Opinion as to the likelihood that the death of David Kelly CMG Dsc was the direct result of haemorrhage due to transection of his left ulnar artery
Martin Birnstingl MS FRCS Formerly Consultant General Surgeon with vascular expertise
Dr Christopher Burns -Cox MD FRCP Consultant Physician
Dr Stephen Frost BSc MB ChB Specialist in Diagnostic Radiology (Stockholm, Sweden)
David S Halpin MB BS FRCS Formerly Consultant Orthopaedic and Trauma Surgeon
Dr Michael J Powers QC FFFLM Examiner to the Faculty of Forensic Law and Medicine
of the Royal College of Physicians and Specialist in Medical Negligence and Causation
Dr Andrew Rouse MB BS MPH FFPHM Interpretation of Health Data
Solicitors Leigh, Day and Co, Priory House, St John's Lane, London EC1M 4LB
We are members of a group of eleven specialist doctors who have called for the reopening of the inquest into the unnatural death of David Christopher Kelly CMG DSc aged 59 (b 14/05/44 d 17/07/-03)
The causes of death were given by Lord Hutton as:
''... and that the principal cause of death was bleeding from incised wounds to the left wrist which Dr Kelly inflicted on himself with the knife found beside his body. It is probable that the ingestion of an excess amount of Coproxamol tablets coupled with apparently clinically silent coronary artery disease would both have played a part in bringing about death more certainly and more rapidly than would have otherwise been the case. Accordingly the causes of death are:
1a Haemorrhage
1b Incised wounds to the left wrist
2 Coproxamol ingestion and coronary artery atherosclerosis ''
Death certificate
<!--[endif]-->This image is taken from a scan of a certified copy of the death certificate. The reader will note under 'Date and Place of Death' .............. 'Found dead at Harrowdown Hill, Longworth, Oxon.Date of Registration Eighteenth of August 2003
Cause of Death The same cause(s) of death, word for word, are given on this certificate as were given by Lord Hutton in his statement on 28 January 2004, five months later.
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We analyse here the key features which arethe basis for rejecting haemorrhage as the prime cause in this unnatural death.
Neither the autopsy nor police reports have been made available or publicised. Thus the following opinions are based on facts which are in the public domain, having been given in evidence at the Hutton Inquiry. We are assuming there was no clotting defect present in Dr Kelly eg gross platelet deficiency, anticoagulants administered etc
Our group has contended that transection of one ulnar artery was highly unlikely to cause bleeding of such volume and rapidity that death would have ensued. Our reasoning, based on key subjects, is set out here.
The Ulnar Artery
This artery has the width of a matchstick in its constricted state. It is not easily felt on the little finger side of the wrist being below fascia. (Gray's Anatomy 36th Edition Transverse section P 582) In contrast, the radial artery pulse is easily felt beneath the skin on the opposite side of the wrist. It is thus more difficult to cut the ulnar artery.
Verbatim extracts from the Hutton Enquiry are printed in italics.
Dr Nicholas Hunt, the forensic pathologist who examined Dr Kelly's corpse noted:
NH He had evidence of a significant incised wound to his left wrist, in the depths of which his left ulnar artery had been completely severed. That wound was in the context of multiple incised wounds over the front of his left wrist of varying length and depth. The arterial injury had resulted in the loss of a significant volume of blood, as noted at the scene. The complex of incised wounds over the left wrist is entirely consistent with having been inflicted by a bladed weapon, most likely candidate for which would have been a knife. Furthermore, the knife present at the scene would be a suitable candidate for causing such injuries. ......... Other features at the scene which would tend to support this impression include the relatively passive distribution of the blood, ..... Many of the injuries over the left wrist show evidence of a well developed vital reaction which suggests that they had been inflicted over a reasonable period of time, minutes, though, rather than seconds or many hours before death.
Mr Knox: What do you mean by a "vital reaction"?
NH A vital reaction, my Lord, is the body's response to an area of damage. It manifests itself chiefly in the form of reddening and swelling around the area.
