and outcome of the investigation. He stated that it was closed but could be reopened at any time, if further evidence came to light. He asked that the Chief Officer of Health would get the message through to staff that if they had information/evidence that they had not yet disclosed they should be encouraged to contact the Police. The Chief Officer agreed. It is unclear whether this was to be as well as the police sending out a final circular as per the previous paragraph (1a-37) or whether it was a change of plan, and was instead of the circular. The Detective Chief Inspector raised concerns about the poor record keeping which had thwarted the investigation. In my opinion, it was unfortunate that none of the attendees considered that the poor record keeping may have been the result of deliberate tampering with the notes by Nurse M. (In fact earlier in the investigation the Police Senior Investigator had wanted to explore this avenue by looking at record keeping where Nurse M had not been involved but the hospital authorities had refused to cooperate. Mention of this first appears in the documents in a report of 11th February 2000 (1a-32) written by the Police Senior Investigator, but this important piece of information does not seem to have been presented at the meetings of 7th July 1999, nor at the meeting of 14th July 1999.) The Detective Chief Inspector (1a-35)made clear that there were concerns about Nurse M’s future employment within the Health service. The inference was that the police retained a significant suspicion that Nurse M had murdered patients, although that was not explicitly noted.

With regard to the UKCC (NMC) he advised that this organisation was aware of the charges against Nurse M which related to theft of drugs and other matters, (the police had informed them in a letter of 21st May 1999) (1a-34) but they were not aware of the homicide investigation. The Chief Officer of Health felt that the police ethically could inform the UKCC, and that he was considering informing the UKCC (NMC). The Detective Chief Inspector later discussed the matter with the Deputy Chief Officer of police who decided that the police would not initiate any correspondence on the matter with the UKCC (NMC) but might respond if approached by them.

Following Nurse M’s later conviction for the charges of theft of drugs and other matters, the police wrote a letter to the UKCC (NMC) detailing the charges for which he had been convicted, and the sentence, which was a one year Probation Order and 80 hours community service. (1a-33) There is no direct information about what details Health Authority gave to the UKCC (NMC), but it appears that Nurse M’s nursing registration was not removed. (He was working as a nurse in 2001 in Palm Springs,) If this is so, it suggests the case was dealt with as a Health matter rather than a Conduct matter. The Health Service apparently decided that they would no longer employ him in their service. They considered informing the other potential employers such as the residential homes, but seem to have not done so as he was subsequently employed in at least one other residential home in the island. The UKCC (NMC) was unaware that he had more than a theft of drugs and probably felt that he was suffering from a stress disorder and so allowed him to stay on the nurse register.

In 2002 Nurse M was employed in a residential home in Jersey, and while there allegedly had consensual sexual intercourse on two occasions with a very vulnerable resident who had a severe progressive neurological disorder. I had treated her in the past, and was informed of the assault by the community staff involved in her care. There seemed absolute conviction on their part that the incident had happened. The case had been referred on to UKCC (NMC), the renamed nurses’ regulatory body. The case however was apparently not considered by the NMC as the patient was not deemed fit enough to be cross examined, although I have no definite evidence that this was the outcome. The lady has subsequently died. My knowledge of the case came from information from staff who had been involved in the care of the patient

I understand that Stuart Syvret believes that Nurse M was employed just over 2 years ago as a manager in another residential home. I have no other evidence on this.

Nurse M continues to be on the NMC register. It is feasible that he could be working from time to time in the UK as there is a great demand there for temporary nursing work. Any criminal offences in Jersey would not appear in any UK review of Criminal records. It is also feasible that he is undertaking private nursing work, for example on a one to one basis.

In his report of 11th February 2000, which was a resume of the investigation into Nurse M, the Police Investigating Officer concluded “The Investigating Officer is firmly of the view that he poses a threat to women that he befriends and terminally ill or infirm patients.” (1a-32)

PART 8: FUTURE RISK MANAGEMENT

There is manifest great concern that this man presents considerable risk to vulnerable persons that he may nurse. It seems wrong in principle that Jersey Health Services has decided not to employ him, but the UKCC (NMC) continue to register him. It seems that he can get work in local nursing and residential nursing homes, and nursing work in the NHS where there is a considerable demand for temporary (bank) registered nurses but is seen as too dangerous to employ in the Jersey Health Service.

This is not fair on Nurse M, who probably feels that he is being victimised by Jersey Health Service.

