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.
Up-date 1 to Interim Medical Report:
Attorney General V Stuart Syvret
“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
“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.
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.
4.2.21 The review team commented “It is also extremely unlikely that diamorphine and Hypnoval (midazolam) would be detected and if diamorphine were detected its presence in the body of a terminally ill patient would have little significance as most are routinely prescribed the drug for pain management. Hypnoval likewise is often prescribed to patients.”
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.
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.”