Dr Hunt describes complete severance of this artery ie transection. Prevailing surgical, pathological and physiological understanding predicts that the elasticity of the artery would have caused the artery to retract within its sheath. Contraction of the circular muscle within the arterial wall would have narrowed the artery, thus reducing or stopping blood flow. Blood clot would have formed in the wound but also within the narrowed artery. That clotting within the artery would have happened more speedily because the cutting was done with considerable trauma thus causing more damage to the lining membrane, the intima. Damage to the cells of the intima causes aggregation of blood platelets, thus hastening clotting within the vessel. The stimulus to clotting would have been less if the cutting had been done with a very sharp razor blade for instance. The contraction force (tone) of the circular muscle would have increased further with the trauma to the vessel and later in response to hormonal and nervous mechanisms. Blood flow through the cut end would have reduced sharply in minutes. A falling blood pressure would also have reduced any persisting flow of blood from the cut end but we believe this mechanism was unlikely to have operated because significant hypovolaemia (reduced blood volume) would not have occurred.
If a 'bleeder' – a cut vein or artery, happens during surgery in a deep wound, a common response is to place a surgical pack in the depths of the wound with gentle pressure exerted. A few minutes are allowed to pass before the pack is removed. The bleeding will have lessened, often greatly, and the source is then more easily seen and dealt with.
The Bleeding – the Haemorrhage
A healthy person has to lose about half his blood volume for death to be threatened. The speed at which blood volume is lost is the main factor governing this risk. The Acute Trauma Life Support teaching of the American College of Surgeons has this maxim:
Class IV Haemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
The slower volume is lost, the greater the effect of compensatory mechanisms that ward off death.
Dr Hunt describes Dr Kelly as being of average weight and height. Without these figures and his haematocrit (the percentage of packed red cells to the total volume of the blood sample) one cannot estimate his normal blood volume with accuracy. Assuming his weight was 90 kg and his haematocrit 50%, his estimated blood volume would be 6750 ml (Miller W.L.) If death was to become likely from haemorrhage alone at the 40% threshold noted above, then 2700 mls would have to have been lost.
We contend that for all the reasons listed under 'ulnar artery', it was impossible for 2700 mls of blood to have been lost through this small artery. Indeed, to lose 500 mls through it would be unlikely.
Historical Evidence that cutting the wrist may or may not lead to death in attempts at suicide
It is very unusual for a patient to die from a single deep cut to the wrist. There have been a number of studies which show this:
a. One from the International Statistical Classification of Diseases where only six patients out of 12,286 died following injury to the wrist. International Statistical Classification of Diseases and Related Health Problems, 10th Revision (Geneva: World Health Organisation 19924)
b. A study from a South Carolina Jail showed that in 275 prisoners who had cut their wrists only one died. Psychological reports (1998), Vol 82,pp.66114
c. A statistical study by Yaser Adi MPH, Systematic Reviewer, Department of Public Health and Epidemiology, University of Birmingham, UK, B15 2TT, and Andrew Rouse, Consultant in Public Health was reported 8 February 2004 in the BMJ Rapid Responses.
/home/david/My Documents/Kelly Group/Rouse, Milroy, Sennett etc in BMJ fe 2004.htm
They presented the statistics for suicide and self inflicted injury by cutting and piercing instruments amongst males 50 to 69 between 1991 and 2000 in the UK (Office of National Statistics) and concluded:
'This statistical evidence, combined with the fact that even after searching the medical literature (2) and speaking to medical and surgical colleagues we have not been able to document that wrist slashing can lead to successful suicide, suggests that for all practical purposes wrist slashing suicide does not exist in Britain
(2) Ovid Medline online searched 1966 to 2003.
Evidence given at the Hutton inquiry as to the volume of blood lost at the scene where Dr Kelly was found
Mr Dingemans examining Vanessa Elizabeth Hunt paramedic
76
8 Q. And is there anything else that you know of about the
9 circumstances of Dr Kelly's death that you can assist
10 his Lordship with?
11 A. Only that the amount of blood that was around the scene
12 seemed relatively minimal and there was a small patch on
13 his right knee, but no obvious arterial bleeding. There
14 was no spraying of blood or huge blood loss or any
15 obvious loss on the clothing.
16 Q. On the clothing?
17 A. Yes.
18 Q. One of the police officers or someone this morning said
19 there appeared to be some blood on the ground. Did you
20 see that?
21 A. I could see some on - there were some stinging nettles
22 to the left of the body. As to on the ground, I do not
23 remember seeing a sort of huge puddle or anything like
24 that. There was dried blood on the left wrist. His
25 jacket was pulled to sort of mid forearm area and from
77
1 that area down towards the hand there was dried blood,
2 but no obvious sign of a wound or anything, it was just
3 dried blood.