In my view there should be an urgent multidisciplinary meeting to share information on this man so that a comprehensive assessment can be carried out. A probable result of that assessment would the referral of Nurse M’s case to the NMC. From last year the NMC investigations require a civil rather than criminal level of proof, and so could reconsider the events and incidents throughout his whole nursing career, including the incidents in Corbiere Ward.

This would be fair on Nurse M who would have the opportunity of clearing his name, and on those who have considerable anxieties about the risk he poses to any future patients.

PART 9: THE RESPONSE OF THE HEALTH SERVICE

There are some criticisms by the police of the Health Services involvement in the investigation particularly directed at the CEO of Health and Social Services. (e.g. 1a-35) What is not apparent in the reports is what advice the CEO sought from the clinical professionals such as his Nurses and Doctors? It would not have been unreasonable to anticipate that the CEO sought the advice from the organisation’s Chief Nurse and one of his Senior Doctors. However there is no evidence that he did so, which in this case seems most remiss. From my personal knowledge of the CEO, I believe his background was in nursing where it was mainly in learning disability and then tutoring. He had been a full-time manager for many years. He would not have been capable of picking up the clinical issues in this matter. Mr GJ did briefly, at the time, mention the case to me. He was not seeking my advice, but was speaking about what was on his mind. He stated that the police may want to exhume some bodies, and he was not happy with it. I made no notes, and my recollection is hazy. It was an informal part of a meeting about something else, but I remember it because it was such a unique occurrence.

There was friction between the police and the CEO over what would be reported to the UK regulatory body for nurses. (1a-35) In the end the police reported nothing of the ward investigations and suspicions. (1a-33) It is not evidenced what Health reported. Again, I think the apparent lack of any input from Nurses and Doctors was lamentable. A Clinician would have probably felt an ethical compulsion to report the concerns to the NMC, so at the very least they could be documented. It also seems probable to me that if a Doctor and Nurse had been advising the CEO they would have been able to give a more appropriate response to the report of Dr Sd, and may well have raised the sort of questions about their relevant expertise that I have raised above.

PART 10: INTERIM PSYCHIATRIC OBSERVATIONS.

[FURTHER DISCLOSURES WERE REQUIRED TO COMPLETE THIS PART.]

PART 11: CONCLUSIONS

The police investigation was probably dropped prematurely for a variety of reasons. Of great relevance is the fact the clinical experts did not have the appropriate specialist medical expertise. I quote from the recommendations of the Shipman inquiry which relates to criticism of the first police investigation in the Harold Shipman case which cleared him, after which he went on to kill 3 more patients. From this it will be clear that getting the right expert is critical:

“One of the problems discussed is the identification of an appropriately qualified and independent expert to assess the evidence gathered and to advise on the issues of culpability. At present, the draft guidance recognises the difficulties but makes no practical suggestions as to how they might be overcome. This is understandable; the solution is by no means straightforward. For reasons of confidentiality, the police must be extremely careful about whom they consult for advice. There are various published directories of experts. However, an officer cannot use a directory effectively if he does not know in which field of expertise he needs advice. In some cases, the police will readily recognise what sort of expert they need but not in all cases. Modern medicine is highly specialised. It seems to me that the police need an established route by which advice of this nature can be found. I make two suggestions. One is that, if and when the medical coroner service comes into being (as I will recommend in my Third Report), it would be appropriate for a medical coroner or a regional medical coroner to maintain a register of suitable experts and to provide confidential advice to the police. A second suggestion is that the police should invite the Crown Prosecution Service to provide access to an in-house solicitor with medico-legal experience. Such a solicitor should have available lists of suitable experts and of counsel with specialist medico-legal knowledge.”

Also the Police did not follow their declared strategy of subjecting Dr Sd’s concerns to a 2nd opinion. If they had done so, it is probable that the investigation would have continued.

Nurse M is registered with the NMC. He may well be crossing to the UK to work there. Furthermore he may still be getting nursing-type work in Jersey. The NMC has recently changed the level of proof required in its inquiries into complaints about nurses from criminal level to civil level. I consider his case should urgently be referred back to the NMC. The fact that the alleged incidents took place 10 years ago is not a barrier to referral.

Nurse M’s risk/dangerousness has no appearance of having been adequately assessed and managed. It is uncertain that the different agencies involved, the NMC, the police, the Psychiatric services have shared their knowledge of this man. There is a need for an urgent multi-agency assessment of Nurse M’s risk to patients.

The Police should be alerted to the apparent problems with the 1999 investigation, so they can make a decision on how to proceed. They may decide to reopen the investigation.

[END of Interim Medical report]