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(85 913)
Mr Knox Is there anything else you would like to say about the circumstances leading to Dr Kelly's death?
David Ian Bartlett ambulance technician Just the same as my colleague actually, we was surprised there was not more blood on the body if it was an arterial bleed.
..................................................................................................................................................................... (23 – 6&7)
Dr Hunt noted 'The arterial injury had resulted in the loss of a significant volume of blood, as
noted at the scene.'
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(28 5-8)
Mr Knox And in summary, what is your opinion as to the major factor involved in Dr Kelly's death?
Dr Hunt It is the haemorrhage as a result of the incised wounds to his left wrist.
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(142 10-11).
Mr Dingemans Did you find anything around the body area of interest?
Mr Roy James Green – forensic biologist Yes. There was blood distribution. cont ............
142
15 Q. Right. I think we have heard from an extract that
16 Mr Page has read out to us that the ulnar artery was
17 severed. Did you understand that to be the case at the
18 time?
19 A. Obviously injuries are a pathologist's domain. However,
20 the blood distribution was what I would expect to see if
21 an artery had been severed. There was bloodstaining
22 typical of that sort of injury.
23 Q. What do you expect to see in such circumstances?
24 A. Well, when veins are severed the blood comes out under a
25 low pressure, but when arteries are severed it comes out
143
1 on a much higher pressure and you get spurting of blood,
2 you get a phenomenon known as arterial rain, where you
3 have a great deal of smallish stains all of about the
4 same size over the area.
5 Q. Did you find that arterial rain?
6 A. Yes.
7 Q. On what?
8 A. On the nettles - there were nettles alongside the body
9 of Dr Kelly.
10 Q. And did you look for the distribution of blood?
11 A. Yes.
12 Q. We have heard from some ambulance personnel, and they
13 said they were not specifically looking, for obvious
14 reasons, at the distribution of blood but they noted,
15 just on their brief glance, not very much blood. What
16 were your detailed findings?
17 A. Well, there was a fair bit of blood.
These pieces of evidence record what blood or blood stains were seen by the two Paramedics, Dr Hunt and Mr Green. From the above evidence it is clear that the various visual estimates would probably not have accounted for a volume in excess of one litre. Was the volume of blood found outside the body measured? It would have been a simple matter to collect all the blood stained/soaked leaf litter, soil and nettle leaves and then to elute the haemoglobin by immersion in cold water. The haemoglobin concentration could then have been measured and the volume of blood that was lost from Dr Kelly established accurately.
Residual blood volume
In the absence of an accurate measure of the volume of 'externalised' blood, the crucial measurement would have been the residual blood volume. This is estimated by measurement of the volume of the liquid and clotted blood within the heart and major vessels of the cadaver. As a matter of sound practice Dr Hunt will have recorded this and it would have allowed him to say with certainty that haemorrhage was the primary cause of death.
Conclusion
We continue to hold that the bleeding from Dr Kelly's ulnar artery was highly unlikely to have been so voluminous and rapid that it was the primary cause of death. We advise the instructing solicitors to obtain the autopsy reports so that the concerns of a group of properly interested medical specialists can be answered. We have confined ourselves to the circumstantial, anatomical and physiological factors that relate to the claim that Dr Kelly died primarily from haemorrhage, thus excluding other questions that relate to the death.
Curriculum Vitae of Mr Martin Birnstingl
MB BS London 1946; FRCS England 1952; MS London 1958
Consultant Surgeon St Bartholomew's Hospital London EC1 1960 1988
Consultant Vascular Surgeon Royal National Orthopaedic Hospital 1961 1988
Honorary Consultant St. Lukes Hospital for the Clergy 1965 l980
Chairman Medical Council St Bartholomew's Hospital 19831985
Senior Examiner University of London
President Vascular Society of GB and Ireland 1986
Past member European Society of Cardiovascular Surgery, International Cardiovascular Society, Association of Surgeons of Great Britain and Ireland, Surgical Research Society,
Royal Society of Medicine, Medical Society of London, Founder member Vascular Surgical Society of GB and Ireland, etc
Publications: Editor "Peripheral Vascular Surgery" Heinemann, 1973;
Chapters on Vascular Injuries in Wilson, J.W. "Watson Jones Fractures and Joint Injuries" Churchill Livingstone 1976
Many publications on vascular surgery.
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Curriculum Vitae of Dr Christopher BurnsCox
MB BS London University 1960
MRCP 1963
Lecturer in Medicine University of Malaya 19679
Senior Registrar University College Hospital London 196970 and Bristol Royal Infirmary 196971
Consultant Physician General Medicine, Diabetes and Endocrinology, Frenchay Hospital and Clinical Lecturer University of Bristol 19711999
MD 1972 1977 FRCP
Locum Consultant Physician at Gloucester, Cheltenham, Caithness, North Bristol and United Bristol NHS Trust 20002007
Published more than 40 peer reviewed papers, started a Palliative Care Unit, a Patient Information Service and a Diabetes Centre.
Co-Founder of Bureau for Overseas Medical Service 1980
Founder member of the Association of British Clinical Diabetologists 1992
WHO Consultant Smallpox Zero Bangladesh 1974 and work in many other disadvantaged countries
Curriculum Vitae of Dr Stephen Frost
BSc and MB ChB Liverpool UK
Specialist in Diagnostic Radiology (Stockholm, Sweden)
Present and Past Appointments: Specialist in Diagnostic Radiology,
University Hospital of Lund, Sweden
Specialist in Diagnostic Radiology,
University Hospital of Uppsala (Akademiska Sjukhuset), Sweden
General Practitioner
Have worked closely with many of the leading radiologists (and clinicians) in Sweden
(and thereby the world)
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Curriculum Vitae of Mr David S Halpin
Home address: Kiln Shotts, Haytor, Newton Abbot, Devon TQ13 9XR Tel/fax 0044 1364 661115 Email dsh@kilnshotts.co.uk
MB BS (London) 1964 FRCS(Eng)1969
Trained at St Mary's Hospital W2 1958 - 1964 including work in vascular surgery and arterial disease units.
Casualty Officer to Paddington General Hospital 1965
Lecturer in Anatomy, King's College Hospital 1965-6
Surgical rotation Bristol hospitals 1968-9
Surgical Registrar Royal Devon and Exeter Hospital, then Senior Registrar Princess Elizabeth Orthopaedic Hospital, Royal Devon and Exeter and Royal Cornwall Hospitals 1970-5.
Consultant in Orthopaedic and Trauma Surgery Torbay and Exeter 1975.
Duties included teaching surgeons training in orthopaedic and trauma surgery.
Training and experience relevant to the case of Dr Kelly's unnatural death:-
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a. A good grounding in pathology at St Mary's.
b. Dealt with cases where suicide had been attempted by the cutting of one or both wrists. Involved closely with the assessment and surgical treatment of these patients because he was usually on duty with one junior doctor. He cannot recall significant blood loss being a feature.
c. Trauma due to road accidents was common, the worst cases usually being motorcyclists. A small minority 'bled out' and died - mostly from bleeding into the thoracic or abdominal cavities and some from rupture of pelvic vessels due to pelvic fractures. These high velocity injuries often had lower limb trauma with complex fractures and considerable wounding. Although arteries and veins were often injured, fresh bleeding from them had ceased. This reflected the bluntness and violence of the trauma and thus the great stimulus to arterial constriction and to clotting which we speak of in relation to the use of the pruning knife in the case of Dr Kelly.
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CURRICULUM VITAE OF DR MICHAEL POWERS
BSc London University 1969
MB BS London University 1972
DA (RCS) 1975
Barrister 1979
QC 1995
MFFLM 2006
FFFLM 2007
Medico-legal practice since 1980 – primarily issues of medical causation
Former Assistant Deputy Westminster Coroner and President of the South of England Coroners’ Society
3 Textbooks (with Dr.Paul Knapman) on Coroners Law
Former Editor of Coroners Law Reports for the JP Journal
Chapter contributions on various medicao-legal subjects in 10 textbooks;
Consulting Editor: Clinical Risk published by Churchill Livingstone
Co-Editor of Clinical Negligence 1990, 1994, 2000, 2008
Examiner to the Faculty of Forensic Law and Medicine, Royal College of Physicians of London
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<!--[endif]-->Martin Birnstingl MS FRCS
Christopher DrBurns - Cox MD FRCP
Dr Stephen Frost BSc MB ChB
David S Halpin MB BS FRCS
Dr Michael J Powers QC FFFLM
Dr Andrew Rouse MB BS MPH FFPHM
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